Elbow Instability

Adam J. Seidl, MD Assistant Professor – University of Colorado School of Medicine Shoulder & Elbow Surgery Division of Sports Medicine and Shoulder Surgery Division of Hand, Wrist, and Elbow Surgery

  

Anatomy and Biomechanics Spectrum of Instability Acute Instability  Diagnosis  Management

Chronic Instability  Diagnosis  Management ▪ “Old School” ▪ State of the Art

Primary Stabilizers  Ulnohumeral

articulation  MCL complex  LCL complex 

Secondary Stabilizers  Radial head

 Capsule  Musculotendinous

Acute Elbow Instability  Simple Elbow Dislocation  Complex Elbow Dislocation

Chronic Elbow Instability  Posterolateral Rotatory Instability

 Valgus Elbow Instability

Simple vs. Complex Elbow Dislocation  Simple ▪ Elbow dislocation without associated fracture ▪ Primarily a capsuloligamentous / soft tissue injury ▪ Post reduction radiographs reveal periarticular fractures in up to 60% of cases and operative exploration reveals high rate of osteochondral injuries

 Complex ▪ Elbow dislocation with associated fracture

Anterior Posterior ~ 90%  Posterior  Posteromedial  Posterolateral

 

Medial Lateral Divergent

Initial Evaluation  Neurovascular examination  Check DRUJ for Essex-Lopresti injury

Reduction  Longitudinal traction, gentle flexion

Post reduction radiographs  Evaluate ulnohumeral radioulnar and radiocapitellar joints, fractures  “Drop sign” - widening of the ulnohumeral joint seen on the lateral radiograph  Represents a subtle resting subluxation - frequently resolves spontaneously

Post reduction management  sling and early ROM can be initiated  May need to splint for 1 week in position of support

   

56% of patients reported residual subjective stiffness of the elbow 8% reported subjective instability 62% reported residual pain The Satisfaction, DASH, and Oxford elbow scores showed good correlation with absolute range of motion in the injured elbow

Posterolateral Rotatory  ”Terrible Triad” ▪ Radial Head ▪ Coronoid ▪ Dislocation – ligaments/capsule

Posteromedial Rotatory  Anteromedial coronoid



Surgical Approach  Lateral/Medial vs global posterior  If RHR – remove  Coronoid/ant capsule 1st  RH ORIF vs RHR 2nd

 LCL 3rd  Assess stability – unstable  MCL

Surgical Approach  Medial Approach ▪ Hotchkiss “over the top” -- small fractures ▪ Between FCU heads – involve sublime tubercle ▪ Elevate Entire FCU – very large fractures

 Lateral Approach ▪ LUCL Repair ▪ Protects fracture fixation ▪ Can be used in isolation in very small fractures

Surgical Approach  Posterior ▪ Work Through the Fracture

 Restore Ulnar length, alignment, rotation ▪ Greater Sigmoid Notch ▪ Coronoid Process

Posterolateral Rotatory Instability  Most common pattern

 Described by O’Driscoll 1991  Deficient LCL

Valgus Instability  Microtrauma from repetitive activity > dislocation

 Overhead athletes

 Diagnosis ▪ History often subtle ▪ Consider in refractory tennis elbow ▪ Exam – unremarkable without provocative tests ▪ PLRI Test ▪ Chair Sign

▪ Imaging ▪ MRI

 Treatment ▪ Open reconstruction of LUCL ▪ Kocher approach  Palmaris autograft vs allograft (semi-T)  Docking  Figure of 8  Interference Screw

▪ State of The Art -- Arthroscopic

 Diagnosis ▪ Anteromedial view during pivot shift ▪ Radial Head will translate posterior

▪ ”Drive-through sign” – insert video here

 Treatment ▪ Repair – Acute > Chroic ▪ Plication -- Chronic

 Technique ▪ Scope Proximal Posterolateral ▪ Sutures from distal to proximal ▪ Percutaneous suture retrieval and tying

 Results

 Diagnosis ▪ Far less common that PLRI ▪ Overhead throwing athletes ▪ History ▪ Pain > Instability sx ▪ Loss of velocity ▪ + Ulnar nerve symptoms

▪ Exam ▪ Milking maneuver ▪ Moving valgus stress

▪ Imaging -- MRI

 Surgical Treatment ▪ Reserved for high level thrower ▪ Technique – numerus ▪ Jobe ▪ ASMI modification ▪ HSS – Docking

▪ Cutting Edge ▪ Scope?

 Diagnosis ▪ Can be used to verify ▪ Anteromedial portal ▪ Elbow at 60 degrees with valgus stress  gapping

 Treatment ▪ Identify & address other pathology ▪ Osteophytes ▪ Loose bodies

▪ Anterior bundle of UCL hard to identify


Elbow Instability

Adam J. Seidl, MD Assistant Professor – University of Colorado School of Medicine Shoulder & Elbow Surgery Division of Sports Medicine and Shoulder Su...

800KB Sizes 0 Downloads 0 Views

Recommend Documents

Elbow Room
Elbow Room. The Varieties of Free Will Worth Wanting new edition. Daniel C. Dennett. A Bradford Book. The MIT Press. Cam

The elbow
Pain is felt over the elbow and, depending on the severity, may be referred into the forearm. If traumatic in origin the

Anterior Elbow Capsulodesis - Kinex
extended posterolateral Kocher approach with a poste- rior midline incision or lateral incision, (2) ORIF of a proximal

Elbow Rizzoli 2015Def
come to the 2"d Meeting of the 2Ind Edition. The new Course will be held in September 15th at the Istituto Ortopedico. R

Javelin throwers elbow - Physiopedia
It's stretching might be provoked by poor technique of the javelin throw: an explosive elbow propulsion ahead of the sho

Shoulder & Elbow - Exeter Shoulder
Feb 1, 2014 - coracoid pain in the SICK scapula syndrome (Scapular malposition,. Inferior medial border prominence, Cora

##Instability in Macbeth | Onword
This causes his downfall. Macbeth does not realise that Macduff was "from his mother's womb untimely ripped". His mother

Dislokasi elbow joint
Frederick dislokasi elbow joint extensible gliff patofisiologi dislokasi panggul kongenital their forks Peeved and conse

Dislocations of the Elbow
retest stability. ▫ If instability persists -. – Kocher approach laterally to repair. LCL/extensors. Elbow Dislocati

Elbow Tendinopathies Self-Assessment
A patient has dorsoradial wrist pain with positive Eichhoff test reproducing his pain. What is the next best step in man