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Thrower's elbow
- 3. www.handsurgery.gr Anatomy Complex hinge joint 3 individual articulations • Ulnohumeral • Radiocapitelar • Proximal Radioulnar
- 6. www.handsurgery.gr Biomechanics Ulnohumeral Joint < 20o / > 120o VALGUS VARUS MCL 20o - 120o LCL 20o - 120o
- 11. www.handsurgery.gr Pathomechanics Tensile loads Medial side pathology • MCL • Flexor tendons • Ulnar nerve
- 12. www.handsurgery.gr Pathomechanics shear loads Posterior side pathology • Valgus extension overload syndrome • Posteromedial impingement • Inflammation • Chondropathy • Osteophyte / spur formation • Loose bodies • Olecranon stress fractures
- 14. www.handsurgery.gr Elbow UCL Injury • Attenuation to complete rupture • Medial elbow pain • Pain during acceleration phase • Loss of velocity, accuracy • POP sensation in acute cases • Ulnar nerve symptoms • Pain w/ palpation over MCL (50o- 70o flexion)
- 15. www.handsurgery.gr Elbow UCL Injury UCL examination • Valgus stress test • 30o of elbow flexion • Opening of the medial joint space +/- pain
- 16. www.handsurgery.gr Elbow UCL Injury UCL examination • Milking maneuver • 90o elbow flexion • Grabbing the affected thumb with the opposite hand passed under the affected arm • Pulling to stress the medial elbow
- 17. www.handsurgery.gr Elbow UCL Injury UCL examination • Moving valgus stress test • Shoulder in ABD and ER • The examiner holds the thumb and supports the elbow • Elbow flexion-extension + valgus stress • Pain between 80o and 120o => positive test
- 19. www.handsurgery.gr Elbow UCL Injury UCL injury / tear • Usually do not respond to conservative treatment Surgical treatment indications: • Acute ruptures • Instability • Chronic pain
- 20. www.handsurgery.gr • Jobe et al. JBJS Am 1986 Tommy John procedure Free tendon graft Figure- eight fashion through bone tunnels 63% return to sports (10 out of 16 athletes) 31% postop ulnar nerve complication UCL reconstruction Hamstrings tendon grafts
- 22. www.handsurgery.gr • Modified Jobe Technique UCL reconstruction Release +/- transposition of UN Muscle splitting through FCU Smith, Altcheket al. AJSM 1996 No neuropathies
- 23. www.handsurgery.gr Docking technique • Altchek et al. AJSM 1996 • Rohrboughet al. AJSM 2002 95% (31 pts) return to sports • Azar et al. AJSM 2010 79% (78 pts) return to sports UCL reconstruction 15-20 mm tunnel depth
- 24. www.handsurgery.gr • Bone tunnels UCL reconstruction central or lateral to the midpoint of the epicondyle 30o in the sagittal plane 15o in the coronal plane anterior and posterior aspects of the sublime tubercle Byram, Ahmad et al. AJSM 2013 bone bridge of 6 to 8 mm
- 26. www.handsurgery.gr Valgus Extension Overload Syndrome • Posteromedial impingement • Chondropathy • Osteophyte formation • Loose bodies
- 27. www.handsurgery.gr Valgus Extension Overload Syndrome • Posterior elbow pain • Loss of full extension • Crepitus / locking • Arm bar test
- 30. www.handsurgery.gr Valgus Extension Overload Syndrome VEO Syndrome Treatment • Open vs. arthroscopic debridement • Reddy et al. Arthroscopy 2000 85% return to sports (55 athletes) • Blonna et al. AJSM 2010 91% return to sports (24 athletes)
- 31. www.handsurgery.gr OsteoChondritis Dissecans • Radiocapitellar joint tenderness • 15o to 20o extension lag • Active compression test
- 32. www.handsurgery.gr OsteoChondritis Dissecans Treatment • Open vs. arthroscopic • Fragment fixation • Removal of loose cartilage • Abrasion chondroplasty • Microfractures • Mosaic plasty • 70-90% return to sports • Rush et al. Arthroscopy 1998 • Baumgarten et al. AJSM 1999
- 33. www.handsurgery.gr Conclusions Elbow injuries are the result of biomechanical forces on the elbow during throwing motion tensile forces medially compressive forces laterally shear forces posteriorly Prognosis for return to competition is very good