Elbow instability and terrible triad

Elbow instability and terrible triad

Adam C Watts Consultant Elbow and Upper Limb Surgeon, Wrightington

Hospital

Visiting Professor, University of Manchester

1

www.wrightington.com2

www.wrightington.com

Approach to instability

Understand anatomy

Pattern recognition

Algorithm for management

3

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

9


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

23


Medial Ligament Tear

Common Flexor Origin Avulsion

Anterior Capsule Tear

Lateral Ligament Tear

Common Extensor Tendon Avulsion


Algorithm

26

Clinical Exam & MRI

EUA

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)

27


Chronic Elbow Instability

Recurrent frank dislocation rare

PLRI

Valgus extension overload

28


Posterolateral rotatory instability of the elbow

Most common chronic instability of elbow

Rotatory instability with incompetence of LUCL

Causes: Trauma Iatrogenic - steroid injection/surgery

29


Presentation PLRI

Lateral elbow pain include in differential diagnosis for tennis elbow

Locking include in differential diagnosis for loose bodies

Recurrent elbow dislocation???

30


PLRI

31


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

55


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

64






b.flexion

3.Longitudinal

65

Terrible TriadPosteromedial fracture dislocation

Ring Type 1Ring Type 3

Essex-Lopresti


Posterior lateral rotation Terrible triad

66


Terrible Triad algorithm

Restore coronoid

Restore radial head

Restore lateral soft tissue restraints

Restore medial soft tissue if still unstable

Apply hinged ex-fix

67


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

68


O’Driscoll Classification

12

3

from Ring et al.


How do we manage the radial head?

72


Radial Head ORIF

73


Intracapsular Fracture

75


Assessment of prosthesis length

Resected head height

Ulna variance

Proximal rim of PRUJ

Ulno-humeral joint line gapping

81


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

83


LCL Complex must be repaired

84


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

85


60°

110°

130°

40°


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

88


Longitudinal - Essex-Lopresti


“Hidden Injury” - IOM

93


Tightrope Reconstruction

111


Bone-ligament-bone graft

113


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

116


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

118






b.flexion

3.Longitudinal

119

Terrible TriadPMRI

Ring Type 1Ring Type 3

Essex-Lopresti

Elbow instability and terrible triad

Health & Medicine

Transcript of Elbow instability and terrible triad