This document discusses elbow instability, including anatomy, stabilizing factors, classification, diagnosis, and management. It covers the soft tissue and bony anatomy of the elbow. Elbow stability relies primarily on the ulnohumeral joint, medial and lateral collateral ligaments. Injuries can range from subluxation to complete dislocation. Diagnosis involves clinical examination and imaging. Management depends on the injury, and may include repair, reconstruction, or fixation of bony and ligamentous injuries.
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Elbow Instability Diagnosis and Management
1. ELBOW INSTABILITY
By:
Dr. Ahmed saleh
Ass.lect. Of orthopaedic surgery
HAND AND UPPER LIMB SURGERY UNIT
Mansoura University Hospitals
Department Of Orthopedic Surgery
Hand & Upper Limb Surgery Unit
7. SOFT TISSUE ANATOMY
⢠Accessory structures:
ď The quadrate ligament: connecting the inferior margin of the annular
ligament to the ulna.
ď The accessory lateral collateral ligament: stabilizes the annular
ligament by connecting its inferior fibres to the supinator crest.
ď Oblique cord: from the lateral ulnar tubercle to the radius just below
the radial tuberosity.
10. PATHOMECHANICS
⢠The most common mode of trauma is falling on outstreched hand
⢠Mechanism of injury:
ď Extension of the elbow till contact
ď Upon contact ; flexion will begin
ď External rotation of the UHJ (triceps effect)
ď Internal rotatio of humerus against forearm
ď Valgus moment (mechanical axis)
ď Combination of ER., valgus and axial compressionâŚâŚ. Instability.
12. CLASSIFICATION
DEGREE OF DISPLACEMENT
⢠HORRI CIRCLE OF DISRUPTION
⢠3STAGES:
⍠1: posterolateral rotatory subluxation
⍠2: incomplete dislocation
⍠3: a: AMCL intact
⍠3:b: no ligaments intact
⍠3:c :flexor pronator origin affected
13. DIAGNOSIS & MANAGEMENT
⢠Diagnosis of acute dislocation
⢠Diagnosis of posterolateral instability
⢠Diagnosis of complex instability
⢠Diagnosis of valgus instability
14. DIAGNOSIS
ACUTE DISLOCATIOAN
⢠Radiological finding of AP and LAT views.
⢠Assesment of instability through ROM
⢠If unstable, test for varus and valgus stability:
ď Full pronation for the valgus stress test
ď Internal rotation of the shoulder for varus test.
ď Both should be examined in full extension and 30 deg. Flexion
⢠Stress x-ray views are important.
16. DIAGNOSIS
POSTEROLATERAL INSTABILITY
⢠Symptoms:
⍠Variable presentation
⍠Pain, clicking popping and snapping on certain positions.
⍠History of trauma or surgery.
⢠Signs:
⍠Lateral pivot shift.
⍠Drower test
⍠Table top relocation test
⍠Active floor push up sign
⍠Chair sign
17. DIAGNOSIS
POSTEROLATERAL INSTABILITY
⢠Radiological evaluation:
⍠A)x-ray:
ď For associatedfractures( head radius and coronoid)
ď Impression fracture
ď Drop sign of the elbow(4mm wideness)
ď Imaging during pivot shift
⍠B) MRI:
ď Of little value
⢠Arthroscopic diagnosis:
ď Shows widening of lateral edge of the joint, elongation of lateral ligament.
⢠IT IS A CLINICAL DIAGNOSIS.
19. MANAGEMENT
POSTEROLATERAL INSTABILITY
⢠The key is to regain the function of LCL.
⢠It is done by:
⢠Correction of bony element if present.
ďśSurgical repair : in acute cases. Not good results.
ďśReconstruction with tendon graft and fixation( different fixation
tech.)
ďśRecently, arthrscopic assisted reconstruction or electrothermal
shrinkage.
20. DIAGNOSIS
COMPLEX INSTABILITY
⢠Elbow dislocation associated with bony element.
⢠Uncommon, poor prognosis.
⢠Most common: radial head and coronid fracture
⢠Others include: transolecranon , terrible triad & posterior
monteggia
21. ASSOCIATED
RADIAL HEAD FRACTURE
⢠Responsible for 30% of valgus stability.
⢠Intact MCLl with excisioN of radial headâŚâŚ.. No instability.
⢠Reconstruction or replacement is mandatory in defecient mcl
⢠Silicon head vs titaneum mono block implant.
24. TERRIBLE TRIAD
⢠Elbow dislocation , radial head fracture and coronoid fracture
⢠Management must be done by correction of the 3 elemnts.
⢠Radial head fixation or replacement alone âŚ.. 50% failure.
⢠Ligament reconstruction and not reapir (avulsion not
midsubstance)
25. POSTERIOR MONTEGGIA LESION
⢠Posterior dislocation of the radial head and a proximal ulna fracture
with an anterior triangular fracture fragment at the level of the
coronoid process
⢠Fixation of the coronoid process is mandatory for acquiring
stability.
27. HINGED EXTERNAL FIXATOR
⢠DYNAMIC OR STATIC
⢠STATIC FIXATOR : Easily applied , no elbow motion
⢠DYNAMIC FIXATOR: demanding frame , active and passive.
⢠Indiations:
⍠Temporary stabilization
⍠persistent elbow instability
⍠protection of comminuted radial head or capitellum
⍠Maintenance of elbow stability in the setting of comminuted coronoid
fractures
⍠Hinged fixators also hava role in providing stability in chronic unreduced
elbow
29. VALGUS INSTABILITY
⢠Mainly occurred in throwing athletes.1st discovered 1946.
⢠MCL injury is the cause.
⢠Diagnosis based on :
⍠History
⍠+ve valgus stress test( baseball player âŚ.+ve)
⍠MRI . MR arthrography with gadolinium.
⍠Dynamic ultrasonography
⢠It is contraindicated to do surgery in:
⍠Asymptomatic athletes who will quit the game
⍠Patient associated with HU or RCJ arthritis.
31. TAKING HOME MESSAGE
⢠Stability of the elbow is gained by osseus and soft tissue.
⢠Ulnar lateral collateral and anterior band of medial collateral are the
passwords for elbow stability.
⢠Horri circle will define the degree of displacement.
⢠Homework of elbow dislocation does not end by reduction.test the
stability before going home.
⢠Pivot shift done in supination and valgus stress test done in pronation.
⢠X-ray is important to assess simplicity of dislocation.
⢠Instability of the elbow is mainly a clinical entity