Management of elbow Management of elbow instability in adultsinstability in adults

An essay submitted for partial An essay submitted for partial fulfillment for Master Degree In fulfillment for Master Degree In

Orthopedic surgeryOrthopedic surgery

Aim of the workAim of the workTo discuss the types of To discuss the types of

elbow instability in elbow instability in adults and the recent adults and the recent

trends in its trends in its management including management including

non-operative and non-operative and operative methods.operative methods.

Anatomy of the elbow Anatomy of the elbow joint and its stabilizersjoint and its stabilizers

3 separate bony articulations (distal 3 separate bony articulations (distal end of the humerus, proximal ulna end of the humerus, proximal ulna and the radial head).and the radial head).

Trochogingylomoid joint (the hinged Trochogingylomoid joint (the hinged motion in flexion and extension and motion in flexion and extension and trochoid motion in pronation and trochoid motion in pronation and supination). supination).

Bony articulations of the Bony articulations of the elbow jointelbow joint

Stability of the elbow Stability of the elbow provided by a ‘‘fortress’’ of static and provided by a ‘‘fortress’’ of static and

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

Stability of the elbowStability of the elbow

Static constrainsStatic constrains Primary static constraints:Primary static constraints:

Ulnohumeral articulationUlnohumeral articulation MCL (mainly anterior bundle)MCL (mainly anterior bundle) LCL (mainly ulnar collaterall part )LCL (mainly ulnar collaterall part )

Secondary static constraints:Secondary static constraints: Radiocapitellar articulationRadiocapitellar articulation Common extensor originCommon extensor origin Common flexor originCommon flexor origin

Dynamic constraints ( muscles around Dynamic constraints ( muscles around elbow joint) elbow joint)

Stabilizers of the elbow Stabilizers of the elbow jointjoint

Biomechanics of the Biomechanics of the elbow jointelbow joint

Range of motion:Range of motion: 0°-140° in extension-flexion0°-140° in extension-flexion 80° of pronation80° of pronation 90° of supination90° of supination

Variation of the flexion axis Variation of the flexion axis throughout range of motion is often throughout range of motion is often described in terms of the screw described in terms of the screw displacement axis (SDA) displacement axis (SDA)

The screw displacement The screw displacement axis (SDA) axis (SDA)

Pathophysiology and types Pathophysiology and types of elbow instabilityof elbow instability

Traumatic typesTraumatic types A. acute elbow dislocationA. acute elbow dislocation

SimpleSimple Complex ( associated with fractures )Complex ( associated with fractures )

B. chronicB. chronic Lateral elbow instability Lateral elbow instability Medial elbow instabilityMedial elbow instability Recurrent elbow dislocationRecurrent elbow dislocation Chronic non reduced elbow dislocationChronic non reduced elbow dislocation

Non-traumatic typesNon-traumatic types Rheumatoid arthritisRheumatoid arthritis Connective tissue disordersConnective tissue disorders Gouty arthritisGouty arthritis

Mechanism of acute Mechanism of acute traumatic elbow dislocationtraumatic elbow dislocation Falling on Falling on

outstretched handoutstretched hand Axial compressive Axial compressive

force during flexion as force during flexion as the body approaches the body approaches the ground. The body the ground. The body rotates internally on rotates internally on the elbow , a the elbow , a supination moment supination moment occurs at the elbow. A occurs at the elbow. A valgus moment results valgus moment results from the fact the from the fact the mechanical axis is mechanical axis is medial to the elbow.medial to the elbow.

O’Driscoll’s ring of O’Driscoll’s ring of instabilityinstability

It has been broken into 3 stages of disruption.It has been broken into 3 stages of disruption.

Stage IStage I involves disruption of the ulnar involves disruption of the ulnar component of the lateral collateral ligament component of the lateral collateral ligament ( ( PLRI ).PLRI ).

Stage IIStage II with continued force, disruption with continued force, disruption occurs anteriorly and posteriorly allowing for occurs anteriorly and posteriorly allowing for an incomplete posterolateral dislocation an incomplete posterolateral dislocation ( Perched ).( Perched ).

Stage IIIStage III ( Dislocated ).( Dislocated ).

O’Driscoll’s ring of O’Driscoll’s ring of instability instability

Complex elbow Complex elbow dislocationdislocation

Associated radial head fractureAssociated radial head fracture Associated coronoid fractureAssociated coronoid fracture Associated olecranon fractureAssociated olecranon fracture The Monteggia lesionThe Monteggia lesion The terrible triad of the elbowThe terrible triad of the elbow

Elbow dislocation, radial head fracture Elbow dislocation, radial head fracture and coronoid fracture and coronoid fracture

Chronic lateral elbow instability Chronic lateral elbow instability ( PLRI )( PLRI ) Patients with chronic cubitus varus Patients with chronic cubitus varus

caused by congenital anomaly, caused by congenital anomaly, childhood supracondylar fracture childhood supracondylar fracture malunion, and longstanding crutch malunion, and longstanding crutch ambulation, such as in post-polio ambulation, such as in post-polio patients.patients.

Leading to lateral static restraint Leading to lateral static restraint overload and subsequent lateral overload and subsequent lateral collateral ligament disruption. collateral ligament disruption.

Chronic elbow instabilityChronic elbow instability

Chronic medial elbow Chronic medial elbow instabilityinstability

results from chronic repetitive injury results from chronic repetitive injury rather than acute injury.rather than acute injury.

Commonly in throwing athletes Commonly in throwing athletes caused by the large valgus force caused by the large valgus force produced during the throwing motion produced during the throwing motion (during the late cocking and early (during the late cocking and early acceleration phases of throwing acceleration phases of throwing motion). Causing disruption of the motion). Causing disruption of the MCL mainly the anterior bundle. MCL mainly the anterior bundle.

Recurrent elbow Recurrent elbow dislocation dislocation

Two basic abnormalities are Two basic abnormalities are present: present:

(1) the trochlear notch of the ulna (1) the trochlear notch of the ulna is misshapen, oris misshapen, or

(2) the collateral ligaments that (2) the collateral ligaments that should stabilize the elbow are should stabilize the elbow are incompetent. incompetent.

Chronic non reduced elbow Chronic non reduced elbow dislocationdislocation

Extensive myositis ossificans around the Extensive myositis ossificans around the jointjoint

Marked shortening of the triceps muscle Marked shortening of the triceps muscle and medial and lateral collateral and medial and lateral collateral ligamentsligaments

Tightening of the ulnar nerve with Tightening of the ulnar nerve with attempts at flexionattempts at flexion

Ossification or dense fibrous thickening of Ossification or dense fibrous thickening of the joint capsulethe joint capsule

And extensive dense fibrous tissue filling And extensive dense fibrous tissue filling the olecranon and coronoid fossaethe olecranon and coronoid fossae

Diagnosis of elbow Diagnosis of elbow instability instability

In acute trauma, a detailed history of In acute trauma, a detailed history of the event must be obtained. The the event must be obtained. The mechanism of injury including the mechanism of injury including the position of the arm at the time of the position of the arm at the time of the initial injury. initial injury.

For non acute elbow conditions, the For non acute elbow conditions, the most common complaint is pain, most common complaint is pain, although stiffness or other mechanical although stiffness or other mechanical symptoms such as locking, snapping or symptoms such as locking, snapping or catching in the elbow catching in the elbow

Special tests for Special tests for instabilityinstability

Varus instabilityVarus instability Varus stress testVarus stress test (Assessment of the (Assessment of the

integrity of the LCL): fully internally integrity of the LCL): fully internally rotating the shoulder, flexing the elbow rotating the shoulder, flexing the elbow to approximately 30° to unlock the to approximately 30° to unlock the olecranon from its fossa and applying a olecranon from its fossa and applying a varus stress to the elbow.varus stress to the elbow.

If the lateral collateral ligament is If the lateral collateral ligament is deficient, the gap between the capitellum deficient, the gap between the capitellum and radial head will increase.and radial head will increase.

Varus stress testVarus stress test

The lateral pivot shift The lateral pivot shift test test

The patient in the supine position and The patient in the supine position and with the shoulder and elbow flexed to 90°. with the shoulder and elbow flexed to 90°. The patient’s forearm is fully supinated, The patient’s forearm is fully supinated, and with the examiner holding the and with the examiner holding the patient’s wrist and forearm a valgus and patient’s wrist and forearm a valgus and axial compression force is applied to the axial compression force is applied to the elbow whilst the elbow is slowly extended. elbow whilst the elbow is slowly extended.

Reproduction of the patient’s symptoms Reproduction of the patient’s symptoms and production of apprehension such that and production of apprehension such that the patient prevents further movement. the patient prevents further movement.

The lateral pivot shift The lateral pivot shift testtest

Push up out of a chair Push up out of a chair testtest

The seated patient The seated patient attempts to push attempts to push up out of a chair up out of a chair with the palms with the palms facing inward on facing inward on the armrests. the armrests.

Reproduction of Reproduction of symptoms symptoms constitutes a constitutes a positive response positive response

Valgus instabilityValgus instability

Valgus stress Valgus stress testtest Full external Full external

rotation of the rotation of the humerus while a humerus while a valgus stress is valgus stress is applied to the applied to the slightly flexed slightly flexed joint. joint.

The milking maneuver The milking maneuver (A)(A) The patient applies the valgus stress to the The patient applies the valgus stress to the

elbow as shown with the contralateral arm. (B ) elbow as shown with the contralateral arm. (B ) In the modified milking sign. The patient locks In the modified milking sign. The patient locks the humerus with the contralateral forearm; the humerus with the contralateral forearm; however, the examiner applies the valgus stress however, the examiner applies the valgus stress

The Moving Valgus The Moving Valgus Stress Test Stress Test

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

The shoulder is abducted and fully The shoulder is abducted and fully externally rotated to lock humeral externally rotated to lock humeral motion. Applying a constant valgus motion. Applying a constant valgus stress as the elbow is moved through stress as the elbow is moved through an arc of flexion and extension, noting an arc of flexion and extension, noting pain between 70° and 120° of flexion pain between 70° and 120° of flexion

The Moving Valgus The Moving Valgus Stress TestStress Test

Radiographic EvaluationRadiographic Evaluation

(A-P) view The (A-P) view The distal humerus, distal humerus, especially the especially the profiles of the profiles of the medial and medial and lateral lateral epicondyles, the epicondyles, the radial head, and radial head, and the proximal the proximal ulna are highly ulna are highly visible in this visible in this viewview

laterolateral (L-L) laterolateral (L-L) projection projection

The distal The distal humerus, the humerus, the olecranon olecranon process, and the process, and the anterior part of anterior part of the radial head the radial head are highly are highly visible in the visible in the lateral viewlateral view

The medial oblique view The medial oblique view

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

The lateral oblique view The lateral oblique view

This view permits This view permits elimination of the elimination of the superimposition superimposition between radius between radius and ulna, and ulna, providing a better providing a better visualization of visualization of the radial head, the radial head, neck, and biceps neck, and biceps tuberositytuberosity

The radial head-The radial head-capitellum view capitellum view

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

The axial view of the The axial view of the elbow elbow

It provides an It provides an excellent excellent visualization of visualization of the olecranon, the olecranon, trochlea and trochlea and epicondylesepicondyles

CT scan CT scan CT scan of the CT scan of the

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

Magnetic ResonanceMagnetic Resonance

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

Magnetic ResonanceMagnetic Resonance A T1-weighted A T1-weighted

SE sequence SE sequence provides good provides good evaluation of the evaluation of the medial and medial and lateral lateral epicondyles and epicondyles and the the radiocapitellar radiocapitellar articular articular surfaces surfaces

Magnetic ResonanceMagnetic Resonance High resolution High resolution

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

Magnetic ResonanceMagnetic Resonance

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

Role of arthoscopy in Role of arthoscopy in diagnosis of elbow diagnosis of elbow

instabilityinstability Diagnostic elbow arthroscopy Diagnostic elbow arthroscopy

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

Posterior subluxation of the radial head Posterior subluxation of the radial head is seen in this same patient with is seen in this same patient with

posterolateral rotatory instability when posterolateral rotatory instability when

the pivot shift test is applied.the pivot shift test is applied.

Treatment of acute simple Treatment of acute simple elbow dislocationelbow dislocation

Closed Closed reductionreduction

Reducible & Reducible & stable in extensionstable in extension

Non atheletic patient →Non atheletic patient →Unrestricted active Unrestricted active

movementmovement

Athletic patients→Athletic patients→Assess medial ligamentAssess medial ligament

If stableIf stable → →Unrestricted active Unrestricted active

movementmovement

If unstableIf unstable→→Repair of MCL or splintRepair of MCL or splint

Unstable dislocationUnstable dislocation

Reducible,unstableReducible,unstable in extensionin extension

IrreducibleIrreducible

Open reduction & Open reduction & stabilizationstabilizationStable Stable <<45° flxion45° flxion Unstable Unstable <<45°45°

Splint with extensionSplint with extensionblockblock

If athlete→If athlete→repair MCLrepair MCL Stable Stable <<45° flxion45° flxion Unstable Unstable <<45°45°

Hinged externalHinged externalfixatorfixator

Mobilization Mobilization recommendationsrecommendations

For simple elbow dislocations, the For simple elbow dislocations, the elbow is immobilized for a maximum of elbow is immobilized for a maximum of 5 to 7 days in slightly less than 90º of 5 to 7 days in slightly less than 90º of flexion depending on the degree of flexion depending on the degree of anterior soft tissue swelling in a anterior soft tissue swelling in a posterior splint. posterior splint.

If the elbow was stable on the post If the elbow was stable on the post reduction examination, full unprotected reduction examination, full unprotected motion should be started no later than motion should be started no later than 1 week after injury. 1 week after injury.

Treatment of complex Treatment of complex elbow dislocation elbow dislocation

Operative treatmentOperative treatment

Fracture of the Fracture of the radial headradial head

Fractures of the coronoidFractures of the coronoid

The terrible triad of the The terrible triad of the elbowelbow

Olecranon fracturesOlecranon fractures

The Monteggia lesionThe Monteggia lesion

Treatment of lateral elbow Treatment of lateral elbow instabilityinstability

Acute lateral Acute lateral ligament repairligament repair

Depicting Depicting transosseous repair transosseous repair with a running, with a running, locking suture locking suture passed through the passed through the humeral isometric humeral isometric point and tied over point and tied over the posterior the posterior humeral column humeral column

Ulnar lateral collateral Ulnar lateral collateral ligament repair and ligament repair and

reconstruction for PLRIreconstruction for PLRI

Treatment of medial elbow Treatment of medial elbow instabilityinstability

Classic Jobe ulnar Classic Jobe ulnar collatereal collatereal ligament ligament reconstruction. reconstruction.

The docking technique creates a The docking technique creates a humeral tunnel that accepts both limbs humeral tunnel that accepts both limbs of the graft with tensioning performed of the graft with tensioning performed

through superior exit holesthrough superior exit holes

Role of arthoscopy in Role of arthoscopy in treatment of elbow treatment of elbow

instabilityinstability Medial instabilityMedial instability It is indicated for It is indicated for

those patients who those patients who maintain maintain symptoms of symptoms of posteromedial posteromedial impingement impingement despite despite nonoperative nonoperative management management

Lateral instabilityLateral instability A, Inserting first suture through spinal needle. B, Suture in place from ulna to lateral A, Inserting first suture through spinal needle. B, Suture in place from ulna to lateral

epicondyle. C, Multiple sutures in place plicating radial ulnohumeral ligamentepicondyle. C, Multiple sutures in place plicating radial ulnohumeral ligament

Application of hinged Application of hinged external fixator in elbow external fixator in elbow

instability instability Compass Compass

external external fixatorfixator

Treatment of recurrent Treatment of recurrent elbow dislocationelbow dislocation

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

Treatment of chronic Treatment of chronic non reduced elbow non reduced elbow

dislocationdislocation The treatment options for old The treatment options for old

unreduced posterior unreduced posterior dislocations of the elbow dislocations of the elbow include closed reduction, include closed reduction, open reduction, excision open reduction, excision arthroplasty, interposition or arthroplasty, interposition or replacement arthroplasty, replacement arthroplasty, and arthrodesisand arthrodesis

Treatment of non-Treatment of non-traumatic causes of traumatic causes of

elbow instabilityelbow instability Medical treatment Medical treatment Physical therapyPhysical therapy Surgical treatmentSurgical treatment

SynovectomySynovectomy Removal of the cysts or Removal of the cysts or

osteophitesosteophites ArthroplastyArthroplasty Arthrodesis Arthrodesis