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Treatment of the chronic medial unstable elbow

Authors: D. Eygendaal

References: SECEC 2005, Rome

Medial sided elbow pain in patients is often the result of a flexor-pronator sprain, tear or tendonitis.  However in overhead throwing sports as baseball, softball, soccer, tennis and athletics the medial collateral ligament (MCL) of the elbow is frequent side of serious injury as throwing generates a large valgus force at the elbow, estimated at 290N.ƒT

Valgus instability is provided by the anterior bundle of the MCL, the primary constraint to valgus load and internal rotatory forces. ƒU'ƒV

Valgus instability may arise due to a single major traumatic event resulting in partial or complete rupture of the MCL, it may be the result of a chronic repetitive micro trauma in throwing athletes or it may be a long term sequel after posterolateral dislocation.  History taking in patients who are suspect for valgus instability is difficult as the only complaint may be ill-defined discomfort at the medial side.  Sometimes a detailed description of the trauma mechanism can  reveal acute or chronic valgus force impaction.  Some patients complain of weakness, popping or clicking of the elbow joint especially at movements that generate valgus load across the elbow joint.  On physical examination the elbow often appears normal without swelling (except in acute cases of MCL rupture) with a normal range of motion.  Increased ulno-humeral joint opening can be palpated under valgus load; a comparison with the uninjured side must be made.  Physical examination may reveal tenderness to palpation on the MCL complex depending on the degree of inflammation at the time of the examination.  Chronic valgus instability can result in chondral damage to the capitellum and formation of postero-medial compression which finally result in osteophytes of the olecranon.  Standard radiography may identify ossification within the MCL.  Loose bodies, osteophytes around the radiohumeral or ulnohumeral articulations or olecranon, and osteochondrotic lesions of the capitellum may be revealed.  Dynamic radiographs under valgus load can be made with a commercially available stress device in which the elbow is flexed 25¢X and the shoulder abducted 65¢X.  From the radiographs the distance (d) in mm between the most distal point on the curved contour of the medial condyle and the ulnar coronoid process is measured at zero (d0) and 15 N valgus stress (d15).  Medial instability is defined as (d15-d0) of the injured elbow minus (d15-d0) of the uninjured side and graded as no instability (0-1 mm), partial unstable (1-3 mm), unstable (3-6 mm) or subluxation (>6 mm) based on previous cadaver studies.ƒU‛ƒW

 

Magnetic Resonance Imaging (MRI) or gadopentetate-dimeglumine enhanced MRI of the elbow joint can also contribute to the decision making in medial instability.  MRI has shown a sensitivity of 57% and specificity of 100% for MCL rupture in previous reports.  Saline or gadopentetate-dimeglumine enhanced MR-arthrography seems to improve sensitivity. ƒX'6'ƒY'ƒZ

 

Most reports on reconstruction for medial instability describe a technique that included a free, double-strand palmaris tendon graft placed within bone tunnels in the humerus and ulna. 9, 10, 11

 

Although good results were reported using the above described technique, it is technically demanding and fracturing of the ulnar tunnel, in particular, is a concern.  Cadaveric studies have shown that graft fixation with interference screws at the medial side of the elbow resulted in normalization of elbow kinematics with less soft tissue dissection and ease of graft insertion, tensioning and fixation.  12

 

In a clinical study for reconstruction of medial or valgus instability of the elbow with a docking technique at the humeral side, good results were reported with a simplified graft tensioning and improved graft fixation. 13

 

Docking technique at both the humeral and the ulnar side of a single-strand ipsilateral triceps tendon graft fixed with bio-absorbable interference screws to reconstruct the MCL in the elbow also shows promising short term results. 14

 

REFERENCES:

1.                  Fleisig GS, Andrews JR, Dillman CJ, et al.  Kinetics of baseball pitching with implications about injury mechanisms.  Am J Sports Med 1995; 23:233-9

2.                  Eygendaal D, Olsen BS, Jensen SL, Seki A, Soejbjerg JO.  Kinematics of partial and total ruptures of the medial collateral ligament.  J Shoulder Elbow Surg 1999; 8:612-6

3.                  Callaway GH, Field LD, Deng ZH, et al.  Biomechanical evaluation of the medial collateral ligament of the elbow.  J bone Joint Surg 79A 1997:1223-31

4.                  Rijke AM, Goitz HT, McCue FC, Andrews JR, Berr SS.  Stress radiography of the medial elbow ligaments.  Radiology 1994; 191:213-6

5.                  Peiss J.  Gadopentetate-dimeglumine-enhanced MR imaging of osteonecrosis and osteochondritis dissecans of the elbow: initial experience.  Skelet Rad 1995; 24:17-20

6.                  Nakanishi P, et al.. MR arthrography of the elbow: evaluation of the UCL of the elbow.  Skel Rad 1996; 25:629-34.

7.                  Eygendaal D, Obermann WR, Heijboer MP, Rozing PM.  Medial instability of the elbow joint in Dutch athletes.  Acta Ortop Scan 2000; 71(5): 475-9

8.                  Schwartz ML, Morwessel RM, Andrews JR.  Ulnar collateral ligament injury in the throwing athlete: evaluation with saline enhanced MR-arthrography.  Radiology 1995; 197: 297-9

9.                  Jobe FW, Stark H, Lombardo SJ.  Reconstruction of the ulnar collateral ligament in athletes.  J Bone Joint Surg 86A 1986;1158-63

10.              Smith GR, Altchek DW, Pagnani MJ, Keeley JR.  A Muscle-Splitting approach to the ulnar collateral ligament of the elbow.  Am J Sports Med 1996; 24:575-80

11.              Lesin BE, Balfour GW:  Acute rupture of the medial collateral ligament of the elbow requiring reconstruction.  J Bone Joint Surg 86A 1986:1278-80

12.              Ahmad S, Thay QL, Elattrache NS.  Biomechanical Evaluation of a New Ulnar Collateral Ligament Reconstruction Technique with inference Screw Fixation.  Am J Sports Med 2003; 31(3):332-8

13.              Rohrbough JT, Altchek DW, Hyman J, Williams RJ, Botts J.  Medial collateral ligament reconstruction of the elbow using the docking technique.  Am J Sports Med 2002; 30:541-8

14.              Eygendaal D.  Ligamentous reconstruction around the elbow using triceps tendon; How I do it.  Acta Orthopaedica Scandinavica 2004;75(5):516-523

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