ELBOW SURGERY : Instability, Arthroscopy, Stiffness. · 2016. 9. 7. · ELBOW STIFFNESS David...
Transcript of ELBOW SURGERY : Instability, Arthroscopy, Stiffness. · 2016. 9. 7. · ELBOW STIFFNESS David...
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ELBOW STIFFNESS
David Hargreaves
Consultant Hand Surgeon
Southampton General Hospital
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Causes
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Incidence
•2nd most common elbow
problem.
•Most common sequelae post
trauma
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Normal Motion
•Flexion: 0-140 deg
•Extension : -5 - 0 deg
•Rotation: 85 sup ,80 pron
•ADL : 30-130 , 50-50
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Loss of Motion
•Extension
•Flexion
•Supination
•Pronation
•Adjacent joint
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Aetiology
Intrinsic
• Intra-articular
•Joint incongruity
•Joint adhesions
NB trauma : combined
Extrinsic
•Extra-art or capsular
•Hetertopic Ossification
•Capsular thickening
•Soft tissue adherence
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Natural History
•Gradual improvement with mobilisation.
•Plateau time : Adults ~9m, Child ~18m.
•Variables:
• Time to treatment
• Post op immobilisation
• Complication
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Patient Evaluation : History
•Occupation
•Previous treatment
•Duration / Static
•Pain
•Metal work prominence
•Ulnar Neuropathy
•Locking
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Patient Evaluation : PROM
•DASH
•Mayo Elbow Eval Score
•Pain : VAS
•Doornberg & Ring
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Patient Evaluation: Examination
•End of range Pain
•End of range : Soft / Hard
•Scar adherence
•Radial head : Grip & Grind
•Ulnar nerve
•Metal work prominence
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Imaging
•Xray : Osteophyte / HO / LB /
Congruence / Nonunion
•CT Arthrogram : Callus / HO / screw perf
•MR Arthrogram: Capsular adherence
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Xrays
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CT Reconstruction
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MR Arthrogram
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Treatment : Prevention
•Avoid immobilisation (2w Max)
•Pain relief
•Physio : encourage usage
Unstable: Overhead
•Closed Dislocation <3w :Mehlhoff 1988 JBJS (Am )
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Treatment : Non Operative
•Home Exercise Programme
•Avoid forceful manipulation.
•Avoid inflammation
•Resting splints (night)
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Treatment : Passive Stretch
•Turnbuckle Splint
Green JBJS Am 1979
Stress relaxation
Plastic deformation
Gelinas JBJS Br 2000
18 hrs /day. Restrictive.
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Treatment : Dynamic Stretch
•Joint Jack
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Treatment : Surgical Principles
• Indication:
Failure to improve
Functional deficit
>6m post injury
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Treatment : Surgical Principles
• Identify the problem
•Soft tissue contracture
•Heterotopic bone
•Bone impingement
•Choose the right procedure for the
condition
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Soft tissue contracture
Distraction Arthroplasty
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Arthroscopic Arthrolysis
•Difficult
•Dangerous :nerves
•Limited aims
•Problems
• Access
• Visualisation
• Safe instrumentation
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Combined Pathology
•Open approach:
-Global restriction Lateral Approach
-Ulnar Neuropathy Medial Approach
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Lateral Column Procedure
•Anterior
• Capsule, coronoid tip,
anterior muscle
•Post
• Capsule, Olecranon, Triceps
•Medial
• Post bundle of MCL
•Lateral Lig elevation
• Allows dislocation of joint
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Heterotopic Ossification
•Pt at risk: Trauma, Head Inj, Burns.
•Classification : Brooker 1-5
•Await maturation (serial XR)
•Plan approach (CT/ MR) (incl NV)
•Treatment:
•Excise
•NSAID: Indomethacin 25mg tds 6wk
•Radiation : 7-8 Gray <72 hrs post op
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Ankylosed Elbow
•Excision bone bridge
• Interposition arthroplasty
• Joint replacement
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Rehabilitation
•Cont Passive Motion
•Alternating flexion
/extension
•Good analgesia
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Cautions
•NV bundle
•Childhood deformity
•Rotational stiffness
•Post op instability
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Conclusion