Elbow Luxations Flashcards by Chloe Tredinnick

The location of the anconeal process within the olecranon fossa prevents luxation of the elbow joint unless it is flexed beyond what angle?

45 degrees

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What is the negative of the removal of UAP?

Increased risk of luxatoin (elbow)

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What are important stabilisers of the elbow joint in extension and flexion? (2)

Lateral collateral ligaments
Medial collateral ligaments

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For elbow luxation to occur significant rotational forces are required to result in dysfunction of which ligament in dogs?

Lateral collateral ligament

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For elbow luxation to occur significant rotational forces are required to result in dysfunction in cats?

Medial collateral ligament

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Where do collateral ligaments run?

From the lateral and medial humeral epicondyle to the radius and ulna.

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What prevents cranial translation of the radius.?

Annular ligament

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Which way are elbow luxations normally?

Lateral

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What stops medial luxation of the elbow?

Large humeral trochlea

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What age are elbow luxations in dogs?

> 3yr

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What age are humeral condylar fractures?

young

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A) Dogs and cats with traumatic elbow luxation usually have a history of?
B) What is the lameness degree?

A) Recent trauma
B) Non weight bear

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Elbow luxation:
A) Elbow position?
B) Antebrachium position?

A) Mildly flexed
B) Abducted and externally rotated

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Elbow luxation - what is different about the lateral humeral epicondyle palp?

Less prominent

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Is the following sentence true or false?

Due to the significant forces that are required to luxate an anatomically normal elbow joint, concurrent injuries (e.g. neurological deficits, pneumothorax) are uncommon.

False

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How to confirm diagnosis of elbow luxation?

Orthogonal radiographs of the elbow joint

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What should be looked at on x-rays for elbow luxation diagnosis?

Look for uneven joint spaces between the humeral condyle and the radius and ulna.

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Which x ray view shows the direction of luxation?

CrCd

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What other xrays (apart from FL) should be taken when looking for luxation?

Thoracic radiographs are recommended to assess for concurrent pathology, such as pneumothorax,

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Can you think of possible contraindications for close reduction? (5)

Chronic luxation;

Prior failed closed reductions;

Concurrent intra-, or peri-articular fractures;

Severe degenerative joint disease of the elbow;

Intra-articular interposition of soft tissue.

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What may be indicated in patients with severe cubarthrosis (Elbow joint arthrosis)? (2)

Total joint replacement
Arthrodesis

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Closed Reduction of a Traumatic Lateral Elbow Luxation:
How long to suspend the limb for? And what does this do?

10mins
to distract the joint and encourage muscle relaxation.

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Closed Reduction of a Traumatic Lateral Elbow Luxation:
- Patient position
- What anatomical landmark is determined
- What elbow movement is performed?

The patient is positioned in lateral recumbency with the affected limb up.

Determine the position of the anconeal process.

Flex the affected elbow beyond 90° and inwardly rotate the antebrachium.

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Closed Reduction of a Traumatic Lateral Elbow Luxation: What does Abduction of the affected antebrachium allow?

the anconeal process to slide over the lateral epicondylar crest into the olecranon fossa.

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Closed Reduction of a Traumatic Lateral Elbow Luxation- What can facilitate reduction?

By applying medially directed pressure to the lateral aspect of the olecranon while stabilising the distal part of the humerus.

once the anconeal process is reduced; what should be done with the affected limb?

The affected limb should be extended, adducted and internally rotated

What will force the elbow luxation medially under the humeral capitulum.

Medial pressure

After the elbow has been reduced, evaluate stability provided by the collateral ligaments by (2)?

Flexing and rotating (Medial+ lateral) the affected leg

What test is performed to assess stability following elbow reduction?

Campbell test

How to perform campbells test?

The elbow and carpus are flexed to 90 degrees. This ensures the anconeal process is positioned caudal to the olecranon fossa, whereby the rotational stability of the joint becomes dependent on the collateral ligaments. Rotating the ante brachium in this position may give mild laxity but a repeat luxation in response to this would be an indicator for surgery.

If the joint is found to be stable or only mildly unstable, conservative treatment can be attempted with the leg held in extension for around ? e.g. with a Spica splint until the soft tissue structures will have healed, as you can see on the image below.

four weeks

The aims of a surgical approach for elbow luxation are? (3)

Reduction of the luxation; Assessment of cartilage damage; Reconstruction of the collateral ligaments.

What should be done prior to the surgical correction of a luxated elbow?

Prior reduction

Approach and open elbow reduction: - Skin incision? - Dissection through subcutaneous tissue is followed by incision of what 2 facia types?

-From just proximal of the lateral humeral epicondyle over the joint distally to the proximal fourth of the radius. -deep fascia and fascia of the triceps brachii.

Approach and open elbow reduction: -The origin of the WHAT? muscle is incised along the lateral epicondylar crest after retraction of the lateral head of the triceps muscle. - Following thorough joint inspection WHAT ? are placed onto the olecranon and the anconeal process is levered over the lateral epicondylar crest into the olecranon fossa.

- anconeal - pointed reduction forceps

Approach and open elbow reduction: - How is the lateral collateral ligament approached?

By separating between the origins of the lateral digital extensor and the tendon of the ulnaris lateralis muscle. It can be imbricated or sutured if required using mattress sutures and monofilament, slowly absorbable suture material.

Open elbow reduction: How can Prosthetic ligament replacement can be carried out?

placement of screws and washers or bone anchors.

Patients with medial and lateral collateral ligament rupture can be managed with (2)

transcondylar bone tunnels and bilateral suture repair.

Open elbow reduction: The humeral transcondylar bone tunnel is drilled A) Where? B) Which direction?

a) Attachment of the lateral collateral lig B) Craniodistal towards medial epicondyle

The A) tunnel is drilled starting at the insertion of the lateral collateral ligament on the B)?

A) Transradial B) Radial head

The A) bone tunnel is drilled starting at the level of the mid-portion of the B)

A) Transulnar B) Ulnar trochlear notch

Open elbow reduction: A double loop of suture material is passed through the ? and cut so that one end can be passed through each of the distal tunnels.

humeral tunnel

Open elbow reduction: Tie the humero-radial and the humero-ulnar suture loops with the elbow in a what angle? Specify

standing angle (135º extension).

This technique of collateral ligament prosthesis provides support of both, the medial and the lateral collateral ligaments and is therefore appropriate for what case?

bilateral ligament deficiency

What technique can be used for a lateral collateral ligament deficiency.? why?

Collateral ligament prosthesis ease of the technique and application from a lateral approach makes it also a feasible technique

collateral ligament prosthesis : Drill bit size?

2.4 mm, 2.7 mm, or 3.5 mm) is selected depending on the size of the dog

What material is used for collateral ligament prosthesis.

braided, polyblend suture material

The postoperative management of collateral ligament prosthesis depends on the severity of the injury and the type of repair chosen. Postoperative joint immobilisation options include: (4)

Modified Robert Jones bandage; Spica splint; Transarticular external skeletal fixation; Flexible external skeletal fixation.

The prognosis for treatment of elbow joint luxation is generally considered as?

good

Can you guess which are the negative prognostic factors for elbow luxations? (5)

Severe cartilage and soft tissue damage Delayed treatment Persistent instability Concurrent orthopaedic injuries Poor patient/owner compliance

What are the 3 subtypes of congenital elbow luxations?

-Type 1 - Humeroradial - Type II - Humeroulnar - Hype III - Combination of humeroulnar and humeroradial

Define Type I Congenital elbow luxation

Humeroradial congenital elbow luxation (type I) results in lateral or caudolateral dislocation of the radial head with the ulna in normal position.

Define Type II Congenital elbow luxation

Humeroulnar congenital elbow luxation (type II) is characterised by lateral rotation and subluxation or luxation of the ulna with occasional dislocation of the radial head.

Define Type III Congenital elbow luxation

Combination of humeroulnar and humeroradial congenital elbow luxation (type III) results in luxation of the radius and ulna, with lateral or caudolateral rotation of the proximal ulna and subluxation or luxation of the humero-ulnar joint.

At what age does secondary remodelling occurs and degenerative changes begin to develop?

3mo

Congenital elbow luxation: A) The olecranon is rotated Which direction? t B) The the trochlear notch does not contact the?

A) lateral to the distal humerus B) humeral condyle.

The bone malpositioning occurs at a young age, and because the bones do not articulate normally, what do not form?

congruent joint surfaces

What are the 5 possible anatomical result/s of congenital elbow luxationi?

Hypoplasia and remodelling of the trochlea and trochlear notch; Hypoplasia of the medial aspect of the humeral condyle with stretching of the medial collateral ligament and joint capsule; Hyperplasia of the lateral aspect of the humeral condyle with contracture of the lateral joint capsule and lateral collateral ligament; Contracture and displacement of the triceps muscle; Degenerative changes of the articular cartilage.

Dogs with humeroradial luxation: A) Degree of lameness B) Antebrachial position? C) Carpus deformity? D) Age?

A) Mild B) Supination mild C) Mild valgus D) 2-5mo

Patients with humeroulnar luxation: A) Degree of lameness? B) Elbow joint position? C) Antebrachium position?

A) Mild B) Flexion C) Pronation

How will you diagnose congenital elbow luxation?

Radiography

Is conservative management an option for humeroradial luxation?

Yes - mild clinical signs

What are the surgical options for humeroradial luxations? (3)

Open joint reduction and stabilisation, Radial head ostectomy Arthrodesis

When should surgery be performed for humeroradial luxations, why?

as soon as possible before secondary degenerative changes and irreversible joint remodelling occurs (usually before the animal is five months of age).

When do you think conservative treatment may be successful for humeroulnar luxations? What does this include?

less than four months of age good function no pain include closed reduction and immobilisation by placement of transarticular pins or applications of modified external skeletal fixation.

What about open reduction and immobilisation, when do you think is recommended for congenital elbow luxations? (2)

older than 4-5 months When closed reduction is unsuccessful.

What is placed for Open reduction and immobilisation of congenital elbow luxations? (2)

External fixators Transarticular pins

How long is the pin left in place for open reduction/immobilisation?

21 days

When is Open reduction and corrective osteotomy used in congenital elbow luxation?

When the joint cannot be manually replaced.

What are the possible techniques for Open reduction and corrective osteotomy in congenital elbow luxation (depending on pathology severity)? (4)

Lateral release of soft tissue (including the joint capsule and anconeus muscle). Medial support of the olecranon using capsular imbrication and stay sutures. Olecranon or ulnar osteotomy and transposition to reconstruct the joint. Redirection of the pull of the triceps muscle to allow joint extension.

What can be used to stabilize osteotomy with congenital elbow luxation? (2)

Kirschner wires and, if necessary, a tension band wire.

Following osteotomy, how long should the limb be bandaged to support the fixation? What position is it splinted in?

2-3 weeks In functional position

Is the following sentence true or false? Following osteotomy (congenital elbow luxation) Activity should be encouraged as soon as the bandage is removed (2 to 3 weeks).

Activity should be restricted to leash walking for 4 to 6 weeks.

The Kirschner wires should be removed when with congenital elbow luxation osteotomy?

When healed

Possible surgical complications following congenital elbow luxation surgery? (8)

reluxation infection implant failure fracture reduced ROM progressive OA physeal damage radioulnar synostosis

When is the prognosis for congenital elbow luxation worse?

If the treatment of chronic elbow luxations is delayed.