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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




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

Angular velocity is between

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. Effects 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

Varus : No




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; 48:340–346

Explanation for this
contradiction ?

•Ciaudo et al. Bases anatomiques pour les luxations récidivantes du
coude. Bull. Assoc. Nancy 1980; 64: 465-476

• O’Driscoll et al. Posterolateral rotatory instability of the elbow. J
Bone Joint Surg Am 1991;73(3):440–6.)

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

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):391–6.

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;
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: 244–9.
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, Pöll 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

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

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

O’Driscoll 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): 231–9.
Veltri DM, O’Brien 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

Stress X-Rays are difficult to
perform and a positive
displacement can be as small
as 0,5 mm

Sonography +++


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. O’Driscoll; Ligamentous repair and reconstruction for posterolateral rotatory instability of the
elbow; J Bone Joint Surg [Br] 2005;87-B:54-61.

Clinical diagnosis

Lateral pain

Snapping or clicking elbow

Feeling of an unstable elbow


r to
the L insta
of p
ain except

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; 13:344–6.


Iatrogenic injury of the LCL after elbow arthrolysis.
Radial head subluxation during push-up test


Static X-rays are rarely

Chip fracture of the lateral

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

Joint widening AND radial
head translation

Treatment of PLRI

Conservative treatment are

Surgical treatment: ligament
reinsertion, plication or

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


Using Cadenat-Kocher approach

Find the supinator crest

Three holes to reconstruct an isometric

Cheung, CORR

PLRI due to
+ humeral
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 =

J. Sanchez-Sotelo, B. F. Morrey, S. W. O’Driscoll; 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

8 /10 patients good to
excellent result

20 arthroscopic repair and
21 open

Superior results in
patients with a tendon

Both objective and
subjective parameters
improved in both groups

Mild flexion contraction

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;12:476–9.

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;14:78–84.
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):975–82.
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;86:2629–35.
Hall JA, McKee MD. Posterolateral rotatory instability of the elbow following radial head resection. J Bone Joint Surg Am