O'Driscoll's 1999 review defines the anatomy, kinematics, classification, and surgical treatment of elbow instability. It centers on posterolateral rotatory instability (PLRI) as the core unifying mechanism for virtually all elbow dislocations. The paper establishes which ligaments fail, in what sequence, and how to diagnose and surgically correct the resulting instability.
Elbow dislocation was historically attributed to hyperextension — a model O'Driscoll dismantled by demonstrating that the true mechanism is supination/valgus/axial compression during flexion, producing the PLRI pattern that explains every stage of soft tissue failure.
When a patient reports recurrent painful clicking or snapping in the extension arc with the forearm supinated, perform the apprehension test first. It is more sensitive than the pivot-shift and does not require anesthesia. A positive apprehension test in that clinical context is sufficient to diagnose PLRI and proceed to surgical planning.
When you encounter a fracture-dislocation with both radial head and coronoid involvement. The terrible triad pattern. Remember the hierarchy: fix the bones first to restore articular congruity, then address the ligaments. Never excise the radial head without replacing it if the coronoid cannot be secured.
Immobilize simple dislocations for no more than 3 weeks. The Melhoff data showing 60% residual symptoms is the evidence base for early mobilization protocols taught in every elbow surgery course today.
O'Driscoll's 1999 review defines the anatomy, kinematics, classification, and surgical treatment of elbow instability. It centers on posterolateral rotatory instability (PLRI) as the core unifying mechanism for virtually all elbow dislocations. The paper establishes which ligaments fail, in what sequence, and how to diagnose and surgically correct the resulting instability.
Elbow dislocation was historically attributed to hyperextension — a model O'Driscoll dismantled by demonstrating that the true mechanism is supination/valgus/axial compression during flexion, producing the PLRI pattern that explains every stage of soft tissue failure.
When a patient reports recurrent painful clicking or snapping in the extension arc with the forearm supinated, perform the apprehension test first. It is more sensitive than the pivot-shift and does not require anesthesia. A positive apprehension test in that clinical context is sufficient to diagnose PLRI and proceed to surgical planning.
When you encounter a fracture-dislocation with both radial head and coronoid involvement. The terrible triad pattern. Remember the hierarchy: fix the bones first to restore articular congruity, then address the ligaments. Never excise the radial head without replacing it if the coronoid cannot be secured.
Immobilize simple dislocations for no more than 3 weeks. The Melhoff data showing 60% residual symptoms is the evidence base for early mobilization protocols taught in every elbow surgery course today.