Terrible triad injury of the elbow: a spectrum of theories

For more than one century, understanding the injury mechanism leading to the terrible triad of the elbow (TTE) was a significant challenge for surgeons. We aimed to summarize: (1) the history of the treatment of TTE and (2) the increasing scientific knowledge that supported its evolution. Five electronic databases were searched between 1920 and 2022. Results were reported as a comprehensive review of the relevant literature. Between 1940 and 1980, surgical exploration allowed observation of complex elbow instability involving both radial head, coronoid process, and ligament(s) injuries. In 1966, Osborne introduced the concept of posterolateral rotatory instability as the first mechanism injury to explain the complex elbow instability. From 1980 to 1995, a biomechanical revolution by American pioneers critically improved our understanding of elbow instability. After 1992, a few unifying theories and surgical protocols were provided, but those have divided the surgeons’ population. The formalization of the TTE treatment allowed avoiding of terrible short-term outcomes. However, post-traumatic osteoarthritis (PTOA) at long-term follow-up is still an issue. No consensual surgical protocol for the treatment of TTE has been widely accepted. While the outcomes of the TTE have been improved, the rate of PTOA at long-term follow-up is still high regardless of the treatments. The terrible triad has given way to the subtle triad with persistent microinstability of the elbow. The next challenge for elbow surgeons is to diagnose and fix this persistent subclinical instability after surgery in order to prevent the onset of PTOA.