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Elbow Instability

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

Overview

Complex elbow instability involves critical osseous and ligamentous stabilizers [1]. Management protocols exist for common patterns of complex elbow injury [1]. Effective treatment of simple elbow dislocations requires detailed clinical assessment [3] and sequential radiographic follow-up [3].

Combined posterolateral and posteromedial rotatory instability requires surgical addressing of both directions to restore stability [2]. Lateral collateral ligament repair for acute posterolateral rotatory instability yields satisfactory outcomes [11]. Patients with lateral collateral ligament instability had resolution of symptoms and regained a near full arc of elbow flexion and forearm rotation [5]. Ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament results in acceptable functional outcomes for complex elbow instability [9] and a reoperation rate comparable with other joint stabilization procedures [9]. All reconstruction methods sufficiently restore posterolateral rotatory stability of the elbow over the full range of motion [17].

Treatments for elbow instability remain challenging in demanding cases, with high rates of persistent instability, post-traumatic arthritis, stiffness, and pain [8]. Long-term outcomes with surgical management of complex elbow injuries are unknown [6]. Instability is the major complication of unlinked total elbow arthroplasty, often requiring revision [13]. Linked arthroplasty is preferred for patients with posttraumatic articular damage, ligamentous instability, deformity, or bone loss [13].

Anatomy & Pathophysiology

Elbow stability relies on the synchronous function of static and dynamic stabilizers [4]. Complex instability involves critical osseous and ligamentous structures [1]. The capitellum alone does not contribute to stability, whereas the trochlea plays an important role [34]. Proper balancing and adequate bone resection from the radial head are mandatory for obtaining normal elbow kinematics during radial head arthroplasty [27].

Posterolateral rotatory instability (PLRI) remains to be fully understood [10]. Both posterolateral and posteromedial rotatory instability directions must be addressed surgically to restore elbow stability [2]. A distinction between healthy and hypermobile elbow joints is not possible via sonography, making complete clinical history and examination vital [7].

Osseous Contributions: * Radial Head: Radial head displacement is greater after a simulated osteochondral lesion (OCL) at 30° to 60° of flexion compared with the intact elbow, but not as great as seen with sectioning of the lateral collateral ligament complex (LCLC) [32]. The Wrightington approach to the radial head is biomechanically superior to the posterolateral approach regarding changes in elbow laxity after surgery to the radial head [31]. * Trochlea: The trochlea has an important role in stability [34].

Ligamentous and Soft Tissue Mechanics: * Varus Loads: Varus loads simulating everyday activities produce changes in varus joint angulation that are linearly dependent on the applied moment and persist after release of lateral stabilizing structures [26]. * Valgus Torque: Elbow valgus torque increases contact pressure in the radiocapitellar joint [28]. * Multidirectional Instability: The circumferential graft technique for multidirectional elbow instability was evaluated for stability against valgus and varus/posterolateral rotatory forces [29]. * Ulnar Collateral Ligament (UCL) Reconstruction: Proximal docking and single-point fixation hybrid ulnar collateral ligament reconstructions provided sufficient joint stability and strength compared to intact elbows, except for the proximal docking method at low flexion angles [30]. Both TightRope (TR) and traditional docking (DO) ulnar collateral ligament reconstruction techniques restored native joint kinematics from 15 to 75 degrees of flexion under low loading conditions [37]. * Ligament Fixation: A novel method for securing ligaments against bone during simultaneous medial and lateral elbow ligament reconstruction successfully prevented graft slippage without excessive construct displacement during static and dynamic testing [35].

External Stabilization: The Orthofix elbow external fixator stabilizes the ligamentous unstable elbow joint efficiently but decreases the range of motion and constrains extension [36].

Classification

Static and Dynamic Stabilizers: The elbow relies on static and dynamic stabilizers that function in synchrony to prevent instability [4]. Complex instability involves important osseous and ligamentous stabilizers [1]. The posterolateral ligament (PLL) of the elbow has a significant role in the elbow's posterolateral stability [16]. Stress ultrasonography shows different amounts of gapping with sectioning of the medial elbow stabilizers in a cadaveric model [24].

Instability Patterns: Simple elbow dislocations require detailed clinical assessment and sequential radiographic follow-up for effective treatment [3]. Acute elbow dislocations are traumatic events often resulting in pan-ligamentous disruption, suggesting the most common injury pattern may begin with medial-sided ligamentous disruption [14]. Combined posterolateral and posteromedial rotatory instability requires surgical addressing of both directions to restore stability [2]. Lateral collateral ligament instability can result in symptoms of instability that resolve with treatment, allowing near full arc of elbow flexion and forearm rotation [5].

Diagnostic Considerations: Sonography cannot objectively distinguish between healthy and hypermobile elbow joints, making complete clinical history and examination vital [7].

Other Considerations: Treatments for elbow instability remain challenging, with high rates of persistent instability, post-traumatic arthritis, stiffness, and pain in demanding cases [8]. Long-term outcomes with surgical management of complex elbow injuries are unknown [6]. Instability is the major complication of unlinked total elbow arthroplasty, often requiring revision [13]. Linked arthroplasty is preferred for patients with posttraumatic articular damage, ligamentous instability, deformity, or bone loss [13].

Clinical Presentation

Elbow instability arises from the complex interplay of static and dynamic stabilizers that function in synchrony to prevent joint laxity [1, 4]. Complex instability involves critical osseous and ligamentous structures [1]. Acute elbow dislocations are traumatic events often resulting in pan-ligamentous disruption, with the most common injury pattern potentially beginning with medial-sided ligamentous disruption [14]. Effective treatment of simple elbow dislocations requires a detailed clinical assessment and sequential radiographic follow-up [3].

A complete clinical history and examination are vital for distinguishing healthy from hypermobile elbow joints, as sonography does not allow an objective or reproducible distinction between stable, hypermobile, and unstable joints [7]. Posterolateral rotatory instability exists in children and may be masked by contracture, though radiographs may show evidence of instability [20]. Instability can coexist with refractory lateral epicondylitis, and over 85% of patients with recalcitrant lateral epicondylitis demonstrate at least one intra-articular abnormality [21, 33]. Almost one half of these patients display signs of lateral ligamentous patholaxity [33].

The posterolateral ligament (PLL) plays a significant role in posterolateral stability [16]. Combined posterolateral and posteromedial rotatory instability requires surgical addressing of both directions to restore stability [2]. In baseball players, symptomatic ulnar collateral ligament (UCL) insufficiency is associated with characteristic high-stress distribution patterns on the anterolateral part of the capitellum and ulna [22]. Elbow arthroscopy is a useful tool for managing valgus extension overload when conservative treatments have failed [15].

Patients with lateral collateral ligament instability typically experience resolution of instability symptoms and regain a near full arc of elbow flexion and forearm rotation [5]. Patients after conservatively treated simple elbow dislocations show good clinical and functional results [12]. However, treatments for elbow instability remain challenging in demanding cases, which are associated with high rates of persistent instability, post-traumatic arthritis, stiffness, and pain [8]. The long-term outcome with surgical management of complex elbow injuries remains unknown [6].

Investigations

Effective treatment of simple elbow dislocations requires a detailed clinical assessment and sequential radiographic follow-up [3]. The elbow consists of static and dynamic stabilizers that function in synchrony to prevent elbow instability [4].

Plain radiography: Posterolateral rotatory instability of the elbow exists in children but may be masked by contracture, with radiographs potentially showing evidence of instability [20]. No numerical value can confidently determine the pathologic status of the ulnar collateral ligament of the elbow when using stress radiography [40].

MRI: An MRI is recommended if healing does not occur by a reasonable time despite successful bony healing to assess potential cartilage damage [41].

Other Considerations: A distinction between healthy and hypermobile elbow joints is not possible using sonography, making a complete clinical history and examination vital [7]. Instability can coexist and may be associated with refractory lateral epicondylitis [21]. Symptomatic ulnar collateral ligament insufficiency is associated with characteristic high-stress distribution patterns on the anterolateral part of the capitellum and the anterolateral part of the ulna [22]. Stress ultrasonography shows different amounts of gapping with sectioning of the medial elbow stabilizers in a cadaveric model [24].

Treatment

Effective management of simple elbow dislocations necessitates a detailed clinical assessment and sequential radiographic follow-up [3]. Conservative treatment of these injuries yields good clinical and functional results [12]. However, despite advancements in surgical techniques and rehabilitation, treating elbow instability remains challenging, with demanding cases often experiencing high rates of persistent instability, post-traumatic arthritis, stiffness, and pain [8]. The long-term outcomes of surgical management for complex elbow injuries remain unknown [6].

Operative

Indications: Surgical intervention is mandatory for combined posterolateral and posteromedial rotatory instability, as both directions of instability must be addressed to restore elbow stability [2]. Elbow arthroscopy serves as a useful tool for managing diseases such as valgus extension overload when conservative treatments have failed [15].

Surgical Approach / Technique: For acute posterolateral rotatory instability, lateral collateral ligament repair produces satisfactory outcomes [11]. In cases of lateral collateral ligament instability, repair results in the resolution of instability symptoms and the regain of a near-full arc of elbow flexion and forearm rotation [5]. Both Jobe and Docking techniques are safe and effective for treating posterolateral elbow instability [19]. For symptomatic minor instability of the lateral elbow (SMILE), R-LCL plication yields subjective satisfaction and positive clinical results at a 2-year median follow-up [18]. Late instability is treated via lateral ligament reconstruction from the humerus to the ulna using tendon grafts, which provides reasonably good outcomes [23]. For ankylosed, severely stiff elbows, ligament repair with suture anchors combined with a hinged external fixator is a viable option [39].

Implant Selection: In the context of total elbow arthroplasty, instability is the major complication of unlinked prostheses and often requires revision [13]. Linked arthroplasty is preferred for patients presenting with posttraumatic articular damage, ligamentous instability, deformity, or bone loss [13].

Other Considerations: Ligament repair utilizing suture-tape augmentation of the lateral ulnar collateral ligament results in acceptable functional outcomes and a reoperation rate comparable to other joint stabilization procedures for complex elbow instability [9].

Complications

Instability: Complex elbow instability involves important osseous and ligamentous stabilizers [1]. The elbow consists of static and dynamic stabilizers that function in synchrony to prevent instability [4]. Acute elbow dislocations are traumatic events often resulting in pan-ligamentous disruption, suggesting the most common injury pattern may begin with a medial-sided ligamentous disruption [14]. Posterolateral rotatory instability (PLRI) of the elbow remains to be fully understood [10]. Combined posterolateral and posteromedial rotatory instability requires surgical addressing of both directions to restore stability [2]. Satisfactory outcomes were obtained with lateral collateral ligament repair for acute posterolateral rotatory instability of the elbow [11]. Ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament for complex elbow instability results in acceptable functional outcomes and a reoperation rate comparable with other joint stabilization procedures [9]. R-LCL plication produces subjective satisfaction and positive clinical results in patients presenting with symptomatic minor instability of the lateral elbow (SMILE) at 2-year median follow-up [18]. Patients with lateral collateral ligament instability had resolution of symptoms and regained a near full arc of elbow flexion and forearm rotation [5].

Prosthetic Instability and Loosening: Instability is the major complication of unlinked total elbow arthroplasty, often requiring revision [13]. Linked arthroplasty is preferred for patients with posttraumatic articular damage, ligamentous instability, deformity, or bone loss [13]. Ligaments of the elbow may not heal or tighten sufficiently over time, and removal of a radial head prosthesis may give rise to problems, even up to 5 years after prosthetic removal [25]. Longer-term studies are required to ascertain whether the apparent benefits of radial head arthroplasty are offset by late complications such as loosening [38].

Other Considerations: Effective treatment of simple elbow dislocations requires detailed clinical assessment and sequential radiographic follow-up [3]. Patients after conservatively treated simple elbow dislocations show good clinical and functional results [12]. Sonography cannot objectively distinguish between healthy and hypermobile elbow joints, making complete clinical history and examination vital [7]. Long-term outcomes with surgical management of complex elbow injuries are unknown [6].

Recovery

Effective treatment of simple elbow dislocations requires a detailed clinical assessment and sequential radiographic follow-up [3]. Patients after conservatively treated simple elbow dislocations show good clinical and functional results [12]. All patients in the series had resolution of their symptoms of instability and regained a near full arc of elbow flexion and forearm rotation [5].

Light activity (weeks): Evidence does not specify a week range for light activity or desk work.

Full activity (months): Evidence does not specify a month range for manual work, sport, or full ROM/strength return.

Complete recovery / outcome plateau (months): Evidence does not specify a month range for final functional outcome stabilization.

Rehabilitation protocol: Evidence does not specify PT phasing, immobilisation duration, weight-bearing/ROM progression, or sling/brace removal timing.

Functional milestones: Ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament results in acceptable functional outcomes for complex elbow instability [9]. R-LCL plication produces subjective satisfaction and positive clinical results in patients presenting with symptomatic minor instability of the lateral elbow (SMILE) at 2-year median follow-up [18]. Satisfactory outcomes were obtained with lateral collateral ligament repair for acute posterolateral rotatory instability of the elbow [11]. No significant difference in clinical outcome or range of motion was observed after direct repair of traumatic tears of the lateral ulnar collateral ligament between acute and delayed treatment cohorts [42]. Treatment of late instability is focused on lateral ligament reconstruction from the humerus to the ulna using tendon grafts with reasonably good outcomes [23].

Other Considerations: Ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament results in a reoperation rate comparable with other joint stabilization procedures for complex elbow instability [9]. 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 [8]. Long-term outcome with surgical management of complex elbow injuries is unknown [6].

Key Evidence

  • [Paper] This article discusses the important osseous and ligamentous stabilizers of the elbow joint and provides management protocols for the common patterns of complex injury encountered by the practising surgeon. (10.1016/j.injury.2013.09.032)
  • [L4] Both directions of instability must be addressed surgically to restore elbow stability. (10.1016/j.injury.2007.01.039)
  • [L5] Effective treatment of simple elbow dislocations requires a detailed clinical assessment and sequential radiographic follow-up. (10.1016/j.hcl.2015.06.002)
  • [L5] The elbow consists of static and dynamic stabilizers that function in synchrony to prevent elbow instability. (10.1016/j.jhsa.2016.11.025)
  • [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. (10.1016/j.hcl.2007.11.001)
  • [L5] Long-term outcome with surgical management of complex elbow injuries is unknown. (10.5435/00124635-200605000-00003)
  • [L3] Nevertheless, a distinction between healthy and hypermobile elbow joints is not possible, and therefore, obtaining a complete clinical history and examination is vital. (10.1016/j.jse.2020.11.023)
  • [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. (10.1136/jisakos-2019-000316)
  • [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. (10.1016/j.jhsa.2022.10.016)
  • [L4] PLRI of the elbow remains to be fully understood. (10.1016/j.arthro.2014.02.029)
  • [L4] We obtained satisfactory outcomes with lateral collateral ligament repair for acute posterolateral rotatory instability of the elbow. (10.1016/j.jse.2013.06.018)
  • [L4] Patients after conservatively treated simple elbow dislocations show good clinical and functional results. (10.1007/s00167-016-4176-0)
  • [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. (10.1016/j.hcl.2007.11.002)
  • [L4] Acute elbow dislocations are traumatic events often resulting in pan-ligamentous disruption, suggesting that the most common injury pattern may begin with a medial-sided ligamentous disruption. (10.1016/j.jhsa.2013.11.031)
  • [Paper] Elbow arthroscopy is a useful tool for managing diseases of the elbow, including valgus extension overload, when conservative treatments have failed. (10.1016/j.eats.2016.04.005)
  • [L4] The PLL of the elbow has a significant role in the elbow's posterolateral stability. (10.1016/j.jse.2023.08.033)
  • [L5] All reconstruction methods were able to sufficiently restore posterolateral rotatory stability of the elbow over the full range of motion. (10.1007/s00167-015-3627-3)
  • [L4] R-LCL plication produces subjective satisfaction and positive clinical results in patients presenting with a symptomatic minor instability of the lateral elbow (SMILE) at 2-year median follow-up. (10.1007/s00167-017-4531-9)
  • [L1] This systematic review showed that both Jobe and Docking techniques are safe and effective in the treatment of posterolateral elbow instability. (10.1016/j.injury.2020.11.010)
  • [L4] Posterolateral rotatory instability of the elbow exists in children but may be masked by contracture; radiographs may show evidence of instability. (10.2106/jbjs.l.00623)
  • [L1] Instability can coexist and may be associated with refractory lateral epicondylitis. (10.1177/0363546520980133)
  • [L4] Symptomatic UCL insufficiency was associated with characteristic high-stress distribution patterns on the anterolateral part of the capitellum and the anterolateral part of the ulna. (10.1177/0363546515624916)
  • [L5] Treatment of late instability is focused on lateral ligament reconstruction from the humerus to the ulna using tendon grafts with reasonably good outcomes. (10.1016/j.jhsa.2012.10.030)
  • [L5] The results suggest that different amounts of gapping are seen on stress ultrasonography with sectioning of the medial elbow stabilizers. (10.1177/0363546514542805)
  • [L5] This case illustrates that sometimes ligaments of the elbow may not heal or tighten sufficiently over time and that despite a careful examination elbow and forearm stability, removal of a radial head prosthesis may give rise to problems, even up to 5 years after prosthetic removal. (10.1016/j.jse.2010.04.046)
  • [L5] Varus loads simulating everyday activities produce changes in the varus joint angulation of the elbow that are linearly dependent on the applied moment and persist after release of the lateral stabilizing structures. (10.1177/03635465211018208)
  • [L5] Proper balancing and adequate bone resection from radial head is mandatory for obtaining normal elbow kinematics during the radial head arthroplasty procedure. (10.1007/s00402-006-0164-z)
  • [L5] Elbow valgus torque increases contact pressure in the radiocapitellar joint. (10.1177/0363546513490652)
  • [L5] The study evaluated stability against valgus and varus/posterolateral rotatory forces in cadaveric elbows. (10.1016/j.jse.2015.07.016)
  • [L5] Both the proximal docking and the single-point fixation hybrid reconstructions provided sufficient joint stability and strength compared to the intact elbows, with the exception of the proximal docking method at low flexion angles. (10.1016/j.jhsa.2014.07.040)
  • [L5] These results suggest that the newly described Wrightington approach is biomechanically superior to the posterolateral approach with regard to changes in elbow laxity after surgery to the radial head. (10.1016/j.jhsa.2007.08.009)
  • [L5] The degree of radial head displacement is greater after a simulated OCL at 30° to 60° of flexion compared with the intact elbow but not as great as seen with sectioning of the LCLC. (10.1016/j.jse.2018.02.045)
  • [L3] Almost one half of patients suffering from recalcitrant lateral epicondylitis display signs of lateral ligamentous patholaxity, and over 85% demonstrate at least one intra-articular abnormality. (10.1007/s00167-017-4530-x)
  • [L5] While the capitellum alone does not contribute to elbow stability, the trochlea has an important role. (10.1016/j.jse.2010.02.002)
  • [L5] This method of fixation to the proximal ulna for the simultaneous reconstruction of medial and lateral elbow ligaments successfully prevented graft slippage without excessive construct displacement during static and dynamic testing. (10.1016/j.jhsa.2023.02.008)
  • [L5] The Orthofix elbow external fixator stabilizes the ligamentous unstable elbow joint efficiently but at the expense of changes in the normal motion pattern, specifically decreasing the range of motion and constraining extension. (10.1016/j.jse.2006.07.012)
  • [L5] Both the TR and DO techniques restored native joint kinematics from 15 to 75 degrees of flexion under low loading conditions. (10.1177/0363546513482567)
  • [L3] Longer-term studies will be required to ascertain whether the apparent benefits of radial head arthroplasty are offset by late complications of arthroplasty, such as loosening. (10.1007/s11999-013-3331-x)
  • [L4] This could be an option for treating ankylosed, severely or very severely stiff elbows. (10.1016/j.jse.2014.03.013)
  • [L3] No numerical value can confidently determine the pathologic status of the ulnar collateral ligament of the elbow when using stress radiography. (10.1177/03635465010290050601)
  • [Case_report] The authors recommend performing an MRI if healing does not occur by a reasonable time despite successful bony healing to assess potential cartilage damage. (10.1007/s00402-005-0018-0)
  • [L3] No significant difference in clinical outcome or range of motion was observed after direct repair of traumatic tears of the lateral ulnar collateral ligament between acute and delayed treatment cohorts. (10.1016/j.jhsa.2014.02.011)

See Also

References

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

[2] Combined posterolateral and posteromedial rotatory instability of the elbow. Injury Extra. 2007. DOI: 10.1016/j.injury.2007.01.039

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

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

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

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

[7] Does sonography allow an objective and reproducible distinction between stable, hypermobile, and unstable elbow joints?. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.11.023

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

[9] Lateral Ulnar Collateral Ligament Repair With Suture-Tape Augmentation for Traumatic Elbow Instability. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2022.10.016

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

[11] Ligamentous repair of acute lateral collateral ligament rupture of the elbow. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2013.06.018

[12] Residual increased valgus stress angulation and posterolateral rotatory translation after simple elbow dislocation. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. DOI: 10.1007/s00167-016-4176-0

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

[14] Magnetic Resonance Imaging Findings in Acute Elbow Dislocation: Insight Into Mechanism. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2013.11.031

[15] Valgus Extension Overload: Arthroscopic Decompression in the Supine‐Suspended Position. Arthroscopy Techniques. 2016. DOI: 10.1016/j.eats.2016.04.005

[16] The posterolateral ligament of the elbow: anatomy and clinical relevance. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.08.033

[17] Reconstruction of the lateral ulnar collateral ligament of the elbow: a comparative biomechanical study. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3627-3

[18] Arthroscopic R-LCL plication for symptomatic minor instability of the lateral elbow (SMILE). Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4531-9

[19] 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

[20] Clinical Presentation of Posterolateral Rotatory Instability of the Elbow in Children. The Journal of Bone and Joint Surgery-American Volume. 2013. DOI: 10.2106/jbjs.l.00623

[21] Systematic Review of Elbow Instability in Association With Refractory Lateral Epicondylitis: Myth or Fact?. The American Journal of Sports Medicine. 2021. DOI: 10.1177/0363546520980133

[22] Alteration of Stress Distribution Patterns in Symptomatic Valgus Instability of the Elbow in Baseball Players. The American Journal of Sports Medicine. 2016. DOI: 10.1177/0363546515624916

[23] Elbow Lateral Collateral Ligament Injuries. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.10.030

[24] Stress Ultrasound Evaluation of Medial Elbow Instability in a Cadaveric Model. The American Journal of Sports Medicine. 2014. DOI: 10.1177/0363546514542805

[25] Delayed valgus instability and proximal migration of the radius after radial head prosthesis failure. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.04.046

[26] Lateral Elbow Laxity Is Affected by the Integrity of the Radial Band of the Lateral Collateral Ligament Complex: A Cadaveric Model With Sequential Releases and Varus Stress Simulating Everyday Activities. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211018208

[27] Importance of radial head on elbow kinematics: radial head prosthesis. Archives of Orthopaedic and Trauma Surgery. 2006. DOI: 10.1007/s00402-006-0164-z

[28] Biomechanical Characteristics of Osteochondral Defects of the Humeral Capitellum. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513490652

[29] The circumferential graft technique for treatment of multidirectional elbow instability: a comparative biomechanical evaluation. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.07.016

[30] A Biomechanical Comparison of 2 Hybrid Techniques for Elbow Ulnar Collateral Ligament Reconstruction. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.07.040

[31] The Wrightington Approach to the Radial Head: Biomechanical Comparison With the Posterolateral Approach. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2007.08.009

[32] The contribution of the posterolateral capsule to elbow joint stability: a cadaveric biomechanical investigation. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.02.045

[33] Intra-articular findings in symptomatic minor instability of the lateral elbow (SMILE). Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4530-x

[34] Effect of coronal shear fractures of the distal humerus on elbow kinematics and stability. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.02.002

[35] Testing of a Novel Method for Securing Ligaments Against Bone During Simultaneous Medial and Lateral Elbow Ligament Reconstruction. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2023.02.008

[36] Kinematics of the ligamentous unstable elbow joint after application of a hinged external fixation device: A cadaveric study. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2006.07.012

[37] Biomechanical Evaluation of the TightRope Versus Traditional Docking Ulnar Collateral Ligament Reconstruction Technique. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513482567

[38] Fixation Versus Replacement of Radial Head in Terrible Triad: Is There a Difference in Elbow Stability and Prognosis?. Clinical Orthopaedics & Related Research. 2014. DOI: 10.1007/s11999-013-3331-x

[39] Stability of severely stiff elbows after complete open release: treatment by ligament repair with suture anchors and hinged external fixator. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2014.03.013

[40] Valgus Laxity of the Ulnar Collateral Ligament of the Elbow in Collegiate Athletes. The American Journal of Sports Medicine. 2001. DOI: 10.1177/03635465010290050601

[41] Are bone bruises a possible cause of osteochondritis dissecans of the capitellum? a case report and review of the literature. Archives of Orthopaedic and Trauma Surgery. 2005. DOI: 10.1007/s00402-005-0018-0

[42] Direct Repair for Managing Acute and Chronic Lateral Ulnar Collateral Ligament Disruptions. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.02.011

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By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.