2. Management of elbow instability in adults
An essay submitted for partial fulfillment for Master Degree In Orthopedic surgery

3. 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.

4. 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).

5. Bony articulations of the elbow joint

6. 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

7. Stability of the elbow Static constrains
Primary static constraints:
Ulnohumeral articulation
MCL (mainly anterior bundle)
LCL (mainly ulnar collaterall part )
Secondary static constraints:
Radiocapitellar articulation
Common extensor origin
Common flexor origin
Dynamic constraints ( muscles around elbow joint)

8. Stabilizers of the elbow joint

9. 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)

10. The screw displacement axis (SDA)

11. Pathophysiology and types of elbow instability
Traumatic types
A. acute elbow dislocation
Simple
Complex ( associated with fractures )
B. chronic
Lateral elbow instability
Medial elbow instability
Recurrent elbow dislocation
Chronic non reduced elbow dislocation
Non-traumatic types
Rheumatoid arthritis
Connective tissue disorders
Gouty arthritis

12. Mechanism of acute traumatic elbow dislocation
Falling on outstretched hand
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.

13. 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 ).

14. O’Driscoll’s ring of instability

15. 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 fracture

16. 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 disruption.

17. 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.

18. Recurrent elbow dislocation
Two basic abnormalities are present:
(1) the trochlear notch of the ulna is misshapen, or
(2) the collateral ligaments that should stabilize the elbow are incompetent.

19. Chronic non reduced elbow dislocation
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 flexion
Ossification or dense fibrous thickening of the joint capsule
And extensive dense fibrous tissue filling the olecranon and coronoid fossae

20. 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

21. 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.

22. Varus stress test

23. 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.

24. The lateral pivot shift test

25. 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 armrests.
Reproduction of symptoms constitutes a positive response

26. Valgus instability Valgus stress test
Full external rotation of the humerus while a valgus stress is applied to the slightly flexed joint.

27. 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

28. 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

29. The Moving Valgus Stress Test

30. 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 view

31. 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

32. The medial oblique view
It allows a better visualization of the trochlea, olecranon, and coronoid process. The radial head is obscured by the ulna

33. The lateral oblique view
This view permits elimination of the superimposition between radius and ulna, providing a better visualization of the radial head, neck, and biceps tuberosity

34. 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)

35. The axial view of the elbow
It provides an excellent visualization of the olecranon, trochlea and epicondyles

36. 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

37. 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 techniques.

38. Magnetic Resonance
A T1-weighted SE sequence provides good evaluation of the medial and lateral epicondyles and the radiocapitellar articular surfaces

39. Magnetic Resonance
High resolution T2-weighted GE sequence shows the normal ulnar collateral ligament (arrow) extending from the medial humeral epicondyle to the proximal ulna and normal radial collateral ligament (arrowhead)

40. 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)

41. 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 information

42. Posterior subluxation of the radial head is seen in this same patient with posterolateral rotatory instability when the pivot shift test is applied.

43. Treatment of acute simple elbow dislocation
Closed reduction

46. 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.

47. Treatment of complex elbow dislocation

49. Operative treatment
Fracture of the radial head

50. Fractures of the coronoid

51. The terrible triad of the elbow

52. Olecranon fractures

53. The Monteggia lesion

54. Treatment of lateral elbow instability
Acute lateral ligament repair
Depicting transosseous repair with a running, locking suture passed through the humeral isometric point and tied over the posterior humeral column

55. Ulnar lateral collateral ligament repair and reconstruction for PLRI

56. Treatment of medial elbow instability
Classic Jobe ulnar collatereal ligament reconstruction.

57. The docking technique creates a humeral tunnel that accepts both limbs of the graft with tensioning performed through superior exit holes

58. Role of arthoscopy in treatment of elbow instability
Medial instability
It is indicated for those patients who maintain symptoms of posteromedial impingement despite nonoperative management

59. 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

60. Application of hinged external fixator in elbow instability
Compass external fixator

61. Treatment of recurrent elbow dislocation
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

62. 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 arthrodesis

63. Treatment of non-traumatic causes of elbow instability
Medical treatment
Physical therapy
Surgical treatment
Synovectomy
Removal of the cysts or osteophites
Arthroplasty
Arthrodesis

64. Thank you