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Terrible triad injury of elbow
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Terrible triad injury of elbow

Contributors: John P. Detherage III MD, Danielle Wilbur MD
Other Resources UpToDate PubMed


Emergent Care / Stabilization:
  • Asses if the injured extremity is neurovascularly intact; if not, immediate reduction and surgical consultation are needed.
  • Assess for signs of compartment syndrome. If present, emergency fasciotomy is needed.
  • Pain control (reasonable use of narcotics).
  • Nothing by mouth (NPO).
(See Best Tests, Management, and Therapy sections for further details.)

The terrible triad injury is a complex dislocation (dislocation with concomitant bony injury) of the elbow. Terrible triad injury includes a posterior elbow dislocation accompanied by a fracture of the radial head or neck and of the coronoid process of the ulna.

Causes / typical injury mechanism: Terrible triad injury is an acute injury. The most common mechanism of action is a fall on an outstretched hand (FOOSH), creating an axial load with mild elbow flexion, internal rotation of the humerus with valgus stress, and forearm supination. High-energy trauma can also lead to terrible triad but is less common than FOOSH.

Classic history and presentation:
  • High-impact sport injuries
  • Falls from height
  • High-impact trauma
  • Terrible triad injuries account for 10%-11% of all adult elbow fractures.
  • No known differences in sex prevalence.
  • Elbow injuries are more common in the elderly population.
  • They are less common in the pediatric population.
  • Up to 20% of elbow dislocations result in a concomitant fracture.
Pathophysiology: The mechanism of action described above leads to posterior elbow dislocation with an impaction fracture of the radial head or neck and a shear fracture of the coronoid process of the ulna. Disruption of soft tissue structures occurs in a lateral to medial progression and can include injury to any or none of the following: lateral collateral ligament (LCL), anterior joint capsule, medial collateral ligament (MCL), and common extensor and flexor-pronator tendons.

Grade / classification system:
  • Ulnohumeral joint dislocation.
  • Radial head or neck fracture.
  • Coronoid fracture of ulna. Smaller fracture fragments off of the coronoid are more likely to be associated with terrible triad injuries.


S53.006A – Unspecified dislocation of unspecified radial head, initial encounter

125596004 – Injury of elbow

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Last Reviewed:04/20/2022
Last Updated:05/03/2022
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Terrible triad injury of elbow
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