Elbow subluxation and dislocation: A spectrum of instability

After sequential releases of the ligaments and capsules of 13 fresh autopsy specimen elbows, external rotation and valgus moments with axial forces resulted in posterior dislocations in 12 of the 13 with the anterior medial collateral ligament (AMCL) intact. Kinematic displacements measured with a three-dimensional electromagnetic tracking device showed that dislocation involved posterolateral rotation of 34°-50° and 5°-23° valgus at about 80° flexion. Dislocation is the final of three sequential stages of elbow instability resulting from posterolateral rotation, with soft-tissue disruption progressing from lateral to medial. In each stage, the pathoanatomy correlated with the pattern and degree of instability. Testing for valgus stability of the elbow during simulated active flexion revealed no significant increase (-0.3°-2.4°) in valgus laxity after reduction compared with the intact specimens (p > 0.05, β = 0.1, Δ = 2.5°). In no case did the digitized AMCL origin-to-insertion distance increase beyond normal during the dislocation (p < 0.01). The mechanism of dislocation during a fall on the outstretched hand would involve the body 'rotating internally' on the elbow, which experiences an external rotation/valgus moment as it flexes. Posterior dislocations should therefore be reduced in supination. If valgus stability in pronation is demonstrated, the AMCL can be assumed to be intact, and rehabilitation in a hinged cast-brace with the elbow in full pronation can be commenced immediately.