Were You Just Told You Have a Terrible Triad Elbow Injury? What Happens in the Operating Room in the Next Few Days Will Define How Your Elbow Functions for the Rest of Your Life.
A terrible triad elbow injury — a radial head fracture, a coronoid fracture, and a dislocation of the elbow joint occurring simultaneously — is one of the most complex and demanding injuries in all of orthopedic surgery. The window for getting it right is narrow. The consequences of an incomplete reconstruction — missed ligament repairs, an oversized radial head implant, an inadequately addressed coronoid — do not always reveal themselves immediately. They reveal themselves over months and years, in the form of persistent instability, progressive cartilage damage, and a dysfunctional elbow that is far harder to revise than it would have been to treat correctly the first time.
The bones are the part that gets fixed. The ligaments are the part that gets missed.
When terrible triad injuries are treated by surgeons whose primary expertise is fracture fixation, the bony reconstruction is often well executed — the radial head is replaced, the coronoid is addressed, the joint is reduced. But the lateral collateral ligament and the ulnar collateral ligament, which are torn in virtually every elbow dislocation, are frequently left unrepaired. The result is a technically adequate bony reconstruction sitting on top of an unstable ligamentous foundation — and persistent elbow instability, stiffness, and dysfunction that no amount of physical therapy will resolve.
Dr. Raffy Mirzayan trained in trauma surgery at LAC+USC Medical Center — one of the busiest trauma centers in the United States — and completed his sports medicine fellowship at Kerlan-Jobe Orthopaedic Clinic, where Tommy John reconstruction was originated and where ligament repair and reconstruction of the elbow was a foundational part of his training. That combination — trauma expertise and sports medicine ligament expertise — gives him a perspective on terrible triad injuries that very few surgeons possess. He has published on this topic across three peer-reviewed studies, including the first paper in the literature to identify radial head diameter overstuffing as an independent risk factor for complications and revision surgery.
If you or a family member has sustained a terrible triad elbow injury — or has persistent instability after prior treatment — call (310) 746-5918. A complete evaluation of both the bony and ligamentous components is essential.
Understanding the Injury: The Terrible Triad
The term "terrible triad" was coined by orthopedic surgeons to describe the combination of injuries that together make this one of the most difficult elbow problems to treat reliably. The three components are a radial head fracture, a coronoid process fracture, and dislocation of the ulnohumeral joint — the primary articulation of the elbow. Each injury alone is manageable. Together, they create a degree of bony and ligamentous instability that is extremely challenging to fully restore.
The radial head is the round top of the radius bone that articulates with the capitellum of the humerus on the lateral side of the elbow. It is a critical stabilizer of the elbow against valgus stress and axial load. When it is fractured in a terrible triad injury, it must either be repaired — if the fracture pattern allows — or replaced with a prosthetic implant. Leaving the radial head unreplaced in the setting of a terrible triad creates intolerable instability.
The coronoid process is the bony hook at the front of the ulna that locks the elbow joint in place and prevents posterior subluxation of the forearm. Even small coronoid fractures — which might be dismissed as minor on X-ray — play a critical stabilizing role in the terrible triad and must be addressed. Ignoring a coronoid fracture in this injury pattern leads to recurrent instability.
The elbow dislocation tears the ligaments that hold the joint together — specifically the lateral collateral ligament complex on the outside of the elbow and the ulnar collateral ligament on the inside. These ligaments do not heal reliably on their own after a dislocation, particularly in the setting of associated fractures. They must be repaired — and in many cases augmented with an internal brace — to restore the stability that the bony reconstruction alone cannot achieve.
Why the Ligaments Are the Critical and Most Commonly Neglected Component
This is where the treatment of terrible triad injuries most commonly falls short — and where the long-term outcomes diverge most dramatically between experienced and inexperienced hands.
Trauma surgeons are trained to prioritize skeletal stability. In the setting of a terrible triad, the operative focus naturally gravitates toward the radial head fracture and the coronoid fracture — the bony injuries that are visible on imaging, measurable, and addressable with familiar fixation techniques. The ligaments, by contrast, are soft tissue structures that require a different skill set to evaluate, repair, and augment. They are not visible on plain X-ray. Their repair requires familiarity with elbow ligament anatomy and the surgical techniques used in sports medicine elbow surgery — techniques that are not part of standard trauma training.
When the lateral collateral ligament is left unrepaired, the elbow remains prone to posterolateral rotatory instability — a pattern of instability in which the forearm rotates and subluxates away from the humerus during functional use. When the ulnar collateral ligament is left unrepaired, valgus instability persists. Neither condition will resolve without surgical attention, and both can result in a chronically dysfunctional elbow despite what appears on imaging to be a well-reduced, well-reconstructed joint.
Dr. Mirzayan repairs both the lateral collateral ligament complex and the ulnar collateral ligament as a standard component of every terrible triad reconstruction. In cases where ligament tissue quality is compromised, he augments the repair with an internal brace — the same high-strength synthetic tape used in ankle ligament reconstruction and UCL repair — to provide immediate structural support while the biological repair heals.
Radial Head Replacement: Why Getting the Size Right Is Everything
When the radial head fracture cannot be repaired — because the fracture is comminuted beyond reconstruction — a prosthetic radial head implant is required. Replacing the radial head is not simply a matter of inserting an implant and closing. The size of the implant — both its length and its diameter — is one of the most critical technical decisions in the entire procedure, and getting it wrong has serious consequences.
Overstuffing — implanting a radial head prosthesis that is too large, too long, or both — is a well-recognized complication of radial head replacement that causes abnormal contact pressures across the radiocapitellar joint, accelerated cartilage wear, capitellar erosion, elbow stiffness, pain, and ultimately implant failure requiring revision surgery.
Length overstuffing — inserting an implant that is too long, causing the radial head to sit proud of its native position — has been recognized in the literature for some time. Dr. Mirzayan's second publication on this topic was the first study in the literature to demonstrate that diameter overstuffing — inserting an implant whose head diameter exceeds the native radial head — is an equally significant and independent risk factor for complications and revision surgery. This finding changed how the surgical community thinks about radial head sizing and introduced diameter as a critical measurement that must be accounted for — not just length.
Getting the size right requires precise pre-operative planning using calibrated imaging measurements, intraoperative assessment of implant fit and elbow mechanics, and the experience to recognize when a seemingly adequate implant is actually too large. It is a judgment that comes from a combination of technical training, anatomic knowledge, and case volume — and it is one of the reasons outcomes for terrible triad injuries vary so dramatically between surgical centers.
Published Evidence
Dr. Mirzayan has published three peer-reviewed studies on elbow fracture dislocation and radial head replacement spanning more than two decades of experience:
His first publication established foundational principles for the treatment of this injury pattern: Elbow Fracture Dislocation — Publication 1
His landmark second publication — the first in the literature to identify radial head diameter overstuffing as an independent risk factor for complications and revision — fundamentally advanced the field's understanding of radial head sizing: Radial Head Diameter Overstuffing — First Publication in the Literature
His third publication provides further clinical evidence on outcomes and complications in this injury pattern: Elbow Fracture Dislocation — Publication 3
The Training Background That Makes the Difference
Dr. Mirzayan is one of a small number of surgeons whose training specifically prepared him to manage both components of a terrible triad injury at the same level of expertise.
His residency at LAC+USC Medical Center — one of the highest-volume trauma centers in the United States — provided deep, hands-on training in fracture management, including complex periarticular fractures of the elbow. He understands the bony reconstruction not as a sports medicine surgeon dabbling in trauma, but as a surgeon who trained in a dedicated trauma environment alongside some of the busiest trauma surgeons in the country.
His fellowship at Kerlan-Jobe Orthopaedic Clinic — the birthplace of Tommy John reconstruction and one of the most respected sports medicine programs in the world — provided equally deep training in elbow ligament anatomy, repair, and reconstruction. The lateral collateral ligament complex, the ulnar collateral ligament, the principles of elbow stability, and the techniques of ligament augmentation are the daily currency of sports medicine elbow surgery.
Most surgeons who treat terrible triad injuries bring one of these two skill sets. Dr. Mirzayan brings both — and the published research to demonstrate that the integration of these two perspectives produces better outcomes for patients with this complex injury.
What to Expect: Evaluation, Surgery, and Recovery
Evaluation
Every terrible triad evaluation includes plain X-rays and CT scanning to fully characterize the fracture patterns, assess bone quality, and plan implant sizing. MRI is obtained when there is uncertainty about ligament integrity or when chronic instability is being evaluated after prior treatment. Dr. Mirzayan will review all imaging personally and give you a detailed assessment of the injury components and the planned reconstruction.
Surgery
Terrible triad reconstruction is performed under general anesthesia, typically through a lateral approach that allows access to the radial head, lateral collateral ligament, and — when needed — the coronoid process. The radial head is repaired or replaced with a precisely sized prosthetic implant. The coronoid fracture is addressed. The lateral collateral ligament complex is repaired and augmented with internal brace as needed. The ulnar collateral ligament is assessed and repaired if indicated. Elbow stability is confirmed through a full range of motion under direct visualization before closure. Patients typically go home the same day or with a one-night hospital stay depending on the complexity of the reconstruction.
Recovery
Recovery from terrible triad reconstruction requires a carefully supervised rehabilitation protocol that balances protection of the reconstruction with the critical need for early motion. Elbow stiffness is a known complication of this injury and its treatment — and the rehabilitation program is designed to minimize it from the first post-operative day. Range of motion exercises begin early under physical therapy supervision. Strengthening follows as healing allows. Return to full function typically occurs between 4 and 6 months, though complex cases may require longer. Dr. Mirzayan will give you a personalized recovery timeline based on the specific components of your injury and reconstruction.
Coming from Las Vegas, Phoenix, or Out of State?
Terrible triad elbow injuries are not common — but when they occur, the quality of the initial surgical treatment determines the long-term outcome in a way that is very difficult to reverse. A missed ligament repair at the index surgery is far harder to address in revision than it would have been to repair primarily. A radial head implant that is too large creates cartilage damage that accumulates with every passing month.
For patients who have sustained a terrible triad injury and want the most complete and experienced surgical reconstruction available — or who have persistent instability after prior treatment and are seeking revision — Dr. Mirzayan offers both the trauma and the sports medicine expertise to address every component of this injury.
Dr. Mirzayan regularly treats patients from Las Vegas, Henderson, Phoenix, Scottsdale, and across the country. If you carry a commercial insurance plan — Blue Cross Blue Shield PPO, Aetna, Cigna, United Healthcare, or a self-funded employer plan — you likely have out-of-network benefits that cover a substantial portion of the cost of surgery. His office will verify your coverage before you commit to anything.
Virtual consultations are available for patients traveling from out of state. You can submit your imaging in advance, meet Dr. Mirzayan on video, and determine the right path forward before committing to travel.
Call (310) 746-5918 or contact us online to schedule your consultation.
Frequently Asked Questions
What is a terrible triad elbow injury? A terrible triad is the simultaneous occurrence of three injuries: a radial head fracture, a coronoid process fracture, and dislocation of the elbow joint. The name reflects the difficulty of treating this injury reliably — the combination of bony and ligamentous disruption creates a level of instability that is extremely challenging to fully restore. Successful treatment requires addressing all three components: the fractures, the dislocation, and the torn ligaments.
Why are the ligaments so important in terrible triad surgery? The lateral collateral ligament and ulnar collateral ligament are torn in virtually every elbow dislocation. Without repair, these ligaments do not heal reliably — leaving the elbow unstable despite an otherwise adequate bony reconstruction. Persistent ligament instability causes ongoing dysfunction, pain, and progressive joint damage. Ligament repair — and augmentation with internal brace when needed — is a standard and essential component of Dr. Mirzayan's terrible triad reconstruction.
What is radial head overstuffing and why does it matter? Overstuffing refers to implanting a radial head prosthesis that is too large — either too long or too wide in diameter. An oversized implant creates abnormal pressure across the radiocapitellar joint, accelerates cartilage wear, causes capitellar erosion, and leads to stiffness, pain, and ultimately implant failure. Dr. Mirzayan's published research was the first in the literature to demonstrate that diameter overstuffing is an independent risk factor for complications and revision surgery — a finding that has advanced how the surgical community approaches radial head sizing.
What happens if the ligaments are not repaired at the time of my terrible triad surgery? Persistent elbow instability. The bony reconstruction may appear adequate on imaging, but without ligament repair, the elbow will remain prone to instability patterns — particularly posterolateral rotatory instability — that cause ongoing pain, dysfunction, and progressive joint damage. Revision ligament reconstruction in a previously operated elbow is significantly more complex than primary repair. If your terrible triad was treated without ligament repair and you have persistent symptoms, a thorough evaluation is warranted.
I had surgery for a terrible triad injury and still have instability. Can anything be done? Yes. Dr. Mirzayan evaluates and treats patients with persistent instability after prior terrible triad surgery, including cases involving missed ligament injuries, oversized radial head implants, and other complications of the index procedure. Revision surgery in this setting requires detailed imaging analysis and careful surgical planning, but it is both feasible and frequently successful in experienced hands.
What is an internal brace and when is it used in elbow surgery? An internal brace is a high-strength synthetic tape that is used to augment a ligament repair — providing immediate structural support alongside the repaired ligament while biological healing occurs. It is used in elbow surgery when ligament tissue quality is compromised, when the repair is under significant tension, or when early rehabilitation is a priority. Dr. Mirzayan uses internal brace augmentation routinely in terrible triad ligament repairs.
Do you offer virtual consultations for out-of-state patients? Yes. Dr. Mirzayan offers virtual consultations for patients traveling from out of state. Please submit your X-rays and CT imaging in advance so the fracture patterns, implant sizing, and ligament status can be fully assessed before your visit. Call (310) 746-5918 to schedule.
Does being out-of-network mean I will pay full price out of pocket? Not necessarily. Many patients with commercial insurance — especially PPO plans and self-funded employer plans — have strong out-of-network benefits. Dr. Mirzayan's office will verify your coverage before your consultation so you have a clear picture of what to expect before making any decisions.
About Dr. Raffy Mirzayan
Dr. Raffy Mirzayan, MD is a double-board certified orthopedic sports medicine surgeon with a uniquely integrated background in both trauma and sports medicine elbow surgery. He completed his residency at LAC+USC Medical Center — one of the highest-volume trauma centers in the United States — and his sports medicine fellowship at Kerlan-Jobe Orthopaedic Clinic, where Tommy John reconstruction was developed and where elbow ligament repair and reconstruction is a foundational area of expertise. He has published three peer-reviewed studies on elbow fracture dislocation and radial head replacement, including the first paper in the literature to identify radial head diameter overstuffing as an independent risk factor for complications and revision surgery. For patients with terrible triad elbow injuries — who need a surgeon who can manage the fractures and the ligaments with equal expertise — Dr. Mirzayan brings a combination of training, experience, and published research that is genuinely rare. He practices at DOCS Health in Los Angeles, serves as a Clinical Professor of Orthopaedic Surgery at USC, and welcomes patients from across the United States, including Las Vegas, Phoenix, and Scottsdale, for virtual consultations and in-person care.
DOCS Health | 8436 W 3rd St #800, Los Angeles, CA 90048 | (310) 746-5918 | raffymirzayan.com
