Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Elbow Collateral Ligaments Treatment & Management

  • Author: Rahi K Yallapragada, MBBS, MRCS, FRCS(T&O), MCh(Orth); Chief Editor: Harris Gellman, MD  more...
 
Updated: Mar 06, 2015
 

Medical Therapy

Most symptomatic conditions of the overhead athlete can initially be treated conservatively. Any thrower who is experiencing medial elbow pain should refrain from pitching until he or she has had a thorough evaluation; a past history of medial elbow pain is a risk factor for fracture of the medial epicondyle. Nonsteroidal anti-inflammatory drugs (NSAIDs) may help relieve the pain and control the inflammatory reaction.

There is no evidence that the results of surgical repair of the ligaments are any better than those of nonsurgical treatment in patients with medial or both lateral and medial laxity of the elbow following nonfracture dislocations.

Postreduction assessment of stability

After reduction of a dislocated elbow, the elbow will generally be stable in 90º or more of flexion. If instability occurs in 30º of flexion, the forearm should be placed in maximum pronation, which maximizes the stress on the medial collateral ligament (MCL) and reduces the posterolateral subluxation. If there is increased stability in pronation, the elbow should be placed in a cast brace with the elbow in pronation.

Next

Surgical Therapy

In cases where conservative treatment is unsuccessful, surgical intervention is indicated.[1, 3, 4, 5, 7, 8, 11, 12, 13, 14, 15, 16, 26]

Direct MCL repair is commonly used in acute ligamentous avulsions from the humeral origin (most commonly) or the sublime tubercle. Graft reconstruction is commonly performed with autologous grafts (palmaris longus, plantaris, 3.5-mm medial strip of Achilles, or hamstrings) and occasionally with allografts. The palmaris longus tendon, the most frequently used graft for elbow ligament reconstruction, is similar in strength to the anterior bundle of the MCL (357 N vs average failure load of 260 N).

No difference has been observed between single-strand and double-strand repair techniques. (See the images below.)

Single-strand reconstructions with interference sc Single-strand reconstructions with interference screw (top) and Endobutton (bottom).
Docking (top) and figure-eight (bottom) techniques Docking (top) and figure-eight (bottom) techniques for medial collateral ligament (MCL) reconstruction. Single-strand reconstruction with ulnar Endobutton fixation technique and 2-strand docking technique appear to be viable options for reconstruction of MCL of elbow to resist valgus loading.

MCL reconstruction is carried out by several means. The strengths achievable with four commonly practiced methods relate to the strength of an intact ligament as follows:

  • The strength of intact ligaments is three times greater than that of docking reconstructions
  • The strength of docking reconstructions is equivalent to that of Endobutton reconstructions
  • The strength of Endobutton reconstructions is greater than that of interference screw reconstructions
  • The strength of interference screw reconstructions is greater than that of figure-eight reconstructions

However, the use of bioabsorbable interference screw fixation has resulted in less valgus angle widening in response to early cyclic valgus load than the use of the docking technique. Hence, the optimal fixation method for a single-strand MCL reconstruction may require improved interference screws or a modified Endobutton procedure.

Lateral collateral ligament (LCL) repair and reconstruction for posterolateral rotatory instability of the elbow using a tendon graft seems to provide better results than direct ligament repair, and the results do not seem to deteriorate with time. In primary cases such as traumatic fracture dislocation of the elbow, it usually is not necessary to employ tendon grafts or to perform ligament augmentations.

In posteromedial olecranon impingement, valgus angulation and varus-valgus laxity increase proportionately with the amount of olecranon resection. At 90° of elbow flexion and 3 N-m of applied torque, olecranon resections of 0, 4, and 8 mm produced varus-valgus laxity of 14°, 15°, and 18°, respectively. Hence, resections of the medial part of the olecranon for the treatment of posteromedial olecranon impingement in the throwing athlete should be limited to the osteophytes alone.

In general terms, surgery is indicated if one is unable to get stability of the LCL even with a hinged brace. If there is avulsion from the bone (usually off the humerus), repair is indicated.

If repair is impossible, reconstruction is indicated.

Previous
Next

Preoperative Details

Isometric fibers do not exist within the anterior bundle of the MCL (AMCL); however, "nearly" isometric areas are located on the lateral aspect of the attachment site of the AMCL on the medial epicondyle, near the anatomic axis of rotation. Hence, it has been postulated that these nearly isometric areas would be the most ideal location for graft attachment during reconstruction of the AMCL.[28]

A tear of the deep layer of the ulnar collateral ligament (UCL) can result in symptomatic instability that is difficult to diagnose with conventional preoperative testing. These throwing-athletic patients present with persistent medial elbow pain, tenderness over the anterior bundle of the UCL, and pain with valgus stressing of the elbow.

Magnetic resonance imaging (MRI) may be normal, and a computed tomography (CT) arthrogram may be negative for extracapsular contrast extravasation. A consistent finding in these patients could be a leak of contrast around the edge of the humerus or ulna, though the contrast is contained within the joint. On open medial elbow surgery, the UCL appears intact externally; but when the anterior bundle is incised, there would be a detachment of the undersurface of the ligament at the ulna or the humerus.

Previous
Next

Intraoperative Details

The docking technique for UCL reconstruction involves a muscle-splitting approach to the ligament, sparing the flexor origin. It also involves the use of one hole in the medial epicondyle rather than three, avoids the need to transpose the ulnar nerve, and simplifies the method of graft-tensioning prior to fixation.[4]

In traumatic fracture dislocation of the elbow, detachment of the lateral ligament complex from the humerus is repaired with nonabsorbable sutures placed either through drill-holes in the bone or with suture anchors. The most important suture is the stitch placed in the center of rotation of the elbow laterally, located at the center of the capitellar circumference in the lateral condyle. Midsubstance tears of the LCL are occasionally seen and are repaired with No. 1 or 2 nonabsorbable sutures.

A split anconeus fascia transfer to reconstruct the LCL complex comprises a strip of anconeus fascia detached from its origin and split in line with its fibers down to its ulnar insertion. The superior segment is passed under the annular ligament (AL) to reconstruct the proper radial collateral ligament (RCL), while the inferior segment is used to reconstruct the lateral ulnar collateral ligament (LUCL). A docking technique is used to secure the fascia to the isometric point on the lateral epicondyle. (See the images below.)

LUCL (lateral ulnar collateral ligament) isometric LUCL (lateral ulnar collateral ligament) isometric point.
LUCL (lateral ulnar collateral ligament) isometric LUCL (lateral ulnar collateral ligament) isometric point.

Thus, a local graft can be used for anatomic reconstruction without the associated morbidity of tendon harvest, especially when instability arises during surgery.

Before definitive closure, the elbow is examined for stability. The goal is concentric reduction with no observed posterior or posterolateral subluxation or dislocation through an arc of flexion.

Previous
Next

Postoperative Details

Postoperative care includes the following:

  • Lateral-side injuries - Treat/immobilize in pronation
  • Medial-side injuries - Treat/immobilize in supination
  • Combined injuries - Treat/immobilize in neutral rotation
Previous
Next

Follow-up

After MCL reconstruction, which is secured in supination, immobilize the elbow for 1 week, then start active range of motion (AROM) for the shoulder, elbow, and wrist in a supination brace. After 6 weeks, begin resistance strengthening. Valgus stress should be avoided for 3 months.

Previous
Next

Complications

Potential complications of surgical treatment include the following:

  • Detachment of the origin of the flexor-pronator muscle group
  • Requirement for transposition of the ulnar nerve owing to ulnar nerve symptoms
  • Extensive drilling of the medial epicondyle
  • Inadequate graft-tensioning during fixation of the graft
  • Transient radial-nerve palsy after intra-articular injection of local anesthetic
  • Permanent flexion contracture of up to 15º and loss of flexion of up to 10º
Previous
Next

Outcome and Prognosis

In one study, the patients with posteromedial olecranon osteophytes had the highest rate of reoperation due to persisting symptoms, and patients who underwent only UCL reconstruction had a higher rate of return to play. At an average of 3.3 years after UCL reconstruction with use of the docking technique, 92% of patients had an excellent result and had returned to, or exceeded, their previous level of play. The docking technique may offer better results than Jobe's original procedure while minimizing the associated risks.[4]

Watson et al conducted a systematic review comparing clinical outcomes of the Jobe, modified Jobe, docking, modified docking, Endobutton, and interference screw techniques for UCL reconstruction in elite overhead athletes.[27] The review included 21 studies that reported on 1368 patients. The investigators concluded that UCL reconstruction utilizing the docking technique results in a significantly higher rate of return to play and a lower complication rate in comparison with the Jobe and modified Jobe techniques.

Previous
 
Contributor Information and Disclosures
Author

Rahi K Yallapragada, MBBS, MRCS, FRCS(T&O), MCh(Orth) Specialty Doctor, Trauma and Orthopaedics, Lister Hospital, UK

Rahi K Yallapragada, MBBS, MRCS, FRCS(T&O), MCh(Orth) is a member of the following medical societies: Royal College of Physicians and Surgeons of Glasgow

Disclosure: Nothing to disclose.

Coauthor(s)

Janos T Patko, MD, MRCS Consultant Orthopaedic & Trauma Surgeon, Special Interest in Lower Limb Arthroplasty & Revision,Honorary Senior Clinical Lecturer Sheffield UniversityDepartment of Orthopedics and Trauma, Barnsley NHS Foundation Trust, UK

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Robert J Nowinski, DO Clinical Assistant Professor of Orthopaedic Surgery, Ohio State University College of Medicine and Public Health, Ohio University College of Osteopathic Medicine; Private Practice, Orthopedic and Neurological Consultants, Inc, Columbus, Ohio

Robert J Nowinski, DO is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, Ohio State Medical Association, Ohio Osteopathic Association, American College of Osteopathic Surgeons, American Osteopathic Association

Disclosure: Received grant/research funds from Tornier for other; Received honoraria from Tornier for speaking and teaching.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

Joseph E Sheppard, MD Professor of Clinical Orthopedic Surgery, Chief of Hand and Upper Extremity Service, Department of Orthopedic Surgery, University of Arizona Health Sciences Center, University Physicians Healthcare

Joseph E Sheppard, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedics Overseas, American Society for Surgery of the Hand

Disclosure: Nothing to disclose.

References
  1. Andrews JR, Timmerman LA. Outcome of elbow surgery in professional baseball players. Am J Sports Med. 1995 Jul-Aug. 23(4):407-13. [Medline].

  2. Kooima CL, Anderson K, Craig JV, Teeter DM, van Holsbeeck M. Evidence of subclinical medial collateral ligament injury and posteromedial impingement in professional baseball players. Am J Sports Med. 2004 Oct-Nov. 32(7):1602-6. [Medline].

  3. Jobe-FW;, Stark-H;, Lombardo-SJ. Reconstruction of the ulnar collateral ligament in athletes. J-Bone-Joint-Surg-Am. 1986 Oct;. 68(8):1158-63.

  4. Paletta GA Jr, Wright RW. The modified docking procedure for elbow ulnar collateral ligament reconstruction: 2-year follow-up in elite throwers. Am J Sports Med. 2006 Oct. 34(10):1594-8. [Medline].

  5. Jobe FW, Stark H, Lombardo SJ. Reconstruction of the ulnar collateral ligament in athletes. J Bone Joint Surg Am. 1986 Oct. 68(8):1158-63. [Medline].

  6. Timmerman LA, Andrews JR. Undersurface tear of the ulnar collateral ligament in baseball players. A newly recognized lesion. Am J Sports Med. 1994 Jan-Feb. 22(1):33-6. [Medline].

  7. Vitale MA, Ahmad CS. The outcome of elbow ulnar collateral ligament reconstruction in overhead athletes: a systematic review. Am J Sports Med. 2008 Jun. 36(6):1193-205. [Medline].

  8. Savoie FH 3rd, Trenhaile SW, Roberts J, Field LD, Ramsey JR. Primary repair of ulnar collateral ligament injuries of the elbow in young athletes: a case series of injuries to the proximal and distal ends of the ligament. Am J Sports Med. 2008 Jun. 36(6):1066-72. [Medline].

  9. de Haan J, Schep NW, Tuinebreijer WE, Patka P, den Hartog D. Simple elbow dislocations: a systematic review of the literature. Arch Orthop Trauma Surg. 2010 Feb. 130(2):241-9. [Medline]. [Full Text].

  10. Ahmad CS, Park MC, Elattrache NS. Elbow medial ulnar collateral ligament insufficiency alters posteromedial olecranon contact. Am J Sports Med. 2004 Oct-Nov. 32(7):1607-12. [Medline].

  11. Paletta GA Jr, Klepps SJ, Difelice GS, Allen T, Brodt MD, Burns ME. Biomechanical evaluation of 2 techniques for ulnar collateral ligament reconstruction of the elbow. Am J Sports Med. 2006 Oct. 34(10):1599-603. [Medline].

  12. King GJ, Dunning CE, Zarzour ZD, Patterson SD, Johnson JA. Single-strand reconstruction of the lateral ulnar collateral ligament restores varus and posterolateral rotatory stability of the elbow. J Shoulder Elbow Surg. 2002 Jan-Feb. 11(1):60-4. [Medline].

  13. Large TM, Coley ER, Peindl RD, Fleischli JE. A biomechanical comparison of 2 ulnar collateral ligament reconstruction techniques. Arthroscopy. 2007 Feb. 23(2):141-50. [Medline].

  14. Paletta GA Jr, Klepps SJ, Difelice GS, Allen T, Brodt MD, Burns ME. Biomechanical evaluation of 2 techniques for ulnar collateral ligament reconstruction of the elbow. Am J Sports Med. 2006 Oct. 34(10):1599-603. [Medline].

  15. Fraser GS, Pichora JE, Ferreira LM, Brownhill JR, Johnson JA, King GJ. Lateral collateral ligament repair restores the initial varus stability of the elbow: an in vitro biomechanical study. J Orthop Trauma. 2008 Oct. 22(9):615-23. [Medline].

  16. Dines JS, Yocum LA, Frank JB, ElAttrache NS, Gambardella RA, Jobe FW. Revision surgery for failed elbow medial collateral ligament reconstruction. Am J Sports Med. 2008 Jun. 36(6):1061-5. [Medline].

  17. Cohen MS, Bruno RJ. The collateral ligaments of the elbow: anatomy and clinical correlation. Clin Orthop Relat Res. 2001 Feb. 123-30. [Medline].

  18. Morrey BF, Tanaka S, An KN. Valgus stability of the elbow. A definition of primary and secondary constraints. Clin Orthop Relat Res. 1991 Apr. (265):187-95. [Medline].

  19. 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 Feb. 33(2):231-9. [Medline].

  20. Regan WD, Korinek SL, Morrey BF, An KN. Biomechanical study of ligaments around the elbow joint. Clin Orthop Relat Res. 1991 Oct. (271):170-9. [Medline].

  21. Søjbjerg JO, Ovesen J, Nielsen S. Experimental elbow instability after transection of the medial collateral ligament. Clin Orthop Relat Res. 1987 May. (218):186-90. [Medline].

  22. Pollock JW, Brownhill J, Ferreira LM, McDonald CP, Johnson JA, King GJ. Effect of the posterior bundle of the medial collateral ligament on elbow stability. J Hand Surg [Am]. 2009 Jan. 34(1):116-23. [Medline].

  23. Cohen MS. Lateral collateral ligament instability of the elbow. Hand Clin. 2008 Feb. 24(1):69-77. [Medline].

  24. Miyake J, Moritomo H, Masatomi T, Kataoka T, Murase T, Yoshikawa H, et al. In vivo and 3-dimensional functional anatomy of the anterior bundle of the medial collateral ligament of the elbow. J Shoulder Elbow Surg. 2011 Oct 28. [Medline].

  25. Wear SA, Thornton DD, Schwartz ML, Weissmann RC 3rd, Cain EL, Andrews JR. MRI of the reconstructed ulnar collateral ligament. AJR Am J Roentgenol. 2011 Nov. 197(5):1198-204. [Medline].

  26. Bennett JB, Green MS, Tullos HS. Surgical management of chronic medial elbow instability. Clin Orthop Relat Res. 1992 May. (278):62-8. [Medline].

  27. Watson JN, McQueen P, Hutchinson MR. A systematic review of ulnar collateral ligament reconstruction techniques. Am J Sports Med. 2014 Oct. 42(10):2510-6. [Medline].

  28. Armstrong AD, Ferreira LM, Dunning CE, Johnson JA, King GJ. The medial collateral ligament of the elbow is not isometric: an in vitro biomechanical study. Am J Sports Med. 2004 Jan-Feb. 32(1):85-90. [Medline].

 
Previous
Next
 
Horii circle.
Schematic diagram of medial collateral ligament of elbow shows 3 bundles. Anterior bundle is major stabilizer of elbow to valgus stress.
Moving valgus stress test. Pronation, valgus of forearm, and internal rotation of shoulder lead to pain at 70-120° flexion arc.
Docking (top) and figure-eight (bottom) techniques for medial collateral ligament (MCL) reconstruction. Single-strand reconstruction with ulnar Endobutton fixation technique and 2-strand docking technique appear to be viable options for reconstruction of MCL of elbow to resist valgus loading.
Single-strand reconstructions with interference screw (top) and Endobutton (bottom).
LUCL (lateral ulnar collateral ligament) isometric point.
LUCL (lateral ulnar collateral ligament) isometric point.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.