Mini-symposium: adult elbow problems(iii) Elbow instability, mechanism and management☆
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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The titles and authors were selected and co-ordinated by Mr S.M. Hay, Consultant Surgeon and Specialist in Shoulder and Elbow Surgery at the Robert Jones and Agnes Hunt Hospital, Oswestry, UK and The Royal Shrewsbury Hospital, Shrewsbury, UK