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Pain during late cocking and acceleration; milking maneuver.
12%
612/5002
Painful clicking during pushoff from armrests of a chair; milking maneuver.
4%
185/5002
Painful clicking during pushoff from armrests of a chair; lateral pivot shift.
65%
3255/5002
Pain during late cocking and acceleration; lateral pivot shift.
10%
517/5002
Painful clicking during pushoff from armrests of a chair; moving valgus stress test.
7%
369/5002
Select Answer to see Preferred Response
This patient has rupture of the lateral ulnar collateral ligament (LUCL), producing posterolateral rotatory instability (PLRI). This is best demonstrated with a positive lateral pivot shift test. PLRI can be diagnosed using the lateral pivot shift or posterolateral drawer. According to O’Driscoll, the elbow dislocates in 3 stages from lateral to medial (circle of Horii). Stage 1 involves disruption of the LUCL and partial/total disruption of the LCL complex (creating PLRI). Patients have pain with varus stress. Stage 2 includes disruption of the anterior capsule from incomplete elbow posterolateral dislocation. Stage 3 is divided into: (a) Disruption of all soft tissues surrounding/ including the posterior MCL except for the anterior bundle. This bundle forms the pivot around which the elbow dislocates in a posterior direction by way of a posterolateral rotatory mechanism; and (b) complete disruption of the MCL. O'Driscoll et al. describe PLRI diagnosed in 5 patients who had elbow dislocation using the posterolateral rotatory instability test, which they describe as being analogous to the test for lateral rotatory instability of the knee after ACL rupture. They believed the condition was laxity of the LUCL, which allowed transient rotatory subluxation of the ulnohumeral joint and secondary dislocation of the radiohumeral joint, without radio-ulnar joint dislocation. They recommended repair of the LUCL to eliminate PLRI. Sanchez-Sotelo et al. retrospectively described 12 cases of direct repair and 33 ligamentous reconstructions for PLRI. 86% were satisfied with the procedure. Better results were obtained with patients with post-traumatic etiology, instability at presentation, and those with augmented reconstruction with tendon graft (compared with ligament repair alone). Figure A shows structures on the lateral side of the elbow. The corresponding labels are seen in Illustration A. Illustration B shows the lateral pivot shift (also known as the posterolateral rotatory instability test). Incorrect Answers: Answers 1, 2, 4, 5: Pain during late cocking/early acceleration is characteristic of valgus instability. The milking maneuver and moving valgus stress tests are valgus tests used to test for this.
5.0
(7)
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