FEATURE ORTHOPAEDICS


physical therapist. A pain-free, stable and fully functional elbow should be expected with a modest loss of terminal extension anticipated.


RECURRENT INSTABILITY Recurrent instability of the elbow is uncommon following simple dislocation. When is does occur, it most frequently involves the lateral ligamentous structures as originally described by Osborne and Cotterill. O’Driscoll et al. further investigated this concept and defined posterolateral rotatory instability (PLRI) of the elbow. Biomechanical studies have defined the ulnar portion of the lateral collateral ligament (LCL), known as the lateral ulnar collateral ligament (LUCL), as the essential lesion leading to this chronic form of elbow instability. The LUCL is a thickening of the LCL complex that originates on the lateral condyle of the humerus at the isometric center of rotation on the lateral side and inserts upon the proximal ulna at the supinator crest. The LUCL both stabilizes the lateral side of the elbow and acts as a posterior buttress to the radial head.


CLINICAL PRESENTATION The clinical presentation and evaluation of patients with PLRI can often be vague and present challenges to arriving at the correct diagnosis. The patient will frequently have a history of one or more elbow dislocations that either spontaneously reduced or required sedation and closed reduction in the emergency room. Iatrogenic injury during surgical procedures on the lateral side of the elbow also can lead to PLRI. The patient will complain of painful clicking,


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«The clinical presentation and evaluation of patients with PLRI can often be vague and present challenges to arriving at the correct diagnosis»


snapping or catching of the elbow and a sense that the joint is sliding out of place, especially in the position of elbow extension and forearm supination. Initial clinical evaluation will reveal a normal appearing elbow with full, painless motion and minimal tenderness. Special tests for PLRI have been described, but can be challenging to perform in an awake patient. The patient’s apprehension to the maneuvers is often the best predictor and should raise one’s suspicion for PLRI. Pain and apprehension with rising from a chair using the arm rests is another easy test to help arrive at the correct diagnosis. MRI is the imaging of choice for further evaluation. Disruption of the LUCL should be evaluated as well as any marrow changes in the capitellum, possibly indicating recurrent subluxation of the radial head. Finally, an exam under anesthesia can provide the definitive evidence of PLRI (figure 1).


TREATMENT Surgery is indicated in symptomatic cases of recurrent elbow instability. Repair of the soft-tissues is not possible given the chronicity of the injury, and thus reconstruction of the LUCL is required. A Kocher approach to the lateral elbow is undertaken with evaluation and confirmation of attenuation of the lateral ligamentous complex – specifically the LUCL. Reconstruction can be undertaken utilizing either autograft (e.g., Palmaris longus) or allograft (e.g., plantaris). The critical elements are to place the graft at the isometric point of the lateral elbow and tension the reconstruction appropriately. Our preferred technique is to pass the graft through converging drill holes along the supination crest and “dock” the humeral insertion (figure 2). We tension the graft with the elbow at 90 degrees of flexion and the forearm in pronation. Incorporating the anterior limb of the graft with the anterior joint capsule is


FIGURE: 1, 2, 3


1


2


3


critical to help re-establish the “buttress” to the radial head (figure 3). Rehabilitation is undertaken with five


to seven days with the elbow protected in a hinged brace, with the forearm in full pronation and initial extension blocked at 60 degrees. The extension block is relieved to 10 degrees weekly under the supervision of a therapist, and active/ passive pronation and supination of the forearm is undertaken daily with the elbow at the patient’s side and at 90 degrees of flexion. Accurate diagnosis and appropriate reconstruction should eliminate recurrent instability and restore the patient’s confidence in a pain-free, stable elbow. ■


AH


 AUTHOR INFO Dr. Maschke, a specialist in hand, wrist, elbow, peripheral nerve surgery, arthroscopy, joint replacement and reconstruction, can be reached at +1 216.445.6426 or maschks@ccf.org.


Arab Health Issue 4 2011 13


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