The Challenges of Elbow Instability

The Challenges of Elbow Instability

Adam C Watts Consultant Elbow and Upper Limb Surgeon, Wrightington

Hospital

Visiting Professor, University of Manchester

1

www.wrightington.com2

www.wrightington.com

Approach to instability

Understand anatomy

Pattern recognition

Algorithm for management

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www.wrightington.com 4

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






Joint Reaction Force

9



Simple Elbow Dislocation

Posterior Anterior (2%) Divergent (Rare, High Energy)

8% Persistent instability (Anakwe 2010)

Predictors of instability?


Simple Elbow Dislocation


O’Driscoll CORR 1992;280:186-197








Medial Ligament Tear

Common Flexor Origin Avulsion

Anterior Capsule Tear

Lateral Ligament Tear

Common Extensor Tendon Avulsion




Chronic Elbow Instability

Recurrent frank dislocation rare

PLRI

Valgus extension overload

23


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???

25


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


Elbow Instability Tests

Varus stress test

Push up test

Bench press

Hypersupination Test
















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




Postero-medial Impingement



Elbow Instability Tests

Varus/Valgus stress test

Milking manoeuvre

Moving valgus stress test




60°

110°

130°

40°


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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b.flexion

3.Longitudinal

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Terrible TriadPosteromedial fracture dislocation

Ring Type 1Ring Type 3

Essex-Lopresti


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.



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




Posterior medial rotation Posteromedial rotatory instability



12

3

from Ring et al.



12

3

from Ring et al.











Transolecranon Monteggia Fracture Dislocations

Proximal ulna fracture with dislocation of radial head from radiocapitellar joint and proximal radioulnar joint


Bado Classification

Anterior

Posterior

Lateral

Radial diaphyseal fracture

105


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











“Hidden Injury” - IOM

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Load transfer

Prevent radius and ulna bowing

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Role of IOM








b.flexion

3.Longitudinal

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Terrible TriadPosteromedial fracture dislocation

Ring Type 1Ring Type 3

Essex-Lopresti


92 F Active

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Health & Medicine

The Challenges of Elbow Instability