Elsevier

Current Orthopaedics

Volume 22, Issue 2, April 2008, Pages 90-103
Current Orthopaedics

Mini-symposium: adult elbow problems
(iii) Elbow instability, mechanism and management

https://doi.org/10.1016/j.cuor.2008.04.007Get rights and content

Summary

Acute dislocations of the elbow without significant fracture are classified as simple. In all cases the medial and lateral ligaments are avulsed, usually as an osteo-periosteal sleeve. The majority are stable on reduction and immediate active mobilisation is encouraged. The incidence of recurrent dislocation and instability is very low. Acute dislocations associated with significant fractures are classified as complex. The most common associated fractures are of the radial head or coronoid process, and if both fractures are present this is termed the “terrible triad”. The principle of management is reduction of the joint, anatomical fixation of the fracture fragments, with repair or reconstruction of ligaments if indicated. If the elbow remains unstable, or if fracture or fixation or ligament repair is tenuous, then the use of a hinged external fixator is recommended.

The most common type of chronic instability is postero-lateral rotatory instability, which is related primarily to incompetence of the lateral ulnar collateral ligament. Conservative treatment is rarely successful and most require a reconstruction of the lateral ulnar collateral ligament with a graft. Medial instability is predominantly seen in throwing athletes with chronic stretch of the medial ligament that interferes with throwing capacity. If conservative management fails then the anterior bundle of the medial collateral ligament can be reconstructed with a tendon graft.

Introduction

Following the shoulder, the elbow is the most commonly dislocated joint in the body, and in children less than ten years old it is the most frequently dislocated articulation.1, 2 Chronic instability may occur as a result of a single event, such as a fall on an outstretched hand, or repetitive stress resulting in laxity.3 This article will concentrate predominately on instability in the adolescent and adult population.

Section snippets

Anatomy and stability of the elbow

Elbow stability is related to the inherent bony stability of the very congruent articular surfaces, and to the surrounding soft tissue stabilizers. These include the static soft tissue stabilizers, consisting of anterior and posterior capsule, both medial and lateral collateral ligaments, and the muscles crossing the elbow joint, which provide dynamic stability, compressing the irregular but congruous joint surfaces against each other.

Acute elbow dislocations

In a Swedish study of 178 acute elbow dislocations, Josefsson and Nilsson demonstrated a peak incidence in the 10–20 year old age group with approximately 10 dislocations per 100 000, and in the 50–60 year old age group an incidence of 4 per 100 000. The most commonly associated fracture affected the medial epicondyle (22), then radial head (17), lateral epicondyle (5), coronoid process (6), capitellum (4) and olecranon process (2). Three quarters of elbow dislocations in patients under 30

Posterolateral rotatory instability

In 1991 O'Driscoll introduced the term posterior lateral rotatory instability (PLRI) of the elbow to describe instability caused by injury predominately to the lateral ulnar collateral ligament (LUCL).11, 28 This is the most common form of recurrent post-traumatic instability of the elbow. PLRI is not a new problem, and a few studies and case reports prior to O'Driscoll describe this condition under the guise of recurrent dislocation of the elbow and radial head. In patients with PLRI the

Acute traumatic rupture of the medial ligament

This can occur following a severe valgus stress, as might occur in rugby or Australian rules football. In this situation the instability is clinically obvious with stress testing. There is usually severe bruising. The management depends on the status of the muscles of the flexor pronator origin. If they are intact then the torn ligament can be treated conservatively with a slab or cast for 2 weeks, followed up with a hinged brace for 6 weeks. If the flexor pronator muscles are ruptured this is

Late unreduced elbow dislocation

The chronically dislocated, or subluxed, elbow is a difficult problem often associated fractures of the coronoid process and/or radial head (Fig. 15). The ligaments, which have been avulsed predominately from the humeral attachments, together with the overlying musculotendinous envelope, heal in a displaced position posterior to the epicondyles. Operative treatment involves mobilization of this entire musculotendinous/ligamentous envelope from its displaced position. The elbow is then

Acknowledgement

The author would like to thank Mr A. Biggs of the Medical Illustration Department at The Robert Jones and Agnes Hunt Hospital for his help in producing figuresone and two for this article.

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