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Terrible Triad of the Elbow

Severe injury pattern combining elbow dislocation, radial head fracture and coronoid process fracture. Systematic surgical treatment. Guarded prognosis with prolonged rehabilitation of 6 to 12 months.

Characteristics

The elbow terrible triad is a defined clinical entity associating dislocation + radial head fracture + coronoid fracture [1]. This term, introduced by Hotchkiss in 1996, emphasizes the prognostic severity of this triple injury which simultaneously compromises the three pillars of elbow stability: the anterior buttress (coronoid), the lateral and axial stabilizer (radial head) and ligamentous constraints (LUCL and often MCL). The resulting multidirectional instability represents approximately 1-2% of elbow injuries [2].

The mechanism is a fall on an outstretched hand with axial, valgus and external rotation forces. Treatment relies on systematic surgery following a codified sequential protocol: 1) radial head fixation or prosthesis, 2) coronoid process repair (lasso suture, screws or buttress plate), 3) LUCL repair with anchors, 4) intraoperative stability assessment and MCL repair if necessary, 5) articulated external fixator if residual instability [3].

Rehabilitation is prolonged, delicate, and must begin early under hinged brace to combat stiffness while respecting surgical repairs. Long-term functional prognosis remains guarded, with frequent residual range-of-motion loss (10-30° extension) and risk of post-traumatic arthritis.

  • The terrible triad injury pattern destroys the three pillars of elbow stability: the anterior bony buttress (coronoid), the lateral valgus and axial stabilizer (radial head), and ligamentous constraints (LUCL systematically ruptured, MCL in 50-70% of cases). The resulting instability is multidirectional.
  • Mechanism: fall on outstretched hand with axial, valgus and supination components. O'Driscoll's injury sequence: LUCL rupture → rotatory subluxation → radial head shearing against capitellum → coronoid fracture by impaction → complete dislocation.
  • Risk factors: high-energy trauma, contact sports or sports with fall risk, road traffic accidents. Peak incidence between 30 and 50 years with slight male predominance. No modifiable risk factor identified.
  • Complications: joint stiffness (60-80% of cases, most frequent complication), residual instability (15-25%), heterotopic ossification (10-20%), post-traumatic arthritis (20-40% long-term), ulnar neuropathy (5-15%), complex regional pain syndrome (5-10%), hardware failure.

Medical and Surgical Management

  • Sequential reconstruction surgery: 1) radial head fixation or prosthesis (prosthesis if Mason III), 2) coronoid repair (lasso suture, screws or buttress plate), 3) LUCL repair with anchors on the lateral epicondyle. Intraoperative stability assessment at each step.
  • Articulated external fixator (Compass type or equivalent): indicated if persistent instability despite osteoligamentous repairs. Allows early protected mobilization within a controlled stability arc. External fixation duration: 4-6 weeks.
  • Close radiological follow-up: check at day 7, day 21, week 6 and week 12. Monitoring of joint congruence, signs of subluxation, fracture healing and heterotopic ossification development. Control CT scan at week 6-8 if in doubt.

Physiotherapy treatment

  • Early mobilization under hinged brace with adjustable stops from day 3-5. Initial protected range of 30° to 100° flexion. Free active forearm rotation. Early mobilization is key to combating stiffness, the main complication.
  • Strengthening of dynamic stabilizers (biceps, brachialis, anconeus, epicondylar and epitrochlear muscles) to compensate for residual ligamentous insufficiency. Early isometric exercises then progressive resistance from week 6-8.
  • Progressive widening of hinged brace stops: gaining 10-15° in extension and flexion every 1-2 weeks based on clinical tolerance and radiographic stability. Brace worn for 6-8 weeks.
  • Global muscle strengthening and functional reintegration from week 8-12. Closed-chain then open-chain exercises. Advanced proprioception. Accept a residual extension deficit of 10-20° which is generally not functionally limiting. Return to sports at 6-12 months.

After the session

You may feel slight fatigue or tightness: this is normal. Continue the exercises taught at home to maintain session benefits.

Questions About Elbow Rehabilitation

When should I start physiotherapy after elbow surgery?

Rehabilitation generally begins between 3 and 21 days after the operation, depending on the type of procedure and the stability of the surgical fixation. For fractures treated with stable internal fixation (screw plate), early mobilization is often authorized from D+3 to D+5 to prevent joint stiffness. In cases of elbow replacement or complex ligament repair, the delay may be extended to 2-3 weeks with initial immobilization in a splint. A systematic review published in the Journal of Shoulder and Elbow Surgery confirms that early mobilization after elbow surgery significantly improves final range of motion without increasing the risk of complications [Hackl et al., 2023] . Your surgeon will advise the optimal timing based on your specific procedure.

What are the goals of elbow rehabilitation?

Elbow rehabilitation pursues several complementary goals, adapted to each phase of recovery. In the initial phase (0-6 weeks), the priority is to restore range of motion in flexion-extension (goal: 30°-130° minimum for daily activities) and in pronation-supination (50° in each direction minimum). In the intermediate phase (6-12 weeks), the focus is on progressive muscle strengthening of the flexors, extensors and rotators of the forearm, as well as restoring joint stability through proprioceptive exercises. In the advanced phase (3-6 months), the emphasis is on functional reintegration: daily activities, work tasks and return to sports. Scientific literature highlights that the minimum functional arc of the elbow (30°-130° of flexion-extension, 50° of pronation and 50° of supination) is necessary to perform 90% of daily activities [Mofidi et al., 2020] . Scar treatment and adhesion prevention complete this comprehensive care approach.

Is elbow rehabilitation painful?

The techniques used are progressive and adapted to your tolerance. The elbow is a joint particularly prone to stiffness and inflammatory reactions: overly aggressive rehabilitation can paradoxically worsen the situation by causing heterotopic ossifications (abnormal bone formations in soft tissues). Exercises must be regular but never forced . The physiotherapist always adapts the intensity to stay below the pain threshold, following the "no pain, more gain" rule specific to the elbow. Gentle, regular active mobilization spread across the day in short sequences is generally preferred to prevent stiffness, with early active mobilization recommended after an elbow injury [Akhtar et al., 2021] . Complementary techniques such as cryotherapy , microcurrents and Novafon vibration therapy also help control pain during sessions.

Scientific sources

Average duration

6 to 12 months of mandatory prolonged rehabilitation, frequent residual extension deficit

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