What are the treatment options for UCL tears of the elbow in - PowerPoint PPT Presentation

What are the treatment options for UCL tears of the elbow in athletes? Christopher Doumas, MD Clinical Assistant Professor Orthopaedic Surgery Rutgers-RWJMS Chief of Hand Surgery JSUMC

Disclosures • President and Founder of LibraryOfMedicine.com www.UOANJ.com

Clinical Question • In the athleGc populaGon, what are the treatment opGons for paGents with an ulnar collateral ligament tear of the elbow, who wish to return to normal physical acGvity? www.UOANJ.com

Overhead Throwing • Results in significant valgus stress to the elbow • Stress concentrated on medial structures • Majority of injuries secondary to repe$$ve overload rather than acute trauma • Baseball players most commonly affected • Medial elbow symptoms account for 97% of elbow complaints in pitchers

Elbow stability • Primary stability at < 20° or >120° of flexion is secondary to bony anatomy • SoZ Gssue restraints provide primary staGc and dynamic stability from 20-120° = arc of moGon of overhead throwing

Ulnar Collateral Ligament Anterior Bundle is primary • restraint to valgus force from 30-120° of flexion Anterior Bundle made up of • anterior (up to 90°) and posterior bands (60°- full flexion) During acceleraGon phase of • throwing subjected to near failure tensile stresses Posterior Bundle vulnerable to • valgus stress only if anterior bundle fails Oblique bundle: serves to expand • sigmoid notch

Stages of Overhead Throwing

Obviously Confused…

Biomechanics of Throwing Generates large valgus and • extension forces Valgus force as high as 64 Nm at • late cocking and early acceleraGon, Compressive force of 500 N lateral radiocapitellar arGculaGon as extend Net effect: Tensile stress along • medial structures, shear stress in posterior compartment, compression stress laterally Together → Valgus Extension • Overload Syndrome

Spectrum of Injury • UCL akenuaGon/tears • Olecranon Gp osteophytes • Loose bodies • Flexor-pronator mass tendoniGs • Ulnar neuriGs • Medial epicondyle apophysiGs in skeletally immature

Evaluation of Elbow Complaints • History: Changes in training regimen Changes in accuracy, velocity, stamina, strength Time of onset Phase of throwing Neurologic or vascular complaints

Evaluation of Elbow Complaints • Physical exam: InspecGon: effusion, carrying angle (nl 11° valgus ♂ , 13° ♀ , adapGve changes in throwers can increase, assess deformity from prior trauma) ROM: acGve, passive (sagital 0-140°±10°, 80-90° pronaGon and supinaGon, assess for contracture, compensaGon w/ shoulder) Flexion contracture present in 50% of pitchers, End points: soZ in flexion, firm bone on bone in extension PalpaGon: bony landmarks: medial epicondyle, radial head, Gp of olecranon; SoZ Gssues: biceps, triceps, flexor-pronator mass, UCL; neurovascular structures Strength TesGng Stability

Evaluation of Elbow Complaints • Plain Radiographs AP, lateral, axial, 2 oblique views Oblique axial view at 110° flexion → posteromedial olecranon osteophytes Stress AP radiographs at 25° flexion w/ comparison to opposite elbow assessing for osteophytes, UCL calcificaGon, OCD of capitellum, loose bodies • CT Scan: olecranon stress fx • Bone Scan: olecranon stress fx • MRI vs CT arthrogram: UCL evaluaGon • Ultrasound – Can be reliably used to assess integrity, early pathologic change and increased laxity to valgus stress. – Early change is increased thickness of the UCL. Ciccop et al.

Evaluation of Valgus Instability: History • Acute Injury: ▪ sudden onset of pain aZer throwing ± pop ▪ unable to conGnue throwing • Chronic Injury: ▪ gradual onset of localized medial elbow pain during late-cocking or acceleraGon ▪ pain aZer episode of heavy throwing w/ subsequent inability to throw at more than 50-70% of nl level ▪ ulnar nerve symptoms 2° to irritaGon from local inflammaGon

Exam of Anterior Band of Anterior Bundle of UCL • Pt seated, wrist secured between examiner’s forearm and trunk • Flex elbow to 20-30° to unlock olecranon from fossa • Apply valgus stress, and palpate UCL along its course • Compare medial joint-space opening to contralateral side • Loss of firm endpoint w/ increased medial joint- space opening → akenuated or incompetent UCL

Exam of Posterior Band of Anterior Bundle of UCL: Milking Maneuver • Pull on pt’s thumb w/ pt’s forearm supinated, shoulder extended, and elbow flexed beyond 90° • Results in valgus stress on flexed elbow • SubjecGve feeling of apprehension and instability + localized medial elbow pain indicates UCL injury

Moving Valgus Stress Test • Pain from 70 -120 • 100% SensiGve • 75% Specific O’Driscoll et al. Am J Sports Med. 2005 Feb; 33(2):231-9

Other Exam findings • Point tenderness and swelling may vary • Decreased Range of moGon w/ loss of terminal extension secondary to flexion contracture may be present w/ chronic valgus instability

Radiographic Findings • CalcificaGon and occasional ossificaGon of the UCL • Stress radiographs compared w/ contralateral elbow, AP view at 25 degrees of flexion w/ gravity valgus stress applied • > 3mm of medial joint opening suggesGve Langer et al. Br J Sports Med. 2006;40:499-506.

Usefulness of MRI vs CT arthrogram • Nonenhanced MRI vs CT arthrogram in 25 paGents w/ surgically confirmed UCL injury MRI CT arthrogram SensiGvity 57% 86% Specificity 100% 91% Both 100% sensiGvity for complete tears • Saline-enhanced arthrogram MRI SensiGvity 92% (95% for complete tear, 86% for parGal) Specificity 100%

Treatment Options • ConservaGve – Therapy – PRP • Surgical – Acute Repair – Chronic ReconstrucGon www.UOANJ.com

PubMed Search • Elbow Ulnar Collateral Ligament Injury • 301 ArGcles • No good Level I or II studies www.UOANJ.com

Conservative Options • Non opera3ve treatment is indicated in non- throwers, and has acceptable results in this lower- demand popula3on • Rehab 2-3 month of non-throwing, splin3ng un3l pain improved and ROM and PT of the shoulder • Injec3on of the UCL with cor3costeroid should be avoided Langer et al. Br J Sports Med. 2006;40:499-506. www.UOANJ.com

Therapy • The flexor-pronator mass dynamically stabilizes the elbow against valgus torque. The flexor carpi ulnaris is the primary stabilizer, and the flexor digitorum superficialis is a secondary stabilizer. The pronator teres provides the least dynamic stability. Park and Ahmad. J Bone Joint Surg Am, 2004 Oct; 86 (10): 2268 -2274 . www.UOANJ.com

Non-Op Literature • 18 NFL players with UCL injuries – All returned to play – Obviously mostly Non-throwers Kenter et al. J Shoulder Elbow Surg. 2000 Jan-Feb;9(1):1-5. • Repg et al found 42% RTP avg of 24.5 weeks aZer diagnosis (Mean age 18) Repg et al. Am J Sports Med. 2001 Jan-Feb;29(1):15-7 www.UOANJ.com

PRP • Case series of 34 athletes (Level 4) – Ultrasound diagnosis and followup measurements – Less widening of medial joint space on follow up – 88% returned to play (avg Gme 12 weeks) – 1 went on to surgery Podesta et al. Am J Sports Med. 2013 Jul;41(7):1689-94. www.UOANJ.com

UCL Direct Ligament Repair • ONLY in acute traumaGc rupture without dislocaGon. • 9/11 collegiate athletes returned to play within 6 months • Works even in throwers Richard et al. J Bone Joint Surg Am. 2009 Oct 1;91 www.UOANJ.com

Primary repair of ulnar collateral ligament injuries of the elbow in young athletes: a case series of injuries to the proximal and distal ends of the ligament • 60 adolescent paGents with direct repair • Good to excellent results in 93% • Less likely to have chronic damage. • 58 of 60 able to return to original or higher level of play within 6 months. Savoie et al. Am J Sports Med 2008. www.UOANJ.com

Repair vs Reconstruct Conway et al. J Bone Joint Surg Am. 1992 Jan;74(1):67-83. • Return to play prior level – 50% of Repair Group – 68% of ReconstrucGon Group • Major League Players Returning – 2/7 Repair Group – 12/16 ReconstrucGon Group www.UOANJ.com

Repair vs Reconstruct • Andrews et al – Repair – 0/2 RTP – Recon – 12/14 (86%) RTP Am J Sports Med. 1995 Jul-Aug;23(4):407-13. www.UOANJ.com

UCL Ligament Reconstruction • 1986 Jobe et al. • Figure of eight graZ • All throwers • 10/16 returned to play www.UOANJ.com

Docking Technique • 1996 Described by Altchek • Rohrbough et al reported 92% RTP for at least one year www.UOANJ.com

Post-operative Rehabiltation • Brief ImmobilizaGon 7-10 days, followed by AAROM and AROM • Hinged brace- 5 weeks aZer splint, 20-140 degrees • Progressive resisGve strengthening exercises of wrist and forearm 4-6 wks • At 6 weeks begin elbow strengthening exercises • Avoid valgus stress unGl 4 months • Throwing program beginning at 4 months • CondiGoning of shoulder and elbow progress w/ return to pre-injury acGvity by 12-18 months University of Pennsylvania Department of Orthopaedic Surgery

Clinical Conclusions • Injury to the medial collateral ligament of the elbow is rela3vely common in athle3cs. • Appropriate clinical exam and diagnos3c studies should be u3lized. • Conserva3ve treatment and rehabilita3on should be considered for injuries that have no significant laxity on exam in a non-thrower. www.UOANJ.com