Elbow instability and terrible triad

Adam C Watts Consultant Elbow and Upper Limb Surgeon, Wrightington

Hospital

Visiting Professor, University of Manchester

www.wrightington.com2

www.wrightington.com

Approach to instability

Understand anatomy

Pattern recognition

Algorithm for management

www.wrightington.com 4

Elbow Stability

Primary stabilisers MCL - anterior bundle Coronoid Lateral ligament complex Olecranon

Secondary stabilisers Radial head Common flexor and extensor origin Anterior capsule

Radial head Coronoid Lateral ligament complex MCL - anterior bundle Common flexor and extensor origin

Joint Reaction Force

Simple Elbow Dislocation

Posterior Anterior (2%) Divergent (Rare, High Energy)

8% Persistent instability (Anakwe 2010)

Predictors of instability?

Simple Elbow Dislocation

O’Driscoll CORR 1992;280:186-197

Examination under anaesthesia

Varus/valgus stress test at 30 degrees

Pivot shift

3 gross valgus instability 2 additional varus instability

All 3 had avulsion medial ligament, common flexor origin and lateral ligament

Open stabilisation performed

Medial Ligament Tear

Common Flexor Origin Avulsion

Anterior Capsule Tear

Lateral Ligament Tear

Common Extensor Tendon Avulsion

Algorithm

Clinical Exam & MRI

Surgical stabilisation

isolated MCL tear

Physio Rehab

MCL tear +

stable unstable

Is PLRI part of simple dislocation?

Recurrent instability rare after simple dislocation 0% (Joseffson) to 8% (Anakwe)

In studies of PLRI only small proportion report previous simple dislocation

those reporting previous dislocation have recurrent frank dislocation (O’Driscoll, Olsen)

Chronic Elbow Instability

Recurrent frank dislocation rare

Valgus extension overload

Posterolateral rotatory instability of the elbow

Most common chronic instability of elbow

Rotatory instability with incompetence of LUCL

Causes: Trauma Iatrogenic - steroid injection/surgery

Presentation PLRI

Lateral elbow pain include in differential diagnosis for tennis elbow

Locking include in differential diagnosis for loose bodies

Recurrent elbow dislocation???

Pivot Shift

Elbow Instability Tests

Varus stress test

Push up test

Bench press

Hypersupination Test

Expected outcome

91% Good or excellent outcome

Improved range of movement

11% risk of complication

8% risk of recurrent instability

Valgus Instability

Postero-medial Impingement

Elbow Instability Tests

Varus/Valgus stress test

Milking manoeuvre

Moving valgus stress test

Elbow fracture dislocations

1.Posterior rotatory a.pronation lateral rotation

b.pronation medial rotation

2.Trans-olecranon a.extension

b.flexion

3.Longitudinal

b.flexion

3.Longitudinal

Terrible TriadPosteromedial fracture dislocation

Ring Type 1Ring Type 3

Essex-Lopresti

Posterior lateral rotation Terrible triad

Terrible Triad algorithm

Restore coronoid

Restore radial head

Restore lateral soft tissue restraints

Restore medial soft tissue if still unstable

Apply hinged ex-fix

Does the coronoid need to be fixed?

Cohort study of 14 consecutive patients (Level 4)

2 Regan-Morrey type I, 12 type 2

No coronoid fixation - Min f/u 24 months

Mean arc of motion 123°

DASH 14

O’Driscoll Classification

from Ring et al.

How do we manage the radial head?

Radial Head ORIF

Intracapsular Fracture

Assessment of prosthesis length

Resected head height

Ulna variance

Proximal rim of PRUJ

Ulno-humeral joint line gapping

Fix or Replace?

No difference in ROM (Level 4)

ORIF more likely to be unstable

33% risk of arthrosis with arthroplasty

Equivalent re-operation rates

LCL Complex must be repaired

Medial collateral ligament

Not fixing MCL is acceptable (Ring 2007)

Fix if having to go medially

If not leave it alone

Argument for decompression of ulnar nerve

Summary

Simple elbow dislocation rarely results in recurrent instability

PLRI is usually an isolated injury

Arthroscopic stabilisation if pivot shift negative

Otherwise open surgical stabilisation with graft

Terrible triad is not so terrible - follow rules

Longitudinal - Essex-Lopresti

“Hidden Injury” - IOM

Tightrope Reconstruction

Bone-ligament-bone graft

Ligament Augmentation and Reconstruction System (LARS)

Polyester rope

Ultimate stress 2600N

Residual Strain at 2500N = 1.5%

Stiffness = 209N/mm (cf 129 native IOM)

No damage after 5 million cycles

Experience to date

15 Procedures (chronic injuries) min follow-up 18

months

1 persistent axial instability - revised to OBF

No other recurrent proximal migration

Mean DASH improved 77 to 41/100

b.flexion

3.Longitudinal

Terrible TriadPMRI

Ring Type 1Ring Type 3

Essex-Lopresti

Elbow instability and terrible triad

Health & Medicine

Transcript of Elbow instability and terrible triad

DONE BY : Rasha Rakan Sara Al-zoubi · the tongue and rarely teeth pain and elbow ... Sweating and nausea are very dangerous sign. ... (Virchow's triad) •Platelets adhere, ...

Operative Treatment of the Terrible Triad Fracture …...Elbow Dislocation with Fracture of the Radial Head • Repeat dislocation and subluxation are uncommon • The ligaments heal

Clinics in Surgery Case Report · Terrible Triad Injury of the elbow (TTI) is characterized by posterior or posterolateral dislocation of the elbow joint along with fractures of the

Review Article Terrible Triad Injury of the Elbow: Current ...upload.orthobullets.com/journalclub/free_pdf/19264707_2009 - King... · Terrible Triad Injury of the Elbow: Current Concepts

Managing Triad 1 – Stacking Triad 5: Gary Huber, D.O.glvhealth.com/LargeFiles/Mod 20b CD/1 Slide Color/3A - Triad 1 and 5... · 1 Managing Triad 1 – Stacking Triad 5: Gary Huber,

Terrible Triad Fracture-Dislocations of the Elbow - FRAKTUR.dkfraktur.dk/wp-content/uploads/2015/11/artikel1albue.pdfTerrible Triad Fracture-Dislocations of the Elbow George Dyer,

Terrible Triad: Tricks for Dealing with the Unstable Elbow · 11/26/2016 · The Terrible Triad Injury 1. Coronoid Fracture 2. Radial Head Fracture 3. Elbow Dislocation Elbow Dislocation

Surgical Approaches for “ Terrible Triad ” Fracture-Dislocations of the Elbow

Solutions About Triad Residential Triad and opportunity ... · About Triad Triad Residential Solutions provides personalized care to adults with intellectual disabilities. We support

Journal club on terrible triad injury of elbow joint.

DIAGNOSIS AND MANAGEMENT OF ELBOW PAIN. ELBOW PAIN Lateral elbow pain Medial elbow pain Posterior elbow pain.

Terrible Triad

Annals of Clinical Case Reports Case ReportThe terrible triad of the elbow is a severe injury that is diftcult to treat and has a poor prognosis in the medium to long term. This lesion

Polytrauma, TBI and Dementia: The Latest Terrible Triad · Polytrauma, TBI and Dementia: The Latest Terrible Triad David X. Cifu, MD Associate Dean for Innovation and System Integrations

Anatomy of the elbow Tennis elbow Golf elbow De Quervain's Tendinitis.

- 15 2014 Elbow: diseases and clinical experiences · 15.00-16.00 Elbow instability 15.00-15.15 Classification from the simple ligamentous lesions up to the terrible triad B. Battiston,

Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

Terrible Triad of Elbow

Terrible triad of the elbow - Bonefix | Orthopaedic | Dr. Vasu Paibonefix.co.nz/portals/160/files/NZOA coronoid.pdf · Microsoft PowerPoint - NZOA coronoid.ppt [Compatibility Mode]

Terrible triad - elbow