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Lateral Elbow Instability Travis Marion, MD. MSc. BEd. Academic Half Day Apr 2012.

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Presentation on theme: "Lateral Elbow Instability Travis Marion, MD. MSc. BEd. Academic Half Day Apr 2012."— Presentation transcript:

1 Lateral Elbow Instability Travis Marion, MD. MSc. BEd. Academic Half Day Apr 2012

2 Outline Intro – definitions Anatomy Biomechanics Evaluation Mechanism of injury Acute  Terrible Triad –Fracture classification –Management –Reconstruction Priniciples –Outcomes Chronic  PRLI –Management –Outcomes

3 Anatomy

4 Proximal Ulna Greater sigmoid notch Lesser sigmoid notch Sublime tubercle Coronoid process

5 Anatomy

6 Coronoid Process Tip Body Anterolateral facet Anteromedial facet

7 Anatomy Radial Head Articulates –Capitellum –Radial notch Safe Zone 2

8 Anatomy MCL 21 Anterior bundle Posterior bundle Transverse

9 Anatomy LCL 19,20 RCL LUCL Accessory lateral collateral Annular

10 Biomechanics

11 Primary Stabilizers Ulnohumeral articulation 3 MCL LCL complex 4 Secondary Stabilizers Radial capitellar 4, 30 Joint capsule Common flexor/pronator and extensors –Compressive force Anconeus, triceps and bracialis –Rotatory stabilizer ECU, EDM

12 Evaluation

13 History –Severity –Mechanism –Precipitants –Chonic Inciting event Clicking/snapping/clunking/locking Apprehensive maneuver Past medical history Physical Acute –Inspection –Open vs closed –Alignment –Joint above and below –Detailed neurologic Physical Chronic –Full pain free ROM –Pain free stressing –Special tests Closed reduction Imaging –Radiographs pre/post reduction AP/Lat/Oblique –CT

14 Instability Classification

15 Classification 18 1)Timing (acute, chronic or recurrent) 2)Articulations (elbow vs radial head vs both) 3)Direction of displacement (valgus, varus, anterior, posterolateral rotatory) 4)Degree of displacement (subluxation or dislocation) – see slide 18 5)Simple or complex

16 Mechanism

17 Mechanism of Injury FOOSH, elbow extended Posteriorly directed force 3 Ulna levers out of trochlea Valgus stress/posterolateral roll out/supination 6 Capsuloligamentous failure lateral to medial, MCL anterior bundle last to rupture 6 Radial head, coronoid fx

18 Mechanism


20 Acute Traumatic Instability

21 Classification Simple Dislocations Capsuloligamentous injury No osseous injury Complex Dislocations Associated osseous injury

22 Patterns of Fracture Dislocation 1.Terrible Triad 2.Posterior dislocation of radial head 3.Varus posteromedial rotatory instability 4.Anterior olecranon fracture dislocations

23 Fracture Classification

24 Regan and Morrey 7 O`Driscoll 8 Fracture Classification


26 Traumatic Instability Terrible Triad 1 1.Elbow dislocation 2.Coronoid fracture 3.Radial head fracture

27 Management

28 Nonsurgical Concentrically reduced ulnohumeral and radiocapitellar Stable to allow sufficient ROM (extension to 30°) Congruency evaluated under fluoroscopically CT evaluation Radial head fx minimally reduced with no mechanical block Type I coronoid fracture Tx as simple dislocation –Splint at 90° –Isometric biceps/triceps

29 Management Surgical Incision –Advantages Posterior Access to medial and lateral Precludes requirement for secondary incision Reduced injury to cutaneous inervation 9 Improved cosmesis –Disadvanages Large flaps

30 Management Kocher Anconeus (radial) ECU (PIN) EDC split

31 Management No Replacement Pros –No healing required –Exposure to coronoid –Faster recovery Cons –Non anatomic –Overstuffing –Stiffness

32 Management Yes ORIF Pros –Anatomic –No overstuffing Cons –Non union –Malunion –Implant complications –PIN palsy

33 Management Yes One less incision No ulnar nerve dissection Amenable to ORIF vs suture technique Use targeting devices to aid in fixation positioning No Medial approach –Hotchkiss –Can address trochlear fractures Ulnar nerve dissection May address MCL if warranted

34 Management LCL Repair Origin at isometric point on lateral epicondyle Suture anchors vs bone tunnels Check anatomy Check stability If unstable repair the MCL Persistent instability = external fixator

35 Reconstruction Principles < 10% coronoid fractures little effect on stability 5 MCL repair more effective than coronoid repair 5 Most triads involve more than 10% MCL most important valgus stabilizer Requires radial head Radial head acts as buttress Radial head tensions LCL providing varus stability

36 Outcomes Pugh and McKee, 2002 Mean arc 20º and 135º Mean rotation 135º Delay in treatment or revision  20% greater loss of motion 25% revision Pugh et al, JBJS AM, patients, multicentred 112º flexion arc 136º rotation 15 excellent, 13 good, 7 fair, 1 poor 8 revisions (synostosis, instability, contracture release, wound infection) Prolonged immobilization worse prognosis

37 Outcomes Frothman et al, J Hand Surgery, patients 117º flexion arc Rotation 135º 77% excellent results Single surgeon, no MCL repairs Similar Findings Chemama et al, Orthop Traumatol Surg Res, 2010 Rodriguez-Martin et al, Int Orthop, 2011 Jeong et al, J Orthop Sci, 2010 Lindenhovius et al, J Hand Surgery 2008 Acute within 2 weeks (ave 6 days) vs subacute repair > 3 weeks (ave 7 weeks) No difference except 20º more flexion arc

38 Chronic Instability

39 Posterolateral Rotatory Instability Most common type of symptomatic instability First described 1991 Recurrent proximal radio-ulnar displacement Prox radius and ulna rotate externally in relation to the humerus Radioulnar joint intact and rotates as a single unit as opposed to isolated radial head dislocation

40 PRLI Failure of LCL complex –Trauma –iatrogenic –chronic attenuation 29 Physical exam –PRLI - analogous to pivot shift –Table top relocation test

41 PRLI Radiographs Avulsion of LCL complex Degenerative changes Faber/King lesion (post capitellum lesion analogous to hill sachs) Drop sign --. Ulnohumeral distance > 4mm on plane lateral

42 Management Avoid further ligamentous injury Arthrotomy anterior to LUCL, anterior capsular release Suture anchor vs lateral ligamentous reconstruction

43 Outcomes Jones et al, J Shoulder Elbow Surg, patients with purely ligamentous PRLI Surgical graft reconstructionr Mean f/u 7.1 years 75% resolution 25% occasional instability with ADLs Olsen and Sojberg, JBJS Brm 2003 Triceps tendon graft in 18 patients 4 persistent apprehension 5 moderate pain Sanchez-Sotelo et al, JBJS Br, patients, ligamentous repair, 32 reconstruction 5 persistent instability (3 from repaired, 2 from recon) 17 rated excellent 17 good 10 fair Similar Findings Lee and Teo, J Shoulder and Elbow, 2003

44 References 1 Hotchkiss, Rockwood and Green’s, Matthew et al, JAAOS, Mezera and Hotchkiss, Rockwood and Green’s, Schneeberger et al, JBJS AM, Beingessner et al, J Shoulder Elbow Surg, O’Driscoll et al, JBJS, Regan and Morrey, JBJS AM, O`Driscoll et al, Instr Course Lect, Dowdy et al, JBJS BR, Morrey et al, CORR, Pugh and McKee, Pugh et al, JBJS AM, Frothman et al, J Hand Surgery, Chemama et al, Orthop Traumatol Surg Res, Rodriguez-Martin et al, Int Orthop, Jeong et al, J Orthop Sci, Lindenhovius et al, J Hand Surgery O’Driscoll, CORR, Mehta and Bain, JAAOS, Imatani et al, Jshoulder Elbow Surg, 1999

45 References 21 Morrey and An, Clin Orthop, Cohen and Hastings, JBJS Am, Dunning et al, JBJS AM, O`Driscoll et al, JBJS, Jones et al, J Shoulder Elbow Surg, Sanchez-Sotelo et al, JBJS Br, Lee and Teo, J Shoulder and Elbow, Olsen and Sojberg, JBJS Br, Beuerlein et al, JBJS Am, Hall and McKee, JBJS, 2005

46 Questions

47 Nathan L Sacevich circa 1998 Future ambition: sports medicine doctor Most memorable experience: losing the soccer championship Nickname: Nate Dogg Closet friends: Mack Daddy, Mr Sauce, P Squared (no mention of Travis) Remembered by: his “stylo” (his style?) When no one was looking: he liked to get his thug on People thought: –he looked like a back street boy –“the illest playa”

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