Elbow dislocation associated with fractures of the radial head and the coronoid process, commonly referred to as the "terrible triad," was initially defined by Hotchkiss in 1996 due to its historically unfavorable outcomes [1,2]. Traditionally, these injuries have required surgical intervention to restore stability and promote early joint movement [3,4]. Surgical approaches typically involve radial head fixation or replacement, lateral collateral ligament repair, and coronoid fracture stabilization when necessary for joint stability [5-7]. However, surgical management is not without risks, which include complications such as limited range of motion, stiffness, heterotopic ossification, nerve damage, infection, and need for reoperation [8,9].

In recent years, nonoperative management of terrible triad injuries (TTIs) has gained increasing attention. While the standard approach has generally favored surgical stabilization, growing evidence suggests that conservative treatment may yield positive results in select patients. However, existing studies on nonoperative TTI management remain limited in several critical aspects: they often include small cohorts, lack consistent inclusion criteria, have variable follow-up durations, and do not clearly define radiographic or clinical thresholds for selecting conservative treatment. Moreover, functional outcomes and complication rates associated with this approach have not been systematically reported in mid- to long-term follow-up studies [10-12]. Given these evolving perspectives on TTI management and the emerging potential of conservative treatment in select cases, this study focuses on patients with TTI who demonstrated concentric reduction and joint stability following closed reduction, with minimally displaced radial head and coronoid fractures, as confirmed by computed tomography (CT). Our aim was to evaluate the clinical and radiographic outcomes of these nonoperatively managed cases over mid- to long-term follow-up. We hypothesized that, in the absence of mechanical block or gross instability, conservative treatment could lead to satisfactory functional results. Through this investigation, we aim to support evidence-based decision-making and clarify criteria for selecting patients suitable for nonsurgical treatment of TTI.

This retrospective study, conducted at Tel Aviv Medical Center, with Institutional Review Board approval (No. 0247-24-TLV), included patients treated conservatively for TTI between 2014 and 2022. Written informed consent was waived due to the retrospective nature of the study.

Patients aged <18 years or with open fractures, multiple traumatic injuries, or pathological fractures were excluded. The dislocations were reduced in the emergency department, with repeat radiographs confirming the reduction. An above-elbow splint cast was applied to stabilize the joint, alleviate pain, and facilitate rest. Post-reduction CT was performed for all patients to evaluate fracture fragment configuration and joint congruency.

The decision to pursue conservative management was based on predefined clinical and radiographic criteria. Conservative treatment was selected when closed reduction achieved a well-aligned elbow, with post-reduction CT confirming concentric joint alignment and minimal displacement of fracture fragments (defined as ≤2 mm of displacement for both radial head and coronoid fractures), without any mechanical block to motion. Clinical assessment included passive range-of-motion testing to evaluate joint stability; cases with recurrent subluxation or palpable instability were excluded [9]. Additionally, conservative management was favored in patients with significant medical comorbidities that increased surgical risk or in those who declined surgical intervention after being informed of the risks and benefits.

Each patient was treated according to a standardized elbow-instability rehabilitation protocol, which included splint removal at the first clinic visit 10 days after the injury. Physiotherapy incorporated full active and active-assisted flexion and extension of the elbow with the forearm in a neutral position, along with forearm rotation (pronation and supination) when the elbow was flexed beyond 90°. Shoulder abduction was avoided to minimize stress on the lateral collateral ligament. Patients were typically evaluated 10 days after injury, at approximately 1 month, and again 1 month later. At each visit, x-rays were obtained, and clinical assessments focused on range of motion, pain, and any additional complaints. By 8 weeks post-trauma, full range of motion was permitted. Following this rehabilitation regimen, stability and function were assessed during subsequent fracture clinic appointments.

The study comprised 39 patients, including 23 men (59%) and 16 women (41%), with a mean age of 44.7±18.3 years (range, 20–82 years). Of these patients, 32 (82%) attended an in-person clinical follow-up. The remaining seven patients (18%) were assessed through structured phone consultations conducted by an independent observer. These consultations collected detailed information regarding pain levels (VAS), complications, rehabilitation progress, and patient-reported functional outcomes. Most participants (87%) were right-hand dominant, with injuries affecting the left hand in 67% of cases and the dominant hand in 41%. The mean follow-up period was 78.5±29.4 months (range, 24–125 months). Regarding occupational status, 29 patients (74%) were engaged in office work, whereas 10 (26%) performed physical labor. The average time to return to work was 2.8 months (range, 1–6 months), though one patient (3%) was unable to resume their prior occupation. Falls were the most common mechanism of injury (46%), followed by scooter accidents (36%) and other causes (18%), including pedestrian and sports injuries, stair falls, and vehicular accidents.

Fractures were classified as Mason type 1 (36%), type 2 (54%), or type 3 (10%) and Regan-Morrey type 1 (69%), type 2 (28%), or type 3 (3%) (Figs. 1 and 2). Concurrent fractures occurred in 20% of patients, with six involving the capitellum (15%) and one affecting each of the medial and lateral epicondyles (3% each). Demographic and clinical data are summarized in Table 1.

The mean duration of physiotherapy was 6.8 months (range, 1–18 months). The final range of motion averaged 128.2°±8.4° of flexion (range, 100°–140°), with a mean extension deficit of 8.2°±7.9° (range, 0°–30°). Forearm rotation was 85.1°±6.5° (range, 70°–90°) of supination and 86°±5.2° (range, 75°–90°) of pronation.

An assessment of functional outcomes using the MEPS confirmed 11 patients attained excellent results (>90), 19 attained good results (75–89), and nine attained fair outcomes (60–74). The mean DASH score was 12.6±12.1 (0–38), while the average pain VAS score was 2.13±2.08 (range, 0–7). Patients reported a mean subjective functional level of 87.9%±10.9% (range, 60%–100%) comparing their injured elbow to the uninjured one.

Radiographic evaluation revealed posttraumatic degenerative changes in eight patients (20.5%). Of these, seven demonstrated grade 1 degenerative changes according to the Broberg and Morrey classification [17], while one patient exhibited grade 2 changes. None of these cases required surgical intervention; however, in the patient with grade 2 changes, nonunion of the coronoid process was also observed. This patient, a 66-year-old woman with an injury to her dominant right elbow, remained asymptomatic at final follow-up, with full range of motion and no functional complaints.

Mechanical clicking was observed in 16 patients (41%), including two from the surgical subset (Table 2). Of the total patients in the study, six were initially recommended to receive surgical treatment but chose to proceed with nonsurgical management. However, three of these patients eventually required surgery and underwent heterotopic ossification resection, removal of radial head fragments, or radial head replacement, respectively. All six patients had Regan-Morrey type 1 fractures, which were further categorized as one Mason type 3, three Mason type 2, and two Mason type 1 fractures. None of these patients had pre-existing medical conditions.

Overall, five patients (13%) who were initially treated conservatively ultimately required surgical intervention. The patients requiring surgery were included in the cohort but excluded from the final functional outcome analysis. One patient underwent complete radial head excision at another institution 6 months after injury for a Mason type 3/Regan-Morrey type 1 fracture. Two additional patients underwent excision of a large radial head fragment, one a Mason type 2/Regan-Morrey type 1 and the other a Mason type 2/Regan-Morrey type 2 fracture, while preserving more than 70% of the radial head. Additionally, one patient underwent radial head arthroplasty 7 months post-injury for a Mason type 3/Regan-Morrey type 1 fracture. Finally, one patient required heterotopic ossification excision 10 months post-injury for Mason type 1/Regan–Morrey type 1 fracture. Their outcomes were largely comparable to those of patients who did not undergo surgery. The mean final elbow flexion was 125°, with a mean extension deficit of 8°. Supination and pronation averaged 88° each. Functional assessment revealed one excellent, three good, and one fair MEPS scores. The mean DASH score was 12.6, and the average VAS pain score was 2.2. Subjective satisfaction rates, compared to the uninjured elbow averaged 88%, and all patients in this subgroup returned to work.

The principal findings of this study are that nonoperative management of TTI can yield generally satisfactory functional outcomes in carefully selected patients. Most of the cohort demonstrated favorable results, with the majority returning to work and reporting minimal pain or functional impairment. Despite these positive outcomes, several complications were observed, including delayed surgical interventions in five of 39 cases (12.8%). Notably, mechanical clicking was present in 41% of patients, though it did not appear to significantly impact function. Additionally, posttraumatic degenerative changes were observed in 20.5% of patients, but none required surgical treatment.

The optimal management strategy for TTI of the elbow remains a subject of ongoing debate in orthopedic trauma. While surgical intervention has traditionally been considered the standard of care, our findings suggest nonoperative treatment as a viable option for carefully selected patients. The present study, which represents one of the largest series examining conservative management of TTIs with extended follow-up, was designed to evaluate functional outcomes, complications, and need for delayed surgical intervention in patients treated nonoperatively. Understanding these outcomes is particularly relevant given the complex nature of these injuries and the potential complications associated with both operative and nonoperative approaches.

The published literature on conservative management of TTI is sparse, consisting of only three small studies. Chan et al. [19] demonstrated the viability of nonoperative treatment for selected TTI cases, reporting good functional outcomes and stable elbow range of motion in their series of 11 patients. While radiographic changes suggesting arthritis were noted, none required intervention during the follow-up period. More recently, Baker et al. [10] studied 19 patients and found that nonoperative treatment could achieve satisfactory outcomes when properly managed. These studies emphasized maintenance of coronoid reduction and joint congruency as key factors for success, regardless of radial head fracture severity. Similarly, Najd Mazhar et al. [12] evaluated 10 patients and supported selective nonoperative management for acute cases, particularly in those with significant comorbidities or declining surgery; however, they noted limitations in rotational motion and potential posttraumatic arthritis, highlighting the need for larger long-term studies.

Our larger cohort allows more robust conclusions while generally supporting the findings of these earlier works. As detailed in Table 3, the demographic characteristics across studies show some variations, with our cohort demonstrating a more balanced sex distribution (59% male) compared to that of Najd Mazhar et al. [12] (90% male) but similar to that in Baker et al. [10] (63% male). Regarding functional outcomes, our results demonstrate the viability of conservative treatment. The mean range-of-motion parameters achieved in our cohort were comparable to those in previous studies, with our reported flexion value (128°) similar to those noted by Baker et al. [10] (131°) and Chan et al. [19] (134°). The extension deficit in our series (8.2°) was notably consistent with the findings of Baker et al. [10] (8°) and Chan et al. [19] (6°) and slightly better than that of Najd Mazhar et al. [12] (11°). Excellent recovery in rotational motion (supination and pronation) was seen across all studies, with our patients achieving means of 85° and 86°, respectively.

The rate of delayed surgery in our series (12.8%) was between previously reported rates (0%, Baker et al. [10]; 18%, Chan et al. [19]), suggesting a relatively consistent failure rate for conservative management. Patients who eventually required delayed surgical intervention achieved functional outcomes comparable to those managed nonoperatively throughout. This suggests that, in select cases, an initial nonoperative approach remains reasonable, as delayed conversion to surgery does not appear to compromise results. However, our study identified a higher incidence of mechanical clicking (41%) compared to previous reports (5.3%–20%), which may reflect more detailed follow-up or different assessment criteria. Return-to-work outcomes in our study and that by Najd Mazhar et al. [12] showed similar time frames (2.8 vs. 2.4 months), with a lower rate of patients unable to return to work in our cohort (2.6% vs. 10%). This suggests that conservative management can facilitate successful occupational reintegration in most cases.

Functional scores, while measured using different tools across studies, consistently indicate good to excellent outcomes. Our MEPS results suggest that 77% of patients had excellent or good outcomes, although this is slightly lower than the 100% of patients reported by both Najd Mazhar et al. [12] and Chan et al. [19]. The mean DASH score in our series (12.6) was higher than those in previous studies (4.76–8), potentially reflecting our larger and more diverse patient population. Among patients with fair outcomes, the majority was young men with low-energy injuries. Although functional limitations and ongoing pain were reported in some cases, return to work was generally achieved. Only one patient required secondary surgery for heterotopic ossification. Importantly, no consistent radiographic abnormalities were observed early in the course that could have reliably predicted poorer results. These findings suggest that, while most patients recover satisfactorily with conservative management, further studies are needed to better identify early risk factors for suboptimal recovery.

Building on previous research and our experience, we propose refined selection criteria for nonoperative management of TTI. The essential prerequisites include stable joint congruity after closed reduction, minimal fracture displacement, and absence of mechanical blocks to motion, all of which are verified by post-reduction CT. However, several critical factors warrant consideration. The assessment of joint stability in the acute setting can be challenging due to pain-related muscle guarding and post-injury swelling that may mask underlying instability, as noted by Waterworth et al. [9]. This observation is supported by our finding that 13% of patients required subsequent surgical intervention despite meeting initial stability criteria. Furthermore, radial head fracture severity was a key determinant of conservative management success, with our data revealing that patients with Mason type 2 or 3 fractures may experience greater benefit from primary surgical intervention. Patient-specific considerations, including functional demands, rehabilitation compliance, and medical comorbidities, also influence treatment outcomes. While our cohort demonstrated successful conservative management across ages 20–82 years, suggesting that age alone should not determine treatment choice, decisions should be based on a comprehensive evaluation of fracture patterns, joint stability, and individual patient factors. We advocate for a structured follow-up protocol with regular clinical and radiographic assessments during the initial 12 weeks to identify early treatment failures and enable timely intervention when needed. Patient education about potential complications and the possibility of delayed surgery is crucial for appropriate expectation management.

In this study, scooter accidents accounting for 36% of total TTIs is particularly noteworthy when considered alongside previous research on such trauma. Prior studies have identified radial head fractures as the most common upper-extremity fracture pattern in e-scooter accidents [20]. Our results suggest that such radial head injuries might, in some cases, present as part of a more complex injury pattern. The relatively high percentage of e-scooter–related injuries in our study likely reflects our urban setting, which has extensive shared e-scooter services and high adoption rates of this transportation mode. Understanding this relationship could have significant implications for both injury-prevention strategies and clinical management protocols.

These findings collectively support the role of conservative management in appropriately selected TTI cases. Our larger cohort validates previous smaller studies while providing new insights into the expected outcomes and potential complications. The consistent achievement of functional range of motion and a high rate of return to work across studies suggests nonoperative treatment as a viable primary treatment strategy for many patients with TTI.

This study has several limitations. Its retrospective design introduces potential selection and recall biases. The absence of a surgical control group limits the ability to directly compare outcomes between operative and nonoperative treatments. Although functional scores (MEPS, VAS) were patient-reported and, therefore, less affected by observer bias, radiographic assessments are still subject to interobserver variability. However, predefined criteria for grading posttraumatic arthritis were used to enhance consistency. A subset of patients was followed via phone consultations; while key outcome measures and complication data were reliably collected, the lack of physical examinations might have limited full clinical evaluation. Furthermore, although all patients underwent routine radiographs and had imaging available for at least 2 years post-injury, the mean follow-up was 78.5 months, which might be insufficient to capture the full extent of degenerative changes in some cases. Additionally, due to the long follow-up period and varying injury timelines, discrepancies existed in the timing of radiographic, clinical, and phone assessments, which may introduce variability in interpreting clinical and radiographic outcomes.

This study suggests nonoperative management of TTI as a viable option for carefully selected patients, yielding generally satisfactory functional outcomes and an acceptable rate of complications over the medium term. While most patients experienced favorable results, some complications, including delayed surgical interventions and persistent mechanical symptoms, were noted. These findings contribute to the growing body of literature on TTI, which has been limited by small sample sizes and shorter follow-up periods.