Pugh terrible triad protocol

Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures.

Pugh DM, Wild LM, Schemitsch EH, et al. The Journal of bone and joint surgery. American volume 2004 · PMID 15173283 · doi:10.2106/00004623-200406000-00002

Question

Does a standardised stepwise surgical protocol restore stability in terrible triad elbow injuries?

Design

Retrospective review of consecutive patients treated with a single protocol at two Canadian university teaching hospitals.

Patients

Patients with elbow dislocation plus radial head and coronoid fractures (terrible triad).

Intervention

Stepwise protocol: coronoid fixation, radial head fixation or replacement, lateral ligament repair, then medial repair or hinged fixator if still unstable

Comparison

None (single-arm series)

Primary outcome

Elbow stability, range of motion and Mayo Elbow Performance Score

Key result

Most elbows regained concentric stability and a functional arc of motion, though reoperation for stiffness or complications was not rare.

Limitations

Uncontrolled case series from expert surgeons.

Impact on practice

The standard teaching sequence for terrible triad injuries, widely examined in FRCS vivas.