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David Ring, MD PhD Massachusetts General Hospital Boston, Massachusetts May 2011 Traumatic Elbow Instability.

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Presentation on theme: "David Ring, MD PhD Massachusetts General Hospital Boston, Massachusetts May 2011 Traumatic Elbow Instability."— Presentation transcript:

1 David Ring, MD PhD Massachusetts General Hospital Boston, Massachusetts May 2011 Traumatic Elbow Instability

2 Simple Elbow Dislocation Definition Dislocation of the elbow No associated fractures

3 Simple Elbow Dislocation What’s Injured? Both collateral ligaments Variable amount of muscle origin Greater instability with greater muscle injury Studies of routine operative treatment Joseffson and colleagues Joseffson and colleagues Durig and colleagues Durig and colleagues

4 Simple Elbow Dislocation What’s Injured? Shawn O’Driscoll –Injury progression from lateral to medial –The anterior band of the MCL is the last structure torn –Elbow can dislocate with the anterior band of the MCL intact

5 Simple Elbow Dislocation Treatment No more than 2 weeks of cast immobilization Early active use and exercises Melhoff and colleagues Protzman and colleagues

6 Simple Elbow Dislocation Duckworth A, Ring D, McKee M, JSES 2008: Active exercises for slight subluxation after elbow dislocation 19 patients 19 patients 4 simple dislocation 4 simple dislocation 4 post-op terrible triad 4 post-op terrible triad Program Program Active rehab Active rehab Avoid varus stress Avoid varus stress Results Results All achieved stable, functional elbow All achieved stable, functional elbow

7 Simple Elbow Dislocation Summary Complete ligamentous injury in most patients Elbow can dislocate with MCL intact Early motion is key Early active motion can accommodate for slight subluxation

8 Simple Elbow Dislocation Unstable Simple Elbow Dislocation Mentioned rarely in literature—Is it uncommon?

9 Simple Elbow Dislocation Unstable Simple Elbow Dislocation

10 Simple Elbow Dislocation Unstable Simple Elbow Dislocation

11 Simple Elbow Dislocation Unstable Simple Elbow Dislocation

12 Simple Elbow Dislocation Unstable Simple Elbow Dislocation

13 Simple Elbow Dislocation Unstable Simple Elbow Dislocation

14 Simple Elbow Dislocation Unstable Simple Elbow Dislocation

15 Simple Elbow Dislocation Unstable Simple Elbow Dislocation Duckworth A, Ring D, McKee M. JSES 2008 Uncommon, but not rare –older women, low energy injury –young men, high energy injury

16 Simple Elbow Dislocation Unstable Simple Elbow Dislocation Treatment –Ligament repair –Hinged External Fixation –Cross pinning

17 Simple Elbow Dislocation Unstable Simple Elbow Dislocation Treatment: Ligament repair

18 Simple Elbow Dislocation Unstable Simple Elbow Dislocation Treatment: Hinged external fixation

19 Simple Elbow Dislocation Chronic Simple Elbow Dislocation

20 Historical Treatment Suggestions

21 Chronic Simple Elbow Dislocation Jupiter and Ring JBJS 2002 Treatment: Open reduction and hinged external fixation 5 patients: dislocated for 2 to 9 months Stable elbow, > 100 degrees motion in all patients

22 Medial Collateral Ligament Insufficiency Throwing athletes Chronic attenuation Inability to throw 95 mph fastballs

23 Medial Collateral Ligament Insufficiency

24 LCL Insufficiency Recurrent Simple Elbow Dislocation Osborne and Cotterill JBJS B 1966 O’Driscoll and colleagues JBJS A 1991 –Insufficiency of the lateral collateral ligament

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27 LCL Insufficiency Recurrent Simple Elbow Dislocation Treatment: LCL reconstruction with tendon graft

28 Traumatic Elbow Instability Associated with Fractures

29 Definition Fracture-dislocation of the elbow –Dislocation of the elbow –Intra-articular fracture

30 Definition Fracture-dislocation of the elbow –Dislocation of the elbow –Intra-articular fracture

31 Definition Fracture-dislocation of the elbow –Dislocation of the elbow –Intra-articular fracture

32 Definition Traumatic Elbow Instability –Combination of fractures and ligament injuries that destabilize the elbow

33 Patterns of Traumatic Elbow Instability With Fracture DislocationOlecranon Fracture- Dislocations Varus Posteromedial Rotational Instability Posterior AnteriorDislocation+ radial head fracture Terrible Triad Few Exceptions

34 Dislocation vs. Disruption DislocationDisruption

35 Dislocation vs. Disruption DislocationDisruption

36 Dislocation vs. Disruption DislocationDisruption

37 Dislocation vs. Disruption DislocationDisruption

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39 Patterns of Traumatic Elbow Instability With Fracture DislocationOlecranon Fracture- Dislocations Posterior AnteriorDislocation+ radial head fracture Terrible Triad Dislocation Injuries Disruption Injuries Varus posteromedial rotational instability

40 Posterior Dislocation + Radial Head Fracture

41 24 patients Ulnohumeral dislocation with radial head fracture Cast 1 month +/- radial head resection “Results better than generally thought” Secondary procedures for radial head No problems with instability

42 Posterior Dislocation + Radial Head Fracture 23 patients Excision of radial head and cast INSTABILITY in patients with CORONOID fractures (4 patients)

43 Posterior Dislocation + Radial Head Fracture

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47 Terrible Triad Posterior dislocation Radial head fracture Coronoid fracture

48 Terrible Triad Posterior dislocation Radial head fracture Coronoid fracture

49 Terrible Triad Posterior dislocation Radial head fracture Coronoid fracture

50 Terrible Triad Posterior dislocation Radial head fracture Coronoid fracture

51 Terrible Triad Only patients with INSTABILITY had CORONOID fractures (4 patients)

52 Terrible Triad Ring, Jupiter, Zilberfarb JBJS patients Regan and Morrey Type 2 coronoid fractures 7 redislocated in splint or cast 5 redislocated after operation Only 4 patients with satisfactory results

53 Terrible Triad Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am Jun;86-A(6):

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57 Regan and Morrey

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62 O’Driscoll Classification 1 3 2

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66 Varus Posteromedial Rotational Injuries Inadequate Treatment

67 Olecranon Fracture-Dislocations Anterior (trans-olecranon) fracture- dislocations Posterior (posterior Monteggia) fracture- dislocations

68 Anterior (Trans-Olecranon Fracture- Dislocation of the Olecranon

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71 POSTERIOR MONTEGGIA TYPE FRACTURE-DISLOCATION Posterior Fracture-Dislocation of the Olecranon

72 POSTERIOR MONTEGGIA TYPE FRACTURE-DISLOCATION Posterior Fracture-Dislocation of the Olecranon

73 Principles of Treatment Restore contour and dimensions of trochlear notch Contoured dorsal plate Fixation of coronoid Bridge fragmention

74 Treatment Techniques

75 Mast and colleagues, 1989

76 Heim

77 Hastings

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89 Summary The LCL is more important than the MCL The ligaments will heal if you keep the elbow concentric, even when treated late Active motion adds to stability (avoid varus stress) Even small coronoid fractures can be a problem

90 Patterns of Traumatic Elbow Instability With Fracture DislocationOlecranon Fracture- Dislocations Posterior AnteriorDislocation+ radial head fracture Terrible Triad Dislocation Injuries Disruption Injuries Varus posteromedial rotational instability

91 Review Articles for Reference 1: Rodriguez-Martin J, Pretell-Mazzini J, Andres-Esteban EM, Larrainzar-Garijo R. Outcomes after terrible triads of the elbow treated with the current surgical protocols. A review. Int Orthop Jun;35(6): Epub 2010 May 8. Review. PubMed PMID: ; PubMed Central PMCID: PMC : Mathew PK, Athwal GS, King GJ. Terrible triad injury of the elbow: current concepts. J Am Acad Orthop Surg Mar;17(3): Review. PubMed PMID: : Ring D. Displaced, unstable fractures of the radial head: fixation vs. replacement--what is the evidence? Injury Dec;39(12): Epub 2008 Aug 13. Review. PubMed PMID: : Cheung EV. Chronic lateral elbow instability. Orthop Clin North Am Apr;39(2):221-8, vi-vii. Review. PubMed PMID: : Grace SP, Field LD. Chronic medial elbow instability. Orthop Clin North Am Apr;39(2):213-9, vi. Review. PubMed PMID: : Ring D. Instability after total elbow arthroplasty. Hand Clin Feb;24(1): Review. PubMed PMID: : Dipaola M, Geissler WB, Osterman AL. Complex elbow instability. Hand Clin Feb;24(1): Review. PubMed PMID: : Martin BD, Johansen JA, Edwards SG. Complications related to simple dislocations of the elbow. Hand Clin Feb;24(1):9-25. Review. PubMed PMID:

92 Review Articles for Reference 9: Tejwani NC, Mehta H. Fractures of the radial head and neck: current concepts in management. J Am Acad Orthop Surg Jul;15(7): Review. PubMed PMID: : Sotereanos DG, Darlis NA, Wright TW, Goitz RJ, King GJ. Unstable fracture-dislocations of the elbow. Instr Course Lect. 2007;56: Review. PubMed PMID: : Tashjian RZ, Katarincic JA. Complex elbow instability. J Am Acad Orthop Surg May;14(5): Review. PubMed PMID: : Bain GI, Ashwood N, Baird R, Unni R. Management of Mason type-III radial head fractures with a titanium prosthesis, ligament repair, and early mobilization. Surgical technique. J Bone Joint Surg Am Mar;87 Suppl 1(Pt 1): Review. PubMed PMID: : McKee MD, Pugh DM, Wild LM, Schemitsch EH, King GJ. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. Surgical technique. J Bone Joint Surg Am Mar;87 Suppl 1(Pt 1): Review. PubMed PMID: : Mehta JA, Bain GI. Posterolateral rotatory instability of the elbow. J Am Acad Orthop Surg Nov-Dec;12(6): Review. PubMed PMID:

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94 Thank you! Return to Upper Extremity Index OTA about Questions/Comments If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an to


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