Elbow Dislocation Nima Rezaie 2020

Elbow Dislocation
Nima Rezaie, MD*, Sunny Gupta, MD, Benjamin C. Service, MD,

Daryl C. Osbahr, MD
KEYWORDS
Simple elbow dislocation Complex elbow dislocation Posterolateral instability
Posteromedial instability Chronic dislocation
KEY POINTS
Acute simple elbow dislocations largely are treated conservatively. If surgical intervention
is required, then early motion rehabilitation is advocated.
Some elbow dislocations with ligament-only injuries may be considered complex disloca-
tions due to the extent of the soft tissue trauma.
Complex elbow fracture-dislocations are treated first with management of bony injuries,
followed by assessment of ligamentous stability if instability persists.
Starting an appropriate early range of motion rehabilitation helps achieve optimal out-
comes with both surgical and nonsurgical treatments of elbow dislocations.
INTRODUCTION
The elbow is the second most commonly dislocated joint1,2 representing 11% to 28%
of elbow injuries,3,4 with an annual incidence of 5.21 per 100,000.5 Historically, acute
dislocations without accompanying bony pathology were considered “simple” and
ones with bony involvement referred to as “complex” dislocations. Simple elbow dis-
locations, the most common, represent approximately 74% of all elbow dislocations.6
Complex dislocations should be subdivided into ligamentous dislocations and
fracture-dislocations, with recognition that certain ligamentous injury patterns can
also represent complex injuries.
Elbow stability is sustained by bony, capsuloligamentous, and musculotendinous
components. The primary stabilizers of the elbow are the ulnohumeral articulation,
the anterior band of the medial collateral ligament (aMCL), and the lateral ulnar collat-
eral ligament (LUCL) complex.7,8 They have fixed positions relative to one another
through the elbow’s arc of motion and function as static stabilizers. The congruent
anatomy of the distal humerus and proximal ulna provide inherent stability to the joint.
The radial head and the medial collateral ligament (MCL) complex contribute to the
valgus stability of the elbow. The muscles across the elbow produce joint compressive
Orlando Health, 1222 South Orange Street, Orlando, FL 32806, USA

* Corresponding author.
E-mail address: Nima8806@gmail.com
Clin Sports Med 39 (2020) 637–655

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638 Rezaie et al
forces and function as dynamic stabilizers. Most elbow dislocations are simple dislo-
cations and occur in the posterior or posterolateral direction. Anterior dislocations are
less common, and divergent dislocations are rare.9
SIMPLE ELBOW DISLOCATIONS
Simple elbow dislocations traditionally were thought to be caused by falling onto an

outstretched hand, resulting in an externally rotated, valgus, and axially directed
load to the elbow.9–11 Multiple theories have tried to explain the sequence of soft tis-
sue injury. Historically, O’Driscoll and colleagues12 described that the typical injury
pattern involves a sequential disruption of anatomic structures from lateral to medial,
termed the Horii circle. First, the lateral collateral ligament (LCL) complex usually
avulses off its origin on the lateral epicondyle of the humerus, leading to posterolateral
instability of the elbow. It is followed by disruption of anterior and posterior capsule
with the coronoid perched under the trochlea. The aMCL is the next to be injured fol-
lowed by the entire MCL complex and possibly the common flexor origin. In some
injury patterns, the MCL complex can remain intact, acting as a pivot for a posterolat-
eral dislocation of the elbow.7
Newer studies evaluating magnetic resonance imaging (MRI) scans after reduction
of a simple elbow dislocation show a higher rate of injury to the anterior bundle of the
MCL when compared with the lateral side.13,14 Schreiber and colleagues,15 in a video
review study from YouTube videos of elbow dislocations, found that the most com-
mon mechanism involves hyperextension, valgus force and an axial load; the extrem-
ity usually was positioned in forearm pronation, shoulder abduction, and forward
flexion. According to their article, the injury first starts medially with the MCL, then pro-
ceeds with anterior capsular tearing, and then progresses laterally. Further cadaveric
studies simulating posterior elbow dislocations showed similarities to these findings,
with a higher incidence of damage to medial-sided ligaments compared with the
lateral ligaments.16 Additionally, common to all of these newer studies is a spectrum
of soft tissue injury starting from the medial side up the injury ladder to the lateral
side with avulsion of the common extensor tendon.17 Realistically, the pattern of
soft tissue injury largely depends on the position of the limb at the time of impact, di-
rection of the force, and the variations in soft tissue laxity of the patient.18
Evaluation
A patient usually presents complaining of severe elbow pain after a trauma, such as a
fall onto an outstretched hand. Patients often present with persistent deformity, but
there may be situations where the elbow has reduced prior to orthopedic evaluation.
After obtaining a thorough history, a comprehensive orthopedic examination is vital
when evaluating patients with a possible elbow dislocation, including the contralateral
upper extremity. Assessment of neurovascular status, bone and joint deformity, and
limitations of elbow motion is necessary for a complete work-up. The most cost-
effective initial imaging should start with plain anteroposterior and lateral radiographs
of the elbow.9 Oblique views can help detect intra-articular fractures19 (Fig. 1).
Computed tomography (CT) is helpful to detect occult fractures that may be missed
on plain radiographs and to identify intra-articular fracture fragments causing mechan-
ical symptoms after reduction20 (Fig. 2). MRI is more useful in chronic elbow instability
to evaluate the integrity of the ligaments.21 MRI can be helpful in the evaluation of
acute dislocations when the postreduction imaging demonstrates nonconcentric
reduction but no fractures. MRI helps determine the extent of injury to the ligaments
as well as show interposed cartilage and soft tissue, such as the annular ligament,
Elbow Dislocation 639
Fig. 1. (A) Anteroposterior radiograph of a posterolateral elbow dislocation. (B) Oblique

radiograph of a posterolateral elbow dislocation. (C) Post reduction lateral radiograph
with posterior splint. (D) Post reduction anteroposterior radiograph with posterior splint.
which can contribute to persistent instability.22 Diagnostic elbow arthroscopy can pro-
vide useful information to detect radial head subluxation, articular damage, ligamen-
tous disruption, or loose bodies.23,24
640 Rezaie et al
Fig. 2. Sagittal CT scan after reduction of an elbow dislocation with an arrow pointing to-
ward a concomitant radial head fracture.
Treatment Algorithm
Joint reduction
In the setting of an injured athlete on the sideline, clinical evaluation is paramount. The
athlete should be taken to a controlled environment away from the sideline. A reduc-
tion attempt should be performed using any one of the several techniques described in
this section, using traction and countertraction. The elbow should be placed into a
posterior slab splint at 90 , and radiographic imaging should be obtained for confirma-
tion of reduction.
A patient in the emergency room must have emergent injuries ruled out. Once eval-
uated from a clinical and radiographic perspective, reduction of the joint should be
performed next. Muscle relaxation usually is required during an elbow reduction
attempt. If the reduction is too difficult or cannot be achieved in a safe manner with
analgesics or conscious sedation, then it can be performed in the operating room
with general or regional anesthesia.9 An intra-articular lidocaine injection may be
used to assist in reduction and may reduce the need for sedation or general anes-
thesia.24 Fluoroscopic imaging can be used to guide the reduction and to assess sta-
bility after the reduction.9
Three different techniques have been described for reducing a posterior elbow
dislocation. In the first technique, the patient lies supine with the elbow flexed and
the forearm supinated. Traction then is applied to the forearm while countertraction
is applied to the arm. Then, the medial or lateral displacement of the olecranon is cor-
rected. Finally, the olecranon is pushed distally to engage the olecranon fossa of the
humerus7,9,12,25 (Fig. 3). The Parvin method can be performed with the patient lying
prone with the arm and forearm hanging over the side of the table. The physician ap-
plies downward traction to the forearm with 1 hand as the other hand pulls the humer-
us upward and laterally. The thumb of the hand pulling on the humerus is used to push
the olecranon distally into the olecranon fossa26 (Fig. 4). A third technique places the
patient supine with the arm across the chest, the elbow flexed to 90 , and the forearm
fully supinated. The physician applies traction to the forearm with 1 hand, while the
other pulls the arm in the opposite direction. The elbow is gently flexed and the thumb
pushes the olecranon into the olecranon fossa.27 Forearm supination during reduction
is important to clear the coronoid under the trochlea in order to minimize additional
Fig. 3. Supine elbow reduction maneuver.
trauma to the intact medial structures.12 A modified version of the cross-arm tech-
nique can be used if there is an assistant available to help get better control of the
olecranon as it is pushed over into the olecranon fossa (Fig. 5).
Assessment of joint stability

Next, the elbow is flexed and extended through a full range of motion in neutral rotation
to assess for stability. Historically, a posterior splint was applied for comfort until the
patient returned to clinic 1 week later, with follow-up visits every 5 days to 7 days for a
total of 3 weeks after injury.7 If the joint is stable throughout the range of motion,
without any subluxation or crepitus, an argument can be made for early active range
of motion with a sling for comfort. Iordens and colleagues28 compared early mobiliza-
tion to plaster immobilization in a multicenter randomized clinical trial, showing that
patients recover faster and return to work earlier without increasing complications.
Another retrospective study showed that the return to work between the 2 groups
can be cut in half,17 with return to work in the early mobilization group at 3.2 weeks
compared with the plaster immobilization group returning to work at 6.6 weeks.29
Any immobilization longer than 1 week consistently has shown poor patient outcomes
with specific regard to elbow stiffness.28–30 Advances in rehabilitation have allowed for
the great patient outcomes that avoid complications. An overhead motion protocol,
described by Schreiber and colleagues,31 can be implemented within 1 week of injury
converting gravity from a distracting force to a stabilizing force (Fig. 6).
642 Rezaie et al
Fig. 4. Parvin prone elbow dislocation reduction maneuver.
Fig. 5. (A) Supine cross-table elbow reduction maneuver. (B) Modification with assistant.
Fig. 6. Overhead motion protocol for early rehabilitation. (A) Patient supine with shoulder
adducted and flexed to 90 with forearm in neutral rotation. (B) Active assistance to achieve
elbow extension. (C) Patient supine with shoulder adducted and flexed to 90 with forearm
in full pronation. (D) Patient supine with shoulder adducted and flexed to 90 with forearm
in full supination.
If there is elbow subluxation or dislocation in extension, Watts32 argues for the use
of MRI to determine the extent of soft tissue injury. Although the authors of this article
do not advocate for routine use of MRI for acute simple dislocation, they acknowledge
that it can be helpful, especially in elbow dislocations that do not involve fracture but
that have questionable joint congruency. Those with grade 3 or grade 4 injuries, el-
bows with recurrent dislocation in extension, and subluxation on postreduction imag-
ing can be managed with examination under anesthesia using fluoroscopic imaging32:
1. Patient supine with forearm in pronation at full extension and 30 of flexion
2. Varus stress applied / if >10 of joint widening seen / lateral ligament complex
repair (Fig. 7)
3. Forearm supinated with elbow in full extension and 30 of flexion
4. Valgus stress applied / if >10 of joint widening seen / medial ligament complex
repair. Please see Fig. 8 for a simplified algorithm.
644 Rezaie et al
Fig. 7. (A) Anteroposterior fluoroscopic image of a concentric elbow joint. (B) Varus stress
applied with the elbow in extension showing a 13 widening of the radiocapitellar joint.
Closed reduction + ROM, gentle varus,

valeus, and rotation
Stable throughout
ROM
Subluxation/dislocation
in extension
Sling + early active

mabilization
No subluxation Subluxation
on x-ray on x-ray
Follow-up in 5-7 d
with repeat x-rays
Congruent Non-Congruent
Continue sling Reassess with full

+ mobilization pronation
Unstable in <45° Unstable in >45°

Stable in pronation extension extension
Hinged brace in full

Hinged brace in full Surgical repair
pronation + extension
pronation
block
Fig. 8. Simple elbow dislocation algorithm. ROM, range of motion.
Surgical Intervention
Indications for surgical treatment of simple dislocations include residual instability in
more than 45 of flexion, joint incongruence on postreduction radiographs, or an
open dislocation.24 The LCL is addressed first before considering repair of the
MUCL. The MCL should be repaired only if there is gross instability after LCL
repair.3,24,33
If a previous repair has failed or if the tissue integrity and quality are poor, then a liga-
mentous reconstruction should be considered. The use of an external fixator in cases
of persistent elbow instability for cases without fracture is rare; furthermore, recently
developed internal joint fixation systems are able to stabilize the elbow without trans-
cutaneous pins, which further decreases the need for external fixation.34 Regardless
of the ligament treatment, attention also should be directed toward potential missed
cartilaginous or osseous injuries in cases where combined MCL and LCL repairs
are insufficient in restoring stability.
Postoperative Rehabilitation
Early understanding of postoperative rehabilitation after a reduction and collateral lig-
ament repair/reconstruction was to immobilize the elbow in a posterior splint for
1 week before beginning active range of motion.24,35 With the progression of nonsur-
gical management for early active range of motion, postoperative rehabilitation also
has shown positive outcomes with earlier mobilization. Based on the ligaments that
are repaired, the elbow can be placed in a hinged braced within 1 week to allow for
active assisted range of motion as tolerated. At 6 weeks, the brace is used intermit-
tently to begin daily activities.36 The brace can be discontinued at 3 months to begin
strengthening exercises. The patient may begin to participate in sporting activities
while in the brace; the brace is recommended to be used for sports activities for a total
of 3 months to 6 months postoperatively.3,24
Progressive static splinting is started 4 weeks to 8 weeks after injury if contracture
develops and the range of active motion is less than 30 to 130 .37 If ongoing elbow
stiffness is present, then a turnbuckle orthosis can be used.38,39 Contracture release
surgery should be considered if no remarkable improvement occurs despite using a
turnbuckle orthosis for 3 months.
COMPLEX ELBOW DISLOCATIONS
This section overviews the topic of complex elbow dislocations with a discussion
covering coronoid fractures, terrible triad injuries, and posterior Monteggia fracture
dislocations (Fig. 9). Each topic is introduced briefly, followed by an overall treatment
algorithm. The overall theme in the management of these injuries is to obtain bony
healing and stability first and then to address and treat the ligamentous injury present.
Treatment protocols and postoperative rehabilitation on how to achieve best patient
outcomes are discussed.
Coronoid Fractures
Coronoid fractures can be small but can contribute significantly to elbow instability40
(Fig. 10). The anteromedial facet of the coronoid, 50% of which is unsupported by ul-
nar metaphysis, is prone to fractures secondary to varus/posteromedial injuries of the
elbow with axial loading. Coronoid fractures almost always present with an associated
injury to the LCL. Additionally, the posterior band of the MCL typically is ruptured while
the anterior band is intact and attached to the anteromedial coronoid facet. The lateral
646 Rezaie et al
Fig. 9. (A) Lateral radiograph of a terrible triad elbow dislocation. (B) Anteroposterior
radiograph of a terrible triad elbow dislocation. (C) A 3-dimensional CT reconstruction post-
reduction image showing the extent of radial head fracture and displacement.
joint space usually is widened. Together with the radial head, coronoid also provides
posterolateral rotatory stability.41
There is a lack of a universally accepted physical examination maneuver to detect
posteromedial rotatory injury. The most useful test is the gravity varus stress test.
The patient is asked to place the shoulder in 90 abduction with the forearm in neutral
rotation. The test is considered positive if the patient experiences instability or crepi-
tation, while the elbow is actively moved from flexion to extension (Fig. 11).
Fig. 10. A sagittal CT image of an arrow pointing toward the coronoid tip fracture.
Fig. 11. (A) Gravity varus stress test to assess for posteromedial varus rotatory instability
with the patient’s shoulder at 90 and forearm in neutral rotation and elbow extended.
(B) Patient maintains neutral forearm rotation and flexes elbow.
Additionally, the hyperpronation test can be used to assess for ulnohumeral subluxa-
tion with hyperpronation of the forearm.42
Monteggia Fracture-Dislocation
The Monteggia fracture is a fracture of proximal third of ulna with dislocation of radial
head. Mechanism of injury can be a fall on an outstretched hand with forearm in exces-
sive pronation or direct blow on the back of the upper forearm. Bado43 described a 4-
category classification of Monteggia fractures based on the direction of radial head
displacement and whether or not an associated fracture of the radial diaphysis was
present. Monteggia fracture types IIB and IID commonly are associated with coronoid
fractures and ligamentous injury with posterior dislocation of radial head. Type I Mon-
teggia usually can be managed with restoring the ulnar length without any complex
reconstruction.
Terrible Triads
The term, terrible triad of the elbow, was used by Hotchkiss to describe the constel-
lation of a traumatic elbow dislocation, radial head fracture, and associated coronoid
fracture.44 This dislocation pattern along with its associated bony fractures historically
has poor outcomes, with a tendency for early recurrent instability, chronic instability,
and posttraumatic arthritis.45–48 Without an algorithmic approach, the historical treat-
ment of patients with elbow dislocations associated with radial head and coronoid
fractures resulted in poor outcomes in 64% of patients.49,50
These injuries may occur due to high-energy trauma and thus a thorough work-up to
rule out concomitant musculoskeletal and visceral injuries must be performed. The
distal radioulnar joint and forearm should be specifically evaluated for tenderness or
648 Rezaie et al
instability as a longitudinal injury of the forearm needs to be ruled out if there is a

concomitant radial head fracture. Good functional outcome can be achieved if appro-
priate repairs are performed that result in a stable, concentric reduction of the elbow
joint. This usually is accomplished via open reduction and internal fixation or arthro-
plasty of all injured osseous structures that contribute to elbow stability, in addition
to necessary ligamentous repairs.45,47,49,51
Treatment algorithm
Generally, the goal of treating a traumatic complex elbow injury is to restore a stable
trochlear notch and to maintain proper joint alignment while the collateral ligaments
heal.40 The exact indications for nonoperative treatment remain controversial for
each of these injury patterns and must be reserved for the appropriate patient. Patient
compliance is pertinent during rehabilitation. Both serial clinical and radiographic
follow-ups are necessary to monitor for recurrent joint incongruence and instability.
The type of surgical procedures for coronoid fractures depends on the subtype of
the fracture according to O’Driscoll and colleagues’ classification.52
Subtype 1: nonoperative versus possible repair of LCL
Subtypes 2 and 3: open reduction internal fixation (ORIF) using a buttress plate
and/or LCL repair
If residual elbow valgus instability is identified after coronoid ORIF and LCL repair,
then the MCL is evaluated for possible repair or reconstruction. Some investigators
advocate suture fixation through capsular attachments if the fracture is too small for
plate and screw fixation because it adds to anterior capsular stability.40,53 Alterna-
tively, in cases of a larger anteromedial facet fracture without comminution where
solid bony stability can be obtained with ORIF, repair of the LCL is not absolutely
necessary.
Treatment of Monteggia injuries is directed at restoration of ulnar length and align-
ment to indirectly achieve radial head reduction. It rarely is necessary that the proximal
radiocapitellar joint be opened to achieve radial head reduction but may be necessary
in some cases as a result of annular ligament interposition.53,54 The posterior Monteg-
gia injury has been shown to have more concomitant injuries involving either the radial
head, coronoid process, or LUCL complex, with resultant ulnohumeral instability.55–57
Advances in contemporary techniques have improved surgical outcomes using in-
ternal fixation.58 When dealing with the multitude of injuries in a posterior Monteggia
fracture dislocation or a terrible triad, a stepwise surgical approach aids in addressing
all the critical components of this injury. This includes
1. Anatomic fixation of proximal ulna fracture, fixation or replacement of the radial
head fracture58–63 (Fig. 12)
2. Fixation of the coronoid fragment40,64,65
3. Repair of the LCL at the center of the arc of the capitellum66 (Fig. 13)
4. Assessment of stability to determine the need for adjunctive treatment such repair
of the MCL67
5. Finally, if necessary, placement of an external fixator or internal joint stabilization
implant
In most terrible triad injuries, the lateral ligament complex (LUCL and radial collateral
ligament) and common extensor origin are avulsed from the lateral epicondyle. Multi-
ple successful repair techniques, including suture repair using transosseous tunnels
and suture anchors, have been described.68 Fig. 14 shows a detailed algorithm to
manage complex elbow dislocations.
Fig. 12. (A) Radial head fracture status post-ORIF. (B) Comminuted radial head fracture with
LUCL injury status post–radial head replacement and LUCL repair.
Postoperative protocol
Postoperatively, patients may be immobilized between 2 days and 3 weeks,
depending on the severity of the injury and the mode of surgical intervention
used.69 Radiographs are taken throughout the postoperative care to verify fracture
healing. Elbow range of motion is initiated as early as possible in a hinged brace.
Shoulder abduction is avoided to minimize varus stress on the elbow. Unlimited
flexion of the elbow is allowed immediately. Some protocols limit extension of
Fig. 13. (A) An anteroposterior fluoroscopic image after LUCL repair. (B) A lateral fluoro-
scopic image after an LUCL repair.
650 Rezaie et al
Fig. 14. Complex elbow dislocation algorithm. ROM, range of motion.
the elbow to 30 until approximately 5 weeks; however, due to concerns for loss of
extension, some surgeons will progress extension quicker. Forearm position is
determined by whether or not a repair was performed on the LCL or MCL.70
Strengthening exercises may be started once satisfactory healing has occurred,
typically at approximately 12 weeks.
CHRONIC ELBOW INSTABILITY
There is no established classification for chronic instability, but this entity can be
classified according to the pattern of injury as posterolateral rotatory, varus, post-
eromedial varus, valgus, anterior, or global instability with injury of both collateral
ligament complexes and circumferential capsular stripping of the elbow. The treat-
ment of chronic elbow dislocation is a challenging problem. Postoperative compli-
cations, including stiffness, recurrent instability, and/or dysfunction related to
violation of the extensor mechanism, have led some surgeons to recommend
against surgical procedures for older patients and patients who are more than
3 months out from initial injury.71 For the elderly, low-demand patients or patients
with severe posttraumatic arthritis, elbow arthroplasty can be considered in appro-
priately selected situations.72 Fig. 15 illustrates the authors’ recommended treat-
ment algorithm.
Fig. 15. Chronic elbow dislocation algorithm.76 PLRI, posterolateral rotatory instability.
(From Hackl M, Müller LP, Wegmann K. The Circumferential Graft Technique for Treatment
of Chronic Multidirectional Ligamentous Elbow Instability. JBJS Essent Surg Tech. 2017;7(1);
with permission.)
SUMMARY
Elbow dislocations are the second most commonly dislocated joint, with a majority
receiving nonoperative management. The most common athletes who sustain this
injury are those in contact and tumbling sports. In a study observing National Colle-
giate Athletic Association athletes, men’s wrestling had the highest incidence of elbow
dislocation, followed by women’s gymnastics and men’s football.73 The most
652 Rezaie et al
common complication with nonoperative management has been elbow stiffness. With
new advances with early motion rehabilitation protocols, such as early overhead mo-
tion protocols, patients have seen a significant improvement in their outcomes. Simple
elbow dislocations in an athlete should be treated with return to play on a case-by-
case basis. The athlete should demonstrate full painless range of motion with strength
equal to contralateral extremity. Return to play can be considered in as early as
2 weeks to 4 weeks in a hinged elbow brace with a contact athlete.74 Even in elite-
level athletes, a study observing National Football League players treated nonopera-
tively showed a mean return to play in 25 days.75 Although complex injuries previously
were described as elbow dislocations with an associated fracture, the authors believe
that complex elbow dislocations should include elbow dislocations that involve
serious ligamentous injury that require surgical intervention for stabilization. Advanced
imaging and improved understanding of the mechanism of injury have helped address
concomitant injuries that can lead to continued instability if missed on initial examina-
tion. An advance toward early motion for complex injuries also has been made specific
to each injury pattern and mode of operative fixation. As fixation techniques continue
to develop and advance, alongside the vast improvement in rehabilitation protocols,
patient outcomes will continue to improve.
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Elbow Dislocation Nima Rezaie 2020

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Elbow Dislocation

Nima Rezaie, MD*, Sunny Gupta, MD, Benjamin C. Service, MD,

Orlando Health, 1222 South Orange Street, Orlando, FL 32806, USA

Clin Sports Med 39 (2020) 637–655

SIMPLE ELBOW DISLOCATIONS

Simple elbow dislocations traditionally were thought to be caused by falling onto an

Fig. 1. (A) Anteroposterior radiograph of a posterolateral elbow dislocation. (B) Oblique

Fig. 3. Supine elbow reduction maneuver.

Assessment of joint stability

Fig. 4. Parvin prone elbow dislocation reduction maneuver.

Closed reduction + ROM, gentle varus,

Sling + early active

Continue sling Reassess with full

Unstable in <45° Unstable in >45°

Hinged brace in full

Fig. 8. Simple elbow dislocation algorithm. ROM, range of motion.

COMPLEX ELBOW DISLOCATIONS

instability as a longitudinal injury of the forearm needs to be ruled out if there is a

Fig. 14. Complex elbow dislocation algorithm. ROM, range of motion.

CHRONIC ELBOW INSTABILITY

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