elbow instability,coronoid fracture,radial head fracture,posterolateral instability,complex instability,masons classification,terrible traid of elbow

1. ELBOW
INSTABILITY
PRESENTER-DR.AAYUSH ARORA
CHAIRPERSON-DR.KIRAN PATIL

13. • 1st Time Dislocation-
• Presentation
• Dislocations of the elbow are reasonably common in
clinical practice and usually occur following a sporting
injury. More complex injuries can occur following high
energy injuries such as industrial accidents and
significant falls.
• Assessment includes:
• a) Examining for localized bruising over the medial and
lateral aspects of the elbow, interosseous membrane,
and the wrist. It is important that Essex-Lopresti injuries
are not overlooked.
• b) Assessment of the neurovascular structures is
important.

14. • c) Plain radiographs must be reviewed to identify
the direction of instability and associated
fractures including those of the coronoid process
and radial head.
• Reduction-
• Can be performed under a general or local
anesthetic. Position the patient supine on a
stretcher
• Stand at the side of the bed, facing the elbow.
• Place one hand anterior on the distal humerus
and the other hand grasping the wrist .
• With the elbow held in extension, pull hard
manual traction across the elbow.

15. • While pushing down on the distal humerus, begin flexing the
elbow while maintaining traction.
• A clunk may be felt when the joint is reduced, but a clunk does
not always occur. If the elbow can be fully flexed with no
crepitus, it is most likely reduced

16. • Unstable in the last 30º of extension - a hinged
brace with an extension block so the patient can
mobilize within stability range.
• Indications for surgery include:
• a) Associated fractures that require stabilization,
such as those of the radial head and coronoid
process.
• b) Patients who have gross instability (unstable
at >30º of flexion or supination).
• C)Recurrent instability symptoms or dislocations

17. Posterolateral Rotatory
Instability
• The patient usually has a history of injury or
dislocation and presents with mechanical
symptoms such as clicking, catching and locking
with or without recurrent dislocations.
• Pathoetiology-
• O’Driscoll postulated that the instability was due
to a fall onto the outstretched hand where the
elbow becomes loaded with an axial, valgus and
supination force. The circle of Horii describes a
pattern of soft tissue injury.

19. • a) Stage 1 is a disruption of the LUCL, which can
produce posterolateral rotatory instability.
• b) Stage 2 is disruption of the anterior and
posterior capsule, which allows the elbow to
become “perched”.
• c) Stage 3 includes injury is to the medial side of
the elbow.
• 3a the MCL is intact,
• 3b the anterior band of the MCL is disrupted,
• 3c the entire distal humerus soft tissue is
stripped leading to gross instability of the joint
so it is stable only at greater than 90º of flexion.

20. • SYMPTOMS-
• Patients with PLRI may present with a spectrum
of different symptoms ranging from vague pain
in the elbow to recurrent posterolateral
dislocations. The most common patient
complaints/symptoms are recurrent popping,
clicking, clunking, or locking, accompanied by a
sense of instability in the elbow. These
symptoms occur during the act of extension and
supination, especially when an axial load is
applied through the upper extremity

21. EXAMINATION-
•Posterolateral rotary pivot-shift test-
• With the patient supine the arm is positioned above the
patient’s head. The examiner grasps the forearm, which
is placed into full supination. With the elbow positioned
in supination and extension the elbow is then slowly
flexed while the examiner applies a slight valgus and axial
load to the elbow. This produces a rotatory supination
torque on the forearm, which can produce a rotatory
subluxation of the radio-ulnar joint. A positive sign is
when the radial head can be seen to subluxate dorsally
and is often associated with a characteristic dimple just
proximal to the subluxated radial head.

23. MRI-
1)Lateral collateral ligament is completely
stripped (yellow arrow).
2)Radial head is subluxed.
3)Marrow edema of the coronoid process due to
the fracture (red arrow).

24. • Treatment
• Patients will instinctively learn to avoid activities
that cause instability in the extension arc due to
their apprehension. There is a significant
disability with PLRI and the majority of patients
prefer surgery.
• The relative contraindications to surgery include;
1)children who have an open physis
2)concomitant arthritis of the joint
3)generalized ligamentous laxity
4)habitual recurrent dislocations

25. •Surgical management
• A) Examination under anesthetic. This is best
performed with the assistance of fluoroscopy.
The MCL is assessed with a valgus force placed
on the pronated arm. The LUL is assessed with a
varus force placed on the elbow and the PLRI
test is performed.
• B) Arthroscopy is very useful in helping to
understand the details of the instability.
• 1) Allows assessment of associated injuries and
debridement of osteochondral lesions.
• 2) Assessment of valgus and varus instability is
best performed in the anterior compartment.

26. • Surgical repair of the lateral ligamentous
complex was recommended by Osborne and
Cotterill and is usually performed by using the
palmaris longus tendon. They recommended an
exposure of the lateral supracondylar ridge and
epicondyle and then plicating the lateral
ligamentous complex. In patients poor quality
tissue a ligamentous reconstruction is preferred
to a repair.

27. Complex instability-
• Elbow dislocation associated with bony
elements.
• Uncomman with poor prognosis
• Most common:-radial head and coronoid
fracture
• Other include:-terrible traid,monteggia
fracture

28. • ASSOCIATED RADIAL HEAD FRACTURE-
• Radial head fractures associated with elbow
dislocations frequently are comminuted and
nonreconstructible and are initially excised.
• More complex associated injury patterns include
either a low coronoid fracture or a medial
collateral ligament rupture. In these situations,
a radial head implant is recommended to help
stabilize the joint.
• A radial head implant may be indicated to
stabilize the elbow joint and allow range-of-
motion exercises to begin early.

29. • Although prosthetic replacement of the radial
head after acute fractures of the radial head and
after radial head excision and elbow
synovectomy is controversial, it is reasonable to
consider this procedure after injury or disease
has caused significant instability of the elbow
joint, radial forearm axis, and distal radioulnar
joint.
• In particular, outcomes of comminuted radial
head fractures treated with radial head
arthroplasty have been reported to be superior
to open reduction internal fixation at short-term
follow-up.

30. MASONS CLASSIFICATION-
Radial head fractures can occur in isolation or
as part of a more complex elbow
dislocation.When confirmed that the fracture is
in isolation, the goal of treatment is a pain-free,
stable arc of motion in flexion-extension and
pronation-supination. The Mason classification
system is widely used to describe these
fractures.

31. • TYPE 1 -Nondisplaced or minimally displaced (<2mm), no
mechanical block to rotation.
• TYPE 2 -Displaced >2mm or angulated, possible mechanical
block to forearm rotation.
• TYPE 3 -Comminuted and displaced, mechanical block to
motion
• TYPE 4 -Radial head fracture with associated elbow dislocation

32. • Most radial head fractures are treated
conservatively (Mason types I and II).
Nonunion and fracture displacement are
rare. Stiffness,however, can be a
complication.
• Critical to making the decision about
operative treatment is determining that (1)
the injury is isolated and not part of a
complex dislocation and (2) there is no
block to flexion-extension or pronation-
supination.

33. • OPERATIVE TREATMENT OF MASON TYPE II
FRACTURES-
• ORIF is the usual form of treatment for these injuries when
surgery is indicated. The use of mini-fragment screws, with or
without a buttress plate placed in the “safe zone” (area of
radial head that does not articulate with the ulna has had
good results.

34. • OPERATIVE TREATMENT OF MASON TYPE III
FRACTURES
• These fractures often are part of a more severe
injury and may occur with elbow dislocation and
other injuries about the elbow. They are less
frequently appropriate for ORIF than are type II
fractures. Radial head resection may be a good
option for isolated fractures in elderly patients, but
it has been associated with variable results in
younger patients.

35. • Recent investigation into radial head
arthroplasty has focused on implant
sizing. An oversized radial head implant
can increase tension on the interosseous
membrane with subsequent risk of
stiffness and pain, and one report found
that more than 2 mm of lengthening can
increase radiocapitellar contact pressures.
Therefore a radial head replacement
should be close to an anatomic substitute.
Generally, the proximal edge of the radial
head is 0.9 mm distal to the lateral
coronoid edge.

36. • To prevent overstuffing the radiocapitellar joint, the proximal
edge of the prosthesis should be level with the lateral
coronoid edge.
Radial head implant.Threedimensional
CT scans used to determine plane defined by distal
margins of articular surface of radial head. Arrow 1, Central ridge
of coronoid process. Arrow 2, Lateral edge of coronoid process.

37. Implant should be checked for stability
during elbow motion to ensure that any
potential edge binding of implant and
capitellum does not occur.
IN FULL EXTENSION,NO EDGE
BINDING CAN BE SEEN
IN 90 DEGREE FLEXION,EDGE
BINDING CAN BE SEEN

38. •After correctly sizing the implant,
appropriate reattachment of the
lateral ligamentous complex also is
necessary to prevent edge binding of
the radial head prosthesis.

39. Types of radial head implants-
• Swanson-type Silastic implants-
• These semi-rigid cementless implants were sometimes
used as temporary spacers to prevent ascending of the
radius in patients with instability of the forearm scaffold.
• However, in patients with ulnar collateral ligament
injuries, Silastic™ implants cannot act as secondary
valgus stabilisers . Finally, high rates of osteolysis
(triggered by silicone particles: siliconitis) and of implant
fractures have been reported.

40. •BIPOLAR IMPLANTS-
•Modular implants offer two
advantages:
•1)The optimal head size can be
chosen.
•2)The height of the head and neck
can be adjusted to match the height
of the resection, which is a crucial
technical point.

41. • ASSOCIATED CORONOID FRACTURE-
• Regan and Morrey classified fractures of the coronoid
process as
• Type I, a small chip fracture;
• Type II, a fracture involving less than 50% of the process;
• Type III, a fracture involving more than 50% of the
process.

42. • Coronoid Fracture Classification (O’Driscoll et
al.)
• Classification of coronoid fracture based on
fragmentation pattern (O’Driscoll et al.)
• Type I:
• Tip (SUBTYPE 1)- ≤2 mm coronoid bony height(i.e., flake
fracture)
• (SUBTYPE 2)- >2 mm coronoid height

43. • Type II:
Anteromedial
(SUBTYPE 1) Anteromedial rim
(SUBTYPE 2) Anteromedial rim + tip
(SUBTYPE 3) Anteromedial rim + sublime tubercle
(± tip)
Type III:
Basal
(SUBTYPE 1) Coronoid body and base
(SUBTYPE 2) Transolecranon basal coronoid fracture

45. LASSO REPAIR
1)A posterolateral approach was used to dissect
between the extensor carpi ulnaris and the
anconeus.
2)Joint capsule is excised, allowing visualization
of the coronoid fracture. Subperiosteal dissection
along the anterior distal humerus may also allow
further exposure of the ulnohumeral joint,
facilitating debridement of loose bodies.
3)The drill guide is then placed in the fracture
bed at the appropriately oriented angle, and the
pilot hole for the initial suture anchor is made.

46. 4) The suture anchor is then placed into the
hole in the standard fashion, and the
fixation is tested to ensure no pull-out.
5)The suture may then be passed through
or around the fracture fragment if it is large
enough or through the anterior capsule if
the fracture is too small or comminuted.
6)Two to three anchors are placed in this
fashion along the breadth of the coronoid
fracture base, with sutures incorporating
the fracture fragment and anterior elbow
capsule from medial to lateral.

47. “TERRIBLE TRIAD” INJURIES
OF THE ELBOW
• Originally described by Hotchkiss, the “terrible
triad” consists of an elbow dislocation in
conjunction with fractures of the radial head
and coronoid. Historically, poor outcomes led to
the designation of this combination of injuries as
“terrible.”
• The essential lesion is disruption of the lateral
collateral ligament with progression to the
medial structures.

48. • Principles of Operative Treatment of
“Terrible Triad” Fracture-Dislocations of
the Elbow
1)Restore coronoid stability through fracture
fixation (type II or III) or through anterior capsular
repair (type I).
2)Restore radial head stability through fracture
fixation or replacement with a metal prosthesis.
3)Restore lateral stability through repair of the
lateral collateral ligament complex and associated
so-called secondary constraints such as the
common extensor origin and/ or the
posterolateral capsule.

49. TREATMENT
• The best approach for treatment of “terrible triad”
injuries remains controversial. The choice of approach
depends primarily fracture pattern, type of instability,
soft tissue injury, and surgeon experience.
• A direct lateral approach or a midline incision with
subcutaneous flaps to the Kocher interval usually is used.
• The fixation strategy usually is from deep to superficial
as seen from the lateral approach (coronoid to anterior
capsule to radial head to lateral collateral ligament to
common extensor origin).

50. • Coronoid fixation depends on the size of the
fragment.Small tip avulsions usually are reduced
and fixed with sutures through holes drilled in
the posterior olecranon. This effectively anchors
the anterior capsule to the coronoid. Larger
fragments are stabilized with lag screws from the
posterior olecranon.
• Management of the radial head fracture is
determined by the ability to obtain a reduction
and whether the quality of the bone allows the
reduction to be maintained.

51. If the fracture cannot be reduced and
stabilized adequately, replacement with a
metal prosthesis is indicated. Although this
decision is made early in the treatment
process, we generally place the radial head
prosthesis after fixation of the coronoid
fracture because removal of the radial head
provides good exposure of the coronoid
fragment.
After coronoid and radial head stabilization
or replacement, the lateral collateral
ligament is reattached to its origin,as is the
common extensor origin.

53. Valgus instability of the elbow
• Overhead athletes, such as baseball pitchers, javelin throwers,
and handball players, are at risk of developing medial elbow
symptoms due to the high valgus stresses generated during
throwing.
• Untreated valgus elbow instability can lead to early joint
degeneration.
• On clinical examination, Ecchymosis may be present in the
case of elbow dislocation.
• The carrying angle, between the humerus and forearm, may
be higher than the average 11° and 13° in men and women,
respectively, as a result of repetitive valgus stretch and MCL
elongation.

54. Treatment
• Nonoperative management
• Conservative treatment consists of a
rehabilitation program after a period of rest and
adequate pain control. Immediate mobilization is
important in the prevention of stiffness and has
been shown not to increase the risk of recurrent
instability. A dynamic brace can be applied for
comfort and for reducing valgus stress on the
elbow, with a stepwise increase to full extension.

55. •Direct repair of the ruptured MCL
is only indicated in cases of acute
avulsion from either the humeral
origin or the coronoid insertion.