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

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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.

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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).

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Bony articulations of the elbow joint
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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

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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)
  

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Stabilizers of the elbow joint
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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)

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The screw displacement axis (SDA)
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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

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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
  elbow.

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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 ).

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ODriscolls ring of instability
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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

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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
  disruption.

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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.

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Recurrent elbow dislocation

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

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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
  flexion
• Ossification or dense fibrous thickening of the
  joint capsule
• And extensive dense fibrous tissue filling the
  olecranon and coronoid fossae

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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

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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.

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Varus stress test
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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.

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The lateral pivot shift test
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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
  armrests.
• Reproduction of symptoms constitutes a positive
  response

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Valgus instability

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

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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

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The Moving Valgus Stress Test

• this test has been shown to be sensitive (100)
  and specific (75) for elbow pain related to UCL
  pathology.
• 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

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The Moving Valgus Stress Test
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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

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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

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The medial oblique view

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

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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

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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)

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The axial view of the elbow

• It provides an excellent visualization of the
  olecranon, trochlea and epicondyles

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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

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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.

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Magnetic Resonance

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

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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)

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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)

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Role of arthoscopy in diagnosis of elbow
instability

• 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
  information

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Posterior subluxation of the radial head is seen
in this same patient with posterolateral rotatory
instability when the pivot shift test is applied.
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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.

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Treatment of complex elbow dislocation

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Operative treatment

• Fracture of the radial head

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Fractures of the coronoid
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The terrible triad of the elbow
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Olecranon fractures
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The Monteggia lesion
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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

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Ulnar lateral collateral ligament repair and
reconstruction for PLRI
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Treatment of medial elbow instability

• Classic Jobe ulnar collatereal ligament
  reconstruction.

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The docking technique creates a humeral tunnel
that accepts both limbs of the graft with
tensioning performed through superior exit holes
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Role of arthoscopy in treatment of elbow
instability

• Medial instability
• It is indicated for those patients who maintain
  symptoms of posteromedial impingement despite
  nonoperative management

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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

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Application of hinged external fixator in elbow
instability

• Compass external fixator

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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

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Treatment of chronic non reduced elbow
dislocation

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

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Treatment of non-traumatic causes of elbow
instability

• Medical treatment
• Physical therapy
• Surgical treatment
• Synovectomy
• Removal of the cysts or osteophites
• Arthroplasty
• Arthrodesis

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Thank you