Elbow dislocation

anatomy of elbow and elbow dislocation

1. ELBOW DISLOCATION Dr. HARSHA NANDINI TALASILA M.S ORTHO

2. Incidence :11 to 28%of elbow injuries POSTERIOR DISLOCATION is common

3. ANATOMY OF ELBOW JOINT Modified Hinge joint ULNOTROCHLEAR(HINGE) RADIOCAPITELLAR JOINT(ROTATION) PROXIMAL RADIOULNAR(ROTATION)

4. CAPSULOLIGAMENTOUS ANATOMY The static soft tissue stabilizers the anterior and posterior joint capsule the medial and LCL complexes. The collateral ligament complexes are medial and lateral capsular thickenings

5. MCL COMPLEX 3 components: the anterior bundle or anterior MCL, the posterior bundle, the transverse ligament The origin of the MCL is at the anteroinferior surface of the medial epicondyle.

6. LCL COMPLEX four components radial collateral ligament, the lateral ulnar collateral ligament, the annular ligament, the accessory collateral ligament The LCL complex originates along the inferior surface of the lateral epicondyle.

7. STABILITY OF ELBOW JOINT ANTERO-POSTERIOR TROCHLEAR-OLECRANON PROCESS : during extension. RADIO-CAPITELLAR,CORONOID FOSSA,BICEPS-TRICEPS-BRACHIALIS: during flexion.

8. VALGUS: MEDIAL COLLATERAL LIGAMENT COMPLEX: Anterior Band: in flexion and extension Anterior capsule in extension

9. VARUS: The lateral ulnar collateral ligament is static stabilizer Anconeus : dynamic stabilizer

10. NORMAL ROM FLEXION:0-150 degrees SUPINATION:80 degrees PRONATION: 85 degrees

11. MECHANISM OF INJURY Fall on outstretched hand or elbow: levering force to unlock the olecranon from the trochlea

12. POSTERIOR DISLOCATION Combination of Elbow hyperextension, valgus stress, arm abduction, forearm supination

13. ANTERIOR DISLOCATION A direct force strikes the posterior forearm with the elbow in a flexed position

14. HORI CIRCLE The capsuloligamentous injury progresses from lateral to medial

15. CLINICAL FEATURES Pain and Swelling of the elbow Careful neurovascular assessment must be done. 3 point bony relationship is lost.

16. ASSOSCIATED INJURIES Radial head Coronoid process of ulna Ulnar nerve Anterior interosseous branch of median nerve Brachial artery

17. RADIOGRAPHIC EVALUATION AP AND LATERAL VIEW VALGUS STRESS VIEW:30degrees elbow flexion,full forearm pronation To see MCL ligamentous complex injury

18. CLASSIFICATION Simple: no assosciated fractures or ligamentous injuries Complex: assosciated with ligamentous injury

19. BASED ON DIRECTION POSTERIOR POSTERIOMEDIAL ANTERIOR LATERAL MEDIAL

20. FRACTURE-DISLOCATION Assosciated radial head fractures Medial and lateral epicondyle fractures Coronoid process

21. ELBOW INSTABILITY MORREY’S INSTABILITY SCALE: Type 1:posterolateral rotational instability: lateral ulnar collateral ligament disrupted. Type 2: perched condyles, Varus instability, lateral ulnar collateral ligament,anterior and posterior capsule disrupted Type 3a: posterior dislocation : valgus instability; lateral ulnar collateral, anterior and posterior capsule and posterior MCL disrupted Type 3b: posterior dislocation: lateral ulnar collateral, anterior and posterior capsule and posterior MCL and anterior MCL disrupted

22. TREATMENT

23. PARVIN’S METHOD Patient in prone Gentle downward traction of the wrist for few minutes As the olecranon fossa begins to slip distally, physician lifts up gently on arm.

24. MEYN and QUIGLEY’S Method Only forearm hangs from the stretcher. Gentle downward traction of the wrist with reduction of the olecranon with the opposite hand.

25. Elbows that are stable through out ROM : splint at 90degrees flexion for 3 to 5 days followed by placement of hinged orthoses ,which allows for a protected full ROM. Subluxation or impending dislocation at 30 degrees or more flexion indicates instability and surgical stabilization is needed.

26. If instability is present in less than 30 degrees of elbow flexion, one should pronate the forearm and reassess the stability. If pronation confers elbow stability, the extremity should be splinted with the elbow flexed 90degrees and the forearm pronated for 3 to 5 days followed by hinged orthoses that maintains forearm pronation. Elbows that sublux in less than 30 degrees of flexion and full forearm pronation : splint the elbow in flexion at 90 degrees and forearm pronated ,followed by placement of hinged orthoses with forearm rotational control and an extension block

27. OPERATIVE MANAGEMENT INDICATIONS: When the elbow cannot be held in a concentrically reduced position, redislocates before post reduction x-rays, dislocates later in spite of splint immobilization, the dislocation is deemed unstable. A large displaced coronoid fragment. Radial head fractures.

28. Open reduction and repair of the soft tissues Lateral collateral ligament is reattached using suture anchors or bone tunnels If instability is present after LCL repair then MCL repair must be addressed. If persistent instability is present: HINGED EXTERNAL FIXATION is done.

29. TERRIBLE TRIAD OF ELBOW

30. TREATMENT OF TERRIBLE TRIAD PRINCIPLES OF TREATMENT: Restore coronoid stability through fracture fixation of type 2 and type 3 fractures, through anterior capsular repair of type 1 fracture Restore radial head stability through fracture fixation or replacement with a metal prosthesis. Restore lateral stability through repair of the lateral collateral ligament complex and associated secondary constrains such as common extensor origin and or posterolateral capsule.

31. Repair the medial collateral ligament in patients with posterior instability Apply a hinged external fixator when the conventional repair does not establish sufficient joint stability to allow early motion.

32. FIXATION STRATEGY From deep to superficial Fixation of coronoid Anterior capsule repair Radial head fixation or replacement Lateral collateral ligament repair Common extensor origin reattachment.

33. COMPLICATIONS Loss of motion(stiffness of elbow) Neurologic compromise: ulnar nerve Exploration is done if there is no recovery after 3months Vascular injury: brachial artery Compartment syndrome( Volkmann contracture ) Persistent instability/ redislocation Arthrosis

34. Heterotopic bone/ Myositis ossificans SITE: Anteriorly :between brachialis muscle and anterior capsule Posteriorly: between triceps and posterior capsule CAUSE: Due to multiple reduction attempts A greater degree of soft tissue trauma Associated fractures

35. REFERENCES: Kenneth A Egol , Kenneth J Koval,Joseph D Zuckerman Handbook of fractures. Campbell’s Operative Orthopaedics,volume 3,13 th edition

36. THANK YOU