Non-operative management of terrible triad injuries of the elbow; not so terrible?

Abstract

Terrible triad injuries (TTIs) of the elbow have traditionally been reported to have poor outcomes, hence requiring surgical stabilisation. We identified and reviewed patients with TTIs treated non-operatively within our department. We retrospectively reviewed patients with TTI treated non-operatively with standardised elbow-instability rehabilitation from 2010 to 2020. We used Mason and Morrey classifications for radial head and coronoid fractures, respectively. Non-operative indications included a congruent joint on CT, significant co-morbidities pre-disposing to high-risk surgery and/or patient preference. Outcomes included Oxford Elbow Score (OES), ROM and complications. Nineteen patients were included (mean age 49; 37% female). At an average of 6 years (range 2-11 years) post-treatment, mean OES was 46 ± 7. At last clinic review, mean 6 months (2-15), average ROM was 131 ± 11° flexion, 8 ± 10° extension, 85 ± 12° supination and 85 ± 13° pronation. One patient required arthrolysis and another had an incongruent ulnohumeral joint which developed clicking with a functional ROM. Our report suggests non-operatively managed and appropriately rehabilitated TTI injuries can achieve good function and ROM. We recommend conservative management as a viable option in cases with joint congruency and no mechanical block in patients with significant co-morbidities or those refusing surgery but patients must be assessed on a case-by-case basis.