Lateral Collateral Ligament Injury (Elbow)
- Lateral Ulnar Collateral Ligament Injury
- Posterolateral Rotatory Instability of the elbow
- Posterolateral Rotatory Instability
- Refers to injuries to the Lateral Collateral Ligament (Elbow) (LUCL) injuries
- This represents a spectrum of disease from 'strains' of the lateral ligament structures to complete ruptures and posterolateral rotatory instability (PLRI)
- PLRI first described by O'Driscoll in 1991
- Not well described in the literature
- Posterolateral rotatory instability (PLRI)
- Trauma, most commonly is the most common cause
- In one study, 67/71 patients with PLRI described a traumatic event
- Can be as a result of elbow dislocation or significant valgus stress with axial load
- Iatrogenic as a result of surgical procedure, for example tenotomy for Lateral Epicondylitis
- Other iatrogenic causes include radial head resection, prior distal humeral fracture repair
- Chronic attenuation
- Due to chronic cubitus varus
- Lateral Collateral Ligament (Elbow) consists of four ligaments, however controversy exists about the exact anatomy
- Important Structures
- Dislocations & Instability
- Ligament Injuries
- Pediatric Considerations
- Most patients will endorse either an acute or chronic, repetitive trauma
- Will complain of pain, clicking, catching, locking, snapping
- They may even endorse recurrent dislocations
- Worse with supination extension and valgus forces, e.g. carrying a bag
- Physical: Physical Exam Forearm
- Tenderness over LCL
- Instability with varus stress
- Special Tests
- Lateral Pivot Shift Test: Reduce subluxated radial head with triceps tendon
- Elbow Varus Stress Test: Reproduce laxity with varus stress of joint
- Table Top Relocation Test: Multi-step test to reproduce symptoms
- Pushup Apprehension Test: Reproduction of symptoms when performing pushup from the floor
- Chair Apprehension Test: Reproduction of symptoms when performing a pushup from a chair
- Rotatory Drawer Test: Arm abducted with elbow flexed, apply posteromedial force
- Standard Radiographs Elbow
- Useful to evaluate other causes of pain, especially in the setting of trauma
- No confirmatory findings for Elbow LCL
- Stress radiography can confirm instability
- AP stress view can show show slight malalignment of the ulnohumeral joint, overlap of the radial head and capitellum
- Can see "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”
- Sometimes referred to as 'Osborne-Cotterill Lesion'
- Helpful to better evaluate soft tissue injuries
- LCL difficult to visualize due to oblique course
- Pathology identified in 50% of patients (need citation)
- Teixeira et al: Able to identify RCL, LUCL and annular ligament 10/10 normal subjects and 8/10 cadaveric elbows
- Future studies needed for dynamic evaluation and clarification of pathological findings
- Timing: acute, chronic, recurrent
- Articulations Involved: ulnohumeral, radiohumeral, proximal radioulnar or both
- Direction of Displacement: posterolateral, anterior, valgus, and varus
- Degree of Displacement: Refers to degree of displacement to posterolateral rotary instability
- Stage 1: elbow subluxates in a posterolateral rotatory direction, patient has positive lateral pivot-shift test.
- Stage 2: elbow has an incomplete dislocation so the coronoid is perched under the trochlea.
- Stage 3: complete elbow dislocation so that the coronoid is behind the humerus.
- Stage 3a: anterior band of the medial collateral ligament (MCL) is intact, and after reduction, the elbow is stable to valgus stress.
- Stage 3b: anterior MCL is disrupted and the elbow is unstable to valgus stress after reduction.
- Stage 3c: complete soft tissue stripping of the elbow and it is grossly unstable even after the application of a splint or cast.
- Presence of Fractures: present or absent
- If acute elbow dislocation
- Posterior Long Arm Splint at 90° flexion for 7 days
- If subacute, can manage nonoperatively in mild instability or low demand patients
- Elbow Brace, what type?
- Physical Therapy with emphasis on extensor strengthening
- Activity modification
- Acute Indications
- OCD or soft tissue in joint space preventing reduction
- ORIF with LCL repair
- Chronic Indicications
- Chronic symptoms refractory to conservative management
Rehab and Return to Play
- No comparative studies on postoperative protocols exist
- Publishes cases series support several weeks of immobilization at 90° flexion and pronated forearm
- Followed by 4-6 weeks in Hinged Elbow Brace
- Followed by prolonged strengthening protocol
Return to Play
- Variable and at discretion of surgeon
- Published case series suggest athletes can return to sport around 6 months
- Avoid: varus stress to the elbow by avoiding activities, particularly weight-bearing activities, with the shoulder in an abducted position
- Recurrent instability
- Cutaneus nerve injury
- Loss of ROM
- Sports Med Review Elbow Pain: https://www.sportsmedreview.com/by-joint/elbow/
- O’Driscoll S, Bell D, Morrey BF. Posterolateral instability of the elbow. J Bone Joint Surg. 1991;73:440–446.
- Anakwenze OA, Kwon D, O’Donnell E, Levine WN, Ahmad CS. Surgical treatment of posterolateral rotatory instability of the elbow. Arthrosc - J Arthrosc Relat Surg. 2014;30(7):866–871. doi: 10.1016/j.arthro.2014.02.029.
- King GJW, Morrey BF, An KN. Stabilizers of the elbow. J Shoulder Elbow Surg. 1993;2(3):165–174.
- O’Driscoll S. Classification and evaluation of recurrent instability of the elbow. Clin Orthop Relat Res. 2000;(370):34–43.
- Osborne G, Cotterill P. Recurrent dislocation of the elbow. J Bone Joint Surg Br. 1966;48(2):340–346.
- . Jeon IH, Micic ID, Yamamoto N, Morrey BF. Osborne-Cotterill lesion: an osseous defect of the capitellum associated with instability of the elbow. AJR Am J Roentgenol. 2008;191(3):727–729.
- Teixeira PAG, Omoumi P, Trudell DJ, et al. Ultrasound assessment of the lateral collateral ligamentous complex of the elbow: imaging aspects in cadavers and normal volunteers. Eur Radiol. 2011;21(7): 1492–1498