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The terrible triad injury of the elbow combines dislocation, radial head fracture and coronoid fracture and is associated with a high risk of stiffness and instability. This systematic review and meta-analysis examined one of the key intraoperative decisions: whether to repair the radial head or replace it. Across the available comparative studies, radial head arthroplasty often showed better functional scores than repair in the setting of fractures that were difficult to reconstruct. The evidence supports replacement when the radial head is non-reconstructible and its contribution to elbow stability is essential. However, the review is limited by small sample sizes and heterogeneous surgical protocols, meaning that it does not justify routine replacement for every radial head fracture. The broader principle is that the radial head should be treated as part of the elbow stabilising system, not simply as a fragment that can be discarded. Surgical strategy must integrate the coronoid injury, collateral ligament status, alignment and the patient's ability to participate in early rehabilitation. For clinicians, the practical takeaway is to plan the entire instability reconstruction before deciding how to address the radial head, because isolated implant selection cannot compensate for an incomplete stabilisation strategy.
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The terrible triad injury of the elbow combines dislocation, radial head fracture and coronoid fracture and is associated with a high risk of stiffness and instability. This systematic review and meta-analysis examined one of the key intraoperative decisions: whether to repair the radial head or replace it. Across the available comparative studies, radial head arthroplasty often showed better functional scores than repair in the setting of fractures that were difficult to reconstruct. The evidence supports replacement when the radial head is non-reconstructible and its contribution to elbow stability is essential. However, the review is limited by small sample sizes and heterogeneous surgical protocols, meaning that it does not justify routine replacement for every radial head fracture. The broader principle is that the radial head should be treated as part of the elbow stabilising system, not simply as a fragment that can be discarded. Surgical strategy must integrate the coronoid injury, collateral ligament status, alignment and the patient's ability to participate in early rehabilitation. For clinicians, the practical takeaway is to plan the entire instability reconstruction before deciding how to address the radial head, because isolated implant selection cannot compensate for an incomplete stabilisation strategy.
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