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

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
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
4 simple dislocation
4 post-op terrible triad
Program
Active rehab
Avoid varus stress
Results
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. Chronic Simple Elbow Dislocation
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

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

33. Patterns of Traumatic Elbow Instability With Fracture
Dislocation+ radial head fracture
Anterior
Posterior
Terrible Triad
Dislocation
Olecranon Fracture-Dislocations
Varus Posteromedial Rotational Instability
Few Exceptions

34. Dislocation vs. Disruption

35. Dislocation vs. Disruption

36. Dislocation vs. Disruption

37. Dislocation vs. Disruption

38. Disruption

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

40. Posterior Dislocation + Radial Head Fracture

41. Posterior Dislocation + Radial Head Fracture
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

44. Posterior Dislocation + Radial Head Fracture

45. Posterior Dislocation + Radial Head Fracture

46. Posterior Dislocation + Radial Head Fracture

47. Posterior dislocation Radial head fracture Coronoid fracture
Terrible Triad
Posterior dislocation Radial head fracture Coronoid fracture

48. Posterior dislocation Radial head fracture Coronoid fracture
Terrible Triad
Posterior dislocation Radial head fracture Coronoid fracture

49. Posterior dislocation Radial head fracture Coronoid fracture
Terrible Triad
Posterior dislocation Radial head fracture Coronoid fracture

50. Posterior dislocation Radial head fracture Coronoid fracture
Terrible Triad
Posterior dislocation Radial head fracture Coronoid fracture

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

52. Terrible Triad Ring, Jupiter, Zilberfarb JBJS 2002 11 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):

57. Regan and Morrey

62. O’Driscoll Classification1 3 2

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

70. Anterior (Trans-Olecranon Fracture-Dislocation of the Olecranon

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

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

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

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
Dislocation+ radial head fracture
Anterior
Posterior
Terrible Triad
Dislocation
Olecranon Fracture-Dislocations
Varus posteromedial rotational instability
Dislocation Injuries
Disruption Injuries

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:

94. Thank you!
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