In this scenario several operative techniques have been described including open collateral ligament repair or reconstruction [6], fixed or hinged external fixators [7] and trans-articular pinning [8, 9]. The mean length of triceps tendon available for use was 106 mm. 1–3 The longitudinal split in the triceps tendon is then closed with sutures. Anterior view of the graft in its final position. (12th Annual Meeting of the OTA); - Dislocation w/ Radial Head Frx - Dislocation + Medial Epicondyle Frx: - following closed reduction, the medial epicondyle fracture is classified with regard to displacement; The elbow is flexed so that the tip of the coronoid process is visible through the fossa. We have demonstrated that it is technically feasible and easy to perform with minimal equipment requirements or costs. Cases J. Unstable elbow dislocations and fracture-dislocations: Temporary transarticular fixation Cramer, Kathryn E. ; Moed, Berton R. ; Karges, David E. ; Watson, J. Tracy Journal of Orthopaedic Trauma: February 2000 - Volume 14 - Issue 2 - p 120 A randomized prospective study of 50 cases, Taylor F, Sims M, Theis JC, Herbison GP (2012), Interventions for treating acute elbow dislocations in adults, Maripuri SN, Debnath UK, Rao P, Mohanty K (2007), Simple elbow dislocation among adults: a comparative study of two different methods of treatment, de Haan J, Schep NW, Tuinebreijer WE, Patka P, den Hartog D (2010), Simple elbow dislocations: a systematic review of the literature, Islam S, Jahangir J, Manzur RM, Chowdury AA, Tripura N, das A (2012), Management of neglected elbow dislocations in a setting with low clinical resources, Primary ligament repair for elbow dislocation, Micic I, Kim SY, Park IH, Kim PT, Jeon IH (2009), Surgical management of unstable elbow dislocation without intra-articular fracture, Josefsson PO, Johnell O, Wendeberg B (1987), Ligamentous injuries in dislocations of the elbow joint, O’Driscoll SW, Morrey BF, Korinek S, An KN (1992), Elbow subluxation and dislocation. Clipboard, Search History, and several other advanced features are temporarily unavailable. Furthermore, the severity of injury to the ligaments being repaired may necessitate augmentation with free tendon graft or skeletal support with hinged external fixators. Management of unstable elbow fractures muscle groups, are any muscles crossing the elbow joint that exert a compressive force on the joint[1]. Most commonly, dynamic stabilisation is achieved with soft tissue repair or reconstruction or hinged external fixation. SICOT J, 1, 23, 1 This gives a calculated tendon length (1/2πD) of 53 mm for the intra-articular portion (B) of the graft. is review on elbow dislocations describes ligament and bone injuries as well as the typical injury mechanisms and the main classi cations of elbow dislocations. A small proportion of simple dislocations are grossly unstable and do not remain reduced with standard non-operative treatment. These bones are the arm bone (humerus) and two forearm bones (radius and ulna). Posterior dislocation of the elbow associated with fracture of the radial head and olecranon, and with medial collateral ligament disruption: A case report. Epub 2008 Aug 2. The technique was then performed on a single cadaveric elbow in which all ligamentous stabilisers were sequentially sectioned to mimic the clinical scenario of a grossly unstable elbow dislocation. Ligamentous repair of acute lateral collateral ligament rupture of the elbow, Outerbridge-Kashiwagi’s method for arthroplasty of osteoarthritis of the elbow—44 elbows followed for 8–16 years, Zantop T, Ferretti M, Bell KM, Brucker PU, Gilbertson L, Fu FH (2008), Effect of tunnel-graft length on the biomechanics of anterior cruciate ligament-reconstructed knees: intra-articular study in a goat model, Qi L, Chang C, Jian L, Xin T, Gang Z (2011), Effect of varying the length of soft-tissue grafts in the tibial tunnel in a canine anterior cruciate ligament reconstruction model, Long-term sequelae of simple dislocation of the elbow, Rafai M, Largab A, Cohen D, Trafeh M (1999), Pure posterior luxation of the elbow in adults: immobilization or early mobilization. The third part is in the bone tunnel in the coronoid process and is fixed at 15 mm. Mark Harris, Timothy Bishop, and Jason Bernard. These symptoms occur during the act of extension and supination, especially when an axial load is applied through the upper extremity.  |  Current treatment concepts of simple, that is, stable, or complex unstable elbow dislocations are outlined by means of case reports. In this rare situation operative treatment is indicated. Elbow Dislocation: Analysis of MR Images of Stable vs. Unstable Dislocation Chul-Hyun Cho 1, Beom-Soo Kim 1, Jaehyuck Yi 2, Hoseok Lee 3 and Du-Han Kim 1,* 1 Department of Orthopedic Surgery, School of Medicine, Keimyung University, Daegu 42601, Korea; oscho5362@dsmc.or.kr (C.-H.C.); BSKim@dsmc.or.kr (B.-S.K.) We believe that our novel technique elegantly avoids many of the problems associated with current methods. By Gregory J. Zeiders, DO, and Minoo K. Patel, MBBS, MS, FRACS Introduction omplex fracture-dislocations of the elbow can often be either irreducible or unstable, with an inability to hold the reduction or with the delayed development of sub- luxation or dislocation. This study evaluates the technique and results of temporary transarticular fixation of the unstable elbow, a previously unreported acute … Surgical management of unstable elbow dislocation without intra-articular fracture. Central strip of triceps tendon harvested and whip stitched. Following the reconstruction it was not possible to re-dislocate the elbow. The most common patient complaints/symptoms are recurrent popping, clicking, clunking, or locking, accompanied by a sense of instability in the elbow. KE Cramer. We would also advocate this technique in the “resource poor” environment. It does not prove clinical applicability of the technique or superiority to current conventional methods. This is primarily a feasibility study to demonstrate that our idea is technically possible. It has been shown that in unstable simple elbow dislocation most if not all the primary soft tissue stabilisers of the joint are ruptured . Poglia P, Wehrli L, Steinmetz S, Zermatten P. J Med Case Rep. 2016 May 11;10(1):121. doi: 10.1186/s13256-016-0904-9. This is often due to interposed soft tissues or alternatively to ligamentous instability. The graft tracked nicely in the trochlea grove with no impingement. In unstable elbow dislocation, PLDL and PMDL are caused by different mechanisms following damage to different structures. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. Patients with PLRI may present with a spectrum of different symptoms ranging from vague pain in the elbow to recurrent posterolateral dislocations. Acta Ortop Bras. already built in. There are three common ways that a shoulder can become unstable. This is exacerbated by prolonged immobilisation following dislocation and is associated with poorer outcomes than early functional rehabilitation [14–17]. Only 2 mm of joint distraction and 10 degrees of varus or valgus angulation were possible with the triceps graft fixed in position. This represents the diameter of our proposed osseo-tendonous ring. Please enable it to take advantage of the complete set of features! In all the elbows there was sufficient triceps tendon length to perform the technique. Int Orthop. Epub 2012 Dec 18. A severe first dislocation can lead to continued dislocations, giving out, or a feeling of instability. Cite this article as: Harris M, Bishop T & Bernard J (2015) Unstable elbow dislocations: the description and cadaveric feasibility study of a new surgical technique. (2001) The unstable elbow. Shoulder dislocation—Severe injury, or trauma, is often the cause of an initial shoulder dislocation.  |  The elbow is the second most frequently dislocated large joint. Thus the joint is stabilised and a normal relationship between the ulna and the elbow axis of rotation is maintained throughout a full range of motion. 2008 Sep 19;1(1):168. doi: 10.1186/1757-1626-1-168. We measured the displacement and angulation possible at the elbow before and after the reconstruction. When the head of the humerus dislocates, the socket bone (glenoid) and the ligaments in the front of the shoulder are frequently injured. Complex fracture-dislocations of the elbow are treated surgically and are challenging injuries to manage. Simple elbow dislocations are usually treated conservatively. However, there is no single protocol to guide the surgeon on which structures should be repaired and in what order. NLM In 3B the anterior bundle is ruptured and in 3C the elbow remains unstable after reduction even in 90 degrees of flexion [22]. The pathomechanics of dislocation proposed by Horii describes sequential failure of the soft tissues from lateral to medial. Elbow stability must be restored by addressing the specific components of the injury. Hinged external fixators must be applied exactly aligned with the axis of rotation of the joint and are associated with high rates of complications, particularly infection [25]. The amount of soft tissue injury to the flexor-pronator and extensor origins is correlated with the instability of the elbow and likelihood of the elbow to redislocate [ 1 ]. This site needs JavaScript to work properly. Does the period of immobilization affect the eventual results? The vast majority of simple dislocations can be reduced closed with sedation and will remain reduced and stable [4]. Initially we believe that the most appropriate role for this procedure is on the cohort of patients who would currently be considered unsuitable for dynamic ligamentous repair or external fixation. 2009 Aug;33(4):1141-7. doi: 10.1007/s00264-008-0624-x. Home; About Journals. Elbow stability must be restored by addressing the specific … In stage 1, the lateral collateral ligament is partially or completely disrupted (the ulnar part is disrupted). EPIDEMIOLOGY AND TREATMENT OF MONTEGGIA LESION IN ADULTS: SERIES OF 44 CASES. Good results have been reported [19, 20]. Elbow dislocation which required an extension block splint over 45°to maintain reduction was considered as an unstable elbow dislocation as previously described by Morrey and O'Driscoll [15, 21]. The elbow is the second most commonly dislocated joint in adults[2]. We describe a new intra articular reconstruction that utilises a slip of triceps tendon to provide immediate stability to the elbow. Management of simple elbow dislocations. This technique utilises the harvest of a central strip of triceps tendon which is distally based and remains attached at its insertion. This type of injury can damage the bone and ligaments that surround the elbow joint and work to keep it stable. A small proportion of simple dislocations are grossly unstable and do not remain reduced with standard non-operative treat- ment. Ozel O et al. The incidence of simple elbow dislocations is 5–6 per 100,000 . SW17 0QT UK. Department of Orthopaedic surgery, St Georges NHS Foundation Trust Blackshaw Road Tooting, London the display of certain parts of an article in other eReaders. The free ends of the whip stitch are passed through the fenestration in the olecranon fossa and through the tunnel in the ulna with the aid of a suture passer. Discussion: This novel technique elegantly avoids many of the problems associated with current methods. et al. Stage 3 is rupture of the medial collateral ligament and is divided into three. The proximal ulna must be anatomically reduced and internally fixed, the radial head must be repaired or replaced, and substantial coronoid fractures must be repaired or reconstructed. In unstable elbow dislocation, PLDL and PMDL are caused by different mechanisms following damage to different structures. Seventeen patients with a posterior dislocation of the elbow and either no fracture or a minimal capsuloligamentous avulsion fracture were treated operatively for persistent redislocation after manipulative reduction. In 3A the posterior bundle of the medial ulnar collateral ligament (MUCL) is ruptured but the anterior bundle is intact. Methods: We assessed 20 cadaveric elbows, measuring the length of triceps tendon available and required to complete the reconstruction. Elbow Dislocation / Instability. Results are generally good, although a small percentage of patients may develop chronic instability. In addition, the graft remains attached to its insertion on the olecranon and remains vascularised. Static stabilisation of the elbow is relatively technically simple and has been described with the use of external fixation or trans-articular pinning. Broadly speaking these can be divided into techniques which maintain the reduction by static or dynamic means. The torn ligament in the front of the shoulder is commonly called a Bankart lesion. The primary disadvantage of this static approach is in the tendency of the elbow to stiffen following severe injury. Micic I, Kim SY, Park IH, Kim PT, Jeon IH. Complex and Unstable Simple Elbow Dislocations: A Review and Quantitative Analysis of Individual Patient Data. It has been shown that in unstable simple elbow dislocation most if not all the primary soft tissue stabilisers of the joint are ruptured [21]. Therefore, different strategies are needed to ameliorate the dislocation and instability. "Terrible Triad" injury describes unstable joint consisting of: Elbow dislocation; Radial head fracture; Coronoid fracture; Clinical Features. Fracture-dislocations of the elbow are devastating injuries. These patients are typically offered trans-articular pinning or non-operative treatment and it is in this setting that we believe our new technique will offer them most advantage. Stage 1 begins with the lateral collateral ligament complex (LCLC) which is comprised of the lateral ulnar collateral ligament (LUCL), the radial … The tendon strip is divided proximally at the musculotendonous junction and longitudinally to its insertion. Instr Course Lect 50:89–102. Most simple elbow dislocations can be reduced closed with sedation and will remain reduced and stable. A posterior longitudinal incision is made from the tip of the olecranon and extended 10 cm proximally. Introduction: A small proportion of simple elbow dislocations are grossly unstable and joint congruence is not maintained after reduction. The elbow is the second most commonly dislocated major joint in the body after the shoulder, with an annual incidence of 6.1 dislocations per 100 000 population. Patterns of unstable fracture-dislocations include the "terrible triad" injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture), transolecranon fracture-dislocations, and the posterior Monteggia lesion. Therefore, different strategies are needed to ameliorate the dislocation and instability. Three bones come together to make up the elbow. There is no need for metal insertion or its subsequent removal. The lateral ulnar collateral ligament and extensor origin reattachment can be easily performed. Acute Simple Elbow Dislocations . Browse by Title Browse by Subject Journal Indexing. The importance of the anterior band of the MUCL and the LUCL has been highlighted by O’Driscoll [23]. This review on elbow dislocations describes ligament and bone injuries as well as the typical injury mechanisms and the main classifications of elbow dislocations. There are potential drawbacks specific to this technique. The posterior olecranon fossa is cleared and a fenestration is made with a 4 mm drill to access the anterior joint space (Figure 3). Elbow held in 45 degree of flexion; Olecranon is prominent posteriorly The next critical step is to intraoperatively assess the stability of the elbow with a range-of-motion assessment with the forearm in pronation. We chose 15 mm as the length of graft in the tunnel because this has been reported as a safe length in anterior cruciate ligament reconstruction [11, 12]. Swelling may be severe; Displaced equilateral triangle of olecranon and epicondyles (undisturbed in supracondylar fracture) Posterior dislocation. Elbow instability is a “looseness” in the elbow joint that may cause the joint to catch, jam, pop, or slide out of place during certain arm movements. Søjbjerg JO, Helmig P, Kjaersgaard-Andersen P (1989) Dislo- cation of the elbow: an … Ligamentous repair can be indicated in high demand patients or if the elbow remains unstable following a closed reduction. The dislocation is classified as simple or complex depending on the presence or absence of an associated fracture [1]. A 4 mm tunnel is then drilled beginning at the tip of the coronoid process and traversing the ulna to exit through the dorsal cortex of the ulna (Figure 4). ### Pathoanatomy The pathoanatomy of an elbow dislocation can be thought of as a disruption of the circle of soft tissue or bone, or both, that begins on the lateral side of the elbow and progresses to the medial side in three stages (Fig. Prior to the reconstruction greater than 30 mm of joint distraction and 90 degrees varus or valgus angulation was possible. The length of B is assumed to be half the circumference of the ring (1/2πD). The tendon is pulled through the tunnel, tensioned and fixed by tying the whip stitch through a transverse 2.5 mm drill hole in the ulna. The triceps tendon may be at risk of donor site morbidity including pain and weakness similar to that seen following patella tendon harvest for ACL reconstruction [27]. [26] Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Despite reduction and fixation of associated fractures, significant soft-tissue injury that occurs as a result of dislocation may result in residual instability. Gently move elbow through its range of motion. The pathomechanics of dislocation proposed by Horii describes sequential failure of the soft tissues from lateral to medial. The OK method has a reported risk of distal humerus fracture [28] and heterotopic ossification [29]. Prior to the reconstruction gross elbow instability was demonstrated. In an unstable simple elbow dislocation, the elbow joint is not congruent or subluxes after reduction, or requires more than a 45° extension block to maintain reduction. A spectrum of instability, Armstrong AD, Ferreira LM, Dunning CE, Johnson JA, King GJ (2004), The medial collateral ligament of the elbow is not isometric: an in vitro biomechanical study, Complications of hinged external fixation compared with cross-pinning of the elbow for acute and subacute instability, Elbow dislocation with complete triceps avulsion, Rosenberg TD, Franklin JL, Baldwin GN, Nelson KA (1992), Extensor mechanism function after patellar tendon graft harvest for anterior cruciate ligament reconstruction, Heterotopic ossification after the Outerbridge-Kashiwagi procedure in the elbow, http://creativecommons.org/licenses/by/4.0. It most often occurs as a result of an injury — typically, a previous elbow dislocation. 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