Terrible Triad of the Elbow

Excerpt

Originally described in 1996 by Hotchkiss, the terrible triad of the elbow constitutes a highly unstable form of fracture-dislocation consisting of elbow dislocation with concomitant radial head or neck and coronoid process fractures.

The historically poor outcomes and high complication rates portend the designation of this injury pattern as “terrible.” Provided its numerous bony and soft tissue structures, the elbow is well known as one of the most stable joints of the body. The complex anatomical structure and higher functional requirements make treating the elbow more difficult.

Owing to those mentioned above, even isolated elbow dislocations without bony fragmentation indicate substantial soft tissue injury with capsular and ligamentous disruption. On the other hand, complex elbow dislocations are defined by an association with fracture(s) of one or more major bony stabilizers. Fracture of the radial head, coronoid process, or olecranon inherently destabilizes the dislocation and nearly always mandates operative intervention to restore functional anatomic alignment and joint stability.

Despite clinical and operative advancements and an increased understanding of pathoanatomy and elbow biomechanics, controversies remain regarding the appropriate treatment algorithm. Standardized surgical protocols and novel algorithmic approaches attempt to improve outcomes for terrible triad patients. Successful evaluation and treatment require detailed knowledge of the functional importance and relationship of each bony and soft tissue component and its contribution to elbow stability.