Adam J. Seidl, MD Assistant Professor University of Colorado School of Medicine Shoulder & Elbow Surgery Division of Sports Medicine and Shoulder

Transcription

1 Adam J. Seidl, MD Assistant Professor University of Colorado School of Medicine Shoulder & Elbow Surgery Division of Sports Medicine and Shoulder Surgery Division of Hand, Wrist, and Elbow Surgery

2 Anatomy and Biomechanics Spectrum of Instability Acute Instability Diagnosis Management Chronic Instability Diagnosis Management Old School State of the Art

3 Primary Stabilizers Ulnohumeral articulation MCL complex LCL complex Secondary Stabilizers Radial head Capsule Musculotendinous

4 Acute Elbow Instability Simple Elbow Dislocation Complex Elbow Dislocation Chronic Elbow Instability Posterolateral Rotatory Instability Valgus Elbow Instability

5 Simple vs. Complex Elbow Dislocation Simple Elbow dislocation without associated fracture Primarily a capsuloligamentous / soft tissue injury Post reduction radiographs reveal periarticular fractures in up to 60% of cases and operative exploration reveals high rate of osteochondral injuries Complex Elbow dislocation with associated fracture

6 Anterior Posterior ~ 90% Posterior Posteromedial Posterolateral Medial Lateral Divergent

7 Initial Evaluation Neurovascular examination Check DRUJ for Essex-Lopresti injury Reduction Longitudinal traction, gentle flexion Post reduction radiographs Evaluate ulnohumeral radioulnar and radiocapitellar joints, fractures Drop sign - widening of the ulnohumeral joint seen on the lateral radiograph Represents a subtle resting subluxation - frequently resolves spontaneously Post reduction management sling and early ROM can be initiated May need to splint for 1 week in position of support

8 56% of patients reported residual subjective stiffness of the elbow 8% reported subjective instability 62% reported residual pain The Satisfaction, DASH, and Oxford elbow scores showed good correlation with absolute range of motion in the injured elbow

9 Posterolateral Rotatory Terrible Triad Radial Head Coronoid Dislocation ligaments/capsule Posteromedial Rotatory Anteromedial coronoid LUCL Trans-olecranon

10 Surgical Approach Lateral/Medial vs global posterior If RHR remove Coronoid/ant capsule 1 st RH ORIF vs RHR 2 nd LCL 3 rd Assess stability unstable MCL

11 Surgical Approach Medial Approach Hotchkiss over the top -- small fractures Between FCU heads involve sublime tubercle Elevate Entire FCU very large fractures Lateral Approach LUCL Repair Protects fracture fixation Can be used in isolation in very small fractures

12 Surgical Approach Posterior Work Through the Fracture Restore Ulnar length, alignment, rotation Greater Sigmoid Notch Coronoid Process

13 Posterolateral Rotatory Instability Most common pattern Described by O Driscoll 1991 Deficient LCL Valgus Instability Microtrauma from repetitive activity > dislocation Overhead athletes

14 Diagnosis History often subtle Consider in refractory tennis elbow Exam unremarkable without provocative tests PLRI Test Chair Sign Imaging MRI

15 Treatment Open reconstruction of LUCL Kocher approach Palmaris autograft vs allograft (semi-t) Docking Figure of 8 Interference Screw State of The Art -- Arthroscopic

16 Diagnosis Anteromedial view during pivot shift Radial Head will translate posterior Drive-through sign insert video here Treatment Repair Acute > Chroic Plication -- Chronic

17 Technique Scope Proximal Posterolateral Sutures from distal to proximal Percutaneous suture retrieval and tying Results

18 Diagnosis Far less common that PLRI Overhead throwing athletes History Pain > Instability sx Loss of velocity + Ulnar nerve symptoms Exam Milking maneuver Moving valgus stress Imaging -- MRI

19 Surgical Treatment Reserved for high level thrower Technique numerus Jobe ASMI modification HSS Docking Cutting Edge Scope?

20 Diagnosis Can be used to verify Anteromedial portal Elbow at 60 degrees with valgus stress gapping Treatment Identify & address other pathology Osteophytes Loose bodies Anterior bundle of UCL hard to identify

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