Complex Elbow Instability: Treatment and Rehabilitation
Complex elbow instability represent a challenging injury even for expert elbow surgeons. Chronic instability, posttraumatic osteo-arthritis, stiffness and poor functional outcomes are frequent if these injuries are not adequately treated. A correct preoperative evaluation includes X-rays, CT scan with 2D and 3D reconstruction and stability tests under fluoroscopy in order to recognize all osseous and ligamentous lesions. The most common patterns of complex elbow instability includes: (1) radial head fractures associated with lateral and medial collateral ligaments lesions; (2) coronoid fractures and lateral collateral ligament lesion; (3) Terrible Triad; (4) fracture-dislocations of the proximal ulna and radius, also referred to as transolecranon fracture-dislocations and Monteggia-like lesions; and (5) humeral shear fractures associated with lateral and medial collateral ligament lesions.
The main goals of the treatment are (1) to perform a stable osteosynthesis of all fractures, (2) to obtain concentric and stable reduction of the elbow throught the repair of soft tissue constraint lesions and (3) to allow early motion. All the patterns of complex elbow instability share the same therapeutic algorithm based on seven main principles: 1) the proximal ulna must be anatomically reduced and fixed; 2) the radial head or humeral shear fracture must be repaired or replaced, 3) bone length, alignment and rotation of ulnar and radial shaft fractures must be recovered; 4) the lateral collateral ligament complex must be repaired to obtain elbow stability; 5) the medial collateral ligament must be repaired if persistent instability is observed after lateral collateral ligament repair; 6) an hinged external fixator must be considered if the elbow remains unstable or the protection of the joint reconstruction is required; 7) re-evaluation of the surgical steps if congruent ulno-humeral and radio-humeral joints have not been achieved.
Following the surgical treatment an adequate rehabilitation programme should be started promptly and continued for at least 6 months since a significant improvement of the range of motion occurs prevalently in this period, which should be considered the critical time period to obtain a functional elbow.
- Boyd HB (1947) Surgical approaches to the elbow joint. Instruct Course Lect 4:147Google Scholar
- Broberg MA, Morrey BF (1987) Results of treatment of fracture-dislocations of the elbow. Clin Orthop Relat Res 216:109–119Google Scholar
- Giannicola G, Zangrando F (2012) Patologie e riabilitazione del gomito. Verduci, RomaGoogle Scholar
- Harding P, Rasekaba T, Smirneos L et al (2011) Early mobilisation for elbow fractures in adults. Cochrane Database Syst Rev 15:CD008130Google Scholar
- Hotchkiss RN (1996) Fractures and dislocations of the elbow. In: Rockwood CA, Green DP, Bucholz RW, Heckman JD (eds) Rockwood and Green’s fractures in adults, vol vol. 1, 4th edn. Lippincott-Raven, Philadelphia, pp 929–1024Google Scholar
- Josefsson PO, Gentz CF, Johnell O et al (1989) Dislocations of the elbow and intraarticular fractures. Clin Orthop Relat Res 246:126–130Google Scholar
- Kaplan EB (1941) Surgical approaches to the proximal end of the radius and its use in fractures of the head and neck of the radius. J Bone Joint Surg 23(86):1941Google Scholar
- Kocher T (1911) Textbook of Operative Surgery, 3rd edn. A. and C, Black, LondonGoogle Scholar
- Marotte JH, Samuel P, Lord G (1982) La fracture-luxation conjointe de l’extremit_e superieure des deux os de l’avant-bras. Rev Chir Orthop 68:104–114Google Scholar
- Monteggia GB (1814) Istruzioni chirurgiche, Vol 5. Pirotta & Maspero, Milano, pp 52–138Google Scholar
- Morrey BF (1993) Radial head fracture. In: Morrey BF (ed) The elbow, 2nd edn. WB Saunders, Philadelphia, pp 383–404Google Scholar
- Morrey BF (2005) The posttraumatic stiff elbow. Orthop Relat Res 431:26–35Google Scholar
- Morrey BF, Tanaka S, An KN (1991) Valgus stability of the elbow. A definition of the primary and secondary constraints Clin Orthop Relat Res 265:187–195Google Scholar
- Søjbjerg JO, Ovesen J, Nielsen S (1987) Experimental elbow instability after transection of the medial collateral ligament. Clin Orthop Relat Res 218:186–190Google Scholar