Elbow sports injuries
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The document discusses common elbow injuries in athletes. It describes the anatomy and biomechanics of the elbow joint and how forces during overhead throwing can lead to injuries. Specific injuries covered include ulnar collateral ligament tears, valgus extension overload syndrome, and osteochondritis dissecans. Surgical treatment options for each injury are presented along with typical return to sport rates.
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Elbow sports injuries
- 1. Elbow Sports Injuries Aaron Venouziou, MD Orthopaedic Surgeon St. Luke’s Hospital Thessaloniki www.handsurgery.gr
- 2. www.handsurgery.gr Anatomy Complex hinge joint 3 individual articulations • Ulnohumeral • Radiocapitelar • Proximal Radioulnar
- 3. www.handsurgery.gr Biomechanics Ulnohumeral Joint < 20o / > 120o VALGUS VARUS MCL 20o - 120o LCL 20o - 120o
- 6. www.handsurgery.gr Pathomechanics tensile loads compressive loads shear loads extremely high valgus stresses
- 7. www.handsurgery.gr PathomechanicsTensileloads 64 Nm of valgus torque Tensile strength of the UCL is only 34 Nm Medial side pathology
- 8. www.handsurgery.gr Pathomechanics Tensileloads Medial side pathology • MCL • Flexor tendons • Ulnar nerve
- 9. 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
- 10. www.handsurgery.gr Pathomechanics compressiveloads Lateral side pathology • OCD • Radiocapitellar arthropathy 500 N
- 11. 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)
- 12. www.handsurgery.gr Elbow UCL Injury UCL examination • Valgus stress test • 30o of elbow flexion • Opening of the medial joint space +/- pain
- 13. 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
- 14. 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
- 15. www.handsurgery.gr Elbow UCL Injury UCL imaging
- 16. www.handsurgery.gr Elbow UCL Injury UCL injury / tear • Usually do not respond to conservative treatment Surgical treatment indications: • Acute ruptures • Instability • Chronic pain
- 17. 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
- 18. www.handsurgery.gr • Modified Jobe Technique UCL reconstruction Release +/- transposition of UN Muscle splitting through FCU Smith, Altchek et al. AJSM 1996 No neuropathies
- 19. www.handsurgery.gr Docking technique • Altchek et al. AJSM 1996 • Rohrbough et 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
- 20. 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
- 21. www.handsurgery.gr Valgus Extension Overload Syndrome • Posteromedial impingement • Chondropathy • Osteophyte formation • Loose bodies
- 22. www.handsurgery.gr Valgus Extension Overload Syndrome • Posterior elbow pain • Loss of full extension • Crepitus / locking • Arm bar test
- 23. www.handsurgery.gr Valgus Extension Overload Syndrome Imaging
- 24. www.handsurgery.gr Valgus Extension Overload Syndrome Imaging
- 25. 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)
- 26. www.handsurgery.gr OsteoChondritis Dissecans • Radiocapitellar joint tenderness • 15o to 20o extension lag • Active compression test
- 27. 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
- 28. 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
Editor's Notes
- The interlocking bony anatomy of the olecranon with the olecranon fossa provides stability at less than 20 of extension and greater than 120 of flexion.26 Within the functional arc of throwing, from 20 to 120, ligamentous restraints provide the majority of elbow stablility. The majority of stress is placed on the anterior bundle of the MCL complex, which is the primary restraint to valgus forces. Throwing load can exceed the tensile failure capacity of the MCL complex, which has been shown to be 33 Nm. The flexor carpi ulnaris has also been shown to perform as a primary dynamic stabilizer, whereas the flexor digitorum superficialis functions as a secondary dynamic stabilizer in the cadaveric model.
- 145 kmh 106=>170
- Repeated valgus stress to the elbow during overhead throwing in athletes leads to (1) traction forces on the medial structures (i.e., UCL, ulnar nerve, fl exor-pronator mass), (2) compression on the lateral side of the elbow, and (3) medially directed posterior shear forces on the posteromedial olecranon.
- Approximately 40% of patients with UCL insufficiency have ulnar neuritis
- Valgus extension overload from chronic UCL laxity results from repetitive impaction of the posteromedial olecranon into the olecranon fossa. This results in posteromedial olecranon osteophytes, fractured osteophytes that may become loose bodies, and chondromalacia.
- MRI is 57–79 % sensitive and 100 % specific for UCL tears [ 18 , 20 ]. MR arthrogram is 97 % sensitive for UCL tears.
- The initial management of a UCL injury in an overhead throwing athlete should be nonsurgical. The regimen includes a 6-week period of rest from throwing as well as strengthening of the flexor-pronator musculature. The probability of return to sports at the same preinjury level following UCL rupture treated nonoperatively is low (42 % in one study) for overhead athletes.
- Dr. Frank Jobe was the fi rst in 1986 to report on a reconstruction technique of MCL [ 37 ]. It is often called “Tommy John” surgery after that Los Angeles Dodgers pitcher was the fi rst athlete to undergo this procedure In 1974. The palmaris longus is the most common graft. Typically 15–17 cm is needed.37 Its use is supported by biomechanical studies,38 which document a failure load (357 N) greater than that of the anterior bundle of the UCL (260 N).
- Maximal humeral tunnel length is achieved by starting central or lateral to the midpoint of the epicondyle, angulated 30 to the humeral axis in the sagittal plane and 15 in the coronal plane. A reasonable goal tunnel depth should range from 15 to 20 mm. Ulnar tunnels should be placed on the anterior and posterior aspects of the sublime tubercle, directed away from the joint to minimize the likelihood of breaching the articular cartilage. A bone bridge of 6 to 8 mm between these tunnels can be reasonably achieved.
- Active compression test is positive for OCD lesions and elicits pain in the lateral compartment of the elbow when the patient pronates and supinates the forearm with the elbow axially loaded in extension