Orthopaedics & Traumatology: Surgery & Research (2010) 96, 147—154
Terrible triad injury of the elbow: How to improve
B. Chemama, N. Bonnevialle, O. Peter, P. Mansat∗, P. Bonnevialle
Orthopaedics-Traumatology Department, Toulouse-Purpan university hospital, place du Dr-Baylac, 31059 Toulouse, France
Accepted: 3 November 2009
Introduction: Dislocation of the elbow joint combined with fractures of the radial head and
ulnar coronoid process is referred to as Terrible Triad Injury (TTI). The purpose of this study is to
report our experience in the management of this specific injury and to validate the therapeutic
choices of our treatment.
Material and methods: Between 1996 and 2006, 23 TTI in 22 patients were treated in our
department. Fifteen males and seven females of mean age 46 years were included in this series.
Internal fixation of the radial head was performed in 13 cases and arthroplasty in four. Fractures
of the coronoid process were managed by surgical fixation in 10 cases. All torn ligaments were
reconstructed which include 19 lateral and six medial ligament reconstructions.
Results: Thirteen patients (14 elbows) were reviewed at a mean follow-up of 63 months, four
patients at a mean follow-up of 11 month (range, 6 to 18 months), and five patients were lost
to follow-up. All patients had stable elbow joint and in 90% of the cases, patients reported
mild or no elbow pain. The arc of extension—flexion ranged from 18 to 127◦, while the average
arc of pronation—supination was 134◦. The mean Mayo Elbow Performance Score was 87. Only
one patient suffered from osteoarthritis 8 years after trauma and all elbows were centred on
X-rays. Negative prognosis factor was associated with Mason type 3 radial head fractures.
Discussion and conclusion: The principle of the surgical management is based on two main
objectives: restoration of bony stabilizing structures (radial head and coronoid process) and
lateral collateral ligament reconstruction. A medial surgical approach is recommended in the
case of persistent posterolateral instability following lateral collateral ligament reconstruction
or when fixation of a large coronoid process fragment is indicated. The use of an external
fixator is only advocated in case of persistent instability following the reconstruction of bony
and ligamentous structures.
Level of evidence: Level IV: Retrospective study.
© 2010 Elsevier Masson SAS. All rights reserved.
∗Corresponding author. Tel.: +33 5 61 77 21 39; fax: +33 5 61 77 76 17.
E-mail address: firstname.lastname@example.org (P. Mansat).
1877-0568/$ – see front matter © 2010 Elsevier Masson SAS. All rights reserved.
148 B. Chemama et al.
Posterolateral dislocation of the elbow joint is the most
common acute traumatic elbow instability and occurs sec-
ondary to a traumatic valgus elbow instability, forearm
supination and axial compression [1,2]. Such traumatism will
induce damages to the radial collateral ligamentous com-
plex extending to the capsule and up to the ulnar collateral
ligament compartment . Early treatment will positively
affect the outcome .
Complete dislocation of the elbow joint associates
ligament damages with radial head, coronoid process,
oleocranon or epicondyle fractures. The ‘‘terrible triad
injury’’ of the elbow, as named by Hotchkiss, is the com-
bination of an elbow dislocation, a radial head fracture and
a coronoid process fracture The main objective in the man-
agement of such injuries is to restore the stabilizing bony
structures of the elbow to convert a complex dislocation of
the elbow joint into a simple one. However, proper identi-
fication of these lesions is quite demanding and their early
management is a favourable prognostic factor for final out-
The principles of this treatment were detailed by McKee
et al.  as well as Ring et al. , however relatively few
clinical reports are available in the literature. The purpose
of that study was to report our experience in the treatment
of this specific pattern of injury in order to precise its ther-
apeutic and diagnostic aspects and evaluate the quality of
Patients and methods
Over a 10-year period, between 1996 and 2006, 22 patients
sustaining an elbow dislocation with associated radial head
Figures 1 and 2
radial head (type 2) and coronoid process (type 2) fractures.
Lateral (Figure 1) and A/P (Figure 2) radiographs of a posterolateral dislocation of the elbow joint with associated
and coronoid process fractures were enrolled in the study
and their clinical results were retrospectively assessed.
This series included 15 males and seven females of mean
age 46 years (range, 26 to 75 years) at the time of trauma.
One of the patients sustained a bilateral injury; therefore,
23 terrible triad injuries were evaluated.
Seven patients had sustained the initial trauma during a
road traffic accident, five during a fall from bicycle, four
after a fall from height, three during a sport accident and
three after a fall of mechanical origin. All patients were
early evaluated. All dislocations were closed injuries and no
included A/P and lateral radiographs of the elbow to rule out
associated bony pathology.
In all cases, it was a posterolateral dislocation of the
elbow joint with associated fractures of the radial head and
coronoid process of the ulna. Fractures of the radial head
were graded according to the Mason classification as mod-
ified by Johnson : type I: non-displaced fractures; type
II: non-comminuted displaced fractures; type III: commin-
uted fractures. Our series included two type I fractures, nine
type 2 II fractures, 10 type III fractures and two radial neck
Fractures of the coronoid process were graded according
three different types of fractures: Type I: Avulsion of the tip
of the bone, type II: detached fragment of less than 50% of
the coronoid process; type III: detached fragment of more
than 50% of the coronoid process. According to this clas-
sification, there was 16 type I fractures and seven type II
fractures. No type III fractures were reported (Figs. 1 and 2).
Early surgical reconstruction was performed in all patients,
after fracture reduction, under general anaesthesia and
Terrible triad injury of the elbow: How to improve outcomes? 149
radial head and reconstruction of the radial ligamentous complex through a lateral surgical approach, and osteosynthesis of the
coronoid process and reconstruction of the ulnar ligamentous plane via a medial surgical approach.
Radiographic results at one postoperative year, after dislocation reduction of the elbow joint, osteosynthesis of the
image intensifier, stability was then assessed. In all cases, a
lateral surgical approach was carried out through the Kocher
interval, between the extensor carpi ulnaris and anconeus
muscles. The lateral approach was associated with a medial
approach in nine cases, thus providing better access to the
coronoid process and the ulnar collateral ligament. In two
cases, an anterior transbrachial surgical approach accord-
ing to Ameur et al.  was associated for osteosynthesis
of the coronoid process. No posterior surgical approach was
Surgical exploration revealed a persistent damage to the
radial ligaments, which were disinserted from the humerus
in all case. Six out of the nine cases with medial surgical
approach had an injury to the ulnar collateral ligament of
Osteosynthesis of the radial head was performed in 13
cases, which included seven type II fractures, four type III
fractures and two radial neck fractures. Fixation was car-
ried out using small-sized 2.0mm diameter screws in all
cases, except for both radial neck fractures which fixation
was performed using two small T-plates. Among the four
cases of non-reconstructible type III fractures, a modular
and bipolar radial head prosthesis (GUEPAR - DePuy) was
placed in three cases and a monoblock metal prosthesis
(Swanson—Wright Medical) was placed in 1 case. In four type
III fractures, the radial head was resected. Two resections
were partial (<30%) and two were complete. Both complete
resections resulted in instability of the humeroulnar joint,
thus requiring the insertion of a stabilizing humeroulnar
Regarding the coronoid process, 10 type I fractures were
neglected. Ten other patients were managed with osteosyn-
thesis performed via the lateral approach in three cases,
the medial approach in five and the anterior approach
in two. Among these patients, five had a type I fracture
which was secured using transosseous sutures tied over the
oleocranon in three cases (one lateral approach, two medial
approaches) and reinsertion with absorbable anchors in two
cases (one lateral approach and one medial approach).
Five other patients sustaining a type II fracture underwent
an osteosynthesis featuring an anteroposterior anterograde
screw system in four cases (one lateral approach, one medial
approach and one anterior approach) or an anteromedial
plating system through a medial approach in one case.
Finally, resection of the coronoid fragment was performed
in three cases (one type I and two type II fractures) (Fig. 3).
All damaged radial and ulnar collateral ligaments were
reconstructed via a transosseous suture repair according
to the technique of Osborne and Cotterill  or using
absorbable anchors (Table 1).
The elbow was maintained in a static orthosis at 90◦of
flexion, for 15 days. In the case of isolated suture of the
radial collateral ligament, the forearm was placed in prona-
tion. When associated with suture of the ulnar collateral
ligament, the forearm was placed in the neutral position.
After 15 days, a hinged orthosis was applied allowing a
flexion—extension and pronosupination rehabilitation pro-
tocol to be initiated with maximum extension limited to
30◦during a 4-week period after which the orthosis could
be definitely removed. Early active mobilization was initi-
ated on the 15th day and consisted of flexion—extension
exercises, to recruit the dynamic stabilizers of the elbow
joint. This mobilization was performed with the forearm
in pronation to protect the lateral ligamentous structures.
Active pronation and supination movements were allowed
with the elbow placed in 90◦of flexion. Up to 6 weeks,
maximum extension was limited to 30 or 60◦according
to the elbow stability assessment performed after reduc-
tion, and to prevent the risk of dislocation. Once complete
healing was achieved, active maximum range of motion
exercises were initiated through physical postures. A mus-
B. Chemama et al.
Presentation of the reviewed patients from the series.
Age Gender Follow-up
Trauma RH CR Surgical
Treatment RH Treatment CR MEPS Ext-Flex (in
Fall from height
Fall from Height 3
Fall from height
Lat & med. Screw
Med & Lat
Lat & Med.
Lat & ant
Lat & Med
fix (3 weeks)
13 41F 24Fall31 LatPartial
14 44M5Fall from height21 LatOrthopaedic 85
M: male; F: female; RH: radial head fracture ; CR: fracture of the coronoid process ; Lat: lateral; Med: medial; Ant: anterior; MEPS: Mayo Elbow Performance Score ; P/S:
pronation/supination; Rev: revision; osteoarthritis: 0: no osteoarthritis; 1: osteoarthritis; RTA: road traffic accident.
Terrible triad injury of the elbow: How to improve outcomes? 151
cular rehabilitation protocol was initiated at 3 months
post-trauma to strengthen the periarticular stabilizing mus-
Method of evaluation
Thirteen patients (14 elbows) were reviewed at a mean
follow-up of 63 months (range, 15 to 128 months) and
were clinically and radiographically evaluated. Four other
patients were evaluated by telephone at a mean follow-up
of 11 months (range, 6 to 18 months) and sent their radio-
graphic for assessment. Five patients were lost to follow-up.
Patients were clinically assessed according to the Mayo
Elbow Performance Score, on the basis of pain, mobility,
ment of the elbow, based on A/P and lateral views, was also
performed at last follow-up.
A single early complication was reported in a 44-year-old
patient demonstrating a persistent instability in the sagit-
tal and frontal plane, after osteosynthesis of a type II radial
head fracture and reinsertion of the lateral collateral lig-
ament. The associated type I coronoid fracture had been
ignored. An isolated lateral approach was performed. At one
month, this persistent instability required surgical revision
performed through a medial approach and revealing a disin-
serted ulnar collateral ligament, which was then repaired.
An external fixator was applied at the end of the operation
to secure the whole reconstruction.
A late complication was reported in a 47-year-old patient
who had sustained a type III radial head fracture and type
I coronoid fracture. A Swanson metal radial head prosthe-
sis had then been implanted through a lateral approach.
Six month later, the implant had to be removed due to the
patient complaining of severe pain on the lateral column. An
anterior arthrolysis was associated with prosthesis removal.
Six month later, an ulnocarpal impingement was reported,
due to the inversion of the distal radioulnar index, thus
requiring an ulnar shortening osteotomy.
The mean Mayo Elbow Performance Score, evaluated in 13
were classified as excellent in four elbows and good in 10.
Eleven patients had no pain while seven reported mild pain.
None of the patients suffered from severe pain. Mean flexion
at last follow-up was 127◦, ranging from 90◦to 140◦. Mean
extension loss was 18◦, ranging from 0◦to 80◦. Mean prona-
tion was 70◦(range, 30◦to 85◦) while mean supination was
64◦(range, 30◦to 80◦). The poorest results regarding prono-
supination were found in patients with type III radial head
fractures and a mean mobility arc of 60◦in pronation and
ciated radial head (type 3) and coronoid process (type 1)
Posterior dislocation of the elbow joint with asso-
50◦in supination. Elbows were stable in flexion—extension
and varus—valgus in all cases.
A/P and lateral radiographs were systematically performed
in all reviewed patients and in those evaluated by telephone
(18 elbows). All elbows were well centred on radiographs
(Figs. 4 and 5). Only one patient had osteoarthritis of the
humeroulnar joint. This patient had previously reported
signs of ulnocarpal impingement following the removal of his
radial head prosthesis. Eight years after the trauma, he com-
plained of anterior and medial pain. Radiographs confirmed
a narrowing of the humeroulnar joint space.
Terrible triad injuries of the elbow have been individualized
by Hotchkiss in 1996 as a clinical entity . This uncom-
mon injury accounts for only 10% of all radial head fractures
according to the epidemiological study of Van Riet et al.
. In the GEEC 2008 multicenter study, Pierrart et al.
report an incidence of 26 out of 229 dislocations of the
elbow joint (11%) . Associated lesions represent a signifi-
of the elbow joint should be systematically considered as
a terrible triad injury unless otherwise proven, since lack
of knowledge of this clinical pattern of injury might be
detrimental to elbow function. Once reduction has been
achieved, a CT scan assessment should be systematically
performed to investigate the associated bone lesions and
plan the most adapted therapeutic management [1,5,7,15].
Surgicaltreatment is highly
orthopaedic management should be avoided due to the high
instability of this condition. The principle of that surgical
management is based on two main objectives: Restoration
of bony stabilizing structures (radial head and coronoid
process) and radial collateral ligament repair [3,6,7,15].
The first series published about fracture-dislocation
of the elbow joint only reported radial head fractures
152 B. Chemama et al.
was replaced with a prosthesis and the coronoid process fracture was neglected.
Radiographic results at 4-year follow-up on an A/P (A) and lateral (B) view and a 45◦oblique view (C); The radial head
[9,16,17]. After dislocation reduction, many authors advo-
cate early complete excision of the radial head. However,
Broberg and Morrey , as well as Josefsson et al. ,
underline the risk of instability and osteoarthritis when
resorting systematically to that treatment option. In the
French literature, Heim  reports the results of the Swiss
experience about the management of fractures occurring in
the elbow region: Severe osteoarthritis and valgus instabil-
ity are the most common terrible triad injury complications
after isolated resection of the radial head. More recently,
Ring et al.  in 2002 have published the results of a
series of 11 patients having sustained a terrible triad
injury of the elbow, and reviewed at a mean follow-up
of 7 years. Complete resection of the radial head was
performed in four patients while lateral collateral liga-
ment was left unrepaired in three patients. Among the 11
patients, five reported a recurrent instability, four out of
which occurred after radial head excision. Seven patients
developed osteoarthritis of the humeroulnar joint at last
follow-up. The authors advocate systematic reconstruction
of the radial head, coronoid process and lateral ligament
complex to reduce complications. In our series, four radial
heads were resected: two partial resections of less than 30%
of the articular surface, with no effect on stability and two
complete resections resulting in intraoperative instability
requiring additional stabilization with humeroulnar pinning.
Therefore, it is now well admitted that type II radial head
fractures and, as long as it is possible, type III fractures
should be preserved and treated with osteosynthesis in case
of terrible triad injuries of the elbow. Non-displaced type
I fractures may be left untreated. However, type III non
reconstructible radial head fractures should be managed
with arthroplasty for proper reconstruction of the lateral
stabilizing column as advocated by several authors [19—22].
The coronoid process is the key element in the humer-
oulnar joint stability. According to the work of Morrey et
An , 50% of the height of the coronoid process is nec-
essary to ensure humeroulnar sagittal stability. In terrible
triad injuries of the elbow, most coronoid process fractures
are type I fractures as confirmed by the series of Doornberg
et al.  and Pierrart et al. . Such fractures may be
neglected even if some authors recommend capsular rein-
sertion via anchors with possible excision of the fragment,
or a retrograde suture repair tied over the oleocranon. Type
II and III fractures require stable osteosynthesis with screws
or plate. Osteosynthesis might be performed through a lat-
eral approach after radial head resection, or via a medial or
an anterior approach. Armstrong  and Ring et al.  advo-
cate the use of a single posterior approach for easier access
to the lateral and medial columns. In our series, 10 type
I fractures were ignored and five were secured via sutures
or anchors. Two type II fractures were screwed through a
medial approach, two through an anterior approach and the
last one via a lateral approach. In the GEEC 2008 series ,
13 out of 14 type I fractures were neglected along with two
type II fractures. Only a single type I fracture was sutured
and two type III fractures were screwed.
Reinsertion of the lateral ligament complex in the man-
agement of elbow joint instabilities was first described by
Osborne and Cotterill . In their series, McKee et al. 
report a disinsertion of the radial ligament complex in 100%
of the cases which is confirmed in our study. Amstrong 
also report a similar incidence of this ligamentous lesion
and recommend transosseous suture of the ligament. Since
this ligament is isometric, a careful reinsertion should be
performed at the centre of rotation of the elbow, which
corresponds to the centre of the lateral epicondyle, to pre-
vent the occurrence of any varus or posterolateral instability
Systematic approach of the ulnar ligament complex
remains constroversial. Pugh et al.  have recently pub-
lished the results of the management of 36 terrible triad
injuries. An isolated lateral approach was used in 26 of
the cases. Osteosynthesis of the coronoid process was per-
formed first using sutures in type I fractures, retrograde
screwing in type II and type III fractures. Radial head fixa-
tion was performed in 16 cases and arthroplasty in 20 cases.
After reconstruction of the lateral ligament complex, sta-
bility of the elbow was evaluated in flexion—extension. In
the absence of any instability, the medial approach was
not performed. In case of instability, a medial approach
was chosen for reconstruction of the ligament complex
and an external fixator was placed in some patients. The
authors advocate a systematic lateral approach, fixation of
Terrible triad injury of the elbow: How to improve outcomes? 153
the coronoid process and osteosynthesis or replacement of
the radial head. A medial approach should be performed
only in case of persistent sagittal instability after recon-
struction of bony structures and radial collateral ligament.
According to the authors, isolated valgus instability in the
coronal plane does not systematically require medial collat-
eral ligament repair insofar as the elbow remains stable in
flexion—extension. This correlates the findings of Amstrong
. In our series, six out of nine elbows treated through
a medial approach reported damages to the ulnar collat-
eral ligament. In all patients, the medial surgical approach
was selected in the presence of persistent flexion—extension
instability and/or significant valgus instability after recon-
struction of the lateral structures: the radial head and radial
collateral ligament. The objective is to achieve sagittal sta-
bility through the useful arc of motion from 30◦to 130◦of
If instability persists despite repair of the medial liga-
ment complex, an external fixator should be placed on the
elbow. Cobb and Morrey , along with McKee et al. ,
have underlined the interest of external fixation in the treat-
ment of complex elbow traumatisms. More recently, Zeiders
et al.  have recommended the use of the external fix-
ator in the case of insufficient stability to allow complete
mobilization after reconstruction of bony and ligamentous
structures. These standard hinged external fixators are cen-
tred on the elbow centre of rotation. The various authors
point out the importance of ensuring proper elbow stability
while protecting osteosyntheses and ligament repairs. The
external fixator allows early mobilization within a protected
range of motion to reduce the risk of secondary stiffness
[14,29—31]. The external fixator may also be used during
surgical revisions in the management of persistent instabil-
ity, as it was the case in our series. In our series, two cases of
instability were observed after resection of the radial head
requiring the need for a temporary stabilizing humeroul-
nar pinning leading to poor results regarding postoperative
bility, in the sagittal and coronal plane, after osteosynthesis
of a type II radial head fracture and reinsertion of the lateral
collateral ligament. The coronoid process fracture had been
ignored. This persistent instability required surgical revi-
sion through a medial approach revealing disinsertion of the
ulnar collateral ligament which was subsequently repaired.
An external fixator was applied at the end of the operation.
Complete dislocations of the elbow joint with associated
fractures of the radial head and coronoid process of the ulna
are complex traumatisms which management may lead to
uncertain outcome. In 2002, Ring et al.  analysed the
treatment results from 11 patients. Recurrent dislocation
under plaster cast after simple reduction was observed in
tion, redislocated after surgical treatment. A last follow-up,
three out 11 patients were considered as a therapeutic
failure. Among the eight remaining patients, evaluated at
7-year follow-up, the mobility arc of flexion—extension was
92◦with a rotation arc of 126◦; The Mayo Elbow Performance
Score was 76. The outcome was considered unsatisfactory in
seven out of 11 cases. In 2004, Pugh et al.  published the
results after treatment of 36 terrible triad injuries with a
more codified management. At 3 years follow-up, the Mayo
Elbow Performance Score was 88, with a mobility arc ranging
from 19◦of extension loss to 131◦of flexion. The prono-
supination arc was 136◦. Eight complications were observed
(22%) which included stiffness in four cases, posterolat-
eral instability in one and proximal radioulnar synostosis in
two cases. Humeroulnar osteoarthritis was noted in 17% of
the cases. The overall rate of satisfactory results reached
78%. In the GEEC 2008 series, Pierrart et al.  reported
good results in 14 cases and poor results in four. The Mayo
Elbow Performance Score was 78. Mean flexion was 135◦
while mean extension loss was 20◦. Ninety-nine percent of
the patients had normal pronation and 78% showed normal
supination. At last follow-up, one out of the 17 patients had
an eccentric elbow, while another one reported nonunion of
the radial head and six showed a nonunion of the coronoid
process. Osteoarthritis was found in nine out of the 17 eval-
uated patients. Five early complications (two dislocations
of the humeroradial prosthesis, two cases of wound dehis-
cence, one dislocation of the humeroulnar joint) and three
late complications (one proximal radioulnar synostosis, one
ulnar nerve pain and one cutaneous pain) were reported.
The terrible triad injury of the elbow is the most com-
plex pattern of all dislocations since it combines ligament
damages with radial head and coronoid process fractures.
Complete dislocations of the elbow joint should be system-
atically considered as a terrible triad injury unless otherwise
proven, since the lack of knowledge of this clinical pattern
of injury might be detrimental to elbow function. CT scan
assessment should be systematically performed after dislo-
cation reduction for proper investigation of bony lesions.
The principle of that surgical management is based on two
main objectives: restoration of the bony stabilizing struc-
ligament reconstruction. Isolated radial head resection
should be avoided since it appears as a bad prognosis fac-
tor for short and long-term outcome whereas arthroplasty is
advised if radial head fracture cannot be reliably managed
with osteosynthesis. A medial surgical approach is recom-
mended in the case of persistent posterolateral instability
following radial collateral ligament reconstruction or when
fixation of a large coronoid process fragment is indicated.
Early external fixation is advocated only in the case of
persistent instability following the reconstruction of bony
and ligamentous structures. It provides joint stability, pro-
some authors systematically advocate the use of external
fixation since it maintains reduction of the elbow and offers
early mobilization within this protected range while assuring
secure ligament and fracture healing.
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