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Elbow Collateral Ligaments Workup

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

Laboratory Studies

The white blood cell count (WBC), the erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) activity should be assessed to rule out any active inflammation.

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Imaging Studies

Radiography

Standard radiographs of the elbow include the anteroposterior (AP) view and the true lateral view. Special views include axial projections to evaluate the olecranon fossa; oblique views to assess the radial head; and stress views to evaluate joint stability (>5 mm abnormally wide joint space on the medial side, with the elbow flexed to 30° in a medial collateral ligament [MCL] tear).

Ultrasonography

Ultrasound examination commonly shows the following:

  • Widening of the medial joint space
  • Lateral shift of the proximal part of the ulna
  • Deformity of the contour of the ulnar collateral ligament (UCL)
  • Osteophyte formation on the distal-medial corner of the trochlea

Magnetic resonance imaging, with or without arthrography

Magnetic resonance imaging (MRI) can be helpful in identifying soft-tissue masses, articular cartilage anatomy, ligament ruptures, and chondral defects.[25]

With MCL tears, MRI (T2) images will show focal discontinuity of the ligament and joint fluid extravasation

High-resolution MR imaging of the elbow, using a microscopy surface coil with a 1.5T clinical machine, is a promising method for accurately characterizing the normal anatomy of the elbow and depicting its lesions in detail (eg, partial MCL injury or a small avulsion of the medial epicondyle).

MCL abnormalities such as thickening, signal heterogeneity, or discontinuity consistent with posteromedial impingement can be seen in asymptomatic throwers' elbows. These baseline findings must be considered when MRI is being used in making treatment decisions. MCL thickening and posteromedial subchondral sclerosis are more consistent findings of posteromedial impingement seen in throwers' elbows.

Other imaging studies

Computed tomography (CT) is useful for delineating complex osseous anatomy. CT arthrography may be useful for defining capsular defects (extracapsular contrast extravasation) and loose bodies. Bone scanning is sensitive but not specific for differentiating between stress fractures, healing fractures, infections, and tumors.

Although other studies can be helpful in confirming a diagnosis (eg, a positive manual pivot shift test result), they are somewhat insensitive. Thus, clinical judgment should prevail in making treatment decisions.

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Other Tests

Electromyography (EMG) and nerve conduction studies are used to evaluate suspected nerve compression syndromes.

Advances in arthroscopic surgical techniques and ligamentous reconstruction ensure that the prognosis for return to preinjury level after arthroscopic surgery is good.

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Diagnostic Procedures

A number of clinical diagnostic procedures are helpful in establishing elbow instability and collateral ligament injury.

In the valgus stress test, the elbow is flexed to 20-30º, and abduction or valgus force is then applied at the distal forearm.[19]

The “milking maneuver” is performed with the arm at 70°, with the valgus force applied by supporting the elbow and tractioning the thumb.

With the moving valgus stress test (the most sensitive of these procedures), pronation, valgus of the forearm, and internal rotation of the shoulder cause pain at 70-120° flexion arc (see the image below).

Moving valgus stress test. Pronation, valgus of fo Moving valgus stress test. Pronation, valgus of forearm, and internal rotation of shoulder lead to pain at 70-120° flexion arc.

In the lateral compression test, the examiner applies valgus stress while going from flexion to extension and back. This is repeated in the radioulnar joint in various degrees of pronation and supination. One hand is just above the elbow joint, and the other is placed on the wrist.

In the varus stress test, the elbow is flexed to 20-30º, and the patient's arm is then stabilized with one of the examiner's hands at the medial distal humerus (elbow) and the other placed above the patient's lateral distal radius (wrist). An adduction or varus force is applied at the distal forearm by the examiner to test the radial collateral ligament (RCL).

In the pivot shift test, the patient lies supine with the arm overhead. The elbow is supinated, and a valgus force and axial force are applied to the elbow. The patient may complain of pain or apprehension. Then, starting in extension, the elbow is flexed with a reduction “clunk” occurring, typically at 40-70° of flexion.

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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
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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.
 
 
 
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