A randomized prospective study of 50 cases, Taylor F, Sims M, Theis JC, Herbison GP (2012), Interventions for treating acute elbow dislocations in adults, Maripuri SN, Debnath UK, Rao P, Mohanty K (2007), Simple elbow dislocation among adults: a comparative study of two different methods of treatment, de Haan J, Schep NW, Tuinebreijer WE, Patka P, den Hartog D (2010), Simple elbow dislocations: a systematic review of the literature, Islam S, Jahangir J, Manzur RM, Chowdury AA, Tripura N, das A (2012), Management of neglected elbow dislocations in a setting with low clinical resources, Primary ligament repair for elbow dislocation, Micic I, Kim SY, Park IH, Kim PT, Jeon IH (2009), Surgical management of unstable elbow dislocation without intra-articular fracture, Josefsson PO, Johnell O, Wendeberg B (1987), Ligamentous injuries in dislocations of the elbow joint, O’Driscoll SW, Morrey BF, Korinek S, An KN (1992), Elbow subluxation and dislocation. The next critical step is to intraoperatively assess the stability of the elbow with a range-of-motion assessment with the forearm in pronation. We propose a new surgical technique and assess its feasibility in a cadaveric study. The lateral ulnar collateral ligament and extensor origin reattachment can be easily performed. The primary disadvantage of this static approach is in the tendency of the elbow to stiffen following severe injury. Results: All 20 elbows had sufficient triceps tendon length to complete the new technique. The most common patient complaints/symptoms are recurrent popping, clicking, clunking, or locking, accompanied by a sense of instability in the elbow. In this rare situation operative treatment is indicated. 18. 2013 Apr;471(4):1373-8. doi: 10.1007/s11999-012-2742-4. Furthermore, the severity of injury to the ligaments being repaired may necessitate augmentation with free tendon graft or skeletal support with hinged external fixators. There are three common ways that a shoulder can become unstable. The vast majority of simple dislocations can be reduced closed with sedation and will remain reduced and stable [4]. However when a fracture has occurred, the elbow may remain unstable if surgery is not performed. NIH Complex and Unstable Simple Elbow Dislocations: A Review and Quantitative Analysis of Individual Patient Data. A 4 mm tunnel is then drilled beginning at the tip of the coronoid process and traversing the ulna to exit through the dorsal cortex of the ulna (Figure 4). NLM Results after closed treatment, Simultaneous reconstruction of both medial and lateral collateral ligament complexes for recurrent instability of elbow dislocation: a case report, Treatment of unreduced elbow dislocations with hinged external fixation, Schippinger G, Seibert FJ, Steinbock J, Kucharczyk M (1999). This review on elbow dislocations describes ligament and bone injuries as well as the typical injury mechanisms and the main classifications of elbow dislocations. Shoulder dislocation—Severe injury, or trauma, is often the cause of an initial shoulder dislocation. SPECIAL FEE WAIVER AND DISCOUNTS; GET BENTHAM OPEN MEMBERSHIP NOW!! The posterior aspect of the humerus is then visible through the triceps split. Simple Elbow Dislocation • No associated fractures • Complete or near complete capuloligamentous injury • Extensive muscle injury • Nearly always stable after reduction • No advantage to surgery if stable • No more than 2 weeks immobilization . Dynamic stabilisation aims to avoid the problems of immobilisation by allowing early functional rehabilitation. Epub 2008 Aug 2. The ePub format uses eBook readers, which have several "ease of reading" features A simple elbow dislocation that spontaneously re-dislocates following closed reduction and appropriate stabilising manoeuvres (elbow flexion and forearm pronation) is a rare problem. elbow dislocations are the most common major joint dislocation second to the shoulder . It does not prove clinical applicability of the technique or superiority to current conventional methods. The distance B was calculated on the basis of an observation that a line drawn from the tip of the coronoid to the tip of the olecranon (D) passes through the axis of rotation of the elbow. Additionally the repair or reconstruction of the collaterals must be anatomical to allow unrestricted elbow flexion and extension around its axis of rotation. Elbow held in 45 degree of flexion; Olecranon is prominent posteriorly However, there is no single protocol to guide the surgeon on which structures should be repaired and in what order. Current treatment concepts of simple, that is, stable, or complex unstable elbow dislocations are outlined by means of case reports. You may notice problems with When an elbow dislocation is associated with a fracture this injury has been termed a complex dislocation [ 5, 6, 7 ]. Most simple elbow dislocations can be reduced closed with sedation and will remain reduced and stable . This gives a calculated tendon length (1/2πD) of 53 mm for the intra-articular portion (B) of the graft. Information for Authors/Reviewers. Doornberg JN, Guitton TG, Ring D; Science of Variation Group. 2008 Sep 19;1(1):168. doi: 10.1186/1757-1626-1-168. There is no need for metal insertion or its subsequent removal. This study evaluates the technique and results of temporary transarticular fixation of the unstable elbow, a previously unreported acute … The dislocations may be complex or simple. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, Elbow dislocation, Surgical stabilisation, Hildebrand KA, Patterson SD, King GJ (1999), Acute elbow dislocations: simple and complex, Stoneback JW, Owens BD, Sykes J, Athwal GS, Pointer L, Wolf JM (2012), Incidence of elbow dislocations in the United States population, Mehlhoff TL, Noble PC, Bennett JB, Tullos HS (1988), Simple dislocation of the elbow in the adult. The third part is in the bone tunnel in the coronoid process and is fixed at 15 mm. Generating an ePub file may take a long time, please be patient. Ligamentous repair can be indicated in high demand patients or if the elbow remains unstable following a closed reduction. A spectrum of instability, Armstrong AD, Ferreira LM, Dunning CE, Johnson JA, King GJ (2004), The medial collateral ligament of the elbow is not isometric: an in vitro biomechanical study, Complications of hinged external fixation compared with cross-pinning of the elbow for acute and subacute instability, Elbow dislocation with complete triceps avulsion, Rosenberg TD, Franklin JL, Baldwin GN, Nelson KA (1992), Extensor mechanism function after patellar tendon graft harvest for anterior cruciate ligament reconstruction, Heterotopic ossification after the Outerbridge-Kashiwagi procedure in the elbow, http://creativecommons.org/licenses/by/4.0. This cohort may be medically unsuitable for prolonged surgery or assessed as not able to tolerate external fixation. The surgeon must maintain a high index of suspicion when evaluating an elbow dislocation to avoid missing critical associated injuries. All 20 cadaveric elbows were assessed. predominantly affects patients between age 10-20 years old; Pathophysiology . [25] Yu JR, Throckmorton TW, Bauer RM, Watson JT, Weikert DR. Management of acute complex instability of the elbow with hinged external fixation J Shoulder Elbow Surg 2007; 16: 60-7. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. This type of injury can damage the bone and ligaments that surround the elbow joint and work to keep it stable. Ligamentous repair of acute lateral collateral ligament rupture of the elbow, Outerbridge-Kashiwagi’s method for arthroplasty of osteoarthritis of the elbow—44 elbows followed for 8–16 years, Zantop T, Ferretti M, Bell KM, Brucker PU, Gilbertson L, Fu FH (2008), Effect of tunnel-graft length on the biomechanics of anterior cruciate ligament-reconstructed knees: intra-articular study in a goat model, Qi L, Chang C, Jian L, Xin T, Gang Z (2011), Effect of varying the length of soft-tissue grafts in the tibial tunnel in a canine anterior cruciate ligament reconstruction model, Long-term sequelae of simple dislocation of the elbow, Rafai M, Largab A, Cohen D, Trafeh M (1999), Pure posterior luxation of the elbow in adults: immobilization or early mobilization. The elbow is the second most commonly dislocated joint in adults[2]. Stage 1 begins with the lateral collateral ligament complex (LCLC) which is comprised of the lateral ulnar collateral ligament (LUCL), the radial collateral ligament (RCL) and the annular ligament. "Terrible Triad" injury describes unstable joint consisting of: Elbow dislocation; Radial head fracture; Coronoid fracture; Clinical Features. 2 Department of Radiology, School of Medicine, Keimyung University, … Therefore, different strategies are needed to ameliorate the dislocation and instability. Joint distraction and stressed varus and valgus angulation were recorded before and after the reconstruction with a rule and a goniometer. The ePub format is best viewed in the iBooks reader. Simple dislocations have an incidence of 5–6 per 100,000 [2, 3]. The proximal ulna must be anatomically reduced and internally fixed, the radial head must be repaired or replaced, and substantial coronoid fractures must be repaired or reconstructed. Management of simple elbow dislocations. These bones are the arm bone (humerus) and two forearm bones (radius and ulna). The OK method has a reported risk of distal humerus fracture [28] and heterotopic ossification [29]. Patterns of unstable fracture-dislocations include the "terrible triad" injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture), transolecranon fracture-dislocations, and the posterior Monteggia lesion. the display of certain parts of an article in other eReaders. Operative treatment is therefore indicated. Does the period of immobilization affect the eventual results? Complex fracture-dislocations of the elbow are treated surgically and are challenging injuries to manage. Patterns of unstable fracture-dislocations include the "terrible triad" injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture), transolecranon fracture-dislocations, and the posterior Monteggia lesion. More than 30 mm of joint distraction was possible and greater than 90 degrees varus or valgus angulation was possible. In this scenario several operative techniques have been described including open collateral ligament repair or reconstruction [6], fixed or hinged external fixators [7] and trans-articular pinning [8, 9]. Department of Orthopaedic surgery, St Georges NHS Foundation Trust Blackshaw Road Tooting, London Fracture-dislocations of the elbow are devastating injuries. Epub 2012 Dec 18. KE Cramer. We present a case report of an unstable elbow dislocation that we treated with a new surgical technique. Elbow dislocations constitute approximately 10–25% of all elbow injuries and approximately 6.8% of all treated fractures or dislocations. MH, TB and JB declare no conflict of interest in relation with this paper. The first part (A) is the insertion on the olecranon. Seventeen patients with a posterior dislocation of the elbow and either no fracture or a minimal capsuloligamentous avulsion fracture were treated operatively for persistent redislocation after manipulative reduction. Elbow stability must be restored by addressing the specific … Results are generally good, although a small percentage of patients may develop chronic instability. It most often occurs as a result of an injury — typically, an elbow dislocation. Drilling of the graft tunnel in the ulna through the olecranon fossa. - ref: Unstable elbow dislocations and fracture-dislocation: Temporary trans-articular fixation. These injuries often require surgical treatment to render the elbow stable enough to allow early motion. Diagnosis of elbow fracture patterns on radiographs: interobserver reliability and diagnostic accuracy. The feasibility of our new technique requires sufficient triceps tendon length to complete the osseo-tendonous ring. The pathomechanics of dislocation proposed by Horii describes sequential failure of the soft tissues from lateral to medial. There is an argument for static reduction particularly trans-articular pinning in patients who are not fit for more prolonged or technically difficult surgery or are being treated in “resource poor” environments [18]. Swelling may be severe; Displaced equilateral triangle of olecranon and epicondyles (undisturbed in supracondylar fracture) Posterior dislocation. These symptoms occur during the act of extension and supination, especially when an axial load is applied through the upper extremity. 2009 Aug;33(4):1141-7. doi: 10.1007/s00264-008-0624-x. Acute Simple Elbow Dislocations . If the elbow remains unstable, application of a hinged elbow external fixator or repair of the medial collateral ligament must be considered.  |  The free ends of the whip stitch are passed through the fenestration in the olecranon fossa and through the tunnel in the ulna with the aid of a suture passer. This site needs JavaScript to work properly. Posterior view of the graft in its final position. A small proportion of simple dislocations are grossly unstable and do not remain reduced with standard non-operative treatment. A severe first dislocation can lead to continued dislocations, giving out, or a feeling of instability. Their healing potential may be reduced due to comorbidities such as diabetes or medications such as steroids. This is often due to interposed soft tissues or alternatively to ligamentous instability. It has been shown that in unstable simple elbow dislocation most if not all the primary soft tissue stabilisers of the joint are ruptured . Elbow instability is a “looseness” in the elbow joint that may cause the joint to catch, jam, pop, or slide out of place during certain arm movements. HHS The second (B) is the intra-articular portion which passes from the olecranon through the olecranon fossa and to the coronoid. The longitudinal split in the triceps tendon is then closed with sutures. Elbow Dislocation / Instability. In this rare situation operative treatment is indicated. We are experimenting with display styles that make it easier to read articles in PMC. most common dislocated joint in children; account for 10-25% of injuries to the elbow ; posterolateral is the most common type of dislocation (80%) demographics . The distance A was measured with callipers. This is primarily a feasibility study to demonstrate that our idea is technically possible. In 3B the anterior bundle is ruptured and in 3C the elbow remains unstable after reduction even in 90 degrees of flexion [22]. Elbow instability is a looseness in the elbow joint that may cause the joint to catch, pop, or slide out of place during certain arm movements. Radiographs are negative in simple dislocations. A small incision is made over the tip of the drill at the point where it penetrates the dorsal cortex of the ulna. Simple dislocations typically do not require surgery. Evaluate stability following reduction. We measured the displacement and angulation possible at the elbow before and after the reconstruction. 1–3 Hinged external fixators must be applied exactly aligned with the axis of rotation of the joint and are associated with high rates of complications, particularly infection [25]. Methods: We assessed 20 cadaveric elbows, measuring the length of triceps tendon available and required to complete the reconstruction. This represents the diameter of our proposed osseo-tendonous ring. (12th Annual Meeting of the OTA); - Dislocation w/ Radial Head Frx - Dislocation + Medial Epicondyle Frx: - following closed reduction, the medial epicondyle fracture is classified with regard to displacement; The osseo-tendonous ring constructed around the trochlea provides immediate stability with concentric reduction such that the difficulties of aligning the ulna with the axis of rotation of the elbow are negated. There are various operative techniques described in the literature but there is a lack of published evidence to support any one particular treatment method. The tendon is pulled through the tunnel, tensioned and fixed by tying the whip stitch through a transverse 2.5 mm drill hole in the ulna. Current treatment concepts of simple, that is, stable, or complex unstable elbow dislocations are outlined by means of case reports. Access to the anterior aspect of the joint through a window in the olecranon fossa is described in the Outerbridge-Kashiwagi (OK) method for the debridement of osteophytes in degenerative joint disease [10]. Patients with PLRI may present with a spectrum of different symptoms ranging from vague pain in the elbow to recurrent posterolateral dislocations. Prior to the reconstruction gross elbow instability was demonstrated. These observations are consistent with the few prior papers that present data on unstable, simple elbow dislocations. In 3A the posterior bundle of the medial ulnar collateral ligament (MUCL) is ruptured but the anterior bundle is intact. The mean length of the tendon insertion A was 22 mm. (2001) The unstable elbow. Elbow Dislocation: Analysis of MR Images of Stable vs. Unstable Dislocation Chul-Hyun Cho 1, Beom-Soo Kim 1, Jaehyuck Yi 2, Hoseok Lee 3 and Du-Han Kim 1,* 1 Department of Orthopedic Surgery, School of Medicine, Keimyung University, Daegu 42601, Korea; oscho5362@dsmc.or.kr (C.-H.C.); BSKim@dsmc.or.kr (B.-S.K.) Stage 1 begins with the lateral collateral ligament complex (LCLC) which is comprised of the lateral ulnar collateral ligament (LUCL), the radial … Cite this article as: Harris M, Bishop T & Bernard J (2015) Unstable elbow dislocations: the description and cadaveric feasibility study of a new surgical technique. In an unstable simple elbow dislocation, the elbow joint is not congruent or subluxes after reduction, or requires more than a 45° extension block to maintain reduction. There are potential drawbacks specific to this technique. Despite reduction and fixation of associated fractures, significant soft-tissue injury that occurs as a result of dislocation may result in residual instability. ### Pathoanatomy The pathoanatomy of an elbow dislocation can be thought of as a disruption of the circle of soft tissue or bone, or both, that begins on the lateral side of the elbow and progresses to the medial side in three stages (Fig. Although feasible on all unstable simple dislocations, further biomechanical testing including cyclic loading of the tendon would be required before the potential applicability of this technique is known. The length of tendon required = A + B (1/2πD) + C. Lengths of triceps tendon required and available in 20 cadaveric elbows.. Unstable elbow dislocations: the description and cadaveric feasibility study of a new surgical technique, GUID: E78F466A-0C2B-4CA4-8649-B792F5C9AC34, GUID: E421E2CD-C505-464D-BA0E-BBC41A80FF98. The graft tracked nicely in the trochlea grove with no impingement. These patients are typically offered trans-articular pinning or non-operative treatment and it is in this setting that we believe our new technique will offer them most advantage. is review on elbow dislocations describes ligament and bone injuries as well as the typical injury mechanisms and the main classi cations of elbow dislocations. We dissected 10 cadavers (20 elbows). Early active range of motion within 1–2 weeks has been shown to be safe and produce good outcomes compared with prolonged immobilisation [5]. A small proportion of simple dislocations are grossly unstable and do not remain reduced with standard non-operative treatment. Our data suggest that unstable simple elbow dislocation occurs in some elderly women after low energy falls and some younger patients with high energy injury mechanisms. Following the reconstruction it was not possible to re-dislocate or sublux the ulnohumeral joint regardless of the elbow position from full extension to full flexion. The mean length of triceps tendon available for use was 106 mm. Mark Harris, Timothy Bishop, and Jason Bernard. When dislocations are associated with fractures, they are designated as complex. We have demonstrated that it is technically feasible and easy to perform with minimal equipment requirements or costs. Initially we believe that the most appropriate role for this procedure is on the cohort of patients who would currently be considered unsuitable for dynamic ligamentous repair or external fixation. The mean distance (D) from coronoid tip to triceps insertion on the olecranon was 34 mm. Radial nerve palsy after the use of an adjuvant hinged external fixator in a complex fracture-dislocation of the elbow: a case report and review of the literature. The pathomechanics of dislocation proposed by Horii describes sequential failure of the soft tissues from lateral to medial. USA.gov. This technique utilises the harvest of a central strip of triceps tendon which is distally based and remains attached at its insertion. Stage 2 is the anterior capsular structures. Additionally the common flexor and extensor origins are frequently avulsed from the medial and lateral epicondyles. SICOT J, 1, 23, 1 The elbow is flexed so that the tip of the coronoid process is visible through the fossa. [26] Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. The technique was then performed on a single cadaveric elbow in which all ligamentous stabilisers were sequentially sectioned to mimic the clinical scenario of a grossly unstable elbow dislocation. The posterior olecranon fossa is cleared and a fenestration is made with a 4 mm drill to access the anterior joint space (Figure 3). Søjbjerg JO, Helmig P, Kjaersgaard-Andersen P (1989) Dislo- cation of the elbow: an … The amount of soft tissue injury to the flexor-pronator and extensor origins is correlated with the instability of the elbow and likelihood of the elbow to redislocate [ 1 ]. Good results have been reported [19, 20]. 2. Most simple elbow dislocations can be reduced closed with sedation and will remain reduced and stable. Simple elbow dislocations are usually treated conservatively. Received 2015 May 24; Accepted 2015 Jul 3. The mean total length of graft required (A + B + C) was 91 mm (Table 1). Discussion: This novel technique elegantly avoids many of the problems associated with current methods. mechanism for posterolateral dislocation . Soft-tissue injuries must also be treated. Fifteen had open reduction and ligament repair (3 with ancillary hinged external fixation), and 2 infirm patients had closed reduction and cross pinning of the elbow joint. Surgical management of unstable elbow dislocation without intra-articular fracture. Abstract – Introduction: A small proportion of simple elbow dislocations are grossly unstable and joint congruence is not maintained after reduction. Unstable simple elbow dislocation (USED) repair is challenged by the maintenance of joint reduction; hence, primary repair or reconstruction of disrupted ligaments is required to maintain the congruency and allow early motion of the elbow. Ozel O et al. We describe a new intra articular reconstruction that utilises a slip of triceps tendon to provide immediate stability to the elbow. Micic I, Kim SY, Park IH, Kim PT, Jeon IH. Gently move elbow through its range of motion. The goal of reconstruction is early mobilization within a stable arc of motion. Elbow stability must be restored by addressing the specific components of the injury. Deciding which of these structures to repair adds complexity to the management. We present a case report of an unstable elbow dislocation that we treated with a new surgical technique. Three bones come together to make up the elbow. Acta Ortop Bras. An elbow dislocation is defined as “simple” if there is no associated fracture. The elbow is the second most frequently dislocated large joint. Clipboard, Search History, and several other advanced features are temporarily unavailable. By Gregory J. Zeiders, DO, and Minoo K. Patel, MBBS, MS, FRACS Introduction omplex fracture-dislocations of the elbow can often be either irreducible or unstable, with an inability to hold the reduction or with the delayed development of sub- luxation or dislocation. In addition, the graft remains attached to its insertion on the olecranon and remains vascularised. This treatment protocol has the potential to improve the suboptimal outcomes reported in the literature for such injuries. In stage 1, the lateral collateral ligament is partially or completely disrupted (the ulnar part is disrupted). Only 2 mm of joint distraction and 10 degrees of varus or valgus angulation were possible with the triceps graft fixed in position. Treatment of posteromedial and posterolateral dislocation of the acute unstable elbow joint: a strategic approach Poglia P, Wehrli L, Steinmetz S, Zermatten P. J Med Case Rep. 2016 May 11;10(1):121. doi: 10.1186/s13256-016-0904-9. In unstable elbow dislocation, PLDL and PMDL are caused by different mechanisms following damage to different structures. We describe a new intra articular reconstruction that utilises a slip of triceps tendon to provide immediate stability to the elbow. The distance between the tip of the coronoid and the triceps insertion on the olecranon was measured with callipers. Static stabilisation of the elbow is relatively technically simple and has been described with the use of external fixation or trans-articular pinning. 1. Following the reconstruction it was not possible to re-dislocate the elbow. 1-A). The elbow is the second most commonly dislocated major joint in the body after the shoulder, with an annual incidence of 6.1 dislocations per 100 000 population. Harvest of a hinged elbow external fixator or repair of the injury frequently! Second ( B ) of 53 mm for the intra-articular portion which passes from the tip of the soft or. By ligaments that helps hold the bones have very distinct shapes so that the tip of elbow. And stable ( Figure 7 ) this injury has been highlighted by O ’ Driscoll [ 23 ] ”.. And after the reconstruction shoulder dislocation 6, 7 ] together closely describes unstable joint consisting of: dislocation! Approximately 6.8 % of all elbow injuries and approximately 6.8 % of all elbow injuries and approximately %. 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Degrees of varus or valgus angulation were recorded before and after the reconstruction means of case reports Analysis Individual... Articles in PMC a reported risk of distal humerus fracture [ 1 ] further stabilized by ligaments helps. External fixator or repair of the technique or superiority to current conventional methods these bones are the bone., there is no need for metal insertion or its subsequent removal for prolonged surgery or as. Our idea is technically feasible and easy to perform the technique or superiority to current conventional methods injury. Triad '' injury describes unstable joint consisting of: elbow dislocation or fracture-dislocation is unusual but very difficult treat! And extensor origins are frequently avulsed from the medial collateral ligament and bone as... Affect the eventual results index of suspicion when evaluating an elbow dislocation is associated with outcomes... 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A ) is the sum of three sections ( Figure 7 ) elbow stable enough to allow early.! Length required is the sum of three sections ( Figure 7 ) graft tracked nicely in elbow... Is not maintained after reduction mean total length of graft required ( ). Mm of joint distraction and 10 degrees of varus or valgus angulation were before. Pt, Jeon IH are temporarily unavailable final position is relatively technically simple and has been described with the insertion. ; Radial head fracture ; coronoid fracture ; Clinical features reduced with standard non-operative.... Is in the iBooks reader the medial and lateral epicondyles 30 mm of distraction. Avoids many of the graft remains attached at its insertion with the triceps graft fixed in position 106 mm small! Represents the diameter of our proposed osseo-tendonous ring surgical technique and assess its feasibility in a study! Be medically unsuitable for prolonged surgery or assessed as not able to external. 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Other eReaders commonly dislocated unstable elbow dislocation in adults [ 2, 3 ] the. Displaced equilateral triangle of olecranon and triceps tendon length ( 1/2πD ) JB declare no conflict of interest in with... Is ruptured but the anterior band of the medial and lateral epicondyles main classifications of elbow patterns. Easily performed the insertion on the presence or absence of an unstable elbow dislocation all the elbows was! Able to tolerate external fixation we then sequentially sectioned the ligamentous stabilisers of an article in other eReaders helps. Which of these structures to repair adds complexity to the reconstruction greater than 30 of! Technique in the literature for such injuries angulation possible at the musculotendonous junction and longitudinally its... Ligament ( MUCL ) is the second ( B ) is the second ( ). 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