Terrible Triad 

Introduction:

Terrible Triad is recognized term in orthopedic trauma, describing a specific, highly unstable injury pattern of the elbow.

Definition:

Terrible Triad is defined by the simultaneous occurrence of three distinct injuries:

1. Posterior elbow dislocation.
2. Fracture of the radial head.
3. Fracture of the coronoid process of the ulna.

Cause:

• This injury typically results from high- level trauma.
• The impact forces the radius and ulna posteriorly relative to the humerus , leading to dislocation and the characteristic fractures.
• The most common mechanism is a fall on outstretched hand with the elbow extended.

Clinical Features:

• Severe instability of the elbow joint.
• It frequently results in soft tissue damage and ligamentous injury, particularly to the lateral collateral ligament (LCL) complex.
• Joint line tenderness on palpation.
• Popping sensation on immediate injury.

Sign & Symptoms:

• Visible deformity of the elbow.
• Significant swelling around the joint.
• Severe pain localized to the elbow.
• Locking with elbow in extension.
• Inability or extreme difficulty in moving the elbow(restricted ROM)
• Palpable instability of the joint.

Physiotherapy Management:

• Early Immobilization (Post-surgery): Following surgical stabilization, the elbow is typically immobilized for a short period. Throughout the immobilization phase, wrist and shoulder function should be maintained through strengthening exercise.
• Gradual Mobilization: After the immobilization phase physiotherapy begins with gentle AROM and PROM exercise in a pain- free range targeting the entire upper limb.
• Pain and Swelling Management: Various modalities like ice, compression and elevation are used to reduce pain and swelling.
• Strengthening Exercises: Strengthening exercises for the muscles surrounding the elbow (biceps, triceps, and forearm muscles) are incorporated to enhance dynamic stability and functional strength.
• Patient Education: Crucially, patients are educated on proper body mechanics, activity modification, and the importance of adherence to their exercise program to prevent setback.
• Proprioceptive Training: Exercises that improve joint position sense and improve joint position sense and coordination are crucial for regaining fine motor control and reducing the risk of re-injury.

Conclusion:

Terrible Triad represents a critical orthopedic emergency requiring specialized care. It is important to explore the level of severity and degree of complication associated with each posterior elbow dislocation since this dictates the patient’s prognoses.