Did you know that a seemingly simple fall onto
an outstretched arm, a common everyday accident,
can unleash one of the most devastating and complex
patterns of orthopedic injury? It really can.
One so challenging to manage that it was historically
and perhaps justifiably labeled the terrible
triad. That's the one. Today we ask, are these
injuries still as formidable? And how has our
understanding and treatment evolved to tackle
this specific kind of chaos in the elbow joint?
Welcome to the deep dive where we transform stacks
of information into clear actionable insights.
I'm your host and in this deep dive we're tackling
that historically ominous terrible triad of the
elbow. a very significant injury. This is a dive
shaped specifically by the collection of articles
and research you, our dedicated listeners, shared
with us. To help navigate the intricate anatomy,
complex mechanics and challenging treatment pathways
detailed in these sources, I'm thrilled to be
joined by an expert with a profound ability to
synthesize dense medical literature into accessible,
practical understanding. It's a privilege to
have you with us today. Thank you. It's a pleasure
to be here. These injuries are certainly a significant
challenge in orthopedics, and the sources you've
provided offer a really comprehensive look at
where we stand in managing them today. And that
understanding is precisely our mission. Because,
as the sources make clear, this isn't just a
collection of random broken bones. No, not at
all. It's a specific, predictable pattern of
failure in a joint built for both stability and
complex motion. Exactly. A delicate balance easily
disrupted. So let's jump straight into the fundamental
questions setting the stage for our deep dive.
If someone were to ask you, what exactly is a
terrible triad injury? Beyond the scary name.
What are the three absolute core components that
define it? Right. The triad refers to the three
key elements that must be present simultaneously.
Firstly, you have a posterior elbow dislocation.
Okay. Secondly, a fracture of the radial head
or the neck. Right, the radius bone. And thirdly,
a fracture of the coronoid process of the ulna.
The ulna. Yeah. It's the combination of this
dislocation with those specific bony injuries
that creates the Well, the profound instability
characteristic of the terrible triad. So it's
the dislocation plus the radial head fracture
plus the coronoid fracture. Got it. That's the
definition. Second question. You mentioned a
simple fall can cause this. What is the specific
mechanism, the typical scenario that brings these
three components together in such a damaging
way? Well, the classic mechanism described in
the sources as accounting for around 60 % of
cases is a fall onto an outstretched arm. Right,
the fail injury. Precisely. The critical forces
involved are axial loading that's force traveling
up the arm through the radius. Okay. Combined
with a valgus force, which is a bending force
pushing the elbow inwards towards the midline
of the body. Ah, okay. And external rotation
or supination of the forearm relative to the
humerus. So twisting outwards. Yes. Imagine planting
your hand slightly lateral to your body as you
fall. This often generates the necessary combination
of forces to disrupt the elbow, typically starting
from the lateral side and progressing inwards.
Axial load, valgus, external rotation. That specific
cocktail of forces from something as common as
a fall is, well, it's quite sobering. It is indeed.
And finally, going back to that name, why was
this injury historically considered so terrible?
What were the outcomes like in the past? Historically,
yes, managing these injuries was fraught with
difficulty, really quite problematic. How so?
Even after they managed to reduce the dislocation
and attempt some sort of fixation, the elbow
often remained unstable or, perhaps more commonly,
became severely stiff. Ah, stiffness. Exactly.
The rates of complications like recurrent dislocation,
the elbow just popping out again and significant
loss of motion were very high. Surgeons really
struggled to reliably restore stability and achieve
good functional outcomes. Leading to long -term
problems. Yes, leading to long -term disability
for many patients. The name... truly reflected
that historical difficulty and the high potential
for a poor result. That historical context certainly
underscores the challenge. It sounds like the
fight against instability on one hand and stiffness
on the other is absolutely central to this injury.
That's the core dilemma. OK, let's unpack this
further, diving into the details from the sources.
To truly appreciate what goes wrong in a terrible
triad, we first need to understand the normal
elbow, its incredibly complex anatomy, and how
it achieves stability. Absolutely. Yeah. You
can't fix it if you don't understand how it's
supposed to work. The elbow is far more sophisticated
than a simple hinge. Right. As the sources detail,
it's actually a single joint capsule containing
three articulations. The humeral nerve joint,
the radiocapitular joint, and the proximal radial
nerve joint. Three joints in one capsule. Yes.
It's described as a trochleogene lemoid joint.
Trochleogene lemoid. Quite a mouthful. It is.
It basically means it's primarily a hinge, but
it also allows rotation. So the hinge part is
where? That's the main articulation, the humeralnar
joint. The trochlea of the humerus, which is
shaped a bit like a spool, articulates with the
greater sigmoid notch of the ulna. This gives
you the primary hinge motion flexion and extension.
And it's inherently quite stable due to the way
the bones fit together, especially in full extension
and near full flexion. And the rotation comes
from the radiocapitalar joint. Is that right?
Precisely. This is where the radial head, which
has a sort of concave, articular surface, rotates
against the capitolum of the humerus, the rounded
end of the humerus on the lateral side. This
allows for pronation and supination, turning
your palm down and up. The proximal radial nar
joint, where the radial head also contacts the
ulna, is critical for this rotation, too. And
it's mainly stabilized by the anular ligament.
Okay, so bending and twisting are both happening
here. The sources particularly highlight the
coronoid process and the radial head as key bony
players in the terrible triad. What are their
specific roles in normal stability? They are
absolutely crucial osseous stabilizers, the bony
parts providing stability. Right. The coronoid
process, which is a projection on the front of
the ulna, acts as an anterior buttress. It's
vital for preventing the ulna from sliding backwards
on the humerus, especially as the elbow flexes
beyond about 30 degrees. So it stops it dislocating
backwards in flexion. Essentially, yes. What's
particularly significant and often fractured
in the terrible triad is a specific part of the
coronoid called the sublime tubercle. It's on
the antiromedial aspects. Antiromedial, front
and inside. Correct. And this is the primary
attachment site for the crucial anterior bundle
of the medial collateral ligament, the MCL. Ah,
so... Fracturing the cornoid isn't just losing
a piece of bone. You're potentially detaching
a major ligament at the same time. Exactly. Especially
if it's a significant fragment involving that
sublime tubercle or the wider anti -romedial
facet as described by the odriscal classification
we'll probably come on to. Okay. Then you have
the radial head. Well, the humoral inner joint
is the main stabilizer in the bending plane.
The radial head plays a vital secondary role.
Secondary. How so? particularly against valgus
stress, that inward bending force, and also against
rotational instability. It contributes up to
30 % of the resistance to valgus forces. 30%.
That's significant. It is. And crucially, it's
also a primary bony restraint to something called
post -relateral rotatory instability, or PLRI.
It helps prevent that abnormal outward twisting
of the radius and ulna on the humerus. Wow. Up
to 30 % of valgus resistance. That's a huge contribution
for a bone we often just think about for rotation.
It really highlights how interconnected these
structures are. Absolutely. Everything works
together. What about the main ligamentous stabilizers
then, the soft tissues? The static stabilizers,
the ligaments and the capsule are arguably even
more critical for stability, especially against
sudden forces. Right. On the medial side, The
inside, you have the medial collateral ligament,
or MCL complex. This is the primary restraint
of algus stress. It also resists internal rotation
stress. It has three bundles described. The anterior
bundle is the strongest. It's taught from 0 to
60 degrees of flexion. The main working range.
Often, yes. Then the posterior bundle is taught
in deeper flexion, say 60 to 120 degrees. And
there's a transverse ligament, which is generally
considered less functionally important. And you
mentioned the anterior bundle attaches to the
cornoid. Yes, it attaches right onto that sublime
tubercle of the cornoid. This connection makes
injuries to that part of the cornoid, particularly
destabilizing for the medial side. Right, you
lose the bone and the ligament anchor. And on
the lateral side, that LCL complex seems key
in the mechanism you described earlier. Yes,
absolutely. The lateral -collateral ligament
complex is the primary restraint to that poster
lateral rotatory instability, the PLRI. It originates
from the lateral epicondyle of the humerus, the
bony prominence on the outside. Okay. Traditionally,
it's described as having several components.
The radial collateral ligament, the annular ligament,
which we mentioned stabilizes the proximal radial
lunar joint. Right. The accessory lateral collateral
ligament, and the key one, the lateral ulnar
collateral ligament, the LUCL. The LUCL is frequently
mentioned in the sources as being paramount.
Is it the single most important lateral structure?
Well, the LUCL is certainly often considered
the main functional component of the lateral
complex. Disruption of this ligament is consistently
associated with PLRI. OK, however, it's maybe
a bit more nuanced. Some biomechanical studies
suggest that the entire complex functions more
as a single unit, originating from a common footprint
on the lateral epicondyle and inserting onto
the ulna. Like a sheet of tissue. Sort of, highlighting
the concept of a continuous capsule ligamentous
complex. There's also a thickening of the post
-relateral capsule, often referred to as the
Osborne Cotteral Ligament, which also contributes
to stability, acting as a check grain against
post -relateral rotation and varus angulation.
Varus is the outward bending. Correct, the opposite
of valgus. So while the L -U -C -L is crucial,
it operates within this broader complex lateral
network. It's not just acting alone. That level
of detail is really helpful. It's not just one
simple rope holding things together. It's more
like a woven structure. A good analogy. And you
also mentioned the joint capsule itself. Yes.
The anterior and posterior capsules are also
important contributors to overall stability.
The anterior capsule provides some secondary
restraint to valgus stress and also contains
nerve endings contributing to proprioception,
the sense of joint position. So it tells your
brain where your elbow is. In part, yes. And
both capsules are typically torn. quite extensively
in elbow dislocations. And finally, the muscles.
The dynamic stabilizers, yes. The muscles crossing
the joint, like the aconius, triceps, brachialis,
and the common flexor and extensor origins. By
providing compressive forces across the joint
during contraction and contributing to proprioception,
they add another layer of stability, especially
during active movement. It's incredible how many
different elements have to work in perfect harmony.
The specific shakes of the bones, the tensile
strength of the ligaments, the integrity of the
capsule, and the coordinated action of the muscles.
It's a truly intricate system, built for stability
during load bearing, but also for remarkable
mobility for function. And when you disrupt key
players from multiple categories like this, bone,
ligament, capsule. You get the profound multiplanar
instability seen in a terrible triad. It's not
just one structure failing. It's a catastrophic
cascading failure involving bony blocks, critical
ligaments, and the surrounding capsular support.
Which brings us back to the mechanism again,
but perhaps in more detail now we understand
the anatomy. How do those specific forces you
described, the axial load, valgus stress, external
rotation, how do they specifically create this
pattern of simultaneous bony and ligamentous
damage? This is where the concept of the Hori
circle comes into play, which the source has
mentioned. It describes the predictable sequence
of injury progression around the elbow. The Hori
circle sounds like a map of destruction. In a
way, yes. It typically starts laterally and spirals
around the elbow medially as the dislocating
forces continue and overcome each stabilizer
in turn. So stage one? Stage one involves the
disruption of the lateral -collateral ligament
complex. This initiates the instability, allowing
the radius and ulna to start rotating post -relaterally
relative to the humerus. The outward twisting
starts? Correct. If the force continues, you
progress to stage two. This involves carrying
of the anterior and posterior capsules. The joint
is now actively dislocating or subluxating. But
the medial side, the MCL, might still be intact,
providing some sort of unstable hinge. However,
in the terrible triad, the forces are usually
higher. Pushing it further. Exactly. Pushing
into stage three, where the medial collateral
ligament is also disrupted. Now you've lost stability
on both sides, plus the capsule. And the bony
fractures are a consequence of this progression.
When do they happen? Precisely. The terrible
triad is considered an osseous extension, a bony
consequence of this stage three disruption of
the whole right circle. Right. As these severe
forces overcome the lateral ligaments, then the
capsule, and finally the medial ligament, the
bones themselves start to fail under the stress.
The radial head is forcefully impacted against
the capitellum causing it to fracture. Stashed
against the humerus. Effectively, yes. Simultaneously,
as the ulma is displaced posteriorly, the coronoid
process acting as that anterior buttress and
also the anchor for the MCL is sheared off or
fractured as it collides with the trochlea of
the humerus. So it gets knocked off from behind.
Or sheared off by the force. So it's a progressive
failure of the soft tissues culminating in these
specific bony injuries occurring at the points
of maximum stress or weakest structure. What's
really insightful from the sources is that the
bony injuries aren't just random events. They
are a direct result of the extreme forces tearing
through the stabilizing soft tissues in that
specific lateral to medial sequence. That sequential
failure from lateral to medial, with the bony
fractures being the sort of final breaking points,
that paints a very clear albeit brutal picture
of the forces at play. It does. It helps understand
why these three injuries occur together. OK,
so a patient presents after this type of fall,
their elbow is maybe obviously dislocated or
just looks severely injured. How do clinicians
confirm the terrible triad diagnosis and understand
the full extent of the damage? Well, a high index
of suspicion is absolutely vital, especially
in the context of any elbow dislocation. Yeah.
You assume it could be this until proven otherwise.
The initial clinical evaluation involves a thorough
assessment. Beyond any obvious deformity, you're
looking carefully for swelling, bruising, and
gently palpating for tenderness, which might
indicate specific fracture sites or ligamentous
injury points. And critically. Critically, a
neurovascular examination is non -negotiable.
You must check the radial pulse and capillary
refill and assess nerve function, sensation,
and motor power, particularly for the ulnar nerve.
Why the ulnar nerve specifically? It runs right
behind the medial epicondyle, so it's very vulnerable
to being stretched or even trapped during the
dislocation or by fracture fragments around the
medial elbow. Assessing instability clinically
can be very difficult in the acute setting. because
of pain and muscle guarding, though sometimes
gross instability is horribly obvious. Is there
anything else you look for clinically, any associated
injuries? Yes, always. Always remember the potential
for associated injuries, particularly distal
ones. Specifically, in the context of a radial
head fracture with elbow instability, you absolutely
must examine the distal radial solnar joint down
at the wrist. The wrist joint. Why? Because the
interosseous membrane, a strong sheet connecting
the radius and ulna along their length, can transmit
force. A severe radial head injury, especially
if it's comminuted or involves the neck, can
disrupt this membrane and also injure the DRUJ
ligaments at the wrist. Ah, that's the S. exlipresti
injury. Exactly. That's the S. exlipresti injury.
And missing it can have severe functional consequences
later on, like wrist pain and instability and
proximal migration of the radius. That's a critical
point. An elbow injury could be directly linked
to a significant wrist problem. And then imaging.
That must be key. Imaging is fundamental, yes.
Plane radiographs are always the first step.
Standard AP and lateral views are essential.
If the elbow is dislocated on arrival, you ideally
need films before reduction and definitely after
reduction to confirm concentric reduction of
both the humeralnar and radiocapitalar joints.
How do you check that concentricity? On the lateral
view. A line drawn through the center of the
radial neck should always pass through the center
of the capitellum, regardless of the flexion
angle. Any deviation suggests subluxation or
malalignment. Radiographs can identify the dislocation
and often show the significant radial head or
coronoid fractures, but... But they have limitations.
Yes. They're often limited in showing complex
bony detail, subtle displacement, or the exact
size and shape of fragments, especially the coronoid.
So x -rays give you the initial picture, but
for the full story, what else is needed? That's
where computed tomography, the CT scan, becomes
absolutely invaluable. It's almost mandatory
in complex elbow fracture dislocations like the
terrible triad. Why is CT so crucial here? CT
provides detailed cross -sectional images and
crucially allows for 3D reconstruction. This
is vital for precisely characterizing the fracture
patterns. For example? For example, the size,
shape, location, and displacement of the coronoid
fragment, which can be much more complex than
it appears on x -ray, particularly those tricky
intramedial facet fractures. It also details
the comminution and displacement of the radial
head fracture any articular step off and helps
identify any small bone fragments that might
be trapped within the joint. So it's like a blueprint
for surgery. Exactly. This detailed 3D blueprint
is essential for accurate surgical planning.
Fluoroscopy using live x -ray under anesthesia
is also often used intraoperatively to dynamically
assess the stability after the bony and ligamentous
repairs have been performed. Right, so the CT
scan is the key to truly understanding the specific
anatomy of the bony damage, which plain x -rays
might easily miss. Combining that detailed imaging
with the clinical picture allows you to confirm
the diagnosis and plan the next steps. Precisely.
Diagnosis and planning are paramount. Okay, once
the diagnosis is made, you're faced with this
really challenging multi -component problem.
The dislocation, the radial head fracture, the
coronoid fracture, and the extensive ligamentous
disruption. The sources discuss various classification
systems for the bony injuries. How do these systems
help surgeons make sense of this chaos and, crucially,
guide treatment decisions? Classification is
absolutely vital, yes. It helps standardize description
and guide surgical management because different
fracture patterns behave differently biomechanically
and often require different fixation strategies.
For coronoid fractures, the traditional classification
is the Regan -Mori system. It's based simply
on the height of the fragment seen on the lateral
x -ray view. Type 1 is just the tip, type 2 is
less than 50 % of the coronoid height, and type
3 is more than 50 % of the height. Seems straightforward,
but the source has noted a limitation there.
Yes, the main limitation of Regan -Mori is that
it doesn't adequately capture the crucial three
-dimensional location of the fracture, particularly
those involving the anteromedial facet. The bit
where the MCL attaches? Exactly. Those anteromedial
facet fractures can be highly destabilizing,
even if they aren't particularly large in height
on the lateral view. The odriscal classification
addresses this much better. How does odriscal
work? It categorizes fractures based on their
anatomical location. Type 1 involves the tip,
type 2 involves the anteromedial facet, and type
3 involves the base of the coronoid. and there
are subtypes within those. And that's more useful
surgically. Yes, the adriscal system is generally
considered more useful for surgical decision
-making because it directly relates the specific
fracture pattern to the injured ligament attachment
like the MCL on the antiremedial facet and therefore
informs the necessary fixation strategy and surgical
approach. That makes sense. Location dictates
strategy. And for the radial head fracture, what
systems are used there? The Mason classification
is the classic system, widely known. It's based
purely on the radiological appearance. Type 1
is non -displaced. Type 2 is displaced, but generally
considered repairable, often causing a mechanical
block to motion. And type 3 is combinated, shattered
into multiple pieces, typically not repairable.
Johnson later added type 4 for any radial head
fracture associated with an elbow dislocation,
which is, of course, the pattern we see in a
terrible triad. And the Hotchkiss modification,
how does that refine Mason? The Hotchkiss modification
builds on Mason by incorporating clinical findings
and explicitly guiding treatment. It helps distinguish
between fractures that might, very rarely, be
treated non -surgically. Type 1, less than 2
millimeter displacement, no block. OK. Those
suitable for open reduction and internal fixation,
or RIF type 2, more than 2 millimeter displacement,
causing a block but still repairable. Right.
And those requiring replacement, usually an arthroplasty.
Type 3 committed, not repairable. This is a more
clinically oriented and treatment -focused classification.
Are there any systems mentioned that try to classify
the entire injury pattern, taking into account
both the bones and the ligaments? Yes, the wants
at all. Reddington classification is mentioned
in the sources. It's based on the three -column
concept of the elbow, a lateral column, a middle
ulnar column, and a medial column. It classifies
complex fracture dislocations based on which
columns and their associated key ligaments are
injured. In this system, a type C injury essentially
aligns with the terrible triad pattern, involving
significant disruption of both lateral and medial
stability structures. So it helps frame the overall
instability pattern. So using these classification
systems helps translate the complex imaging findings
into categories that directly inform the treatment
plan. What does that treatment plan typically
look like? Is non -surgical management ever a
realistic option for such an inherently unstable
injury? For the vast, vast majority of terrible
triad injuries, surgical management is necessary.
Non -surgical treatment is only appropriate in
extremely rare and select cases that meet very
strict criteria. Such as? The elbow must be perfectly
concentric, perfectly reduced after the initial
reduction. The radial head and coronoid fractures
must be very small and judged to be inherently
stable. And critically, there must be enough
inherent stability to allow immediate, protected
early range of motion without any risk of the
elbow subluxating or re -dislocating. So very
specific circumstances. Extremely specific. Even
then, it involves maybe a week or so of immobilization,
followed by a very cautious restricted motion
protocol. Essentially, if there's any significant
displacement of the fractures or any ongoing
concern for instability, surgery is indicated,
which is most cases. So surgery is definitely
the mainstay. What's the overarching goal of
the surgery, then? The primary goal, the absolute
key, is to restore enough stability to permit
early motion. Why is early motion so important?
Because prolonged immobilization leads to severe
stiffness, which, as we said, is the most common
and often most debilitating complication. So,
surgery aims to fix the bony fractures and repair
the torn ligaments reliably enough that the patient
can safely start moving the elbow actively within
just a few days. OK. The sources describe the
principle of inside outward, or perhaps more
commonly, lateral to medial repair. This involves
addressing the lateral structures first, then
the bone, and finally addressing the medial side,
only if instability persists, sequentially restoring
stability. Let's delve into the surgical procedures
mentioned in the soredices. What are the common
approaches the incisions use to get to these
structures? Surgeons typically use either separate
approaches or sometimes a single larger approach,
depending on the specific injury pattern and
their preference. A direct lateral approach provides
excellent access to the radial head and the LCL
complex. Okay. A medial approach gives access
to the MCL and also allows for fixation of some
coronoid fractures, particularly those antiremedial
facet ones. Right. Alternatively, a universal
posterior approach, often using a technique that
spares or reflects the triceps tendon, can allow
access to both the medial and lateral columns
through a single large incision. Some specific
coronary fractures might even require an additional
small anterior approach for fixation. The choice
really depends on the surgeon's experience and
the specific fractures needing fixation. And
the specific techniques for fixing the bony and
ligamentous injuries. Let's start with the radial
head. Okay. For the radial head, if it's deemed
repairable, generally fitting the Mason type
two or Hotchkiss type two criteria, meaning usually
less than three or four pieces, less than 40
% of the articular surface involved and displaced.
Then ORF. Yes. Then open reduction and internal
fixation, O -R -A -F, is performed using small
specialized screws and sometimes plates. The
sources emphasize the importance of careful screw
or plate placement within the safe zone. The
safe zone, what's that? That's the post -relateral
aspect of the radial head, roughly a 90 to 110
degree arc measured from the radial styloid when
the forearm is held in neutral rotation. Placing
hardware here minimizes the risk of it impinging
on the ulna or humerus during pronation and supination
and reduces risk to the posterior interosseous
nerve. Okay, crucial detail. What if the radial
head is just too shattered to repair? Mason type
3. If it's severely commended, Mason type 3,
Haschges type 3, typically more than three or
four fragments, basically irreparable, then it's
usually replaced with a radial head arthroplasty.
That's a metal implant that mimics the shape
of the radial head. And sizing is important here.
Absolutely critical. Sources stress that meticulous
attention must be paid to implant sizing. An
implant that is too long or over lengthened can
cause significant pain, stiffness by overstuffing
the joint, and wear on the capotella. An implant
that is too short or undersized will simply not
provide adequate stability. It won't restore
the secondary valgus and rotational restraint.
The goal is usually to seat the radial head implant
approximately two millimeter distal to the tip
of the native coronoid process. Right. And the
sources were very clear about not just removing
the radial head. Extremely clear. Radial head
resection, just cutting it out and leaving nothing,
is generally strongly contraindicated in unstable
or dislocated elbows like the terrible triad.
It removes a key secondary stabilizer, massively
increasing the risk of proximal migration of
the radius over time, leading to risk problems
that Essex -Lepresti issue again. That's a really
critical point about not just removing it if
it's broken and the elbow's unstable. Okay, what
about the coronoid fracture? How is that fixed?
Coronoid fixation techniques vary quite a bit
based on the fracture size and location, often
guided by that otriscal classification. Smaller
tip fractures, type 1, might be fixed with sutures
passed through drill holes in the ulna or sometimes
using suture anchors. Occasionally they can even
be lassoed with sutures passed through a radial
head implant if one is being used. And bigger
fragments? Larger fragments, especially those
involving the anti -remedial facet or the base
of the coronoid, or Driscoll type 2 or 3, typically
require more robust fixation with screws or even
small plates for stability. These fractures can
sometimes be quite challenging to access and
fix directly, requiring specific surgical approaches.
Right. And finally, the torn ligaments, the LCL
and maybe the MCL. The LCL complex is nearly
always injured and requires repair. It's typically
repaired by reattaching it anatomically back
to its origin on the lateral epicondyle. Often,
it's avulsed as a sleeve of tissue from the bone.
How is it re -appatched? Suture anchors, small
implants drilled into the bone with strong sutures
attached, are commonly used to re -secure the
ligament footprint back to the bone, typically
centered around the axis of rotation near the
center of the capitella curvature. And the forearm
position matters during LCL repair? Yes, the
forearm position during the LCL repair is important.
Sources suggest repairing the LCL with the forearm
held in pronation if the MCL is intact. Pronation
tends to tighten the LCL and helps reduce that
post -relateral rotation. And if the MCL is also
torn? If the MCL is also significantly injured
and requires repair, then the LCL is usually
repaired with the forearm held in supination
or perhaps neutral rotation to allow appropriate
tensioning of both ligaments simultaneously.
And is the MCL always repaired? Not always. The
MCL itself is typically repaired only if the
elbow remains unstable after fixing the bony
injuries and repairing the LCL. Instability is
often checked dynamically under anesthesia, particularly
looking for gapping on the medial side when nevelgus
stress is applied, especially in extension beyond
30 degrees. If it's still unstable, then the
MCL needs repair too. Okay, that's a lot of complex
repair work. What if, even after fixing the bone
and repairing the ligaments, the elbow still
doesn't feel stable enough for that crucial early
motion? That's a challenging situation, indicating
persistent growth instability. In such cases,
some form of supplementary stabilization might
be required temporarily. Like what? This could
involve applying a hinged external fixator. This
is a frame outside the arm, connected by pins
above and below the elbow, that allows controlled
motion within a set range but protects the internal
repairs by spanning the joint externally. Are
there other options? Static external fixators
rigidly hold the joint in one position. usually
flexion, but carry a much higher risk of stiffness
due to the complete immobilization. Internal
joint stabilizer devices are also an option,
implants placed across the joint internally,
but they often require a second surgery for removal
and have their own potential complications. Cross
-kitting the humeral Nar joint in a reduced position
with temporary wires is also mentioned in one
source as a possibility for very short -term
stability. But the goal is always to achieve
enough primary stability from the internal repairs
to allow that early motion if at all possible.
It's clearly a very complex surgical undertaking
involving multiple intricate repairs. The timing
of the surgery is also something highlighted
quite strongly in the sources. Yes, this seems
to be a critical factor impacting the final outcome.
Several sources emphasize that delayed surgery,
particularly if it performed more than 14 days
after the initial injury, is associated with
significantly higher rates of stiffness and generally
poorer functional outcomes compared to surgery
performed within a shorter time frame. Sooner
is better. Generally, yes. Surgery performed
ideally within 24 hours up to perhaps 14 days
seems preferable. Early anatomical reduction
and scable fixation appear to interrupt the inflammatory
and scarring processes that lead to severe joint
contracture and potentially heterotopic ossification.
Which means? Which means accurate and timely
diagnosis, often requiring that prompt CT scanning
we discussed, is key not just for planning the
surgery, but for facilitating early surgical
intervention to improve the chances of a good
outcome. So diagnose quickly. operate comprehensively
and in a timely manner, and then what? What's
the crucial next step in the patient's journey
towards regaining function? Post -operative rehabilitation.
It is absolutely paramount and in many ways equally
as challenging as the surgery itself. Why so
challenging? It's a very delicate balancing act
between protecting the surgical repairs, which
need time to heal, and regaining motion to prevent
stiffness. How is that balance managed initially?
Initial immobilization is kept to an absolute
minimum. usually just seven to 10 days. The elbow
is typically held in a splinter brace at around
90 degrees of flexion, potentially with specific
forearm rotation pronation or neutral, depending
on which ligaments were repaired and how. And
after that brief period, what happens then? Early
active motion is initiated very quickly, often
within 48 hours or at least within a few days
postoperatively, once the initial pain and swelling
start to settle. Active motion, so the patient
moves the elbow themselves? Yes, gentle active
range of motion. Studies strongly support that
initiating this as soon as stability permits
significantly improves functional outcomes and
is the best strategy we have to combat stiffness.
Patients are typically guided by a therapist
through controlled flexion and extension within
a safe prescribed arc of motion. Are there any
specific movements or ranges to avoid initially
to protect repairs? Yes. Often patients are advised
to avoid achieving full or near full extension,
particularly the last 30 degrees or so of extension
for the first few weeks. typically around four
weeks. Why avoid full extension? That terminal
extension position can put significant stress
on the healing LCL and potentially the MCL repairs,
depending on the specific pattern of instability.
Avoiding it helps protect the reconstruction
during the early healing phase. Strengthening
exercises are introduced much more gradually,
usually starting around six to eight weeks post
-op. What sort of strengthening? beginning with
low resistance activities like gentle wall push
-ups or weight bearing on the hands in a quadruped,
all -force position, progressing slowly as tolerated
and as healing progresses. This clearly requires
close collaboration and expert guidance. Absolutely.
A dedicated physiotherapist, ideally one experienced
with complex elbow injuries, plays a vital role
throughout the entire rehabilitation process.
They guide the patient, monitor progress, adjust
the program based on response, and manage expectations.
And how is success measured? Functional outcomes
are commonly tracked using validated questionnaires
like the D -A -S -H score disabilities of the
arm, shoulder, and hand, and the M -E -P -S,
the male elbow performance score. M -E -P -S
scores range from 0 to 100, with scores of 90
-100 indicating an excellent functional result.
Despite the best surgery and dedicated rehab,
what are the potential setbacks or complications
that patients and surgeons might still encounter?
This injury sounds like it can fight back. Unfortunately,
yes. Given the severity of the initial trauma
and the complexity of the reconstruction, complications
are relatively common, even with optimal management.
Stiffness is arguably the most frequent significant
complication. Stiffness again. Yes, reported
incidences range from 5 % up to as high as 15
% or even more in some series, requiring further
intervention. It often presents as a significant
loss of extension of flexion contracture. It
can be caused by excessive scar tissue formation
within and around the joint or by heterotopic
ossification. Ulnar nerve irritation or entrapment
is also a significant risk factor for pain and
can contribute to limiting motion. Heterotopic
ossification, that's the abnormal bone growth
outside the normal skeleton you mentioned earlier.
Yes, exactly. HO is a major concern after these
complex elbow injuries. Its incidence in operatively
treated terrible triads can be disturbingly high,
reported up to 43 % radiographically in some
studies, though not all of that is clinically
significant. What causes it? HO seems associated
with a severe of the initial soft tissue injury,
the amount of tissue damage during surgery, prolonged
immobilization, any associated nerve injury,
infection, and significantly delayed surgical
intervention seems to increase the risk. When
does it appear? It typically appears radiographically
within three to four weeks post -injury and can
cause really severe restrictions in range of
motion, potentially leading to ankylosis, which
is complete fusion of the joint in the worst
cases. Excision of the HO may be required later
on, but that's a complex procedure itself with
risks. Is there anything done to prevent HO?
Sources discuss prophylaxis. like using anti
-inflammatory drugs such as endomethacin. But
note the evidence for its effectiveness specifically
in traumatic elbow HO is still debated. Radiation
prophylaxis is sometimes used, particularly after
HO excision. But it's often considered too risky
after the initial fracture surgery due to potential
negative effects on fracture healing, though
it is mentioned for severe burn patients with
associated elbow injuries. So HO is a significant
potential hurdle. What else is on the complication
list after a terrible triad? surgery? Well, recurrent
instability is another risk. This can happen
if the initial surgical repairs fail, perhaps
the fixation wasn't robust enough, or if subtle
injuries, especially smaller coronoid fractures,
were underestimated or inadequately fixed initially.
Infection? Infection is a serious concern, especially
with implants present. Rates have been reported
up to 17 .5 % in some older series, which can
be devastating, often requiring multiple further
surgeries. Nerve problems? Nerve injuries, such
as ulnar or radial nerve, specifically the posterior
interosseous branch entrapments or palsies, can
occur in up to 23 .5 % of cases according to
some sources. These can be due to the initial
injury, swelling, scar tissue formation later
on, or sometimes proximity to surgical hardware.
And other issues. Non -union or malunion of the
fractures, meaning they don't heal or heal in
a bad position. Post -traumatic arthritis or
degenerative joint disease is a long -term risk
due to the initial cartilage damage sustained
at the time of injury, or due to residual instability
or joint incongruity. And issues related to the
hardware itself, painful, prominent, or loose
implants sometimes requiring removal, are also
potential complications. It really underscores
why this injury pattern is so challenging to
manage comprehensively. Given all those potential
issues, what's the realistic long -term outlook?
What can someone generally expect in terms of
prognosis after navigating this very difficult
injury in its treatment? Historically, as the
name terrible triad implied, the prognosis was
often poor. High rates of chronic pain, significant
stiffness, limiting function, and persistent
instability leading to disability were common.
But things have improved. Yes. Thankfully, with
significant advancements in our understanding,
better imaging, modern surgical techniques, particularly
more stable fixation methods, and reliable radial
head replacement options, and structured early
rehabilitation protocols, the outcomes have substantially
improved. Generally, Good to excellent functional
results, as measured by those MEPs and DASH scores,
often averaging above 75, are now achievable
for many patients. So the terrible aspect is
perhaps less about the inevitable outcome nowadays
and more about the complexity of the injury and
its management. Precisely. I think that's a fair
summary. With appropriate timely and skilled
care, it is often possible to achieve a good
functional outcome, allowing return to most activities.
What predicts a better outcome? The sources consistently
highlight that key predictors of a better prognosis
include accurate and timely diagnosis, often
relying on that crucial CP scan, prompt surgical
reduction and stable fixation or replacement
that allows for early protected motion, and,
very importantly, adherence to a rigorous therapist
-guided postoperative rehabilitation program.
But it's important to have realistic expectations.
Yes, absolutely. It's also important for patients
to have realistic expectations. Achieving a completely
normal elbow with full symmetrical range of motion
compared to the uninjured side is actually quite
rare, even with optimal treatment. What sort
of range is typical? Sources consistently cite
average functional arcs of motion after surgery,
typically around 110 to 115 degrees of combined
flexion and extension. Often there's some degree
of flexion contracture, a loss of full extension,
maybe 10, 15, even 20 degrees, that persists.
While not fully normal, this range of motion
is usually sufficient for most activities of
daily living. So it sounds like aiming for a
highly functional elbow rather than a perfectly
normal one is the realistic goal. That's often
the case, yes. Maximizing function within the
limits imposed by the injury. The source has
also suggested that where you receive care might
matter, the experience level. Yes, that was noted.
Some sources, including the one from Mayo Clinic,
have reported better outcomes in these highly
complex cases when managed at higher volume centers
by surgeons who have significant experience specifically
in complex elbow trauma and reconstruction. It
makes sense. The technical demands of these surgeries,
the nuances of fixation, implant choice, ligament
repair, and the careful orchestration of postoperative
management likely benefit from that focused experience.
That was a truly deep dive into a remarkably
challenging injury. Let's try and consolidate
some key facts with our lightning round. Quick
questions, sharp answers based purely on the
sources we've explored today. Ready? Ready when
you are. Okay. What are the three essential structural
components defining a terrible triad injury?
That's the posterior elbow dislocation, the radial
head or neck fracture, and the coronoid process
fracture. Which classification system for cornoid
fractures is generally considered most useful
for guiding surgical planning, and why? That
would be the odriscal classification, because
it's based on the anatomical location, the tip,
antiremedial facet, or base, which directly dictates
the surgical approach and the fixation strategy
needed. For a severely comminuted, irreparable
radial head fracture in a terrible triad, what
is the usual surgical treatment? Radial head
arthroplasty, so replacement of the radial head
with an implant. What forearm position is often
recommended during LCL repair if the MCL is intact
and what's the reasoning? Pronation is often
recommended because pronation tensions the LCL
and helps to reduce that tendency towards poster
lateral rotation. What is the most common major
complication encountered after surgical fixation
of a terrible triad injury? Stiffness. or loss
of motion, often due to scar tissue, capsular
contracture, or sometimes heterotopic ossification.
And what specific type of imaging is considered
essential beyond plain x -rays for effective
surgical planning? Computed tomography, the CT
scan, especially valuable with 3D reconstruction
views. Excellent. Those cover the core factual
anchors from our comprehensive sources. To try
and summarize this very complex topic into practical
takeaways for you, our listener, here are five
key points from this deep dive into terrible
triad entries. First. Always maintain a high
index of suspicion for a terrible triad following
any elbow dislocation. It's a specific and severe
pattern. Don't underestimate it. Crucial first
step. Second, detailed imaging, particularly
a CT scan, often with 3D reconstruction, is vital
for accurately characterizing the complex bony
injuries and planning the appropriate surgical
intervention. Can't plan without the full picture.
Third. Surgical treatment is necessary in nearly
all cases. The main goal is to restore stability,
fixing both bone and ligaments reliably enough
to allow immediate, protected early range of
motion. Stability for motion is key. Fourth,
timely surgical management, ideally within about
14 days of the injury, combined with a rigorous
early post -operative rehabilitation program
focused on controlled motion, are absolutely
critical for optimizing recovery and minimizing
that dreaded complication of stiffness. Timing
and rehab are paramount. And fifth, given the
intricate nature of these injuries and their
demanding management, seeking care from orthopedic
surgeons or centers with specific experience
in complex elbow trauma can significantly influence
the potential outcomes. Experience likely matters
here. That brings us towards the close of this
deep dive into the terrible triad. If you found
this discussion valuable and insightful, please
do consider rating and sharing the show on LinkedIn
or X. And thank you immensely for guiding us
through this really challenging orthopedic topic
with such clarity and detail. It was my pleasure.
A fascinating and important injury to discuss.
As we conclude, here's a final thought for you
to reflect on, drawing directly from the sources
we've explored. Despite considerable advances
in our understanding and techniques, the management
of terrible triad injuries remains a profound
balancing act. It truly does. It's a continuous
effort by the surgical and therapy teams to achieve
just enough stability to prevent re -dislocation
and allow healing, while simultaneously allowing
enough early motion to regain functional use
and fight off stiffness. The patient's entire
journey involves navigating this fine line, where
the ultimate outcome really hinges on the success
of both the initial surgical reconstruction and
their dedicated long -term rehabilitation. A
partnership between surgeon, therapist, and patient.
Until next time, keep diving deep.