Long-term sequel of posterolateral rotatory instability of the elbow: a case report
© Cheng; licensee BioMed Central Ltd. 2010
Received: 28 August 2009
Accepted: 27 January 2010
Published: 27 January 2010
The natural course of untreated posterior lateral rotatory instability of the elbow is unclear. A case of elbow arthrosis with progressing deformity and flexion contracture after an episode of elbow dislocation about 20 years ago presented the possibility the long term outcome of untreated posterior lateral rotatory instability of the elbow.
The lateral collateral ligament complex of the elbow is the main stabilized of posterolateral rotatory instability and was described by O'Driscoll at 1991. Posterolateral rotatory instability of the elbow results from insufficiency of the lateral ligamentous and muscular support of the elbow, which allows the radial head and proximal ulna to subluxate away from the humeral capitellum and trochlea when axially loaded in supination . The long term outcome of unrecognized posterior lateral rotatory instability of the elbow is unclear and rarely reported. The author described a case of progressing deformed elbow with flexion contracture after an episode of elbow dislocation about 20 years ago with the symptom of tardy ulna nerve palsy for 4 months; the ulnar nerve symptom and elbow function was improved after a surgical repair of the lateral collateral ligament complex and anterior transposition of the ulnar nerve. This case of elbow arthrosis presented the possibility of the nature course of posterior lateral rotatory instability of the elbow.
A 46-year-old, right-hand-dominant male presented with left ring and little fingers numbness and hand weakness that had been aggravated over the previous 4 months. He had chronic pain and progressive deformity of lateral elbow, and lost extension after one episode of elbow dislocation about 20 years ago. He was transferred to our office for further assessment with above symptoms. Tracing back his trauma history revealed that he noted a daily sensation of painful slip in and out on the lateral elbow joint after a dislocation underwent a closed reduction by a bonesetter. His elbow symptom didn't improve or got a diagnosis after visiting three orthopedic surgeons for the first 6 months. Although his elbow symptom was persisting but he was tolerable at eating, dressing, carrying or pulling of daily activity or working ability except lifting or push-up and he didn't visiting any physician for further help since then until this new symptom of hand numbness occurred.
Neglected or under-diagnosis the posterolateral rotatory instability of the elbow is possible because plain radiographs are commonly nondiagnosised. The symptoms of this condition including pain, instability or mechanical snapping or popping are subtle and relevant. The clinical assessment of subluxation and reduction sometimes by provocative test is hampered by patient apprehension and guarding or only detected under anesthesia. Most orthopedics surgeon didn't understand the existence of posterior lateral rotatory instability before the Dr. O'Driscoll's description at 1991 .
The patient presented the symptom and sign of loss of extension, degenerative changes in the joint, ectopic calcification or neurological changes are common residual sign and symptom following elbow dislocation [3, 4]. The patient's symptom of radial head subluxation and lost concave deformity of radial head without symptom of forearm rotation and the sign of plain radiographs showed arthrosis of the elbow joint with the radiohumeral joint more sever than ulnohumeral joint are different from the consequence of simple elbow dislocation or radial head dislocation. The diagnosis of posterolateal rotatory instability in this case is undoubted because there is positive lateral pivot shift test and lateral stress test of fluoroscan under anesthesia and identified avulsed fragment of lateral collateral ligament complex during operation.
The cause of joint degeneration may be multiple factors, but the relation of joint instability and joint degeneration is interesting and deserving to be concern. The relation of scapholunate ligament injury or scapholunate dissociation (instability) in the wrist with scapholunate advanced collapsed degeneration is well known; we need more clinical studies of posterolatreal rotatory instability of the elbow and biomechanical investigations of the pivot-shift test of lateral collateral ligament complex to establish this relationship and understanding the natural course of posterolateral rotatoy istability of the elbow. The radiographic findings of this case with elbow arthrosis more severs on the radiohumeral joint than ulnohumeral joint and the radial head hypertrophic deformity and subluxation may be to characterize a neglected ligament injury with rotatory instability.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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