Complex Elbow Instability

Abstract

Complex elbow instability consists of dislocation of the ulnohumeral joint with a concomitant fracture of one or several of the bony stabilizers of the elbow, including the radial head, proximal ulna, coronoid process, or distal humerus. Recurrent instability is not often associated with simple dislocation, but an improperly managed complex dislocation may be a prelude to chronic, recurrent elbow instability. Complex instability is significantly more demanding to manage than simple instability. Radial head, coronoid, and olecranon fracture associated with dislocation each must be assessed and often require surgery. Longterm outcome with surgical management of complex elbow injuries is unknown. A few published series examine combinations of different injury patterns managed with various methods. Recently, however, several well-designed prospective outcome studies have evaluated management of several different individual fracture-dislocation patterns with a unified treatment algorithm. Fixation or replacement of injured bony elements, ligamentous repair, and hinged fixation may be used to successfully manage complex elbow instability. E lbow instability may occur after any one of a large group of diverse injuries, such as a fall on an outstretched hand, motor vehicle accident, or direct trauma, resulting in fractures or dislocations. Instability may be categorized anatomically as simple (with no associated fracture) or complex (with associated fracture) or chronologically as acute, chronic, or recurrent. These categories are not mutually exclusive. The elbow is one of the most commonly dislocated joints in the body, with an average annual incidence of acute dislocation of 6 per 100,000 persons. 1 Simple dislocations, which are much more common than complex dislocations, are described by the direction of the dislocated ulna. Posterolateral dislocation is the most common simple dislocation. 2 Complex dislocations may include fracture of the radial head, coronoid process, olecranon, or distal humerus. The risk of recurrent or chronic instability and posttraumatic arthrosis is increased significantly with complex dislocation. 3,4 Chronic unreduced dislocations and recurrent instability in complex injuries are very difficult to manage. In addition to surgical intervention, they often require the use of a hinged external fixator to hold the elbow in a reduced position. 5,6 Early clinical series laid the groundwork for understanding the natural history of fractures of the coronoid process and radial head with and without associated dislocation. 1,3,4,7-9 Recent clinical research has focused on outcomes of

Coronoid Fixation Using Suture Anchors

“…Small coronoid tip fractures or anteromedial facet fractures may be repaired with suture fixation either alone or supplemented with one to two screws [2,[14][15][16]22]. Various techniques have also been described for osteosynthesis of larger fractures.…”

“…Various techniques have also been described for osteosynthesis of larger fractures. Acute treatment may consist of fixation with sutures through drill holes, threaded K-wires, cannulated screw fixation, plate and screw fixation, or buttress plating, all performed through a medial or posterior approach [2,3,7,9,10,12,[14][15][16][17][18]22]. In cases of significant comminution, supplemental fixation may be obtained using additional screws, a second plate, suture, threaded wires, or suture anchors [2,9,10,14].…”

“…Repair of coronoid fractures has been described from lateral, medial [8,10,11,15,16,22], posterior [7, 10-12, 15, 22], and anterior [21] approaches, as well as a combination of these [17]. Treatment of transverse fractures of the coronoid tip in the case of terrible triad injuries can be achieved through a lateral exposure by using a small extension of the existing capsuloligamentous and muscular damage and retracting the radial head out of the way [2, 7, 10-12, 14-16, 22].…”

“…These sutures may be placed through drill holes in the fracture fragment when it is large enough or used to engage the capsular attachment otherwise [7, 10-12, 14, 15, 22]. The sutures are then secured to the proximal ulna through drill holes from the dorsal surface to the bed of the coronoid fracture near the joint using a Keith needle, suture passers, or some similar device [7,11,12,14,15,22]. The repair of coronoid fractures with suture anchors as outlined above provides an additional technique in management of these demanding injuries.…”

Bandinstabilitäten am Ellenbogengelenk

“…Seltener findet man auch isoliert radiale und ulnare sowie ven trale und divergierende Luxationen [7]. Ausgehend von der Ringtheorie von O'Driscoll et al [14], welche sich auf bio mechanische Untersuchungen stützt [12,13,14] [9,8,18,19].…”