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Lateral Collateral Ligament Injury (Elbow)

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Other Names

  • Lateral Ulnar Collateral Ligament Injury
  • PLRI
  • Posterolateral Rotatory Instability of the elbow
  • Posterolateral Rotatory Instability

Background

  • 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[1]
    • Defined as LUCL injury, subsequent posterolateral subluxation or dislocation of the Radius on the Capitellum
    • The proximal Radioulnar joint is preserved

Pathophysiology

Etiology

  • Trauma, most commonly is the most common cause
    • In one study, 67/71 patients with PLRI described a traumatic event[2]
    • 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

Pathoanatomy

Associated Injuries


Risk Factors

  • Unknown

Differential Diagnosis


Clinical Features

  • General: Physical Exam Forearm
  • History
    • 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
    • Woirse with supination extension and valgus forces, e.g. carrying a bag
  • Physical
    • Tenderness over LCL
    • Instability with varus stress
  • Special Tests

Evaluation

  • Radiographs
    • 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[4]
    • 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”[5]
      • Sometimes referred to as 'Osborne-Cotterill Lesion'[6]
  • MRI
    • Helpful to better evaluate soft tissue injuries
    • LCL difficult to visualize due to oblique course
    • Pathology identified in 50% of patients (need citation)
  • Ultrasound
    • Teixeira et al: Able to identify RCL, LUCL and annular ligament 10/10 normal subjects and 8/10 cadaveric elbows[7]
    • Future studies needed for dynamic evaluation and clarification of pathological findings

Classification

O'Driscoll Classification

  • 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

Management

Nonoperative

  • If acute elbow dislocation
  • 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

Operative

  • Acute Indications[8]
    • OCD or soft tissue in joint space preventing reduction
    • Complex
    • Instability
  • Technique
    • ORIF with LCL repair
  • Chronic Indicications
    • Chronic symptoms refractory to conservative management

Rehab and Return to Play

Rehabilitation

  • 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

Complications

  • Recurrent instability
  • Postoperative
    • Infection
    • Cutaneus nerve injury
    • Loss of ROM

See Also


References


  1. O’Driscoll S, Bell D, Morrey BF. Posterolateral instability of the elbow. J Bone Joint Surg. 1991;73:440–446.
  2. 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.
  3. King GJW, Morrey BF, An KN. Stabilizers of the elbow. J Shoulder Elbow Surg. 1993;2(3):165–174.
  4. O’Driscoll S. Classification and evaluation of recurrent instability of the elbow. Clin Orthop Relat Res. 2000;(370):34–43.
  5. Osborne G, Cotterill P. Recurrent dislocation of the elbow. J Bone Joint Surg Br. 1966;48(2):340–346.
  6. . 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.
  7. 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
  8. https://www.orthobullets.com/shoulder-and-elbow/3129/lateral-ulnar-collateral-ligament-injury-plri
Created by:
John Kiel on 18 June 2019 01:54:07
Authors:
Last edited:
11 November 2020 14:50:59
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