CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 370, pp. 34-43 0 2000 Lippincotl Williams & Wilkins, Inc.

Classification and Evaluation of Recurrent Instability of the Elbow

Shawn W. ODriscoll, MD, PhD

The clinical presentation, diagnosis, radiographic features, mechanism, pathologic changes, and treatment of elbow instability are understood better now. Elbow instability can be classified according to five criteria: (1)the timing (acute, chronic or recurrent); (2) the articulation(s) involved (elbow versus radial head); (3) the direction of displacement (valgus, varus, anterior, posterolateral rotatory); (4) the degree of displacement (subluxation or dislocation); and (5) the presence or absence of associated fractures. Posterolateral rotatory instability is the most common pattern of elbow instability, particularly that which is recurrent. Posterolateral rotatory instability can be considered a spectrum consisting of three stages according to the degree of soft tissue disruption. Patients typically present with a history of recurrent painful clicking, snapping, clunking, or locking of the elbow and careful examination reveals that this occurs in the extension portion of the arc of motion with the forearm in supination. There are four principle physical examination tests. The most sensitive is the lateral pivot-shift apprehension test, or posterolateral rotatory apprehension test, just as the anterior apprehension test of the shoulder is the most sensitive test for a patient with shoulder instability. Next is the lateral pivot-shift test, or posterolateral rotatory instability test. Reproducing the actual sub-

luxation and the clunk that occurs with reduction usually can be accomplished only with the patient under general anesthesia or occasionally after injecting local anesthetic into the elbow. The third test is the posterolateral rotatory drawer test, which is a rotatory version of the drawer or Lachman test of the knee. The final test is the stand up test as reported by Regan. The patients symptoms are reproduced as he or she attempts to stand up from the sitting position by pushing on the seat with the hand at the side and the elbow fully supinated. A lateral stress radiograph can show the rotatory subluxation.

From the Mayo Clinic, Rochester, Minnesota. Reprint requests to Shawn W. ODriscoll, MD, PhD, Department of Orthopedics, Mayo Clinic, 200 lStStreet, SW, Rochester, MN 55905.

In the current study the classification, evaluation, and mechanism of recurrent instability (dislocations, subluxations, or both) of the elbow will be discussed. This clinical problem has created much confusion for numerous reasons. First, although elbow instability has been documented for decades, the mechanism by which an elbow becomes recurrently unstable was only described in the last decade.21 Perhaps more importantly, the clinical tests for making the diagnosis of elbow instability had not been described until re~ent1y.l~ Finally, elbow instability was thought to be rare, although it is not as uncommon as previously thought. The clinical presentation, diagnosis, radiographic features, mechanism, pathologic changes, and treatment of this condition are

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understood better now. Therefore, the clinician is well advised to become familiar with it.

CLASSIFICATION OF ELBOW INSTABILITY

A simple classification for elbow instability does not exist. If it is to be useful for treatment decision making, at least five criteria must be considered: (1) the timing (acute, chronic, or recurrent); (2) the articulation(s) involved (elbow versus radial head); (3) the direction of displacement (valgus, varus, anterior, posterolateral rotatory); (4) the degree of displacement (subluxation or dislocation); and ( 5 ) the presence or absence of associated fractures.16J7 Some, but not all of these, can be congenital and acquired.

head from the ulna. This is can be congenital or acquired. Dislocation of the radial head from the ulna usually is traumatic and often part of a Monteggia fracture-subluxation.
Elbow and Proximal Radioulnar Joints (Divergent) Elbow and proximal radioulnar joint instability usually is traumatic and represents a combination of the previous two categories. Functionally, it can be thought of as a variant of elbow dislocation.

Direction of Displacement
Posterolateral Rotatory Instability Posterolateral rotary instability is the most common pattern of elbow instability, particularly that which is r e c ~ r r e n t . ' ~ It~ ~ , ' ~ is , usually posterolateral rather than direct posterior so that the coronoid can pass inferior to the trochlea. Posterolateral rotatory instability represents a spectrum of instability, which is discussed in detail in the section on the pathomechanics of elbow instability. It is three-dimensional displacement of the ulna on the humerus (the radius moving with the ulna) such that the ulna supinates, that is, externally rotates, away from the trochlea (Figs 1-4). Anterior Anterior instability of the elbow is rarez7 and typically is seen in association with fractures of the olecranon.l8 The collateral ligaments may be torn, but can be either intact or still attached to bony fracture fragments when the olecranon fracture is comminuted and close to the coronoid. Valgus Valgus instability is seen in one of two varieties: posttraumatic or chronic overload. Posttraumatic valgus instability implies rupture of the media1 collateral ligament.7 It may be associated with disruption of the other soft tissues on the medial side of the elbow, including the common flexor and pronator origin. Valgus instability usually is found in patients with radial head fractures that are associated

Timing Elbow instability can be acute, chronic, or recurrent. The current study concerns only recurrent instability. Articulation(s) Involved Because the elbow is a trochoginglymoidjoint with two articulations within one capsule, there are two categories of elbow instability, according to the articulation(s) involved: the hinge joint (the radius and ulna as a unit articulating with the humerus) or the proximal radioulnarjoint. Of course the instability can involve both joints in a combined fashion.
Elbow The most common category of elbow instability is that involving the hinge joint (ulnohumeral and radiohumeral joints). The instability can be congenital or acquired, although the former is rare. It is most commonly the hinge joint that is predisposed to recurrent instability, which will be the focus of the current study. Proximal Radioulnar Joint The second category of elbow instability is that involving the proximal radioulnar joint, with subluxation or dislocation of the radial

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n
Reduced

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i

2 -

3
Dislocated

PLRI

Perched

LUC

1
CL

Fig 1A-B. (A) Elbow instability is a spectrum from subluxation to dislocation. The three stages shown correspond with the pathoanatomic stages of capsuloligamentous disruption shown in Figure 1B. Forces and moments responsible for displacements are shown. (PLRI = posterolateral rotatory instability.19 (Reprinted with permission from ODriscoll SW, Morrey, BF, Korinek S, An KN: Elbow subluxation and dislocation. Clin Orthop 280:186-197, 1992). (B) Soft tissue injury progresses in a circle from lateral to medial in three stages correlating with those shown in Figure 1A. In Stage 1, the ulnar part of the lateral collateral ligament, the lateral ulnar collateral ligament, is disrupted. In Stage 2 the other lateral ligamentous structures and the anterior and posterior capsule are disrupted. In Stage 3, disruption of the medial ulnar collateral ligament can be partial with disruption of the posterior medial ulnar collateral ligament only (Stage 3A), or complete (Stage 3B). The common extensor and flexor origins also are often disrupted LUCL = lateral ulnar collateral ligament; MUCL = medial ulnar collateral ligament. (Reprintedwith permission from ODriscoll SW, Morrey, BF, Korinek S, An KN: Elbow subluxation and dislocation. Clin Orthop 280:186-197, 1992.)

with tears of the medial collateral ligament, or in patients with severe elbow instability such as occurs after a dislocation that has disrupted the lateral ligament complex. The medial collateral ligament usually heals after an elbow dislocation, perhaps because of the vascularized muscles that surround it. Valgus instability also can occur from repetitive microtrauma or overload. Attenuation or rupture of the anterior band of the medial collateral ligament, the pathologic changes responsible for this pattern of instability, usually is seen in athletes who perform overhead movements such as baseball pitcher^.^
Varus Varus instability is attributable to disruption of the lateral collateral ligament complex and can be shown acutely in patients with elbow dislocations and in many patients with recurrent or chronic instability when this ligament fails to heal. The forces across the elbow are principally valgus because of the anatomic

alignment, with the result that it is not often subjected to varus stress. This pattern of instability therefore may not be obvious. Posterolateral rotatory instability (see below) is a more likely clinical problem when the lateral collateral ligament is disrupted. Patients are more likely to complain of the symptoms of posterolateral rotatory instability than symptoms of varus instability, except perhaps those patients who use their arms as weightbearing extremities (patients who have had polio and other patients who use crutches to walk). Previous descriptions of elbow dislocations sometimes have distinguished medial and lateral dislocations from posterior or other dislocations but this is not necessary. The pathology in such medial or lateral dislocations is not different from that in complete posterior dislocations described in Stage 3B dislocations. In the authors experience, a pure medial or lateral dislocation or subluxation is most commonly seen after incomplete reduction of a posterior dislocation. That is, only the posterior dis-

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Fig 2A-D. (A) The Lateral Pivot-Shift Test o The Elbow for posterolateral rotatory instability is perf formed with the patient supine and the arm overhead. Supination and valgus moments with axial compression is applied during flexion causing the elbow to subluxate maximally at approximately40" to 70" flexion. (Reprinted with permission from O'Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg 73A:441, 1991). (6). Additional flexion produces a palpable visible clunk as the elbow reduces if the patient is able to relax enough to permit that part of the examination. Unfortunately,the subluxation and reduction maneuver is usually not possible in the patient who is awake. (C) This creates apprehension in the patient, who feels the sensation that the elbow is about to dislocate. The posterolateral rotatory apprehensiontest is highly sensitive, with false negative results having been observed only in patients with profound instability or severe soft tissue laxity. (Reprinted with permission from O'Driscoll SW: Elbow instability. Hand Clin 10: 405-415, 1994.) (D) If the patient is able to relax adequately, or is under general anesthesia, the elbow can be observed to subluxate so that the radius and ulna rotate off the humerus. The skin is sucked in behind the radial head as shown. U = ulnar; R = radius.
placement has been corrected, as seen on the lateral radiograph, and the medial or lateral displacement remains. One therefore must ensure that the reduction is complete in the coronal plane (medial to lateral on the anteroposterior (AP) film) and not just the sagittal plane. according to the degree of soft tissue disruption (Fig 1). In Stage 1, the elbow subluxates in a posterolateral rotatory direction and the patient will have a positive lateral pivot-shift test. In Stage 2, the elbow dislocates incompletely so that the coronoid is perched under the trochlea. In Stage 3, the elbow dislocates fully so that the coronoid rests behind the humerus. Stage 3 is subclassified into three categories. In Stage 3A, the anterior band of

Degree of Displacement Posterolateral rotatory instability can be considered a spectrum consisting of three stages

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Fig 3A-B. The posterolateral rotatory drawer test is similar to the drawer or Lachman tests of the knee.
(A) From the reduced position the arm is held in the overhead position such that it resembles a leg, and the elbow resembles a knee, and the shoulder is in full external rotation in preparation of displacement in the direction of the arrow. (B)The lateral side of the forearm is rotated away from the humerus, pivoting around the medial Collateral ligament so that the radius and ulna subluxate away from the humerus, leaving a dimple in the skin behind the radial head.

the medial collateral ligament is intact and the elbow is stable to valgus stress after reduction. In Stage 3B, the anterior medial collateral ligament is disrupted so that the elbow is unstable in valgus. In Stage 3C, the entire distal humerus is stripped of soft tissues, rendering the elbow grossly unstable even when a splint

or cast is applied with the elbow in a semiflexed position. Each stage has specific clinical, radiographic, and pathologic features that are predictable and have implications for treatment, which are discussed below in greater detail. The validity of this classification system has been confirmed in the authors clinical

Fig 4A-B. (A) Patient positioning for lateral stress radiograph is shown. It is difficult to control humeral rotation adequately when the xray beam is directed from lateral to medial. Insteadstress is best obtained by placingthe lateral side of the elbow against the xray plate with the shoulder and wrist in the same plane as the elbow, then directing the xray beam from medial to lateral. (B) Corresponding lateral stress radiograph showing posterolateral rotatory instability. A lateral stress radiograph taken during the lateral pivot-shifttest reveals the radius and ulna to have supinated away from the humerus leaving a gap in the ulnohumeral articulation and the radial head posterior to the capitellum.

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practice by the fact that the pathologic changes can be predicted from the clinical examination (including stress radiographs).

EVALUATION OF RECURRENT ELBOW INSTABILITY

(Posterolateral Rotatory Instability)

Associated Fractures Elbow subluxations and dislocationscan be associated with fractures about the elbow. Fracture-dislocations most commonly involve the coronoid and or radial head, an injury so difficult to treat and prone to unsatisfactory results that it has been termed the terribletriad of the elbow.4When the radial head and coronoid are fractured in a dislocated elbow, the capsule still is attached to the humerus and the coronoid fragment, and the medial soft tissues are often still intact, that is, the elbow is stable to valgus when holding the foreann pronated (see below regarding pseudovalgus instability). Some fractures, such as intraarticularsupracondylar fractures of the humerus and comminuted fractures of the olecranon and coronoid, can cause elbow instability without disruption of the collateral ligaments. However, the majority of unstable elbows also have disruption of one or both ligaments,even in the presence of fractures. Radial head fractures do not cause clinically significant instability unless the medial collateral ligament is disrupted.14These fractures can have a strong influence on prognosis and treatment. In many cases, they are the main indication for surgery. An important feature of elbow injuries to recognize is that the small flake fracture of the coronoid, commonly seen in elbow dislocations, is not an avulsion fracture because nothing attaches to the very tip of the coronoid. Indeed the tip can be clearly seen arthroscopically. The capsule inserts on the distal slope of the coronoid, just past its tip.l Based on this fact, and confirmed by experience, the capsule can be assumed to be attached to coronoid fractures greater in size than a small flake. The brachialis inserts farther distally on the ulna. This fracture is a shear fracture and is likely pathognomonic of an episode of elbow subluxation or dislocation, analogous to the bony Bankart lesion of anterior shoulder instability. , I 7

Clinical Presentation It has become apparent that recurrent elbow instability is probably more common than previously thought. Indeed, in two long-term reports, 15% and 35% of patients, respectively were interpreted to have symptoms of recurrent instability, although the authors usually could not show the instability on examination.8,12This might be because the physical examination maneuvers permitting the diagnosis of recurrent instability of the elbow were not familiar to those authors.19 Patients typically present with a history of recurrent painful clicking, snapping,clunking, or locking of the elbow. Careful examination reveals that this occurs in the extension portion of the arc of motion with the forearm in supination. With a history of dislocation, the diagnosis of recurrent elbow instability is to be suspected, but should be considered even when there has been trauma without dislocation or surgery for tennis elbow or surgery on the radial head. The most common cause is a dislocation with inadequate ligamentous healing. However,just as there is a spectrum of instability in the shoulder, from subluxations to frank dislocations requiring reduction, there also is a spectrum of instability in the elbow. The author has confirmed the presence of recurrent symptomatic subluxations in patients after minor injuries such as sprains of the elbow and successfully treated them by ligament reconstruction.Rarely, severe tissue laxity or chronic overload, as seen in patients who use crutches to walk or in patients with connective tissue disorders, also can be responsible for this condition. Causes of severe tissue laxity or chronic overload are iatrogenic caused by violation of the ulnar part of the lateral collateral ligament complex with inadequate attention to its repair during surgery.13,15319 typically occurs from lateral This releases for tennis elbow or after surgery on the radial head.

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Diagnosis
The history is characteristic, but the findings on physical examination are subtle. The most sensitive test is the lateral pivot-shift apprehension test or posterolateral rotatory apprehension test, just as the anterior apprehension test of the shoulder is used for a patient with shoulder instability (Fig 2C). With the patient in the supine position and the effected extremity overhead, the patients wrist and elbow are grasped as though one might think of holding the ankle and knee when examining the leg. The elbow is supinated with a mild force at the wrist and a valgus moment and compressive force is applied to the elbow during flexion. This results in a typical apprehension response with reproduction of the patients symptoms and a sense that the elbow is about to dislocate. Reproducing the actual subluxation, and the clunk that occurs with reduction, usually can only be accomplished with the patient under general anesthesia or occasionally after injecting local anesthetic into the elbow. The lateral pivot shift test performed under those circumstances results in subluxation of the radius and ulna away from the humerus, producing a prominence posterolaterally over the radial head and a dimple between the radial head and the capitellum (Fig 2D). As the elbow is flexed to 40 or more, reduction of the ulna and radius together on the humerus occurs suddenly with a palpable, visible clunk. It is the reduction that is apparent. A lateral stress radiograph taken before the clunk can be helpful to show the rotatory subluxation (see next section). It is important to realize that subtle degrees of instability are easily missed and require a high index of suspicion for diagnosis. Two additional physical examination methods exist. The first is the posterolateral rotatory drawer test, which is a rotatory version of the drawer or Lachman test of the knee. During this test, the lateral side of the forearm subluxates away from the humerus, pivoting around the medial collateral ligamentlo (Fig 3A-B). The second is the stand up test reported by W. Regan, MD (verbal communica-

tion, 1997) in which the patients symptoms are reproduced as he or she attempts to stand up from the sitting position by pushing on the seat with the hand at the side and the elbow fully supinated. Combined instability patterns also are ruled out by examining the elbow for valgus and varus instability. This is best performed using stress radiographs (preferably image intensification) as described in the next section.

Radiographic Features Apart from the physical examination, stress radiographs are useful to confirm the diagnosis of recurrent elbow instability. Continuous imaging with an image intensifier is preferable, but careful positioning and examination in the radiology suite are satisfactory after some experience has been obtained. A lateral stress radiograph at the point of maximum rotatory subluxation during the pivot-shift test is useful. To control humeral rotation, and therefore to accurately align the elbow with the xray beam, the stress radiograph is best obtained by placing the lateral side of the elbow against the xray plate with the shoulder and wrist in the same plane as the elbow, then directing the n a y beam from medial to lateral (Fig 4). Malrotation makes the stress radiograph very difficult to interpret. The AP radiograph taken during the posterolateral rotatory stress test shows a slight malalignment of the ulnohumeral joint, overlap of the radial head and capitellum or both. Valgus and varus stability also always are assessed. It is essential to realize that pseudovalgus instability can exist in the presence of posterolateral rotatory instability. This occurs as the coronoid and radial head slide under the trochlea because of posterolateral rotatory displacement, then permit valgus angulation to occur by pivoting around the intact medial collateral ligament. A false positive valgus stress test is most likely to be observed during open radial head excision when the lateral collateral ligament complex has been opened and therefore destabilized. To prevent this, valgus instability always should be tested while keeping the forearm fully pronated with a modest force.

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Arthroscopy confirms that there is excessive ulnohumeral joint space opening when the joint is stressed in posterolateral rotation.20 It is only necessary for patients with subtle elbow instability.

MECHANISM OF ELBOW INSTABILITY

The traditional teaching that the mechanism of dislocation is hyperextension was unsubstantiated by data.25Although the previously proposed mechanism might occur, it is reasonable to consider the following as a unified concept that can be used to explain the full clinical spectrum of acute, chronic, and recurrent elbow instability. This mechanism now has been confirmed in videos of two patients obtained during the actual dislocations (data not shown). Elbow dislocations or subluxations typically occur as a result of falls on the outstretched hand. The elbow experiences an axial compressive force during flexion as the body approaches the ground. As the body rotates internally on the elbow (forearm rotates externally on the humerus) a supination moment occurs at the elbow. A valgus moment results as the mechanical axis passes through the lateral side of the elbow. This combination of valgus and supination with axial compression during flexion is precisely the mechanism that results in a posterolateral rotatory subluxation or dislocation of the elbow and can be reproduced clinically by what is referred to as the lateral pivot shift test, which is described below. The pathoanatomy can be thought of as a circle of soft tissue disruption from lateral to medial in three stages (Fig 1A). In Stage 1 the ulnar part of the lateral collateral ligament is disrupted (the remainder of the lateral collateral ligament complex maybe intact or disrupted). This results in posterolateral rotatory subluxationof the elbow, which reduces spontaneously. With additional disruption anteriorly and posteriorly the elbow in Stage 2 instability is capable of an incomplete posterolateral dislocation in which the medial

edge of the ulna rests on the trochlea such that a lateral radiograph gives the impression of the coronoid being perched under the trochlea (Fig 1B). This can be reduced readily with minimal force or by the patient manipulating the elbow himself or herself. In Stage 3, the coronoid and radial head are fully posterior to the trochlea and capitellum, respectively. Depending on the severity of tissue disruption in Stage 3 (A, B, or C ) as described previously, the elbow will be stable in valgus (Stage 3A), unstable in valgus (Stage 3B), or grossly unstable except when flexed greater than 90" after reduction (Stage 3C). Dislocation is the final of three sequential stages of elbow instability resulting from posterolateral ulnohumeral rotatory subluxation, with soft tissue disruption progressing from lateral to medial. In each stage, the pathoanatomy correlates with the pattern and degree of instability. This was confirmed in a cadaver study, in which 12 of 13 elbows could be dislocated posteriorly with the anterior medial collateral ligament intact.21 Josefsson et a17,9documented that the medial and lateral collateral ligaments were disrupted in acutely dislocated elbows that were explored surgically. However, this is entirely compatible with the proposed mechanism of dislocation because the final stage is disruption of the anterior medial collateral ligament and then the common flexor pronator origin by any continuation of the axial force or external rotatory moment once the coronoid passes behind the trochlea. The observation that the medial collateral ligament usually is tom in simple dislocations (no fractures) and not in fracturedislocations corroborates the observation of Josefsson et al. When the elbow dislocates without fracturing the coronoid or radial head, the forearm has a tendency toward sudden severe displacement once the coronoid and radial head clear the trochlea and capitellum, respectively. Therefore, displacement can be severe enough to cause extensive soft tissue tearing. However, when the coronoid and radial head are fractured, significant energy is absorbed in a gradual progression by the fractures, thereby

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dissipating the force that otherwise would have caused sudden severe displacement after the coronoid passes beneath the trochlea. These pathoanatomic stages all correlate with the clinical degrees of elbow instability. The roles of the flexor and pronator and common extensor tendon origins are not known, but they probably are important secondary stabilizers of the elbow. Certainly, their fibers blend with and augment those of the collateral ligaments with which they are contiguous. In severely unstable elbows that have not sustained any fractures, both tendon origins usually are disrupted. This posterolateral rotatory mechanism of dislocation results in less soft tissue damage than would a hyperextension or valgus mechanism. The kinetics are clinically relevant and reproducible. They explain the spectrum of instability, from posterolateral rotatory instability to perched dislocation, to posterior dislocation without or with disruption of the anterior medial collateral ligament, which occurs with additional posterior displacement. Such a posterolateral rotatory mechanism for dislocation would be compatible with those mechanisms suggested by Osborne and Cotteri1122and Roberts.24 For several reasons other mechanisms such as hyperextension need not be implicated to explain the majority of clinical observations (although other mechanisms probably occur in some cases). A posterolaterai rotatory mechanism would be consistent with the observation that some patients experience recurrent dislocations requiring reduction and also have a positive lateral pivot-shift test.l9 Furthermore, such patients with recurrent dislocations are treated successfullyby surgical reconstruction of the lateral collateral ligament complex alone, without any surgery on the medial side.2,3J5J9,22,23,26 Together, these observations suggest that the essential lesion of such instability is on the lateral side. Finally, it has not been shown that the results of surgical repair of the anterior medial collateral ligament after acute dislocations are superior to the results of nonoperative treatment.6.7

An important concept in elbow stability is that an elbow with intact joint surfaces (no fractures or bone defects) requires only two ligamentous structures for functional stability. These are the anterior band of the medial collateral ligament and the ulnar part of the lateral collateral ligament. Both are conceptually simple bands of tissue with attachments to bone at each end and can be reconstructed.

References
1. Cage DJ, Abrams RA, Callahan JJ, Botte MJ: Soft tissue attachments of the ulnar coronoid process. Clin Orthop 320:154-158,1995. 2. Diirig M, Miiller W, Riiedi TP, Gauer EF: The operative treatment of elbow dislocation in the adult. J Bone Joint Surg 61A:239-244, 1979. 3. Hassmann GC, Brunn F, Neer CS: Recurrent dislocation of the elbow. T. Bone Joint Surg 57A: 10801084,1975. 4. Hotchkiss RN: Fractures and Dislocations of the Elbow. In Rockwood CA, Green DP, Bucholz RW, Heckman JD (eds). Fractures in Adults. Philadelphia, Lippincott Raven 980-981, 1996. 5. Jobe FW,Stark H, Lombard0 S: Reconstmction of the ulnar collateral ligament in athletes. J Bone Joint Surg 68A: 1158-1 163,1986. 6. Josefsson PO, Gentz C-F, Johnell 0, Wendeberg B: Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint. Clin Orthop 214:165-169, 1987. 7. Josefsson PO, Gentz C-F, Johnell 0, Wendeberg B: Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint. A prospective randomized study. J Bone Joint Surg 69A:605-608, 1987. 8. Josefsson PO, Johnell 0, Gentz CF: Long-term sequelae of simple dislocation of the elbow. J Bone Joint Surg 66A:927-930, 1984. 9. Josefsson PO, Johnell 0, Wendeberg B: Ligamentous injuries in dislocations of the elbow joint. Clin Orthop 221:221-225,1987. 10. Kinast C, Jakob RP: Differentialdiagnostik bei ellbogengelenksblockierungen-die subluxationsstressaufnahmetechnik. Hefte Unfallheilkd 181:339-341, 1986. 11. Linscheid RL, ODriscoll SW: Elbow Dislocations. In Morrey BF (ed). The Elbow and Its Disorders. Philadelphia, WB Saunders Company 441452, 1993. 12. Melhoff TL, Noble PC, Bennett JR, Tullos HS: Simple dislocation of the elbow in the adult. J Bone Joint Surg 70A:244-249, 1988. 13. Morrey B: Reoperation for failed surgical treatment of refractory lateral epicondylitis. J Shoulder Elbow Surg 1:47-55, 1992. 14. Morrey BF, An K-N, Tanaka S: Valgus stability of the elbow. A definition of primary and secondary constraints. Clin Orthop 265:187-195, 1991. 15. Nestor BJ, ODriscoll SW, Morrey BF: Ligamentous

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16.

17.
18.

19. 20. 21.

reconstruction for posterolateral instability of the elbow. J Bone Joint Surg 74A: 1235-1241,1992. ODriscoll SW: Classification and Spectrum of Elbow Instability: Recurrent Instability. In Morrey BF (ed). The Elbow and Its Disorders Philadelphia, WB Saunders Company 453463,1993. ODriscoll SW: Elbow instability. Hand Clin 10:405415, 1994. ODriscoll SW: Technique for unstable olecranon fracture-subluxations. Oper Tech Orthop 4:49-53, 1994. ODriscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg 73A:440-446,1991. ODriscoll SW, Morrey B F Arthroscopy of the elbow: Diagnostic and therapeutic benefits and hazards. J Bone Joint Surg 74A:8&94,1992. ODriscoll SW, Morrey BF, Korinek S, An K-N: El-

22. 23. 24. 25. 26.

27.

bow subluxation and dislocation: A spectrum of instability. Clin Orthop 280: 186197, 1992. Osbome G , Cotterill P: Recurrent dislocation of the elbow. J Bone Joint Surg 48B:340-346, 1965. Rang M: Childrens Fractures. Philadelphia, JB Lippincott 192, 1983. Roberts PH: Dislocation of the elbow. Br J Surg S6:806-8 15, 1969. Schwab GH, Bennett JB, Woods GW, Tullos HS: Biomechanicsof elbow instability.The role of the medial collateral ligament. Clin M o p 146:42-52,1980. Symeonides PP, Paschaloglou C, Stavrou Z, Pangalides TH: Recurrent dislocation of the elbow. Report of three cases. J Bone Joint Surg 57A:10841086,1975. Torchia M, DiGiovine N: Anterior dislocation of the elbow in an arm wrestler. J Shoulder Elbow Surg 7539-541, 1998.