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Elbow Instability

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Elbow ligamentous and bony instability, including dislocation and the terrible-triad pattern.

Updated Aug 20269 citations
A hand-drawn illustration of a faceless person holding their elbow after it gave way in a fall.
Ligaments of the elbow — the ulnar and radial collateral ligaments are the main stabilisers. Kieran Hirpara 4.0

What you're feeling

You may feel a sense of your elbow giving way or slipping out of place. This instability often happens when you try to straighten your arm or bear weight through it. You might notice clicking, locking, or a sudden pop during these movements. The pain is usually sharp and located on the outer side of the elbow. It can radiate down your forearm or up into your upper arm.

Daily tasks become difficult when your arm feels unreliable. You may struggle to lift a heavy shopping bag, push open a heavy door, or support your body weight when standing up from a chair. Simple actions like turning a doorknob or holding a glass of water can feel precarious if the joint feels loose. You might instinctively hold your arm close to your body to protect it from sudden movements.

Symptoms often flare after activity that stresses the joint. You may feel increased stiffness and ache in the morning, making it hard to fully straighten your arm at first. Night pain is common if you sleep on the affected side, as the joint bears pressure. If you have had a previous dislocation, you might feel a lingering fear of re-injury during sports or physical work.

In cases of chronic instability, you might experience persistent swelling or a feeling of fullness around the joint. You may notice weakness when trying to grip objects tightly. If the instability is due to a ligament injury, you might feel pain on the inner side of the elbow when throwing or lifting. Recognising these patterns helps us understand the precise nature of your injury. This understanding is critical in preventing long-term pain and weakness.

Most simple dislocations heal well with rest and early movement. However, if you experience recurrent giving way or persistent instability, further assessment is needed. We aim to restore stability so you can return to your normal activities with confidence. Your surgeon will guide you through the appropriate steps to manage your symptoms effectively.

What's actually happening

Your elbow is a hinge joint that relies on a precise balance between bone and soft tissue to stay stable. Think of it like a sturdy door hinge where the pins (bones) must align perfectly with the frame (ligaments and tendons). In a healthy elbow, these parts work together in synchrony to prevent unwanted movement. When you suffer a dislocation, this delicate balance is disrupted. The bones may slip out of place, tearing the ligaments that act as the primary stabilisers.

Simple dislocations often heal well because the joint surfaces fit together tightly, providing inherent stability. However, complex injuries involve more than just a simple slip. They may include fractures of the radial head or coronoid process, which are critical bony structures that prevent the joint from sliding backward or rotating abnormally. Without these bony supports, the ligaments alone cannot keep the joint secure. This is why understanding the exact pattern of injury is so important for your recovery.

If the stabilising structures are not repaired correctly, you may experience chronic instability, pain, and weakness. In severe cases, the elbow may remain unstable even after it has been put back in place. This is particularly risky for contact sports, where the lateral ulnar collateral ligament plays a critical role in preventing the joint from dislocating under force. If your elbow remains unstable or if you have significant bone damage, your surgeon may recommend surgery to restore the osseoligamentous support. This ensures you can move your arm safely and regain function without the fear of the joint slipping again.

What we can do about it

Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. For simple elbow dislocations, we begin with conservative treatment and early functional training. This means you start moving your elbow gently within a safe range as soon as possible. Our physiotherapy programs focus on active movement through the stable parts of your elbow’s motion. We aim to restore strength and stability without forcing the joint. In many cases, this approach is all you need. Only 2% of patients with simple elbow dislocations require surgical intervention. For throwing athletes with valgus instability, we may also manage the condition nonsurgically.

If you have pain or swelling, we discuss medical management to help you stay comfortable while your elbow heals. This may include pain medication and anti-inflammatories. We do not routinely recommend injections for acute instability unless specific soft-tissue issues arise. For chronic or degenerative changes, we might consider cortisone or hyaluronic acid injections to reduce inflammation and lubricate the joint. Platelet-rich plasma (PRP) injections are another option some patients explore to support tissue healing. The effect of these injections varies; cortisone relief may last weeks to months, while hyaluronic acid effects can persist longer. We monitor your response closely and adjust the plan if symptoms persist.

Surgery is considered when your elbow remains unstable despite non-operative care, or if you have a complex fracture-dislocation. We operate to repair or reconstruct the lateral ulnar collateral ligament, which is the most critical structure for stability. Our goal is to achieve a concentric reduction, meaning the bones sit perfectly together again. This allows for early motion and prevents long-term stiffness or arthritis. We use arthroscopy (keyhole surgery) where possible to manage soft tissue and bone lesions with minimal disruption. This technique helps restore sufficient stability for safe, early movement. If conservative care has not given enough improvement after a reasonable trial, or if your injury pattern requires immediate structural repair, we recommend surgery. We discuss the risks and benefits with you to ensure this is the right shared decision for your recovery.

What to expect

Your outlook depends largely on whether your elbow injury is simple or complex. For simple dislocations, non-operative management usually yields good long-term outcomes. Most of you will recover well without surgery. Approximately 2% of patients treated without operation require surgical intervention later. Approximately 8% develop persistent instability symptoms. Recurrent instability is uncommon after simple dislocations because the bone structure itself provides stability.

If your injury is complex, such as a fracture-dislocation, the path is different. Operative repair is indicated for most of these cases to restore support. This approach allows safe, early motion and provides a stable functional elbow in the long term. Recognising the precise pattern of injury is critical in restoring function and preventing chronic instability, pain, and weakness.

Recovery feels different depending on your specific injury. Athletes with elbow dislocation demonstrate high return to sport rates. Most athletes return to sport within 10 weeks. For complex injuries involving radial head and coronoid fractures, a standard surgical protocol restores sufficient stability to allow early motion. This early movement enhances functional outcomes.

You should be aware that some challenges can arise. Persistent subclinical instability after surgery is a challenge that can lead to the onset of post-traumatic osteoarthritis. If you require surgery for soft-tissue stabilisation or contracture release, this most commonly happens within 4 years of the initial injury. For those needing joint replacement, linked arthroplasty is preferred if you have ligamentous instability or bone loss, as instability is the major complication of unlinked implants.

Overall, the goal is to balance stability and mobility. With appropriate management, whether through rest or surgery, most patients achieve a functional elbow. Your surgeon will guide you on the best path for your specific injury pattern.

When to see someone

See your GP if you have persistent pain, weakness, or a feeling that your elbow is giving way. These are signs of mechanical instability. Seek urgent care if your elbow locks, clicks, or dislocates repeatedly. This may indicate posterolateral rotatory instability. Go to an emergency department if you cannot straighten your arm or if you suspect a fracture. Early assessment helps prevent long-term stiffness or arthritis. For complex injuries, your surgeon may use arthroscopy to diagnose the issue safely. Most simple dislocations heal well with rest and early movement, but persistent symptoms need specialist review to ensure proper healing and stability.

Advanced reading: the deeper science (optional)

This section goes further than you need for your own treatment decisions. It is here because "elbow instability" covers several quite different problems with quite different outlooks, and because the single biggest influence on how a simple dislocation ends up is a decision made in the first fortnight — one where the evidence and the instinct to protect the joint point in opposite directions.

"Elbow instability" is not one diagnosis

The term covers everything from a joint that has dislocated once and is now stable, to a joint that gives way on everyday tasks, to a fracture-dislocation where bone as well as ligament has failed. Surgeons have been trying to classify these patterns for well over a century, and still disagree: a review of 130 years of attempts concluded that "uncertainties about both nomenclature and classification still exist", and prompted a national society working group to try again [1].

This matters to you for one practical reason. When you read outcome figures for "elbow instability", they may describe a group of patients whose injuries were nothing like yours. The distinction that matters most is simple (ligaments only) versus complex (ligaments plus broken bone) — those two travel very different paths.

The two directions that have names: PLRI and PMRI

Beyond simple versus complex, the pattern that determines the operation is the direction the joint gives way. Two named patterns account for most of it [1].

Posterolateral rotatory instability (PLRI) is the common one, and it is what most people mean by "unstable elbow". It is the pattern produced by the usual injury: a fall onto the outstretched hand loading the elbow with the forearm turning outwards. The damage runs in a circle around the joint, starting at the lateral ulnar collateral ligament on the outer side and progressing forwards and backwards around the capsule, reaching the inner ligament last. Because it begins laterally, the first stage is a subluxation rather than a full dislocation, and the outer ligament is the structure that has to be repaired or reconstructed to fix it. When you read earlier in this section about lateral ligament reconstruction and its 0–33% recurrence range, that is PLRI being treated.

Symptomatically it is the pattern that makes you wary of pushing up out of a chair or loading the arm with the palm turned up — positions that let the joint rotate open.

Posteromedial rotatory instability (PMRI) is less common, easier to miss, and less forgiving. The mechanism is the opposite — a varus (inward-bending) force with the forearm rotating inwards — and it damages the outer ligament while shearing off the anteromedial facet of the coronoid, a small shelf of bone on the inner front of the ulna that the joint leans on.

That fragment is the problem. Anatomical work shows that on average 58% of the anteromedial facet is unsupported by the bone shaft behind it, so it fractures as a separate piece and is easily overlooked on a plain X-ray [2]. Missing it is costly: the joint is left slightly malaligned and grinds. One report described established arthrosis just 26 months after the injury in an elbow whose instability had not been addressed [3]. This is why a CT scan is often requested when the injury pattern suggests it, and why a coronoid fragment that looks small can still warrant fixation.

The practical point for you: these are different injuries needing different operations, and "my friend had an unstable elbow and had X done" may not transfer to your elbow at all.

The first two weeks matter more than almost anything else

The instinct after a dislocation is to protect the joint in a cast or a brace. The elbow punishes that instinct. It is unusually prone to stiffening, and the stiffness is roughly proportional to how long it was held still.

One review put numbers on it: after a simple dislocation, a permanent loss of full straightening of at least 30 degrees may be expected if immobilisation runs beyond 25 days — but as little as 3 degrees if the elbow is moving again within five days [4]. That is close to the whole difference between an elbow you forget about and one you notice every day.

A randomised trial (FuncSiE) tested this directly, comparing early movement against three weeks in plaster for simple dislocations. At six weeks the early-movement group had a noticeably larger arc of motion (121° versus 102°), less disability, and returned to work 10 days versus 18. By one year the two groups were indistinguishable — and, critically, no elbow in either group re-dislocated [5]. The protection bought by the plaster was protection against a risk that did not materialise, paid for with stiffness and lost weeks.

This is why your rehabilitation starts early and why a simple sling is used for comfort rather than a hinged brace holding the joint in a fixed arc.

Simple dislocations do well — with an honest asterisk

Most simple dislocations recover without an operation. But "most" is not "all": roughly 8% of people treated non-operatively go on to have symptoms of persistent instability, and about 2% eventually need surgery [6]. A small number of injuries that look simple on the day behave badly afterwards, which is why we review you rather than discharging you at the first sign of a reduced joint.

"Terrible triad" is a worse name than it is an injury

The combination of elbow dislocation with fractures of the radial head and the coronoid was named the "terrible triad" because its early results were dismal. Modern results are much better: a review pooling 37 studies and 1609 patients found an average Mayo Elbow Performance Score of 90 — rated excellent [7].

The honest half of that sentence is the complication rate, which is not low. Around 30% of patients have some complication, and 7.8% need further surgery. The commonest are extra bone forming in the soft tissues (11%) and ulnar nerve symptoms (2.6%) [7]. So: a good result is now the expectation rather than the hope, but this is an injury with a genuine chance of a second operation, and it is reasonable to know that before you start.

When ligament surgery does not hold, bone is often the reason

Repair or reconstruction of the lateral ligament is well established for the commonest pattern of chronic instability. Reported recurrence after it, though, ranges from 0% to 33% — a spread wide enough to tell you the operation is not the only variable [8].

Part of the explanation is that instability is not always purely a soft-tissue problem. Wear or defects in the bone at the outer side of the joint can keep an elbow unstable even after the ligament has been properly reconstructed, and combined bony lesions act together to raise the risk of failure [8]. Revision surgery is correspondingly harder: the only published series of revision lateral ligament reconstruction reported a 27% failure rate [8]. The practical implication is that if your elbow stays unstable after a ligament repair, the next question is usually about bone, not about redoing the same soft-tissue operation.

Holding the joint reduced from the inside

For elbows too unstable to trust to a repair alone, the traditional answer was an external hinged frame worn on the outside of the arm for weeks. An alternative is an internal joint stabiliser — a temporary internal device that holds the joint reduced while the soft tissues heal, and is removed later. It allows the elbow to move through a good arc while protected, with the original series reporting a mean flexion of 134 degrees at final follow-up [9].

The reason this approach is preferred here is the same principle as the rest of this page: protection that still permits movement beats protection that prevents it.

Reviewed by Dr Kieran Hirpara · 7 August 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

References for the advanced reading
  1. Marinelli A, Guerra E, Rotini R. Elbow instability: are we able to classify it? Review of the literature and proposal of an all-inclusive classification system. Musculoskelet Surg. 2016;100(Suppl 1):61-71.
  2. Doornberg JN, de Jong IM, Lindenhovius AL, Ring D. The anteromedial facet of the coronoid process of the ulna. J Shoulder Elbow Surg. 2007;16(6):667-70.
  3. Ramirez MA, Stein JA, Murthi AM. Varus posteromedial instability. Hand Clin. 2015;31(4):557-63.
  4. Martin BD, Johansen JA, Edwards SG. Complications related to simple dislocations of the elbow. Hand Clin. 2008;24(1):9-25.
  5. Iordens GIT, Van Lieshout EMM, Schep NWL, De Haan J, Tuinebreijer WE, Eygendaal D, et al. Early mobilisation versus plaster immobilisation of simple elbow dislocations: results of the FuncSiE multicentre randomised clinical trial. Br J Sports Med. 2017;51(6):531-8.
  6. Robinson PM, Griffiths E, Watts AC. Simple elbow dislocation. Shoulder Elbow. 2017;9(3):195-204.
  7. Stambulic T, Desai V, Bicknell R, Daneshvar P. Terrible triad injuries are no longer terrible! Functional outcomes of terrible triad injuries of the elbow: a systematic review. JSES Rev Rep Tech. 2022;2(2):214-8.
  8. O'Driscoll SW, Chaney GK. Preoperative and operative risk factors for failed lateral collateral ligament reconstruction. JSES Int. 2023;7(6):2578-86.
  9. Orbay JL, Mijares MR. The management of elbow instability using an internal joint stabilizer. Clin Orthop Relat Res. 2014;472(7):2049-60.
Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

  • Complex elbow instability requires balancing stability, mobility, and concentric reduction [1].
  • Further research, particularly multicenter prospective trials, is needed for complex elbow instability due to the rare nature of these injuries [1].
  • Elbow instability in children involves nontraumatic causes as well as traumatic injuries [2].
  • Elbow arthroscopy is a valid and safe option for diagnosing and treating acute elbow instability [3].
  • Elbow arthroscopy is a valid and safe option for diagnosing and treating chronic elbow instability [3].
  • Elbow arthroscopy allows management of soft tissue lesions in elbow instability with minimal disruption [3].
  • Elbow arthroscopy allows management of associated intra-articular bone or cartilage lesions in elbow instability with minimal disruption [3].
  • Elbow arthroscopy is a valuable tool for diagnosing chronic elbow instability [6].
  • Elbow arthroscopy is a valuable tool for managing chronic elbow instability [6].
  • Elbow instability injuries are an infrequent source of disability for select NCAA athletes [4].
  • Elbow instability injuries are a serious source of disability for select NCAA athletes [4].
  • There are associated risk factors for elbow instability injuries in NCAA athletes [4].
  • Good long-term outcomes are reported after non-operative management of simple elbow dislocations [8].
  • Approximately 2% of patients require surgical intervention if simple elbow dislocations are treated nonoperatively [8].
  • Approximately 8% of patients develop persistent instability symptoms if simple elbow dislocations are treated nonoperatively [8].
  • A standard surgical protocol for treating elbow dislocations with radial head and coronoid fractures restores sufficient stability to allow early motion postoperatively [17].
  • Early motion postoperatively enhances functional outcome in elbow dislocations with radial head and coronoid fractures treated with a standard surgical protocol [17].
  • Operative repair is indicated for most fracture-dislocations of the elbow to restore sufficient osseoligamentous support [20].
  • Restoring sufficient osseoligamentous support allows safe, early motion in elbow fracture-dislocations [20].
  • Restoring sufficient osseoligamentous support provides a stable functional elbow in the long term for elbow fracture-dislocations [20].
  • Current evidence regarding the optimal elbow flexion angle for graft fixation in ulnar collateral ligament reconstruction possesses a high degree of fragility [25].
  • Further studies with objective measurements are needed to determine the optimal elbow flexion angle for graft fixation in ulnar collateral ligament reconstruction [25].
  • Surgery is indicated for unstable elbows requiring flexion beyond 50 to 60 degrees to remain reduced [27].
  • Surgery is indicated for unstable periarticular fractures [27].
  • Instability is the major complication of unlinked total elbow arthroplasty [30].
  • Instability after unlinked total elbow arthroplasty often requires revision [30].
  • Linked arthroplasty is preferred for patients with posttraumatic articular damage [30].
  • Linked arthroplasty is preferred for patients with ligamentous instability [30].
  • Linked arthroplasty is preferred for patients with deformity [30].
  • Linked arthroplasty is preferred for patients with bone loss [30].

Anatomy & Pathophysiology

  • The elbow consists of static and dynamic stabilizers that function in synchrony to prevent elbow instability [18].
  • Simple dislocations of the elbow are highly congruent joints with inherent stability provided by bony structures and dynamic stabilizers [28].
  • Understanding elbow biomechanics and the injury mechanism provides valuable insight into the variations of pathology that may be observed [21].
  • Recognising the precise pattern of injury is critical in restoring elbow function and preventing chronic instability, pain and weakness [9].
  • An understanding of the relevant anatomy and the factors associated with elbow stability allows for the application of a systematic algorithm for treatment [12].
  • Optimal outcomes are founded upon concentric reduction of the elbow [19].
  • The primary goal of treatment is stable reduction of the ulnohumeral joint and functional elbow motion [15].
  • A stiff, congruent elbow is preferable to an unstable elbow [36].
  • PLRI of the elbow remains to be fully understood [34].

Classification

  • Complex elbow instability is a distinct clinical entity requiring a balance between stability, mobility, and concentric reduction [1].
  • Complex elbow instability is rare, necessitating multicenter prospective trials for further research [1].
  • Elbow instability in children includes nontraumatic causes in addition to traumatic injuries [2].
  • The Wrightington classification of traumatic elbow instability is a comprehensive, reliable, and valid classification system [32].
  • The Wrightington classification is associated with treatment algorithms that lead to good functional outcomes [32].
  • Understanding the precise pattern of injury is critical for restoring elbow function and preventing chronic instability, pain, and weakness [9].
  • Elbow instability injuries are an infrequent but serious source of disability for select NCAA athletes [4].
  • Elbow instability injuries in NCAA athletes have associated risk factors [4].
  • The elbow consists of static and dynamic stabilizers that function in synchrony to prevent instability [18].
  • Understanding elbow biomechanics and injury mechanisms provides insight into variations of pathology in traumatic elbow instability [21].
  • Understanding patterns of traumatic elbow instability helps surgeons counsel and manage patients [7].
  • An algorithmic approach to diagnosis and treatment of complex elbow fracture-dislocations can improve diagnostic assessment and reconstruction of bony and ligamentous restraints [29].
  • A systematic algorithm for treatment of terrible triad injuries, based on anatomy and stability factors, ensures sufficient stability for early motion and improved outcomes [12].
  • A treatment algorithm for elbow dislocations, ranging from soft tissue injuries to complex fracture-dislocations, is based on clinical evidence and addresses basic scientific aspects of treating elbow stiffness [22].

Clinical Presentation

  • Complex elbow instability is a challenging clinical entity requiring a balance between stability, mobility, and concentric reduction [1].
  • Elbow instability in children includes nontraumatic causes [2].
  • Elbow arthroscopy is a valid and safe option for the diagnosis of acute elbow instability [3].
  • Elbow arthroscopy is a valid and safe option for the diagnosis of chronic elbow instability [3].
  • Elbow arthroscopy is a valid and safe option for the treatment of acute elbow instability [3].
  • Elbow arthroscopy is a valid and safe option for the treatment of chronic elbow instability [3].
  • A simple elbow dislocation that is rotationally unstable can be stabilized by simply repositioning the forearm [5].
  • Understanding the patterns of traumatic elbow instability helps the surgeon counsel and manage patients with these injuries [7].
  • Good long-term outcomes have been reported after non-operative management of simple elbow dislocations [8].
  • A small proportion (2%) of patients require surgical intervention if simple elbow dislocations are treated nonoperatively [8].
  • All patients in the series of lateral collateral ligament instability had resolution of their symptoms of instability [10].
  • Patients with lateral collateral ligament instability regained a near full arc of elbow flexion and forearm rotation [10].
  • Fixation or replacement of injured bony elements, ligamentous repair, and hinged fixation may be used to successfully manage complex elbow instability [11].
  • An understanding of the relevant anatomy and factors associated with elbow stability allows the application of a systematic algorithm for treatment of terrible triad injuries [12].
  • The systematic algorithm for terrible triad injury treatment helps ensure sufficient elbow stability to allow early motion [12].
  • Early motion in terrible triad injury leads to improved outcomes in most patients [12].
  • The next challenge for elbow surgeons is to diagnose and fix persistent subclinical instability after surgery to prevent the onset of post-traumatic osteoarthritis [13].
  • Simple elbow dislocations are usually managed by closed reduction and early motion [16].
  • Recurrent instability is uncommon in simple elbow dislocations due to intrinsic bony stability [16].
  • Posterolateral rotatory instability of the elbow is a clinical syndrome caused by insufficiency of the lateral ulnar collateral ligament [23].
  • Posterolateral rotatory instability of the elbow presents with clicking, locking, or recurrent dislocation [23].
  • Most simple elbow dislocations are readily managed nonoperatively [24].
  • Most simple elbow dislocations are amenable to early mobilization [24].
  • The variability in patients' pathoanatomic conditions in chronic complex persistent elbow instability requires customized surgical treatment [31].
  • Surgical treatment for chronic complex persistent elbow instability is aimed at elbow stabilizer reconstruction when the ulnohumeral joint is preserved [31].
  • Surgical treatment for chronic complex persistent elbow instability is aimed at joint replacement in case of severe articular degeneration [31].

Investigations

  • Complex elbow instability requires recognition of the precise injury pattern to restore function and prevent chronic instability, pain, and weakness [9].
  • Elbow instability injuries are an infrequent but serious source of disability for select National Collegiate Athletic Association (NCAA) athletes [4].
  • Proximal radioulnar translocation with radial neck fracture and elbow dislocation is an extremely rare injury in children that requires careful radiographic evaluation to avoid delayed diagnosis [46].
  • Concomitant vascular lesions, such as brachial artery transection, must be considered when confronted with elbow dislocations [44].
  • Elbow arthroscopy is a valid and safe option for the diagnosis of both acute and chronic elbow instability [3].
  • Elbow arthroscopy is a valuable tool in the diagnosis of chronic elbow instability [6].
  • Nontraumatic causes of elbow instability in children are addressed in current concepts of pediatric elbow injuries [2].

Treatment

Non-Operative Management

  • Most simple elbow dislocations are readily managed nonoperatively and are amenable to early mobilization [24].
  • Conservative treatment with early functional training of the elbow remains the first-line therapy for simple elbow dislocation [43].
  • Simple elbow dislocations should be managed with early range of motion, as most do not require surgery [42].
  • Rehabilitation programs for simple elbow dislocations should stress early active range of motion through the stable arc of motion [5].

Operative Management

  • Operative repair is indicated for most fracture-dislocations of the elbow to restore sufficient osseoligamentous support to allow safe, early motion and provide a stable functional elbow in the long term [20].
  • Surgery is indicated for unstable elbows requiring flexion beyond 50 to 60 degrees to remain reduced or for unstable periarticular fractures [27].
  • Elbow valgus instability in the throwing athlete may be managed either nonsurgically or surgically [39].
  • Use of a standard surgical protocol for elbow dislocations with radial head and coronoid fractures restored sufficient elbow stability to allow early motion postoperatively, enhancing the functional outcome [17].
  • Both Jobe and Docking techniques are safe and effective in the treatment of posterolateral elbow instability [26].

Arthroscopic Management

  • Elbow arthroscopy has become a valid and safe option for the diagnosis and treatment of both acute and chronic elbow instability, allowing for the management of soft tissue lesions and associated intra-articular bone or cartilage lesions with minimal disruption [3].
  • Elbow arthroscopy is a valuable tool in the diagnosis and management of chronic elbow instability [6].
  • Elbow arthroscopy is not necessarily contraindicated in patients with a subluxating or transposed ulnar nerve [35].

Surgical Goals and Outcomes

  • The primary goal of treatment for nonacute elbow fracture with persistent ulnohumeral dislocation or subluxation is stable reduction of the ulnohumeral joint and functional elbow motion [15].
  • Optimal outcomes for traumatic elbow instability are founded upon concentric reduction of the elbow [19].
  • Complex elbow instability requires a balance between stability, mobility, and concentric reduction [1].
  • Despite progress in surgical techniques and rehabilitation, treatments for elbow instability remain challenging with high rates of persistent instability, post-traumatic arthritis, stiffness, and pain in demanding cases [33].
  • Few patients with simple elbow dislocations develop complications requiring surgery [14].
  • Patients with simple elbow dislocations who require surgery most commonly undergo soft-tissue stabilisation or contracture release within 4 years of the injury [14].
  • A small proportion (2%) of patients require surgical intervention for simple elbow dislocations [8].

Complications

  • Approximately 8% of patients treated nonoperatively for simple elbow dislocation develop persistent instability symptoms [8].
  • A small proportion (2%) of patients with simple elbow dislocation require surgical intervention [8].
  • Persistent subclinical instability after surgery can lead to the onset of post-traumatic osteoarthritis [13].
  • Patients with simple elbow dislocations who develop complications most commonly undergo soft-tissue stabilisation or contracture release within 4 years of the injury [14].
  • Instability is the major complication of unlinked total elbow arthroplasty, often requiring revision [30].
  • Linked arthroplasty is preferred for patients with posttraumatic articular damage, ligamentous instability, deformity, or bone loss [30].
  • Ulnar collateral ligament reconstruction (UCLR) demonstrates low complication and revision rates at minimum 48-month mean follow-up [38].
  • There is a distinct difference in complication profile between external fixation and the IJS when used as treatment for traumatic elbow instability [40].

Recovery

  • Rehabilitation programs for rotationally unstable simple elbow dislocations should stress early active range of motion through the stable arc of motion [5].
  • Non-operative management of simple elbow dislocations yields good long-term outcomes [8].
  • Approximately 2% of patients treated nonoperatively for simple elbow dislocation require surgical intervention [8].
  • Recognizing the precise pattern of injury is critical in restoring elbow function and preventing chronic instability, pain, and weakness [9].
  • Diagnosing and fixing persistent subclinical instability after surgery is necessary to prevent the onset of post-traumatic osteoarthritis [13].
  • Patients with simple elbow dislocations who require subsequent surgery most commonly undergo soft-tissue stabilization or contracture release within 4 years of the injury [14].
  • Recurrent instability is uncommon after simple elbow dislocation due to intrinsic bony stability [16].
  • Use of a standard surgical protocol for elbow dislocations with radial head and coronoid fractures restores sufficient elbow stability to allow early motion postoperatively [17].
  • Early motion postoperatively enhances functional outcome in the treatment of elbow dislocations with radial head and coronoid fractures [17].
  • Athletes with elbow dislocation demonstrate excellent functional outcomes and high return to sport rates [41].
  • Most athletes with elbow dislocation return to sport within 10 weeks [41].
  • The prognosis for simple elbow dislocations is better than for complex dislocations [47].
  • Prolonged immobilization is associated with unsatisfactory results in elbow dislocations [47].

Key Evidence

  • [L5] Complex elbow instability remains a challenging clinical entity requiring a balance between stability, mobility, and concentric reduction; further research, particularly multicenter prospective trials, is needed due to the rare nature of these injuries. [1] (10.1016/j.hcl.2007.11.010)
  • [L5] The article reviews current concepts of injuries leading to elbow instability in children, discusses recognition and treatment of instability, and addresses nontraumatic causes. [2] (10.1016/j.hcl.2007.11.007)
  • [L5] Elbow arthroscopy has become a valid and safe option for the diagnosis and treatment of both acute and chronic elbow instability, allowing for the management of soft tissue lesions and associated intra-articular bone or cartilage lesions with minimal disruption. [3] (10.1016/j.jseint.2022.12.001)
  • [L4] Elbow instability injuries are an infrequent but serious source of disability for select NCAA athletes, with a number of associated risk factors. [4] (10.1177/2325967117750105)
  • [L5] A simple elbow dislocation that is rotationally unstable can be stabilized by simply repositioning the forearm, and rehabilitation programs should stress early active range of motion through the stable arc of motion. [5] (10.1016/j.hcl.2015.06.002)
  • [L4] Elbow arthroscopy is a valuable tool in the diagnosis and management of chronic elbow instability. [6] (10.1016/j.arthro.2013.08.016)
  • [L5] Understanding the patterns of traumatic elbow instability helps the surgeon counsel and manage patients with these injuries. [7] (10.1016/j.jhsa.2010.05.002)
  • [L5] Good long-term outcomes have been reported after non-operative management of simple elbow dislocations; however, a small proportion (2%) of patients require surgical intervention and approximately 8% develop persistent instability symptoms if treated nonoperatively. [8] (10.1177/1758573217694163)
  • [Paper] Recognising the precise pattern of injury is critical in restoring elbow function and preventing chronic instability, pain and weakness. [9] (10.1016/j.injury.2013.09.032)
  • [L4] All patients in the series had resolution of their symptoms of instability and regained a near full arc of elbow flexion and forearm rotation. [10] (10.1016/j.hcl.2007.11.001)
  • [L5] Fixation or replacement of injured bony elements, ligamentous repair, and hinged fixation may be used to successfully manage complex elbow instability. [11] (10.5435/00124635-200605000-00003)
  • [L5] Despite the complexities of this injury, an understanding of the relevant anatomy and the factors associated with elbow stability allows the application of a systematic algorithm for treatment that can help ensure sufficient elbow stability to allow early motion, thereby leading to improved outcomes in most patients. [12] (10.5435/00124635-200903000-00003)
  • [L5] The next challenge for elbow surgeons is to diagnose and fix persistent subclinical instability after surgery to prevent the onset of post-traumatic osteoarthritis. [13] (10.1016/j.jseint.2023.03.018)
  • [Paper] Few patients with simple elbow dislocations develop complications requiring surgery, but those that do most commonly undergo soft-tissue stabilisation or contracture release within 4 years of the injury. [14] (10.1016/j.injury.2015.02.009)
  • [L5] The primary goal of treatment is stable reduction of the ulnohumeral joint and functional elbow motion. [15] (10.2106/jbjs.m.00817)
  • [L5] Simple elbow dislocations are usually managed by closed reduction and early motion, with recurrent instability being uncommon due to intrinsic bony stability. [16] (10.1016/j.hcl.2007.11.012)
  • [L4] Use of the surgical protocol restored sufficient elbow stability to allow early motion postoperatively, enhancing the functional outcome. [17] (10.2106/jbjs.d.02933)
  • [L5] The elbow consists of static and dynamic stabilizers that function in synchrony to prevent elbow instability. [18] (10.1016/j.jhsa.2016.11.025)
  • [L5] Optimal outcomes are founded upon concentric reduction of the elbow. [19] (10.1016/j.jseint.2023.03.020)
  • [L5] Operative repair is indicated for most of these injuries to restore sufficient osseoligamentous support to allow safe, early motion and provide a stable functional elbow in the long term. [20] (10.1016/j.hcl.2004.06.005)
  • [L4] Understanding elbow biomechanics and the injury mechanism provides valuable insight into the variations of pathology that may be observed. [21] (10.5435/jaaos-d-14-00023)
  • [L5] The authors present a treatment algorithm based on their clinical evidence and discuss new basic scientific aspects of treating elbow stiffness. [22] (10.1155/2013/951397)
  • [L5] Posterolateral rotatory instability of the elbow is a clinical syndrome caused by insufficiency of the lateral ulnar collateral ligament, presenting with clicking, locking, or recurrent dislocation. [23] (10.5435/00124635-200411000-00005)
  • [L5] Most simple elbow dislocations are readily managed nonoperatively and are amenable to early mobilization. [24] (10.1016/j.hcl.2020.07.013)
  • [L4] However, the available current evidence possesses a high degree of fragility, and further studies are needed with objective measurements to determine the optimal elbow flexion angle for graft fixation. [25] (10.1016/j.jse.2018.07.029)
  • [L1] This systematic review showed that both Jobe and Docking techniques are safe and effective in the treatment of posterolateral elbow instability. [26] (10.1016/j.injury.2020.11.010)
  • [L5] Surgery is indicated for unstable elbows requiring flexion beyond 50 to 60 degrees to remain reduced or for unstable periarticular fractures. [27] (10.5435/00124635-199801000-00002)
  • [L5] Simple dislocations of the elbow are highly congruent joints with inherent stability provided by bony structures and dynamic stabilizers, allowing for early active range of motion during rehabilitation. [28] (10.1016/j.hcl.2004.07.002)
  • [L5] An algorithmic approach to the diagnosis and treatment of complex elbow fracture-dislocation injuries can improve the diagnostic assessment and reconstruction of the bony and ligamentous restraints to restore a stable and functional elbow. [29] (10.5435/jaaos-d-23-00460)
  • [L4] Instability is the major complication of unlinked total elbow arthroplasty, often requiring revision, whereas linked arthroplasty is preferred for patients with posttraumatic articular damage, ligamentous instability, deformity, or bone loss. [30] (10.1016/j.hcl.2007.11.002)
  • [L4] The variability in patients' pathoanatomic conditions requires customized surgical treatment aimed at elbow stabilizer reconstruction when the ulnohumeral joint is preserved or aimed at joint replacement in case of severe articular degeneration. [31] (10.1016/j.jse.2019.11.021)
  • [L5] The Wrightington classification of elbow fracture dislocation is a comprehensive, reliable, and valid classification with treatment algorithms that are associated with good functional outcomes. [32] (10.1016/j.jseint.2022.12.002)
  • [L5] Despite progress in surgical techniques and rehabilitation, treatments for elbow instability remain challenging with high rates of persistent instability, post-traumatic arthritis, stiffness, and pain in demanding cases. [33] (10.1136/jisakos-2019-000316)
  • [L4] PLRI of the elbow remains to be fully understood. [34] (10.1016/j.arthro.2014.02.029)
  • [L4] Elbow arthroscopy is not necessarily contraindicated in patients with a subluxating or transposed ulnar nerve. [35] (10.1016/j.arthro.2009.04.024)
  • [L5] A stiff, congruent elbow is preferable to an unstable elbow. [36] (10.1016/j.hcl.2017.09.008)
  • [L4] UCLR provides excellent patient-reported and clinical outcomes to patients at medium-term follow-up with low complication and revision rates. [38] (10.1136/jisakos-2021-000614)
  • [L5] Elbow valgus instability in the throwing athlete may be managed either nonsurgically or surgically. [39] (10.5435/00124635-200611000-00014)
  • [L4] The literature demonstrates a distinct difference in complication profile between external fixation and the IJS when used as treatment for traumatic elbow instability. [40] (10.1016/j.xrrt.2023.12.004)
  • [L4] Athletes with elbow dislocation demonstrated excellent functional outcomes and high return to sport rates, with most returning within 10 weeks. [41] (10.1177/23259671261419505)
  • [L5] Simple elbow dislocations should be managed with early range of motion, as most do not require surgery. [42] (10.1016/j.hcl.2016.08.003)
  • [L1] Conservative treatment with early functional training of the elbow remains the first-line therapy for simple elbow dislocation. [43] (10.1186/s12891-024-07260-0)
  • [Case_report] This case should sensitize the readers for concomitant vascular lesions when confronted with elbow dislocations. [44] (10.1007/s00167-010-1202-5)
  • [Case_report] Proximal radioulnar translocation with radial neck fracture and elbow dislocation is an extremely rare injury in children that requires careful radiographic evaluation to avoid delayed diagnosis. [46] (10.1007/s00402-013-1820-8)
  • [L5] The prognosis for simple dislocations is better than for complex dislocations, and prolonged immobilization is associated with unsatisfactory results. [47] (10.1016/j.csm.2004.04.014)

References

[1] Complex Elbow Instability. Hand Clinics. 2008. DOI: 10.1016/j.hcl.2007.11.010

[2] Elbow Instability in Children. Hand Clinics. 2008. DOI: 10.1016/j.hcl.2007.11.007

[3] The role of arthroscopy in instability of the elbow. JSES International. 2023. DOI: 10.1016/j.jseint.2022.12.001

[4] Elbow Dislocation and Subluxation Injuries in the National Collegiate Athletic Association, 2009-2010 Through 2013-2014. Orthopaedic Journal of Sports Medicine. 2018. DOI: 10.1177/2325967117750105

[5] Simple Elbow Dislocation. Hand Clinics. 2015. DOI: 10.1016/j.hcl.2015.06.002

[6] The Role of Arthroscopy in Chronic Elbow Instability. Arthroscopy. 2013. DOI: 10.1016/j.arthro.2013.08.016

[7] Traumatic Elbow Instability. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.05.002

[8] Simple elbow dislocation. Shoulder & Elbow. 2017. DOI: 10.1177/1758573217694163

[9] Complex instability of the elbow. Injury. 2017. DOI: 10.1016/j.injury.2013.09.032

[10] Lateral Collateral Ligament Instability of the Elbow. Hand Clinics. 2008. DOI: 10.1016/j.hcl.2007.11.001

[11] Complex Elbow Instability. Journal of the American Academy of Orthopaedic Surgeons. 2006. DOI: 10.5435/00124635-200605000-00003

[12] Terrible Triad Injury of the Elbow: Current Concepts. Journal of the American Academy of Orthopaedic Surgeons. 2009. DOI: 10.5435/00124635-200903000-00003

[13] Terrible triad injury of the elbow: a spectrum of theories. JSES International. 2023. DOI: 10.1016/j.jseint.2023.03.018

[14] The frequency and risk factors for subsequent surgery after a simple elbow dislocation. Injury. 2015. DOI: 10.1016/j.injury.2015.02.009

[15] Nonacute Treatment of Elbow Fracture with Persistent Ulnohumeral Dislocation or Subluxation. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.00817

[16] Acute Dislocations of the Adult Elbow. Hand Clinics. 2008. DOI: 10.1016/j.hcl.2007.11.012

[17] Standard Surgical Protocol to Treat Elbow Dislocations with Radial Head and Coronoid Fractures. Journal of Bone and Joint Surgery. 2005. DOI: 10.2106/jbjs.d.02933

[18] Elbow Instability: Anatomy, Biomechanics, Diagnostic Maneuvers, and Testing. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2016.11.025

[19] Coronoid fractures and traumatic elbow instability. JSES International. 2023. DOI: 10.1016/j.jseint.2023.03.020

[20] Fracture-dislocation of the elbow: diagnosis, treatment, and prognosis. Hand Clinics. 2004. DOI: 10.1016/j.hcl.2004.06.005

[21] Management of Complex Elbow Dislocations. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-d-14-00023

[22] Elbow Dislocations: A Review Ranging from Soft Tissue Injuries to Complex Elbow Fracture Dislocations. Advances in Orthopedics. 2013. DOI: 10.1155/2013/951397

[23] Posterolateral Rotatory Instability of the Elbow. Journal of the American Academy of Orthopaedic Surgeons. 2004. DOI: 10.5435/00124635-200411000-00005

[24] Elbow Instability. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.07.013

[25] Elbow flexion angle during graft fixation for ulnar collateral ligament reconstruction: a systematic review of outcomes and complications. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.07.029

[26] Lateral collateral ulnar ligament reconstruction techniques in posterolateral rotatory instability of the elbow: A systematic review. Injury. 2022. DOI: 10.1016/j.injury.2020.11.010

[27] Acute Elbow Dislocation: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199801000-00002

[28] Simple dislocations of the elbow: evaluation and treatment. Hand Clinics. 2004. DOI: 10.1016/j.hcl.2004.07.002

[29] Complex Elbow Fracture-Dislocations: An Algorithmic Approach to Treatment. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-00460

[30] Instability After Total Elbow Arthroplasty. Hand Clinics. 2008. DOI: 10.1016/j.hcl.2007.11.002

[31] Chronic complex persistent elbow instability: a consecutive and prospective case series and review of recent literature. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.11.021

[32] “How the Wrightington classification of traumatic elbow instability can simplify the algorithm for treatment”. JSES International. 2023. DOI: 10.1016/j.jseint.2022.12.002

[33] Treatment of elbow instability: state of the art. Journal of ISAKOS. 2021. DOI: 10.1136/jisakos-2019-000316

[34] Surgical Treatment of Posterolateral Rotatory Instability of the Elbow. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.02.029

[35] Is Elbow Arthroscopy Safe in Patients with a Subluxating ulnar nerve or Previous Ulnar Nerve Transposition? (SS‐24). Arthroscopy. 2009. DOI: 10.1016/j.arthro.2009.04.024

[36] Elbow Fractures with Instability. Hand Clinics. 2018. DOI: 10.1016/j.hcl.2017.09.008

[38] Ulnar collateral ligament reconstruction of the elbow at minimum 48-month mean follow-up demonstrates excellent clinical outcomes with low complication and revision rates: systematic review. Journal of ISAKOS. 2021. DOI: 10.1136/jisakos-2021-000614

[39] Elbow Valgus Instability in the Throwing Athlete. Journal of the American Academy of Orthopaedic Surgeons. 2006. DOI: 10.5435/00124635-200611000-00014

[40] Comparing internal and external stabilization for traumatic elbow instability: a systematic review. JSES Reviews, Reports, and Techniques. 2024. DOI: 10.1016/j.xrrt.2023.12.004

[41] Return to Sport Following Elbow Dislocation: A Systematic Review. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261419505

[42] Elbow Dislocations in Contact Sports. Hand Clinics. 2017. DOI: 10.1016/j.hcl.2016.08.003

[43] Treatment strategies for simple elbow dislocation - a systematic review. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07260-0

[44] Brachial artery transection caused by closed elbow dislocation in a mature in‐line skater: a case report with review of the literature. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1202-5

[46] Proximal radioulnar translocation associated with elbow dislocation and radial neck fracture in child: a case report and review of literature. Archives of Orthopaedic and Trauma Surgery. 2013. DOI: 10.1007/s00402-013-1820-8

[47] Elbow dislocations in adults and children. Clinics in Sports Medicine. 2004. DOI: 10.1016/j.csm.2004.04.014

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