Treatment of Chronic Elbow Instability
M.D.,
RANDALLF. DRYER,M.D., JOSEPHA. BUCKWALTER,
Although recurrent subluxation or dislocation
of the elbow rarely follows a simple traumatic
dislocation, the persistent elbow instability can
be disabling. We have treated 4 patients who
developed chronic elbow instability following a
closed traumatic posterior dislocation. All 4
patients had avulsed the insertion of the brachi-
alis and detached the elbow capsule from the
coronoid process. This paper describes a proce-
dure to correct this lesion.
METHOD
With the patient supine and the arm draped free, a
curvilinear incision was made with the transverse
portion of the incision paralleling the elbow flexor
crease. The cephalic vein was identified and pre-
served; the lacertus fibrosus was incised; and the bi-
ceps tendon was retracted medially, protecting the
median nerve and brachial artery. The brachialis
muscle was dissected free from the anterior portion
of the elbow joint capsule, and the capsule was
opened in a longitudinal fashion. The joint was re-
duced under direct vision and the area of insertion of
the brachialis and anterior capsule roughened to pro-
vide an area for reattachment. Suture passers were
used to create 2 suture holes passing from the
roughened area of the coronoid to the posterior aspect
of the ulna. The brachialis, avulsed fragment, and
capsule were reapproximated to their anatomic posi-
tion by passing # 1 Tevdec sutures through these tis-
sues and through the previously made holes in the
ulna, thereby securing the sutures on the posterior
aspect of the ulna. In one patient we also reefed the
radial collateral ligament of the elbow. After reduc-
From the Department of Orthopaedics, University of
Iowa, Iowa City, Iowa.
Reprint requests to: Dr. Joseph A . Buckwalter, Depart-
ment of Orthopaedics, University of Iowa, Iowa City, IA
52242.
Received: August 31, 1979.
0009-921X/80/0500/254 $00.60 0J. B . Lippincott Co
254
AND BRUCEL. SPRAGUE,
M.D
tion was verified by roentgenograms, the subcutane-
ous tissue and skin were closed and the elbow was
immobilized for 2 weeks in 110" of flexion in a
supinated position. At 2 weeks, the sutures were
removed and the arm placed in a sling. The patient
was encouraged to begin gentle, active flexion-
extension and pronation-supination exercises.
RESULTS
During the period 1972-1978, 3 female pa-
tients and one male patient with chronic poste-
rior subluxation or dislocation of the elbow
were seen at University of Iowa hospitals (Table
1). In each patient, an avulsion of the brachialis
muscle and anterior elbow joint capsule was
identified at the time of surgery. The time of
follow-up ranged from 6 months to 76 months
with an average follow-up of 45 months. Post-
operative motion ranged from full extension to
140 of flexion in one patient to 10 to 130 of
flexion in another patient. All patients had full
pronation and supination. There were no post-
operative wound infections and no complicating
neurovascular injuries. At follow-up, all pa-
tients were satisfied with their results and said
they had no symptoms of recurrent pain or sub-
luxation.
DISCUSSION
Despite the small number of previously de-
scribed patients with recurrent posterior dislo-
cation of the elbow,7 many different operative
repairs have been proposed for the treatment of
this condition including reefing of the capsule,
reconstruction of the ligaments, and anterior
bone-block placement. 1,2,4,9 Osborne and
Cotterill reviewed these procedures and
 Number 148
May, 1980
TABLE 1.
Numbers of Attempted
Number of Patient Age (years), Sex Closed Reductions
1 30, F
2 40, F
3 54,M
4 23, F
grouped them into 4 major types6 Reichen-
helm's operation involves placement of the
biceps tendon through the coronoid process.'
This procedure reportedly produces good re-
sults; however, it may result in loss of strength
and pronation. The bone-block procedure of
Milch deepens the trochlear notch anteriorly to
prevent posterior dislocation and e x t e n ~ i o n . ~
Primary problems of this procedure include
nonunion and fragmentation of the bone block
and the need for a bone donor site. In 1951
Kapel described a procedure involving the con-
struction of artificial ligaments from strips of
biceps and triceps t e n d ~ n Constructing
.~ these
tendonous slings is a challenge, and the proce-
dure requires a wide dissection, which increases
the possibility of extra-articular ossification.
The Spring procedure involves reinforcement of
the medial collateral ligament using fascia1 or
tendonous strips.8 Although this procedure has
reportedly reduced elbow instability, the pri-
mary defect in the anterior surface of the elbow
joint was not reconstructed. In 1966 Osborne
and Cotterill described 18 patients with a con-
sistent capsular defect anteriorly with secondary
articular changes analogous to those that occur
in recurrent dislocation of the shoulder.'j After
placing transverse holes through the distal as-
pect of the humerus both medially and laterally,
they used absorbable sutures to reef the medial
and lateral collateral ligaments. This procedure
has the disadvantage of relying on the weak-
ened capsular tissue commonly found following
chronic dislocations.
In our 4 patients, the consistent finding of a
thin anterior capsule, avulsed or torn from the
coronoid process, associated with avulsion of
the insertion of the brachialis led us to consider
Chronic Elbow Instability 255
Summary of Results
Range of Motion
Postsurgep Redislocation Pain
3 -0 to 140 0 0
2 - 10 to 130 0 0
2 -0 to 130 0 0
3 0 to 140 0 0
the anterior approach to repair of the soft tis-
sues. This approach allows extension of the dis-
section to repair medial and lateral collateral
ligaments as necessary and centers repair and
subsequent scarring in the area of the anterior
defect. The operation has proven simple to per-
form, there have been no complications second-
ary to the surgical procedure, and the stability
of the elbow has been restored.
SUMMARY
Four patients developed chronic elbow insta-
bility following closed traumatic dislocations.
All patients had disruption of the anterior cap-
sule of the elbow joint with avulsion of the
brachialis from its insertion on the coronoid
process. Repair of the anterior soft tissues re-
stored elbow stability with minimal difficulty
and no significant complications.
REFERENCES
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dislocation of the elbow, J. Bone Joint Surg. 57A:1080,
1975.
3 . Kapel, 0 . :Operation for habitual dislocation of the
elbow, J . Bone Joint Surg. 33A:707, 1951.
4 . King, T.: Recurrent dislocation of the elbow, J . Bone
Joint Surg. 35B:50, 1953.
5. Milch, H.: Bilateral recurrent dislocation of the ulna at
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