The collateral ligaments of the elbow: anatomy and clinical correlation

Elbow Ulnar Collateral Ligament (UCL) Repair Using Suture Augmentation, Anchors, and Bone Tunnels

Ulnar collateral ligament (UCL) repair with suture augmentation has been increasingly used to treat UCL pathology in overhead athletes. For the appropriately indicated patient, UCL repair with suture augmentation without reconstruction has promising results. Advantages of repair with suture augmentation include earlier return to sport, low complication rate, and decreased operative time since there is no need for graft harvest. Previously reported techniques use suture anchors with high-tensile and collagen-coated nonabsorbable sutures. This article provides an alternative augmentation method using a combination of anchors and bone tunnels to obtain an isometric repair.

Skin Graft Versus Local Flaps in Management of Post-burn Elbow Contracture

Introduction

Contracture is a pathological scar tissue resulting from local skin tissue damage, secondary to different local factors. It can restrict joint mobility, resulting in deformity and disability. This study aimed to investigate the outcomes of skin grafts compared to local flaps to reconstruct post-burn elbow contractures. These parameters included regaining function, range of movement, recurrence, and local wound complications.

Methodology

A retrospective study reviewed 21 patients for elbow reconstruction over 12 months. Only patients with post-burn elbow contracture were included. Other causes, including previous corrective surgery, associated elbow stiffness, and patients who opted out of post-operative physiotherapy, were excluded. Patients were categorized according to the method of coverage into three groups: graft alone (G1), local flap (G2), or combined approach (G3). 

Results

Females were three times at higher risk to suffer a burn injury, while almost half of the cases were children. Scald injury represented 81% of burn causes. G1,2,3 were used in 47.6%, 42.9% and 9.5% of cases retrospectively. The overall rate of infection was 28.6%. Hundred percent graft taken was recorded in 83.3 % of cases; however, flap take was 91.1%. After 12 months of follow-up, re-contracture was 60% and 22.8% in G1 and G2; however, the satisfaction rate was 70% and 100% in both groups retrospectively. The overall satisfaction was 85.7% in all groups.

Conclusion

Grafts and local flaps are reasonable options for post contracture release; however, flaps are superior. Coverage selection depends on the lost tissue area and exposure of underlying deep structures. Physiotherapy and patient satisfaction are crucial in the outcomes. 

Elbow Dislocation

This article is a brief overview of the elbow dislocations focusing on updates in treatment and rehabilitation protocols. The fight between obtaining elbow stability without leading to long-term elbow stiffness has been a continued focus in field of sports medicine. This article highlights advances made to help treat the injuries appropriately and obtain optimal patient outcomes.

[Plate osteosynthesis of the coronoid process of the ulna]

OBJECTIVE

The aim of surgical treatment is reconstruction of the coronoid process' bony anatomy.

INDICATIONS

Large shear fractures of the coronoid process (Regan-Morrey type II-III, O'Driscoll "tip" subtype 2 and "basal" subtype 1-2) and fractures of the anteromedial facet (O'Driscoll "anteromedial" subtype 1-3) can occur isolated or as part of the "terrible triad" injuries to the elbow. Due to the resulting instability of these injuries, surgical reconstruction is generally indicated.

CONTRAINDICATIONS

In case of major accompanying soft tissue injuries to the elbow or an elbow infection, primary operative treatment using anatomical plate osteosynthesis is contraindicated.

SURGICAL TECHNIQUE

Plate osteosynthesis of the coronoid process is performed through a medial approach (Hotchkiss or M. flexor carpi ulnaris split). After repositioning of the fracture fragments, a preformed anatomical plate can be fixed to the coronoid process.

POSTOPERATIVE MANAGEMENT

The arm is immobilized in an over-the-elbow cast until the wounds are dried. Afterwards, the elbow should preferably be treated functionally without varus or valgus stress.

RESULTS

Between January 2015 and July 2018, a total of 11 patients underwent osteosynthesis of the coronoid using anatomically preformed plate osteosynthesis. After a mean follow-up of 10.7 months, the mean Mayo Elbow Performance Score showed an excellent result with 78.89 points. The Quick Disabilities of Arm, Shoulder and Hand (Q-DASH) score showed a median of 18.64 points with a mean functional arc of 118°.

Optimal Elbow Positions for Identification of the Radial Collateral Ligament Using Ultrasonography

BACKGROUND

The standard position for examining the lateral elbow with ultrasonography is an "extended" or "slightly flexed" position. However, because the radial collateral ligament (RCL) is more deeply attached on the lateral epicondyle than the common extensor tendon, an anisotropic artifact of the RCL could be observed in the conventional positions, making it difficult to fully visualize the RCL.

OBJECTIVES

To determine optimal elbow positions for accurate identification of the RCL and to explore the relevant landmarks in ultrasonography.

DESIGN

Prospective study.

SETTING

Tertiary university hospital.

PARTICIPANTS

Forty healthy elbows of 20 participants.

METHODS

The RCL was evaluated using ultrasonography in six elbow flexion positions (0°, 30°, 60°, 90°, 120°, and 140°). The relative depth, defined as the depth of the capitellum subtracted by the depth of the radial head under ultrasonography, was measured at each angle. The rates of successful identification of ultrasonographic landmarks for localizing the RCL were calculated. After ultrasonography, the optimal elbow position for identifying the RCL was determined by group consensus.

MAIN OUTCOME MEASUREMENTS

Relative depth between radial head and capitellum, rates of successful identification of ultrasonographic landmarks, and consensus-based determination of the optimal angle.

RESULTS

The relative depth significantly decreased with an increase in the flexion angle (P for trend <.001), approaching zero at the angles of 90° and 120°. The rates of successful identification of the superior tubercle, hyperechogenic line, and anterior and posterior tubercles were 100%, 100%, 90%, and 80%, respectively. In the group consensus, the 90° and 120° flexion angles were selected with the highest frequency (90%; 36/40).

CONCLUSION

Our findings suggest that elbow flexion at 90° or 120° is optimal for visualization of the RCL with the least possibility of anisotropy under ultrasonography, suggesting that the elbow should be flexed considerably beyond the conventional extended or slightly flexed position.

Dual reconstruction of lateral collateral ligament is safe and effective in treating posterolateral rotatory instability of the elbow

PURPOSE

Although reconstruction of the lateral ulnar collateral ligament (LUCL) has been considered the procedure of choice for posterolateral rotatory instability (PLRI), recent studies have reported that the entire lateral collateral ligament complex (LCLC), rather than its posterior part only, contributes to preventing PLRI. Thus, it was hypothesized that dual reconstruction of the radial collateral ligament (RCL) and LUCL for the treatment of elbow PLRI could provide favourable clinical results regardless of the mechanism of injury.

METHODS

This retrospective study reviewed the clinical results of 21 patients who underwent dual reconstruction of the RCL and LUCL between 2011 and 2016. Functional outcomes were assessed using the numeric rating scale (NRS) score, Mayo Elbow Performance Score (MEPS), quick Disabilities of the Arm, Shoulder, and Hand (quick DASH) score, and manual varus instability. To identify any difference in outcomes according to the aetiologies for LCLC insufficiency, our patients were divided into LCLC insufficiency associated with elbow dislocation and that with lateral epicondylitis.

RESULTS

At a median follow-up of 27 months (range 13-65 months), all patients showed resolved instability and achieved a functional arc of motion. In addition, lateral pivot shift tests were negative in all patients. The median MEPS significantly improved after surgery from 70 (range 60-75) to 85 (range 75-100) (p < 0.001), while the median quick DASH score improved from 38.6 (range 26.6-54.5) to 11.4 (range 0-34.1) (p < 0.001). Clinical outcomes according to the aetiology of LCLC insufficiency were not significantly different except for the NRS score.

CONCLUSION

The results suggest that the dual reconstruction technique leads to a clinical outcome similar to that of conventional LUCL reconstruction in LCLC insufficiency regardless of aetiology. In addition, the dual reconstruction technique was technically easier than the conventional LUCL reconstruction technique and may be a potential alternative when a bone tunnel created at the proximal ulna by the original technique has failed.

LEVEL OF EVIDENCE

IV.

Insertional anatomy of the anterior medial collateral ligament on the sublime tubercle of the elbow

BACKGROUND

Acute injuries to the anterior medial collateral ligament (AMCL) can occur due to valgus trauma or during other dislocating events to the elbow. AMCL lesions are often associated with bony lesions, such as radial head fractures or fractures of the coronoid process. We analyzed the insertion of the AMCL on the sublime tubercle in relation to surrounding osseous structures. We aimed to increase the understanding of the involvement of the AMCL in bony lesions to the sublime tubercle.

METHODS

We investigated 86 elbows from 43 embalmed human specimens. We measured the most ventral extensions of the AMCL at the sublime tubercle in relation to a clearly defined and reproducible landmark. We used as our landmark a horizontal line (baseline) originating on the lesser sigmoid notch in a right angle to the ulnar ridge.

RESULTS

The mean distance of the coronoid process tip to the baseline was 4.0 mm (standard deviation [SD], 1.3 mm; range, 1.4-6.7 mm). The mean distance of the ventral extension of the AMCL to the horizontal line was 3.7 mm (SD, 2.6 mm; range: 9.4-2.2 mm). The mean horizontal distance between the ventral aspect of the AMCL and the coronoid tip was 13.7 mm (SD, 2.5 mm; range, 7.7-20.5 mm).

CONCLUSIONS

We present a detailed description of the insertional anatomy of the AMCL at the sublime tubercle. These values could be helpful for classifications of coronoid fractures and to estimate the involvement of the AMCL in fractures of the sublime tubercle.

Availability of ultrasound screening for asymptomatic elbow injuries in judo athletes

OBJECTIVE

We conducted ultrasonography (US) examination for asymptomatic elbow injuries in judo athletes to confirm availability of US screening for elbow.

MATERIALS AND METHODS

One hundred and thirty-two black belts in judo (85 males and 47 females; mean age, 20.0 ± 1.6 years) participated in this screening. Forty-eight participants had a history of elbow injury (elbow-injury group), and 84 did not (no-elbow-injury group). All participants completed a survey in the form of a questionnaire. Subsequently, US scanning of both elbows was performed.

RESULTS

The maximal thickness of the medial collateral ligament of both elbows was significantly larger in the elbow-injury group than in the no-elbow-injury group. The width of the joint space was significantly larger in the right radiohumeral joint in the elbow-injury group than in the no-elbow-injury group. Combination injuries involving ligament and bone and those involving both the medial and lateral collateral ligaments were most commonly seen in both elbows in the elbow-injury group; however, these combined lesions of both elbows were also found in the no-elbow-injury group.

CONCLUSIONS

Because US screening can reveal abnormalities of the asymptomatic elbow, US is recommended as a complementary imaging modality that is useful for evaluation of elbow injuries in athletes.

Understanding the medial ulnar collateral ligament of the elbow: Review of native ligament anatomy and function

The medial ulnar collateral ligament complex of the elbow, which is comprised of the anterior bundle [AB, more formally referred to as the medial ulnar collateral ligament (MUCL)], posterior (PB), and transverse ligament, is commonly injured in overhead throwing athletes. Attenuation or rupture of the ligament results in valgus instability with variable clinical presentations. The AB or MUCL is the strongest component of the ligamentous complex and the primary restraint to valgus stress. It is also composed of two separate bands (anterior and posterior) that provide reciprocal function with the anterior band tight in extension, and the posterior band tight in flexion. In individuals who fail comprehensive non-operative treatment, surgical repair or reconstruction of the MUCL is commonly required to restore elbow function and stability. A comprehensive understanding of the anatomy and biomechanical properties of the MUCL is imperative to optimize reconstructive efforts, and to enhance clinical and radiographic outcomes. Our understanding of the native anatomy and biomechanics of the MUCL has evolved over time. The precise locations of the origin and insertion footprint centers guide surgeons in proper graft placement with relation to bony anatomic landmarks. In recent studies, the ulnar insertion of the MUCL is described as larger than previously thought, with the center of the footprint at varying distances relative to the ulnar ridge, joint line, or sublime tubercle. The purpose of this review is to consolidate and summarize the existing literature regarding the native anatomy, biomechanical, and clinical significance of the entire medial ulnar collateral ligament complex, including the MUCL (AB), PB, and transverse ligament.

Ulnar Collateral Ligament Repair With Suture Bridge Augmentation

The gold standard for management of elbow ulnar collateral ligament (UCL) injuries in elite athletes is reconstruction of the UCL with a tendon graft. Over the past several years, UCL repair for acute tears, as well as partial tears, in young athletes has gained increasing popularity, with studies reporting good outcomes and high rates of return to sports. Additionally, there is increased interest in ligament augmentation using the InternalBrace concept. A recent technique paper describes a direct repair of the UCL augmented with a spanning suture bridge. Although clinical outcomes for this method are promising, one possible concern when using this technique is bone loss at the ulnar origin of the UCL should revision reconstruction be required. We propose an alternative augmentation method that allows for stress shielding of the healing native ligament while minimizing bone compromise in the face of UCL reconstruction at a later time point.

Clinical Anatomy and Assessment of the Elbow

BACKGROUND

The elbow is a complex synovial hinge joint comprising of three articulations. Satisfactory function and stability are provided by bony and soft tissue stabilising structures. Injuries around the elbow joint are common.

METHODS

A literature search was performed and the authors' personal experiences reported.

RESULTS

The article discusses the osseous and ligamentous anatomy around the elbow joint and their relevance when assessing and managing elbow injuries.

CONCLUSION

Knowledge of the intricate anatomy around the elbow joint is essential to successfully assessing and managing elbow injuries and restoring good function.

Retrospective Comparative Analysis of Elbow Arthroscopy Used to Treat Primary Osteoarthritis With and Without Release of the Posterior Band of the Medial Collateral Ligament

PURPOSE

To evaluate the clinical and functional outcomes of arthroscopic debridement arthroplasty with the release of the posterior band of the medial collateral ligament in patients with primary osteoarthritis.

METHODS

We evaluated 43 patients treated with arthroscopic debridement arthroplasty for elbow osteoarthritis from February 2006 to February 2014. In group A (n = 19), the posterior band of the medial collateral ligament was released, and in group B (n = 24), it was not released. The mean follow-up period in groups A and B was 55.4 months (range, 24-100 months) and 62.2 months (range, 24-103 months), respectively. Clinical results were evaluated by measuring the preoperative and postoperative range of motion (ROM) of the elbow, visual analog scale score, and Mayo Elbow Performance Score.

RESULTS

Both groups showed significant improvement in clinical outcome (visual analog scale and Mayo Elbow Performance Score) at the final follow-up compared with preoperative evaluation (group A, P = .009 and .013, respectively; group B, P = .015 and .008, respectively). Group A showed significant improvement in increased flexion at 6 months of follow-up (P = .043). However, there was no statistically significant difference in postoperative ROM and clinical results between the 2 groups at the final follow-up (P = .482).

CONCLUSIONS

Arthroscopic debridement arthroplasty with the release of the posterior band of the medial collateral ligament was associated with improved flexion at the 6-month postoperative follow-up, but no significant difference between the groups was observed at the final follow-up. Therefore, the additional release of the posterior band of the medial collateral ligament may be unnecessary for improving postoperative ROM.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Elbow Injuries in Adult Overhead Athletes

OBJECTIVE

The purpose of this article is to review common elbow injuries found in overhead athletes with focus on mechanism, clinical features, imaging appearance, and treatment options.

CONCLUSION

The overhead throwing motion subjects the elbow to a variety of complex forces, which places both osseous and soft-tissue structures at high risk for injury.

Biomechanical testing of the reconstructed ulnar collateral ligament: a systematic review of the literature

PURPOSE

The purpose was to perform a systematic review of the literature investigating biomechanical studies of ulnar collateral ligament reconstruction (UCLR) techniques to summarize the most commonly analyzed methods of fixation (at both the ulna and humerus), the degree of elbow flexion at the time of fixation, graft characteristics, and modes of failure with these techniques.

MATERIALS AND METHODS

A systematic review was performed. All cadaveric biomechanical studies that tested a reconstruction method for UCLR were included. Descriptive statistics were calculated for each study and parameter/variable analyzed.

RESULTS

Twenty-three studies were included with a total of 397 elbows in 242 cadavers (mean age 54.8 ± 20 years, range 16-96). The majority of studies (65 %) used a palmaris longus graft. The docking technique (37.2 %) was the most commonly tested reconstruction method. Significant heterogeneity between studies precluded assimilation of specific techniques (each of the 23 studies utilized a unique technique). Fixation was performed at 30°-90° of elbow flexion. The most common mode of failure was suture failure (51 %), followed by midsubstance rupture (27.00 %), and bone tunnel fracture (14.00 %). No significant differences were observed amongst techniques for all measures analyzed.

CONCLUSION

This study found the docking technique to be the most commonly tested technique, while the mode of reconstruction failure was most commonly at the suture interface. If the graft failed at the bone interface, it was most likely to occur at the ulna. Surgeon preference and comfort level with a specific technique should dictate choice.

Functional anatomy of the lateral collateral ligament of the elbow

INTRODUCTION

The aim of this study was to analyze the functional anatomy of the lateral collateral ligament complex (LCLC) and the surrounding forearm extensors.

MATERIALS AND METHODS

Using 81 human cadaveric upper extremities, the anatomy of the forearm extensors-especially the anconeus, supinator and extensor carpi ulnaris (ECU)-was analyzed. After removal of aforementioned extensors the functional anatomy of the LCLC was analyzed. The origin of the LCLC was evaluated for isometry. The insertion types of the lateral ulnar collateral ligament (LUCL) were analyzed and classified.

RESULTS

The ECU runs parallel to the RCL to dynamically preserve varus stability. The supinator and anconeus muscle fibers coalesce with the LCLC and lengthen during pronation. The anconeus fibers run parallel to the LUCL in full flexion. The LCLC consists of the annular ligament (AL) and the isometric radial collateral ligament (RCL). During elbow flexion, its posterior branches (LUCL) tighten while the anterior branches loosen. When performing a pivot shift test, the loosened LUCL fibers do not fully tighten in full extension. The LUCL inserts along with the AL at the supinator crest. Three different insertion types could be observed.

CONCLUSIONS

The LUCL represents the posterior branch of the RCL rather than a distinct ligament. It is non-isometric and lengthens during elbow flexion. The RCL was found to be of vital importance for neutralization of posterolateral rotatory forces. Pronation of the forearm actively stabilizes the elbow joint as the supinator, anconeus and biceps muscle work in unison to increase posterolateral rotatory stability.

Common medial elbow injuries in the adolescent athlete

Recently there has been increased year-round sports participation among children and adolescents with limited to no rest periods. This has led to increases in pediatric repetitive stress injuries, once considered a rarity. Whether in the throwing athlete or in the athlete that experiences repetitive axial loading; increased medial tension and overload syndromes can lead to stress reactions and fractures. This occurs in the developing athlete due to the bone being weaker than the surrounding tendons and ligaments. The medial elbow is a high stress area and is susceptible to many conditions including apophysitis , avulsion fractures and ulnar collateral ligament disruption. Valgus stress can cause injury to the medial elbow which can lead to increased lateral compression, Panner's disease and osteochondral lesions of the capitellum and olecranon. The purpose of this manuscript is to review common elbow disorders in the adolescent population, outline management and highlight important features of rehabilitation.

Management of Elbow Trauma: Anatomy and Exposures

The elbow is a complex joint from the anatomic and biomechanical point of view. A thorough understanding of elbow anatomy greatly aids the surgeon in dealing with elbow trauma. The close vicinity of neurovascular structures should always be kept in mind when selecting a surgical approach. Any approach to the elbow needs to be safe and versatile. Knowledge of the attachment and orientation of elbow ligaments reduces the risk of inadvertent intraoperative injury and/or postoperative instability. Surgeons dealing with elbow trauma should have a good working understanding of elbow anatomy and the available approaches to effectively and efficiently conduct the surgical procedure to maximize outcomes and minimize complications.

Open surgical release for contractures of the elbow

Compared with arthroscopic release, open release is more commonly used for the treatment of stiff elbow. Flexion is recovered by releasing posterior tethering soft-tissue structures and by removing anterior impingement between the coronoid and/or radial head and the distal humerus. Extension is improved by releasing anterior soft-tissue tethers and by removing impingement between the olecranon tip and the olecranon fossa. Open elbow release is most commonly performed via ligament-sparing approaches. Ulnar nerve identification and transposition is recommended in the presence of nerve dysfunction or when correction of significant loss of elbow flexion is anticipated. Long-term improvement in flexion and extension can be expected with proper patient selection. Less predictable results are obtained in adolescent patients and in those with underlying traumatic brain injury.

Recognition and fixation of crista supinatoris fractures in Monteggia injuries

In Monteggia fracture dislocations of the elbow, the lateral collateral ligament complex is disrupted as the radial head dislocates from the capitellum. A persistently incompetent lateral ulnar collateral ligament (LUCL) predisposes to posterolateral rotary instability of the elbow, thus restoration of the LUCL is essential for recovery. Although LUCL disruptions following elbow dislocations typically occur at the lateral humeral origin, we have identified a series of Monteggia injuries where the LUCL is avulsed from its ulnar insertion along with a fracture fragment containing the crista supinatoris. Failure to recognize and appropriately treat the crista supinatoris fracture in this injury may result in LUCL incompetence and risk symptomatic instability. The following technique describes the recognition and surgical treatment of Monteggia injuries, specifically recognizing the crista supinatoris fracture. Using this technique, patients reliably experience good functional outcomes with normal elbow stability.

Optimal Elbow Angle for Sonographic Visualization of the Ulnar Collateral Ligament

OBJECTIVE

To formally examine the sonographic appearance of the elbow ulnar collateral ligament (UCL) at 30° versus 70° of elbow flexion in asymptomatic baseball pitchers.

DESIGN

A prospective, cross-sectional design.

SETTING

Sports medicine clinic in a tertiary academic medical center.

PARTICIPANTS

Thirty asymptomatic adolescent baseball pitchers 13-18 years of age (mean 15.8 years), with at least 3 years of continuous pitching experience and no significant history of elbow pain or injury.

METHODS

Static sonographic images of the bilateral UCLs were obtained at 30° and 70° of elbow flexion by a single experienced examiner. Images were anonymized and randomized into a slide set. Three clinicians with different levels of ultrasound experience reviewed the static 30° and 70° images for each elbow and chose their preferred image based on UCL conspicuity. The clinicians reviewed a re-randomized slide set 1 week later. A different study co-investigator measured UCL cross-sectional area (CSA) on all images using ultrasound machine electronic calipers.

MAIN OUTCOME MEASURES

Preference for the sonographic conspicuity of the UCL at 30° versus 70° of elbow flexion, and UCL CSA at 30° versus 70° of flexion.

RESULTS

Each clinician demonstrated a significant preference for UCL images obtained at 70° of flexion when compared to those obtained at 30° (80.3% overall preference for 70°, P < .001). There was no statistically significant effect of clinician experience or arm dominance on image preference. The sonographically determined CSA of the UCLs were on average 1.4 mm(2) greater at 70° than at 30° of flexion (P < .001) when combining dominant and nondominant arms.

CONCLUSIONS

Static sonographic evaluation of the UCL at 70° of elbow flexion should be integrated into UCL imaging protocols. Furthermore, when performing sonographically guided procedures targeting the UCL, clinicians should consider positioning the elbow at >30° of flexion to optimize UCL conspicuity and CSA.

Graft diameter does not influence primary stability of ulnar collateral ligament reconstruction of the elbow

BACKGROUND

Ulnar collateral ligament insufficiency may result in medial elbow pain, instability, and reduced athletic performance in throwing athletes. Several reconstruction methods have been described, but biomechanical studies suggest that in general, stability of the graft construct is inferior to the native ulnar collateral ligament. This study investigates whether a stronger graft would yield greater resistance to valgus load over the range of motion.

METHODS

Ten cadaveric elbows were mounted to a testing fixture and incremental valgus moments of 2.5, 5, and 7.5 Nm were applied with the elbow in 120°, 90°, 60°, 30° and 0° of flexion and in varying rotational forearm positions. The intact and the ulnar collateral ligament released elbow joint were compared with the docking ulnar collateral ligament reconstruction technique, using different graft sources with increasing cross-sectional areas: palmaris longus, tricpes brachii, extensor carpi radialis longus, and semitendinosus. The resulting angular displacement was evaluated and compared between graft sources and different elbow positions.

RESULTS

Compared with the intact situation, ulnar collateral ligament release resulted in a significant increase in valgus deformation over the entire range of flexion-extension motion. Ligament reconstruction using any graft source significantly restored valgus stability at 60°, 90°, and 120°, while at 0° and 30°, angular valgus deformation did not significantly differ from the ulnar collateral ligament deficient situation. There were no significant differences in angular valgus deformation between the graft sources over the range of flexion motion or forearm rotation.

CONCLUSIONS

This study did not prove that a thicker graft yielded more resistance to valgus moments when using the docking technique. Thicker grafts require larger bone tunnels, cannot be adequately tensioned, and are non-anatomic. Therefore, the palmaris longus or a triceps tendon strip are considered more appropriate for ulnar collateral ligament reconstruction.

Strategic approach to O'Driscoll type 2 anteromedial coronoid facet fracture

BACKGROUND

The purpose of this study was to suggest a strategic approach to the management of anteromedial coronoid facet (AMCF) fracture that is related to posteromedial rotational instability of the elbow through investigation of the surgical outcome of diverse combinations, including internal fixation of AMCF fractures and repair of collateral ligament injury.

METHODS

The study enrolled 18 patients. On the basis of the size of the coronoid fracture and the degree of the soft tissue injuries that were evaluated with computed tomography, magnetic resonance imaging, and varus stress test under anesthesia, these fractures were managed differently. Functional outcomes were evaluated with the visual analog scale score, modified Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder and Hand score. Plain radiographs were used to evaluate the degree of arthrosis.

RESULTS

There were 2 cases of O'Driscoll type 2, subtype 1 fractures; 14 cases of type 2, subtype 2 fractures; and 2 cases of type 2, subtype 3 fractures. Seven cases were managed with only AMCF fracture fixation, 4 cases with only lateral ulnar collateral ligament (LUCL) repair, 6 cases with concomitant repair of the LUCL and AMCF fracture, and 1 case with a conservative method. There were no significant differences among O'Driscoll types and among the subgroups of type 2-2 (P > .05). When the elbow showed instability on the varus stress test after AMCF fracture fixation, the soft tissue injuries of the lateral elbow were more severe (P =. 015). Arthrosis was not correlated with the patient's symptoms (P > .05).

CONCLUSION

AMCF fracture can be treated by only AMCF fracture fixation, only LUCL repair, or a combination of these techniques, depending on the size of the AMCF fracture fragment and the degree of the lateral soft tissue injuries.

Anatomical parameters in the lateral ulnar collateral ligament reconstruction: a cadaver study

Introduction

The purpose of this study was to indentify the ulnar insertion of the LUCL using the olecranon tip and the radial head as parameters to guide the ligament reconstruction surgery.

Methods

Thirteen elbows of eight fresh cadavers were dissected for the study of the LUCL. The distances between the proximal and distal insertion of the LUCL (footprint), between the radial head and the footprint and between the olecranon tip and the footprint were measure with a digital pachimeter.

Results

The average distance from the radial head to the proximal and distal ulnar insertion of the LUCL was 13.6 and 22.99 mm, respectively. The average distance between the olecranon tip and the proximal and distal ulnar insertion of the LUCL was 38.25 and 47.6 respectively. The mean length of the LUCL footprint was 9.35 mm.

Conclusions

The LUCL insertion has a wide footprint with average 9.3 mm (7.5-11 mm). Ulnar insertion half point be located at 18.2 mm of the radial head and at 42.9 mm of olecranon tip.

Dual reconstruction of the radial collateral ligament and lateral ulnar collateral ligament in posterolateral rotator instability of the elbow

Recent studies have found that the radial collateral ligament (RCL) plays a key role in the lateral stability of the elbow joint, and there is no truly isometric location for LUCL tendon graft reconstruction tunnels using the original technique. However, no report has been issued on the treatment including RCL reconstruction and the modification of LUCL reconstruction in patients with posterolateral rotatory instability (PLRI). Three patients with PLRI were treated using two different ways and produced good results. First, dual reconstruction of the LUCL and RCL was performed, and second, the insertion of the reconstructed LUCL was shifted to the AL instead of to the original ulna to produce a more flexible isometric point setting. We want to report on the management of PLRI by dual reconstruction of the RCL and LUCL and a modification of the original technique of LUCL reconstruction.

Nonoperative Management of Complete Lateral Elbow Ligamentous Disruption in an NFL Player: A Case Report

Disruptions of the lateral soft tissue restraints of the elbow, including the lateral ulnar collateral ligament, are a well-recognized clinical entity which may result in chronic elbow instability. When symptomatic, most authors recommend surgery to reconstruct the LUCL. We report on a case of a professional football player who sustained complete disruption of the lateral collateral ligamentous complex from the lateral humeral epicondyle with extension of his injury into his common extensor origin. He was treated conservatively and returned to play after 4 weeks. Treatment algorithm and a review of the literature are discussed.

Reconstruction of the medial collateral ligament of the elbow

Since Dr. Frank Jobe initially reported his first series for reconstruction of the medial collateral ligament (MCL) of the elbow in 1986, many modifications have been developed to improve the strength, safety, and efficacy of the procedure. High stresses occur across the anterior bundle of the MCL during the late cocking and early acceleration phases of throwing. Reported failures for reconstruction of the MCL have included stress fractures at the ulnar bone bridge or the distal humerus tunnels. In early techniques, graft placement was not anatomic, and it could not be tensioned appropriately in surgery. Hybrid modifications have arisen to improve patient outcomes and lessen patient morbidity. We propose an alternative, hybrid technique using small bone tunnels in the medial epicondyle and a single, bioabsorbable screw in the ulna for anatomic reconstruction of both bundles of the MCL that can be tensioned before fixation.

Traumatic valgus instability of the elbow: pathoanatomy and results of direct repair. Surgical technique

BACKGROUND

The medial collateral ligament provides valgus stability to the elbow. The purpose of the present study was to describe the pathoanatomy of acute traumatic medial collateral ligament ruptures and to report the rationale and results of direct repair.

METHODS

Between 1996 and 2006, eleven athletes presented with acute rupture of the medial collateral ligament of the elbow and no history of dislocation. Three patients had received steroid injections for the treatment of medial epicondylitis, but none had a history of medial elbow insufficiency. All patients demonstrated gross valgus instability on clinical examination and medial joint space widening on valgus stress radiographs. Complete avulsion of the medial collateral ligament from its humeral origin was documented with magnetic resonance imaging in all patients. Operative findings uniformly demonstrated avulsion of the flexor-pronator muscles with distal retraction. The underlying medial collateral ligament was avulsed in a sleeve-like fashion from the denuded medial epicondyle. The ligament was directly reattached to its footprint. The avulsed flexor-pronator tendon was repaired to the residual tendon with use of interrupted figure-of-eight nonabsorbable sutures. All patients were followed for a minimum of sixteen months with serial clinical examinations, radiographs, and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

RESULTS

Full active range of motion was achieved in ten patients; the remaining patient had a 20 degrees flexion contracture. Three patients had acute ulnar nerve palsies at the time of the injury, and all three recovered complete motor and sensory function by six months after the injury. Nine of the eleven patients returned to competitive college athletics between four and six months. The mean DASH score at the time of the most recent follow-up was 6.

CONCLUSIONS

Direct repair of an acute traumatic medial collateral ligament avulsion of the elbow reliably restores valgus stability, even in throwing athletes.

Combined surgical treatment for missed rupture of triceps tendon associated with avulsion of the ulnar collateral ligament and flexor-pronator muscle mass

Triceps tendon ruptures are rare injuries. Coexistence of ipsilateral ulnar collateral ligament injury is even rarer. Here, we describe an unusual combination injury to elbow of a 39-year-old male construction worker consisting of triceps tendon rupture, avulsion of elbow ulnar collateral ligament and flexor pronator muscle origin ipsilaterally. A simultaneous repair and reconstruction of all damaged structures was proposed with individualized postoperative rehabilitation. Return to pre-injury level of activities obtained with this treatment protocol. High degree of suspicion and careful examination were needed to prevent missed diagnosis and prolonged instability which may be inevitable after inappropriate treatment of such injury.

Traumatic valgus instability of the elbow: pathoanatomy and results of direct repair

BACKGROUND

The medial collateral ligament provides valgus stability to the elbow. The purpose of the present study was to describe the pathoanatomy of acute traumatic medial collateral ligament ruptures and to report the rationale and results of direct repair.

METHODS

Between 1996 and 2006, eleven athletes presented with acute rupture of the medial collateral ligament of the elbow and no history of dislocation. Three patients had received steroid injections for the treatment of medial epicondylitis, but none had a history of medial elbow insufficiency. All patients demonstrated gross valgus instability on clinical examination and medial joint space widening on valgus stress radiographs. Complete avulsion of the medial collateral ligament from its humeral origin was documented with magnetic resonance imaging in all patients. Operative findings uniformly demonstrated avulsion of the flexor-pronator muscles with distal retraction. The underlying medial collateral ligament was avulsed in a sleeve-like fashion from the denuded medial epicondyle. The ligament was directly reattached to its footprint. The avulsed flexor-pronator tendon was repaired to the residual tendon with use of interrupted figure-of-eight nonabsorbable sutures. All patients were followed for a minimum of sixteen months with serial clinical examinations, radiographs, and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

RESULTS

Full active range of motion was achieved in ten patients; the remaining patient had a 20 degrees flexion contracture. Three patients had acute ulnar nerve palsies at the time of the injury, and all three recovered complete motor and sensory function by six months after the injury. Nine of the eleven patients returned to competitive college athletics between four and six months. The mean DASH score at the time of the most recent follow-up was 6.

CONCLUSIONS

Direct repair of an acute traumatic medial collateral ligament avulsion of the elbow reliably restores valgus stability, even in throwing athletes.

Release of the medial collateral ligament to improve flexion in post-traumatic elbow stiffness

Contracture of the collateral ligaments is considered to be an important factor in post-traumatic stiffness of the elbow. We reviewed the results of isolated release of the medial collateral ligament in a series of 14 patients with post-traumatic loss of elbow flexion treated between 1998 and 2002. There were nine women and five men with a mean age of 45 years (17 to 76). They were reviewed at a mean follow-up of 25 months (9 to 48). The operation was performed through a longitudinal posteromedial incision centred over the ulnar nerve. After decompression of the ulnar nerve, release of the medial collateral ligament was done sequentially starting with the posterior bundle and the transverse component of the ligament, with measurement of the arc of movement after each step. If full flexion was not achieved the posterior half of the anterior bundle of the medial collateral ligament was released.

At the latest follow-up, the mean flexion of the elbow improved significantly from 96° (85° to 115°) pre-operatively to 130° (110° to 150°) at final follow-up (p = 0.001). The mean extension improved significantly from 43° (5° to 90°) pre-operatively to 22° (5° to 40°) at final follow-up (p = 0.003). There was a significant improvement in the functional outcome. The mean Broberg and Morrey score increased from a mean of 54 points (29.5 to 85) pre-operatively to 87 points (57 to 99) at final follow-up (p < 0.001). All the patients had normal elbow stability.

Our results indicate that partial surgical release of the medial collateral ligament is associated with improved range of movement of the elbow in patients with post-traumatic stiffness, but was less effective in controlling pain.

Lateral collateral ligament instability of the elbow

Lateral elbow support is provided by a combination of bony anatomy and the ligaments and tendons that originate at the lateral epicondyle. Instability is typically posttraumatic in nature. In the acute setting of elbow fracture-dislocation, restoration of lateral soft tissue support can be typically accomplished by a direct repair of the lateral ligament and extensor tendon origins to the humeral epicondyle. In chronic settings, a reconstruction is most commonly necessary using a free tendon graft. Indications and surgical techniques are discussed.

MR imaging of the elbow in baseball pitchers

Baseball pitcher throwing biomechanics are important to understanding the pathophysiology and magnetic resonance (MR) imaging appearances of injuries in baseball pitchers. Baseball pitchers experience repetitive excessive valgus forces at the elbow. Typical injuries are secondary to medial joint distraction, lateral joint compression, and rotatory forces at the olecranon. MR imaging is useful for evaluation of the elbow in baseball pitchers.

Ligament fibre recruitment of the elbow joint during gravity-loaded passive motion: an experimental study

BACKGROUND

Knowledge of elbow collateral ligament length during passive motion is essential in understanding ligament physiology and pathology, such as tightness and instability.

METHODS

Five anatomical unembalmed specimens were passively placed in six flexion positions together with three forearm rotations, using equipment with gravity as motion force. These 18 positions were recorded using CT-scan. Three-dimensional data of ligament insertions were obtained through anatomical millimetre sections. Ligament length was measured in each position.

FINDINGS

In neutral rotation, the lateral collateral ligament was long between 0 degrees and 30 degrees as well as at 90 degrees, and short between about 60 degrees and 120 degrees of flexion. In pronation, it was long at about 0 degrees and between 60 degrees and 120 degrees, short at about 30 degrees of flexion. In supination, it was long at about 30 degrees and 90 degrees and short between 120 degrees and 150 degrees of flexion. In any forearm rotation, the highest length of the anterior bundle of the ulnar collateral ligament was measured at about 90 degrees, its smallest length between 120 degrees and 150 degrees of flexion, position at which the posterior bundle length was greatest.

INTERPRETATION

At 60 degrees of flexion, the collateral ligaments were slackened in any forearm rotations. Forearm rotation plays an indirect role in the posterolateral stability of elbow as it changes length of the lateral collateral ligament. This ligament can be tested passively at 90 degrees of flexion in supination, the anterior bundle of the ulnar collateral ligament between 0 degrees and 30 degrees in neutral rotation and the posterior bundle between 120 degrees and 150 degrees in neutral rotation.

Complex elbow instability

This article attempts to outline the most current relevant literature regarding diagnosis, pathoanatomy, and treatment options for complex elbow instability. Specific attention is directed toward unique injury patterns, important biomechanical principles, and recent clinical outcome studies. Directions for future research are suggested.

Two ulnar collateral ligament reconstruction methods: the docking technique versus bioabsorbable interference screw fixation--a biomechanical evaluation with cyclic loading

We compared the effects of cyclic valgus loading on 2 techniques for reconstruction of the elbow ulnar collateral ligament (UCL): the docking procedure and the bioabsorbable interference screw procedure. A cyclic valgus load was applied to the 16 unembalmed elbows, and the valgus angle was measured at 1, 10, 100, and 1000 cycles. Testing was repeated after UCL palmaris tendon reconstruction via either the docking technique or bioabsorbable interference screw fixation. At cycle 1, the valgus angle was not different between treated and intact cases. At cycles 10 and 100, the valgus angle for the docking technique was significantly greater than that for both the intact cases and the interference screw technique. By the 1000th cycle, no difference was measured between the 2 techniques. In this study, bioabsorbable interference screw fixation resulted in less valgus angle widening in response to early cyclic valgus load as compared with the docking technique.

The effect of arthroscopic sectioning of the lateral ligament complex of the elbow on posterolateral rotatory stability

This study evaluates the relative roles of the radial collateral ligament, the lateral ulnar collateral ligament, and the overlying musculature in posterolateral rotatory instability of the elbow. Fourteen cadaveric upper limbs underwent sequential arthroscopic sectioning of the lateral collateral ligament complex. After sectioning, arthroscopic and fluoroscopic evaluation of a lateral pivot shift test was done. Minimal instability was noted after the first section, but no difference between radial collateral or lateral ulnar collateral ligament sectioning was found. A greater degree of instability was seen between the first and second cut ( P = .0001), but no significant difference was seen between sectioning the 2 groups ( P = .61). Complete instability occurred only after sectioning the overlying musculature. On the basis of this study, injury to both the radial collateral and lateral ulnar collateral ligaments is necessary to cause significant posterolateral rotatory instability of the elbow. Furthermore, the overlying musculature plays an important role in overall stability.