Our Summary

The “terrible triad” of the elbow is a serious injury that involves a dislocated elbow, a broken radial head (part of the forearm bone), and a break in the coronoid process (a small bony projection on the front of the ulna, one of the bones in the forearm). These injuries can cause long-term problems like instability, stiffness, pain, and arthritis.

Over the last 20 years, we’ve learned a lot about these injuries and how they occur. To prevent serious complications, it’s important to understand how the injury happened and to carefully analyze all the damage.

Surgery for these injuries is aimed at restoring stability to the joint by repairing the damage in a specific sequence. This allows for early movement of the joint, which can help prevent stiffness.

This paper discusses the anatomy and functions of the elbow joint, emphasizing the importance of the humeroradial column (the joint between the upper arm bone and the radial bone in the forearm) and the lateral collateral ligament (a ligament on the outside of the elbow). It also discusses the role of the coronoid process.

There is some debate about certain aspects of treatment, such as whether to always repair the medial collateral ligament (a ligament on the inside of the elbow) or use a type of brace known as an articulated external fixator.

The paper also proposes a simple guide for repairing these types of injuries.

FAQs

  1. What is the “terrible triad” of the elbow?
  2. What are the long-term risks associated with the terrible triad of the elbow?
  3. What is the aim of surgery for the terrible triad of the elbow?

Doctor’s Tip

One helpful tip a doctor might tell a patient about elbow surgery is to follow the post-operative rehabilitation plan closely. This may include physical therapy exercises to help regain strength and range of motion in the elbow. It is important to be patient and consistent with these exercises to ensure the best possible outcome after surgery.

Suitable For

Patients who are typically recommended for elbow surgery include those with the terrible triad of the elbow, which consists of posterior dislocation, radial head fracture, and coronoid process fracture. This complex trauma involves severe bone and ligament lesions, with a high risk of residual instability, stiffness, pain, and osteoarthritis. Surgery aims to restore stability through anatomic repair and early mobilization to prevent stiffness. Important factors in surgery include understanding the lesion mechanism, precise analysis of all lesions, and proper repair of the humeroradial column and lateral collateral ligament. Controversial aspects of treatment include the repair of the medial collateral ligament and the use of an articulated external fixator. Overall, surgery is recommended for patients with the terrible triad of the elbow to prevent long-term complications and improve outcomes.

Timeline

Before elbow surgery:

  1. Patient experiences a traumatic injury to the elbow, such as a fall or a sports-related incident.
  2. Patient may feel severe pain, swelling, and limited range of motion in the elbow.
  3. Patient undergoes imaging tests, such as X-rays or MRI, to determine the extent of the injury.
  4. Orthopedic surgeon evaluates the images and decides on a treatment plan, which may include surgery for severe cases.

After elbow surgery:

  1. Patient undergoes the surgical procedure to repair the damaged structures in the elbow, such as the radial head, coronoid process, and ligaments.
  2. Patient may experience pain and discomfort immediately after surgery, which can be managed with pain medication.
  3. Patient undergoes physical therapy to regain strength, range of motion, and function in the elbow.
  4. Patient follows a rehabilitation program to gradually return to normal activities and prevent stiffness and complications.
  5. Patient may require follow-up appointments with the surgeon to monitor the healing process and address any concerns or complications.

What to Ask Your Doctor

  1. What specific type of elbow surgery do you recommend for my condition?
  2. What are the potential risks and complications associated with this surgery?
  3. What is the expected recovery time and rehabilitation process after surgery?
  4. Will I need any additional treatments or therapies after the surgery?
  5. What are the long-term outcomes and potential complications I should be aware of?
  6. How experienced are you in performing this type of surgery?
  7. Can you explain the specific steps of the surgical procedure and how it will address my condition?
  8. Are there any alternative treatments or procedures that could be considered instead of surgery?
  9. Will I need any assistive devices or modifications for daily activities after surgery?
  10. Are there any specific lifestyle changes or precautions I should take before or after surgery to optimize my recovery?

Reference

Authors: Ohl X, Siboni R. Journal: Orthop Traumatol Surg Res. 2021 Feb;107(1S):102784. doi: 10.1016/j.otsr.2020.102784. Epub 2021 Jan 9. PMID: 33333276