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Elbow Instability

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

119 citationsUpdated Oct 2026

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Overview

Complex elbow instability is a challenging clinical entity that requires a precise balance between stability, mobility, and concentric reduction [3]. Recognizing all possible lesions is critical to achieving optimal outcomes, although consistent success has not yet been achieved despite improved understanding of the joint [1, 2]. These injuries are infrequent but represent a serious source of disability for select athletes [13]. The condition encompasses traumatic fracture-dislocations, such as the terrible triad, as well as nontraumatic causes in children [5, 79]. Surgical management is indicated when the elbow remains unstable, particularly if flexion beyond 50 to 60 degrees is required to maintain reduction or in the presence of unstable periarticular fractures [77]. For most elbow fracture-dislocations, operative repair is necessary to restore sufficient osseoligamentous support, allowing for safe early motion and a stable functional elbow in the long term [49].

Non-operative management of simple elbow dislocations yields good long-term outcomes, with all patients in reported series regaining a near-full arc of flexion and forearm rotation [4, 8]. However, approximately 8% of patients develop persistent instability symptoms, and a small proportion (2%) require surgical intervention [8]. Arthroscopy provides a safe and objective means to evaluate and diagnose both medial and lateral instability, allowing for the management of soft tissue and associated intra-articular bone or cartilage lesions with minimal disruption [6, 9, 11]. A systematic diagnostic pathway that assesses stability and applies individualized, less invasive surgical procedures has acquired high patient satisfaction and good clinical outcomes with a low complication rate [29]. Starting appropriate early range of motion rehabilitation helps achieve optimal outcomes with both surgical and nonsurgical treatments [28].

Treatment of the terrible triad must restore the integrity of the elbow by repairing all structures using a standardized surgical protocol to ensure the best results and prognosis [79]. In cases of persistent instability after fracture-dislocation, a treatment protocol incorporating hinged external fixation can restore a stable, functional elbow in most patients [48]. Ulnohumeral cross-pinning for persistent and recurrent instability results in maintained ulnohumeral joint alignment, functional arcs of range of motion, and acceptable patient-reported outcome measures [30]. For patients with posttraumatic articular damage, ligamentous instability, deformity, or bone loss, linked arthroplasty is preferred over unlinked total elbow arthroplasty, where instability is the major complication often requiring revision [83]. The lateral ulnar collateral ligament is the most critical structure to repair or reconstruct when surgical management is indicated for persistent instability [86]. Further research, particularly multicenter prospective trials, is needed due to the rare nature of these injuries [3].

Anatomy & Pathophysiology

Bony Anatomy

The elbow is a trocho-ginglymoid joint consisting of medial and lateral articulations that afford bony stability [97]. The ulnohumeral joint is a hinged or trochoid portion where the trochlea articulates with the ulna within the greater sigmoid notch [97]. This articulation provides highly congruent anatomy through almost 180° of articular contact, with the exception of a bare area of the greater sigmoid notch devoid of cartilage [97]. The coronoid process has medial and lateral facets that buttress the trochlea anteriorly [97]. The sublime tubercle is located just distal and medial to the coronoid and provides the attachment site for the anterior bundle of the medial ulnar collateral ligament [97]. The radiocapitellar joint is formed by the capitellum and radial head [97]. The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [97]. The radius is held in close approximation to the ulna at the proximal radioulnar joint by the annular ligament [97].

The distal humeral articulation is angled 30° from the longitudinal axis [97]. The axis of rotation is 5° to 7° angulated in the coronal plane to the epicondylar axis, with the medial side more distal than the lateral side [97]. The ulna medially bends approximately 8° at 8 cm from the tip of the olecranon [97]. The articulation to the tip of the coronoid is approximately 30° from the long axis of the ulna in the sagittal plane [97]. The humeroulnar joint is a ginglymus (hinge) joint with intrinsic stability resulting from the depth of the trochlear fossa [62]. The trochlear groove is made more stable by the olecranon and coronoid processes [62]. The ulnohumeral articulation contributes to elbow stability, and olecranon resection increases valgus angulation and medial collateral ligament strain during valgus stress [22]. In full extension, 60% of axial load is transmitted through the radiocapitellar joint [100].

The normal range of elbow flexion/extension is 0 to 150 degrees [100]. The normal forearm pronosupination is 80 to 85 degrees in each direction [100]. The functional range of motion for the elbow is 30 to 130 degrees of flexion/extension and 50 degrees of pronosupination [100]. The normal valgus carrying angle of the elbow is 5 to 10 degrees for men and 10 to 15 degrees for women [100].

Ligamentous Anatomy

The medial collateral ligament complex comprises three ligaments: the anterior oblique, the posterior oblique, and the transverse [36]. The anterior oblique ligament is the strongest component of the medial collateral ligament complex and is the primary stabilizer to valgus stress [36]. It is composed of anterior and posterior bands that provide reciprocal function in resisting valgus stress through the range of flexion-extension motion [36]. The anterior band of the medial collateral ligament is taut in extension, and the posterior band is tight in flexion [36]. The anterior oblique ligament originates on the anterior-inferior edge of the medial epicondyle and inserts on the sublime tubercle of the ulna [36]. The posterior bundle of the medial collateral ligament is the primary restraint to valgus stress with the elbow in maximal flexion [100]. Stability in full extension is provided by the medial collateral ligament, joint capsule, and ulnohumeral articulation [100].

The lateral collateral ligament complex includes the radial collateral ligament, annular ligament, and lateral ulnar collateral ligament [148]. The lateral collateral ligament is the primary varus and posterolateral rotational stabilizer of the elbow [148]. The radial collateral ligament arises from the lateral epicondyle and blends with the annular ligament [148]. The lateral ulnar collateral ligament is posterior to the radial collateral ligament and attaches to the crista supinatoris of the proximal ulna, just distal to the annular ligament [148]. The radial head plays a minor role in posterolateral rotatory stability by tensioning the lateral ulnar collateral ligament [145]. Both the lateral ulnar collateral ligament and radial collateral ligament must be compromised for the lateral ligaments to become insufficient [145].

The coronoid blocks rotational instability and posterior subluxation of the ulna from the posterior pull of the triceps or when weight bearing on the hand [145]. Fifty percent of the coronoid height is needed to provide substantial stability [145]. Sagittal plane fractures of the coronoid may disrupt the medial collateral ligament insertion or cause substantial articular deformity [145]. The medial collateral ligament becomes the primary constraint to valgus instability when the radial head is resected [145]. Injuries to the medial collateral ligament in isolation are typically well tolerated, except in overhead throwers [145].

Stability Mechanisms

Elbow stability is provided by a combination of bony congruity, static ligamentous and capsular restraints, and dynamic muscular activation [82]. The primary static constraints to elbow instability are the ulnohumeral articulation, the anterior bundle of the medial collateral ligament, and the lateral collateral ligament complex [145]. The secondary static constraints include the capsule, the radiocapitellar articulation, and the common flexor and extensor tendon origins [145]. The joint capsule has the most stabilizing effect with the elbow extended [145]. The radiocapitellar articulation is an important secondary valgus stabilizer [145].

Dynamic constraint is provided by the muscles that cross the elbow joint, specifically the anconeus, triceps, and brachialis, which apply compressive force [145]. The common extensor muscles provide varus stability and the common flexor muscles provide valgus stability [148]. Pronation stabilizes the lateral collateral ligament-deficient elbow while supination decreases stability in this setting [148]. The elbow ligaments may provide significant sensory function to the elbow joint, in addition to being its major mechanical restraints [119]. A healthy elbow is reduced, meaning its joint surfaces are well aligned, and stable, meaning joint alignment is maintained throughout its entire range of movement regardless of physiological stresses [12]. Dislocation or subluxation is defined as a static condition characterized by a loss of normal joint relationships [12]. Instability is defined as a dynamic condition where, due to movement or mechanical stress, a reduced joint can lose its congruency [12].

Pathophysiology of Instability

Elbow instability is considered a spectrum of injuries from the acute, traumatic dislocation to the chronic ligamentous laxity that results in transient joint subluxation [44]. The mechanism of elbow dislocation can be thought of as a circle of soft tissue disruption starting from the lateral side and progressing to the medial side in three stages [44]. The first stage of soft tissue disruption involves disruption of the lateral collateral ligament, resulting in subluxation of the joint surfaces [44]. The second stage involves disruption of the anterior and posterior capsular structures, which allows posterior rotation of the proximal ulna [44]. The third stage involves frank dislocation of the elbow as the remaining medial structures are partially or completely disrupted, allowing the coronoid process to rest behind the humerus [44].

Simple elbow dislocations are typically the result of a fall on an outstretched hand involving a valgus, axial, and posterolateral force [134]. The soft tissue injury in simple dislocation is thought to begin on the lateral side of the elbow with disruption of the lateral collateral ligament and then proceeds through the capsule to the medial side with the medial collateral ligament being injured last [134]. Magnetic resonance imaging and video studies have shown that complete ligamentous tears are more common on the medial side of the elbow with the lateral ligaments being preserved in some cases [134]. These studies suggest that the sequence of failure may begin on the medial side of the elbow with acute valgus instability in an extended elbow [134]. Patients with simple elbow dislocations routinely have disruption of both the medial and lateral collateral ligaments and the elbow capsule [148]. The injury to the lateral common extensor origin is typically more extensive than the medial common flexor origin in simple dislocations [148].

Residual instability after simple dislocation is usually due to incompetence of the lateral collateral ligament in the majority of patients, as most activities of daily living exert a varus force on the elbow [148]. The medial collateral ligament is the most important stabilizer of the elbow joint only in patients who routinely load their elbow in valgus, such as throwing athletes [148]. When the elbow dislocates, the radial head may cause an impression fracture of the posterior capitellum which can contribute to recurrent instability [148]. Posterolateral rotatory instability is one part of the spectrum of elbow instability and must be regarded from a global perspective [62]. In posterolateral rotatory instability, the coronoid process abuts the trochlea, and increasing external rotation (supination) of the ulna will push the coronoid process beneath the trochlea [62]. Recognising the precise pattern of injury is critical in restoring elbow function and preventing chronic instability, pain and weakness [23].

Elbow trauma can disrupt static and dynamic stabilizers leading to predictable patterns of instability dependent on the mechanism of injury and a progressive failure of anatomic structures [82]. Loads across the elbow joint at the time of injury seem to lead to specific patterns of complex elbow instability [184]. There are 3 main patterns of instability in elbow fracture-dislocation: valgus posterolateral rotatory instability, varus posteromedial rotatory instability, and transolecranon fracture-dislocation [92]. The classic mechanism for posterolateral dislocations is a combination of axial load, external rotation of the forearm (supination), and valgus force [145]. Posterolateral elbow dislocation may also occur with a combination of axial load, external rotation of the forearm, and varus force [145]. The lateral collateral ligament complex is disrupted with all elbow dislocations [145]. Some authors believe that the medial collateral ligament is always disrupted with elbow dislocation, but this is controversial [145].

Elbow dislocations are characterized according to direction of the distal bone, with posterior dislocation being the most common type at 80% [19]. Posterior dislocations result from an axial force applied to the extended elbow and involve disruption of both collateral ligaments [19]. Anterior dislocations are relatively rare and typically involve severe soft-tissue damage [19]. Isolated radial head dislocation is rare and is usually accompanied by an ulnar fracture (Monteggia fracture) [19]. Isolated ulnar dislocations occur when the humerus pivots around the radial head, causing the coronoid process to be displaced posterior to the humerus or the olecranon anterior to the humerus [19]. The more common isolated ulnar dislocation is posterior, which causes cubitus varus deformity of the forearm [19]. Elbow dislocations occur when loads are placed on the structures about the elbow that exceed the intrinsic stability provided by the anatomic shape of the joint surfaces and soft-tissue constraints [19]. Elbow dislocations are potentially limb-threatening, as vascular compromise is a possible sequela [19].

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 coronoid fractures and traumatic elbow instability are founded upon concentric reduction of the elbow [76]. A stiff, congruent elbow is preferable to an unstable elbow [73]. The terrible triad injury of the elbow involves complex elbow instability involving both radial head, coronoid process, and ligament(s) injuries [14]. Post-traumatic osteoarthritis at long-term follow-up is still an issue for terrible triad injuries regardless of the treatments [14]. The terrible triad has given way to the subtle triad with persistent microinstability of the elbow [14]. The next challenge for elbow surgeons is to diagnose and fix persistent subclinical instability after surgery in order to prevent the onset of post-traumatic osteoarthritis [14]. Complex elbow dislocations may result in significant patient morbidity, including chronic instability, posttraumatic arthrosis, and poor functional outcomes [51].

Elbow dislocations represent the second most common medium to large joint dislocation of the upper extremity after the glenohumeral joint [92]. The incidence of elbow dislocations has been reported at 5.2 cases per 100,000 person-years [92]. Roughly one-quarter of all elbow dislocations involve a fracture [92]. The sequelae of elbow fracture-dislocations may include recurrent instability, posttraumatic arthritis, contracture, and poor functional results [92]. Approximately 8% of patients with simple elbow dislocations develop persistent instability symptoms if treated nonoperatively [8]. A small proportion (2%) of patients with simple elbow dislocations require surgical intervention [8]. A simple elbow dislocation that is rotationally unstable can be stabilized by simply repositioning the forearm [10]. Rehabilitation programs for simple elbow dislocations should stress early active range of motion through the stable arc of motion [10]. 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 [32].

Although it is uncommon following simple elbow dislocation, residual instability has been reported, with posterolateral instability being the best documented [89]. There do not appear to be any predisposing factors that pose any particular risk to patients for residual instability following simple elbow dislocation [89]. Posterolateral instability may develop in some patients despite the development of secondary contracture, suggesting that some ligamentous complexes heal in a contracted manner while others do not heal at all [89]. The lateral ulnar collateral ligament injury is the cause of recurrent instability following simple dislocation [19]. Posterolateral dislocation has been associated with persistent valgus instability in some patients, which is associated with a worse overall clinical result [19]. A loss of extension of 5–10 degrees compared with the contralateral elbow can be expected following uncomplicated elbow dislocation [19].

Elbow instability in the skeletally immature group is more commonly associated with a traumatic event than overuse injuries [80]. A review of 145 elbow dislocations at a single institution found that 80% of dislocations presented with a fracture [80]. The presence of multiple fractures, the need for surgical intervention, and prolonged immobilization were correlated with less than excellent functional outcome scores in pediatric elbow dislocations [80]. Posterolateral rotatory instability is much less common in children and is often diagnosed in a delayed manner [80]. Any child with a contracture of unclear etiology should be considered for posterolateral rotatory instability pathology [80]. Surgical correction of posterolateral rotatory instability in children is technically difficult and ligament reconstruction can risk injury to the lateral physes and apophyses [80]. The normal attachment of the anterior bundle of the medial ulnar collateral ligament is on the apophysis or epicondyle itself, and not on the condyle [80].

Little Leaguer’s elbow is an overuse injury in which there is stress at the medial epicondyle apophysis due to valgus overload caused by repetitive throwing [43]. The maximal valgus moment on the elbow occurs during the late cocking through early acceleration phase of throwing [43]. The valgus-hyperextension overloading of the elbow during throwing causes repetitive microtrauma and shear stresses to the medial elbow at the medial epicondyle physis, ulnar collateral ligament, and flexor pronator origin [78]. The syndrome of Little Leaguer’s elbow is associated with throwing curveballs or with an infielder bent-elbow throw that involves a whipping mechanism used to gain adequate speed [78]. The younger the patient, the more likely the diagnosis is to be an apophysitis or an avulsion injury, rather than an ulnar collateral ligament sprain [78]. Valgus extension overload syndrome is caused by the olecranon being repeatedly and forcefully driven into the olecranon fossa during throwing, exerting shear forces on the medial aspect of the olecranon tip and the olecranon fossa [22]. Medial ligamentous laxity commonly exacerbates valgus extension overload syndrome [22]. The pathoanatomy of valgus extension overload syndrome includes chondrosis, oste

Classification

Elbow dislocations are classified according to whether they are simple or complex and the direction of displacement [41]. A simple elbow dislocation is defined as a dislocation without osseous injury, whereas a complex elbow dislocation is defined as a dislocation with osseous injury [41]. Posterior dislocations are the most common direction of displacement and can be further classified as posterior, posterolateral, or posteromedial [41]. Anterior, medial, lateral, and divergent dislocations also occur in the elbow [41].

Terrible Triad: This entity is characterized by an elbow dislocation with an LCL complex tear, a radial head fracture, and a coronoid fracture [41].

Varus Posteromedial Rotatory Instability: This pattern is characterized by an LCL tear with a fracture of the medial facet of the coronoid or a comminuted coronoid fracture [41].

Three Main Types of Instability: All forms of elbow instability and dislocation can be grouped into three main types: not reduced-unstable, reduced-unstable, and not reduced-not reducible [12]. The "not reduced-unstable" type includes simple elbow dislocation not yet reduced and acute complex elbow instability [12]. The "reduced-unstable" type includes forms of temporary instability after a recent reduction of a simple elbow dislocation and chronic recurrent instability [12]. The "not reduced-not reducible" type includes simple elbow dislocation that is not reducible and persistent chronic dislocation [12]. Parameters for characterizing elbow instability include the stabilizers involved (simple or complex forms), timing (acute, chronic recurrent, or chronic persistent), and the extent of dislocation (subluxation or dislocation) [12].

Spectrum and Criteria: Elbow instability is considered a spectrum of injuries ranging from acute traumatic dislocation to chronic ligamentous laxity that results in transient joint subluxation [44]. Criteria for classifying elbow instability include timing (acute, chronic, recurrent), direction of displacement (valgus, varus, posterior, anterior), and the presence of articular subluxation or associated fractures [44].

Chronic Instability Patterns: Chronic instability of the adult elbow without associated fracture can be divided into valgus instability, posterolateral instability, and isolated radial head instability [154]. There are three main patterns of instability in elbow fracture-dislocation: valgus posterolateral rotatory instability, varus posteromedial rotatory instability, and transolecranon fracture-dislocation [92].

Wrightington Classification: The Wrightington classification of elbow fracture dislocation is a comprehensive, reliable, and valid classification with treatment algorithms associated with good functional outcomes [136].

Regan and Morrey Classification: This system classifies coronoid fractures into three types. Type I is defined as a fracture of the tip of the coronoid process [63]. Type II is defined as a fracture of 50% or less of the coronoid [63]. Type III is defined as a fracture of greater than 50% of the coronoid [63].

Modified Mason Classification: This system classifies radial head fractures into four types. Type I is defined as nondisplaced [63]. Type II is defined as partial articulation with displacement [63]. Type III is defined as comminuted fractures involving the entire head of the radius [63]. Type IV is defined as fractures associated with ligamentous injury or other associated fractures [63].

Clinical Presentation

General Principles and Classification

Elbow instability represents a spectrum of injuries ranging from acute traumatic dislocation to chronic ligamentous laxity resulting in transient joint subluxation [44]. A healthy elbow is defined as reduced, with joint surfaces well aligned, and stable, maintaining alignment throughout the range of movement regardless of physiological stresses [12]. Dislocation or subluxation is a static condition characterized by a loss of normal joint relationships, while instability is a dynamic condition where a reduced joint loses congruency due to movement or mechanical stress [12]. Elbow instability patterns are grouped into three main types: not reduced-unstable, reduced-unstable, and not reduced-not reducible [12]. The "reduced-unstable" type includes temporary instability after recent reduction of a simple elbow dislocation and chronic recurrent instability [12]. Complex elbow instability requires a balance between stability, mobility, and concentric reduction [3]. Classification of elbow instability considers timing (acute, chronic, recurrent), direction of displacement (valgus, varus, posterior, anterior), and the presence of articular subluxation or associated fractures [44]. Recognizing the precise pattern of injury is critical in restoring elbow function and preventing chronic instability, pain, and weakness [23]. Understanding the patterns of traumatic elbow instability helps the surgeon counsel and manage patients with these injuries [20]. Despite improved understanding in recent years, optimal results for elbow joint instability have not been consistently achieved [2]. Elbow instability injuries are an infrequent but serious source of disability for select NCAA athletes, with associated risk factors [13].

Physical Examination and Diagnostic Tests

The physical examination of the elbow should focus on functional anatomy and includes inspection, palpation, range of motion, strength, stability, and special tests [166]. A comprehensive approach to the physical examination of the elbow, including special tests, may facilitate improved diagnosis of elbow pathology [103]. The location, quality or type, context, duration, and severity of elbow pain are important to understanding patients’ pathology and focusing the physical examination [166]. Loss of full extension is the first motion altered by most pathology and the last to be regained [168]. The simple extension test has a sensitivity of 97% and a negative predictive value of 98% for significant joint pathology in trauma situations [168]. Specific stress tests and different imaging techniques, both static and dynamic, allow assessment of the elbow stabilisers and detection of the instability direction and mechanism even in subtle forms [16]. The diagnosis of post-traumatic elbow instability is established using a combination of clinical examination, including standard instability tests, and imaging studies such as MRI or CT [110].

For posterolateral rotatory instability, the "lateral pivot shift test" and the stress lateral elbow radiograph are emphasized for establishing the diagnosis [24]. In purely ligamentous posterolateral rotatory instability, radiographs will be normal, though associated lesions of the radial head, capitellum, coronoid, and articular surface may be seen [169]. MRI is unreliable to assess the integrity of the lateral ulnar collateral ligament because of the oblique course of the ligament [169]. CT evaluation of the dropping sign and radial head subluxation provides valuable diagnostic information for posterolateral elbow instability, particularly in subtle cases [54]. Arthroscopic techniques provide safe and objective means to evaluate and diagnose both medial and lateral elbow instability [6]. Elbow arthroscopy is a valid and safe option for the diagnosis of both acute and chronic elbow instability [9]. A high index of suspicion is required in patients, especially children, with recurrent instability of the elbow after an initial traumatic dislocation [38]. Differential diagnosis of lateral elbow instability should be considered in patients presenting with tennis elbow [18].

Simple Elbow Dislocation

Posterior dislocations are the most common type of elbow dislocations, accounting for 80% of cases [19]. The extremity in a posterior elbow dislocation is typically shortened and the elbow is held slightly flexed [19]. Simple dislocations are defined as those without fracture [19]. Most simple elbow dislocations are readily managed nonoperatively and are amenable to early mobilization [66]. Uncomplicated elbow dislocations have a favorable long-term prognosis, with an expected loss of extension of 5–10 degrees compared with the contralateral elbow [19]. 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 [42]. All patients in a series of lateral collateral ligament instability had resolution of their symptoms of instability and regained a near full arc of elbow flexion and forearm rotation [4]. All patients in a study of residual increased valgus stress angulation and posterolateral rotatory translation after simple elbow dislocation showed excellent to very good elbow function [70]. One patient in a study of simple elbow dislocation showed signs of valgus instability and three patients had clinical signs of posterolateral rotatory instability while performing stress tests [70].

Complex Elbow Instability and Terrible Triad

The terrible triad injury of the elbow involves injuries to the radial head, coronoid process, and ligaments [14]. The most common problems after terrible triad lesions are recurrent and chronic instability, stiffness, posttraumatic arthrosis, and pain [19]. Post-traumatic osteoarthritis at long-term follow-up remains an issue for terrible triad injuries regardless of treatment [14]. An understanding of the relevant anatomy and 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 [34]. Complex elbow fracture dislocations are difficult to manage and associated with poor outcomes [131]. Elbow instability due to Ehlers-Danlos Syndrome is a rare but disabling condition, especially in young active patients [7]. Elbow instability can occur due to a capitellum lesion without radial ligamentous complex involvement [61].

Pediatric and Athletic Populations

Little Leaguer’s elbow presents primarily as medial elbow pain in the throwing athlete, loss of velocity, tenderness over the medial epicondyle, and pain with valgus stress [43]. Patients with medial collateral ligament injuries report medial elbow pain during the acceleration phase of throwing, which may occur only when throwing at more than 50% to 75% of maximal effort [36]. Chronic medial elbow instability can be a debilitating problem for the throwing athlete [118]. The evaluation of injury in the skeletally immature elbow involves a segmental analysis of the lateral, medial, and posterior structures [172]. In skeletally immature athletes, medial epicondyle apophysitis can occur as a result of ulnar collateral ligament incompetency [71].

Investigations

Clinical Examination and Physical Tests

The physical examination of the elbow is directed by the history and the location of the patient's pain in the anterior, posterior, medial, or lateral aspect [33]. Stability is determined by primary stabilizers, including the ulnohumeral articulation, medial ulnar collateral ligament (MUCL), and lateral ulnar collateral ligament (LUCL) complex, as well as secondary stabilizers such as the radiocapitellar articulation, common flexor and extensor tendons, and joint capsule [33]. Lateral ulnar collateral ligament injury is the cause of recurrent instability following simple elbow dislocation [19]. The 'lateral pivot shift test' and stress lateral elbow radiograph are emphasized as important for establishing the diagnosis of posterolateral rotatory instability [24]. A sonographic ulnohumeral laxity greater than 4 mm should raise suspicion of underlying instability [192]. Neurovascular status should be documented both before and after elbow reduction [41]. Open injuries and compartment syndrome, which require immediate surgical treatment, should be ruled out during the physical examination of acute dislocation [41]. Preoperative MRI can be used to exclude subtle instability, and surgeons should consider checking for subtle instability, especially when patients have a history of multiple corticosteroid injections (≥3) or severe pain [189].

Imaging Modalities

Plain radiography: Plain radiographs remain the initial imaging study of choice in all patients presenting with elbow trauma and nonspecific elbow pain [46]. Plain AP and lateral radiographs of the elbow are necessary to document congruent reduction after dislocation [41]. Oblique views may be useful to identify periarticular fractures in the setting of elbow dislocation [41]. Postreduction radiographic assessment (AP and lateral views with the elbow at 90° and appropriate forearm rotation) is performed to confirm concentric reduction [41]. In Little Leaguer's elbow, plain radiographs can potentially show widening of the apophysis or fragmentation of the medial epicondyle, and comparison views can be useful in the diagnosis [43]. AP, lateral, oblique, and axillary views of the elbow may reveal posteromedial olecranon osteophytes and/or loose bodies in valgus extension overload syndrome [22].

MRI: MRI is the imaging modality best suited for evaluating soft-tissue structures in the elbow including ligaments, tendons, cartilage, and nerves [111]. Magnetic resonance arthrography (MRA) is particularly beneficial in the evaluation of osteochondral lesions, loose bodies, and ulnar collateral ligament (UCL) injury in a throwing athlete [111]. MRI can be used to evaluate ligaments and tendons, but it is rarely indicated for elbow stiffness [35]. MRI from one institution was able to identify the cause of medial elbow pain in 20 (95%) of 21 throwing athletes [182]. The article presents eight surgically proven cases of typical and atypical patterns of injury of the annular ligament in the setting of posterolateral elbow instability using MRI [40]. MRI studies in symptomatic youth athletes often show edema at the distal humerus or medial epicondyle apophysis [43]. MRI may be most helpful in evaluating associated injuries including partial or complete tears of the MCL in valgus extension overload syndrome [22].

CT: CT is useful to identify associated osseous injury in elbow dislocations [41]. With an incongruous reduction, CT or MRI should be considered to identify potential incarcerated osteocartilaginous fragments [41]. CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies in elbow stiffness [35]. Three-dimensional CT is used to check for heterotopic ossification in the evaluation of elbow stiffness [35]. CT is not necessary when elbow stiffness is entirely soft-tissue related [35]. CT markers provide valuable diagnostic information for posterolateral elbow instability, particularly in subtle cases [54]. CT with two-dimensional reconstruction and three-dimensional surface rendering best visualizes the pathology of valgus extension overload syndrome [22].

Ultrasonography: Ultrasonography allows dynamic imaging, which may be useful in evaluating for ulnar nerve subluxation or a snapping triceps [111]. Ultrasonographic soft-tissue evaluation in the elbow is most useful in evaluating the distal biceps and the common flexor and extensor tendons [111]. Changes present in the UCL and detectable on ultrasound may help distinguish elbows at risk for later clinical UCL insufficiency [185].

Other Considerations: Electromyography/nerve conduction velocity studies should be performed if any question about neurologic dysfunction exists during the evaluation of elbow stiffness [35]. An assessment for ulnar nerve subluxation should be performed during the evaluation of elbow stiffness [35]. Subluxation of the ulnar nerve is a relative contraindication for an arthroscopic procedure secondary to possible iatrogenic nerve injury [35].

Arthroscopic Evaluation

Arthroscopy allows for the management of soft tissue lesions and associated intra-articular bone or cartilage lesions with minimal disruption [9].

Treatment

General Principles and Outcomes

Although understanding of elbow joint instability has improved, optimal results have not been consistently achieved [2]. Significant improvements in surgical diagnosis and treatment have been introduced for both acute and chronic elbow instability cases [16]. Despite this progress, surgical treatments for elbow instability can be challenging even for expert surgeons, with high rates of persistent instability, post-traumatic arthritis, stiffness, and pain in demanding cases [16]. The biology of soft-tissue healing remains a critical aspect for future investigation to improve confidence and reproducibility in elbow instability management [16]. Understanding the patterns of traumatic elbow instability helps the surgeon counsel and manage patients [20]. Good functional prognosis of the upper limb requires rapid and adequate management of floating elbows [25]. A systematic diagnostic pathway including assessment of elbow stability and individualized, less invasive surgical procedures yields high patient satisfaction and good clinical outcomes with a low complication rate [29].

Non-Operative

Conservative treatment with early functional training of the elbow remains the first-line therapy for simple elbow dislocation [178]. Simple elbow dislocations are usually managed by closed reduction and early motion, with recurrent instability being uncommon due to intrinsic bony stability [87]. A small proportion (2%) of patients with simple elbow dislocations require surgical intervention despite nonoperative treatment [8]. Closed reduction of the elbow is usually performed in the emergency room or operating room with adequate conscious sedation [132]. After closed reduction of a simple elbow dislocation, the elbow is immobilized in a light plaster splint with the forearm in pronation, neutral, or supination depending on the position of maximal stability and the elbow at 90 degrees of flexion [132]. Isometric exercises should be encouraged while immobilized in the splint to promote muscle activation and improved dynamic stability [132]. The splint is removed after 1 week, and a rehabilitation program is initiated encouraging active and active-assisted motion [132]. Immobilization greater than 3 weeks for simple elbow dislocations should be avoided as it causes an increased incidence of stiffness and poorer functional outcomes [132]. Patients with simple elbow dislocations typically move only within their stable arc and are unlikely to redislocate if they had a stable reduction and examination initially [132]. An overhead motion protocol is advantageous for early motion in a protected position for simple elbow dislocations [132]. A hinged splint with an extension block can be used for patients with residual instability past 30 degrees of extension where compliance with avoiding this position is of concern [132]. The extension block is decreased by 10 degrees per week for the first 3 weeks, and the patient may resume most normal activities and start a light strengthening program at 6 weeks [132]. Varus or valgus loading should be avoided until 12 weeks post-injury in the rehabilitation of simple elbow dislocations [132]. For patients with subtle residual mild posterolateral subluxation following closed reduction, an active motion protocol avoiding varus stress at all times should be employed [132]. In the active motion protocol for residual posterolateral subluxation, active motion is performed with the forearm pronated through the full range of motion, and supination is performed with the forearm flexed to 90 degrees or greater [132]. Treatment of simple elbow dislocations that are stable throughout an arc of motion following reduction has been shown to benefit from 2 days of immobilization and then early motion to avoid stiffness [142].

Nonsurgical treatment for partial ulnar collateral ligament (UCL) tears in athletes includes rest, supportive measures, and physical therapy [153]. The Elbow UCL Injury Prognosis Score was created to predict which patients would succeed with nonoperative management and avoid unnecessary surgery [159]. Elbow valgus instability in the throwing athlete may be managed either nonsurgically or surgically [170]. Nonsurgical treatment for medial collateral ligament (MCL) injuries includes a period of rest from throwing, flexor-pronator strengthening, optimization of throwing mechanics, and a progressive throwing program [36]. Nonsurgical treatment for UCL sprains involves a brace to restrict range of motion and prevent valgus stresses, with range of motion permitted in a nonpainful arc typically from 10° to 100° [128]. In the immediate motion phase (weeks 0-2) of nonsurgical UCL treatment, isometric exercises are performed for the shoulder, elbow, and wrist to prevent muscular atrophy [128]. Elbow flexion and extension range of motion is increased gradually by 5° to 10° per week during the second phase of nonsurgical UCL rehabilitation, with full ROM achieved by at least 3 to 4 weeks [128]. Rhythmic stabilization exercises are initiated as tolerated in the acute stages of UCL rehabilitation to develop dynamic stabilization and neuromuscular control [128]. Strengthening exercises for the flexor carpi ulnaris and flexor digitorum superficialis can assist the UCL in resisting valgus stresses at the elbow [128]. An interval return to throwing program is initiated after the athlete regains full motion, adequate strength, and dynamic stability of the elbow [128]. If symptoms recur during the interval throwing program for UCL injuries, they typically present when throwing at longer distances or with greater intensity [128].

For nondisplaced or minimally displaced medial epicondyle fractures in athletes, immobilization in a posterior splint, long-arm cast, or sling for 1 to 2 weeks followed by early active range-of-motion exercises is recommended [27]. A throwing program can be initiated at 8 to 12 weeks for nondisplaced medial epicondyle fractures based on radiographic and clinical healing, with no throwing until the fracture site is pain-free [27]. Nonsurgical treatment for valgus extension overload syndrome includes activity modification, intra-articular corticosteroid injections, NSAIDs, flexor-pronator muscle strengthening, and pitching instruction correction [22]. Nonoperative management of chronic posterolateral rotatory instability (PLRI) is ineffective, and surgical treatment is generally required to stabilize the joint [163].

Operative

Indications: Persistent instability within 30 degrees of full extension after simple elbow dislocation is an indication for acute ligamentous repair [139]. Surgery for PLRI is indicated in patients with persistent, symptomatic instability of the elbow causing pain or functional deficit [163]. Operative repair is indicated for most complex elbow fracture-dislocations to restore sufficient osseoligamentous support to allow safe, early motion and provide a stable functional elbow in the long term [49]. In most cases, the terrible triad of the elbow dictates an indication for surgical intervention [135].

Surgical Approach / Technique: Conservative management remains the gold standard for most simple elbow dislocations [161]. If open reduction is required for simple elbow dislocations, a stepwise surgical approach should be followed [41]. Open reduction of the elbow with repair or reconstruction of the lateral collateral ligament (LCL) complex is performed first, followed by stability assessment [41]. If the elbow is still unstable after LCL repair, the medial collateral ligament (MCL) is repaired or reconstructed, followed by another stability assessment [41]. Hinged or static external fixation is required only if the elbow is unstable after other surgical procedures have failed to maintain a concentric, stable reduction [41]. The most common pitfall in treating simple elbow dislocations is failure to attain and maintain a concentric reduction after surgical or nonsurgical treatment [41]. Forearm rotation is used to its fullest advantage to attain or maintain concentric reduction in simple elbow dislocations [41]. Early active range of motion through a stable arc with the use of splints can help prevent contracture in simple elbow dislocations [41]. The lateral ligamentous complex is always repaired for persistent instability in simple elbow dislocations, followed rarely by MCL repair if instability persists [139].

The purpose of lateral elbow instability treatment approaches is to present a method effective in the early management of lateral elbow instability [67]. Suture-augmented lateral ulnar collateral ligament and radial collateral ligament reconstruction provides a reproducible, anatomically based construct that restores posterolateral elbow stability [69]. Both Jobe and Docking techniques are safe and effective in the treatment of posterolateral elbow instability [72]. For complex elbow instability, ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament results in acceptable functional outcomes and a reoperation rate comparable with other joint stabilization procedures [133]. Chronic instability of the lateral elbow is treated with reconstruction of the lateral ulnar collateral ligament (LUCL) with tendon autograft [139]. Primary repair of the chronically ruptured LCL complex depends on the integrity and quality of the remaining tissue [163].

The terrible triad of the elbow consists of an elbow dislocation with lateral collateral ligament injury, radial head fracture, and coronoid fracture [63]. The most challenging complex dislocation to manage is the combination of radial head fracture, coronoid process fracture, and multiligamentous disruption [135]. Terrible triad injuries must restore the integrity of the elbow by repairing all structures using a standardised surgical protocol to achieve the best results and prognosis [79]. Specifically addressing all elements of the terrible triad injury has proven to be the most reliable method of restoring elbow stability and function [135]. Treatment for the terrible triad includes coronoid ORIF, radial head ORIF or replacement, lateral collateral ligament repair, and possible MCL repair depending on stability [63]. The goal of treatment for the terrible triad is active range of motion within 48 hours after the ORIF/stabilization procedure [63]. The sequence of surgical treatment for the terrible triad occurs in the following order: repair of the coronoid process or anterior capsule, repair or replacement of the radial head, and repair of the LUCL [135]. Repair of the MCL may not always be necessary for the terrible triad and should be undertaken only when the elbow demonstrates posterior medial rotatory instability after the coronoid, radial head, and LUCL have been addressed [135]. If the coronoid is not repairable in a terrible triad injury, a piece of the radial head or the posterior process of the olecranon may be used for reconstruction [135]. Anterior capsulodesis can be performed for terrible triad injuries, particularly if the coronoid fragment is small [135]. A block, or resistance, to the posterior pull of the triceps must be restored to avoid recurrent dislocations in terrible triad injuries [135]. 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 [75]. In isolated cases, nonsurgical treatment of the terrible triad has shown to yield satisfactory results in the setting of a congruous joint, with unrestricted forearm rotation to 60° of pronation and supination and no instability at 45° of flexion [135].

Implant Selection: Radial head Type III fractures require replacement of the radial head if there are three or more fragments, usually with a metal implant, or ORIF if fewer than three pieces [63]. Radial head Type IV fractures require surgical repair with either ORIF or metallic radial head replacement, and excision must not be done without addition of a radial head implant [63]. Excision of the radial head is only indicated in elderly patients with low functional demands [63]. Synovitis can occur if a silicone elastomer (e.g., Silastic) radial head implant is used [63].

Other Considerations: The lateral collateral ligament injury in the terrible triad is typically a ligamentous avulsion from the origin on the distal humerus [63]. Coronoid Type I fractures are associated with episodes of elbow instability, and if instability persists, cerclage wire or No. 5 suture is applied through drill holes [63]. Coronoid Types II and III fractures require ORIF to help restore elbow stability, and stability must be confirmed before nonoperative treatment begins [63]. When part of a terrible triad injury, the coronoid can potentially be fixed through the radial head defect if planning to replace the radial head [63]. Radial head Type I fractures are splinted for no more than 7 days, and then allowed motion [63]. Radial head Type II fractures are treated nonsurgically with analgesics and active ROM if the elbow is stable and there is no block to motion with good reduction, otherwise ORIF is performed [63]. The safe zone for ORIF of the radial head/neck is a 110-degree arc (i.e., 25%) along the lateral side, defined by the radial styloid and Lister tubercle [63]. Persistent instability after terrible triad treatment is managed with a hinged external fixator or transarticular ulnohumeral pinning [139]. Early ROM for terrible triad injuries starts with the intraoperative arc of stability [139]. If the LCL is repaired and the MCL is intact, the elbow is kept in forearm pronation to increase stability [139].

Complications

Simple Elbow Dislocation

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]. Residual instability following simple elbow dislocation is uncommon, with posterolateral instability being the best documented form [89]. The reason why some patients experience posterolateral instability following simple elbow dislocation is unclear, and no predisposing factors pose particular risk [89]. Simple elbow dislocations can have devastating complications resulting in prolonged rehabilitation, surgery, and loss of function, even with appropriate and timely care [89].

Complex Elbow Instability and Terrible Triad

Post-traumatic osteoarthritis (PTOA) at long-term follow-up is still an issue for terrible triad injuries regardless of the treatments [14]. The rate of post-traumatic osteoarthritis (PTOA) at long-term follow-up for terrible triad injuries is still high regardless of the treatments [14]. Complications of terrible triad injuries include stiffness, heterotopic bone formation, infection, ulnar neuropathy, persistent instability, nonunion, and malunion [177]. Revision surgery is necessary in 20% to 25% of cases for terrible triad injuries [177]. Surgical treatments for elbow instability can be challenging even for expert surgeons, and the rate of persistent instability, post-traumatic arthritis, stiffness and pain can be still high especially in most demanding cases [16].

Pediatric and Special Populations

In skeletally immature athletes, a review of 145 elbow dislocations found that 80% of dislocations presented with a fracture [80]. In skeletally immature athletes, the presence of multiple fractures, the need for surgical intervention, and prolonged immobilization were correlated with less than excellent functional outcome scores [80]. Complications were found in 20% of the cohort in a large study on medial ulnar collateral ligament reconstruction in overhead athletes, 4% of which were major (ulnar nerve injuries, medial epicondyle fractures, and revision surgery for osteophyte formation) [80].

Arthroplasty and Reconstruction

Strut allograft augmentation in revision elbow arthroplasty has a survivorship free of revision with death as competing risk that approaches 75% at 10 years [94]. Ulnar collateral ligament reconstruction provides excellent patient-reported and clinical outcomes to patients at medium-term follow-up with low complication and revision rates [162]. The literature demonstrates a distinct difference in complication profile between external fixation and the internal joint stabilizer (IJS) when used as treatment for traumatic elbow instability [175].

Rehabilitation Protocols

The rehabilitation programme for complex elbow instability is divided into three phases: the acute phase (0 to 6 weeks post-injury or until union), the sub-acute phase (6 to 12 weeks post-injury), and the functional phase (after 3 months) [84]. In the acute stage of rehabilitation, patients are instructed in rest, limb elevation, precautions, activity modification, and pain management [84]. Patients in the acute stage begin exercises for passive range of motion (PROM) during the first seven postoperative days [84]. Patients in the acute stage begin exercises for active assisted range of motion (AAROM) after the first postoperative week [84]. Patients in the acute stage begin exercises for active range of motion (AROM) after the second postoperative week [84]. Physiotherapy is performed five times a week for one hour each time under the supervision of a personal therapist [84]. The therapist treats the wrist, hand, and shoulder to avoid secondary complications during rehabilitation [84]. Rehabilitation programs for rotationally unstable simple elbow dislocations should stress early active range of motion through the stable arc of motion [10].

Functional Outcomes and Recovery Metrics

At 1-year follow-up, a patient with a neglected elbow dislocation treated by open reduction and elbow fixator had full range in flexion/extension and rotation, with a Mayo elbow functional score of 100 [146]. At 6 weeks, a patient with a greatly delayed complication of medial epicondyle injury had full range of movement at the elbow with no obvious deformity and no weakness in the limb [93]. At two years postoperatively, a patient with congenital bilateral flexion deficit maintained 120 degrees of bilateral elbow flexion [90]. At a mean follow-up of 22 months, 67% of patients with total brachial plexus palsy achieved M3 elbow flexion, and 62% achieved M3 active elbow extension [165]. At 43 months mean follow-up, none of the patients treated for varus posteromedial instability had significant postoperative contracture, clinically apparent signs of instability, or suffered subluxation or re-dislocation [95]. Ulnohumeral cross-pinning for persistent and recurrent elbow instability results in maintained ulnohumeral joint alignment, functional arcs of elbow range of motion, and acceptable patient-reported outcome measures [30]. Biomechanical and clinical outcomes show that the External Joint Stabilizer – Elbow (EJS-E) via the posterior approach can restore mobility and stability in all patients [39]. The prognosis for the outcome of anterior dislocation of the elbow is favorable, provided that no vascular, nerve, tendon (triceps), or gross ligament lesions are present [195]. In a review of 21 elbow operations in 17 patients who underwent a percutaneous release for lateral epicondylitis, 20 of 21 elbows resumed normal function and had an Andrews-Carson rating of approximately 198/200 [198]. According to the Mayo Clinic elbow performance index, seven elbows out of 12 were significantly improved by surgery for inveterate dislocations, although three patients retained a 70-degree extension deficit [197]. In a limited number of initial patients treated with an anterior approach for coronoid fractures, acceptable functional results were achieved with no observed neurovascular complications, wound complications, hardware failure, anterior heterotopic ossification, or recurrent elbow instability in short-term follow-up [17]. A study on structural restoration of the medial collateral ligament using cubital tunnel retinaculum concluded that the technique showed satisfactory outcomes in elbow stability among patients during the follow-up period [47].

Key Evidence

• [L5] Complex elbow instability is a challenging injury where recognizing all possible lesions is critical to achieve an optimal outcome. [1] (10.1007/s12306-010-0065-8)
• [L4] Although our understanding of elbow joint instability has improved in recent years, in reality, optimal results have not been consistently achieved. [2] (10.1007/s00068-012-0205-y)
• [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. [3] (10.1016/j.hcl.2007.11.010)
• [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. [4] (10.1016/j.hcl.2007.11.001)
• [L5] The article reviews current concepts of injuries leading to elbow instability in children, discusses recognition and treatment of instability, and addresses nontraumatic causes. [5] (10.1016/j.hcl.2007.11.007)
• [Paper] Despite the invasive nature of arthroscopy in comparison to modalities such as ultrasonography and radiography, these described techniques provide safe and objective means to evaluate and diagnose both medial and lateral elbow instability. [6] (10.1016/j.eats.2023.04.029)
• [L5] Elbow instability due to EDS is a rare but disabling condition, especially in young active patients. [7] (10.2106/jbjs.cc.19.00355)
• [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)
• [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. [9] (10.1016/j.jseint.2022.12.001)
• [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. [10] (10.1016/j.hcl.2015.06.002)
• [L4] Elbow arthroscopy is a valuable tool in the diagnosis and management of chronic elbow instability. [11] (10.1016/j.arthro.2013.08.016)
• [L4] [12] (10.1007/s12306-016-0424-1)
• [L4] Elbow instability injuries are an infrequent but serious source of disability for select NCAA athletes, with a number of associated risk factors. [13] (10.1177/2325967117750105)
• [L5] [14] (10.1016/j.jseint.2023.03.018)
• [L5] The primary goal of treatment is stable reduction of the ulnohumeral joint and functional elbow motion. [15] (10.2106/jbjs.m.00817)
• [L5] [16] (10.1136/jisakos-2019-000316)
• [L4] In these limited number of initial patients, the authors achieved acceptable functional results and have not observed any neurovascular complications, wound complications, hardware failure, anterior heterotopic ossification, or recurrent elbow instability in short-term follow-up. [17] (10.1097/bth.0b013e31824e6a74)
• [L5] Differential diagnosis of lateral elbow instability in patients presenting with tennis elbow should be considered. [18] (10.1016/j.main.2007.05.002)
• [L5] Understanding the patterns of traumatic elbow instability helps the surgeon counsel and manage patients with these injuries. [20] (10.1016/j.jhsa.2010.05.002)
• [Paper] Recognising the precise pattern of injury is critical in restoring elbow function and preventing chronic instability, pain and weakness. [23] (10.1016/j.injury.2013.09.032)
• [L5] The authors emphasize the importance of the 'lateral pivot shift test' and the value of the stress lateral elbow radiograph in establishing the diagnosis of this rare and subtle entity. [24] (10.1016/j.main.2011.01.014)
• [L4] Good functional prognosis of the upper limb requires rapid and adequate management of floating elbows. [25] (10.1016/j.main.2012.08.008)
• [L5] Fixation or replacement of injured bony elements, ligamentous repair, and hinged fixation may be used to successfully manage complex elbow instability. [26] (10.5435/00124635-200605000-00003)
• [Paper] Starting an appropriate early range of motion rehabilitation helps achieve optimal outcomes with both surgical and nonsurgical treatments of elbow dislocations. [28] (10.1016/j.csm.2020.02.009)
• [Paper] Using a systematic diagnostic pathway including assessment of elbow stability and consecutive individualized, respectively, less invasive surgical procedure we acquired high patients satisfaction and good clinical outcome with a low complication rate. [29] (10.1007/s00402-014-2087-4)
• [L4] Ulnohumeral cross-pinning for persistent and recurrent elbow instability results in maintained ulnohumeral joint alignment, functional arcs of elbow range of motion, and acceptable patient-reported outcome measures, particularly in the setting of a primary procedure indicated for persistent intraoperative instability. [30] (10.1016/j.jhsa.2024.06.003)
• [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. [32] (10.1016/j.hcl.2004.07.002)
• [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. [34] (10.5435/00124635-200903000-00003)
• [L5] We conclude that a high index of suspicion is required in those patients, especially children, with recurrent instability of the elbow after an initial traumatic dislocation. [38] (10.1067/mse.2000.106320)
• [L4] Biomechanical and clinical outcomes show that EJS-E via the posterior approach can restore mobility and stability in all patients, thus serving as a valuable alternative option for the treatment of persistent instability of the elbow. [39] (10.1186/s12891-022-06103-0)
• [L4] The article presents eight surgically proven cases of typical and atypical patterns of injury of the annular ligament in the setting of posterolateral elbow instability. [40] (10.2214/ajr.13.12263)
• [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. [42] (10.1016/j.injury.2015.02.009)
• [L5] [44] (10.1055/s-2005-867103)
• [Paper] Radiographs remain the initial imaging study of choice in all patients presenting with elbow trauma and nonspecific elbow pain. [46] (10.1197/j.jht.2006.02.007)
• [L4] The study concluded that this technique showed satisfactory outcomes in elbow stability among these patients during the follow-up period. [47] (10.4103/0366-6999.244115)
• [L4] A stable, functional elbow can be restored in most patients with persistent instability after fracture-dislocation of the elbow using a treatment protocol incorporating hinged external fixation. [48] (10.1016/j.jhsa.2004.01.005)
• [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. [49] (10.1016/j.hcl.2004.06.005)
• [L4] [51] (10.5435/jaaos-d-14-00023)
• [Paper] These markers provide valuable diagnostic information for posterolateral elbow instability, particularly in subtle cases. [54] (10.1016/j.jseint.2025.101602)
• [L5] The most common indications are acute or chronic instability of the elbow after trauma, distraction interposition arthroplasty, or use after contracture release or excision of heterotopic ossification. [56] (10.1016/j.hcl.2010.04.004)
• [L5] The case illustrates elbow instability due to a Capitellum lesion without radial ligamentous complex involvement. [61] (10.1016/j.hansur.2017.10.168)
• [L5] [62] (10.5435/00124635-200411000-00005)
• [L5] Most simple elbow dislocations are readily managed nonoperatively and are amenable to early mobilization. [66] (10.1016/j.hcl.2020.07.013)
• [L5] The purpose of this article is to present a treatment approach that has been found to be effective in the early management of lateral elbow instability. [67] (10.1197/j.jht.2006.02.008)
• [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. [68] (10.1016/j.jse.2018.07.029)
• [L5] The described method provides a reproducible, anatomically based construct that restores posterolateral elbow stability and addresses the complex spectrum of lateral-sided injuries observed in PLRI. [69] (10.1016/j.eats.2025.103797)
• [L4] [70] (10.1007/s00167-016-4176-0)
• [L1] This systematic review showed that both Jobe and Docking techniques are safe and effective in the treatment of posterolateral elbow instability. [72] (10.1016/j.injury.2020.11.010)
• [L5] A stiff, congruent elbow is preferable to an unstable elbow. [73] (10.1016/j.hcl.2017.09.008)
• [L4] Use of the surgical protocol restored sufficient elbow stability to allow early motion postoperatively, enhancing the functional outcome. [75] (10.2106/jbjs.d.02933)
• [L5] Optimal outcomes are founded upon concentric reduction of the elbow. [76] (10.1016/j.jseint.2023.03.020)
• [L5] Surgery is indicated for unstable elbows requiring flexion beyond 50 to 60 degrees to remain reduced or for unstable periarticular fractures. [77] (10.5435/00124635-199801000-00002)
• [L4] They must restore the integrity of the elbow repairing all structures, using a standardised surgical protocol, which gives the best results and prognosis by restoration of the elbow stability. [79] (10.1016/s0020-1383(15)70004-5)
• [L5] [82] (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. [83] (10.1016/j.hcl.2007.11.002)
• [L3] [84] (10.1016/j.injury.2013.11.033)
• [L5] Surgical management is indicated when the elbow remains unstable, with the lateral ulnar collateral ligament being the most critical structure to repair or reconstruct. [86] (10.1016/j.hcl.2016.08.003)
• [L5] Simple elbow dislocations are usually managed by closed reduction and early motion, with recurrent instability being uncommon due to intrinsic bony stability. [87] (10.1016/j.hcl.2007.11.012)
• [Paper] [89] (10.1016/j.hcl.2007.11.013)
• [L5] At two years postoperatively, the patient maintained 120 degrees of bilateral elbow flexion. [90] (10.1016/j.main.2008.12.003)
• [L5] [92] (10.1016/j.hcl.2020.07.011)
• [L5] The patient had full range of movement at the elbow with no obvious deformity at 6 weeks and no weakness in the limb. [93] (10.1016/s0020-1383(98)00141-7)
• [L4] Despite early success of this technique for most elbows within the first two tears, survivorship free of revision with death as competing risk approaches 75% at 10 years. [94] (10.1016/j.jseint.2025.101581)
• [L4] At 43 months mean follow-up, none of the patients had significant postoperative contracture, and none had any clinically apparent signs of instability or suffered subluxation or re-dislocation. [95] (10.1016/j.jseint.2024.08.043)
• [L5] A comprehensive approach to the physical examination of the elbow, including special tests, may facilitate improved diagnosis of elbow pathology. [103] (10.5435/jaaos-d-16-00622)
• [L3] [110] (10.1016/j.jse.2025.11.011)
• [L5] Chronic medial elbow instability can be a debilitating problem for the throwing athlete. [118] (10.1016/j.ocl.2007.12.003)
• [L5] It was concluded that the elbow ligaments may provide significant sensory function to the elbow joint, in addition to being its major mechanical restraints. [119] (10.1016/s0363-5023(05)80470-8)
• [L1] [131] (10.1016/j.jse.2024.02.038)
• [L4] For complex elbow instability, ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament results in acceptable functional outcomes and a reoperation rate comparable with other joint stabilization procedures. [133] (10.1016/j.jhsa.2022.10.016)
• [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. [136] (10.1016/j.jseint.2022.12.002)
• [L5] At 1-year follow-up, the patient had full range in flexion/extension and rotation, and the Mayo elbow functional score was 100. [146] (10.1016/s1058-2746(03)00089-2)
• [L3] [153] (10.1177/17585732241235631)
• [L5] Chronic instability of the adult elbow without associated fracture can be divided into valgus instability, posterolateral instability, and isolated radial head instability. [154] (10.1016/s0030-5898(05)70062-6)
• [L3] The Elbow UCL Injury Prognosis Score was created to predict which patients would succeed with nonoperative management and avoid unnecessary surgery while simultaneously identifying patients for whom nonoperative management would delay the inevitable need for a surgical intervention. [159] (10.1177/03635465251366318)
• [L4] Conservative management remains the gold standard for most simple elbow dislocations. [161] (10.1016/j.arthro.2014.02.037)
• [L4] UCLR provides excellent patient-reported and clinical outcomes to patients at medium-term follow-up with low complication and revision rates. [162] (10.1136/jisakos-2021-000614)
• [L5] [163] (10.1302/2058-5241.160033)
• [L4] At a mean follow-up of 22 months, 67% of patients achieved - M3 elbow flexion, and 62% achieved - M3 active elbow extension. [165] (10.1016/j.hansur.2016.05.006)
• [L5] Elbow valgus instability in the throwing athlete may be managed either nonsurgically or surgically. [170] (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. [175] (10.1016/j.xrrt.2023.12.004)
• [L1] Conservative treatment with early functional training of the elbow remains the first-line therapy for simple elbow dislocation. [178] (10.1186/s12891-024-07260-0)
• [L3] MRI from our institution was able to identify the cause of medial elbow pain in 20 (95%) of 21 throwing athletes. [182] (10.1016/s1058-2746(95)80208-8)
• [L5] [184] (10.1302/2058-5241.1.000036)
• [L2] Our data suggests that changes present in the UCL and detectable on ultrasound may help distinguish elbows at risk for later clinical UCL insufficiency. [185] (10.1177/2325967115s00162)
• [L4] Preoperative MRI could be used to exclude subtle instability, and surgeons should consider checking for subtle instability, especially when patients have a history of multiple corticosteroid injections (≥3) or severe pain. [189] (10.1186/s12891-018-2069-8)
• [L4] A sonographic ulnohumeral laxity greater than 4 mm should raise suspicion of underlying instability. [192] (10.1016/j.pmrj.2016.06.014)
• [L5] The prognosis for the outcome of anterior dislocation of the elbow is favorable, provided that no vascular, nerve, tendon (triceps), or gross ligament lesions are present. [195] (10.1016/j.jse.2004.12.005)
• [L4] According to the Mayo Clinic elbow performance index, seven elbows out of 12 were significantly improved by surgery, although the score did not fully reflect patient satisfaction as three patients retained a 70-degree extension deficit. [197] (10.1016/j.main.2010.03.009)
• [L4] In a review of 21 elbow operations in 17 patients who underwent a percutaneous release, 20 of 21 elbows resumed normal function and had an Andrews-Carson rating of approximately 198/200. [198] (10.1097/00132589-200112000-00003)

See Also

• Elbow Arthroplasty
• Radial Head Fracture
• Elbow Arthroscopy
• Tennis Elbow
• Ligament Injuries
• Radial head arthroplasty

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