Elbow Instability Steve Kronlage, MD
Elbow Instability
Steve Kronlage, MD
Elbow Dislocation
• 5.2 cases per 100,000 people in US per yr.
• 26% have associated fracture Stonebach et. al JBJS 2012
• Simple• Complex
Elbow Joint
• Not a “simple hinge”• 2 degrees of freedom:• flexion-‐extension• pronation-‐supination• Tight articulation• REQUIRES Stability
Elbow Stability
Primary Stabilizers
• Ulno-‐humeral articulation• (Bones)• Anterior Band of the MCL• Lateral Ligament Complex
Secondary Stabilizers• Radial Head• Capsule• Common Flexor and Extensor Origins
(Muscles)
Elbow Stabilityanatomy
• Bones• Ligaments
Elbow AnatomyBony Stability
• 180º of motion is captured between the trochlea and trochlear notch
• Stabilizing Columns1. Ant.medial coronoid facet and
the medial lip of trochlea2. Radial head and capitellum
Pollock et al J Bone Joint Surg Am, 2009
Lateral Collateral Ligaments
• Radial collateral ligament• Lateral ulnar collateral
ligamentPrimary lateral stabilizer
• Annular ligamentradial head
G King
Medial Collateral Ligament
• Two discrete portions of the ligament
• Neither of which attach to the humerus at the point of rotation
• Anterior Bundleligament shapedTight in extension
• Posterior BundleFan shapedTight in Flexion
Elbow Capsule
• Fibrous sac that keeps articular fluid within the joint
• The capsule allows flow of synovial fluid from the anterior to posterior compartments (they are not separate)
• Ligaments are very tightly associated with the capsule, often thickenings
• Anterior Capsule is important in stability
Elbow InstabilityTYPES
• Simple• no fracture, most common• Complex• multiple types, complex, bony injury
Simple Dislocation
• Fall on outstretched hand• Ligaments tear, elbow hinges out of joint
Schrieber, et.al J. Hand Surg 2013
Simple Dislocation
• Valgus stress + Supination + Axial Load during flexion = PRLI• (posterior rotatory ligamentous instability)• MCL is usually torn in simple dislocations• Patients with recurrent dislocations – LCL is always torn
• Confusing• MCL torn, but doesn’t lead to problems• LUCL torn = instability if not healed
Schrieber, et.al J. Hand Surg 2013
Treatment Simple Elbow Dislocation
• Can usually be treated with closed manipulation
• Done in flexion• “Pull” olecranon forward• Start ROM early• Depends on age and stability after
reduction• Older earlier
Simple Dislocationoutcomes
• Most common complication is loss of extension
• ROM should start at 5-‐7 days• Extension is limited early because that is where the instability occurs
• If treated restricted motion, most likely will not need intervention
Complex Elbow Dislocations
•Elbow Dislocation plus:• Radial head fracture• Olecranon fracture• Radial head and coronoid
(terrible triad)
Complex Elbow Instability
1. Convert to simple dislocations by resorting bony anatomy2. Initial treatment is important3. Restoration of motion results from restoration of a congruent
stable jointEbrahimzadeh, et al J Hand Surg 2010
Radial Head Fracture with Dislocation
• First priority is to reconstruct radial head
• *plates and/or screws, more commonly replacement
• Fix LCL (will be torn from • humeral epicondyle)• Move early, protected
Radial head fractures and ligaments
• Radial head fractures: MRI evaluation of associated injuries• Itamura J1, RoidisN, Mirzayan R, Vaishnav S, Learch T, Shean C.
• J Shoulder Elbow Surg. 2005 Jul-‐Aug;14(4):421-‐4
• 24 patients with Mason II or III fractures• MRI• MCL tear 55%• LCL tear 80%
Elbow Instability with olecranon fracture
• Instability usually comes through the olecranon
• Olecranon is injured, usually sparing the ligaments
• Fixation of the olecranon will usually grant stability to the elbow
• Often will have radial head fractures
Terrible Triad
• Elbow dislocation• Radial head fracture• Coronoid fracture
• *named because offrequent problems with instability, stiffness and degenerative changes
Terrible Triadtreatment
• Repair or most commonly replacement of radial head• Repair coronoid• usually through drill holes/suture loop• Repair LCL
• *if still unstable, will need MCL repair or hinged external fixator
Ebrahimzadeh, et al J Hand Surg 2010
Terrible Triad rehab
• Depends on intra-‐operative stability• Early motion decreases stiffness but can increase potential instability
• Needs careful attention and frequent radiographic evaluation• Hinged elbow brace slowly increasing extension
Fracture SubluxationsVarus Posteromedial instability
• Results from anteromedial facet coronoid fracture in addition to a LCL injury
• Can result in persistent instability and early arthrosis
• Treated with buttress plate and ligament repair
Ebrahimzadeh, et al J Hand Surg 2010
Posterolateral Rotatory Instability
• The LCL complex resists varus forces (these are the predominant forces on the elbow during ADLs)
• Chronic injury to the lateral ligaments causes the radial head to subluxate posteriorly giving symptoms and pain
Posterolateral Rotatory Instabilitysymptoms
• Lateral elbow pain• Weakness• May have had surgery for lateral epicondylitis• Pain over ligaments (soft spot)• May have mechanical symptoms
Posterolateral Rotatory InstabilityExam
• Tenderness over lateral elbow• May have lack of extension due
to splinting• Chair lift off test• “Pivot Test” Odriscoll, et al J Bone Joint Surg Am, 2000
Posterolateral Rotatory InstabilityImaging
• Radiographs to check for abnormalities and subluxations
• MRI essential• Arthrogram through triceps is important
Treatment PLRI
• The injury is always off the lateral epicondyle• Initially all were treated with free graft reconstruction• More and more now are treated with direct repair of ligaments to lateral elbow
• Surgeons choice on treatment• *I use graft reconstruction when there is no local tissue for reconstruction or the patient has excessive ligamentous laxity (often allograft)
Direct Repair for Managing Acute and Chronic Lateral Ulnar Collateral Ligament Disruptions
Dalunsiski, Schrumpf, Schreiber, Nguyen, Hotchkiss J Hand Surg 2014; 39(6) 1125-‐1129
• 34 patients• Compared acute vs delayed primary repair• No difference in outcome between groups• Can do primary repair of ligaments late
• Retrospective, no graft patients included
Case Example
• 42 year old female, lateral elbow pain after a fall• One tennis elbow surgery• Second surgery, ATS where the surgeon debrided an area of synovitis
around the lateral ligaments• Normal ROM, pain over lateral ligaments, + chair lift off test• Normal plain films• MRI consistent with lateral ligament disruption and lateral epicondylitis
Chronic Instability
• Challenging problem• Multiple techniques describes with varying results
Case Example
• 39 year old female• Fracture dislocation, reduced in
ER, dislocated in splint• Referred in after 9 weeks of
splinting• Very little motion
Elbow InstabilityConclusion
• Simple dislocation do well with guided treatment and early motion
• Radial head fractures can have associated LCL injuries• MCL torn in most elbow dislocations, LCL injury gives the
symptoms• Complex elbow injuries should be converted to simple by
stabilizing bones• Early recognition and treatment of injury is important
Thank you