Arch Hand Microsurg.  2018 Jun;23(2):69-77. 10.12790/ahm.2018.23.2.69.

Posterolateral Rotatory Instability of the Elbow Joint

• Rhyou IH

• KMID: 2412475
• DOI: http://doi.org/10.12790/ahm.2018.23.2.69

Abstract

Posterolateral rotatory instability (PLRI) of the elbow joint is not rare and has been known to be caused by the insufficiency of the lateral ulnar collateral ligament (LUCL), since the first description by O'Driscoll et al. However, many anatomical, clinical, and experimental studies cast doubts on the main role of the LUCL and highlight the lateral collateral ligament complex consisting of radial collateral ligament, LUCL, annular ligament, and accessory collateral ligament all work together to prevent PLRI. Because the original LUCL reconstruction technique does not uniformly lead to good clinical results, new techniques based on biomechanical background have been developed and attempted to obtain better results. Here, review of the anatomical and biomechanical knowledge about the PLRI including the basic concept till now is presented to provide better understanding and management of PLRI.

Keyword

Posterolateral; Rotatory; Instability; Elbow

MeSH Terms

Collateral Ligaments
Elbow Joint*
Elbow*
Lateral Ligament, Ankle
Ligaments

Figure

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  Fig.1. (A) In the case of Monte-ggia's fracture and dislocation, only the radial head is dislocated from the proximal radioulnar joint due to the rupture of annular ligament and ulnohumeral joint is intact. (B) However, in the case of the PLRI, radial head is subluxable with the intact proximal radioulnar joint, showing subluxation of ulnohumeral joint.

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  Fig.2. A case of PLRI after multiple steroid injection therapy in a patient with lateral epicondylitis can be seen in the proximal portion of the lateral ulnar collateral ligament ruptured from the lateral eicondyle (black arrow).

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  Fig.3. (A) The relationship between the type of external force exerted on the elbow and the type of damage to the soft tissues. The varus force causes the LCL complex and the overlying extensor muscle to form a distractive type injury (white arrow). And this case is difficult to cure with conservative treatment, so surgical repair is needed in most cases. (B) The forearm external rotation force applied to the forearm peels off the lateral collateral ligament (LCL) complex and the superficial extensor muscle from the lateral epicondyle (blue arrow) to be a stripping type injury (three azure arrows). In this case, when the elbow is reduced, the injured LCL complex and extensor muscle is likely to be reduced the original attachment site and conservative treatment is possible.

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  Fig.4. The relationship between the damage of the lateral collateral ligament complex and the overlying extensor muscle and the external force and clinical characteristics are summarized here.

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  Fig.5. The attenuation of the lateral ulnar collateral ligament in the magnetic resonance arthrogram and a slightly posterior subluxated radial head were observed in posterolateral rotatory instability patients. LUCL: lateral ulnar collateral ligament.

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  Fig.6. (A) In the posterolateral pivot shift test, we can see a dimple in the posterolateral aspect of the elbow (black arrow) due to the subluxated radial head during elbow extension. (B) When the elbow flexes, the subluxated radial head is reduced and a dimple disappears.

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  Fig.7. In contrast to conventional LUCL reconstruction, reconstruction of the RCL and the LUCL together, namely “Dual reconstruction of the LUCL and RCL” is based on biomechanical studies and focus on the proximal reconstruction of the LUCL, suturing this to the annular ligament instead of supinator crest of the ulna through bone tunneling. LUCL: lateral ulnar collateral ligament, RCL: radial collateral ligament, AL: annular ligament.

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  Fig.8. (A, B) Simple radiographs of a patient with the PLRI showing an ectopic ossification on the lateral epicondyle of the humerus and traces of crushed coronoid process on the anterior aspect of the elbow joint due to previous elbow injuries. (C) The radial head was subluxated posteriorly on the MR arthrogram. (D, E) There was a slight flexion and extension limitation in the active range of motion test. (F, G) On the intraoperative pictures, the crushed multiple fragments of coronoid process were removed and the weakened lateral collateral ligament complex was reconstructed with dual reconstruction technique using an autogenous palmaris longus graft (black arrow). (H, I) Simple radiographs taken at 6 months postoperatively showing removal of crushed fragments of coronoid process and an ectopic ossification around the elbow joint. (J, K) Normal finding was seen on table top relocation test performed at 6 months after surgery. (L-O) At 6 months after surgery, the flexion and extension deficits observed before surgery disappeared and there was no limitation of joint motion compared to the contralateral side.

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