Clinical presentation and findings
The symptoms of lateral and posterolateral rotatory instability are not typical. They vary according to the degree of instability. Redislocations are rare. Most commonly complaints are vague: diffuse elbow pain, clicking, catching, locking and snapping during activity. Posterolateral rotatory instability most often shows as episodes of apprehension when the arm is supinated in extension, or during supination in slight flexion when valgus stress is applied to the arm [18,51].
Demonstration of instability can be difficult. The varus and valgus stress tests should be performed to reveal medial and lateral instability. In the case of instability, the valgus test should be repeated with the forearm in pronation, and if positive, this is indicative of medial instability, which should be addressed. The pivot-shift test should be performed, and if negative should be repeated under anesthesia if history makes posterolateral rotatory instability possible. In some cases instability can only be demonstrated during elbow arthroscopy, in which subluxation of the radial head can be directly visualized during the pivot-shift test.
Instability may be demonstrated on stress X-rays. The radial head subluxation can be shown, if the pivot-shift test is performed during stress X-rays . Ligament disruption can be demonstrated nicely on MRI .
Treatment and prognosis
Acute disruption of the lateral ligaments should be treated with a hinged elbow brace in 4-6 weeks with the forearm in pronation .
Chronic, symptomatic lateral or posterolateral instability can only be treated operatively. If the radioul-nar ligament is detached but intact, it can be reinserted or tightened during open operation, and the lateral capsule tightened as well. Tightening of the lateral structures can also be performed arthroscopically. If the ligamentous tissue is poor, the ligament can be reconstructed with the palmaris longus tendon, placed in drill holes in humerus and ulnar in the anatomic position of the ligament . The results after operative treatment are optimistic, with 85% categorized as excellent or good.
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