The Challenges of Elbow Instability
Adam C Watts Consultant Elbow and Upper Limb Surgeon, Wrightington
Hospital
Visiting Professor, University of Manchester
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Approach to instability
Understand anatomy
Pattern recognition
Algorithm for management
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Elbow Stability
Primary stabilisers MCL - anterior bundle Coronoid Lateral ligament complex Olecranon
Secondary stabilisers Radial head Common flexor and extensor origin Anterior capsule
Radial head Coronoid Lateral ligament complex MCL - anterior bundle Common flexor and extensor origin
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Joint Reaction Force
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Simple Elbow Dislocation
Posterior Anterior (2%) Divergent (Rare, High Energy)
8% Persistent instability (Anakwe 2010)
Predictors of instability?
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Simple Elbow Dislocation
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O’Driscoll CORR 1992;280:186-197
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Medial Ligament Tear
Common Flexor Origin Avulsion
Anterior Capsule Tear
Lateral Ligament Tear
Common Extensor Tendon Avulsion
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Chronic Elbow Instability
Recurrent frank dislocation rare
PLRI
Valgus extension overload
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Posterolateral rotatory instability of the elbow
Most common chronic instability of elbow
Rotatory instability with incompetence of LUCL
Causes: Trauma Iatrogenic - steroid injection/surgery
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Presentation PLRI
Lateral elbow pain include in differential diagnosis for tennis elbow
Locking include in differential diagnosis for loose bodies
Recurrent elbow dislocation???
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Is PLRI a result of simple dislocation?
Recurrent instability rare after simple dislocation 0% (Joseffson) to 8% (Anakwe)
In studies of PLRI only small proportion report previous simple dislocation
those reporting previous dislocation have recurrent frank dislocation (O’Driscoll, Olsen)
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PLRI
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Pivot Shift
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Elbow Instability Tests
Varus stress test
Push up test
Bench press
Hypersupination Test
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Expected outcome
91% Good or excellent outcome
Improved range of movement
11% risk of complication
8% risk of recurrent instability
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Valgus Instability
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Postero-medial Impingement
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Elbow Instability Tests
Varus/Valgus stress test
Milking manoeuvre
Moving valgus stress test
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60°
110°
130°
40°
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Summary
Simple elbow dislocation usually has good outcome
Recurrent true dislocation is rare
PLRI most common recurrent instability
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92 F Active
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Fracture Dislocations
Recognisable patterns of injury
Management plan based on anatomical principles
Consider “hidden” injury
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Elbow fracture dislocations
1.Posterior rotatory a.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranon a.extension
b.flexion
3.Longitudinal
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Elbow fracture dislocations
1.Posterior rotatory a.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranon a.extension
b.flexion
3.Longitudinal
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Terrible TriadPosteromedial fracture dislocation
Ring Type 1Ring Type 3
Essex-Lopresti
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Posterior lateral rotation Terrible triad
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Terrible Triad algorithm
Restore coronoid
Restore radial head
Restore lateral soft tissue restraints
Restore medial soft tissue if still unstable
Apply hinged ex-fix
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Does the coronoid need to be fixed?
Cohort study of 14 consecutive patients (Level 4)
2 Regan-Morrey type I, 12 type 2
No coronoid fixation - Min f/u 24 months
Mean arc of motion 123°
DASH 14
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O’Driscoll Classification
12
3
from Ring et al.
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How do we manage the radial head?
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Radial Head ORIF
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Intracapsular Fracture
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Assessment of prosthesis length
Resected head height
Ulna variance
Proximal rim of PRUJ
Ulno-humeral joint line gapping
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Fix or Replace?
No difference in ROM (Level 4)
ORIF more likely to be unstable
33% risk of arthrosis with arthroplasty
Equivalent re-operation rates
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“Hidden” injury
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LCL Complex must be repaired
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Medial collateral ligament
Not fixing MCL is acceptable (Ring 2007)
Fix if having to go medially
If not leave it alone
Argument for decompression of ulnar nerve
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Timing of fixation
Best results if fixed acutely (within 2 weeks)
Stability and strength can be restored subacutely
ROM better in acute
Earlier treatment is more straightforward (Lindenhovius 2008)
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25 Male PE teacher
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Cat like observation not neglect
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Terrible triad with concentric reduction and small or undisplaced radial head and coronoid fragments
no sign of subluxation on radiographs rapid return to elbow flexion/extension no mechanical block to forearm rotation no neurovascular deficit patient choice
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Outcome Non-Op Management
DASH 8 (Level 4 evidence)
ROM 134°
1/12 required surgery for early instability
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My View
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Fix coronoid if large fragment or anteromedial facet fracture
Fix or replace radial head
Fix lateral soft tissue structures
Fix medial soft tissue structures if still unstable
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Posterior medial rotation Posteromedial rotatory instability
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O’Driscoll Classification
12
3
from Ring et al.
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O’Driscoll Classification
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3
from Ring et al.
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Transolecranon Monteggia Fracture Dislocations
Proximal ulna fracture with dislocation of radial head from radiocapitellar joint and proximal radioulnar joint
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Bado Classification
Anterior
Posterior
Lateral
Radial diaphyseal fracture
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Jupiter Classification of Type II Fractures
IIa Coronoid level
IIb Metaphyseal/Diaphyseal junction
IIc Distal to coronoid
IId Fracture extending to distal 1/2 ulna
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Ring Classification
Type I Apex anterior diaphyseal ulna fracture with anterolateral dislocation of radiocapitellar and PRUJ
Type II Metaphyseal buckle fractures with anterolateral radiocapitellar dislocation (paediatric only)
Type III Apex posterior ulna fractures with posterior dislocation radiocapitellar joint
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Aims of treatment
Restoration of normal ulna alignment
Restoration of elbow stability
coronoid buttress radial head lateral ligament complex
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Bado I, Ring I
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Jupiter IIb, Ring III
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Jupiter IIa, Ring III
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“Hidden Injury” - IOM
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Load transfer
Prevent radius and ulna bowing
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Role of IOM
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Elbow fracture dislocations
1.Posterior rotatory a.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranon a.extension
b.flexion
3.Longitudinal
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Terrible TriadPosteromedial fracture dislocation
Ring Type 1Ring Type 3
Essex-Lopresti
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92 F Active
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