case report open access long-term sequel of posterolateral rotatory instability of the ... · 2017....

CASE REPORT Open Access

Long-term sequel of posterolateral rotatoryinstability of the elbow: a case reportChun-Ying Cheng*

Abstract

The natural course of untreated posterior lateral rotatory instability of the elbow is unclear. A case of elbow arthro-sis with progressing deformity and flexion contracture after an episode of elbow dislocation about 20 years agopresented the possibility the long term outcome of untreated posterior lateral rotatory instability of the elbow.

IntroductionThe lateral collateral ligament complex of the elbow isthe main stabilized of posterolateral rotatory instabilityand was described by O’Driscoll at 1991[1]. Posterolat-eral rotatory instability of the elbow results from insuffi-ciency of the lateral ligamentous and muscular supportof the elbow, which allows the radial head and proximalulna to subluxate away from the humeral capitellumand trochlea when axially loaded in supination [2]. Thelong term outcome of unrecognized posterior lateralrotatory instability of the elbow is unclear and rarelyreported. The author described a case of progressingdeformed elbow with flexion contracture after an epi-sode of elbow dislocation about 20 years ago with thesymptom of tardy ulna nerve palsy for 4 months; theulnar nerve symptom and elbow function was improvedafter a surgical repair of the lateral collateral ligamentcomplex and anterior transposition of the ulnar nerve.This case of elbow arthrosis presented the possibility ofthe nature course of posterior lateral rotatory instabilityof the elbow.

Case presentationA 46-year-old, right-hand-dominant male presentedwith left ring and little fingers numbness and handweakness that had been aggravated over the previous 4months. He had chronic pain and progressive deformityof lateral elbow, and lost extension after one episode ofelbow dislocation about 20 years ago. He was trans-ferred to our office for further assessment with abovesymptoms. Tracing back his trauma history revealed

that he noted a daily sensation of painful slip in and outon the lateral elbow joint after a dislocation underwenta closed reduction by a bonesetter. His elbow symptomdidn’t improve or got a diagnosis after visiting threeorthopedic surgeons for the first 6 months. Althoughhis elbow symptom was persisting but he was tolerableat eating, dressing, carrying or pulling of daily activity orworking ability except lifting or push-up and he didn’tvisiting any physician for further help since then untilthis new symptom of hand numbness occurred.Physical examination revealed the elbow with flexion

arc from 20° to 120° and full forearm rotation comparedwith contra lateral side, and grip strength 105 lb (125 lbon the right side). Palpation revealed the deformedelbow with prominent radial head not lateral epicondyleon the lateral of the elbow. The result of neurologicexamination was abnormal including paresthesias in theulnar half of ring finger and little finger and dorsalulnar wrist with positive Tinnel sign and nerve compres-sion test of the ulnar nerve at elbow, little finger abduc-tion weakness but without claw hand deformity. Plainradiographs showed arthrosis of the elbow joint with theradiohumeral joint more sever than ulnohumeral joint,radial head deformity including lost normal concaveshape and hypertrophic marginal osteophyte with lateralsubluxation and some chip bone or ectopic bone overlateral epicondyle (Fig. 1). Patient was arranged toreceive operation with the surgical plan to decompressthe ulnar nerve by anterior transposition of the nerveand evaluate the elbow joint stability under anesthesia.After general anesthesia, the lateral pivot shift test by

O’Driscoll’s method [1] with the patient’s arm overheadwas positive and the elbow stress test at fluoroscanrevealed negative valgus and varus stress test and

* Correspondence: [email protected] of Orthopaedic Surgery, Chang Gung Memorial Hospital, ChangGung University, Taoyuan, Taiwan

Cheng Journal of Orthopaedic Surgery and Research 2010, 5:5http://www.josr-online.com/content/5/1/5

© 2010 Cheng; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.

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positive lateral stress test [2], which the radiograph istaken with provocative stress applied during the lateralpivot shift test (Fig. 2). The operation was performedwith the patient positioned supinely and supported by ahand table. The elbow was approached with two sepa-rate lateral and medial incision. The traction neuropathyof ulnar nerve at cubital tunnel was noted and intactmedial collateral ligament was identified after subcuta-neously anterior transposition of the ulnar nerve. Thelateral structure was exposure through the Kocher inter-val and an avulsed bone fragment of lateral collateralligament complex including common extensor from lat-eral epicondyle was noted, the radial head was found totranslate posterior by provocative test stress at 30° offlexion and the annular ligament was found to be intact.The lateral collateral ligament complex was repairedwith a bone anchor with No.2 polyester braided non-absorbable suture, which in a running locked fashion at

origin of tendon and ligament [2] and augmented with abone screw to fix the avulsed fragment. Postoperatively,the elbow was protected by a hinged brace with theforearm in a neutral position for 4 to 6 weeks and theflexion angle of the brace was allowed to step decreased10° per week. Progressing loading and strengthening arepermitted for the late of 2 to 6 months.At 24 months after surgery, the patient was satisfied

with the procedure; the symptom of ulnar nerve wasrecovering and he felt that his elbow was more comfor-table and stable at daily activities except lifting. Exami-nation revealed motion from 10° of extension to 130° offlexion, 75° of pronation and 80° supination, and nosigns instability and grip strength increased to left 115lb (126 lb on the right). Post-operative plain radiographsshowed the deformed radial head still subluxation atanterior-posterior view but no progressing arthrosis ofthe elbow joint(Fig. 3).

Figure 1 (A) Posteroanterior (B) lateral radiographs of elbow showed degeneration of ulnohumerus and radiohumerus joint withradial head deformity and subluxcation and avulsed bone around the lateral epicondyle.


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DiscussionNeglected or under-diagnosis the posterolateral rotatoryinstability of the elbow is possible because plain radio-graphs are commonly nondiagnosised. The symptoms ofthis condition including pain, instability or mechanicalsnapping or popping are subtle and relevant. The clini-cal assessment of subluxation and reduction sometimesby provocative test is hampered by patient apprehension

and guarding or only detected under anesthesia. Mostorthopedics surgeon didn’t understand the existence ofposterior lateral rotatory instability before the Dr.O’Driscoll’s description at 1991 [1].The patient presented the symptom and sign of loss of

extension, degenerative changes in the joint, ectopic cal-cification or neurological changes are common residualsign and symptom following elbow dislocation [3,4].

Figure 2 Fluroscan of elbow without and with lateral stress (provocative stress applied) showed subluxed radial head posterior to themidline of the capitellum.


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The patient’s symptom of radial head subluxation andlost concave deformity of radial head without symptomof forearm rotation and the sign of plain radiographsshowed arthrosis of the elbow joint with the radiohum-eral joint more sever than ulnohumeral joint are differ-ent from the consequence of simple elbow dislocationor radial head dislocation. The diagnosis of posterolatealrotatory instability in this case is undoubted becausethere is positive lateral pivot shift test and lateral stresstest of fluoroscan under anesthesia and identifiedavulsed fragment of lateral collateral ligament complexduring operation.The cause of joint degeneration may be multiple fac-

tors, but the relation of joint instability and joint degen-eration is interesting and deserving to be concern. Therelation of scapholunate ligament injury or scapholunatedissociation (instability) in the wrist with scapholunate

advanced collapsed degeneration is well known; we needmore clinical studies of posterolatreal rotatory instabilityof the elbow and biomechanical investigations of thepivot-shift test of lateral collateral ligament complex toestablish this relationship and understanding the naturalcourse of posterolateral rotatoy istability of the elbow.The radiographic findings of this case with elbowarthrosis more severs on the radiohumeral joint thanulnohumeral joint and the radial head hypertrophicdeformity and subluxation may be to characterize aneglected ligament injury with rotatory instability.

ConsentWritten informed consent was obtained from the patientfor publication of this case report and accompanyingimages. A copy of the written consent is available forreview by the Editor-in-Chief of this journal.

Figure 3 (A)Posteroanterior (B) lateral radiographs of elbow 2 years after operation showed anchor suture and bone screw at lateralepicondyle and incompletely reattached avulsed bone.


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Competing interestsThe author declares that they have no competing interests.

Received: 28 August 2009Accepted: 27 January 2010 Published: 27 January 2010

References1. O"Driscoll SW, Bell DF, Morrey BF: Posterolateral lateral rotatory instability

of the elbow. J Bone Joint Surg 1991, 73A:440-446.2. Cohen MS: Lateral collateral ligament instability of the elbow. Hand Clin

2008, 24:69-77.3. Josefsson PO, Johnell O, Gentz CF: Long-term sequela of simple

dislocation of the elbow. J Bone Joint Surg 1984, 66A:927-930.4. Eygendaal D, Verdegaal SH, Obermann WR, VanVugt AB, Poll RG,

Rozing PM: Poterolateral dislocation of the elbow joint. Relationship tomedial instability. J Bone Joint Surg 2000, 82A:555-560.

doi:10.1186/1749-799X-5-5Cite this article as: Cheng: Long-term sequel of posterolateral rotatoryinstability of the elbow: a case report. Journal of Orthopaedic Surgery andResearch 2010 5:5.

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http://www.ncbi.nlm.nih.gov/pubmed/18299021?dopt=Abstract

AbstractIntroductionCase presentationDiscussionConsentCompeting interestsReferences

case report open access long-term sequel of posterolateral rotatory instability of the ... · 2017....

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