Terrible Triad ORIF - Elbow Dislocation with Radial Head and Coronoid Fractures

Indication. The terrible triad is an unstable elbow fracture-dislocation. Closed reduction alone, non-operative care, or radial-head excision all fail with high rates of recurrent instability, stiffness and post-traumatic arthritis - which is why the injury earned its name. Operative reconstruction of all three stabilisers is the standard of care, ideally within the first two to three weeks while the tissues are still mobile. Assess before you cut. Plain radiographs (AP, lateral, oblique) confirm the dislocation and the fractures, but a CT with 3D reconstruction is mandatory - the anteromedial coronoid facet is frequently invisible on a lateral X-ray and is the single most commonly missed fragment. Examine the elbow under anaesthesia for valgus laxity (an associated MCL injury, complete rupture in roughly 20-30 percent of cases) and read the whole injury pattern: coronoid type, radial head pattern, ligamentous injury, and any associated capitellar or distal humerus injury. Mechanism. A fall on the outstretched hand with the elbow extended, the forearm supinated, and an axial plus valgus load: the ulnohumeral joint dislocates posteriorly, the coronoid is sheared off (anterior buttress lost), the radial head is crushed against the capitellum (lateral column lost), and the LCL complex - above all the LUCL - avulses from the lateral epicondyle (posterolateral stability lost). Consent specifically for recurrent instability, stiffness (the most common complication), heterotopic ossification, hardware prominence and possible later hardware removal, posterior interosseous nerve (PIN) injury, post-traumatic arthritis, ulnar or median nerve symptoms if a medial or anterior exposure is needed, the possible need for a hinged external fixator, and a reoperation rate of around 22 percent. The strategy is the same every time - reconstruct every stabiliser in a fixed order, then test stability and escalate only if needed:

Setup. Supine with the arm across the chest on a radiolucent table (preferred - gives excellent lateral access and easy intra-operative ROM testing), or lateral decubitus if a medial approach for an anteromedial facet fragment is anticipated. Proximal arm tourniquet at 250 mmHg, the whole limb prepped circumferentially and draped free for ROM testing, and the C-arm brought from the contralateral side with AP and true lateral elbow views confirmed before draping. Antibiotics (cefazolin 2 g IV within 60 minutes, or vancomycin 15 mg/kg if penicillin-allergic).

The goal is to restore a concentrically stable, congruent elbow through the lateral Kocher approach: expose the joint, then work inside-out - fix the coronoid first, then the radial head, then repair the LCL complex - testing stability at the end and adding a hinged fixator only if it remains unstable. The exposure is laid out in full as the first steps below (and in depth on the Kocher approach to the elbow page).

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Rehabilitation | Situation | Timing | Immobilisation | Therapy | |-----------|--------|----------------|---------| | Stable reconstruction | 0-2 weeks | Posterior splint at 90 degrees flexion, forearm neutral (splint off at 3-5 days) | Gentle active and active-assisted flexion-extension avoiding the terminal 20-30 degrees; full flexion; rotation as tolerated; hand, wrist and shoulder immediately | | Hinged fixator | 0-2 weeks | Fixator with motion blocks (about 30-120 degrees) | ROM in the fixator from day 1, therapist-supervised daily | | Early motion | 2-6 weeks | Splint discarded by 2 weeks (fixator removed at 4-6 weeks) | Active ROM to 30-130 degrees by week 6; full rotation; light ADLs; no lifting more than 1-2 kg, no valgus stress | | Strengthening | 6-12 weeks | None (night splint only if stiff) | Isometrics then isotonics; dynamic splinting if stiff (most effective weeks 6-12) | | Return to activity | 3-6 months | None | Sedentary work 6-8 weeks, heavy labour 4-6 months; non-contact sport 3 months, contact sport 6 months; avoid valgus sports (throwing, tennis, golf) for 6 months | Across published series, anatomic sequential reconstruction yields good-to-excellent results in roughly 80-90 percent of patients, with a final arc typically around 10-130 degrees, a common 5-30 degree flexion contracture that is usually asymptomatic when under 30 degrees, grip strength of 80-90 percent of the contralateral side, and minimal or absent pain in most at one year. Radiographic proximal migration of a replaced head and mild post-traumatic arthritis are common long-term findings and are often only mildly symptomatic. Heterotopic ossification prophylaxis. HO is common in the terrible triad (Foruria 2013: radiographic HO in 37 percent, interfering with motion in 20 percent). Where prophylaxis is used the options are a short course of indomethacin (about 25 mg three times daily for around 6 weeks) or a single fraction of peri-operative radiotherapy - each with trade-offs, and routine use remains a matter of surgeon judgement rather than firm consensus.

Additional complications. Wound infection (2-5 percent): superficial - local care and oral antibiotics; deep - irrigation and debridement with culture-directed IV antibiotics, retaining hardware if stable. Complex regional pain syndrome (3-5 percent): a multidisciplinary approach with gabapentin or pregabalin, desensitisation therapy, and stellate ganglion blocks. Loss of fixation (3-5 percent): usually the coronoid in osteoporotic bone, or a radial head plate - revise with ORIF if ununited, osteotomy for malunion. Radioulnar synostosis (1-3 percent): bony bridging causing loss of forearm rotation - excise after maturation (12-18 months) with an interposition graft and prophylaxis; results are guarded.

Epidemiology. The elbow is the second most commonly dislocated major joint in adults (after the shoulder), and the terrible triad is a high-energy subset of posterolateral elbow dislocation. It classically affects younger adults after a fall, and bilaterality and recurrence are features of inadequately treated injuries. Why "terrible". Hotchkiss (1996) popularised the name to capture the historically poor outcomes of this pattern when treated non-operatively, by closed reduction alone, or by radial-head excision - with high rates of recurrent instability, stiffness and post-traumatic arthritis. Radial-head excision is particularly harmful here because it removes a key lateral-column and valgus stabiliser at a moment when the coronoid and ligaments are already deficient. The modern protocol-driven sequential reconstruction with early motion (Pugh and McKee, 2004) transformed outcomes to roughly 78-90 percent good-excellent. Stabilisers. The elbow's stability rests on three primary constraints: the ulnohumeral joint (the coronoid is the anterior buttress preventing posterior subluxation, and the anteromedial facet resists varus and anteromedial rotatory load), the radiocapitellar joint (the radial head is the key secondary valgus and axial stabiliser and a critical lateral-column buttress when the coronoid and MCL are deficient), and the collateral ligaments (the MCL anterior bundle is the primary valgus restraint and inserts on the sublime tubercle; the LUCL prevents posterolateral rotatory instability). Bony constraints provide roughly 50-60 percent of stability, the MCL about 30-35 percent of valgus stability, and the LCL complex about 10-15 percent of varus stability - but 100 percent of PLRI prevention. Combined loss of the coronoid and radial head produces gross instability even with the ligaments intact, which is why neither can be sacrificed.

Key evidence. The foundational paper is Pugh et al. (2004), whose standardised protocol (radial head ORIF/replacement, coronoid fixation, lateral ligament repair, selective MCL repair and/or hinged fixation, motion at 7-10 days) gave a mean Mayo Elbow Performance Score of 88 with 28 of 36 (78 percent) good-excellent and concentric stability in 34 of 36, at the cost of a 22 percent reoperation rate. Doornberg et al. (2007) quantified the anteromedial facet - on average about 58 percent projects medially beyond the supporting metaphysis - explaining why it fractures as a discrete, mechanically critical fragment. Grewal et al. (2006) showed modular metallic radial head replacement to be safe and reliable in unreconstructable comminuted fractures (all stable, no revision, no overstuffing). Leigh and Ball (2012) found repair and replacement equivalent within an identical protocol - reconstruct the head when a stable anatomic repair is achievable, replace it when it is not. O'Driscoll, Bell and Morrey (1991) defined posterolateral rotatory instability and the LUCL as its essential lesion, mandating anatomic LUCL repair. The pooled systematic review by Chen et al. (2014) confirmed satisfactory function but a 22.4 percent reoperation rate with HO (12.5 percent) and arthrosis (11.2 percent) dominant, and Foruria et al. (2013) quantified the high HO burden (37 percent radiographic, 20 percent limiting motion) with surgical delay as a modifiable risk.