Background <p>Pediatric elbow fracture-dislocations are challenging to diagnose and manage due to their complexity and the cartilaginous nature of the immature elbow.</p> Case Presentation <p>A 6-year-old girl sustained a complex elbow injury consisting of a posterior elbow dislocation with fractures of the olecranon and radial neck. Surgery via a posterior approach revealed an associated occult coronoid fracture. Stabilization was achieved using a retrograde crossed K-wire for the radial neck fracture and a tension band construct for the olecranon-coronoid complex. The patient regained near-complete, pain-free elbow function and returned to age-appropriate activities by 3.5 months postoperatively.</p> Results <p>A systematic literature review identified 25 relevant studies reporting 54 pediatric cases of complex elbow fracture-dislocations, primarily TOFD and terrible triad injuries. The majority of patients were male (68.5%) with an average age of 8.7 years. Most TOFD cases (83%) were anterior, and 90.7% underwent surgical treatment.</p> Conclusion <p>The combination of posterior elbow dislocation with fractures of the olecranon, radial neck, and coronoid represents a rare and severe injury pattern in children. This constellation may be descriptively referred to as a “terrible elbow tetrad,” representing a severe variant of existing injury patterns. Early recognition and appropriate surgical management are essential to achieve favorable functional outcomes.</p>