Terrible Triad Injuries & Complex Elbow Fracture-Dislocations

An elbow dislocation with fractures of the radial head and coronoid, and how stability is restored.

Understanding Terrible Triad Injuries & Complex Elbow Fracture-Dislocations

A terrible triad injury combines three injuries: an elbow dislocation, a fracture of the radial head, and a fracture of the coronoid, the front lip of the ulna that keeps the elbow from sliding backward. It usually happens in a fall on an outstretched hand. The name reflects how difficult these injuries were to treat in the past, with high rates of recurrent instability, stiffness and arthritis ^[1].

Because the bony and ligament stabilizers on both sides of the elbow are damaged, most terrible triad injuries are unstable and need surgery. A standard surgical protocol, which fixes or replaces the radial head, repairs the coronoid when needed and repairs the lateral ligaments, with medial repair or a hinged fixator for elbows that remain unstable, has substantially improved results ^{[2, 3]}.

Motion begins early after surgery because stiffness is common after these injuries ^[3]. Coronoid fractures can also occur with other patterns of elbow instability, which are evaluated with a CT scan to plan treatment.

Causes & Risk Factors

A fall on an outstretched hand
High-energy injuries such as sports collisions or falls from a height
Dislocation combined with radial head and coronoid fractures

Symptoms

Common signs and symptoms of Terrible Triad Injury include:

Severe elbow pain and swelling after a fall
Deformity of the elbow
Inability to move the elbow
A feeling that the elbow is unstable after it is put back in place
Numbness or tingling in the hand

Treatment Options

Treatment for Terrible Triad Injury depends on the severity of your condition and may include:

Urgent reduction of the dislocation
CT scan to define the fractures
Fixation or replacement of the radial head
Coronoid fixation when needed
Lateral (and sometimes medial) ligament repair
Hinged external fixator for persistent instability
Early, protected range of motion

References

Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am. 2002;84(4):547-51. doi.org/10.2106/00004623-200204000-00006
Pugh DM, Wild LM, Schemitsch EH, et al. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am. 2004;86(6):1122-30. doi.org/10.2106/00004623-200406000-00002
Fahs A, Waldron J, Afsari A, et al. Management of Elbow Terrible Triad Injuries: A Comprehensive Review and Update. J Am Acad Orthop Surg. 2024;32(19):e982-e995. doi.org/10.5435/JAAOS-D-24-00310

Common Questions

Frequently Asked Questions

Why is it called the "terrible triad"?

The name comes from the three injuries together and from how poor results were before modern surgical techniques. Today, most patients regain a functional, stable elbow with surgery and early motion.

Do terrible triad injuries always need surgery?

Most do, because the elbow is usually unstable. A small number of carefully selected injuries with small fractures and a stable elbow may be treated without surgery.

Will my elbow move normally again?

Most patients regain a functional range of motion, although some loss of motion and stiffness are common. Early guided therapy is important.

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