Review Question - QID 214124

Simple elbow dislocations with persistent instability after closed reduction are best treated with the acute repair of lateral collateral ligament (LCL) repair with or without medial collateral ligament repair.

Elbow dislocations can be catastrophic injuries. Ligamentous injury is common with avulsion of the lateral collateral ligaments off of the humerus. There can be associated fractures of the radial head and coronoid process of the ulna, which can contribute to continued instability. In the setting of a simple elbow dislocation without associated fracture, if there is persistent instability requiring elbow flexion greater than 60 degrees, then acute repair of the injured ligaments should be performed. This will help restore stability. Typically the lateral collateral ligament is repaired first, then if there is persistent instability the medial collateral ligament should also be repaired.

Tashjian and Katarincic reviewed complex elbow instability, which they define as ulnohumeral dislocation with an associated fracture. Commonly associated fractures include radial head, coronoid process, olecranon, and monteggia fractures. Their recommendation in the setting of complex instability is for boney reduction and fixation, ligamentous repair, and possible hinged fixation for supplemental stability.

Wyrick et al. reviewed the management of elbow dislocations by categorizing treatments by the mechanism of injury. Mechanisms discussed include axial load, valgus posterolateral rotatory, and varus posteromedial rotary. For each, they break down the expected injuries and specific management. LCL injuries fall under valgus posterolateral mechanisms in the review and they recommend direct repair to the humerus with bone tunnels or suture anchor fixation. Repair should be tightened at 90 degrees elbow flexion with forearm pronation.

Figure A and B demonstrate an AP and lateral Xray of an elbow with dislocation of the ulnohumeral and radiocapitellar joints without evidence of fracture.

Incorrect answer:
Answer 1: Prolonged immobilization would likely create a stiff elbow, however, would not address the underlying etiology for persistent instability.
Answer 2: External fixator can be used to hold the joint in a reduced position, however is a temporary solution and not appropriate for this otherwise healthy patient.
Answer 3: An internal joint stabilizer can be used to augment soft tissue repairs within the elbow, however does not replace repair of the collateral ligaments.
Answer 5: Elbow stiffness is the most common complication after elbow dislocations, therefore prolonged periods of immobilization should not be used.