David Ring, MD PhD Massachusetts General Hospital Boston, Massachusetts May 2011

1. Traumatic Elbow Instability David Ring, MD PhD Massachusetts General Hospital Boston, MassachusettsMay 2011

2. Simple Elbow Dislocation Definition • Dislocation of the elbow • No associated fractures

3. Simple Elbow Dislocation What’s Injured? • Both collateral ligaments • Variable amount of muscle origin • Greater instability with greater muscle injury Studies of routine operative treatment • Joseffson and colleagues • Durig and colleagues

4. Simple Elbow Dislocation What’s Injured? • Shawn O’Driscoll • Injury progression from lateral to medial • The anterior band of the MCL is the last structure torn • Elbow can dislocate with the anterior band of the MCL intact

5. Simple Elbow Dislocation Treatment • No more than 2 weeks of cast immobilization • Early active use and exercises Melhoff and colleagues Protzman and colleagues

6. Simple Elbow Dislocation Duckworth A, Ring D, McKee M, JSES 2008: Active exercises for slight subluxation after elbow dislocation • 19 patients • 4 simple dislocation • 4 post-op terrible triad • Program • Active rehab • Avoid varus stress • Results • All achieved stable, functional elbow

7. Simple Elbow Dislocation Summary • Complete ligamentous injury in most patients • Elbow can dislocate with MCL intact • Early motion is key • Early active motion can accommodate for slight subluxation

8. Simple Elbow Dislocation Unstable Simple Elbow Dislocation • Mentioned rarely in literature—Is it uncommon?

9. Simple Elbow Dislocation Unstable Simple Elbow Dislocation

10. Simple Elbow Dislocation Unstable Simple Elbow Dislocation

11. Simple Elbow Dislocation Unstable Simple Elbow Dislocation

12. Simple Elbow Dislocation Unstable Simple Elbow Dislocation

13. Simple Elbow Dislocation Unstable Simple Elbow Dislocation

14. Simple Elbow Dislocation Unstable Simple Elbow Dislocation

15. Simple Elbow Dislocation Unstable Simple Elbow Dislocation • Duckworth A, Ring D, McKee M. JSES 2008 • Uncommon, but not rare • older women, low energy injury • young men, high energy injury

16. Simple Elbow Dislocation Unstable Simple Elbow Dislocation • Treatment • Ligament repair • Hinged External Fixation • Cross pinning

17. Simple Elbow Dislocation Unstable Simple Elbow Dislocation • Treatment: Ligament repair

18. Simple Elbow Dislocation Unstable Simple Elbow Dislocation • Treatment: Hinged external fixation

19. Simple Elbow Dislocation Chronic Simple Elbow Dislocation

20. Chronic Simple Elbow Dislocation • Historical Treatment Suggestions

21. Chronic Simple Elbow Dislocation Jupiter and Ring JBJS 2002 • Treatment: Open reduction and hinged external fixation • 5 patients: dislocated for 2 to 9 months • Stable elbow, > 100 degrees motion in all patients

22. Medial Collateral Ligament Insufficiency • Throwing athletes • Chronic attenuation • Inability to throw 95 mph fastballs

23. Medial Collateral Ligament Insufficiency

24. LCL Insufficiency Recurrent Simple Elbow Dislocation • Osborne and Cotterill JBJS B 1966 • O’Driscoll and colleagues JBJS A 1991 • Insufficiency of the lateral collateral ligament

27. LCL Insufficiency Recurrent Simple Elbow Dislocation • Treatment: LCL reconstruction with tendon graft

28. Traumatic Elbow Instability Associated with Fractures

29. Definition • Fracture-dislocation of the elbow • Dislocation of the elbow • Intra-articular fracture

30. Definition • Fracture-dislocation of the elbow • Dislocation of the elbow • Intra-articular fracture

31. Definition • Fracture-dislocation of the elbow • Dislocation of the elbow • Intra-articular fracture

32. Definition • Traumatic Elbow Instability • Combination of fractures and ligament injuries that destabilize the elbow

33. Patterns of Traumatic Elbow Instability With Fracture Dislocation+ radial head fracture Anterior Posterior Terrible Triad Dislocation Olecranon Fracture-Dislocations Varus Posteromedial Rotational Instability Few Exceptions

34. Dislocation vs. Disruption Dislocation Disruption

35. Dislocation vs. Disruption Dislocation Disruption

36. Dislocation vs. Disruption Dislocation Disruption

37. Dislocation vs. Disruption Dislocation Disruption

38. Disruption

39. Patterns of Traumatic Elbow Instability With Fracture Dislocation+ radial head fracture Anterior Posterior Terrible Triad Dislocation Olecranon Fracture-Dislocations Varus posteromedial rotational instability Dislocation Injuries DisruptionInjuries

40. Posterior Dislocation + Radial Head Fracture

41. Posterior Dislocation + Radial Head Fracture • 24 patients • Ulnohumeral dislocation with radial head fracture • Cast 1 month +/- radial head resection • “Results better than generally thought” • Secondary procedures for radial head • No problems with instability

42. Posterior Dislocation + Radial Head Fracture • 23 patients • Excision of radial head and cast • INSTABILITY in patients with CORONOID fractures (4 patients)

43. Posterior Dislocation + Radial Head Fracture

44. Posterior Dislocation + Radial Head Fracture

45. Posterior Dislocation + Radial Head Fracture

46. Posterior Dislocation + Radial Head Fracture

47. Terrible Triad • Posterior dislocation • Radial head fracture • Coronoid fracture

48. Terrible Triad • Posterior dislocation • Radial head fracture • Coronoid fracture

49. Terrible Triad • Posterior dislocation • Radial head fracture • Coronoid fracture

50. Terrible Triad • Posterior dislocation • Radial head fracture • Coronoid fracture