American Shoulder and Elbow Surgeons
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Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
A 19-year-old male complained of right elbow pain 4 months ago after pitching in a collegiate baseball game. He underwent a period of rest and forearm strengthening and now has recurrence of pain during a throwing interval program. A MRI is shown in Figure A. What is the next most appropriate step in management?
Open ECRB tendon release and removal of the diseased tendon with repair of the tendon remnant
Arthroscopic debridement of lesion and osteotochondral autograft transplant from ipsilateral knee
Excision of the diseased tendon and reattachment of the origin of the flexor-pronator muscle group to the medial epicondyle
Open reconstruction of the ligament using ipsilateral palmaris longus tendon
Diagnostic elbow arthroscopy, removal of posteromedial olecranon osteophytes and débridement of chondromalacia
Select Answer to see Preferred Response
Open reconstruction of the medial (ulnar) collateral ligament using ipsilateral palmaris longus tendon is indicated in medial collateral ligament injuries in high level overhand throwing athletes with symptoms recalcitrant to conservative management.
Conservative treatment of medial (ulnar) collateral ligament injuries in over-hand throwing athletes includes a period of rest from throwing followed by a flexor-pronator mass strengthening regimen. Next, the patient participates in a progressive throwing interval program.
Rettig et al. performed a Level 4 review of 31 throwing athletes with ulnar collateral ligament injuries that were treated in a nonoperatively with a minimum of 3 months rest. They found that 42% of the athletes were able to return to sport after an average of 6 months of rest, forearm strengthening, and throwing interval program.
Davidson et al. present data from a cadaveric dissection study of 11 elbows. They found that the flexor carpi ulnaris (FCU) muscle and flexor digitorum superficialis (FDS)muscle, provide medial elbow support to the medial (ulnar) collateral ligament.
Figure A is a T2 coronal MRI of the right elbow that demonstrates a ruptured medial (ulnar) collateral ligament off of the ulna.
Answer 1: This would be a reasonable method of management for recalcitrant ECRB tendonitis.
Answer 2: This would be a reasonable method of management for an osteochondral defect.
Answer 3: This would be a reasonable method of management for recalcitrant flexor-pronator tendonitis.
Answer 5: This would be a reasonable method of management for valgus extension overload syndrome.
Rettig AC, Sherrill C, Snead DS, Mendler JC, Mieling P.
Am J Sports Med. 2001 Jan-Feb;29(1):15-7. PMID: 11206249 (Link to Abstract)
Rettig, AJSM 2001
Davidson PA, Pink M, Perry J, Jobe FW.
Am J Sports Med. 1995 Mar-Apr;23(2):245-50. PMID: 7778713 (Link to Abstract)
Davidson, AJSM 1995
Title: UCL Reconstruction: Technical Variations Speaker: Anthony A. Romeo, MD L...
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A 22-year-old collegiate pitcher sustains a medial collateral ligament (MCL) rupture of his throwing elbow requiring surgical reconstruction. Anatomic restoration of the MCL is desired to maximize function. Which of the following best describes the kinematics of the native MCL?
Anterior bundle becomes tight in flexion and lax in extension
The posterior bundle demonstrates the greatest change in tension from flexion to extension
Posterior bundle becomes lax in flexion and tight in extension
Posterior bundle is isometric
The posterior bundle is isometric, but the anterior is not
The MCL (also known as the medial ulnar collateral) is an important static stabilizer of the medial elbow that can become attenuated and rupture in throwing athletes leading to pain, valgus instability, and loss of throwing velocity.
Morrey et al dissected 10 cadaver elbows to pinpoint the origin and insertion of both the medial and lateral stabilizing ligaments of the elbow. Most pertinent to this question, the anterior bundle of the MCL was found to be isometric throughout the flexion/extension arc of motion. The posterior bundle of the MCL became elongated with elbow flexion. It demonstrated the greatest change in length from extension to flexion of all the elbow ligaments.
Moritomo et al performed an in-vivo kinematic study to determine the isometric point of the lateral elbow ligaments. The radial collateral ligament was determined to be isometric through flexion and extension. The lateral ulnar collateral ligament was found to be lax in extension and tight in flexion.
In a separate study, Moritomo et al reviewed 9 patients who underwent excision of heterotopic ossification that included resection of the posterior oblique ligament of the medial collateral ligament. Range of motion was improved and no patient demonstrated instability at 4 year follow-up.
Elbow anatomy diagrams demonstrating this ligament are provided in Illustrations A and B.
Moritomo H, Murase T, Arimitsu S, Oka K, Yoshikawa H, Sugamoto K
J Bone Joint Surg Am. 2007 Sep;89(9):2011-7. PMID: 17768199 (Link to Abstract)
Moritomo, JBJS 2007
Moritomo H, Tada K, Yoshida T.
J Shoulder Elbow Surg. 2001 Mar-Apr;10(2):164-8. PMID: 11307081 (Link to Abstract)
Moritomo, JSES 2001
Morrey BF, An KN.
Clin Orthop Relat Res. 1985 Dec;(201):84-90. PMID: 4064425 (Link to Abstract)
Morrey, CORR 1985
Title: Augmented UCL Repair Speaker: Christopher S. Ahmad, MD Length: 7 mins 32...
Average 3.0 of 24 Ratings
A 25-year-old professional baseball pitcher complains of medial elbow pain during the early acceleration phase of throwing. He has lost 10 mph on his fastball. Radiographs of the elbow are provided in Figure A. EMG studies demonstrate no entrapment of the ulnar nerve. Which of the following physical exam maneuvers will most strongly confirm the correct diagnosis?
Evaluating for pain with resisted wrist flexion
Testing for Froment's sign
Evaluating for pain with Hawkins impingement test
Evaluating for pain with moving valgus stress test
Performing the lateral pivot shift test
The clinical presentation is classic for rupture of the UCL of the elbow, and the moving valgus stress test is a sensitive and specific test for diagnosis.
The moving valgus stress test is performed by applying a valgus load to the fully flexed elbow, and then quickly extending the elbow. Reproduction of pain is a positive finding for UCL rupture.
O'Driscoll et al evaluated 21 patients with MRI's suggestive of partial UCL tear. All patients underwent the moving valgus stress test prior to diagnostic surgery. Seventeen of the 21 patients demonstrated rupture of the UCL intra-operatively. The moving valgus stress test demonstrated a sensitivity of 100% (17/17) and specificity of 75%(3/4).
Azar et al reviewed 91 throwers who underwent surgical treatment of elbow UCL ruptures. Subcutaneous nerve transposition was performed in all patients although only 9 had concomitant symptoms of ulnar nerve entrapment. Eighty percent returned to their prior level of throwing by one year following surgery.
Figure A shows a normal xray. Illustration A demonstrates an example of the moving valgus stress test. Illustration V is a video showing a moving valgus stress test.
Answer 1: Pain with resisted wrist flexion suggests medial epicondylitis.
Answer 2: Froment's sign is present with ulnar neuropathy.
Answer 3: Hawkin's test evaluates the shoulder for impingement.
Anawer 5: The lateral pivot shift test evaluates for posterolateral rotatory instability.
O'Driscoll SW, Lawton RL, Smith AM
Am J Sports Med. 2005 Feb;33(2):231-9. PMID: 15701609 (Link to Abstract)
O'Driscoll, AJSM 2005
Azar FM, Andrews JR, Wilk KE, Groh D.
Am J Sports Med. 2000 Jan-Feb;28(1):16-23. PMID: 10653538 (Link to Abstract)
Azar, AJSM 2000
Average 3.0 of 20 Ratings
All of the following protect the elbow from valgus loads during the throwing cycle EXCEPT?
Flexor-pronator muscle contraction
Reduced fastball velocity
Increased glenohumeral internal rotation torque
During a thrower's kinetic chain, increased shoulder internal rotation torque contributes to increased valgus elbow loads. Marshall et al described the importance of proximal to distal control of the upper extremity in producing angular and racket velocity and theorized that longitudinal rotations should be considered during injury prevention programs. Davis et al demonstrated that correct pitching mechanics offered the most efficient throwing velocity for a given shoulder internal rotation torque and elbow valgus load. Thus scapular dynamic control, correct pitching mechanics, pronation of the forearm with dynamic flexor-pronator muscle contraction protects the elbow from valgus loads.
Marshall RN, Elliott BC.
J Sports Sci. 2000 Apr;18(4):247-54. PMID: 10824641 (Link to Abstract)
Davis JT, Limpisvasti O, Fluhme D, Mohr KJ, Yocum LA, Elattrache NS, Jobe FW
Am J Sports Med. 2009 Aug;37(8):1484-91. PMID: 19633301 (Link to Abstract)
Davis, AJSM 2009
Title: Rehabilitation and Throwing Programs Following UCL Surgery Speaker: Micha...
Average 2.0 of 38 Ratings
Which of the following is the primary stabilizer to resist valgus stress in mid-flexion of the elbow?
Anterior oblique ligament of the medial ulnar collateral ligament
Posterior oblique ligament of the medial ulnar collateral ligament
Flexor-pronator muscle mass
The anterior oblique ligament (formerly known as the anterior bundle) provides the major contribution to valgus stability. The terminology has changed over the past decade as the anatomy is now better understood.
Hariri and Safran have a recent review which describes the anatomy and present terminology well. The UCL is a complex consisting of the anterior oblique ligament (AOL), the posterior oblique ligament (POL), and the transverse ligament. (see Illustration A) The anterior oblique ligament is composed of an anterior band and posterior band that tighten in a reciprocal fashion as the elbow is flexed and extended. In the presence of valgus overload, the anterior band is most vulnerable in elbow extension, whereas the posterior band is more vulnerable in elbow flexion. The olecranon is an important stabilizer of the elbow in extension; at 25 degrees flexion the olecranon is unlocked from its fossa and the ulnar collateral ligament becomes the most important stabilizer. The radial head is an important secondary stabilizer in extension as well as flexion. The transverse band plays no role in joint stability because it originates and inserts on the same bone.
A large source of confusion is the fact that what is now known as the "AOL" is also formerly referred to as the anterior bundle (or even just anterior band which you will encounter on older questions/texts), see Illustration B.
Jobe FW, Stark H, Lombardo SJ.
J Bone Joint Surg Am. 1986 Oct;68(8):1158-63. PMID: 3771597 (Link to Abstract)
Jobe, JBJS 1986
Instr Course Lect. 1986;35:59-68. PMID: 3819430 (Link to Abstract)
Hariri S, Safran MR.
Clin Sports Med. 2010 Oct;29(4):619-44. PMID: 20883901 (Link to Abstract)
Title: Outcomes of UCL Reconstruction Speaker: Stan Conte, PT, DPT ATC Length:...
Average 3.0 of 19 Ratings
The greatest stress on the medial ulnar collateral ligament of the elbow occurs during which phase of throwing?
The late cocking and early acceleration phase of the overhead throw causes the greatest amount of valgus stress to the elbow. During this phase, the forearm lags behind the upper arm and generates valgus stress while the elbow is primarily dependent on the anterior band of the UCL for stability. The windup phase is benign for the elbow. In early cocking, the rotator cuff and deltoid are active, not the elbow. Ball release is the culmination of cocking and acceleration, but the maximal joint forces have already occurred across the UCL due to the rapid combination of valgus and extension during late cocking and early acceleration. In deceleration, the elbow flexors are most active to prevent hyperextension.
Bennett JM, Mehlhoff TL
J Hand Surg Am. 2009 Nov;34(9):1729-33. PMID: 19896014 (Link to Abstract)
Bennett, JHS 2009
Maloney MD, Mohr KJ, el Attrache NS.
Clin Sports Med. 1999 Oct;18(4):795-809. PMID: 10553236 (Link to Abstract)
Title: Pitching Flaws and UCL Injury Speaker: Nikhil N. Verma, MD Length: 11 mi...
Average 3.0 of 18 Ratings
During which phase of the overhead throwing cycle is a baseball pitcher most likely to rupture the medial ulnar collateral ligament complex of the elbow?
The medial UCL is subjected to near-failure tensile stresses during the late cocking/early acceleration phase of throwing.
The medial ulnar collateral ligament, or medial collateral ligament of the elbow, is composed of three bundles: an anterior bundle, a posterior bundle, and a variable transverse oblique bundle. The anterior bundle of the ulnar collateral ligament is the primary restraint to valgus force of the elbow from 30 to 120 degrees of flexion. Biomechanical testing has shown that valgus forces as high as 64 N.m at the elbow during late cocking and early acceleration phases of throwing with compressive forces of 500 N at the lateral radiocapitellar articulation as the elbow moves from 110 to 20 degrees of flexion and velocities as high as 3000 deg/sec.
The Cain et al. paper is a current concepts review of elbow injuries in throwers from the group with the world's largest experience in treating these injuries.
Cain EL Jr, Dugas JR, Wolf RS, Andrews JR.
Am J Sports Med. 2003 Jul-Aug;31(4):621-35. PMID: 12860556 (Link to Abstract)
Cain, AJSM 2003
Average 3.0 of 17 Ratings
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