The Terrible Triad refers to a fracture of the Radial Head and Coronoid Process, and Dislocation of the elbow. There aren't too many things in medicine and especially Orthopedics where the diagnosis has the word "terrible" in it. There's a good reason for this, and that's because this is a SERIOUS injury that often leads to suboptimal results, even with proper treatment.
Radial Head is the end of the Radius bone (one of the two forearm bones) where it meets the elbow, and is located on the outside part of the elbow. It is an important bone to help transmit force from the hand to the elbow, to help with rotation of the elbow, and also contributes to elbow stability. It is often fractured from a fall with an outstretched hand, transmitting force from the hand, up the wrist and forearm, and eventually breaking the Radial head.
Pain and swelling on the outside part of the elbow and even gross instability can be felt with range of motion of the elbow and especially with rotation of the forearm or weightbearing on the elbow such as when trying to do a pushup or getting up from a chair by pushing up on the armrests with your arms. Patients may feel pain not only on the outside part of the elbow, but also on the inner portion of the elbow, the forearm, and the wrist.
On physical examination, there is typically localized tenderness over the Radial head, which is just past the Lateral Epicondyle (bony prominence on the outside part of the elbow), and significant pain with forearm pronation and supination (rotation of the forearm).
X-rays are normally ordered to determine whether there is a fracture and or other associated injuries. If the fracture pattern needs further investigation, a CAT Scan may be ordered, especially in those fractures that involve the joint. Also, an MRI may be ordered to help work up soft tissue and other pathology.
Radial head fractures that have less than 2 mm of step off at the joint, or have less than 30 degrees of angulation, and do not have a mechanical block to range of motion can often be treated non-operatively. Depending on the presumed amount of stability and other associated injuries as well as how much pain the patient is in, this might entail a brief stint of immobilization in a sling or even a splint. In general, range of motion of the elbow and physical therapy will usually be encouraged as soon as possible in order to minimize the amount of stiffness that may occur from this injury. However, it is important for the patient to understand that even though movement is encouraged, the use of the arm beyond this such as lifting more than the weight of a mug and weight bearing on the arm is definitely not recommended and may jeopardize the fracture reduction.
In general, it can take at least 6-8 weeks for the bone to heal, and an additional 6-8 weeks of physical therapy for the elbow to regain functional range of motion and use.
Surgery is carefully recommended based on a number of different variables, but is usually indicated for fractures that are displaced more than 2 mm at the joint, for angulation greater than 30 degrees, and especially in those who experience a significant loss of motion. Various treatment options are available in our armamentarium to fix Radial Head fractures, and includes plates, screws, and pins.
Elbow surgery is an area requiring special expertise in order to master because some elbow surgery is typically performed by hand surgeons, and others by sports surgeons, yet neither of them typically do a large quantity of elbow surgery. Dr. Steven Lee is uniquely fellowship trained in both hand/upper extremity surgery as well as sports medicine, and has is one of the most experienced orthopaedic surgeons for elbow surgery in NYC. He also regularly instructs courses teaching other orthopaedic surgeons how to perform this operation. Learn more about scheduling surgery.
All surgical patients are immediately immobilized in a non-removable splint from above the level of the elbow to the hand for 7-10 days following surgery. During this time, patients are encouraged to elevate their hand above their heart, keep their dressings clean and dry, and to move their fingers. Patients are allowed to use their fingers to text and type, but not to lift anything heavier than a cup of coffee or that which causes them more than a 2/10 pain level.
Patients will then be transitioned into a locked elbow brace and wrist immobilizer for 3-6 weeks. Depending on the stability of the fracture after it is fixed, the patient will be required to start occupational therapy (OT) as soon as possible to regain back strength and mobility. The fracture typically takes at least 6-8 weeks to heal, and therapy is often needed for at least 6 weeks.
Of note, the elbow is a particular area that can often become stiff with any trauma, including and especially Radial Head fractures, even when surgery is not required. The combination of trauma, surgery, and immobilization are all independent factors that cause stiffness, and therefore it is almost expected, even with optimal treatment with meticulous surgery and strict adherence to physical therapy protocols. It will be important for the patient to be very attentive to their instructions throughout the course of treatment to optimize the results.
Immediate Post-Operative Instructions
Please refer to the following pages for more information:
*It is important to note that all of the information above is not specific to anyone and is subject to change based on many different factors including but not limited to individual patient, diagnosis, and treatment specific variables. It is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopedic advice or assistance should consult Dr. Steven Lee or an orthopedic specialist of your choice.
*Dr. Steven Lee is a board certified orthopedic surgeon and is double fellowship trained in the areas of Hand and Upper Extremity Surgery, and Sports Medicine. He has offices in New York City, Scarsdale, and Westbury Long Island.