Elbow Ligamentous Injuries

Clinically Relevant Anatomy[edit|edit source]

Theelbow jointis stabilized primarily by three ligaments:

1. Medial collateral ligament
2. 横向抵押品ligament
3. Annular ligament

The medial and lateral collateral ligaments provide valgus and varus stability, and allow for rotation. The annular ligament encircles the head of the radius, stabilizing it in the radial notch. Each of these ligaments can be injured by elbow trauma or overuse.^[1]

Mechanism of Injury / Pathological Process
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横向抵押品ligamentousinjuries are typically associated with fracture ordislocation(shown below).Medial collateral ligamentousinjuries are typically caused by overuse. Some common causes of elbow ligamentous injuries include:

• Forced twisting of the arm
• Falling on an outstretched arm
• 重复开销运动(如在投球,volleyball, or tennis)

Clinical Presentation[edit|edit source]

Although ligamentous injuries are rare, patients may present with varus or valgus laxity due to overuse or trauma.Lateral Collateral Ligamentinjury is often associated with trauma and forceful motion into varus. These injuries are commonly associated with a fracture or subluxation at the elbow joint. AnUlnar Collateral Ligamenttear or sprain could occur with valgus overload or stress movement from pitching or throwing. Typically seen in younger male pitchers, a UCL tear or sprain could also be found in athletes involved in repetitive overhead activities like tennis or volleyball. Another common name for UCL tear isLittle League Elbow Syndrome.

Diagnostic Procedures[edit|edit source]

• Varus Stress Test, tests for laxity of the Lateral Collateral Ligament (LCL).
  
• Valgus Stress Test, tests for laxity of the Ulnar Collateral Ligament (UCL).
  
• Moving Valgus Stress Test, tests for chronic UCL sprain or tear from overuse (sensitivity: 100, specificity: 0.75).
  
• Modified Milking Maneuver, tests for UCL sprain or tear from overuse.
  
• Palpation, in order to manually exam the integrity of the ligaments.
  
  

[2]

[3]

[4]

[5]

Outcome Measures[edit|edit source]

Three common patient reported outcome measures are used for elbow ligamentous injuries:

1. TheDASH是30个问题得分从0 - 100,0意义没有迪sability. The DASH is well studied and validated with a minimally clinical important difference or MCID of 15 point or MCD of 12.7 points.
   
2. The Quick DASH, commonly used in place of The DASH. The patient chooses the response that is the most true from 1-5 for each question. The scoring instructions are listed on the bottom of the form, however The Quick DASH has no known MCID unlike the DASH.
   
3. The Patient Specific Functional Scale is a scale where the patient chooses 5 activities that are difficult to perform and rates those tasks from 0-10, 0 being not able and 10 being able. The MCID for the average of the 5 activities is 2, while for 1 activity the MCID is 3.
   

Management / Interventions
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Due to lack of high quality literature for these conditions, it is recommended that an impairment-based approach be used to guide management.

• Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used forrelief of pain and inflammation. If pain is severe, a mild narcotic or corticosteroid injections may be prescribed.
• Commonimpairmentsto assess in examination could include decreased elbow or shoulder range of motion,joint effusion, and decreased strength of the upper extremity musculature.
  • Glenohumeral internal rotation deficitsare typically seen with pitchers and athletes performing repetitive overhead activities. Studies have shown a direct correlation with decreased internal rotation and excessive external rotation in baseball pitchers and UCL injuries.^[6]
    
• It is recommended that individuals with these conditions remain active, whileprotecting the ligament from stress. Activities that aggravate the symptoms should initially be minimized in order to allow for ligamentous healing. Activity level can thereafter be increased gradually.
• Pain and swelling may be relieved through the intermittentapplication oficeduring the acute stages.
• Surgeryfor theUCLis indicated in complete tears and for athletes wanting to resume previous level of activity. The most common surgical procedure, Tommy John surgery, is when the UCL is replaced with a tendon from elsewhere in the body (often from forearm, hamstring, knee or foot of the same patient). This procedure is most common with athletes from several sports, most notably baseball.
• Surgeryto repair theLCLalone is rare and is typically associated with a fracture, dislocation, or subluxation of the elbow. Due to the decreased structural stability of the joint and ORIF may be considered at the discretion of the surgeon.
  

Differential Diagnosis
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• Heterotopic Ossification: Considerable loss of passive range of motion without loss of strength
• Malignancy: Severe progressive pain that is not affected by movement
• Inflammatory Arthrithides: Abnormal systemic signs
• Fracture: History of trauma,Elbow Extension Test(specificity: 0.69, sensitivity: 0.97), marked limitations in range of motion and ecchymosis
• Dislocation: Exaggerated boney prominence, effusion, or appearance of elongation of forearm and could affect neurovascular status.
• Infection: Sudden swelling without trauma
• Vascular Compromise: numbness, tingling, pulse abnormalities
• Referred Cervical Pain
• Referred Shoulder Pain
  

Lateral Elbow Differential Diagnosis

• Radial Tunnel Syndrome
• Lateral Epicondylalgia
  

Medial Elbow Differential Diagnosis

• Cubital Tunnel Syndrome
• Medial Epicondylalgia

关键证据[edit|edit source]

Szekeres M, Chinchalkar SJ, King GJ. Optimizing Elbow Rehabilitation After Instability. Hand Clinics. 2008 Feb; 24(1):27-38

Resources
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Richard M, Aldridge M, Wiesler E, Ruch D, Traumatic Valgus Instability of the Elbow: Pathoanatomy and Results of Direct Repair. The Journal of Bone and Joint Surgery. 2008;90:2416-2422.f

Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint. A prospective randomized study. J Bone Joint Surg Am. 1987 Apr;69(4):605-8.

Case Studies[edit|edit source]

Muller MS, Drakos MC, Feeley B, Barnes R, Warren RF. Nonoperative Management of Complete Lateral Elbow Ligamentous Disruption in an NFL Player: A Case Report. HSS J. 2010 Feb;6(1):19-25.

Yang C, Li W, Gong YB, Li SQ, Qi X. Posterolateral rotatory instability of the elbow: a case report and literature review. Chin J Traumatol. 2010 Dec;13(6):380-2.

Recent Related Research (fromPubmed)[edit|edit source]

References[edit|edit source]