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Management of elbow instability in adults


On A-P view (d) the fracture is not clearly visualized Magnetic Resonance MRI of the elbow can clearly define numerous types of osseous and soft tissue pathology. – PowerPoint PPT presentation

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Title: Management of elbow instability in adults

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Management of elbow instability in adults
  • An essay submitted for partial fulfillment for
    Master Degree In Orthopedic surgery

Aim of the work
  • To discuss the types of elbow instability in
    adults and the recent trends in its management
    including non-operative and operative methods.

Anatomy of the elbow joint and its stabilizers
  • 3 separate bony articulations (distal end of the
    humerus, proximal ulna and the radial head).
  • Trochogingylomoid joint (the hinged motion in
    flexion and extension and trochoid motion in
    pronation and supination).

Bony articulations of the elbow joint
Stability of the elbow
  • provided by a fortress of static and dynamic
    constraints. The three primary static constraints
    include the ulnohumeral articulation, the
    anterior bundle of the medial collateral ligament
    (MCL), and the lateral collateral ligament (LCL)
    complex. Secondary constraints include the
    radiocapitellar articulation, the common flexor
    tendon, the common extensor tendon, and the
    capsule. Muscles that cross the elbow joint are
    the dynamic stabilizers

Stability of the elbow
  • Static constrains
  • Primary static constraints
  • Ulnohumeral articulation
  • MCL (mainly anterior bundle)
  • LCL (mainly ulnar collaterall part )
  • Secondary static constraints
  • Radiocapitellar articulation
  • Common extensor origin
  • Common flexor origin
  • Dynamic constraints ( muscles around elbow joint)

Stabilizers of the elbow joint
Biomechanics of the elbow joint
  • Range of motion
  • 0-140 in extension-flexion
  • 80 of pronation
  • 90 of supination
  • Variation of the flexion axis throughout range of
    motion is often described in terms of the screw
    displacement axis (SDA)

The screw displacement axis (SDA)
Pathophysiology and types of elbow instability
  • Traumatic types
  • A. acute elbow dislocation
  • Simple
  • Complex ( associated with fractures )
  • B. chronic
  • Lateral elbow instability
  • Medial elbow instability
  • Recurrent elbow dislocation
  • Chronic non reduced elbow dislocation
  • Non-traumatic types
  • Rheumatoid arthritis
  • Connective tissue disorders
  • Gouty arthritis

Mechanism of acute traumatic elbow dislocation
  • Falling on outstretched hand
  • Axial compressive force during flexion as the
    body approaches the ground. The body rotates
    internally on the elbow , a supination moment
    occurs at the elbow. A valgus moment results from
    the fact the mechanical axis is medial to the

ODriscolls ring of instability
  • It has been broken into 3 stages of disruption.
  • Stage I involves disruption of the ulnar
    component of the lateral collateral ligament (
    PLRI ).
  • Stage II with continued force, disruption occurs
    anteriorly and posteriorly allowing for an
    incomplete posterolateral dislocation ( Perched
  • Stage III ( Dislocated ).

ODriscolls ring of instability
Complex elbow dislocation
  • Associated radial head fracture
  • Associated coronoid fracture
  • Associated olecranon fracture
  • The Monteggia lesion
  • The terrible triad of the elbow
  • Elbow dislocation, radial head fracture and
    coronoid fracture

Chronic elbow instability
  • Chronic lateral elbow instability ( PLRI )
  • Patients with chronic cubitus varus caused by
    congenital anomaly, childhood supracondylar
    fracture malunion, and longstanding crutch
    ambulation, such as in post-polio patients.
  • Leading to lateral static restraint overload and
    subsequent lateral collateral ligament

Chronic medial elbow instability
  • results from chronic repetitive injury rather
    than acute injury.
  • Commonly in throwing athletes caused by the large
    valgus force produced during the throwing motion
    (during the late cocking and early acceleration
    phases of throwing motion). Causing disruption of
    the MCL mainly the anterior bundle.

Recurrent elbow dislocation
  • Two basic abnormalities are present
  • (1) the trochlear notch of the ulna is misshapen,
  • (2) the collateral ligaments that should
    stabilize the elbow are incompetent.

Chronic non reduced elbow dislocation
  • Extensive myositis ossificans around the joint
  • Marked shortening of the triceps muscle and
    medial and lateral collateral ligaments
  • Tightening of the ulnar nerve with attempts at
  • Ossification or dense fibrous thickening of the
    joint capsule
  • And extensive dense fibrous tissue filling the
    olecranon and coronoid fossae

Diagnosis of elbow instability
  • In acute trauma, a detailed history of the event
    must be obtained. The mechanism of injury
    including the position of the arm at the time of
    the initial injury.
  • For non acute elbow conditions, the most common
    complaint is pain, although stiffness or other
    mechanical symptoms such as locking, snapping or
    catching in the elbow

Special tests for instability
  • Varus instability
  • Varus stress test (Assessment of the integrity
    of the LCL) fully internally rotating the
    shoulder, flexing the elbow to approximately 30
    to unlock the olecranon from its fossa and
    applying a varus stress to the elbow.
  • If the lateral collateral ligament is deficient,
    the gap between the capitellum and radial head
    will increase.

Varus stress test
The lateral pivot shift test
  • The patient in the supine position and with the
    shoulder and elbow flexed to 90. The patients
    forearm is fully supinated, and with the examiner
    holding the patients wrist and forearm a valgus
    and axial compression force is applied to the
    elbow whilst the elbow is slowly extended.
  • Reproduction of the patients symptoms and
    production of apprehension such that the patient
    prevents further movement.

The lateral pivot shift test
Push up out of a chair test
  • The seated patient attempts to push up out of a
    chair with the palms facing inward on the
  • Reproduction of symptoms constitutes a positive

Valgus instability
  • Valgus stress test
  • Full external rotation of the humerus while a
    valgus stress is applied to the slightly flexed

The milking maneuver
  • (A) The patient applies the valgus stress to the
    elbow as shown with the contralateral arm. (B )
    In the modi?ed milking sign. The patient locks
    the humerus with the contralateral forearm
    however, the examiner applies the valgus stress

The Moving Valgus Stress Test
  • this test has been shown to be sensitive (100)
    and specific (75) for elbow pain related to UCL
  • The shoulder is abducted and fully externally
    rotated to lock humeral motion. Applying a
    constant valgus stress as the elbow is moved
    through an arc of flexion and extension, noting
    pain between 70 and 120 of flexion

The Moving Valgus Stress Test
Radiographic Evaluation
  • (A-P) view The distal humerus, especially the
    profiles of the medial and lateral epicondyles,
    the radial head, and the proximal ulna are highly
    visible in this view

laterolateral (L-L) projection
  • The distal humerus, the olecranon process, and
    the anterior part of the radial head are highly
    visible in the lateral view

The medial oblique view
  • It allows a better visualization of the
    trochlea, olecranon, and coronoid process. The
    radial head is obscured by the ulna

The lateral oblique view
  • This view permits elimination of the
    superimposition between radius and ulna,
    providing a better visualization of the radial
    head, neck, and biceps tuberosity

The radial head-capitellum view
  • On this view the radial head is seen without
    overlap by the coronoid process and an subtle
    fracture of the radial neck is apparent (arrow)

The axial view of the elbow
  • It provides an excellent visualization of the
    olecranon, trochlea and epicondyles

CT scan
  • CT scan of the elbow.Axial (a) and coronal
    reformatted CT images (b) demonstrate the linear
    fracture of articular surface of the radial head
    with a small fragment. (c) 3D reconstruction of
    the elbow. On A-P view (d) the fracture is not
    clearly visualized

Magnetic Resonance
  • MRI of the elbow can clearly define numerous
    types of osseous and soft tissue pathology.
    Improved soft tissue contrast and numerous image
    planes provide advantages over CT and other
    imaging techniques.

Magnetic Resonance
  • A T1-weighted SE sequence provides good
    evaluation of the medial and lateral epicondyles
    and the radiocapitellar articular surfaces

Magnetic Resonance
  • High resolution T2-weighted GE sequence shows the
    normal ulnar collateral ligament (arrow)
    extending from the medial humeral epicondyle to
    the proximal ulna and normal radial collateral
    ligament (arrowhead)

Magnetic Resonance
  • Oblique coronal image (3D GE) shows the radial
    collateral ligament (large arrow) as a linear
    band of signal void just deep to the extensor
    tendon group (small arrow)

Role of arthoscopy in diagnosis of elbow
  • Diagnostic elbow arthroscopy performed as an
    isolated procedure for the purposes of
    recognizing instability is rarely, if ever,
    indicated. However, as a surgical adjunct
    performed in concert with other arthroscopic
    and/or open surgical procedures, arthroscopic
    elbow instability assessment can provide valuable

Posterior subluxation of the radial head is seen
in this same patient with posterolateral rotatory
instability when the pivot shift test is applied.
Treatment of acute simple elbow dislocation
  • Closed reduction

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Mobilization recommendations
  • For simple elbow dislocations, the elbow is
    immobilized for a maximum of 5 to 7 days in
    slightly less than 90º of flexion depending on
    the degree of anterior soft tissue swelling in a
    posterior splint.
  • If the elbow was stable on the post reduction
    examination, full unprotected motion should be
    started no later than 1 week after injury.

Treatment of complex elbow dislocation

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Operative treatment
  • Fracture of the radial head

Fractures of the coronoid
The terrible triad of the elbow
Olecranon fractures
The Monteggia lesion
Treatment of lateral elbow instability
  • Acute lateral ligament repair
  • Depicting transosseous repair with a running,
    locking suture passed through the humeral
    isometric point and tied over the posterior
    humeral column

Ulnar lateral collateral ligament repair and
reconstruction for PLRI
Treatment of medial elbow instability
  • Classic Jobe ulnar collatereal ligament

The docking technique creates a humeral tunnel
that accepts both limbs of the graft with
tensioning performed through superior exit holes
Role of arthoscopy in treatment of elbow
  • Medial instability
  • It is indicated for those patients who maintain
    symptoms of posteromedial impingement despite
    nonoperative management

Lateral instability
  • A, Inserting first suture through spinal needle.
    B, Suture in place from ulna to lateral
    epicondyle. C, Multiple sutures in place
    plicating radial ulnohumeral ligament

Application of hinged external fixator in elbow
  • Compass external fixator

Treatment of recurrent elbow dislocation
  • In these cases surgical treatment is not
    indicated unless dislocation recurs despite
    immobilization. In theses instances repair of the
    medial collateral ligament and other medial
    structures generally stabilizes the elbow

Treatment of chronic non reduced elbow
  • The treatment options for old unreduced posterior
    dislocations of the elbow include closed
    reduction, open reduction, excision arthroplasty,
    interposition or replacement arthroplasty, and

Treatment of non-traumatic causes of elbow
  • Medical treatment
  • Physical therapy
  • Surgical treatment
  • Synovectomy
  • Removal of the cysts or osteophites
  • Arthroplasty
  • Arthrodesis

Thank you