Elbow LCL Reconstruction and Repair

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• A form of elbow instability characterized by posterolateral subluxation or dislocation of the radiocapitellar and ulnohumeral joints
  • usually associated with a traumatic elbow dislocation
  • caused by insufficiency of the lateral elbow collateral ligament complex
  • caused primarily by insufficiency of the LUCL
• Pathophysiology
  • traumatic
  • most often discussed as a result of elbow dislocation
  • combination of forearm supination, axial loading, valgus (posterolateral) stress, and elbow extension causes progressive failure of the lateral collateral ligament complex and anterior capsule, resulting posterolateral subluxation of the radial head and external rotation of the semilunar notch away from trochlea
  • common extensor origin can also be avulsed
  • radioulnar articulation remains intact
  • iatrogenic injury
  • from arthroscopic or open procedures of the lateral elbow that go posterior to equator of radial head (e.g. debridement of lateral epicondylitis)
  • arthroscopic debridement should be kept anterior to equator of the radial head
  • chronic attenuation
  • secondary to chronic cubitus varus malunion
  • abnormal lateral thrust stretches out the LUCL with time
  • abnormal triceps vector further stretches LUCL
• Associated conditions
  • elbow dislocations

Anatomy:

• Lateral collateral ligament complex consists of 4 components
• accessory lateral collateral ligament
• annular ligament
• lateral radial collateral ligament (LCL)
• lateral ulnar collateral ligament (LUCL)

• LUCL is the primary stabilizer to varus & ER stress
  • origin
    • lateral humeral epicondyle
  • insertion
    • the tubercle of the supinator crest of the ulna

• Symptoms
• pain is the primary symptom
• mechanical symptoms (clicking, catching, etc.)
  • often with elbow extension and when pushing off from arm of chair
• Physical exam
  • inspection and palpation
    • tenderness over LUCL
  • motion and stability
    • varus instability
  • provocative tests
  • lateral pivot-shift test
    • patient lies supine with affected arm overhead; forearm is supinated and valgus stress is applied while bringing the elbow from full extension to 40 degrees of flexion
    • with increased flexion, triceps tension reduces the radial head
    • often more reliable on anesthetized patient
  • posterior drawer test
    • patient lies supine with affected arm overhead; forearm is supinated and the examiner's index finger is placed under the radial head and the thumb over it.
    • application of a posterior force will cause posterior subluxation of the radial head
  • apprehension test
    • patient lies supine with affected arm extended overhead; forearm is supinated and valgus stress is applied while flexing the elbow
  • chair rise test
  • table-top relocation test
  • floor push-up test
    • patient cannot do push-ups with forearm supinated
• Radiographs
  • recommended views
    • AP and lateral views of elbow
  • findings
    • important to rule out associated fractures and confirm concentric reduction in setting of acute dislocation
    • standard radiographs are often of little value in evaluating PLRI
      • fluoroscopic imaging during provocative testing (e.g. pivot-shift) may demonstrate radial head subluxation
• MRI
• indications
  • may not be helpful in the setting of recurrent instability and LUCL attenuation as visualizing ligament difficult due to oblique course
• findings
  • can identify acute avulsion of LUCL in acute instability
• sensitivity and specificity
  • LUCL pathology identifed in 50% of patients
• Nonoperative
• acute reduction followed by immobilization at 90° flexion for 5-7 days
  • indications
  • acute elbow dislocations
  • technique
    • following reduction assess post-reduction stability
    • place in posterior splint for 5-7 days, with elbow at 90 degrees of flexion and forearm appropriately positioned based on post-reduction stability
    • LCL disrupted, but MCL intact
    • splint in full pronation (tightens lateral structures)
    • LCL + MCL disrupted
    • splint in neutral
    • will not splint in full supination (for MCL rupture only) as the LCL is always disrupted in PLRI
    • early active ROM following splint removal (+/- extension block)
    • full supination/pronation from 90° to full flexion
    • progress with increasing extension by 30° weekly, but with the forearm in full pronation; after 6 weeks full supination in extension allowed
• bracing, extensor strengthening, activity modification w/ avoidance of gravity varus positions
• Operative
• open reduction, fracture fixation, LUCL repair
• indications
  • osteochondral fragment or soft-tissue entrapment prevents concentric reduction
  • complex dislocation (associated fractures are present)
  • acute instability
  • open & arthroscopic techniques described
• LUCL reconstruction w/ graft
  • indications
  • chronic PLRI