Treatment of elbow instability: state of the art

The elbow is a congruent joint with high degree of inherent stability, provided by osseous and soft-tissue constraints; however, when substantial lesions these stabilising structures happen, instability the occurs. Significant improvements in surgical diagnosis treatment have been recently introduced both for acute chronic cases. Specific stress tests, clinical practice, different imaging techniques, static dynamic, allow assessment stabilisers detection direction mechanism even subtle forms. Many techniques standardised instruments devices, specifically dedicated to treatment, developed. rehabilitation protocols designed protect healing while minimising stiffness. However, despite progress, treatments can be challenging expert surgeons rate persistent instability, post-traumatic arthritis, stiffness pain still especially most demanding biology remains one important aspects future investigation. If research will help understand, correct or modulate biological response healing, our confidence management reproducibility tremendously improve. In this paper, state art current knowledge presented, focusing on modern used solve repair reconstruction damaged stabilisers. constraints.1Morrey BF An K-N Stability elbow: constraints.J Shoulder Elbow Surg. 2005; 14: S174-S17810.1016/j.jse.2004.09.031http://www.ncbi.nlm.nih.gov/pubmed/15726078Abstract Full Text PDF PubMed Scopus (131) Google Scholar, 2Safran MR Baillargeon D Soft-tissue stabilizers elbow.J S179-S18510.1016/j.jse.2004.09.032http://www.ncbi.nlm.nih.gov/pubmed/15726079Abstract (101) 3O'Driscoll SW Jupiter JB King GJ et al.The unstable elbow.Instr Course Lect. 2001; 50: 89-102http://www.ncbi.nlm.nih.gov/pubmed/11372363PubMed Scholar When occur, becomes unstable. more common than previously thought mildly symptomatic elbows hide forms instability. Treatment presents challenge balance opposing risks: progressive Especially severe forms, strategy requires an extensive anatomical biomechanical understand complex interactions between that are injured. has (bone, ligament capsular) dynamic (muscle) 4Morrey KN Articular ligamentous contributions stability joint.Am J Sports Med. 1983; 11: 315-31910.1177/036354658301100506http://www.ncbi.nlm.nih.gov/pubmed/6638246Crossref (636) 5King Morrey Stabilizers 1993; 2: 165-17410.1016/S1058-2746(09)80053-0http://www.ncbi.nlm.nih.gov/pubmed/22959409Abstract (96) (table 1).Table 1Based anatomy action, divided into capsular ligament) constraints. Based their effectiveness preserving primary secondary constrainersStaticStabilisersFunctionPrimary•Ulno-humeral joint: coronoid, olecranon trochlea•MCL (anterior bundle)•LuCL•Provides all planes, mostly <20° >120° flexion•Resists valgus PMRI•Resists PLRISecondary•Radio-humeral Joint: radial head, capitellum•Capsule•Common flexor origin•Common extensor origin•Resists PLRI varus stress•Provides PLRILuCL, lateral ulnar collateral ligament; MCL, medial PLRI, posterolateral rotatory instability; PMRI, posteromedial Open table new tab LuCL, There three stabilisers: ulno-humeral joint, (LCL) (MCL) (figure 1). LCL consists parts: (LuCL), (RCL) annular ligament.6Morrey Functional ligaments elbow.Clin Orthop Relat Res. 1985; : 84-90http://www.ncbi.nlm.nih.gov/pubmed/4064425PubMed 7Cohen MS Hastings H Rotatory elbow. role stabilizers.J Bone Joint Surg Am. 1997; 79: 225-23310.2106/00004623-199702000-00010http://www.ncbi.nlm.nih.gov/pubmed/9052544Crossref (74) LuCL effective part spans from epicondyle supinator crista ulna 2). MCL composed anterior bundle, posterior bundle transverse ligament. antero-inferior edge sublime tubercle 3).8Fuss FK human joint. Anatomy, function biomechanics.J Anat. 1991; 175: 203-212http://www.ncbi.nlm.nih.gov/pubmed/2050566PubMed 9Morrey Tanaka S Valgus A definition constraints.Clin 265: 187-195http://www.ncbi.nlm.nih.gov/pubmed/2009657PubMed 10Floris Olsen BS Dalstra M kinematics.J 1998; 7: 345-35110.1016/s1058-2746(98)90021-0http://www.ncbi.nlm.nih.gov/pubmed/9752642Abstract (134) ScholarFigure 2Lateral complex: (AL). (Copyright Dr Gregory Bain Max Crespi)View Large Image Figure ViewerDownload (PPT)Figure 3Medial (aMCL light blue) (pMCL) shown. (PPT) Primary constrainers provide main stability. lesion occurs stabiliser, if other constraints intact. stabilisers, support prevent Even they seriously injured, does not occur work synchrony resist various patterns instability: (PLRI) (an external dislocation radioulnar relation humerus, causing postero-lateral subluxation forearm complex), (PMRI) internal postero-medial stress, direct axial load. For prognosis it how restraints interact among specific 2).Table 2Based mechanism, same stabiliser differently involved cases, final result trauma depend amount energy involvedStabilisersResisting againstPLRIPMRIVarusValgusDirect posteriorU-H joint√√√√√LCL√√√MCL√√Radio-humeral joint√√√Capsule√√√√√Flexo-pronator muscle√√Extensor muscles√√LCL, LCL, combination history, physical examination diagnose Standard anteroposterior radiographic views mainstay initial diagnostic tool. necessary, CT scan 3D generally second-level examination. demonstrates presence incongruency involvement bony X-Rays do detail lesions, but often inferred. appropriate MRI valuable information regarding injuries including ligament, tendon lesions. also useful show osteochondral injuries, bone bruises oedema. Radiography, examinations therefore cannot identify recurrent instabilities.11Camp CL Smith O'Driscoll Posterolateral Part II. Supplementary techniques.Arthrosc Tech. 2017; 6: e407-e41110.1016/j.eats.2016.10.012http://www.ncbi.nlm.nih.gov/pubmed/28580260Abstract (10) Static radiographs fluoroscopy confirm instability.12Schnetzke Bergmann Wegmann K al.Determination laxity sequential injury model: cadaveric study.J 2018; 100: 564-57110.2106/JBJS.17.00836http://www.ncbi.nlm.nih.gov/pubmed/29613925Crossref (6) uncomfortable expose patient operator radiation. Evaluation under anaesthesia method certainly allows improved accuracy cases 3). Additional tools diagnosing ultrasound examination13Camp Wempe MK sonographic test validation study.Pm R. 9: 275-28210.1016/j.pmrj.2016.06.014http://www.ncbi.nlm.nih.gov/pubmed/27317917Crossref (11) 14DeMoss Millard N McIlvain G al.Ultrasound-assisted stability.J Ultrasound 37: 2769-277510.1002/jum.14631http://www.ncbi.nlm.nih.gov/pubmed/29655251Crossref (3) arthroscopy.15Holt Savoie FH Field LD al.Arthroscopic trauma.Hand Clin. 2004; 20: 485-49510.1016/j.hcl.2004.07.003http://www.ncbi.nlm.nih.gov/pubmed/15539103Abstract (15) 16Arrigoni P Cucchi D'Ambrosi R al.Intra-articular findings minor (SMILE).Knee Traumatol Arthrosc. 25: 2255-226310.1007/s00167-017-4530-xCrossref (24) 17van Riet RP Arthroscopic surgery simple dislocations.in: Eygendaal van Surgical sports related Springer, Berlin, Heidelberg2020Crossref (1) former dependent training experience, latter should performed only where subsequent indicated. reason, choice evaluation considered history resources available.Table 3Diagnostic provocation tests instability11Camp 87Karbach LE Elfar anatomy, biomechanics, maneuvers, testing.J Hand 42: 118-12610.1016/j.jhsa.2016.11.025http://www.ncbi.nlm.nih.gov/pubmed/28160902Abstract (29) ScholarDiagnostic testsInstabilityLesionTestSensitivityPLRILCLPosterolateral drawerMostLateral pivot-shiftGoodSupinated push-up tests: •Table top relocation•Prone push-up•Chair push-upHigh Good GoodValgusMCLValgus stressFairMilking manoeuvreGoodModified milking manoeuvreGoodMoving stressHighPMRIAntero-medial coronoid LCLGravity-assisted grindHighLCL, 4D tool assess throughout range motion.18Carr MacLean Slavotinek al.Four-dimensional computed tomography scanning wrist disorders: prospective analysis recommendations utility.J Wrist 2019; 8: 161-16710.1055/s-0038-1675564http://www.ncbi.nlm.nih.gov/pubmed/30941259Crossref Therefore, technique unmask instabilities at extremes motion. Provocation performed. We expect modalities (4D scan, position-sensing technologies movement analysis) widely future. some arthroscopic Arthroscopically, space appreciated, so tears possible intra-articular detected treated. there capsular/ligamentous tear, then open wider, manoeuvre 4). It point out medially force laterally varus. influenced and, case pronation due supination LuCL. positive drive-through sign may insufficiency pattern.19O'Brien MJ elbow.Sports Med Arthrosc Rev. 2014; 22: 194-20010.1097/JSA.0000000000000029http://www.ncbi.nlm.nih.gov/pubmed/25077750Crossref (19) With ‘drive through sign’ placing arthroscope gutter moving straight across articulation gutter: possible, evident directly observed inside scope portal.20Savoie O'Brien elbow.in: (0) flexed 30°, producing compression, manoeuvre, lift off fossa, open, tear adjacent epicondyle. little supination, without major force, bare area trochlear groove seen. just combined would indication bilateral reconstruction. Another typical suggestive 5): antero-medial portal, droops down neck gapping head. Tightening following adequate repair.20Savoie signs subtle: anteromedial synovitis, chondropathy head and/or aspect capitellum, antero-lateral capsule findings, which identified wet dry arthroscopy.21Bain Phadnis Mwaturura T Dry arthroscopy.in: Some currently investigation, described associated lateral-sided pain: ‘annular drive-through’ ‘R-LCL pull-up sign’.17van single entity. Rather, includes wide spectrum presentations.22O'Driscoll Korinek al.Elbow dislocation. instability.Clin 1992; 280: 186-197http://www.ncbi.nlm.nih.gov/pubmed/1611741PubMed accurate characterisation we need consider six parameters: 1.Timing: (a) forms: fractures fracture-dislocations; (b) elbow, basically reduced, depending applied partial complete dislocation; (c) statically dislocated reduce release.2.Involved ‘simple’ soft tissues involved; ‘complex’ involved.3.Aetiology: caused traumatic, overuse congenital, inflammatory, iatrogenic, post-infective disorders.4.Involved radio-humeral joint.5.Severity complete.6.Direction: conditions load, stress. Considering first two parameters, timing, classify patterns: acute, recurrent, persistent, persistent. Since 2015, classification followed Italian Surgeon Society (SICSeG).23Marinelli Guerra E Rotini able it? Review literature proposal all-inclusive system.Musculoskelet 2016; 61-7110.1007/s12306-016-0424-1http://www.ncbi.nlm.nih.gov/pubmed/27900701Crossref (8) This group traumatic isolated lesion. detachment epicondylar tendons (lateral medial) occur. Simple classified as posterior, divergent. Most adults, nearly always posterior. known PLRI24O'Driscoll Bell DF 73: 440-446http://www.ncbi.nlm.nih.gov/pubmed/2002081Crossref (608) 25Mehta JA GI Am Acad 12: 405-41510.5435/00124635-200411000-00005http://www.ncbi.nlm.nih.gov/pubmed/15615506Crossref (77) Scholar: falling hand extended, produces circular starts progressively involves capsule, until (Horii circle).3O'Driscoll 22O'Driscoll Stage 1: LucL temporary subluxation. Lesion adds injury. trochlea perched process. 3: previous sequentially MCL. completely dislocated. increasing severity involvement, stage 3 further divided: •Stage 3a: portion involved. Thanks integrity band after reduction maintain reduced centred full motion, keeping pronation.•Stage 3b: resulting postero-lateral, varus-valgus, avoiding last 30–45° extension.•Stage 3c: insertions add Complete stripping (ligaments, tendons) distal humerus uncontrollable hard control rotation using cast brace 6). More recently, past,26Søjbjerg JO Helmig Kjaersgaard-Andersen Dislocation experimental study injuries.Orthopedics. 1989; 461-463http://www.ncbi.nlm.nih.gov/pubmed/2710708Crossref 27Josefsson PO Johnell O Wendeberg B Ligamentous dislocations joint.Clin 1987; 221-225http://www.ncbi.nlm.nih.gov/pubmed/3301144PubMed several authors postulated might opposite direction, lateral, compression stress.28Schreiber JJ Potter HG Warren RF al.Magnetic resonance dislocation: insight mechanism.J 39: 199-20510.1016/j.jhsa.2013.11.031http://www.ncbi.nlm.nih.gov/pubmed/24480682Abstract (58) 29Robinson PM Griffiths Watts AC dislocation.Shoulder Elbow. 195-20410.1177/1758573217694163http://www.ncbi.nlm.nih.gov/pubmed/28588660Crossref (28) After reviewing scans, Robinson his belief side likely site origin tears30Robinson stabilization dislocation.in: 7). recent argued extremely injury, recognise damage complex, requiring treatment.31Cho C-H Kim B-S Rhyou IH al.Posteromedial relevant lesions: characteristics, patterns, treatments, outcomes.J 2066-207210.2106/JBJS.18.00051http://www.ncbi.nlm.nih.gov/pubmed/30516630Crossref Regardless occurs, same: reduction, (about 90%) treated conservatively, 10%) usually surgically. complication strong attitude treat injured capsule. emergency department, closed neurovascular carried sedation, lasting hours. supine prone position (if awake), arm extension gentle pressure tip proximal move distally anteriorly embrace trochlea, obtaining sensation, tactile, audible visual, reduction. assessed evaluating rotation. immobilisation programme guided residual evaluated clinically radiographically.3O'Driscoll permits congruency achieved rule articular fractures. repeated 1 week