elbow instability adam watts
TRANSCRIPT
Elbow instabilityAdam 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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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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Summary
Simple elbow dislocation usually has good outcome
Recurrent true dislocation is rare
PLRI most common recurrent instability
Consider all elements for stability
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