Instabilidade do Cotovelo

Question 1

Quais são a origem e inserções do ligamento colateral lateral do cotovelo?

Answer 1

The lateral collateral ligament of the elbow arises from the epicondyle and inserts on the annular ligament.

Question 2

Qual parte do complexo ligamentar lateral do cotovelo é a mais importante?

Answer 2

The lateral ulnar collateral ligament, arises at the lateral epicondyle and blends with fibers of the annular ligament before inserting on the tubercle on the crest of the supinator on the ulna. This band has been described as the main lateral stabilizer, taut in flexion and extension, with disruption of this portion of the lateral complex resulting in posterolateral rotatory instability.

Question 3

Qual a contribuição do ligamento colateral lateral para a estabilização em varo do cotovelo?

Answer 3

The lateral collateral ligament contributes only 14% of the varus stability of the elbow with the joint in full extension and only 9% with the joint in 90 degrees of flexion.

Question 4

Qual o principal estabilizador em varo do cotovelo?

Answer 4

The remainder of the stability is contributed by the bony articular surfaces and the anterior capsule, with the bony surfaces supplying most of the stability.

Question 5

Quantas bandas apresenta o ligamento colateral medial?

Answer 5

The medial collateral ligament of the elbow is a well-developed ligament that can be described as three distinct portions (1, anterior oblique; 2, posterior oblique; 3, transverse oblique).

Question 6

Qual a importância do ligamento colateral medial para a estabilização em valgo do cotovelo?

Answer 6

Valgus stability is divided equally among the medial collateral ligament, the anterior capsule, and the bony articulation with the elbow in full extension. At 90 degrees of flexion, the medial collateral ligament provides 55% of the stability to valgus stress, with the anterior bundle being the primary stabilizer.

Question 7

Quais são as modalidades de instabilidade do cotovelo?

Answer 7

Elbow instability may be congenital, traumatic, or attritional.

Question 8

Quais são as estruturas que formam o complexo ligamentar lateral do cotovelo?

Answer 8

Lateral collateral ligament, annular ligament, and the lateral ulnar collateral ligament.

Question 9

Quais são os estabilizadores primários do cotovelo?

Answer 9

The primary stabilizers of the elbow are the anterior band of the medial ulnar collateral ligament and the lateral collateral ligament complex.

Question 10

Quais são os estabilizadores secundários do cotovelo?

Answer 10

Secondary stabilizers consist of the capsule, the ulnohumeral and radiocapitellar articulations and the dynamic stabilizers, consisting of all muscle-tendon units that cross the elbow joint (i.e., biceps, brachialis, triceps, wrist flexors, and wrist extensors).

Question 11

Quais são as possíveis sequelas dos pacientes que apresentam luxação simples do cotovelo?

Answer 11

60% of patients had residual stiffness with loss of extension and residual pain.

Question 12

Qual a porcentagem de pacientes com luxação simples do cotovelo desenvolve instabilidade funcional?

Answer 12

Only 8% had functional instability.

Question 13

Como O’Driscoll descreveu o mecanismo de lesão das estruturas do cotovelo na forças em valgo, supinação e compressão axial?

Answer 13

Injury pattern for traumatic elbow dislocation described by O’Driscoll et al. A, Three stages of elbow instability from subluxation to dislocation: stage 1, disruption of the ulnar part of the lateral collateral ligament; stage 2, disruption of the other lateral ligamentous structures and posterior capsule; stage 3A, partial disruption of the medial ulnar collateral ligament and posterior medial ulnar collateral ligament only; and stage 3B, complete disruption of the medial ulnar collateral ligament and posterior medial ulnar collateral ligament. Soft tissue injury progresses in a circle from lateral to medial.

Question 14

Quais são as estruturas mais comumente envolvidas nas luxações recorrentes ou instabilidade persistente?

Answer 14

When recurrence or persistence in instability results, the posterolateral structures are most commonly afected, but the medial structures also can be involved and cause significant instability.

Question 15

Qual a forma mais comum de instabilidade do cotovelo?

Answer 15

Valgus instability from attritional disruption of the anterior bundle of the medial ulnar collateral ligament is by far the most common form of recurrent elbow instability.

Question 16

Como é dividido a banda anterior do ligamento colateral medial?

Answer 16

The anterior bundle is divided into two nonisometric bands: an anterior band, which is taut at 0 to 60 degrees, and a posterior band, which is taut at 60 to 120 degrees.

Question 17

O que acontece com a falha dos estabilizadores primários do cotovelo?

Answer 17

Failure of the primary stabilizer results in increased stress on secondary stabilizers, with resulting capsular contractures, chondromalacia, osteophytes, and loose bodies from the radiocapitellar joint and the posteromedial tip of the olecranon. Ulnar nerve symptoms may develop from traction, scarring, or osteophyte impingement.

Question 18

Qual o local para se mensurar a circunferência do antebraço?

Answer 18

The forearm circumference is measured 7 cm below the medial epicondyle to compare with the opposite extremity.

Question 19

Qual sinal do exame físico pode indicar uma fratura por estresse do olécrano?

Answer 19

Tenderness and swelling 2 to 3 cm distal to the olecranon tip may indicate an olecranon stress fracture.

Question 20

Como se avalia a estabilidade do cotovelo?

Answer 20

Active and passive range of motion is recorded, and a valgus stress is applied to the elbow with the forearm in the supinated and the pronated positions and the elbow in about 30 degrees of flexion. The amount of medial opening, the firmness of the end point, and the production of medial pain should be noted when valgus is applied with the forearm pronated.

Question 21

Como é realizado o teste de extensão e sobrecarga com estresse em valgo do cotovelo?

Answer 21

The valgus extension overload test is done by maintaining a valgus stress on the elbow, while the elbow is passively extended from 30 degrees down. Pain along the posteromedial aspect of the olecranon can be produced when subacute or chronic instability has resulted in posteromedial olecranon impingement.

Question 22

Como é realizado o teste de extensão ativa com sobrecarga e estresse em valgo, descrito por O’Driscoll?

Answer 22

With the patient’s shoulder abducted and externally rotated, a valgus stress is applied on the elbow as it is passively extended from 120 degrees down to 30 degrees and then flexed back in a rapid sequence. Generation of medial pain may indicate ligamentous incompetence.

Question 23

Como é realizado o teste da ordenha?

Answer 23

The milking maneuver is likewise performed by putting valgus stress on the elbow by pulling on the patient’s thumb while stabilizing the arm and ranging the elbow between 30 and 120 degrees.

Question 24

Como avaliar a subluxação do nervo ulnar e a instabilidade postero-lateral do cotovelo?

Answer 24

The patient is placed prone, and the ulnar nerve is evaluated by the Tinel test. With the shoulder abducted to 90 degrees and the elbow lexed 90 degrees, the ulnar nerve is evaluated to see if it subluxes anteriorly from its groove with passive elbow motion or with manual stress on the nerve. Valgus stress again can be applied to the elbow when flexed greater than 30 degrees to detect medial instability. Postero-lateral instability can be evaluated by supinating the forearm and applying a valgus moment and axial force with the elbow flexed 20 to 30 degrees. A clunking sensation may indicate posterolateral laxity.

Question 25

Como é realizado o Jerk test para o cotovelo?

Answer 25

The test is performed with the extremity over the patient’s head and the shoulder fully externally rotated. With the forearm fully supinated and valgus stress applied, the elbow is moved from a fully extended position to a flexed position. As the elbow is flexed near 40 degrees, a posterolateral prominence is produced by subluxation of the radial head; as the joint is flexed further, a dimple in the soft spot area appears and eventually disappears as the radius and ulna snap back into place on the humerus.

Question 26

Como é realizado o teste da elevação da cadeira?

Answer 26

Performed by having the patient push up with the forearm supinated while the examiner feels and observes for radial head instability. Wall or loor push-ups with the forearm in supination accomplish the same objective.

Question 27

Qual o objetivo da incidência de Jones para instabilidade crônica do cotovelo?

Answer 27

Jones view of the elbow is indicated to determine if posteromedial osteophytes are present.

Question 28

Como é realizado a radiografia de estresse gravitacional?

Answer 28

A gravity stress radiograph can be obtained with the patient supine, the shoulder abducted 90 degrees and externally rotated, the forearm supinated, and the elbow flexed 20 to 30 degrees. A lateral radiograph is obtained to show the opening of the medial side of the elbow to gravity stress. This is not a highly sensitive test, although a positive test does indicate a significant injury to the ulnar collateral ligament.

Question 29

Qual o melhor exame para instabilidade do ligamento colateral ulnar?

Answer 29

Currently, the best test of ulnar collateral ligament instability is a gadolinium-enhanced MRI of the elbow to evaluate for extravasation of fluid (T sign) or degenerative changes in the ulnar collateral ligament.

Question 30

Como tratar conservadoramente uma luxação instável do cotovelo?

Answer 30

For unstable elbows, an elbow splint is used to control range of motion, blocking extension at 45 degrees for 1 week, 30 degrees for the next week, and allowing full motion thereafter. If a contracture of more than 30 degrees is still present after 6 weeks, an extension splint can be used to improve motion.

Question 31

Qual a posição do antebraço para as instabilidades mediais? E laterais?

Answer 31

For incomplete injuries that involve disruption of the medial side of the elbow, the forearm is placed in supination. Lateral injuries are treated by placing the forearm in pronation with the elbow flexed 90 degrees for 1 to 2 weeks, followed by use of an elbow brace.

Question 32

Como é realizado o teste artroscópico para instabilidade medial do cotovelo?

Answer 32

Andrews et al. described a valgus stress test done arthroscopically with the patient under general anesthesia. Using the anterolateral portal to view the medial compartment, valgus stress is applied to the elbow, which is flexed to 70 to 90 degrees, and the opening between the ulna and trochlea is measured. An opening of more than 1 to 2 mm indicates medial instability.

Question 33

Geralmente, quando se preconiza o tratamento cirurgico para instabilidade do cotovelo?

Answer 33

Surgical intervention is directed toward the side of greatest instability, generally the lateral side, or in the case of global instability, both the lateral and medial sides may need to be treated. Suggested indications for ulnar collateral ligament reconstruction are (1) an acute complete rupture in a competitive throwing athlete who wishes to remain active and (2) chronic pain or instability without improvement after at least 4 to 6 weeks of supervised conservative treatment.

Question 34

Como é a técnica original de Jobe para a reconstrução do ligamento colateral medial?

Answer 34

In the original technique, the flexor mass was released from the epicondyle and open-ended tunnels were placed in the ulna and the medial humeral condyle. A palmaris longus graft was used to reconstruct the ligament, and the ulnar nerve was transferred anteriorly under the flexor muscle mass.

Question 35

Quais as vantagens da reconstrução do ligamento colateral lateral com a técnica "docking"?

Answer 35

The beneits of this “docking procedure” include (1) reconstruction through a split in the muscle in a safe zone, (2) avoidance of obligatory nerve transfer, (3) placement of tendon grafts in bone tunnels, (4) reduction in number of humeral tunnels, and (5) simplification of graft tensioning.

Question 36

Quais são os pontos tecnicamente importantes na reconstrução do ligamento colateral ulnar pela técnica de Jobe?

Answer 36

(1) calcification should be removed from the ligament; (2) drill holes must correspond to ulnar collateral ligament attachment sites; (3) the graft should not rub on the epicondyle or ulna, and the ends of the graft should be buried in the tunnels; (4) a figure-of-eight configuration of the graft ensures strength and approximates ulnar collateral ligament biomechanics; and (5) meticulous handling of medial antebrachial cutaneous and ulnar nerves, their branches, and their vasculature is essential.

Question 37

Qual cuidado se deve ao se utilizar o tendão do palmar longo?

Answer 37

Absence of the palmaris longus tendon occurs in 15% to 20% of individuals. When the palmaris longus tendon is present on one side only, it often has muscle extending distally, which usually is a short deficient tendon. One must be aware and prepared for the potential need of a hamstring graft with the patient being informed of the possibility. Alternative sources of tendon graft include the contralateral palmaris longus tendon, a trimmed gracilis tendon, the plantaris tendon, or the extensor tendon from the fourth toe.

Question 38

A luxação recorrente do cotovelo geralmente ocorre em qual direção?

Answer 38

Posterior