Beyond the terrible triad: a rare case of complex elbow injury and its surgical approach

This case report presents a rare and complex elbow injury that expands the conventional scope of the "terrible triad" pattern. A 21-year-old male sustained high-energy trauma resulting in posterior elbow dislocation, radial head and coronoid process fractures, intra-articular distal humerus fractures involving the trochlea and capitellum, and a midshaft ulna fracture. Surgical management was performed using the posterior trans olecranon approach. The ulnar shaft fracture was stabilized by using a locking reconstruction plate and interfragmentary screw fixation. Intra-articular fractures were reduced and fixed using Herbert screws followed by dual-column plating of the distal humerus. The lateral collateral ligament was repaired, and olecranon osteotomy was fixed with tension-band wiring. A structured rehabilitation protocol was implemented postoperatively. At nine months, the patient returned to light activity with fair range of motion and no complications. This case highlights the importance of individualized surgical planning and early rehabilitation in managing complex elbow injuries that transcend the traditional definition of the terrible triad. The use of a trans-olecranon approach, stable fracture fixation, and anatomical articular reconstruction are the key elements for achieving satisfactory functional outcomes.