# Terrible Triad of the Elbow

> Terrible triad of the elbow for NEET-PG Orthopaedics: dislocation with radial head and coronoid fractures, stepwise stabilisation and lateral ligament repair.

- Canonical URL: https://prepelephant.com/topics/neet-pg/orthopaedics/terrible-triad-of-the-elbow
- Exam / course: NEET-PG · Subject: Orthopaedics
- Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team
- First published: 2026-10-08
- Last updated: 2026-10-08
- Reference basis: Rockwood and Green's Fractures in Adults; Campbell's Operative Orthopaedics; Maheshwari Essential Orthopaedics
- How to cite: "Terrible Triad of the Elbow", PrepElephant, https://prepelephant.com/topics/neet-pg/orthopaedics/terrible-triad-of-the-elbow

## Direct answer

The terrible triad of the elbow is a posterior elbow dislocation combined with fractures of the radial head and coronoid process, named for its high risk of instability and stiffness. The radial head is a key stabiliser, and its loss with coronoid fracture and lateral ligament disruption leaves the joint prone to recurrent dislocation. Management restores the radial head, fixes the coronoid, repairs the lateral ligament and allows early controlled motion.

## What you must remember

- **Components:** posterior elbow dislocation, radial head fracture and coronoid fracture, with lateral collateral ligament disruption usually present as well.
- **Coronoid:** the fracture is usually a small transverse tip fragment, yet it is a key buttress against posterior displacement of the ulnohumeral joint, so it is fixed or sutured.
- **Radial head:** fixed if it can be reconstructed, and replaced with a prosthesis if not; excision is avoided in this setting.
- **Lateral ligament:** disruption of the lateral collateral ligament complex drives posterolateral rotatory instability and is repaired to the lateral epicondyle.
- **Recurrence:** the combination of fractures and ligament injury makes recurrent dislocation the main threat if the injury is not stabilised in order.
- **Stiffness:** the commonest functional problem, so controlled early motion in a hinged brace is preferred to long immobilisation.
- **Principle:** address the coronoid and radial head in a sequence, repair the lateral ligament, then test stability through motion.

## A stepwise route to a stable elbow

Stabilisation proceeds in a sequence, because each component supports the next. The order below reflects the usual logic of the surgery.

1. **Reduce and assess stability:** the dislocation is reduced under sedation, and the elbow is tested through its range to see what remains unstable.
2. **Fix the coronoid:** the fragment is fixed with screws or a suture lasso, since it anchors the joint, and it is usually done before the radial head is dealt with.
3. **Address the radial head:** it is fixed if reconstructable, with screws or a plate, or replaced with a prosthesis when fixation is not possible.
4. **Repair the lateral ligament:** the lateral collateral ligament complex is reattached to the lateral epicondyle with sutures or anchors.
5. **Retest stability:** the elbow is taken through motion again, and if it remains unstable, a temporary hinged external fixator is considered.
6. **Rehabilitate in a hinged brace:** early controlled motion limits stiffness while the repairs heal.

The sequence works from deep to superficial, because a repaired lateral ligament cannot stabilise an elbow whose coronoid is still broken. The surgeon's aim is a joint that moves early without subluxing.

## Where the exam tries to catch you

The triad is a classic setting for choosing the wrong salvage operation.

- **Trap:** excising the radial head to simplify surgery — **Correct:** excision removes a stabiliser and risks proximal migration and recurrent instability in this setting.
- **Trap:** repairing only the radial head and ignoring the coronoid — **Correct:** an unaddressed coronoid fracture leaves the elbow unstable, so it is fixed or sutured.
- **Trap:** immobilising the elbow in plaster for long periods — **Correct:** stiffness is the dominant problem, so early controlled motion in a hinged brace is preferred.

## Frequently asked questions

### What three injuries form the terrible triad of the elbow?

Posterior elbow dislocation, a radial head fracture and a coronoid process fracture together form the triad. Lateral collateral ligament disruption usually accompanies the pattern as well.

### Why is radial head excision avoided in the terrible triad?

Excision removes a key stabiliser of the elbow, increasing the risk of proximal migration of the forearm and recurrent instability. When the radial head cannot be repaired, replacement with a prosthesis is generally preferred.

### What kind of coronoid fracture occurs in the terrible triad?

The terrible triad coronoid fracture is usually a small transverse tip fragment, not the large anteromedial facet fracture of varus posteromedial injuries. Even so, the coronoid buttresses the ulnohumeral joint, so fixing it is a key step in restoring stability.

### How is stability restored in the terrible triad?

Surgeons address the coronoid, the radial head and the lateral collateral ligament in a stepwise sequence, then test stability through the range of motion. A hinged brace allows early controlled motion to limit stiffness.