Chronic lateral elbow instability

Management of elbow
instability in adults
 An
essay submitted for partial
fulfillment for Master Degree In
Orthopedic surgery
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.
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).
Bony articulations of the elbow joint
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
Stability of the elbow
Static constrains
Primary static constraints:
Secondary static constraints:
Ulnohumeral articulation
MCL (mainly anterior bundle)
LCL (mainly ulnar collaterall part )
Radiocapitellar articulation
Common extensor origin
Common flexor origin
Dynamic constraints ( muscles around elbow joint)
Stabilizers of the elbow joint
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)
The screw displacement axis (SDA)
Pathophysiology and types of elbow
Traumatic types
A. acute elbow dislocation
B. chronic
Complex ( associated with fractures )
Lateral elbow instability
Medial elbow instability
Recurrent elbow dislocation
Chronic non reduced elbow dislocation
Non-traumatic types
Rheumatoid arthritis
Connective tissue disorders
Gouty arthritis
Mechanism of acute traumatic elbow
Falling on outstretched
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.
O’Driscoll’s 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 ).
O’Driscoll’s ring of instability
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
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
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.
Recurrent elbow dislocation
Two basic abnormalities are present:
(1) the trochlear notch of the ulna is misshapen,
 (2) the collateral ligaments that should stabilize
the elbow are incompetent.
Chronic non reduced elbow
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
Ossification or dense fibrous thickening of the
joint capsule
And extensive dense fibrous tissue filling the
olecranon and coronoid fossae
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
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.
Varus stress test
The lateral pivot shift test
The patient in the supine position and with the
shoulder and elbow flexed to 90°. The patient’s forearm
is fully supinated, and with the examiner holding the
patient’s wrist and forearm a valgus and axial
compression force is applied to the elbow whilst the
elbow is slowly extended.
Reproduction of the patient’s symptoms and
production of apprehension such that the patient
prevents further movement.
The lateral pivot shift test
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
Reproduction of
symptoms constitutes a
positive response
Valgus instability
Valgus stress test
 Full external rotation
of the humerus while
a valgus stress is
applied to the slightly
flexed joint.
The milking maneuver
(A) The patient applies the valgus stress to the elbow as
shown with the contralateral arm. (B ) In the modified
milking sign. The patient locks the humerus with the
contralateral forearm; however, the examiner applies the
valgus stress
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
The Moving Valgus Stress Test
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
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
The medial oblique view
It allows a better
visualization of the
trochlea, olecranon,
and coronoid
process. The radial
head is obscured by
the ulna
The lateral oblique view
This view permits
elimination of the
between radius and
ulna, providing a
better visualization of
the radial head, neck,
and biceps tuberosity
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)
The axial view of the elbow
It provides an
visualization of the
olecranon, trochlea
and epicondyles
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
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
Magnetic Resonance
A T1-weighted SE
sequence provides
good evaluation of
the medial and lateral
epicondyles and the
articular surfaces
Magnetic Resonance
High resolution T2weighted GE
sequence shows the
normal ulnar
collateral ligament
(arrow) extending
from the medial
humeral epicondyle to
the proximal ulna and
normal radial
collateral ligament
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)
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
Posterior subluxation of the radial head is seen in
this same patient with posterolateral rotatory
instability when the pivot shift test is applied.
Treatment of acute simple elbow
Closed reduction
Reducible &
stable in extension
Non atheletic patient →
Unrestricted active
Athletic patients→
Assess medial ligament
If stable →
Unrestricted active
If unstable→
Repair of MCL or splint
Unstable dislocation
in extension
Stable <45° flxion
If athlete→
repair MCL
Splint with extension
Unstable <45°
Open reduction &
Stable <45° flxion
Unstable <45°
Hinged external
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.
Treatment of complex elbow
Operative treatment
Fracture of the radial
Fractures of the coronoid
The terrible triad of the elbow
Olecranon fractures
The Monteggia lesion
Treatment of lateral elbow instability
Acute lateral ligament
Depicting transosseous
repair with a running,
locking suture passed
through the humeral
isometric point and tied
over the posterior
humeral column
Ulnar lateral collateral ligament
repair and reconstruction for PLRI
Treatment of medial elbow
Classic Jobe ulnar
collatereal ligament
The docking technique creates a humeral tunnel that
accepts both limbs of the graft with tensioning
performed through superior exit holes
Role of arthoscopy in treatment of
elbow instability
Medial instability
It is indicated for those
patients who maintain
symptoms of
impingement despite
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
Application of hinged external fixator
in elbow instability
Compass external
Treatment of recurrent elbow
 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
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
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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