terrible triad of elbow joint is very unstable injury of elbow joint. triad of elbow dislocation with radial head fracture with ulnar coronoid process fracture is known as terrible triad. In this injury medial collateral ligament of elbow is also mostly damaged so in this triad elbow joint becomes very unstable and surgical fixation should be done by experienced elbow surgeon.
Elbow dislocation with fracture of radial head with fracture of ulnar coronoid process (terrible triad elbow)

Terrible triad of elbow joint is a severe traumatic injury to elbow joint and this injury makes elbow joint very unstable.

What are that injury which makes terrible triad

  • Elbow dislocation
  • Radial head fracture
  • Coronoid process of ulna fracture

When you fall on out stretched hand your elbow joint may be dislocate either isolated elbow joint dislocation without fracture or with fracture of radial head and fracture of coronoid process of ulna, when your elbow joint dislocate with radial head and coronoid process of ulna fracture, your joint becomes very unstable and only conservative treatment can not hold up your joint in place.

Symptoms (what you feel)

  • You feel severe pain on  elbow joint
  • Your pain increase on movement of hand
  • Your limb seems deform at elbow joint
  • You may feel something clicking (crepitus) in your elbow joint

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Diagnosis

Physical examination (what your doctor feel)

Your doctor will check your elbow for swelling and tenderness — comparing your injured elbow to your normal elbow. He may try to  move your elbow into a variety of positions if your pain allowed to reduce your elbow joint in place as early as possible.

Often the diagnosis of fracture can be made on the basis of the physical examination, but you need investigations to determine the severity of the injury. These investigations may include:

  • X-rays- X-rays may be needed to confirm fracture or dislocation and to rule out other bone fractures. In X-ray your doctor can see the various parameter of fractures to decide treatment. However, X-rays don’t show soft tissues, such as ligaments and tendons. But there may be some sign in the X-ray which can tell your doctor about ligaments injury.
  • CT Scan- Elbow joint is very complicated joint so in elbow joint injury if your doctor suspect terrible triad injury  or your elbow fracture includes more bones and intraarticular fractures then your clinician advise for CT Scan with 3D reconstruction to understand your fracture pattern more clearly and to plan surgical exposure and fixation.
  • Magnetic resonance imaging (MRI)-  When your doctor suspect some ligaments injuries he may advise MRI scan. MRI can show the extent of a ligament injury and signs of damage to other tissues in the elbow, including the cartilage

Treatment

First-aid care include reduction of elbow joint under anaesthesia or in emergency room in sedation it will decrease pain and swelling to your elbow.

In terrible triad injury you feel severe pain so  your orthopaedic doctor will apply a plaster support after reduction of elbow joint in place to hold the joint in place and to reduce pain and swelling. if pain is intolerable then you can take anti-inflammatory and analgesic.

Nonsurgical treatment (Close reduction and Plaster support)

Treatment for a terrible triad injury mostly surgical because elbow becomes very unstable in this injury. In very selected patients if radial head fracture and coronoid process of ulna fracture is undisplaced or minimally displaced after elbow joint reduction and elbow joint reduction remain in place after close reduction then your doctor may advise you for conservative treatment. During conservative treatment it is very important for close watch on any subluxation or displacement on your follow up visit. Your orthopaedic doctor will start early mobilisation of your elbow joint supervised physiotherapy.

The goal of physiotherapy is to reduce pain and swelling, restore your elbow’s full range of motion, and strengthen muscles.

This course of physical therapy successfully treat a undisplaced terrible triad injury in very limited selected supervised patients.

Terrible triad fixation (Surgery)

Your doctor may recommend surgery if:

    • Your radial head fracture need to be fix
    • Your coronoid fracture is either displaced or large size
    • Your elbow joint is unstable after reduction
    • Your elbow joint subluxate or dislocate in course of conservative treatment

In surgical fixation of terrible triad it is you should go for orthopaedic surgeon who is experienced in all type of elbow surgery. Your elbow surgeon uses mini-plates and various type of headless mini screw for radial head fracture and mini plates or suture anchors or fibre wire fixation method for coronoid process of ulna fracture so it will not impinge on joint movement.

Dr. Anil sharma has experience of terrible fixation surgery. His surgical exposure technique and fixation technique is very good so there is no problem of hardware prominence or impingement.

when coronoid process of ulna fracture is associated with radial head fracture then there is very high chance of medial collateral ligament tear
CT Scan showing Terrible triad of elbow
Operated case of terrible triad injury shown in above CT scan

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