Elbow Instability

Introduction

Often mistaken for arthritis and tendonitis because of symptom similarities, elbow instability is the weakening or detachment of an elbow ligament - resulting in an unstable elbow joint. The instability can affect the outer, or lateral, portion of the elbow, or the inner, or medial, portion.

Types of Instability

Acute - a traumatic episode disrupts one or more of the elements contributing to stability (bones, ligaments, muscles) by placing abnormal forces on to a normal elbow

Chronic/Recurrent - as a result of previous injury one or more of the stabilising elements is deficient and normal forces applied to the abnormal elbow can result in repeated dislocation or subluxation of the elbow.

Simple - A dislocation where there are no fractures but the soft tissues  (ligaments, capsule and/or muscle origins) are disrupted.

Fracture Dislocation - dislocation of the elbow with a fracture of one or more of the bones of the elbow (humerus, radius or ulna).

As with other fractures and dislocations elbow instability can be either open injuries (with a breach to the skin) or closed.

When is Elbow Instability Surgery recommended?

The symptoms are usually those of clicking, snapping, clunking or locking of the elbow. This is typically when the arm is almost completely straight and with the palm turned upwards. There is almost always a history of trauma or prior surgery to the elbow. It may also be associated with soft tissue and collagen disorders.

What are the causes?

Generally caused by athletic throwing activities, or a trauma that resulted in a dislocation, the severity of the instability is determined based on how the injury is classified - actue, chronic (recurring), area of impact and irritation, the direction of the displacement, the degree of displacement, and presence of associated fractures.

How is Elbow Instability diagnosed?

The diagnosis of elbow instability can occasionally be made by simple clinical examination and investigations are often not helpful. More often the diagnosis is only made at the time of surgery with the patient under a general anaesthetic. With the patient awake the muscles around the elbow contract and help to stabilise the elbow. The anaesthetic allows the muscles around the joint to be relaxed enough for the joint to sublux or be dislocated by the examiner to prove the diagnosis.

What are the treatment options for Elbow Instability?

The goals of treatment include a concentric reduction of the elbow, immobilizing the elbow within a stable construct and early range-of-motion and rehabilitation.

After completing a detailed history and physical exam, a closed reduction should always be attempted in the emergency department. Adequate muscle relaxation and analgesia are essential in facilitating reduction, which is most often achieved with conscious sedation.

The reduction manoeuvre for a posterior dislocation first begins with inline traction to correct medial and lateral displacement of the elbow. The forearm should be supinated and pressure is applied to the tip of the olecranon while flexing the elbow. A palpable “clunk” is a favorable sign of joint reduction.  

After reduction, the stability of the elbow must be examined. In posterior dislocations, the elbow is typically less stable in extension and therefore is splinted in at least 90 degrees of flexion. If the LCL is disrupted and the MCL intact, the elbow will be more stable in forearm pronation. If the LCL is intact and the MCL disrupted, the elbow will be more stable in supination. 

Post-reduction radiographs are obtained to confirm a concentric reduction and exclude associated fractures. A posterior splint is applied with the appropriate forearm rotation for 5 to 7 days. Depending on stability, the splint can be removed for early range-of-motion exercises using a brace with or without an extension block.

Indications for surgical intervention include a failure to obtain stability of the elbow with reduction and immobilization, osteochondral fragment of soft tissue entrapment that prevents concentric reduction and complex dislocations with associated fractures.

What are the risk factors for Elbow Instability?

Individuals involved in throwing sports are at greater risk for medial (inner) elbow instability. Lateral (outer) elbow instability is most often diagnosed in those suffering a trauma or earlier repair of a dislocated elbow.

Can Elbow Instability be prevented?

There are no specific preventative measures beyond avoiding incidental trauma to the upper extremity. Motor vehicle accidents, sports injuries, and other high-energy mechanisms account for most elbow dislocations in young individuals.

How fast can you recover?

To be shared by the doctor.

After Discharge?

9weeks: start isotonic strengthening with concentric flexor-pronator and eccentric elbow flexor training. Full speed pitching not recommended for 12 months after reconstruction.

What are the results of the surgery?

The results of the surgery are very reliable at restoring stability of the elbow but some patients do have ongoing pain, loss of motion or subtle symptoms of instability after their surgery. Almost all patients are noticeably better than they were before the operation.

What are the complications?

  1. Posteromedial olecranon impingement

  2. Ulnohumeral arthritis

Your surgeon will discuss your particular problem and its treatment with you.

Cost of Surgery?

The cost of surgery for Elbow Instability depends on many factors. They include the cost of being in the hospital for several days. Unexpected events that result in an extended hospital stay will also increase the overall cost.

Costs also vary depending on the type of insurance coverage you have. Many insurance companies cover the cost of the surgery, the hospital stay, and the instruments to straighten the spine. You may owe a co-payment or you may be billed the balance of what your insurance does not cover.

Be sure to contact your insurance provider prior to surgery to discuss the extent of your coverage. Discuss with your surgeon, as well as the hospital billing department to make sure you understand all the costs involved.

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