Elbow instability

Diagnosis and Treatment

Christian Dumontier, MD, PhD
Guadeloupe, France

Elbow instability

Acute vs Chronic

Ligaments vs bone

If bony architecture is modified an elbow

cannot be stable !

Stabilizing factors of the elbow

are of unequal importance

Bones

Muscles

Ligaments

Bone stabilizing factors

The osseous structures are

estimated to be responsible for
50% of the elbow stability

A dislocated elbow is usually stable

after reduction, even though all
ligaments are disrupted

Muscular stabilizing
factors

Angular velocity is between

2100-2700/sec

Estimated load on the MCL is 290 N

Load to failure of MCL is 261 N

A Pitcher should torn his MCL on

every pitch !. MCL is protected by
the medial muscles +++ (FDS or FCU
being the most important)

Udall JH et al. Eects of flexor-pronator muscle loading on valgus stability of the elbow with an intact, stretched, and
resected medial ulnar collateral ligament. J Shoulder Elbow Surg (2009) 18, 773-778

Ligamentous stabilizing factors

Medial collateral ligament

Is said to be responsible of 78% of

the stability in the frontal AND
sagittal planes

Lateral collateral ligament

The humero-ulnar ligament is said to

be the most important to prevent
rotatory subluxation

Chronic elbow instability

MCL

Varus : No

Valgus

Postero-lateral

?
LCL

Which ligament is the major

stabilizer of the elbow ?

Historical review

Treatment of recurrent elbow

dislocation done by a plication
of the lateral ligament complex
(Osborne & Cotterill - 1966)

an osteochondral fracture in the

posterolateral margin of the capitellum with
or without a crater or shovel-like defect in
the radial head

Experimental works: the

medial ligament is responsible
for 78% of elbow stability in the
valgus plane

Osborne G, Cotterill P. Recurrent dislocation of the elbow. J Bone Joint Surg Br 1966; 48:340346

Explanation for this

contradiction ?

Ciaudo et al. Bases anatomiques pour les luxations rcidivantes du

coude. Bull. Assoc. Nancy 1980; 64: 465-476

ODriscoll et al. Posterolateral rotatory instability of the elbow. J

Bone Joint Surg Am 1991;73(3):4406.)

External rotation (supination) of the forearm in supination under

the arm allows the radial head to engage under the capitulum if
the lateral collateral ligament is dehiscent

According to the radial head displacement, it can present as a

instability of the elbow, a subluxation or a true dislocation

Anatomical lesions
Cheung CORR 2008

During surgery, the lateral collateral ligament appears dehiscent

and frequently avulsed from the lateral condyle

Other lesions ?

Bony lesions (stigmatas that

favor recurrence)

Disruption of the common

extensor origin (66% of 62
cases)

McKee MD, Schemitsch EH, Sala MJ, et al. The pathoanatomy of lateral ligamentous disruption in complex elbow instability. J
Shoulder Elbow Surg 2003;12(4):3916.

So the humero-ulnar ligament

is the most important ?

Not so simple - In elbow dislocations, lesions seem to start

on the medial side

X-Rays and MRI study of postero-lateral elbow dislocations:

lesions start on the medial side (Rhyou)

62 videos of elbow dislocations on youtube (Schreiber):

92% were in extension, with the forearm in pronation (68%),

shoulder in abduction (97%) and flexion (63%).

Rhyou IH, Kim YS. New mechanism of the posterior elbow dislocation. Knee Surg Sports Traumatol Arthrosc. 2012 Dec;
20(12):2535-41
Schreiber JJ, Warren RF, Hotchkiss RN, Daluiski A. An online video investigation into the mechanism of elbow dislocation. J
Hand Surg Am. 2013 Mar;38(3):488-94.

MRI study

Quality of ligaments

Completely torn >70%, and severe 30% for the MCL

Completely torn 63% for UCL, but the other cases can be intact

Start on the lateral side ?

In 100% of cases, there was a valgus instability, in 39% of

cases a varus instability at testing

Bone ? Coronoid lesions were only seen with associated lesions

of the UCL
Schreiber et al. Magnetic resonance imaging findings in acute elbow
dislocation: insight into mechanism.JHS 2014;39(2):199-205

There may be two elbow

valgus instability ?

Very similar but not exactly

the same

One in the frontal plane, due

to disruption of the MCL

One in a rotational plane, due

to insufficiency of the LCL

Valgus elbow instability

After elbow dislocation

8% are unstable (Anakwe)

Up to 35% of instability (Melhoff)

24 patients out of 50 had instability

at 9 years FU (Eygendaal)

Post-traumatic (macro or microtrauma

- Pitchers)

Melhoff TL, Noble PC, Bennett JB, et al. Simple dislocation of the elbow in the adult: results after closed treatment. J Bone Joint Surg
Am 1988;70: 2449.
Anakwe RE et al. Patient-reported outcomes after simple dislocation of the elbow. JBJSAm 2011;93:1220-1226.
Eygendaal D, Verdegaal SH, Obermann WR, van Vugt AB, Pll RG, Rozing PM. Posterolateral dislocation of the elbow joint. Relationship
to medial instability. J Bone Joint Surg Am. 2000 Apr;82(4):555-60.

Valgus elbow instability

Insufficiency of the MCL increases the loads of the forearm over the
humerus

Cartilage contusion then arthritis of the MEDIAL side of the olecranon

at the beginning

15 yrs

Valgus elbow instability

Pain, elbow flexum, ulnar nerve

irritation (40%)

Physical exam:

Painful palpation of the MCL,

Increase valgus laxity in

pronation,

Valgus deformity (30%)

Stress tests

Moving test: From flexion to extension

(and opposite) with the elbow placed in
valgus. Pain between 70-120 is positive
for a anterior MCL injury

Milk test: With the non-injured hand, you

hold the thumb of the injured side which
places the elbow in valgus en flexion.
MCL pain is positive for an injury

ODriscoll SW, Lawton RL, Smith AM. The moving valgus stress test for medial collateral ligament tears of the
elbow. Am J Sports Med 2005;33(2): 2319.
Veltri DM, OBrien SJ, Field LD, et al. The Milking Maneuver: A New Test to Evaluate the MCL of the Elbow in the
Throwing Athlete. Presented at the 10th Open Meeting of the American Shoulder and Elbow Surgeons Specialty
Day. New Orleans, LA, February 17, 1994.

Imaging techniques

X-rays can show bone

stigmata

Stress X-Rays are difficult to

perform and a positive
displacement can be as small
as 0,5 mm

Sonography +++

ArthroCT/MRI

Bruce JR. How much valgus instability can be expected with ulnar collateral ligament (UCL) injuries? A review of 273 baseball players
with UCL injuries. J Shoulder Elbow Surg (2014) 23, 1521-1526

Arthroscopic diagnostic

20-30% of the anterior bundle of the MCL

is visible with a 70 arthroscope using a
proximo-lateral approach (only 15-20%
with a 30 scope)

30-50% of the posterior bundle is visible

through a posterior portal

1 mm opening of the humero-ulnar joint

when tested in valgus at 60 elbow flexion
(and pronation) is positive for anterior
bundle disruption of the MCL. 4 mm
opening is seen in complete MCL rupture

Timmerman LA. Histology and arthroscopic anatomy of the ulnar collateral ligament of the elbow. Am J Sports.
Med 1994; 22: 667-673)

Causes of postero-lateral
elbow instability

Previous elbow dislocation (60%) or

repeated valgus micro-truma (10%)

Iatrogenic (20%): tennis elbow surgery

or radial head resection

Cubitus varus deformity after

supracondylar fracture in childhood

Unexplained (10%)

J. Sanchez-Sotelo, B. F. Morrey, S. W. ODriscoll; Ligamentous repair and reconstruction for posterolateral rotatory instability of the
elbow; J Bone Joint Surg [Br] 2005;87-B:54-61.

Clinical diagnosis
Very
s

Lateral pain

Snapping or clicking elbow

Feeling of an unstable elbow

imila

r to
MC
the L insta
site
bility
of p
ain except
for

Mostly in elbow extension and forearm in supination

Extension deficit (5-20) in 50% of cases

Physical examination

Pain over the ligament insertion

Increased instability in valgus testing

(forearm in supination)

Positive drawer test

positive Lateral pivot shift test (rare

w/o anesthesia)

Stress tests

Pain +/- instability when raising from

a chair

Push-ups test: elbow flexed at 90,

forearm in supination and the arm
lateral to the shoulders

More sensitive that the lateral pivot

shift test in awake patients

Regan W, Lapner PC. Prospective evaluation of two diagnostic apprehension signs for posterolateral instability of the
elbow. J Shoulder Elbow Surg 2006; 13:3446.

Look

Iatrogenic injury of the LCL after elbow arthrolysis.

Radial head subluxation during push-up test

Imaging

Static X-rays are rarely

evocative

Chip fracture of the lateral

condyle

Anterior impaction of the

radial head

Tip fracture of the coronoid

Stress X-rays may help

Usually difficult to interpret

ArthroCT or ArthroMRI

May show bony stigmata

of instability

Insufficiency of LCL (bony

avulsion, leakage,)

Arthroscopic diagnostic

A lateral pivot shift test can

be done under arthroscopy
using a proximo-medial
approach

Joint widening AND radial

head translation

Treatment of PLRI

Conservative treatment are

useless

Surgical treatment: ligament

reinsertion, plication or
augmentation

Not to forget preventive

treatment: Reconstruction of
LCL in lateral elbow surgery

Ligament augmentation using a strip of the ECU tendon

Tendon re-insertion with

capsular plication

Ligamentoplasty with
capsular plication

Ligamentoplasty

Using Cadenat-Kocher approach

Find the supinator crest

Three holes to reconstruct an isometric

ligament

Cheung, CORR

PLRI due to
condylar
hypoplasia:
ligamentoplasty
+ humeral
osteotomy,
1 yr FU

Results of PLRI treatment

45 pts, 6 yrs FU (33 ligamentoplasty, 12 direct repair)

All stable but 5

MEPS: 85 points (60 to 100).

Excellent results in 19, good in 13, fair in seven and

poor in five patients. 86% subjectively satisfied

Better results: post-traumatic (p = 0.03), subjective

symptoms at presentation (p = 0.006), tendon graft (p =
0.04).

J. Sanchez-Sotelo, B. F. Morrey, S. W. ODriscoll; Ligamentous repair and reconstruction for posterolateral rotatory instability of the
elbow; J Bone Joint Surg [Br] 2005;87-B:54-61.

Other series of PLRI

treatment

8 /10 patients good to

excellent result

20 arthroscopic repair and

21 open

Superior results in
patients with a tendon
graft.

Both objective and

subjective parameters
improved in both groups

Mild flexion contraction

(10)

10 patients treated early

have better results

Lee B, Teo L. Surgical reconstruction for

posterolateral rotatory instability of the elbow. J
Shoulder Elbow Surg 2003;12:4769.

Savoie FH: Arthroscopic and open radial ulnohumeral

ligament reconstruction for PLRI of the elbow. Hand
Clin 2009; 25: 323-329

Preventive treatment

Arthroscopic sectioning of both the LUCL and the radial collateral

ligament is required to cause significant PLRI (Mac Adams;
Dunning) During surgical approaches, preserve either the
anterior or posterior regions of the LCL complex and/or repair it

Clinical and biomechanical studies coronoid process and

radial head contribute significantly to posterolateral rotatory
stability. Excision of the radial head results in decreased tension
in the LUCL, which permits laxity to occur during varus and
external rotatory stresses Preserve radial head

Jensen S, Olsen B, Tyrdal S, et al. Elbow joint laxity after experimental radial head excision and lateral collateral ligament rupture:
efficacy of prosthetic replacement and ligament repair. J Shoulder Elbow Surg 2005;14:7884.
Schneeberger AG, Sadowski MM, Jacob HA. Coronoid process and radial head as posterolateral rotatory stabilizers of the elbow.
J Bone Joint Surg Am 2004;86(5):97582.
Van Glabbeek F, Van Riet R, Baumfeld J, et al. Detrimental effects of overstuffing or understuffing with a radial head replacement
in the medial collateralligament deficient elbow. J Bone Joint Surg Am 2004;86:262935.
Hall JA, McKee MD. Posterolateral rotatory instability of the elbow following radial head resection. J Bone Joint Surg Am
2005;87(7):15719.