Skip to content

Patients › Elbow

肘关节不稳定

PDF Evidence

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

Updated Jun 2026
一幅手绘插图，描绘了一个无脸的人在一场摔倒后肘部失去支撑，用手扶住肘部。
肘关节韧带——尺侧和桡侧副韧带是主要的稳定结构。 Kieran Hirpara 4.0

本页面由机器翻译，尚未经临床医生审核。英文版本为权威版本。

您的感受

您可能会感觉肘关节有脱位或打软腿的感觉。这种感觉通常发生在伸手取物或提举物品时。疼痛可能是尖锐且突然的，也可能是一种持续存在的深部酸痛。您可能会注意到，在完成日常任务（如塞衬衫下摆或伸手到背后扣文胸）后，疼痛会加重。有些人发现侧卧于患侧会使不适感加重，而另一些人则在早晨刚醒来时感到僵硬。

这种不稳定性通常源于维持肘关节骨骼连接的韧带损伤。这些韧带如同强韧的带子，保持关节的稳定。当它们受损时，肘关节的活动可能不再顺畅。在弯曲或伸直手臂时，您可能会感到松弛或“卡住”的感觉。这会使简单的动作变得困难。例如，转动门把手或倒水时可能会感觉别扭或不安全，因为您不确定肘关节是否能保持稳定。

在某些情况下，疼痛不仅局限于关节本身，还会向下放射至前臂。您可能会将其与网球肘混淆，网球肘表现为肘关节外侧的疼痛。然而，如果休息后疼痛仍持续存在，则可能与潜在的不稳定性有关。您可能还会注意到活动后关节周围出现肿胀或发热。当日常任务变得具有挑战性时，感到沮丧是很常见的。您的外科医生将通过仔细检查和影像学检查帮助您准确了解导致这些症状的原因。

如果您曾经发生过脱位，您可能会更清楚地意识到肘关节的运动方式。您可能会避免某些姿势，以防止关节移位。这种谨慎态度随着时间的推移可能导致僵硬。您可能会发现无法像以前那样完全伸直或弯曲手臂。这种活动度的丧失会影响您执行日常活动的能力。了解这些感受是获得正确治疗以恢复稳定性和舒适感的第一步。

实际发生了什么

您的肘关节是一个复杂的铰链结构，依靠两种类型的支撑来保持稳定。静态稳定器是像坚固绳索一样起作用的骨骼和韧带。动态稳定器是拉动以保持一切固定的肌肉。这些部分必须完美同步地协同工作。当它们无法协调时，您的肘关节就会变得不稳定。

这种不稳定性通常涉及骨骼和韧带稳定器的损伤。韧带是保持关节完整的厚实组织带。在许多情况下，损伤会导致旋转性不稳定。这意味着骨骼向异常方向扭转，例如向后和向侧面。您的外科医生必须解决这些特定的扭转力以恢复稳定性。如果仅治疗一个方向，肘关节可能仍然感觉松动或疼痛。

您经历的疼痛和关节“打软腿”感源于这种机械性失效。由于缺乏适当的支持，关节表面会错误地相互摩擦。这会增加对软骨的压力，软骨是覆盖在骨端的平滑涂层。随着时间的推移，这种磨损可能导致关节炎。这些症状是您的身体发出的信号，表明关节的结构完整性已受损。

有时，区分健康、灵活的肘关节与真正不稳定的肘关节是很困难的。仅靠超声检查并不总能做出这种区分。这就是为什么您的外科医生依赖于完整的临床病史和体格检查。他们寻找特定的运动模式，以指示哪些稳定器正在失效。

治疗旨在修复或替换这些受损的支撑。韧带修复可以产生令人满意的结果，帮助您恢复接近完整的活动范围。在更复杂的情况下，可能需要重建以平衡关节受力。目标始终是阻止异常扭转并恢复您肘关节的自然运动学。

我们能采取的措施

您对稳定性的追求始于谨慎的监测和轻柔的活动。对于简单的肘关节脱位，您的外科医生将进行详细的临床评估，并安排连续的影像学随访。这能确保关节正确愈合，而不再次发生脱位。如果您的脱位属于简单类型，保守治疗通常能带来良好的临床和功能结果。您将配合物理治疗师进行运动功能恢复。目标是恢复接近完全的肘关节屈曲和前臂旋转活动范围。您必须给予这个过程足够的时间。耐心是关键，因为您的韧带正在愈合，肌肉正在恢复力量。

如果疼痛或僵硬持续存在，您的外科医生可能会讨论药物治疗方案。这些治疗旨在减轻炎症并在关节愈合过程中提供保护。您可能会接受注射治疗以帮助控制症状。皮质类固醇注射可在短期内减轻肿胀和疼痛。透明质酸注射可能有助于润滑关节，但关于其长期益处的证据各不相同。富血小板血浆（PRP）注射利用您自身的血液成分来促进愈合，但效果因人而异。这些选项并不能修复结构性不稳定，但可以帮助您在专注于康复期间使日常活动更加舒适。

当保守治疗达到极限或不稳定情况复杂时，会考虑手术治疗。如果您存在双向复合不稳定，则必须通过手术来恢复稳定性。您的外科医生可能会使用缝合带增强或缝合锚钉修复外侧副韧带。对于迟发性不稳定，他们可能会使用来自您身体其他部位的肌腱移植物进行韧带重建。在肘关节僵硬或强直的严重病例中，可能会在修复的同时使用铰链式外固定架。对于存在显著骨质丢失或韧带损伤的患者，与无连接型假体相比，更倾向于使用连接型全肘关节置换术（关节置换），以防止进一步的不稳定。虽然手术结果可能令人满意，但治疗仍然具有挑战性。在要求较高的病例中，可能会出现持续的不稳定、僵硬或疼痛的高发生率。您的外科医生将讨论在您特定情况下，手术的益处是否大于这些风险。

预期情况

您的预后主要取决于肘关节不稳是单纯性还是复杂性。单纯性脱位通常通过保守治疗即可获得良好恢复。大多数患者的症状可完全缓解。您通常可以恢复接近完整的肘关节屈曲和前臂旋转活动范围。功能结果通常良好。

复杂性不稳涉及维持关节稳定的骨骼和韧带遭受更严重的损伤。此类情况治疗难度较大。即使采用现代技术，在要求较高的病例中，预后也可能充满挑战。您可能面临持续的不稳、僵硬、疼痛或创伤后关节炎。这些问题可能在初始损伤后长期存在。

如果您存在轻微的桡侧肘关节不稳，您可能通过特定的手术（如韧带折叠术）获得缓解。在中位随访时间为两年的情况下，患者报告主观满意度高且临床结果积极。对于需要韧带修复或重建的更严重病例，目标是恢复稳定性。缝合带增强术是其中一种可获得可接受功能结果的选项。这些手术的再手术率与其他关节稳定手术相当。

重要的是要知道，复杂性肘关节损伤的长期预后尚不明确。我们目前尚无足够的数据来预测术后多年会发生什么情况。在某些情况下，韧带可能无法随时间推移充分愈合或收紧。即使在切除桡骨头假体后长达五年，仍可能出现相关问题。

若不予处理，不稳通常会持续存在。肘关节依赖静态和动态稳定结构协同工作。当这些结构失效时，关节将变得不可靠。单纯性脱位需要详细的评估和连续的影像学随访，以确保正确愈合。复杂性病例通常需要对后外侧和后内侧方向进行手术处理，以恢复稳定性。

您的外科医生将根据您的具体损伤模式制定治疗方案。无论您选择非手术治疗还是手术治疗，密切监测都至关重要。超声检查无法客观区分健康关节与过度活动关节，因此您的病史和体格检查至关重要。请做好需要耐心进行康复的准备。虽然许多患者恢复良好，但部分患者仍持续出现症状。您的外科医生将帮助您以现实的预期应对这些可能性。

何时就诊

若肘部疼痛持续且休息后无改善，请咨询全科医生。若感到无力、关节不稳，或关节出现卡顿、脱位感，请要求专科医生评估。若症状干扰睡眠或工作，请及时就医。创伤事件后症状突然加重也需引起重视。复杂性不稳涉及重要的骨性和韧带稳定结构。单纯性脱位需进行详细的临床评估及系列影像学随访。超声检查无法客观区分正常关节与过度活动关节。完整的病史采集和体格检查对于准确诊断至关重要。

Reviewed by AI synthesis (v2) — pending human review · 18 May 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

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

Evidence & references

Overview

  • Complex instability of the elbow involves important osseous and ligamentous stabilizers [1].
  • Management protocols exist for common patterns of complex elbow injury [1].
  • Combined posterolateral and posteromedial rotatory instability requires surgical addressing of both directions to restore elbow stability [2].
  • Effective treatment of simple elbow dislocations requires a detailed clinical assessment [3].
  • Effective treatment of simple elbow dislocations requires sequential radiographic follow-up [3].
  • Patients with lateral collateral ligament instability had resolution of symptoms and regained a near full arc of elbow flexion and forearm rotation [5].
  • Long-term outcomes with surgical management of complex elbow injuries are unknown [6].
  • Treatments for elbow instability remain challenging in demanding cases, with high rates of persistent instability, post-traumatic arthritis, stiffness, and pain [8].
  • Ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament results in acceptable functional outcomes for complex elbow instability [9].
  • 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].
  • Lateral collateral ligament repair provides satisfactory outcomes for acute posterolateral rotatory instability of the elbow [11].
  • Instability is the major complication of unlinked total elbow arthroplasty, often requiring revision [13].
  • Linked total elbow arthroplasty is preferred for patients with posttraumatic articular damage, ligamentous instability, deformity, or bone loss [13].
  • All reconstruction methods for the lateral ulnar collateral ligament were able to sufficiently restore posterolateral rotatory stability of the elbow over the full range of motion [17].

Anatomy & Pathophysiology

  • The elbow consists of static and dynamic stabilizers that function in synchrony to prevent elbow instability [4].
  • Complex instability of the elbow involves important osseous and ligamentous stabilizers [1].
  • 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].
  • Posterolateral rotatory instability (PLRI) of the elbow remains to be fully understood [10].
  • 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].
  • Proper balancing and adequate bone resection from the radial head are mandatory for obtaining normal elbow kinematics during radial head arthroplasty [27].
  • Elbow valgus torque increases contact pressure in the radiocapitellar joint [28].
  • The circumferential graft technique for multidirectional elbow instability was evaluated for stability against valgus and varus/posterolateral rotatory forces [29].
  • 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].
  • 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].
  • 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 capitellum alone does not contribute to elbow stability, whereas the trochlea has an important role [34].
  • 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].
  • The Orthofix elbow external fixator stabilizes the ligamentous unstable elbow joint efficiently but decreases the range of motion and constrains extension [36].
  • 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].

Classification

  • Complex instability of the elbow involves important osseous and ligamentous stabilizers [1].
  • Combined posterolateral and posteromedial rotatory instability requires surgical addressing of both directions to restore stability [2].
  • Simple elbow dislocations require detailed clinical assessment and sequential radiographic follow-up for effective treatment [3].
  • The elbow consists of static and dynamic stabilizers that function in synchrony to prevent instability [4].
  • 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].
  • Long-term outcomes with surgical management of complex elbow injuries are unknown [6].
  • Sonography does not allow an objective and reproducible distinction between healthy and hypermobile elbow joints [7].
  • Treatments for elbow instability remain challenging, with high rates of persistent instability, post-traumatic arthritis, stiffness, and pain in demanding cases [8].
  • Instability is the major complication of unlinked total elbow arthroplasty, often requiring revision [13].
  • Linked total elbow arthroplasty is preferred for patients with posttraumatic articular damage, ligamentous instability, deformity, or bone loss [13].
  • 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].
  • The posterolateral ligament 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 [24].

Clinical Presentation

  • Complex instability of the elbow involves important osseous and ligamentous stabilizers [1].
  • Combined posterolateral and posteromedial rotatory instability requires surgical addressing of both directions to restore stability [2].
  • 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 instability [4].
  • Patients with lateral collateral ligament instability had resolution of symptoms and regained a near full arc of elbow flexion and forearm rotation [5].
  • Long-term outcomes with surgical management of complex elbow injuries are unknown [6].
  • Sonography cannot objectively distinguish between healthy and hypermobile elbow joints, making complete clinical history and examination vital [7].
  • Treatments for elbow instability remain challenging with high rates of persistent instability, post-traumatic arthritis, stiffness, and pain in demanding cases [8].
  • Patients after conservatively treated simple elbow dislocations show good clinical and functional results [12].
  • 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].
  • Elbow arthroscopy is a useful tool for managing valgus extension overload when conservative treatments have failed [15].
  • The posterolateral ligament of the elbow has a significant role in the elbow's posterolateral stability [16].
  • Posterolateral rotatory instability of the elbow exists in children but may be masked by contracture, with radiographs potentially showing evidence of instability [20].
  • Instability can coexist and may be associated with refractory lateral epicondylitis [21].
  • Symptomatic ulnar collateral ligament insufficiency in baseball players is associated with characteristic high-stress distribution patterns on the anterolateral part of the capitellum and the anterolateral part of the ulna [22].
  • Almost one half of patients suffering from recalcitrant lateral epicondylitis display signs of lateral ligamentous patholaxity [33].
  • Over 85% of patients with symptomatic minor instability of the lateral elbow (SMILE) demonstrate at least one intra-articular abnormality [33].

Investigations

  • Effective treatment of simple elbow dislocations requires a detailed clinical assessment [3].
  • Effective treatment of simple elbow dislocations requires sequential radiographic follow-up [3].
  • The elbow consists of static and dynamic stabilizers that function in synchrony to prevent elbow instability [4].
  • A distinction between healthy and hypermobile elbow joints is not possible using sonography [7].
  • Obtaining a complete clinical history and examination is vital because sonography cannot distinguish between healthy and hypermobile elbow joints [7].
  • Posterolateral rotatory instability of the elbow exists in children but may be masked by contracture [20].
  • Radiographs may show evidence of instability in children with posterolateral rotatory instability [20].
  • 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].
  • Different amounts of gapping are seen on stress ultrasonography with sectioning of the medial elbow stabilizers [24].
  • No numerical value can confidently determine the pathologic status of the ulnar collateral ligament of the elbow when using stress radiography [40].
  • An MRI should be performed if healing does not occur by a reasonable time despite successful bony healing to assess potential cartilage damage [41].

Treatment

  • 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].
  • Both directions of instability must be addressed surgically to restore elbow stability in combined posterolateral and posteromedial rotatory instability [2].
  • 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 for complex elbow instability [9].
  • Satisfactory outcomes are obtained with lateral collateral ligament repair for acute posterolateral rotatory instability of the elbow [11].
  • All patients in the series had resolution of their symptoms of instability and regained a near full arc of elbow flexion and forearm rotation following treatment for lateral collateral ligament instability [5].
  • 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].
  • Both Jobe and Docking techniques are safe and effective in the treatment of posterolateral elbow instability [19].
  • Treatment of late instability is focused on lateral ligament reconstruction from the humerus to the ulna using tendon grafts with reasonably good outcomes [23].
  • Elbow arthroscopy is a useful tool for managing diseases of the elbow, including valgus extension overload, when conservative treatments have failed [15].
  • Ligament repair with suture anchors and hinged external fixator could be an option for treating ankylosed, severely or very severely stiff elbows after complete open release [39].
  • 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].
  • 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].

Complications

  • Complex elbow instability involves important osseous and ligamentous stabilizers [1].
  • Combined posterolateral and posteromedial rotatory instability requires surgical addressing of both directions to restore stability [2].
  • Effective treatment of simple elbow dislocations requires detailed clinical assessment and sequential radiographic follow-up [3].
  • The elbow consists of static and dynamic stabilizers that function in synchrony to prevent instability [4].
  • Patients with lateral collateral ligament instability had resolution of symptoms and regained near full arc of elbow flexion and forearm rotation [5].
  • Long-term outcomes with surgical management of complex elbow injuries are unknown [6].
  • Sonography cannot objectively distinguish between healthy and hypermobile elbow joints, making complete clinical history and examination vital [7].
  • 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].
  • Posterolateral rotatory instability (PLRI) of the elbow remains to be fully understood [10].
  • Satisfactory outcomes were obtained with lateral collateral ligament repair for acute posterolateral rotatory instability of the elbow [11].
  • Patients after conservatively treated simple elbow dislocations show good clinical and functional results [12].
  • 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].
  • 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].
  • 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].
  • 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].

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].
  • Residual increased valgus stress angulation and posterolateral rotatory translation can occur after simple elbow dislocation [12].
  • Ligaments of the elbow may not heal or tighten sufficiently over time, and removal of a radial head prosthesis may give rise to stability problems even up to 5 years after prosthetic removal [25].
  • For complex elbow instability, ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament results in acceptable functional outcomes [9].
  • Ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament for complex elbow instability has a reoperation rate comparable with other joint stabilization procedures [9].
  • Direct repair of traumatic tears of the lateral ulnar collateral ligumant yields satisfactory outcomes 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].
  • 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].
  • Treatment of late instability is focused on lateral ligament reconstruction from the humerus to the ulna using tendon grafts, which yields reasonably good outcomes [23].
  • All patients in a series of lateral collateral ligament instability cases had resolution of their symptoms of instability and regained a near full arc of elbow flexion and forearm rotation [5].
  • 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. [1] (10.1016/j.injury.2013.09.032)
  • [L4] Both directions of instability must be addressed surgically to restore elbow stability. [2] (10.1016/j.injury.2007.01.039)
  • [L5] Effective treatment of simple elbow dislocations requires a detailed clinical assessment and sequential radiographic follow-up. [3] (10.1016/j.hcl.2015.06.002)
  • [L5] The elbow consists of static and dynamic stabilizers that function in synchrony to prevent elbow instability. [4] (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. [5] (10.1016/j.hcl.2007.11.001)
  • [L5] Long-term outcome with surgical management of complex elbow injuries is unknown. [6] (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. [7] (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. [8] (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. [9] (10.1016/j.jhsa.2022.10.016)
  • [L4] PLRI of the elbow remains to be fully understood. [10] (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. [11] (10.1016/j.jse.2013.06.018)
  • [L4] Patients after conservatively treated simple elbow dislocations show good clinical and functional results. [12] (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. [13] (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. [14] (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. [15] (10.1016/j.eats.2016.04.005)
  • [L4] The PLL of the elbow has a significant role in the elbow's posterolateral stability. [16] (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. [17] (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. [18] (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. [19] (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. [20] (10.2106/jbjs.l.00623)
  • [L1] Instability can coexist and may be associated with refractory lateral epicondylitis. [21] (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. [22] (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. [23] (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. [24] (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. [25] (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. [26] (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. [27] (10.1007/s00402-006-0164-z)
  • [L5] Elbow valgus torque increases contact pressure in the radiocapitellar joint. [28] (10.1177/0363546513490652)
  • [L5] The study evaluated stability against valgus and varus/posterolateral rotatory forces in cadaveric elbows. [29] (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. [30] (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. [31] (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. [32] (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. [33] (10.1007/s00167-017-4530-x)
  • [L5] While the capitellum alone does not contribute to elbow stability, the trochlea has an important role. [34] (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. [35] (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. [36] (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. [37] (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. [38] (10.1007/s11999-013-3331-x)
  • [L4] This could be an option for treating ankylosed, severely or very severely stiff elbows. [39] (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. [40] (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. [41] (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. [42] (10.1016/j.jhsa.2014.02.011)

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

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

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.