The Terrible Triad of the Elbow: Evolving Surgical Approaches and Patient Outcomes

Background: The “terrible triad” (TT) of the elbow refers to a challenging injury combination characterized by posterior elbow dislocation along with fractures of both the radial head and the coronoid process. Once labeled “terrible” because of historically poor prognosis, advancements in surgical methods and a better grasp of elbow biomechanics have led to markedly improved clinical outcomes.

Objectives: To evaluate the surgical outcomes and functional results of terrible triad injuries treated at our institution and assess the effectiveness of current treatment protocols.

Methods: A retrospective analysis was performed on 24 patients with terrible triad injuries of the elbow treated between March 2018 and December 2024. Surgical stabilization aimed at restoring both bony alignment and ligament integrity was undertaken in all cases. Functional outcomes were evaluated using the Mayo Elbow Performance Score (MEPS).

Results: Mean MEPS at final follow-up was 80 points (range 70-90). Thirteen patients achieved excellent results, seven achieved good results, and Three achieved fair results. ‘Mean flexion was 112° with extension loss of 12°. Four patients developed residual elbow stiffness as the primary complication.

Conclusion: Advances in surgical techniques emphasizing anatomical reconstruction, combined with structured rehabilitation protocols, have altered the prognosis of terrible triad injuries. With a systematic surgical approach, most patients now achieve favorable functional outcomes.