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.com
Approach to instability
Understand anatomy
Pattern recognition
Algorithm for management
3

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

11
Simple Elbow Dislocation
Posterior
Anterior (2%)
Divergent (Rare, High Energy)
8% Persistent instability (Anakwe 2010)
Predictors of instability?

12
Simple Elbow Dislocation

O’Driscoll CORR 1992;280:186-197

20
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
24

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)
26

Pivot Shift

31
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
46

47
Valgus Instability

Postero-medial Impingement

52
Elbow Instability Tests
Varus/Valgus stress test
Milking manoeuvre
Moving valgus stress test

55
60°
110°
130°
40°

Summary
Simple elbow dislocation usually has good
outcome
Recurrent true dislocation is rare
PLRI most common recurrent instability
56

92 F Active
57

Fracture Dislocations
Recognisable patterns of injury
Management plan based on anatomical principles
Consider “hidden” injury
58

Elbow fracture dislocations
1.Posterior rotatory
a.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranon
a.extension
b.flexion
3.Longitudinal
59

2.Trans-olecranon
a.extension
b.flexion
3.Longitudinal
60
Terrible Triad
Posteromedial fracture
dislocation
Ring Type 1
Ring Type 3
Essex-Lopresti

Posterior lateral rotation
Terrible triad
61

Terrible Triad algorithm
Restore coronoid
Restore radial head
Restore lateral soft tissue restraints
Restore medial soft tissue if still unstable
Apply hinged ex-fix
62

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
63

65
O’Driscoll Classification
1
2
3
from Ring et al.

How do we manage the radial
head?
67

Radial Head ORIF
68

Intracapsular Fracture
70

Assessment of prosthesis length
Resected head height
Ulna variance
Proximal rim of PRUJ
Ulno-humeral joint line gapping
76

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
78

“Hidden” injury
79

LCL Complex must be repaired
80

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
81

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)
82

25 Male PE teacher
83

Cat like observation not neglect
86

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
87

Outcome Non-Op Management
DASH 8 (Level 4 evidence)
ROM 134°
1/12 required surgery for early instability
88

My View
89
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

92
Posterior medial rotation
Posteromedial rotatory instability

93
1
2
3
from Ring et al.

94
1
2
3
from Ring et al.

104
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
106

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
107

Aims of treatment
Restoration of normal ulna alignment
Restoration of elbow stability
coronoid buttress
radial head
lateral ligament complex
108

Bado I, Ring I
109

Jupiter IIb, Ring III
112

114
Jupiter IIa, Ring III

“Hidden Injury” - IOM
124

Load transfer
Prevent radius and ulna
bowing
125
Role of IOM

2.Trans-olecranon
a.extension
b.flexion
3.Longitudinal
128
Terrible Triad
Posteromedial fracture
dislocation
Ring Type 1
Ring Type 3
Essex-Lopresti

92 F Active
129

The Challenges of Elbow Instability

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