Restricted accessReview articleFirst published online 2025-10
Characteristics of rehabilitation protocols following operative treatment of terrible triad elbow injuries and the influence of early motion: A systematic review and meta-analysis
As no consensus exists on the optimal postoperative rehabilitation protocol in terrible triad injuries, we sought to characterize the reported protocols and relate them to postoperative range of motion (ROM) measures and Mayo Elbow Performance Score (MEPS).
Methods
A systematic review was performed by searching PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles on the operative treatment of terrible triad injuries reporting postoperative rehabilitation protocols were included. Included studies were descriptively summarized. Methodologic quality was assessed using the Methodological Index for Non-randomized Studies criteria. Meta-analysis compared postoperative ROM measures and the MEPS between patients initiating passive ROM exercises at ≤7 days vs. >7 days.
Results
Our review included 36 articles with 1123 elbows (66% male, mean age: 43 years, follow-up: 27 months). Of the studies reporting physical therapy protocols, it was most commonly initiated at 7 days postoperatively (6/36, 17%), passive ROM exercises at 7 days (3/25, 12%), and active ROM at 21 days (4/26, 15%). On meta-analysis, early passive ROM initiation was not associated with improved elbow ROM or MEPS.
Discussion
While rehabilitation protocols commonly advised passive ROM at one week post-operatively, meta-analysis did not support functional benefits of early passive ROM.
WaterworthRFinlaysonGFranklinM, et al.Current concepts in the management of ‘Terrible Triad’ injuries of the elbow. Injury2023; 54: 110889.
6.
FitzgibbonsPGLouieDDyerGSM, et al.Functional outcomes after fixation of ‘terrible triad’ elbow fracture dislocations. Orthopedics2014; 37: e373–e376.
7.
AkhtarAHughesBWattsAC. The post-traumatic stiff elbow: a review. J Clin Orthop Trauma2021; 19: 125–131.
8.
CuiHYuYHeY, et al.Management of elbow stiffness after postoperative treatment of terrible triad elbow injury: maintaining mobility and stability using a combined protocol. Int Orthop2018; 42: 609–618.
9.
GreinerSKochMKerschbaumM, et al.Repair and augmentation of the lateral collateral ligament complex using internal bracing in dislocations and fracture dislocations of the elbow restores stability and allows early rehabilitation. Knee Surg Sports Traumatol Arthrosc2019; 27: 3269–3275.
10.
WangWLiuJLiuS, et al.Arthrolysis combined with reconstruction for treatment of terrible triad injury with a poor outcome after surgical as well as conservative intervention. Arch Orthop Trauma Surg2014; 134: 325–331.
11.
IssackPSEgolKA. Posttraumatic contracture of the elbow: current management issues. Bull Hosp Jt Dis2006; 63: 129–136.
KamelSAShepherdJAl-ShahwaniA, et al.Postoperative mobilization after terrible triad injury: systematic review and single-arm meta-analysis. J Shoulder Elbow Surg2024; 33: e116–e125.
14.
ChenHWHuangSM. Risk factors of efficacy for patients receiving surgical treatment following terrible triad of the elbow joint: a comparative study. Medicine (Baltimore)2019; 98: e13836.
15.
ChenHWLiuGOuS, et al.Operative treatment of terrible triad of the elbow via posterolateral and anteromedial approaches. PloS One2015; 10: e0124821.
16.
GuptaABareiDKhwajaA, et al.Single-staged treatment using a standardized protocol results in functional motion in the majority of patients with a terrible triad elbow injury. Clinical Orthopaedics & Related Research2014; 472: 2075–2083.
17.
DimanthaWHDPathinathanKSivakumaranD, et al.Pediatric anterior elbow dislocation due to a rare mechanism of injury: a case report. Int J Surg Case Rep2021; 85: 106210.
18.
JungSWKimDHKangSH, et al.Risk factors that influence subsequent recurrent instability in terrible triad injury of the elbow. J Orthop Trauma2019; 33: 250–255.
19.
RingDJupiterJBZilberfarbJ. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am2002; 84: 547–551.
20.
LongoUGFranceschiFLoppiniM, et al.Rating systems for evaluation of the elbow. Br Med Bull2008; 87: 131–161.
21.
CuetoRJKakalecikJBurnsMQ, et al.Reported outcome measures in complex fracture elbow dislocations: a systematic review. J Shoulder Elbow Surg2024; 33: 1709–1723.
22.
The PRISMA 2020 statement: an updated guideline for reporting systematic reviews | The BMJ, https://www.bmj.com/content/372/bmj.n71 (accessed 10 June 2023).
23.
MorreyBFAnKChaoE. Functional evaluation of the elbow. In: MorreyBF (ed) The elbow and its disorders. Philadelphia: W.B. Saunders, 1993, pp.86–97.
24.
SlimKNiniEForestierD, et al.Methodological index for non-randomized studies (MINORS): development and validation of a new instrument: methodological index for non-randomized studies. ANZ J Surg2003; 73: 712–716.
25.
BorensteinMHedgesLVHigginsJPT, et al.A basic introduction to fixed-effect and random-effects models for meta-analysis. Res Synth Methods2010; 1: 97–111.
26.
ViechtbauerW. Conducting meta-analyses in R with the metafor package. J Stat Softw2010; 36: 1–48.
27.
AfifiALymonaAMGalalS. Radial head fixation vs replacement in terrible triad: preliminary results of a prospective cohort study with patient reported outcome. Indian J Orthop2020; 54: 254–259.
28.
Muñoz MÁGarcía JMPLamas LG, et al.Protocolised surgical treatment of terrible triad of elbow. Results and complications. Rev Esp Cir Ortopédica Traumatol Engl Ed2019; 63: 281–288.
29.
BrigatoRMMourariaGGKikutaFK, et al.Functional evaluation of patients with surgically treated terrible triad of the elbow. Acta Ortopédica Bras2015; 23: 138–141.
ChemamaBBonnevialleNPeterO, et al.Terrible triad injury of the elbow: how to improve outcomes?Orthop Traumatol Surg Res2010; 96: 147–154.
32.
ChenH-WBiQ. Surgical outcomes and complications in treatment of terrible triad of the elbow: comparisons of 3 surgical approaches. Med Sci Monit2016; 22: 4354–4362.
33.
DomosPGriffithsEWhiteA. Outcomes following surgical management of complex terrible triad injuries of the elbow: a single surgeon case series. Shoulder Elbow2018; 10: 216–222.
34.
DuSWeiLHeB, et al.Dynamic fixation using rigid tape in rehabilitation after surgery of terrible triad injury of the elbow: a randomized trial. J Back Musculoskelet Rehabil2021; 34: 957–964.
35.
GalbiattiJACardosoFLFerroJAS, et al.Tríade terrível do cotovelo. Avaliação do tratamento cirúrgico. Rev Bras Ortop2018; 53: 460–466.
36.
GiannicolaGCalellaPPiccioliA, et al.Terrible triad of the elbow: is it still a troublesome injury?Injury2015; 46: S68–S76.
37.
HouFLiangXFanW, et al.Analysis of twenty-five cases of terrible triad injury of the elbow surgically treated with a single lateral approach. Int Orthop2021; 45: 241–246.
38.
IkemotoRYMurachovskyJBuenoRS, et al.Terrible triad of the elbow: functional results of surgical treatment. Acta Ortopédica Bras2017; 25: 283–286.
39.
JeongW-KOhJ-KHwangJ-H, et al.Results of terrible triads in the elbow: the advantage of primary restoration of medial structure. J Orthop Sci2010; 15: 612–619.
40.
KaneshiroYYanoKYokoiT, et al.Is repair of a small coronoid fracture required in the surgical treatment of terrible triad injury of the elbow?J Hand Surg Asian-Pac Vol2022; 27: 345–351.
41.
LeeSHLimKHKimJW. Case series of all-arthroscopic treatment for terrible triad of the elbow: indications and clinical outcomes. Arthrosc J Arthrosc Relat Surg2020; 36: 431–440.
42.
LeighWBBallCM. Radial head reconstruction versus replacement in the treatment of terrible triad injuries of the elbow. J Shoulder Elbow Surg2012; 21: 1336–1341.
43.
LiDSongDNiJ, et al.Single modified posterior approach through the space of the proximal radioulnar joint for terrible triad injury: a comparative study. Orthop Surg2022; 14: 2159–2169.
44.
LiuGHuJMaW, et al.Surgical treatment for terrible triad injury of the elbow with anteromedial coronoid fracture through a combined surgical approach. J Int Med Res2018; 46: 3053–3064.
45.
LiuGMaWLiM, et al.Operative treatment of terrible triad of the elbow with a modified Pugh standard protocol: retrospective analysis of a prospective cohort. Medicine (Baltimore)2018; 97: e0523.
46.
ReinaresFRojasNCalvoA, et al.Results of standardized treatment of elbow fracture dislocations as per their injury pattern: a retrospective cohort of 89 patients. JSES Int2021; 5: 588–596.
47.
TangtiphaiboontanaJAgelJBeingessnerD, et al.Prolonged dislocation and delay to surgery are associated with higher rates of heterotopic ossification in operatively treated terrible triad injuries. JSES Int2020; 4: 238–241.
48.
TurnerRGRispoliDLopez-GonzalezFM, et al.Partial allograft replacement of the radial head in the management of complex fracture-dislocations of the elbow. J Shoulder Elbow Surg2012; 21: 396–404.
49.
VernetEBacleGMarteauE, et al.Lateral elbow ligamentoplasty by autologous tendon graft in posterolateral rotatory instability: results in 18 cases at a mean 5 years’ follow-up. Orthop Traumatol Surg Res2015; 101: S199–S202.
50.
WangYHuangLMaS. Surgical treatment of “terrible triad of the elbow”: technique and outcome: surgery for terrible triad of the elbow. Orthop Surg2010; 2: 141–148.
51.
WattersTSGarriguesGERingD, et al.Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis?Clin Orthop Relat Res2014; 472: 2128–2135.
52.
WuHLiaoQZhuY, et al.Surgical reconstruction of comminuted coronoid fracture in terrible triad injury of the elbow. Eur J Orthop Surg Traumatol2012; 22: 667–671.
53.
YanMNiJSongD, et al.Radial head replacement or repair for the terrible triad of the elbow: which procedure is better? Radial head replacement or repair?ANZ J Surg2015; 85: 644–648.
54.
ZaidenbergEEAbregoMODonndorffAG, et al.Treatment of terrible triad injuries at a mean follow-up of nine years. Shoulder Elbow2019; 11: 450–458.
55.
ZhaY-JXiaoDHuaK-H, et al.Lateral minimal approach to the terrible triad of the elbow: a treatment protocol in Beijing Jishuitan Hospital. Ann Transl Med2021; 9: 1232–1232.
56.
ZhangCZhongBLuoC. Treatment strategy of terrible triad of the elbow: experience in Shanghai 6th People’s Hospital. Injury2014; 45: 942–948.
57.
ZhangJTanMKwekEBK. Outcomes of coronoid-first repair in terrible triad injuries of the elbow. Arch Orthop Trauma Surg2017; 137: 1239–1245.
58.
MazharFNEbrahimiHJafariD, et al.Radial head resection versus prosthetic arthroplasty in terrible triad injury: a retrospective comparative cohort study. Bone Jt J2018; 100-B: 1499–1505.
59.
Gutiérrez-EspinozaHRubio-OyarzúnDOlguín-HuertaC, et al.Supervised physical therapy vs home exercise program for patients with distal radius fracture: a single-blind randomized clinical study. J Hand Ther2017; 30: 242–252.
60.
OlneySJNymarkJBrouwerB, et al.A randomized controlled trial of supervised versus unsupervised exercise programs for ambulatory stroke survivors. Stroke2006; 37: 476–481.
61.
de HaanJSchepNTuinebreijerW, et al.Complex and unstable simple elbow dislocations: a review and quantitative analysis of individual patient data. Open Orthop J2010; 4: 80–86.
62.
HardingPRasekabaTSmirneosL, et al.Early mobilisation for elbow fractures in adults. Cochrane Database Syst Rev2011; 6: CD008130.
63.
GiannicolaGPolimantiDBullittaG, et al.Critical time period for recovery of functional range of motion after surgical treatment of complex elbow instability: prospective study on 76 patients. Injury2014; 45: 540–545.
64.
EllerinBEHelfetDParikhS, et al.Current therapy in the management of heterotopic ossification of the elbow: a review with case studies. Am J Phys Med Rehabil1999; 78: 259–271.
65.
HacklMBeyerFWegmannK, et al.The treatment of simple elbow dislocation in adults. Dtsch Ärztebl Int2015; 112: 311–319.
66.
JonesV. Conservative management of the post-traumatic stiff elbow: a physiotherapist’s perspective. Shoulder Elbow2016; 8: 134–141.
67.
ZhangDNazarianARodriguezEK. Post-traumatic elbow stiffness: pathogenesis and current treatments. Shoulder Elbow2020; 12: 38–45.
68.
MacdermidJCVincentJIKiefferL, et al.A survey of practice patterns for rehabilitation post elbow fracture. Open Orthop J2012; 6: 429–439.
KannusRJòzsaLRenströmR, et al.The effects of training, immobilization and remobilization on musculoskeletal tissue. Scand J Med Sci Sports1992; 2: 100–118.
71.
RossGMcDevittERChronisterR, et al.Treatment of simple elbow dislocation using an immediate motion protocol. Am J Sports Med1999; 27: 308–311.
72.
HäggmarkTErikssonE. Cylinder or mobile cast brace after knee ligament surgery: a clinical analysis and morphologic and enzymatic studies of changes in the quadriceps muscle. Am J Sports Med1979; 7: 48–56.
73.
SalterRBHamiltonHWWedgeJH, et al.Clinical application of basic research on continuous passive motion for disorders and injuries of synovial joints: a preliminary report of a feasibility study. J Orthop Res Off Publ Orthop Res Soc1984; 1: 325–342.
74.
SandbergRBalkforsBNilssonB, et al.Operative versus non-operative treatment of recent injuries to the ligaments of the knee. A prospective randomized study. The Journal of Bone & Joint Surgery1987; 69: 1120–1126.
75.
StoffelenDBroosP. Minimally displaced distal radius fractures: do they need plaster treatment?The Journal of Trauma: Injury, Infection, and Critical Care1998; 44: 503–505.
76.
IordensGITVan LieshoutEMMSchepNWL, et al.Early mobilisation versus plaster immobilisation of simple elbow dislocations: results of the FuncSiE multicentre randomised clinical trial. Br J Sports Med2017; 51: 531–538.
77.
GummessonCWardMMAtroshiI. The shortened disabilities of the arm, shoulder and hand questionnaire (QuickDASH): validity and reliability based on responses within the full-length DASH. BMC Musculoskelet Disord2006; 7: 44.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
