Elbow Lateral Collateral Ligament Injuries

CURRENT CONCEPTS

Elbow Lateral Collateral Ligament Injuries Lee M. Reichel, MD, Graham S. Milam, MD, Sean E. Sitton, BS, Michael C. Curry, MD, Thomas L. Mehlhoff, MD CME INFORMATION AND DISCLOSURES The Review Section of JHS will contain at least 3 clinically relevant articles selected by the editor to be offered for CME in each issue. For CME credit, the participant must read the articles in print or online and correctly answer all related questions through an online examination. The questions on the test are designed to make the reader think and will occasionally require the reader to go back and scrutinize the article for details. The JHS CME Activity fee of $20.00 includes the exam questions/answers only and does not include access to the JHS articles referenced. Statement of Need: This CME activity was developed by the JHS review section editors and review article authors as a convenient education tool to help increase or affirm readers’ knowledge. The overall goal of the activity is for participants to evaluate the appropriateness of clinical data and apply it to their practice and the provision of patient care. Accreditation: The ASSH is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. AMA PRA Credit Designation: The American Society for Surgery of the Hand designates this Journal-Based CME activity for a maximum of 2.00 “AMA PRA Category 1 Credits™”. Physicians should claim only the credit commensurate with the extent of their participation in the activity. ASSH Disclaimer: The material presented in this CME activity is made available by the ASSH for educational purposes only. This material is not intended to represent the only methods or the best procedures appropriate for the medical situation(s) discussed, but rather it is intended to present an approach, view, statement, or opinion of the authors that may be helpful, or of interest, to other practitioners. Examinees agree to participate in this medical education activity, sponsored by the ASSH, with full knowledge and awareness that they waive any claim they may have against the ASSH for reliance on any information presented. The approval of the US Food and Drug Administration is required for procedures and drugs that are considered experimental. Instrumentation systems discussed or reviewed during this educational activity may not yet have received FDA approval. Provider Information can be found at http://www.assh.org/Pages/ContactUs.aspx. Technical Requirements for the Online Examination can be found at http://jhandsurg. org/cme/home. Privacy Policy can be found at http://www.assh.org/pages/ASSHPrivacyPolicy.aspx.

ASSH Disclosure Policy: As a provider accredited by the ACCME, the ASSH must ensure balance, independence, objectivity, and scientific rigor in all its activities. All authors participating in the activity are required to disclose to the audience any relevant financial relationships with any commercial interest to the provider. The intent of this disclosure is not to prevent authors with relevant financial relationships from serving as authors, but rather to provide members of the audience with information on which they can make their own judgments. The ASSH must resolve any conflicts of interest prior to the commencement of the educational activity. It remains for the audience to determine if the audience’s relationships may influence the educational content with regard to exposition or conclusion. When unlabeled or unapproved uses of drugs or devices are discussed, these will also be indicated. Disclosures for this Article Editors The editors involved with this CME activity and all content validation/peer reviewers of this journal-based CME activity have reported no relevant financial relationships with commercial interest(s). Authors All authors of this journal-based CME activity have reported no relevant financial relationships with commercial interest(s). Planners The planners involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s). The editorial and education staff involved with this journal-based CME activity has reported no relevant financial relationships with commercial interest(s). Learning Objectives • Discuss the anatomy of the lateral collateral ligament (LCL) complex of the elbow. • State the definition of posterolateral rotatory instability. • State the role of the radial head with respect to tension within the LCL complex of the elbow. • Discuss the various etiologies that can lead to an LCL complex and posterolateral elbow instability. • Describe childhood distal humerus fractures that can lead to posterolateral elbow instability. • Summarize the provocative maneuvers to reproduce posterolateral elbow instability. Deadline: Each exam purchased in year 2012 must be completed by January 31, 2013 to be eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to complete each month’s JHS CME activity is 2 hours. Copyright © 2013 by the American Society for Surgery of the Hand. All rights reserved.

Current Concepts

The lateral collateral ligament (LCL) of the elbow is a complex capsuloligamentous structure critical in stabilizing the ulnohumeral and radiocapitellar articulations. LCL injury can result in elbow instability, allowing the proximal radius and ulna to externally rotate away from the humerus as a supination stress is applied to the forearm. Elbow dislocation is the most common cause of LCL injury, followed by iatrogenic injury. LCL pathology resulting in late recurrent instability is rare but disabling. The diagnosis requires a high index of suspicion, detailed history, and focused physical examination maneuvers. Stress radiographs are often the most useful imaging modality. Despite controversy over the anatomy of the LCL complex and the relative importance of its component structures, treatment of late instability is focused on lateral ligament reconstruction from the humerus to the ulna using tendon grafts

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with reasonably good outcomes. (J Hand Surg 2013;38A:184–201. Copyright © 2013 by the American Society for Surgery of the Hand. All rights reserved.) Key words Lateral collateral ligament, posterolateral elbow instability, posterior lateral rotatory instability, elbow instability.

From the Department of Orthopedic Surgery, Baylor College of Medicine, Ben Taub General Hospital, Houston, Texas; and Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX. Received for publication October 7, 2012; accepted October 25, 2012. TheauthorsthankWhitneyL.Reichel,BFA,forpreparationofillustrationsandScottyBolleter,Chief,Officeof ClinicalDirection,CentreforEmergencyHealthSciences,BulverdeSpringBranchEmergenceMedicalService.

of the lateral collateral ligament (LCL) allowed for “transient rotatory subluxation of the ulnohumeral joint and secondary dislocation of the radio-humeral joint.” They also reported on successful ligament reconstruction using palmaris graft and triceps fascia for treatment of recurrent posterolateral rotatory instability.4 Since the report by O’Driscoll in 1991,4 other studies have opposed the idea that the lateral ulnar collateral ligament (LUCL) is the primary restraint to posterolateral elbow instability, suggesting that various portions of the LCL complex can also oppose posterolateral elbow instability.5–7 FUNCTIONAL ANATOMY The LCL complex of the elbow has been traditionally divided into 4 structures: the annular ligament, radial collateral ligament (RCL), LUCL, and accessory LCL. Controversy exists regarding its components and their relative importance8 (Fig. 1). Variations in normal anatomy of the LCL complex have been well described. These variations are not only of interest in repairing and reconstructing the injured complex, but an understanding of anatomy and variations may also be important in the development and use of unconstrained total elbow prostheses, which are dependent on ligament integrity. Anatomists were the first to describe the lateral collateral ligamentous complex of the elbow. B. F. Martin in 1958 reported that Henle in 1871 described, “the lateral ligament of the elbow joint as spreading out on the annular ligament, some of its fibers passing forwards and others backwards to gain the ulnar interosseous border; presumably this should be taken to mean the supinator crest, which continues into the interosseous border.”9 Morrey and An in 19853 noted that in 5 of 10 specimens, “a well-defined posterior margin of the radial collateral ligament inserted on the ulna at the

Corresponding author: Lee M. Reichel, MD, Department of Orthopedic Surgery, Baylor College of Medicine, Ben Taub General Hospital, 1504 Taub Loop, Houston, TX 77030; e-mail: [email protected]. 0363-5023/13/38A01-0037$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2012.10.030

No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.

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Current Concepts

BRIEF HISTORY Eduard Albertfirst, in 1881, in a German report entitled “Lehrbuch der Chirurgie und Opertionslehre,” described a case of recurrent dislocation, in which the radius and ulna displaced medially. Bloch in 1900 reported on recurrent posterior dislocation of the radius and ulna.1 Osborne and Cotterill in 19662 described mechanism of injury and pathology associated with acute and recurrent elbow dislocations. They reported that acute dislocations were caused by a fall on the outstretched hand with the elbow incompletely extended. According to their report, this mechanism resulted in greatest movement on the lateral aspect of the joint, with the lateral ligament being stripped superiorly, as well as tearing of the posterolateral capsule, allowing the radial head to rotate backward from the “capitular” surface.2 With regard to recurrent dislocation, they wrote, “the essential pathological defect causing recurrent dislocation of the elbow is failure of the posterolateral ligamentous and capsular structures, torn or stretched at the time of an initial simple traumatic dislocation, to become reattached. . . . [A] simple vertical thrust, as in leaning on the arm, will force the coronoid process against the laterally sloping surface of the trochlea, which imparts to it a posterolateral rotation movement. The coronoid process is disengaged from under the trochlea and the whole forearm then rides posteriorly. The lateral structures are more lax than the medial structures and the head of the radius, therefore, travels farther, rotating through a greater arc than the ulna, which simply displaces behind the humerus.”2 Morrey and An in 19853 described functional anatomy of the elbow and also suggested that release of the “radial collateral ligament” of the elbow increases rotatory laxity of the ulna. O’Driscoll et al in 19914 coined the term, “posterolateral rotatory instability” of the elbow and believed that the laxity of the ulnar part

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FIGURE 1: A–D Cadaveric specimens depict the capsuloligamentous anatomy of the lateral collateral ligament (LCL) complex. H, humerus; R, radius.

Current Concepts

tubercle of the crista supinatoris.” They termed this the lateral ulnar collateral ligament. In 9 of 10 specimens, they noted that fibers from the inferior margin of the annular ligament were observed to insert on the ulna at the crista of the supinator, which had been previously termed the “accessory posterior annular ligament.3,9 Interestingly, O’Driscoll et al in 19914 in their report on posterolateral elbow instability reported that the ulnar part of the LCL is “the major structure that prevents the ulna from rotating on its long axis away from the

trochlea” and cited Morrey and An’s report,3 previously cited, even though the LUCL was found only in 5 of 10 specimens in that report (Fig. 2). Cohen and Hastings in 199710 performed anatomical dissections and experiments on 40 cadaveric specimens. They noted that, in 22 specimens, the insertion onto the ulna of the LCL was bilobed, and in 18 specimens a single broad conjoined ligament inserted onto the ulna. In addition, they performed serial sectioning studies and concluded that the primary restraint

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to posterolateral elbow instability was the combination of the LCL and annular ligaments, “which coalesce to insert broadly over a two-centimeter area on the proximal aspect of the ulna.”10 They also detailed the role of muscular stabilizers to the lateral elbow; specifically that the extensor carpi ulnaris and its fascial band can provide significant support to the lateral elbow. Importantly, they noted that, “. . . damage of more than one structure is necessary to have a substantial amount of lateral instability of the elbow . . . attenuation or avulsion of both the ligamentous and the muscular origins from the lateral epicondyle.”10 Their cadaveric study suggested that the supinator, which becomes confluent with the LCL complex, and the extensor fascia/septae support the LCL complex and resist subluxation and external rotation (Figs. 3–5).

We have seen that recovery of a radial nerve injury can coincide with improved stability following lateral ligamentous complex repair, suggesting that muscular stabilizers are indeed clinically important to overall elbow stability (Fig. 6). Imatani et al in 19997 performed gross anatomical and cross-sectional histological studies on 15 cadaveric elbows. They reported it was difficult to define the boundaries between the LUCL and other structures, but on microscopy, histological sections of the LUCL were identified as “slender and vague” posterior to the RCL. They concluded that the LUCL contributes to, rather than acts as a major constraint to, posterolateral elbow instability. In addition, they distinguished the LUCL as passing directly from the humerus to the ulna, unlike

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FIGURE 2: A Cadaveric specimen demonstrates the lateral ulnar collateral ligament (LUCL) insertion to the supinator crest. Of note the distal extent of the LUCL insertion when present also serves as the origin for the supinator muscle. RCL, radial collateral ligament. B A separate cadaveric specimen demonstrates no LUCL inserting onto the supinator crest. In this specimen, prominent ligamentous tissue inserts onto annular ligament. The asterisk denotes the thickened band of lateral collateral ligament (LCL) complex tissue, which is uniformly confluent with the extensor digitorum communis origin, making the Kaplan approach (extensor digitorum comminus/extensor carpi radialis brevis interval) a more LCL-sparing approach for radial head fractures and lateral epicondylitis surgery. C Posterior view of B demonstrating again no LUCL. The lateral collateral ligament complex ends at the lesser sigmoid notch. Blue markings demonstrate the course of fibers (note no significant fibers course directly from the humerus to the ulna).

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FIGURE 3: A Cadaveric specimen shows specific muscular contributions to common extensor origin. ECRB, extensor carpi radialis brevis; ECU, extensor carpi ulnaris; EDC, extensor digitorum communis; EDQ, extensor digiti quinti. B Rendering of specific muscular contributions to the common extensor origin. ECRL, extensor carpi radialis longus. C Kocher interval to the LCL demonstrated between ECU and anconeus. D Supinator is the deepest muscular layer and proximal fibers are anchored to the LCL complex. When the lateral ulnar collateral ligament is present, the supinator arises from the anterior medial portion of its distal insertion and the bony supinator crest. LCL, lateral collateral ligament.

Current Concepts

the LCL complex and RCL, which blends with the annular ligament.7 Beckett et al in 200011 evaluated 39 embalmed cadaveric elbow joints and identified 4 anatomical groups. Group 1 (23%) contained the posterior band of the LCL, the LCL (what appears to be the RCL in their diagrams), and annular ligaments. Group 2 (44%) contained the posterior band of the LCL, the LCL (what appears to be the RCL in their diagrams), annular ligament, and LUCL. Group 3 (25%) contained the posterior band of the LCL, the LCL (what appears to be the RCL in their diagrams), annular ligament, and accessory collateral ligament. Finally, group 4 (7%) contained the posterior band of the LCL, the LCL (what appears to be the RCL in their diagrams), annular ligament, LUCL, and accessory collateral ligament. They noted that the LUCL was present in only 50% of their specimens. This finding supports the notion that the lateral collateral ligament (RCL) may act as the primary constraint to posterolateral instability, and that the annular ligament and the LUCL together act as secondary

restraint.11 They also noted that anomalous insertions of the LUCL inserting more distally into the ulna.11 Dunning et al in 20015 performed a cadaveric study to determine whether an intact RCL alone or an intact LUCL alone is sufficient to prevent posterolateral elbow instability when the annular ligament is intact. In a cadaveric model, they performed a sectioning study of the RCL, LUCL, or entire LCL from the humerus and determined varus-valgus laxity in forearm pronation and supination throughout the entire range of motion in 5° intervals. In addition, a pivot-shift test was performed after each differential sectioning. Interestingly, they found that, compared with the intact specimen, there were no significant differences of varus-valgus laxity of the ulna or internal-external rotation with either the RCL or the LUCL intact, but when both were sectioned from the humerus, a significant difference was detected in both varus-valgus and internal-external rotation. Also, the pivot-shift test was positive only when the entire LCL was sectioned from the humerus.5

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FIGURE 4: A, B Cadaveric specimens show the anatomical configuration of the lateral collateral ligament (LCL) complex between the anconeus and the extensor carpi ulnaris. ECU, extensor carpi ulnaris; LUCL, lateral ulnar collateral ligament.

Clinically, this information suggests that, with an intact annular ligament, sectioning of the RCL or the LUCL, but not both, poses little risk for the development of posterolateral elbow instability. They still recommended repair of the individual components if transected during surgery. Seki et al in 2002,6 in a sectioning study in 5 cadaveric elbows, hypothesized that the LCL complex is a 3-dimensional “Y”-shaped structure. Using 3-dimensional kinematic testing, they concluded that the LCL complex restrains rotatory stress when all 3 bands are tight. They hypothesized that application of external rotatory stress to the forearm tensions the 3 bands (which are fixed on the radial head and act as virtual insertion to the ulna), stabilizing the radioulnar, radiohumeral, and ulnohumeral joints simultaneously. Takigawa et al in 200512 performed a morphological and strain study on 26 fresh-frozen cadavers. They noted 3 types of LUCL morphologies. The LUCL in 8 specimens were bilobed similar to that described by

Cohen and Hastings (type 1).10 In 9 specimens, the LUCL attached to the ulna as a broad expansion similar to that described by Cohen and Hastings (type 2). In addition, they described a “type 3” insertion pattern in 9 specimens in which there was a broad single expansion along with a thin membranous fiber. They determined that onset of strain in proximal fibers occurs between 30° to 40° of flexion maximizing at 50° to 60° and that proximal strain measurements in the proximal fibers were significantly greater than in the distal fibers (0.21 vs 0.01). Also, proximal fiber strain was not influenced by forearm rotation. They concluded that distal fibers have little function in stability and that the most important constraint to posterolateral elbow instability is the continuity of the RCL and proximal fibers of the LUCL with the annular ligament.12 Reichel and Morales in 201213 evaluated the gross anatomy of 6 paired cadaveric specimens and identified 3 discrete anterior capsular bands in each specimen: the anterior lateral, the anterior medial oblique, and the

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FIGURE 5: A Cadaveric specimen demonstrates the confluence of the lateral collateral ligament (LCL) complex and the supinator muscular origin. B Rendering of the blending of the LCL complex and the supinator muscle.

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Current Concepts

FIGURE 6: Improved lateral elbow stability following recovery of radial nerve palsy demonstrating the importance of muscular stabilizers following lateral collateral ligament (LCL) injury. A Injury films of a 4-week-old elbow dislocation. B Following open reduction/ligament repair/hinged external fixation. C Day of removal of fixator 8 weeks after surgery. D Twelve weeks postoperative x-ray demonstrates varus laxity. E, F Thirteen-month follow-up after recovery of radial nerve palsy with improved but not eliminated varus laxity. G, H Resolved radial nerve palsy. I, J Thirteen-month flexion-extension clinical photographs.

anterior transverse bands, all of which have insertion points on the annular ligament (Fig. 7). They hypothesized that based on anatomical course, these bands may have stabilizing effects on the LCL, as well as conferring stability against hyperextension of the elbow joint.

Morrey and An in 1983,14 in a cadaveric study, found the anterior capsule to be a significant stabilizer to varus stress. This is contrasted by Nielsen and Olsen in 199915 who performed a cadaveric biomechanical study and reported that the elbow capsule had no sta-

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bilizing effect. They did hypothesize that the elbow capsule may act as a secondary constraint after rupture of the collateral ligaments. Ligament isometry is believed to be important during ligament reconstruction of LCL injuries to maintain concentric reduction of the ulnohumeral and radiocapitellar joints throughout the range of motion and to prolong the integrity of the tendon graft (Fig. 8). Considerable interest exists in identifying whether isometric points exist on the humerus and ulna for the LCL. This has proved a challenging task because the LCL has multiple components and broad origin and insertion points. Current literature suggests that the LCL is not isometric but that various components may be complementary, although many reconstructive elbow surgeons feel isometric points do exist. Moritomo et al in 200716 created 3-dimensional models of elbow bones, the LCL, and the RCL from magnetic resonance imaging (MRI) data of 6 subjects with elbow MRIs taken at various degrees of flexion. The origins and insertions of the ligament models were based solely on the osseous geometry, and they used anatomical landmarks for the origin and insertion points on the elbow, not the actual ligament insertion points.

Based on this theoretical study, they concluded that the LUCL lengthens during the flexion of the elbow whereas the RCL changes little and is nearly isometric. They considered, based on these theoretical findings, the RCL to be more important for elbow stability than the LUCL.16 Goren et al in 201017 performed a cadaveric study intended to locate the isometric point for LUCL tunnel placement in the humerus and ulna using electromagnetic sensors that can detect distances between sensors placed in varying locations in the distal humerus and ulna. The points that mostly approximated isometry on the humerus were at 3:00 and 4:30 o’clock when paired with ulnar points 16 mm to 20 mm distal to the head of the radius on the ulna. They concluded that there is no truly isometric location for LUCL tendon graft reconstruction. Drawbacks of this study were that markers, not actual tunnels, were used and tendon grafts were not actually inserted. Elbow flexion and extension as well as forearm rotation are believed to affect elbow stability and collateral ligament component length and tension. These concepts are important in understanding pathology, determining optimal surgical approach, limb positioning

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FIGURE 7: Cadaveric specimens demonstrate the anterior capsular bands inserting onto the annular ligament of the lateral collateral ligament (LCL) complex. A Anterior capsular bands. B Overlying markings demonstrating course of bands and insertion onto annular ligament. (Reprinted with permission from Reichel LM, Morales OA. Gross anatomy of the elbow capsule: a cadaveric study. J Hand Surg Am. 2013 [in press].)

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FIGURE 8: Technique commonly used to locate the isometric point on the humerus. A suture passed through the ulnar tunnels is placed on the humerus while the elbow is brought through flexion-extension. The point where the limbs of suture remain taut throughout the range of motion is considered the isometric point.

Current Concepts

during repair, and postoperative splint positioning. Current studies to elucidate contribution of various components of the LCL are primarily biomechanical and cadaveric. Jensen et al in 199918 performed a biomechanical study using cadaveric specimens to study the effect of radial head excision on laxity in varus and external rotation. In that study, they noted that the laxity observed after radial head excision was “of the same nature” but not as great as the laxity that occurs after the LCL is cut. They suggested that removal of the radial head reduces tension in the LCL, inducing laxity in forced varus and external rotation. This implies that the radial head serves to properly tension the LCL complex. This may have implications in proper repair or replacement of the radial head in assisting with proper tensioning of the LCL complex. Dunning et al in 200119 performed a cadaveric biomechanical study demonstrating that, when a cadaveric arm was placed in a vertical position (vs varus orientation), stability of the LCL-deficient elbow was similar to the intact elbow with the forearm held in pronation, but not similar to the intact elbow in supination. They suggested that therapy of the LCL-deficient elbow should avoid shoulder abduction to minimize varus stress, focus on active rather than passive motion, and when passive motion is performed, it should be performed in forearm pronation. Wavreille et al in 200820 performed a detailed cadaveric study using computed tomography (CT) scan-

ning and anatomical millimeter sectioning of 5 fresh cadaveric specimens to evaluate the pattern of fiber recruitment of collateral ligaments during passive motion and to determine the effect of forearm rotation position on ligament length. They divided the LCL into 4 components RCL, LUCL, annular ligament, and accessory collateral ligament. They found that, in extension, the RCL fibers were longer than the LUCL and that, in “extreme” flexion, the LUCL fibers were longer than the RCL fibers. They also reported that the LCL is longest in supination and shortest in pronation. They recommended that testing the LCL be done at 90° of flexion in supination because the LCL is longest in this position.20 It is clear from anatomical studies that variations in LCL anatomy exist and that the issue of isometry is complex. We know that injury to the entire LCL complex at the humeral origin can result in posterolateral elbow instability because both the RCL and the LUCL are affected. It is likely that the various components of the LCL, and not just the LUCL, function in concert to resist posterolateral instability. ETIOLOGY Any injury to the LCL complex and its secondary supporting structures can cause posterior lateral elbow instability. Injury to the LCL complex resulting in recurrent posterolateral elbow instability has been associated with simple and complex elbow dislocations, iatrogenic injury during surgery for lateral epicondylitis

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CLASSIFICATION O’Driscoll22 proposed a classification using 5 criteria: timing, articulations involved, direction of displacement, degree of displacement, and the presence or absence of fractures. Regarding timing, elbow instability

can be classified as acute, chronic, or recurrent. Articulations include the ulnohumeral and radiohumeral (called elbow articulation), proximal radioulnar joint, or both. Direction of displacement included posterolateral, anterior, valgus, and varus. Degree of displacement pertains to posterior lateral rotatory instability (PLRI). O’Driscoll22 defined stages of PLRI: stage 1, when the elbow subluxates in a posterolateral rotatory direction and the patient will have a positive lateral pivot-shift test. Stage 2 is when the elbow has an incomplete dislocation so the coronoid is perched under the trochlea. In stage 3, there is a complete elbow dislocation so that the coronoid is behind the humerus. With stage 3a, the anterior band of the medial collateral ligament (MCL) is intact, and after reduction, the elbow is stable to valgus stress. With Stage 3b, the anterior MCL is disrupted and the elbow is unstable to valgus stress after reduction. Finally, in stage 3c, there is complete soft tissue stripping of the elbow and it is grossly unstable even after the application of a splint or cast. Rhyou and Kim in 201228 proposed a new mechanism for posterolateral dislocation of the elbow after evaluating MRI scans of 15 patients with a simple elbow dislocation and 19 patients with pure ligamentous injuries to the elbow. They hypothesized based on MRI analysis that posterior lateral elbow dislocation begins from the medial side. Their hypothesis was based on the finding that more severe soft tissue damage occurred on the medial side of the elbow joint than on the lateral side and that medial-sided injury had a distractive injury pattern. This finding was in contrast to the lateral-sided injury where the soft tissues were detached from the lateral epicondyle near the original insertion and torn tissues were well marginated. They purported that axial force applied through the forearm acts as the valgus distractive force secondary to the normal anatomical cubitus valgus. This mechanism is in contrast to the mechanism and classification proposed by O’Driscoll.22 CLINICAL PRESENTATION AND PHYSICAL EXAMINATION Patients with chronic LCL injuries and posterolateral elbow instability typically present following a history of trauma, such as simple elbow dislocation. Posterolateral elbow instability following surgery should raise concern for iatrogenic injury to the LCL. A spectrum of complaints, including pain, locking, clicking, snapping, and frank dislocation, is common. Symptoms are accentuated with activities resulting in supination, extension, and valgus forces such as carrying a grocery bag,

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as well as sequelae from nonoperative care of lateral epicondylitis, surgery to the radial head, and cubitus varus.21,22 Typically, in traumatic mechanisms, the LCL complex avulses from its humeral origin. Morrey in 199223 evaluated a cohort of 13 patients who had failure following surgery for lateral epicondylitis. Three of 13 patients demonstrated evidence of laxity (lateral capsuloligamentous insufficiency) following surgical intervention for lateral epicondylitis. Abe et al in 199524 reported posterolateral elbow instability resulting from childhood distal humerus fractures with subsequent varus malalignment and gunstock deformity. O’Driscoll et al in 2001,25 in a more comprehensive report, detailed 21 patients with longstanding cubitus varus: 3 secondary to congenital deformity (2 patients), 17 secondary to supracondylar malunion, and 2 secondary to lateral condylar fracture. Treatment consisted of reconstruction of the LCL and distal humeral osteotomy in 7 elbows, LCL reconstruction alone in 10, distal humerus osteotomy alone in 4, and total elbow arthroplasty alone in 1. They concluded that ligament reconstruction alone could provide excellent results in patients with small (⬍ 15°) varus angulation, those with new injury to the ligament, the low-demand patient, and nonathletic persons. They noted that not performing distal humerus osteotomy does place greater stress on the repair, and they performed valgus osteotomy of the distal humerus on all patients with greater than 15° varus angulation.25 Beuerlein et al in 200426 confirmed in a cadaveric biomechanical study that cubitus varus deformity of the elbow results in increased strain in the LUCL with an increase in the ulnohumeral joint opening and posterolateral rotatory instability seen clinically. Fifteen degrees and 20° of deformity were found to be significant in increasing lateral strain. Kalainov and Cohen in 200521 reported 3 patients with posterolateral rotatory instability of the elbow in association with lateral epicondylitis. All 3 patients had received corticosteroid injections before developing posterolateral elbow instability. Dzugan et al in 201227 reported on 7 patients who were being treated for chronic lateral epicondylitis who sustained an acute injury to there elbow and developed posterolateral rotatory instability. In all patients, a “pop” was reported at the time of their injury.

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and patients will report the elbow “feels like it’s giving out.” Confirmation of posterolateral elbow instability/LCL injuries can be difficult, particularly when the patient presents with vague symptoms. Several provocative maneuvers have been described to reproduce posterolateral elbow instability on clinical exam. O’Driscoll et al in 19914 described the posterolateral rotatoryinstability test (pivot shift). This physical examination maneuver and is considered the “gold standard.” This test is performed often with the patient lying down on the back with the arm over the head. The examiner grasps the patient’s forearm and, beginning in full extension and supination, slowly flexes the elbow applying valgus and supination forces and axial compression, resulting in external rotation of the ulna about humerus and eventual dislocation of the radiocapitellar joint. Maximal posterolateral rotatory displacement occurs at 40° and a dimple sign can be visualized at the lateral proximal forearm if there is dislocation from the absent radial head.4 Continued flexion results in joint reduction. They reported apprehension as a positive result. This test is best demonstrated under general anesthesia and, hence, has limited application in the office setting. Other provocative tests in the awake patient have been developed to diagnose posterolateral elbow instability LCL injuries. Arvind and Hargreaves in 200629 described the table-top relocation test. This test consists of 3 parts. The patient stands in front of a table and places the symptomatic extremity over the lateral edge of the table with the hand grasping the table. First, the patient presses up with the elbow pointing laterally, keeping the forearm in supination. Next, pressure is pushed down as the elbow is flexed while the patient brings her or his weight toward the table. Positive apprehension and pain reproduction occurs as the elbow reaches approximately 40° of flexion. The examination is then repeated with the examiner’s thumb supporting the radial head, preventing subluxation and relieving pain and instability. They reported this test and a pivotshift test were positive in 8 patients, 6 of whom underwent surgery. Six months after surgery, all patients had negative pivot-shift and table-top relocation tests. Regan and Lapner in 200630 reported on the pushup and chair apprehension signs for posterolateral elbow instability. The pushup sign is demonstrated while having the patient carry out an active floor pushup. The elbows are placed at 90° flexion with the forearms supinated and the arms abducted greater than shoulder width. The test is considered “positive” if apprehension occurs when the affected elbow is terminally extended from a flexed position with voluntary and involuntary

guarding or complete dislocation. The chair sign is elicited while having the patient perform a sitting pushup. The patient begins seated with elbows flexed to 90°, forearms supinated, and arms abducted greater than shoulder width. A positive test is demonstrated by the reluctance to extend the elbow fully while using arms to raise up from the chair. Eight patients with posterolateral elbow instability were examined. Three demonstrated a positive posterolateral rotatory instability test (pivot shift) while awake and all while under anesthesia, and 7 patients demonstrated positive pushup and chair signs. Following reconstruction at follow-up of 2 years, 7 patients were asymptomatic with negative pivot-shift, pushup, and chair signs, yielding a sensitivity of 87% for each individual test and 100% for both tests combined. This compared with a sensitivity of 38% for the pivot-shift test in the awake patient. A significant drawback of this study was that there were no true negatives so specificity could not be determined. IMAGING Various imaging modalities can be used to confirm the diagnosis of posterolateral elbow instability, including plain radiographs, stress radiographs, and MRI. Stress radiographs (including fluoroscopic examination) are typically the most useful. There are currently differing opinions regarding the use of MRI. Savoie et al in 200931 reported that MRIs were most helpful when contrast was added, either with formal arthrogram or, in the case of an office MRI, with the injection of 20 mL to 30mL of sterile saline just before the scan. Sanchez-Sotelo et al in 200532 reported that, if the clinical diagnosis is in doubt, a fluoroscopic examination should be performed and occasionally an examination under anesthesia, but the “other imaging studies such as MRI are usually not needed.”32 Several subtle findings can be noted when interpreting static and stress radiographs. Osborne and Cotterill in 19662 noted that a “permanent defect or crater in the postero-lateral margin of the capitulum occurs, and, with repeated dislocation, the edge of the radial head can become similarly damaged, sometimes with a crater or ‘shovel-like’ defect” and provided radiographs in their report. A similar radiographic finding was also described by Jeon et al in 2008,33 which they called the “Osborne-Cotterill lesion.” This was also described by Faber and King in 1998.34 O’Driscoll in 200022 reported that anteroposterior radiographs taken during the posterolateral rotatory stress test show slight malalignment of the ulnohumeral joint, overlap of the radial head and capitellum, or both. O’Driscoll noted it is “essential to realize that pseudovalgus instability can

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FIGURE 9: Demonstration of advantage of hinged elbow external fixation to allow early protected elbow range of motion (ROM) in concomitant wrist and elbow trauma. High-energy open wrist injury A with ipsilateral unstable elbow dislocation B. C Soft tissue coverage with hinged elbow external fixation application. D, E Internal fixation of wrist injury. F, I Plain films of the elbow after external fixation. G, H Elbow flexion-extension 4 weeks after surgery.

10 cadaveric subjects. Current studies have focused on determining the ability to reproducibly and accurately assess the LCL. Future studies are needed to define the role of ultrasound imaging in pathological settings. REPAIR Absolute indications for primary repair of the lateral ligament complex of the elbow have not been clearly defined. It is generally accepted that primary repair is indicated in acute injuries; however, the factors that influence surgical decision making have not been rigorously investigated. LUCL repair is well described in major texts as appropriate treatment to restore posterolateral stability in the setting of simple and complex elbow dislocation, but no primary literature regarding precise indications and techniques is routinely cited.37–39 Repair techniques typically employ bone anchors with nonabsorbable suture (#2 or #5) placed in the “bare area,” or site of avulsion of the humeral origin of the ligament. Nonabsorbable suture passed through bone tunnels drilled through the lateral epicondyle are also commonly used. Osborne and Cotterill in 19662 described repair of the lateral capsuloligamentous complex to address recurrent instability in cases of simple elbow dislocation. Their technique involved a lateral approach from lateral epicondylar ridge to annular lig-

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exist in the presence of posterolateral rotatory instability. This occurs as the coronoid and radial head slide under the trochlea because of posterolateral rotatory displacement, then permit valgus angulation to occur by pivoting around the intact medial collateral ligament.”22 He suggested that valgus instability always be tested while keeping the forearm fully pronated with a modest force. Garrigues et al in 201135 recently described the “hanging arm test” to assess intraoperative stability during terrible triad injury treatment. In this test, the elbow is placed in full extension and the forearm supinated with a stack of towels under the upper arm. The weight of the hanging arm results in a dislocating force and a lateral fluoroscopic image is obtained to determine whether the elbow remains reduced during this maneuver. Concentrically reduced elbows are considered stable. Reliability and validity for this test have not been published. Ultrasound assessment of the LCL is an attractive alternative to MRI because it is more widely available and lower cost than MRI imaging. Teixeira et al in 201036 evaluated 10 cadaveric elbows and 10 normal subjects with ultrasound to determine whether the RCL, LUCL, and annular ligament could be distinguished from surrounding structures. They were able to identify all of these structures in all normal subjects and in 8 of

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FIGURE 10: A Clinical photograph of a lateral ulnar collateral ligament (LUCL) reconstruction with a palmaris longus autograft. B Rendering of LUCL reconstruction with a tendon graft.

Current Concepts

ament, debridement of bony fragments, and direct repair through bone tunnels in the humerus with “catgut” suture. O’Driscoll et al in 19914 addressed posterolateral rotatory instability with repair in 3 of 5 patients. Reportedly, all patients regained normal range of motion (ROM) without instability. Sanchez-Sotelo et al32 described outcomes in 44 patients after surgical treatment for PLRI. Twelve of their 44 patients were treated with repair. Three of 12 developed recurrent instability and 1 sustained a new traumatic dislocation. Two required surgery to revise the repair to reconstruction. Seven of 12 were found to have satisfactory outcome, and those treated with reconstruction fared statistically significantly better as judged by the Mayo Elbow Performance Score (MEPS).40 Savoie et al in 200141 reported an arthroscopic technique for addressing the insufficient lateral ligamentous complex in posterior lateral elbow instability through anchor placement and capsular plication. Tensioning the structures at 60° of elbow flexion is recommended to prevent overtightening with loss of flexion.42 In 2009, Savoie et al31 reported results of both arthroscopic and open repair of the lateral ligament complex in 51 patients. Andrews-Carson scores were improved in all groups, with best results in the acute setting.31 Fraser et al in 200843 performed a biomechanical cadaveric study to evaluate the effectiveness of LCL transosseous suture repair and influence of ligament tensioning on the kinematics and stability of the elbow. Six cadavers were evaluated in a motion simulator with a tracking system. Transosseus sutures were placed and suture tension of 20, 40, and 60 N were evaluated. Initial kinematics of the elbow were restored at 20 N of tension. Greater tension resulted in overcorrection and varus instability with excessive valgus and internal ro-

tation tracking.43 Interestingly, they noted that “benchtop” studies with experienced surgeons have shown suture tension is in the order of 40 N and suggested that surgeons should be cautious to avoid excessive tension when performing LCL repairs.43 Hinged external fixators have been indicated to assist in maintaining reduction of the ulnohumeral joint and protecting repaired and reconstructed collateral ligaments.44 We have found that hinged elbow external fixators are essential in the multiply injured extremity (especially in ipsilateral wrist and elbow trauma and higher-energy injury) and polytrauma patients who do not have the ability to protect a lateral ligamentous repair. In these cases, a laterally placed external fixator acts as a tension band protecting against varus stress (Fig. 9). RECONSTRUCTION Significant effort has been made toward developing strategies to treat chronic LCL injuries and symptomatic posterior lateral elbow instability, but optimal treatment regimens have not been elucidated. Clinical studies have focused on reconstructive techniques and outcomes. These are primarily retrospective with small cohorts of patients. Comparative studies are lacking between repair and reconstruction and between various reconstruction techniques (Fig. 10 and Table 1). Recent studies have focused on subtle variations in older techniques and newer techniques including single-bundle repair and arthroscopic repair. Sanchez-Sotelo et al in 200532 reported the largest series to date of 44 patients treated surgically for PRLI over a 13-year period. Twelve patients were treated with repair and 32 with reconstruction. Their average

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Author

Comparative Studies of Lateral Collateral Ligament Reconstruction Year

Patients (n)

2012

14

Reconstruction with tendon grafts

8 Palmaris longus, 6 gracilis

Jones et al47

2012

8

Reconstruction with tendon graft

8 palmaris longus graft

Rhyou and Park50

2011

3

Palmaris longus, half slip of flexor carpi radialis tendon

Savoie et al31

2010

54

Sanchez-Sotelo et al32

2005

44

Dual reconstruction not using ulnar bone tunnels, tendon weave through capsule and ligament tissue 41 Plication and repair (20 arthroscopic, 21 open) 10 Repairs, 3 reconstructions with tendon grafts 12 Direct repair, 33 reconstructions with tendon grafts

Rizio51

2005

1 (skeletally immature)

1 Reconstruction with fascia graft

Eygendaal53

2004

12

12 Reconstruction with fascia graft

Triceps fascia graft

Lee and Teo54

2003

10

10 Reconstruction with tendon graft

Olsen and Søjbjerg55

2003

18

18 Reconstruction with fascia graft

Palmaris longus, trimmed semitendinosus Triceps fascia graft

DeLaMora and Hausman56

2002

5

Nestor et al46

1992

O’Driscoll et al4

1991

Lin et al

45

Type of Reconstruction

Graft Type

Outcome

Complications

10 Excellent 3 Good 1 Fair (6 of 8) Complete symptom resolution. 4 Excellent 4 Good “Complete resolution of PRLI was observed in 3 patients”

(1 of 14) With persistent instability

Semitendinosus allograft

All groups with improvement in Andrews-Carson scores

None

20 Palmaris longus, 4 triceps fascia, 3 tendo Achilles, 3 plantaris, 2 semitendinosus 1 Fascia lata allograft

19 Excellent 13 Good 7 Fair 5 Poor

(5 of 44) Recurrent instability

No change in carrying angle at 34 mo follow-up, resolution of all symptoms 6 Loss of 5°–10° extension 10 Excellent 2 Good 1 Moderate 3 Excellent 5 Good 2 Fair (3 of 18) Lost ⬎ 10° of extension 12 Excellent 4 Good 2 Fair No recurrent instability, postoperative ROM 10°–135° All 3 repair patients had an excellent results. Five patients with palmaris reconstruction, 3 excellent and 2 fair. One patient with triceps fascia had excellent results. All patients with normal flexion, extension, pronation, supination, and no recurrence of instability

None

5 Triceps tendon transfer

None

11

3 Repair, 7 reconstructions with palmaris longus tendon, 1 reconstruction with triceps fascia

Palmaris longus, triceps fascia

5

2 Repair, 3 reconstruction (2 with palmaris tendon graft and 1 with triceps fascia graft)

Palmaris longus tendon, triceps fascia

(2 of 8) Occasional instability with certain activities None

(1 of 12) Persistent apprehension

Postoperative hematoma

(4 of 18) Persistent apprehension to pivot shift

None

(2 of 8) With evidence of recurrent instability (both with palmaris longus tendon). (1 of 8) with DVT who had prior history of DVT

DVT, deep vein thrombosis; PRLI, posterolateral rotatory instability; ROM, range of motion.

MEPS at a 6-year follow up was 85 (19 excellent, 13 good, 7 fair, 5 poor). They reported that better results were achieved in patients with post-traumatic causes,

symptomatic instability at presentation, and those reconstructed with a tendon graft. Sanchez-Sotelo et al32 reported their rational for repair verses reconstruction.

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TABLE 1.

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Current Concepts

They repaired ligament avulsion at the isometric point using heavy nonabsorbable suture. When ligamentous laxity was present, they overlapped and advanced both the ligament and the capsule, and when the tissue was of poor quality they reconstructed with a tendon graft. Lin et al in 201245 investigated the outcomes of posterolateral elbow instability reconstruction and stage of PRLI at time of reconstruction. They utilized the classification system proposed by O’Driscoll in 2000.22 Stage 1 was defined as subluxation of the elbow in a posterolateral direction. Stage 2 is subluxation of the elbow joint in which the coronoid is perched beneath the trochlea. Stage 3 is complete dislocation of the coronoid resting posterior to the trochlea: stage 3a including a tear of posterior band of the MCL, and stage 3b including a tear of the anterior and posterior band of the MCL.45 Of their 14 patients, 5 presented with stage 1, 6 with stage 2, 2 with stage 3a, and 1 with stage 3b. The average time between injury and surgery was 45 months. All patients were treated with autograft reconstruction through ulnar and humeral bone tunnels, 8 with palmaris and 6 with gracilis autograft. At 49 months’ follow-up, 13 of 14 patients had a stable elbow. The single patient with stage 3b posterolateral elbow instability had persistent instability, which required MCL reconstruction, which ultimately eliminated the instability. Nine of 14 patients (64%) were pain free and 5 of 14 (36%) had mild lateral elbow pain. All elbows had negative lateral pivot-shift tests at final follow-up. In 3 patients with stage 3 posterolateral elbow instability, the MEPS was 85 for 2 patients with stage 3 instability and 65 in the single patient with stage 3b posterolateral elbow instability, compared with 9 of 11 patients stage 1 or 2 PRLI who scored a 100 MEPS. Using the scoring system reported by Nestor et al46 in their report of 11 patients with posterolateral elbow instability, those with stage 1 or 2 posterolateral elbow instability (11 patients), 10 achieved excellent results compared with 0 with stage 3 posterolateral elbow instability.45 One hundred percent reported they were satisfied with the procedure. There was no control group. They concluded that, of patients with posterolateral elbow instability, stage 1 and 2 have better functional results than those with stage 3. As an aside, they noted that a gracilis graft has several advantages over a palmaris graft including superior tensile strength (837 N vs 357 N) and small caliber allowing passage through appropriately sized bone tunnels.45 Jones et al in 201247 reported on a case series of 8 patients with posterolateral elbow instability who underwent surgical reconstruction of their LUCL using a “docking” technique similar that described by

Rohrbough et al48 for the MCL. Over a 14-year period, they treated 8 patients with surgical reconstruction using the “docking” technique and palmaris autograft. Average follow-up was 7 years, with 6 patients reporting complete symptom resolution and 2 patients reporting occasional instability with activities of daily living. All patients had a negative pivot-shift test at final follow-up. The mean MEPS was 87.5 (4 excellent and 4 good results).47 Dargel et al in 201249 described a percutaneous LUCL reconstruction technique with biomechanical testing in a cadaveric model. They hypothesized that maintaining secondary muscular stabilizers by minimizing dissection with percutaneous reconstruction may shorten operating times and accelerate postoperative recovery. They compared open versus percutaneous single-strand palmaris autograft reconstruction of the LUCL fixed with biotenodesis screws. Grafts were tensioned in 30° of flexion and full pronation. Biomechanical testing to simulate posterolateral elbow instability was performed at 0°, 30°, 60°, and 90°. There were no significant differences between intact specimens, open reconstruction, and percutaneous reconstruction over the ROM. Rhyou and Park in 201150 reported on a new technique of ligament reconstruction for posterolateral elbow instability that they purport represents a dual reconstruction of the RCL and LUCL, performed on 3 patients. They used palmaris longus tendon or half slip of flexor carpi radialis tendon autograft and passed the tendon through 2 slits, 1 just distal to the insertion site of the annular ligament and a second just distal to the “equator” of the annular ligament, which were then fixed near the capitellum. They report complete resolution of posterolateral elbow instability in all 3 patients, although no other follow-up information is given. Savoie et al in 200931 reported on arthroscopic repair, open repair, and reconstruction for posterolateral elbow instability in 54 patients. Of this group, there were 24 arthroscopic repairs, 27 open repairs, and 3 open reconstructions using tendon grafts. Outcomes were analyzed by comparing Andrews-Carson scores. Overall, there was statistically significant improvement in both groups and no statistically significant difference between the groups. Scant literature exists on recurrent lateral elbow instability in the pediatric population. Rizio in 200551 reported on LUCL reconstruction in a skeletally immature patient, age 11. They utilized a fascia lata allograft fixed through 2 ulnar tunnels and a single humeral tunnel. They reported the use of a docking procedure with only 1 humeral drill hole to decrease injuring the distal humeral physis. Lehman in 200552 described a technique of lateral

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TABLE 2.

199

Lateral Collateral Ligament Reconstruction Postoperative Protocols

Author

Postoperative Protocol

Lin et al45

Elbow immobilized 0–2 wk 90° of flexion and full forearm pronation. 0–6 wk ROM exercises in hinged brace with 30° extension block. 8 wk–6 mo bracing discontinued but varus stress and extension-supination avoided for 6 mo. Return to sports at 9 mo.

Jones et al47

Elbow immobilized 0–2 wk in 90° of flexion and forearm in full pronation. 2–6 weeks elbow in hinged elbow brace in neutral position, initially allowing 30°–90° extension to flexion motion then gradually increasing to full extension and flexion achieved. Strengthening initiated at 8–10 wk. Return to full activity 4–6 mo.

Rhyou and Park50

Elbow immobilized 0–6 wk in 90° of flexion and slight forearm pronation. 6 wk on active assistive ROM initiated without ROM restriction. Care taken to avoid gravitational varus stress. 4–6 mo return of full activity.

Sanchez-Sotelo et al32

Elbow immobilized 0–12 wk in 80° flexion and forearm full pronation. 2–6 wk protected motion in hinged elbow brace. 6–12 weeks can take off brace for sedentary activities. Full activity at 6 mo. General avoidance of activates with shoulder abduction, lifting with elbow close to body.

Rizio51

Elbow immobilized 0–1 wk 90° of flexion. 1–4 wk hinged elbow brace with 30° extension block. 4–8 weeks full motion in brace allowed with strengthening. 8 weeks discontinue immobilization. 6 months return to sports

Eygendaal53

Elbow immobilized 0–1 wk 90° of flexion and maximal forearm pronation. 1–7 wk hinged brace allowing full flexion extension in forearm pronation. Normal activity at 6 mo.

Lee and Teo54

Elbow immobilized 0–3 wk at 90° of flexion. 3–6 wk hinged elbow brace with 30° extension block. 6–12 wk, full ROM in brace. 12 wk–6 mo no brace, avoid varus stress and extension-supination maneuvers, work forearm strengthening. Return to sport 9 mo.

DeLaMora and Hausman56

Elbow immobilized 0–3 wk in 45° of flexion and full pronation. 6–12 wk on active motion with full extension in pronated position only. Full activity after 12 wk.

Olsen and Søjbjerg55

Elbow immobilized 0–6 wk at 90° flexion and pronation. 6–12 wk supervised therapy in hinged elbow brace avoiding supination and varus stress. Return to sport 6 mo.

Nestor et al46

Elbow immobilized 0–4 wk 90° of flexion and forearm fully pronated. 4–10 wk hinged brace with 30° extension block. 10–16 wk hinged brace with no extension block. Normal activity at 6 mo.

O’Driscoll et al4

Elbow immobilized 3–5 wk in 90° of flexion. Hinged elbow brace with 30° extension block is worn for additional 6–12 wk

ROM, range of motion.

prehension. Following LCL reconstruction using tendon grafts, a loss of terminal extension of 5° to 15° is not uncommon. POSTOPERATIVE PROTOCOL No comparative studies on postoperative protocols exist following lateral ligament reconstruction. Published series of repair and reconstruction of recurrent instability generally purport a several-week period of immobilization with the elbow at 90° of flexion and the forearm pronated (Table 2). This is followed by a protective period of 4 to 6 weeks in a hinged elbow brace, followed by a strengthening protocol. Return to sport is generally allowed around 6 months after surgery. Most recommend avoidance of varus stress to the elbow by avoiding activities, particularly weight-bearing activities, with the shoulder in an abducted position. In conclusion, recurrent lateral instability of the el-

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ligament reconstruction using a palmaris tendon graft fixed to the ulna and the humerus through single drill holes and secured with an interference screw. The report is of technique only; no outcomes are reported. Review of the literature reveals the most common autograft tendon used is palmaris longus tendon, although triceps fascia, gracilis, tendo Achilles, semitendinosis, and plantaris are other reported grafts used with success. Generally, it is believed that results are better with reconstruction in all but the acute injury. Questions that still remain include optimal placement of humeral and ulnar tunnels, optimal graft choice, positioning for graft tensioning, and fixation methods. Percutaneous and arthroscopic repair and reconstruction represent more cutting edge methods of addressing lateral ligament instability. Most patients undergoing reconstruction with a tendon graft will achieve gross stability, although a small percentage may continue to have ap-

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bow is a rare clinical entity typically resulting from traumatic injury, most commonly elbow dislocations, and less commonly iatrogenic injury during lateralsided elbow surgery. Complaints are not always recognizable as instability and a strong clinical suspicion combined with specific physical examination tests including table-top and pushup tests are helpful in diagnosis. Stress radiographs can confirm the diagnosis. When ligament tissue is of good quality, acute repair may provide acceptable results. Ligament reconstruction with fascia or tendon grafts has provided generally good results. Future comparative studies are needed to establish best practices. REFERENCES

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25.

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Current Concepts

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JHS 䉬 Vol A, January 

ELBOW LCL INJURIES

41. Smith JP III, Savoie FH III, Field L. Posterolateral rotatory instability of the elbow. Clin Sports Med. 2001;20(1):47–58. 42. Savoie FH III, O’Brien MJ, Field LD, Gurley DJ. Arthroscopic and open radial ulnohumeral ligament reconstruction for posterolateral rotatory instability of the elbow. Clin Sports Med. 2010;29(4):611– 618. 43. Fraser GS, Pichora JE, Ferreira LM, et al. Lateral collateral ligament repair restores the initial varus stability of the elbow: an in vitro biomechanical study. J Orthop Trauma. 2008;22(9):615– 623. 44. Morrey BF. Ligament injury and the use of hinged external fixators at the elbow. In: Tornetta PI, Pagnano M, eds. Instructional Course Lectures. Vol. 61. Philadelphia: JAAOS; 2012:215–225. 45. Lin KY, Shen PH, Lee CH, et al. Functional outcomes of surgical reconstruction for posterolateral rotatory instability of the elbow. Injury. 2012;43(10):1657–1661. 46. Nestor BJ, O’Driscoll SW, Morrey BF. Ligamentous reconstruction for posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. 1992;74(8):1235–1241. 47. Jones KJ, Dodson CC, Osbahr DC, et al. The docking technique for lateral ulnar collateral ligament reconstruction: surgical technique and clinical outcomes. J Shoulder Elbow Surg. 2012;21(3):389 –395. 48. Rohrbough JT, Altchek DW, Hyman J, Williams RJ III, Botts JD. Medial collateral ligament reconstruction of the elbow using the docking technique. Am J Sports Med. 2002;30(4):541–548.

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49. Dargel J, Burkhart K, Pennig D, et al. Percutaneous lateral ulnar collateral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. Epub ahead of print 2012;May 1 50. Rhyou IH, Park MJ. Dual reconstruction of the radial collateral ligament and lateral ulnar collateral ligament in posterolateral rotatory instability of the elbow. Knee Surg Sports Traumatol Arthrosc. 2011;19(6):1009 –1012. 51. Rizio L. Lateral ulnar collateral ligament reconstruction in a skeletally immature patient. Am J Sports Med. 2005;33(3):439 – 442. 52. Lehman RC. Lateral elbow reconstruction using a new fixation technique. Arthroscopy. 2005;21(4):503–505. 53. Eygendaal D. Ligamentous reconstruction around the elbow using triceps tendon. Acta Orthop Scand. 2004;75(5):516 –523. 54. Lee BP, Teo LH. Surgical reconstruction for posterolateral rotatory instability of the elbow. J Shoulder Elbow Surg. 2003;12(5):476 – 479. 55. Olsen BS, Søjbjerg JO. The treatment of recurrent posterolateral instability of the elbow. J Bone Joint Surg Br. 2003;85(3):342– 346. 56. DeLaMora SN, Hausman M. Lateral ulnar collateral ligament reconstruction using the triceps fascia. Orthopedics. 2002;25(9): 909 –912.

JOURNAL CME QUESTIONS Elbow Lateral Collateral Ligament Injuries Therapy of lateral collateral ligament– deficient elbow should avoid what positions? a. Shoulder abduction and supination b. Shoulder abduction and pronation c. Shoulder flexion and supination d. Shoulder extension and pronation e. Shoulder extension and supination

What childhood distal humerus fractures can lead to posterolateral elbow instability? a. Extension malalignment b. Flexion malalignment c. Valgus malalignment d. Varus malalignment e. External rotation malalignment

Current Concepts

To take the online test and receive CME credit, go to http://www.jhandsurg.org/CME/home.

JHS 䉬 Vol A, January 