elbow instability and terrible triad
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Elbow instability and terrible triad
Adam C Watts Consultant Elbow and Upper Limb Surgeon, Wrightington
Hospital
Visiting Professor, University of Manchester
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Approach to instability
Understand anatomy
Pattern recognition
Algorithm for management
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Elbow Stability
Primary stabilisers MCL - anterior bundle Coronoid Lateral ligament complex Olecranon
Secondary stabilisers Radial head Common flexor and extensor origin Anterior capsule
Radial head Coronoid Lateral ligament complex MCL - anterior bundle Common flexor and extensor origin
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Joint Reaction Force
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Simple Elbow Dislocation
Posterior Anterior (2%) Divergent (Rare, High Energy)
8% Persistent instability (Anakwe 2010)
Predictors of instability?
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Simple Elbow Dislocation
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O’Driscoll CORR 1992;280:186-197
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Examination under anaesthesia
Varus/valgus stress test at 30 degrees
Pivot shift
3 gross valgus instability 2 additional varus instability
All 3 had avulsion medial ligament, common flexor origin and lateral ligament
Open stabilisation performed
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Medial Ligament Tear
Common Flexor Origin Avulsion
Anterior Capsule Tear
Lateral Ligament Tear
Common Extensor Tendon Avulsion
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Algorithm
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Clinical Exam & MRI
EUA
Surgical stabilisation
isolated MCL tear
Physio Rehab
MCL tear +
stable unstable
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Is PLRI part of simple dislocation?
Recurrent instability rare after simple dislocation 0% (Joseffson) to 8% (Anakwe)
In studies of PLRI only small proportion report previous simple dislocation
those reporting previous dislocation have recurrent frank dislocation (O’Driscoll, Olsen)
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Chronic Elbow Instability
Recurrent frank dislocation rare
PLRI
Valgus extension overload
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Posterolateral rotatory instability of the elbow
Most common chronic instability of elbow
Rotatory instability with incompetence of LUCL
Causes: Trauma Iatrogenic - steroid injection/surgery
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Presentation PLRI
Lateral elbow pain include in differential diagnosis for tennis elbow
Locking include in differential diagnosis for loose bodies
Recurrent elbow dislocation???
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PLRI
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Pivot Shift
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Elbow Instability Tests
Varus stress test
Push up test
Bench press
Hypersupination Test
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Expected outcome
91% Good or excellent outcome
Improved range of movement
11% risk of complication
8% risk of recurrent instability
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Valgus Instability
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Postero-medial Impingement
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Elbow Instability Tests
Varus/Valgus stress test
Milking manoeuvre
Moving valgus stress test
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Elbow fracture dislocations
1.Posterior rotatory a.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranon a.extension
b.flexion
3.Longitudinal
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Elbow fracture dislocations
1.Posterior rotatory a.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranon a.extension
b.flexion
3.Longitudinal
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Terrible TriadPosteromedial fracture dislocation
Ring Type 1Ring Type 3
Essex-Lopresti
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Posterior lateral rotation Terrible triad
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Terrible Triad algorithm
Restore coronoid
Restore radial head
Restore lateral soft tissue restraints
Restore medial soft tissue if still unstable
Apply hinged ex-fix
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Does the coronoid need to be fixed?
Cohort study of 14 consecutive patients (Level 4)
2 Regan-Morrey type I, 12 type 2
No coronoid fixation - Min f/u 24 months
Mean arc of motion 123°
DASH 14
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O’Driscoll Classification
12
3
from Ring et al.
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How do we manage the radial head?
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Radial Head ORIF
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Intracapsular Fracture
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Assessment of prosthesis length
Resected head height
Ulna variance
Proximal rim of PRUJ
Ulno-humeral joint line gapping
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Fix or Replace?
No difference in ROM (Level 4)
ORIF more likely to be unstable
33% risk of arthrosis with arthroplasty
Equivalent re-operation rates
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LCL Complex must be repaired
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Medial collateral ligament
Not fixing MCL is acceptable (Ring 2007)
Fix if having to go medially
If not leave it alone
Argument for decompression of ulnar nerve
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60°
110°
130°
40°
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Summary
Simple elbow dislocation rarely results in recurrent instability
PLRI is usually an isolated injury
Arthroscopic stabilisation if pivot shift negative
Otherwise open surgical stabilisation with graft
Terrible triad is not so terrible - follow rules
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Longitudinal - Essex-Lopresti
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“Hidden Injury” - IOM
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Tightrope Reconstruction
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Bone-ligament-bone graft
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Ligament Augmentation and Reconstruction System (LARS)
Polyester rope
Ultimate stress 2600N
Residual Strain at 2500N = 1.5%
Stiffness = 209N/mm (cf 129 native IOM)
No damage after 5 million cycles
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Experience to date
15 Procedures (chronic injuries) min follow-up 18
months
1 persistent axial instability - revised to OBF
No other recurrent proximal migration
Mean DASH improved 77 to 41/100
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Elbow fracture dislocations
1.Posterior rotatory a.pronation lateral rotation
b.pronation medial rotation
2.Trans-olecranon a.extension
b.flexion
3.Longitudinal
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Terrible TriadPMRI
Ring Type 1Ring Type 3
Essex-Lopresti