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C OPYRIGHT Ó 2018 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Commentary & Perspective

How Do Elbows Dislocate?
Commentary on an article by Marc Schnetzke, MD, et al.: “Determination of Elbow Laxity in a Sequential Soft-Tissue Injury Model. A Cadaveric
Study”

Shawn W. O’Driscoll, PhD, MD

The report by Schnetzke et al. documents fluoroscopic measurements of varus-valgus joint angulation with sequential ligament
and anterior capsular release. Two messages come from this paper. The first, which is supported by the data, is that fluoroscopic
assessment is accurate for determining varus-valgus laxity in the coronal plane in proportion to the degree of soft-tissue
release. A strength of this study is its carefully controlled methodology in which humeral rotation and forearm rotation were
controlled with transfixing pins and valgus and varus torques were applied using reproducible techniques. Schnetzke et al.
correlate these findings with their clinical experience using stress fluoroscopy, which I also routinely use in assessing grossly
unstable elbows and fracture-dislocations. I have not used it routinely for simple elbow dislocations that remain reduced
following closed reduction.
The second message presented in this paper represents its main weakness. The authors claim that their observations support
an idea proposed by Schreiber et al.1 that elbow dislocations occur by a valgus mechanism commencing with medial soft-tissue
disruption and then progressing around laterally. The present study involved transfixing the humerus and forearm with pins to
prevent rotation, making it impossible to relate this model to elbow dislocations. In a kinematic study of elbow subluxation and
dislocation, my colleagues and I established that injuries occur by a coupled 3-dimensional posterolateral rotatory motion pattern
involving angulation around all 3 axes and displacement along ‡1 axes2 (Fig. 1). Unfortunately, Schnetzke et al. fail to reference or
discuss that work when presenting their argument. In that same investigation, we documented what has come to be known as the

Fig. 1
Kinematics of elbow dislocation. As the elbow begins to flex under axial load, dislocation occurs by external rotatory subluxation and slight valgus of the ulna.
Ulnohumeral rotatory subluxation reaches a maximum of about 40° as the coronoid clears the trochlea just before dislocation occurs (at the 4-second
mark). Once the coronoid is posterior to the trochlea, the ulna derotates somewhat. (Reproduced, with permission, from: O’Driscoll SW, Morrey BF, Korinek S,
An KN. Elbow subluxation and dislocation. A spectrum of instability. Clin Orthop Relat Res. 1992 Jul;280:186-97.)

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Fig. 2
Figs. 2-A, 2-B, and 2-C Mechanism of elbow dislocation deduced from kinematic analysis, prior to the availability of any supporting video evidence.
LUCL = lateral ulnar collateral ligament, MUCL = medial ulnar collateral ligament, and PLRI = posterolateral rotatory instability. Fig. 2-A With the
shoulder abducted, a fall onto the outstretched hand produces an axial force on the elbow as it flexes. As the body rotates internally on the hand and
approaches the ground, valgus moments and external rotation are applied to the elbow. Figs. 2-B and 2-C Soft-tissue injury progresses in what has
2
come to be known as the “Horii circle.” Progression is from lateral to medial in 3 stages. (By permission of Mayo Foundation for Medical Education
and Research. All rights reserved.)

“Horii circle” of soft-tissue disruption beginning laterally and progressing around anteriorly and posteriorly to the medial side with
increasing degrees of subluxation2 (Fig. 2).
Schreiber et al. studied public-domain YouTube videos of accidental elbow dislocations1. Their methodology was flawed in
that rotational motion of the humerus and forearm while the elbow is in any degree of angulation (whether from reflection or varus/
valgus) cannot be determined from 2-dimensional analyses. We proposed the posterolateral rotatory mechanism long before
YouTube videos existed and before there was any documented video of an elbow dislocation. Subsequently, we have received videos
of elbow dislocations showing a mechanism very similar to that proposed in our original study2.
Careful use of the literature is important when presenting evidence for one’s arguments. The authors incorrectly quote my clinical
report of posterolateral rotatory instability as a cadaveric experiment3. They also cite a second paper by Schreiber et al., on magnetic
resonance imaging (MRI) analysis of elbow ligaments4. In that paper, Schreiber et al. included elbow dislocations that had occurred up to
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8 weeks before the MRI as acute injuries, but soft-tissue changes in a 4 to 6-week-old dislocation are substantial and can hardly be
considered acute.
The study by Schnetzke et al. lacks some details, such as where the ligaments were cut. This is important because the ligaments
are bonded to the adjacent tendon structures to which loads can be transferred. Schnetzke et al. released the anterior aspect of the
capsule but do not mention the posterior aspect of the capsule, which must be released to dislocate the elbow. They did not define
dislocation, and in fact the elbows did not dislocate 24% to 50% of the time after completion of all of the releases. This highlights the
limitations of their method in studying dislocation.
In conclusion, this paper demonstrates a common phenomenon in which the question that was answered differs from the
question that was asked. The authors used a setting “intended to resemble clinical conditions,” but the model did not manage to do
so with respect to how an elbow dislocates. The goal of any research study should be to advance our understanding and/or to
generate insight. Understanding shapes our beliefs, and our beliefs determine our actions. Ultimately our actions determine patient
outcomes, for better or for worse. The one message that we can take from this study is that fluoroscopic assessment is reliable for
assessing varus-valgus laxity. I recommend that it also be performed in the sagittal plane to assess posterolateral and posteromedial
rotatory instabilities.
Shawn W. O’Driscoll, PhD, MD
Mayo Clinic College of Medicine, Rochester, Minnesota
E-mail address: odriscoll.shawn@mayo.edu

ORCID iD for S.W. O’Driscoll: 0000-0002-8225-3372

Disclosure: The author indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest form, which
is provided with the online version of the article, the author checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena
outside the submitted work (http://links.lww.com/JBJS/E624).

References
1. Schreiber JJ, Warren RF, Hotchkiss RN, Daluiski A. An online video investigation into the mechanism of elbow dislocation. J Hand Surg Am. 2013 Mar;38(3):488-94. Epub
2013 Feb 5.
2. O’Driscoll SW, Morrey BF, Korinek S, An KN. Elbow subluxation and dislocation. A spectrum of instability. Clin Orthop Relat Res. 1992 Jul;280:186-97.
3. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. 1991 Mar;73(3):440-6.
4. Schreiber JJ, Potter HG, Warren RF, Hotchkiss RN, Daluiski A. Magnetic resonance imaging findings in acute elbow dislocation: insight into mechanism. J Hand Surg Am.
2014 Feb;39(2):199-205.