Terrible triad injury of the elbow (TTI) is usually managed surgically because of instability and the risk of poor outcomes. Recent reports suggest that a carefully selected subgroup with concentric reduction and satisfactory early stability may be managed nonoperatively. This study aimed to describe the long-term functional and radiographic outcomes of patients with TTI in whom nonoperative management was maintained and to identify the common characteristics of this selected subgroup.

We hypothesized that, in carefully selected TTIs with stable concentric reduction and low-grade radial head and coronoid fractures, maintained nonoperative treatment may be associated with high long-term functional scores and limited radiographic degeneration.

This retrospective single-center case series included adult patients with TTI who were initially selected for nonoperative management between 2002 and 2022 and had at least 2 years of follow-up when available. Initial candidacy for nonoperative management required concentric reduction, no mechanical block, and fluoroscopic stability through a functional arc or to at least 30 degrees short of full extension. Among 17 patients initially selected for nonoperative treatment, 3 underwent acute-phase surgical conversion, 4 were lost to follow-up, and 2 declined participation, leaving 8 patients for final evaluation. Mayo Elbow Performance Score (MEPS), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), visual analog scale (VAS), range of motion (ROM), and radiographic osteoarthritis graded with the Broberg-Morrey classification were assessed.

Eight patients (7 men) with a mean age of 36.4 ± 7.7 years were evaluated at a mean 11.3 ± 7.4 years after injury. All had Mason type I–II radial head fractures and Morrey type I coronoid fractures. Among patients in whom nonoperative management was maintained, no delayed surgery was required. Mean MEPS was 96.3 ± 7.4, mean QuickDASH was 1.7 ± 2.3, and mean flexion was 128.8 ± 3.5 degrees. Radiographically, 7 patients had Broberg-Morrey stage 0 changes and 1 had stage I changes.

In this highly selected subgroup, patients in whom nonoperative treatment was maintained had high functional scores, minimal pain, preserved motion, and limited radiographic degeneration at long-term follow-up. These data do not estimate the overall success rate of nonoperative treatment, because 3 of 17 initially selected patients underwent acute-phase surgical conversion. The findings should therefore be interpreted as descriptive and hypothesis-generating rather than as evidence of equivalence or superiority to surgery.

IV; retrospective case series