Hand Clin 24 (2008) 139–152

Elbow Instability in Children

Lisa L. Lattanza, MDa,b,*, Greg Keese, MDc
a
Division of Hand and Upper Extremity Surgery, Department of Orthopaedic Surgery, University of California,
San Francisco Medical Center, 500 Parnassus Avenue, MU320W, San Francisco, CA 94143, USA
b
Shriner’s Hospital of Northern California, Sacramento, CA, USA
c
1360 West 6th Street, Suite 305, San Pedro, CA 90732, USA

Recurrent instability in the adult elbow post
trauma has been well documented [1–7]; however,
little has been written about instability in the
pediatric elbow. Instability in the pediatric elbow
can be secondary to trauma, developmental disor-
ders, congenital anomalies, inherited disorders, or
acquired systemic processes. The purpose of this
article is to review current concepts of injuries
leading to elbow instability, discuss how to recog-
nize and treat the instability, and address other,
nontraumatic causes of elbow instability.
Dislocations of the elbow are the most common
type of dislocation in the pediatric age group.
Elbow fractures account for 7% to 9% of all
pediatric fractures [8–11], whereas the incidence
of dislocations is quoted to be 3% to 6% [12,13],
increasing at age 13 to 14 years as the growth plates
close. Fractures and dislocations can lead to insta-
bility of the pediatric elbow by direct injury to sta-
bilizing structures or indirectly by way of malunion
or nonunion.
As in the adult patient, fractures and disloca-
tions of the elbow are the leading cause of
instability in the elbow. The mechanism of injury
is that of a fall on an outstretched hand with an
axial load to the elbow in forearm pronation, as
described by O’Driscoll and colleagues [14].
Elbow radiographs in children can be difficult to
evaluate due to the cartilaginous nature of the joint
* Corresponding author. Division of Hand and Up-
per Extremity Surgery, Department of Orthopaedic Sur-
gery, University of California, San Francisco Medical
Center, 500 Parnassus Avenue, MU320W, San Francisco,
CA 94143.
E-mail address: lattanza@orthosurg.ucsf.edu
(L.L. Lattanza).
0749-0712/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2007.11.007
in childhood and the multiple ossification centers
appearing at different times during development
(Fig. 1). When a pediatric patient presents to the
emergency department with an elbow injury, a frac-
ture or dislocation must be ruled out. It is
frequently helpful to also radiograph the uninjured
extremity for a normal comparison. It is much
more common in children for a dislocated elbow
to spontaneously reduce; therefore, a high index
of suspicion is necessary at times to make the diag-
nosis of a dislocation in a child. It is possible that
radiographs may benormal in appearance or have
only subtle signs such as an avulsion fracture of
the tip of the coronoid, a radial head fracture, or
a medial epicondyle fracture. The significance is
that late instability can be seen when these injuries
are unrecognized or undertreated.
The examiner must also carefully assess the
neurovascular status of the extremity. Although
uncommon, the median nerve can become entrap-
ped in the joint with reduction after dislocation. It
can have devastating consequences when it goes
unnoticed.
Traumatic causes of instability
Medial epicondyle fracture/nonunion
During a dislocation of the elbow, the medial
epicondyle can be disrupted and become entrapped
in the joint. Incarceration usually occurs in
conjunction with an elbow dislocation and sponta-
neous ulnohumeral reduction. The garden-variety
medial epicondylar separation due to indirect ten-
sioning of the flexor origin generally does not
produce enough energy to displace the epicondyle
below the trochlea. The epicondylar incarceration
hand.theclinics.com
140 LATTANZA & KEESE
Fig. 1. Secondary ossification centers of the elbow. Num-
bers represent the year of age that the ossification center
appears. (From Mizuno K, Hirohata K, Kashiwagi D.
Fracture-separation of the distal humeral epiphysis in
young children J Bone Joint Surg Am 1979;61:570; with
permission.)
typically presents with significant swelling and
limited elbow motion, with a variable degree of ulnar
neuropathy. Lateral radiographs show epicondylar
displacement at the joint line. Anteroposterior
radiographs are often difficult to interpret due to
a block of elbow extension. In children 5 years or
younger, the diagnosis can only be made on clinical
examination, arthrogram, or MRI because the
ossification center is not seen radiographically until
age 5 to 7 years. Generally, this displacement can be
manipulated back into place by applying a valgus
stress to open the medial joint line while flexing and
extending the elbow (the forearm is supinated and
digits are extended, tensioning the common flexor
origin to aid in the reduction) [15].
In rare cases, an open reduction may be
necessary to remove the epicondyle from the joint.
Surgical indications in the absence of entrapment
are widely variable [16–20]. No consensus has been
established with respect to the amount of displace-
ment and need for surgery. Multiple investigators
report success using 3 mm as a cut-off [16–18].
Blount [19] recommended greater than 5 mm,
whereas Wadsworth [20] used displacement greater
than 50% of the base of the fracture fragment.
Adding to the confusion, Josefsson and Danielsson
[21] reported 35-year follow-up on 51 fractures
with displacement ranging from 1 to 15 mm. Con-
servative management yielded a high (50%)
nonunion rate, but the amount of displacement
had no correlation with fracture union. In addi-
tion, the presence of pseudoarthrosis did not im-
pact function such as symptomatic medial
instability; however, pseudoarthrosis was associ-
ated with ulnar nerve symptoms.
The significance of the medial epicondyle is the
attachment of the ulnar collateral ligament. A rare
complication of fracture nonunion is symptomatic
valgus instability of the elbow [22]. It is believed
to result from motion at the fracture site, distal dis-
placement of the epicondyle, and medial collateral
ligament stretching at the time of injury. The inci-
dence and the severity of this problem relate to the
activity demands of the patient [23,24] and have
important treatment implications in the setting of
acute pediatric medial epicondylar fractures, be-
cause operative treatment yields a higher union rate.
Historical treatment recommendations for me-
dial epicondyle fractures were made during a time
when our awareness of subtle instability was non-
existentdbefore the description of several essential
physical examination maneuvers. In addition, the
past several decades have seen a surge in high-level
athletic participation without a commensurate
change in the treatment philosophy. A frank
discussion with the patient’s parents should ensue
regarding the risks of surgery versus possible long-
term implication of chronic instability. Operative
intervention should be recommended based on
clinical findings of instability and the activity
requirements of the individual child.
The treatment of symptomatic medial epicon-
dyle nonunion is open reduction internal fixation
or fragment excision with repair/reconstruction
of the ulnar collateral ligament, particularly if
the fragment is small [25,26]. In the largest series
reported in the literature, Gilchrist and McKee
reported excellent results using fragment excision
and suture anchor fixation of the medial collateral
ligament [22].
Lateral ulnar collateral ligament injury
after dislocation
Posterolateral rotatory instability (PLRI) in
the adult secondary to trauma was well defined in
the literature by O’Driscoll and others in 1991
[4,14]. O’Driscoll and colleagues [27] described
a spectrum of injury to the soft tissues, with dislo-
cation traveling from lateral to medial (Fig. 2). In
most cases, the elbow becomes stable with a simple
short period of immobilization after reduction. In
some cases, however, injury of the lateral ulnar
 ELBOW INSTABILITY IN CHILDREN
Fig. 2. Drawing of the Horii circle of soft tissue injury
progressing from lateral to medial. LUCL, lateral ulnar
collateral ligament; MUCL, medial ulnar collateral liga-
ment. (From O’Driscoll. The unstable elbow. J Bone
Joint Surg Am 2000;82:725; with permission.)
collateral ligament (LUCL) leads to ulnohumeral
joint instability as evidenced on radiography by
a posterior subluxation of the radial head in rela-
tion to the capitellum (Fig. 3).
As in the adult, to make the diagnosis of PLRI,
one must have a high index of suspicion. PLRI
can present in children in many ways. A docu-
mented history of an elbow dislocation is helpful;
however, in the authors’ practice, patients are
frequently seen late as referrals from other
institutions with a chief complaint of ‘‘stiffness
Fig. 3. Radiograph of PLRI. The radiocapitellar joint is
not aligned. The radial head is subluxed posteriorly, and
there is incongruence of the ulnohumeral joint.
141
or pain’’ in the elbow and a remote history of
vague trauma. Often, the specific type of injury is
not known. A history of open reduction internal
fixation of a radial head fracture or a lateral scar
on the elbow should also alert one to the possibil-
ity of iatrogenic injury.
Unlike adults, young children do not tend to
complain of a sensation of ‘‘giving way’’ of the
elbow with PLRI, although adolescents more often
do. Children may simply complain of pain or more
commonly present with a forearm pronation
contracture. A possible explanation for this is
that the child senses a subluxation of the joint
with extension and supination and simply begins to
guard against these motions. A contracture then
develops overtime.
Thorough examination, although important,
can be less than satisfying. Positive findings may
include tenderness to palpation along the course
of the LUCL. The pivot shift test is rarely positive
in the office, although an apprehension sign with
this test should lead one to at least consider
the diagnosis. Radiographs of the injured and
uninjured side for comparison can be diagnostic.
In some cases, the subluxation of the radial head
posteriorly with a widening of the ulnohumeral
joint can be seen [28].
One should be suspicious of an LUCL injury in
a child who has loss of forearm rotation with or
without evidence of an old radial head fracture with
overgrowth. MRI has not been shown to be helpful
in confirming the diagnosis of PLRI in the adult
[29]. Obtaining an MRI in a child usually requires
sedation and, although it may show a tear in the
LUCL, it does not necessarily confirm the diagnosis
of PLRI. Ultimately, examination under anesthesia
with a well-thought-out plan for reconstruction is
in order for the pediatric patient presenting with
these complaints. Arthroscopy can be an invalu-
able tool for visualizing loose bodies, addressing
radial head overgrowth or articular damage, and
assessing stability.
Clough and colleagues [30] reported a case of
an 11-year-old boy who had a history of recurrent
dislocations after injuring his elbow falling from
his bike at age 6 years. A diagnosis of PLRI was
made by a positive pivot shift test on examination
under anesthesia. These investigators reported
that the isometric point of the LUCL on the
lateral epicondyle is proximal to the capitellar
growth plate and therefore does not pose a prob-
lem with tunnel placement for reconstruction.
MRI and radiographic assessment, however,
do not support this statement. The lateral
142 LATTANZA & KEESE
epicondyle and distal humerus share a confluent
physis near skeletal maturity. The LUCL isometric
origin is distal to this common physis, rendering it
vulnerable during tunnel placement (Fig. 4). In re-
ality, only the lateral epicondylar physis and the
most lateral aspect of the capitellar physis should
be vulnerable during tunnel placement. It remains
to be determined whether a 4.5-mm tunnel travers-
ing an apophyseal physis near skeletal maturity
would have any detrimental impact. Most girls
fuse this common physis by age 13 years, whereas
most boys are fused by age 15 years [31]. In some
cases, the distal humeral growth plates close early
after severe elbow trauma, making this a nonissue;
however, some patients who have PLRI have open
growth plates, especially when the diagnosis is
made shortly after the trauma has occurred.
The authors recommend ligament repair in
cases of avulsion or when suitable soft tissue exists.
Repair may be performed using suture tunnels or
suture anchor. In cases of tissue attenuation,
reconstruction with palmaris longus or suitable
allograft is advocated. There are some technical
differences between pediatric and adult reconstruc-
tion. The diameter of the ulnar bone tunnels should
be reduced to 2 to 3 mm, and the spanning bone
bridge may have to be slightly narrower depending
on the size of the ulna. Graft size should be
adjusted accordingly. At the isometric point,
bone tunnel placement in linear direction and
depth must be accurate to avoid multiple passes
and the need for tunnel enlargement in the physis.
The authors do not believe that distal humerus
Fig. 4. AP radiograph and MRI of a skeletally immature elbow. Relationship of growth plate to LUCL origin. Arrows
depict insertion sites of LUCL and placement of bone tunnel for reconstruction.
growth arrest is a concern with accurate tunnel
placement, and lateral epicondylar growth arrest
should not have any clinical consequences in the
context of LUCL reconstruction.
An 11-year-old boy presented to the clinic
1 year after an injury to his dominant elbow
with inability to rotate the forearm fully (range of
motion [ROM] 90 pronation and 20 supination
with 0/140 elbow ROM). Radiographs showed
an old radial head fracture (Fig. 5). The patient
was taken to the operating room for an elbow
arthroscopy and examination under anesthesia.
An osteochondral loose body that had attached
to the radial head and scar tissue around the
head were excised. Full forearm ROM was
restored arthroscopically; however, when the fore-
arm was supinated, the patient demonstrated
PLRI clinically and on flouroscan (Fig. 6). The
elbow was opened through a Kocher approach.
The LUCL was found to have a midsubstance
tear with a redundant capsule (Fig. 7). The liga-
ment was of adequate quality for repair, and the
capsule was imbricated. At 2-year follow-up, the
patient has full ROM of the elbow and forearm
without evidence of instability. He is participating
in sports, including baseball.
Lateral ulnar collateral ligament attenuation
due to cubitus varus
PLRI of the elbow after cubitus varus defor-
mity was reported in the literature in 1995 by Abe
and colleagues [32]. They described four patients
 ELBOW INSTABILITY IN CHILDREN
Fig. 5. Lateral radiograph showing old radial head
fracture with overgrowth.
who had childhood elbow injuries and developed
PLRI in adulthood. In 1997, these researchers
reported a case of an adolescent who sustained
a supracondylar humerus fracture at age 5 years
and then developed PLRI at age 14 years. The
patient was treated with lateral closing wedge
osteotomy and LUCL repair that resolved the
instability [33]. O’Driscoll and colleagues [34], in
a multicenter study in 2001, reported a ‘‘causal’’
Fig. 6. Intraoperative fluoroscan showing PLRI with
ulnohumeral joint incongruence and posterior subluxa-
tion of the radial head in relation to the capitellum.
143
Fig. 7. Midsubstance tear in LUCL. The arrows are on
the two portions of the LUCL. The capitellum is to the
left and radial head to the right.
relationship between cubitus varus deformity of
the elbow and tardy PLRI in 24 patients. Six of
the 24 patients presented in the second decade
between 13 and 19 years of age (average age,
14 years). In some cases, the development of insta-
bility was related to a second injury or surgery. The
investigators reported improvement in all patients
after LUCL reconstruction with or without osteo-
tomy, although 3 continued to have some instabil-
ity. No patient lost motion, and motion improved
in some.
The investigators proposed a viable biome-
chanical explanation for the development of the
tardy PLRI. Varus deformity creates a repetitive
varus torque at the elbow during axial loading
and resisted extension such as when rising from
a chair. This varus torque can lead to chronic at-
tenuation of the LUCL complex over time (Fig. 8)
[34–36]. Confirmation of this theory was accom-
plished intraoperatively in three patients by stim-
ulating the medial triceps while resisting
extension, which caused the elbow to sublux post-
erolaterally. They concluded that the combination
of varus malalignment and medial elongation of
the olecranon permitted the triceps to roll the
ulna into external rotation and to subluxate the el-
bow posterolaterally. After correction of the varus
deformity and transposition of part of the medial
triceps to the lateral olecranon, this same maneu-
ver did not cause subluxation [34].
Adolescents presenting with a childhood frac-
ture resulting in a cubitus varus deformity with new
complaints of lateral elbow pain, catching, or
giving way especially with a superimposed new
injury, should be carefully evaluated and
144 LATTANZA & KEESE

Fig. 8. Biomechanics of the triceps mechanism and its effect on ulnohumeral stability. (A) Normal alignment with a slightly
valgus carrying angle. The triceps force vector (FT), which is almost perpendicular to the joint line, can be resolved into two
perpendicular vectors. A slight valgus force (F2val) exists. (B) Cubitus varus. The triceps force vector (FT1) can be resolved
into two force vectors: F1, which is perpendicular to the joint surface, and F2var, which is directed medially. This medial force
vector causes external rotation of the ulna about its long axis (Mroll). The offset between F1 and the axis of rotation (due to
the deformity at the supracondylar level) causes a moment arm (MA) through which external rotation and varus deforming
torques occur with triceps contraction. (From O’Driscoll SW. Tardy posterolateral rotatory instability of the elbow due to
cubitus varus. J Bone Joint Surg Am 2001;83:1364; with permission.)

considered for the diagnosis of tardy PLRI. Again,
careful lateral palpation and pivot shift, Lach-
man’s, chair, and push-up tests should be per-
formed [16,17]. Radiographs to measure varus and
assess ulnohumeral and radiocapitellar alignment
should be obtained. Examination under anesthesia
may be necessary to confirm the diagnosis.
Current recommendations are for corrective
osteotomy to restore the normal carrying angle
and LUCL reconstruction. In some isolated cases
with a varus deformity less than 15 in a low-
demand patient, LUCL reconstruction alone may
be adequate [34].
Osteochondritis dissecans
Osteochondritis dissecans (OCD) involves
avascular necrosis of a localized area of subchon-
dral bone, with loss of support for the adjacent
cartilage. Only 6% of patients who have OCD
have elbow involvement [37]. It occurs in early
adolescents after the capitellum has ossified.
The exact mechanism for development of OCD
is not known. It is more commonly seen in
throwing athletes and gymnasts, although it can
be seen in other circumstances. Biomechanical
theories of valgus overload to the radiocapitellar
joint during the acceleration phase of throwing
[38–41] or during weight bearing in gymnastics are
commonly proposed mechanisms for the develop-
ment of OCD [42,43].
In some patients, OCD can lead to late
instability of the radial head as the problem
progresses [44]. Klekamp and colleagues [44]
have also seen progressive subluxation of the
radial head in OCD of the elbow. The reasons
for this are not entirely clear.
In a study by Morrey and An [45], it was dem-
onstrated that the osseous articular cartilage
between the radius and the capitellum contributed
33% of the resistance to valgus stress at 90 of
elbow flexion. Schenck and Goodnight [46], in
a cadaveric model, showed a mismatch in stiffness
between the capitellum and radial head. They pro-
posed that the less-stiff capitlellum is at risk from
compressive forces at the radiocapitellar joint,
which could account for the fragmentation of
the capitellum but still does not fully explain the
instability sometimes seen with the radial head
subluxing or dislocating in some patients.
 ELBOW INSTABILITY IN CHILDREN
Although not discussed in the literature pre-
viously, one other possible contributing factor
could be subtle ligamentous instability on the
lateral side of the elbow. Adult patients who have
PLRI usually have a lesion on the capitellum,
similar in location to OCD, caused by the
impaction of the radial head as it subluxes poster-
olaterally. It may be possible that athletes placing
high demands on the elbow develop a very subtle
instability similar to that seen in the shoulder in
pitchers. This subtle instability could lead to this
lesion in a minority of cases; however, it has not
been proved biomechanically and is only a clinical
observation seen by the authors in a few cases.
At this point, there is no way to determine which
patients who have OCD will develop a radial head
dislocation. In the authors’ experience, however,
the loss of motion is greater in patients who go on
to develop a dislocation of the radial head.
Treatment of OCD lesions varies depending on
the severity of the lesion. The Internal Cartilage
Repair Society (ICRS) has suggested the following
arthroscopic classification system for OCD lesions
[47]: ICRS OCD grade I indicates a stable lesion
with a continuous but softened area covered by in-
tact cartilage; ICRS OCD grade II denotes a lesion
with partial discontinuity that is stable when
probed; ICRS OCD grade III denotes a lesion
with a complete discontinuity that is not yet dislo-
cated; and ICRS OCD grade IV indicates an empty
defect or a defect with a dislocated fragment or
a loose fragment lying within the bed.
Several treatment recommendations have been
made by Takahara and colleagues [48] based on
a retrospective study of 106 patients who had
OCD. Patients who had an open physis, normal
elbow ROM, and a flattening of the capitellum
radiographically were considered to have stable
lesions. These patients responded well to rest
without operative intervention.
Takahara and colleagues [48] further classified an
unstable lesion as presenting with one of the follow-
ing: a mature capitellum with closed growth plates,
radiographic fragmentation, and loss of motion of
at least 20 . These patients had a better outcome
with operative intervention. For grade II lesions,
bone peg fixation was recommended. For grade III
lesions, fragment fixation and bone grafting was rec-
ommended, and for grade IV lesions covering
greater than 50% of the capitellar surface, osteo-
chondral mosaicplasty provided the best results.
The use of the mosaicplasty in the elbow is
a relatively new technique, with a report by
Iwasaki and colleagues [49] showing good to
145
excellent clinical and radiographic results in seven
of eight patients and return to sport in six of eight
patients, including three pitchers.
Monteggia fractures
The Monteggia lesion (ulna fracture with
radial head dislocation) is uncommon but not
rare. The results of this injury when recognized
and treated acutely are generally good; however,
the results of treatment in the unrecognized or
chronic lesion are much less predictable. Sixteen
percent to 33% of Monteggia lesions are missed
according to Dorman and Rang [50]. The reasons
for this are varied. Often, trauma radiographs are
inadequate or read by someone who has little
experience interpreting pediatric elbow radio-
graphs. Even when recognized, the lesion may be
undertreated because some of the fractures/dislo-
cations can redisplace in a cast with closed treat-
ment alone. When this lesion is not recognized
during the course of treatment, the patient will
go on to have a chronic radial head dislocation.
There are also some Monteggia fractures that
are irreducible or ‘‘unstable.’’
There is no controversy regarding the treat-
ment of acute Monteggia fractures. The ulnar
angulation is corrected and held in position,
which usually corrects the radial head dislocation.
In some cases, however, a reduction of the radial
head cannot be achieved by closed reduction
secondary to soft tissue interposition. Fig. 9A
shows the radiograph of a 9-year-old who had
an acute Monteggia injury and radial nerve palsy.
The radial head was irreducible with closed treat-
ment. An open reduction was performed. Fig. 9B
shows the radial nerve that was interposed in the
joint, blocking the reduction. The radial nerve
was carefully removed from the joint, and the
patient regained full function 3 months post oper-
ation. It is important to be aware of the possibility
of nerve entrapment and to not attempt repeated
reductions under those circumstances without
opening the joint.
There is no consensus for absolute operative
indications for the chronic Monteggia lesion. There
is certainly debate with regard to surgical interven-
tion in an asymptomatic child with good ROM.
There are implications for decreased function,
pain, progressive valgus instability, tardy ulnar
nerve palsy, and dislocation of the distal radioulnar
joint when left untreated [51]. Some investigators
[52] state that as long as the radial head has a nor-
mal concave shape, the joint should be reduced.
146 LATTANZA & KEESE

Fig. 9. Radiograph (A) and intraoperative photo (B) of an acute Monteggia injury with soft tissue, including the radial
nerve, blocking the reduction.

One of the main considerations in entertaining
operative intervention is the high complication rate
associated with surgical correction [53]. The list of
potential complications includes nerve palsy,
nonunion of the ulnar osteotomy, loss of reduc-
tion, compartment syndrome, infection, radioul-
nar synostosis, loss of motion, and malunion of
the ulnar shaft. A thorough discussion with the
parents regarding these potential complications is
imperative.
The authors’ preferred method for reduction of
the chronic Monteggia lesion is an ulnar osteotomy
with iliac crest bone graft or allograft. The ulnar
length and the proper angulation must be restored
and held with a plate (Fig. 10). The radiocapitellar
joint is opened to remove any interposed material,
and an assessment is made with regard to the
stability of the joint after osteotomy. In some cases,
an annular ligament reconstruction is necessary to
augment the reduction but should not be relied on
to hold the reduction. Overcorrection of the ulnar
deformity is necessary to hold the radial head in
a reduced position throughout the arc of motion.
Inoue and Shionoya [54] found that, ultimately,
annular ligament reconstruction and pinning of
the joint had no effect on stability. The only signi-
ficant difference in the result was whether the ulna
deformity was overcorrected.
Radial head dislocations
The most common cause of pediatric instability
at the elbow is radial head subluxation or disloca-
tion. Pediatric radial head instability can be

Fig. 10. Chronic Monteggia fracture/dislocation (A) and correction by ulnar osteotomy (B).
 ELBOW INSTABILITY IN CHILDREN 147

classified by the direction, chronicity, and etiology.

The direction of the radial head subluxation/ Box 1. Abnormalities and syndromes
dislocation can be anterior, posterior, or lateral. associated with congenital
Acute injuries are usually directed anteriorly, developmental dislocation
whereas chronic instability is usually posterior. of the radial head
The etiology is classified as congenital, develop-
mental, or post-traumatic; however, the termi- Skeletal abnormalities
nology of congenital versus developmental Radio-ulnar synostosis
is confusing because it is often used interchange- Absence of ulna
ably. Box 1 is a list of most anomalies associates Antecubital pterygium
with dislocation of the radial head. Below-elbow deficiencies
Absence of thumb ray
Absence of ulnar ray
Congenital Ulnar oligodactyly
Radial head dislocation is the most common Metacarpal fusion
congenital anomaly of the elbow joint. It can Side-to-side phalangeal fusion
occur as an isolated anomaly or in association Cleft hand
with multiple syndromes. There has been debate Thumb duplication
in the past as to whether unilateral congenital Sprengel’s shoulder
dislocations exist or are just a missed Monteggia Multiple exostosis
injury. Agnew and Davis [55] reported on 6 cases Multiple enchondromatosis
of congenital radial head dislocations in which an Multiple epiphyseal dysplasia
elbow abnormality was noted by the parents Syndromes
or the physician at birth. Other investigators Acrocephalosyndactyly (Apert
[56–59] have reported similar cases of unilateral syndrome)
radial head dislocations present at birth. Acrocephalopolysyndactyly (Carpenter
The radiographic appearance of a congenital syndrome)
radial head dislocation is one of a convex radial Acro-osteolysis congenital
head (Fig. 11), sometimes associated with a hypo- Auriculo-ostedysplasia
plastic capitellum. Other possible radiographic Bird-headed dwarfism
findings are a more slender or longer radius than Cornelia de Lange syndrome
normal and a lack of anterior angulation of the Chondroectodermal dysplasia
distal humerus. In the case of a posterior disloca- Craniocarpotarsal dystrophy
tion, the posterior bow to the ulna is frequently Craniostenosis
exaggerated. It may be that the only certain crite- Cleidocranial dysostosis
rion for radiographic diagnosis of congenial radial Detenbach-Abrams syndrome
head dislocation is severe hypoplasia of all the Diastrophic dwarfism
bony elements of the elbow in conjunction with Ehlers-Danlos syndrome
a radial head dislocation. Konig disease (Hereditary
Morrey and Bell [60,61] devised a radiographic osteochondritis dessicans)
classification based on the amount of subluxation Larsen syndrome
of the radial head. Radiographs of type I lesions Mid-facial cleft syndrome
show a subluxation of the radiocapitellar joint, Nail-patella syndrome
but a portion of the radial head is still in contact Nievergelt syndrome
with the capitellum. In type II lesions, there is Oculomelic complexes
complete dislocation inferior to the capitellum, Robinow mesomelic dysplasia
but the radial head has not migrated proximal Rubinstein-Taybi syndrome
to a line drawn through the center of the humerus. Silver-Russell syndrome
In type III lesions, the radial head has migrated
proximal to the midline of the humerus. In this se-
ries, the type I lesions had the worst prognosis for dislocated radial head. Similarly, there is agree-
arthritis and pain. ment that radial head excision at skeletal maturity
There is general consensus that there is no is the operation of choice for pain but that
role for operative reduction of the congenitally restoration of motion is unpredictable at best.
148 LATTANZA & KEESE
Fig. 11. Posterior congenital radial head dislocation
with a convex radial head and exaggerated posterior
bowing of the ulna.
Developmental
This category refers to any condition, inherited
or acquired, resulting in differential growth
between the forearm bones, leading to a radial
head dislocation. One of the most common
examples is multiple hereditary exostoses. In the
case of developmental radial head dislocation, the
dislocation is not present at birth. The radial head
gradually subluxes with growth. As with congen-
ital dislocations, open reduction is generally not
advised.
A possible subgroup of the developmental
dislocation is the ‘‘paralytic’’ dislocation seen in
some patients who have brachial plexus birth
palsy and cerebral palsy. The incidence in brachial
plexus birth palsy has been reported as high as
25% [62].
Post-traumatic
Isolated radial head dislocations as pure liga-
mentous injury are rare at best. Lincoln and
Mubarak [63] disputed the existence of such an
entity and contested that all radial head disloca-
tions are a variant of a Monteggia lesion. They
described a method for scrutiny of the bow of
the ulna radiographically and recommended com-
paring these values to the uninvolved side. The
authors agree with this assessment. This theory
would also support the fact that in most series
on missed Monteggia lesions, patients undergoing
ligament reconstruction alone, without addressing
the ulnar bow, generally do not do well.
It is important to determine whether an acute
or chronic traumatic radial head dislocation is
present versus a unilateral isolated congenital
dislocation so that treatment can be planned
accordingly. Of course, a history of elbow trauma
can be helpful but is often vague. When there is no
other history of skeletal abnormalities or trauma,
careful scrutiny of the radiographs may be help-
ful. If the radial head is convex or the capitellum is
hypoplastic, then it is likely a congenital disloca-
tion. A longstanding, chronic missed Monteggia
injury, however, can lead to a similar radiographic
appearance, causing confusion in making the
diagnosis.
Mizuno [33] recommended arthrography to
help differentiate congenital from traumatic radial
head dislocations. In congenital dislocations,
arthrography shows the radial head to be located
within the joint capsule, whereas in the traumatic
situation, the radial head is outside the joint
capsule. If one is contemplating surgical interven-
tion for a presumed chronic traumatic radial head
dislocation, then arthrography may be helpful to
confirm the diagnosis.
Nontraumatic causes of instability
Collagen disorders
Elbow instability is seen in multiple types of
collagen disorders. Joint laxity (or hypermobil-
ity) can be classified into one of seven categories
according to Beighton and colleagues [64]. These
categories are as follows: physiologic joint laxity,
generalized joint laxity, inherited joint laxity
syndromes, joint laxity in inherited connective
tissue disease, joint laxity in skeletal dysplasias
with dwarfism, syndromes with joint laxity as
a minor component, and acquired joint laxity
(Box 2).
The Wynne-Davies criteria [65] for diagnosing
hypermobility requires that at least three of the
following five conditions be present: elbow exten-
sion beyond straight, ability to touch the thumbs
to the forearm passively on wrist flexion, fingers
that lie parallel to the forearm on passive exten-
sion of the wrist and metacarpophalangeal joints,
passive dorsiflexion of the ankle to 45 or more,
and knee extension beyond straight.
Generalized laxity
Multiple investigators [66–68] have quoted
the incidence of generalized joint laxity to be
anywhere from 5% to 12% among school-aged
children. Joint laxity decreases throughout child-
hood. It is thought that joint laxity predisposes
 ELBOW INSTABILITY IN CHILDREN 149

Inherited joint laxity

Box 2. Inherited and acquired Recurrent elbow dislocations and laxity can
syndromes associated with joint laxity occur with many of the syndromes (Fig. 12).
Splinting and therapy are the mainstays of treat-
Inherited joint laxity syndromes ment. In most cases, surgical intervention is not
Ehlers-Danlos syndrome warranted and can be fraught with complications.
Familial undifferentiated joint laxity Soft tissue procedures are often unsatisfying
syndromes owing to the underlying abnormal collagen and
Joint laxity in inherited connective propensity for recurrent instability. In general,
tissue disease bony stabilization procedures are usually more
Marfan syndrome successful but may sacrifice mobility for stability.
Marfanoid hypermobility syndrome Larsen’s syndrome, in particular, is commonly
Achard syndrome associated with elbow and radial head disloca-
Osteogenesis imperfecta tions. There is generally total disruption of the
Larsen syndrome radiocapitellar and ulnohumeral joints, at least in
part due to distal humeral and condylar hypopla-
Joint laxity in skeletal dysplasias sia [69]; however, the function is often good.
with dwarfism
Spondyloepimetaphyseal dysplasia Acquired joint laxity
with joint laxity Systemic disease processes such as juvenile
Pseudoachondroplasia rheumatoid arthritis and systemic lupus erythe-
Morquio syndrome matosis can also lead to instability of the elbow
(mucopolysaccharidosis IV) joint over time. This instability is usually a varus/
Desbuquois syndrome valgus instability from a stretching of the soft
Spondyloepipyseal dysplasia congenital tissue envelope from the disease process itself and
from the treatment with steroids. Bracing can be
Syndromes with joint laxity as a minor
an effective treatment when the instability and
component
Hajdu-Cheney syndrome pain are not severe. When pain and instability are
severe, however, total elbow arthroplasty may be
Hyperlysinemia
considered. Connor and Morrey [70], in a series of
Opitz trionocephaly syndrome
(C syndrome) 24 patients who had juvenile rheumatoid arthritis
and who underwent total elbow arthroplasty,
Trichorhinophalangeal syndrome
found that 9% were grossly unstable and 35%
X-linked cutis laxa
Aarskog syndrome were moderately unstable. The youngest patient
to require total elbow arthroplasty was 25 years
Cohen syndrome
old. Total elbow replacement in this group of
Multiple endocrine neoplasia type III
patients should not be entered into lightly. The
syndrome
complication rate is high and the surgery is techni-
Coffin and Siris syndrome
cally demanding, but in the well-chosen patient,
Acquired joint laxity total elbow replacement can lead to pain relief
Chronic renal failure and increased function.
Systemic lupus erythematosis
Cerebral palsy
Juvenile rheumatoid arthritis Summary
Elbow instability in children can be secondary
to trauma, developmental disorders, congenital
anomalies, inherited disorders, or acquired sys-
to injuries such as joint dislocations, including temic processes. Our knowledge and understand-
dislocations of the elbow. Treatment is symptom- ing of these problems are continuing to evolve.
atic and may include splinting, therapy, or surgi- Although the determination of what constitutes
cal reconstruction for ligament tears secondary appropriate treatment of some post-traumatic
to traumatic dislocations. Surgery simply to conditions may still be up for debate, it is the
address the underlying laxity is usually not authors’ opinion and experience that it may be
indicated. better to treat some nonunions, malunions, and
150 LATTANZA & KEESE

Fig. 12. (A) Lateral radiograph of a patient who has familial undifferentiated joint laxity syndrome. The radiograph
demonstrates subluxation of the elbow. (B) MRI scan of the same patient demonstrating subluxation of the elbow,
with a hypoplastic fossa. (C) Additional MRI image of the patient demonstrating radiocapitellar joint incongruency.

chronic instability of the post-traumatic nature
more aggressively than has been done in the past.
Only in the past 15 years have some instability
patterns of the elbow been recognized in the adult,
and this information should be applied to the
pediatric elbow as is appropriate. In addition, the
pediatric elbow presents unique challenges with
regard to open growth plates, propensity for
dislocation and spontaneous reduction, and
increased time for the development of post-
traumatic deformity into adulthood. Many of
these deformities and complications have no
good solution for treatment in adulthood.
The challenge going forward is to improve our
ability to recognize injury patterns to enable
children to get appropriate treatment acutely
and to devise more effective surgical interventions
for treating the sequelae of injury and instability.
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