scholarly journals PEDIATRIC ELBOW COLLATERAL AND ANNULAR LIGAMENT ANATOMY: A CT-BASED CADAVERIC STUDY

2020 ◽  
Vol 8 (4_suppl3) ◽  
pp. 2325967120S0026
Author(s):  
Tyler J. Stavinoha ◽  
Peter C. Cannamela ◽  
Theodore J. Ganley ◽  
Kevin G. Shea
Keyword(s):  
Sports Medicine ◽  
Articular Surface ◽  
Ulnar Collateral Ligament ◽  
Longitudinal Axis ◽  
Joint Surface ◽  
Annular Ligament ◽  
Collateral Ligament ◽  
Reconstructive Procedures ◽  
Lateral Epicondyle ◽  
The Sublime

Background: The medial and lateral ligamentous complexes of the elbow provide static restraint to the elbow and serve as important components of posteromedial and posterolateral rotatory instability. Many collateral ligament and medial epicondylar injuries require surgical repair in those with open physes. Little is known about the anatomy of the pediatric elbow and the relationship between these ligaments and physes. Purpose: To evaluate the anterior bundle of the medial collateral ligament complex, lateral ulnar collateral ligament, annular ligament, and relationships to the joint surfaces and physes. Methods: Two cadaveric elbows from a 3 year-old donor were dissected. Collateral and annular ligaments were isolated and left intact at their osseous attachment. Pins were placed at the origins and insertions and CT scans were used to establish precise anatomic relationships. All dissections and measurements were performed by a single orthopedic surgeon with specialization in pediatric sports medicine. Results: The MUCL origin was a mean 4.10 mm distal and anterior to the medial epicondyle, 10.09 mm from the distal humeral articular surface, and 9.01 mm distal to the medial physis. The distal insertion of the MUCL spanned a mean 3.09 mm and was posterior and medial to the sublime tubercle. In the longitudinal axis, the MUCL insertion footprint spanned the tubercle. The origin was a mean 1.20 mm proximal to the sublime tubercle and the distal extent averaged 2.53 mm distal to the tubercle. The center of the MUCL insertional footprint was 0.38 mm distal to the tubercle. The center of the MUCL was 3.87 mm from the olecranon articular surface. The annular ligament had consistent medial and lateral attachments to the ulna. Distance from the annular ligament attachments to the tip of the coronoid averaged 4.6 mm (4.46 & 4.74 lateral and medial for left; 4.80 & 5.27 lateral and medial for right). The LUCL origin was distal and anterior to the lateral epicondyle. It was 3.43 mm from the lateral epicondyle, 7.51 mm from the articular surface and 0.74 mm distal to the physis. Conclusions: This study is the first to describe anatomy of the elbow collateral and annular ligaments in pediatric cadaveric specimens, through a reliable, CT-based identification method. Knowledge of the precise ligamentous attachments and relationships to the physis and to the joint surface is important for reconstructive procedures. A better understanding of these relationships may assist with surgical planning that preserves adjacent physeal growth regions.

scholarly journals Arthroscopically-assisted fixation of anteromedial coronoid facet fracture and lateral ulnar collateral ligament repair for acute posteromedial rotatory fracture dislocation of the elbow

2017 ◽  
Vol 11 (5) ◽  
pp. 378-383 ◽  
Author(s):  
Abbas Rashid ◽  
David Copas ◽  
Jeremy Granville-Chapman ◽  
Adam Watts
Keyword(s):  
Articular Surface ◽  
Ulnar Collateral Ligament ◽  
Fracture Dislocation ◽  
Ligament Repair ◽  
Collateral Ligament ◽  
Coronoid Fracture ◽  
Elbow Arthroscopy ◽  
Lateral Ulnar Collateral Ligament ◽  
Arthroscopically Assisted ◽  
Facet Fracture

If left untreated, varus posteromedial rotatory injuries of the elbow result in poor functional outcomes. Surgical treatment allows restoration of elbow kinematics, minimizing the chances of chronic varus instability and early onset osteoarthritis. However, large exposures are associated with extensive soft tissue stripping, a high risk of infection, nerve injury, poor visualization of the articular surface and longer recovery. Consequently, there has been renewed interest in the use of elbow arthroscopy to circumvent these problems. Arthroscopic treatment offers the potential advantage of a swift recovery, with instant rehabilitation, less stiffness and swelling than might be expected after open repair. We present the first combined arthroscopic-assisted anteromedial facet coronoid fracture fixation and lateral ulna collateral ligament repair in a varus posteromedial rotatory injury of the elbow.

Comparison of the Biomechanical Profile of the Intact Ulnar Collateral Ligament with the Modified Jobe and the Docking Reconstructed Elbow

2009 ◽  
Vol 37 (5) ◽  
pp. 974-981 ◽  
Author(s):  
Michael G. Ciccotti ◽  
Sorin Siegler ◽  
John A. Kuri ◽  
John H. Thinnes ◽  
Daniel J. Murphy
Keyword(s):  
Degrees Of Freedom ◽  
Ulnar Collateral Ligament ◽  
Elbow Flexion ◽  
Collateral Ligament ◽  
Valgus Stress ◽  
Anterior Portion ◽  
Reconstructive Procedures ◽  
Kinematic Coupling ◽  
Loading System ◽  
4 Degrees Of Freedom

Background The modified Jobe and Docking techniques are commonly used to reconstruct the elbow's ulnar collateral ligament. Hypothesis Valgus laxity and kinematic coupling after these reconstructive procedures are similar to those of the native ulnar collateral ligament. Study Design Controlled laboratory study. Methods Testing was conducted on 10 pairs of cadaver elbows using a 4 degrees of freedom loading system. Subfailure valgus loads were applied to the native elbows at different flexion angles; motion and ligament elongation were measured. The elbows were then loaded to failure in valgus at 90° of flexion. The reconstructive techniques were then applied and testing was repeated. Results Only the resting length of the anterior portion of the ulnar collateral ligament anterior bundle remained isometric throughout range of motion. Valgus laxity was nearly equal for the native and reconstructed ligaments at flexion angles of 90° or higher. However, both reconstructions provided less valgus stability than the native ulnar collateral ligament at low flexion angles. Kinematic coupling decreased with increased flexion for both native and reconstructed ligaments. Conclusion The modified Jobe and Docking techniques reconstruct restraint of the native ulnar collateral ligament to valgus laxity and kinematic coupling at 90° of flexion and higher angles where peak valgus torque is experienced in the throwing elbow. Clinical Relevance Both reconstructions provide valgus stability comparable to that of the native ulnar collateral ligament at 90° and higher, helping to explain their success in treating throwing athletes. Both reconstructions provide less valgus stability than the native ulnar collateral ligament at low flexion angles, suggesting that patients undergoing ulnar collateral ligament reconstruction should be cautioned against activities that provide valgus stress at low elbow flexion angles, such as side-arm throwing. This study suggests caution against overtightening the reconstructions at the common 30° of flexion.

MRI of the pediatric elbow: Assessment of ligaments, plicae, and cartilage in the clinical setting

2021 ◽  
Keyword(s):  
Sports Medicine ◽  
Ulnar Collateral Ligament ◽  
Poor Quality ◽  
Collateral Ligament ◽  
Young Athletes ◽  
Maximum Extension ◽  
Helpful Tool ◽  
Adolescent Patients ◽  
Elbow Injuries ◽  
And Cartilage

Elbow injuries in young athletes are becoming an increasing concern for orthopedic sports medicine specialists, but imaging is frequently complicated. The purpose of this study was to assess MRI in imaging ligaments, plicae, and cartilage in 65 pediatric and adolescent patients. 9 MRIs (13%) did not allow assessment because of poor quality. In skeletally mature patients, the radial and ulnar collateral ligament were clearly discernable in 94% and 77%, measuring 1.5 ± 0.6 mm and 1.9 ± 0.6, compared to 55% and 59% in the immature patients with a mean thickness of 1.1 ± 0.6 and 1.4 ± 0.6 mm (p<0.05). 12 patients (18%) revealed a cartilaginous pseudodefects, 5 (8%) had a true OCD. 23 (35%) showed a posterolateral plica with a maximum extension of 1.6 ± 1.7 mm. In OCD the plica was significantly larger compared to patients without OCD (p=0.001). While MRI is a helpful tool in assessing elbow injuries, its usefulness is restricted in pediatric and adolescent patients. 1 in 10 MRI studies was too distorted to be read. However, ligaments ad plicae could be well discerned in most patients. At 18% pseudodefects are much less common than in adults (85%).

Finite Element Analysis of the Ulnar Tunnel in Ulnar Collateral Ligament Reconstruction

2010 ◽  
Author(s):  
Harold A. Cook ◽  
Sam Akhavan ◽  
Patrick J. DeMeo ◽  
Mark Carl Miller
Keyword(s):  
Ligament Reconstruction ◽  
Failure Load ◽  
Ulnar Collateral Ligament ◽  
Medial Epicondyle ◽  
Collateral Ligament ◽  
Element Analysis ◽  
Proximal Ulna ◽  
The Sublime ◽  
Throwing Motion ◽  
Ulnar Collateral Ligament Reconstruction

The ulnar collateral ligament (UCL) of the elbow originates on the medial epicondyle of the humerus and inserts on the sublime tubercle of the proximal ulna. This ligament is classically composed of three distinct structures: the anterior bundle, the posterior bundle, and the transverse bundle. Of these three, the anterior bundle has been shown to be the primary stabilizer to valgus load between 20° and 120° of flexion [1]. Injuries to the anterior bundle of the UCL are commonly seen in baseball pitchers, where the valgus load on the elbow during the throwing motion approaches the failure load of the ligament [2].

scholarly journals The Middle and Distal Aspects of the Ulnar Footprint of the Medial Ulnar Collateral Ligament of the Elbow Do Not Provide Significant Resistance to Valgus Stress: A Biomechanical Study

2019 ◽  
Vol 7 (2) ◽  
pp. 232596711882529 ◽  
Author(s):  
Brandon J. Erickson ◽  
Michael Fu ◽  
Kate Meyers ◽  
Christopher L. Camp ◽  
David W. Altchek ◽  
...  
Keyword(s):  
Ulnar Collateral Ligament ◽  
Biomechanical Study ◽  
Collateral Ligament ◽  
Valgus Stress ◽  
3 Dimensional ◽  
The Sublime ◽  
Intact Condition ◽  
Load Frame ◽  
Distal Aspect ◽  
Joint Gapping

Background: The medial ulnar collateral ligament (UCL) insertion of the elbow has been shown to extend distally beyond the sublime tubercle. The contribution to valgus stability of the distal aspect of the footprint is unknown. Purpose/Hypothesis: The purpose of this study was to determine the contribution of each part of the UCL footprint to the elbow valgus stability provided by the UCL. It was hypothesized that the distal two-thirds of the ulnar UCL footprint would not contribute significantly to valgus stability provided by the UCL. Study Design: Descriptive laboratory study. Methods: Fifteen cadaveric arms were dissected to the capsuloligamentous elbow structures and potted. A servohydraulic load frame was used to place 5 N·m of valgus stress on the intact elbow at 30°, 60°, 90°, and 120° of flexion. The UCL insertional footprint was measured and divided into thirds (proximal, middle, and distal). One-third of the UCL footprint was elevated off the bone (leaving the ligament in continuity), and the elbow was retested at the same degrees of flexion. This was repeated until the entire UCL footprint on the ulna was sectioned. Each elbow was randomized for how the UCL would be sectioned (sectioning the proximal, then middle, and then distal third or sectioning the distal, then middle, and then proximal third). Ulnohumeral joint gapping (millimeters) was recorded with a 3-dimensional motion capture system using physical and virtual markers. Two-group comparisons were made between each sectioned status versus the intact condition for each flexion angle. Results: When the UCL was sectioned from distal to proximal, none of the ligaments failed prior to complete sectioning. When the UCL was sectioned from proximal to distal, 3 of the 6 ligaments failed after sectioning of the proximal third, while 2 more failed after the proximal and middle thirds were sectioned. Of the specimens with the distal third of the ligament sectioned first, no significant differences were found between intact, distal third cut, and distal plus middle thirds cut at all flexion angles. Conclusion: The middle and distal thirds of the insertional footprint of the UCL on the ulna did not significantly contribute to gap resistance at 5 N·m of valgus load. The proximal third of the footprint is the primary resistor of valgus load. Clinical Relevance: This cadaveric biomechanical study demonstrated that the middle and distal thirds of the native UCL insertion onto the ulna did not significantly contribute to valgus resistance at the elbow. When a UCL reconstruction is performed, the proximal third of the UCL insertion may be the most clinically important portion of the ligament to reconstruct.

scholarly journals Comparison of articular exposure through extended lateral approaches to the tibial plateau

2020 ◽  
Vol 8 (5_suppl4) ◽  
pp. 2325967120S0031
Author(s):  
Jannik Frings ◽  
Matthias Krause ◽  
Hüseyin Isik ◽  
Karl-Heinz Frosch
Keyword(s):  
Soft Tissue ◽  
Tibial Plateau ◽  
Articular Surface ◽  
Lateral Collateral Ligament ◽  
Joint Surface ◽  
Anatomical Reconstruction ◽  
Anterolateral Approach ◽  
Popliteus Tendon ◽  
Lateral Tibial Plateau ◽  
Lateral Epicondyle

Aims and Objectives: Comminuted lateral tibial plateau fractures pose a challenge to surgeons, resulting in non-anatomical reductions in 70-89% of all cases. Anatomical reconstruction requires the direct visualization of the joint after a fragment reduction, which is impaired using the common anterolateral approach. Although numerous lateral extended approaches are described, there is currently no data on which approach provides better visibility of the posterolateral tibial plateau. The aim of this study was to evaluate, which parts of the tibial plateau can be visualized with the use of the lateral femoral epicondyle osteotomy or the fibula osteotomy? Further, the study investigated wether the combined osteotomy of the femoral footprints of the lateral collateral ligament (LCL) and popliteus tendon (PLT) provide better access to the posterolateral joint surface than the isolated osteotomy of the femoral LCL footprint or the fibula osteotomy? Materials and Methods: Extended lateral (femoral or fibular LCL osteotomy) and posterolateral (additional femoral osteotomy of the PLT tendon) approaches were performed on twelve human cadaver knee joints. After preparing of each surgical approach, the visible joint surface was marked with diathermy. The tibial plateau was disarticulated and the markings were measured digitally with open-source processing software. Differences in mean values were tested with a paired t-test (p < 0.05). Results: The greatest articular exposition was realized by the fibula osteotomy (1011.52 ± 227.05 mm2 [86.64 ± 4.84%] compared to either osteotomy of LCL and PLT (p = 0.036) or LCL alone (p<0.001). The lateral femoral epicondyle osteotomy of the LCL including the PLT (937.45 ± 237.84 mm2 [80.29 ± 8.25 %]) exposed a significantly larger articular surface of the lateral tibial plateau than without the PLT (755.71 ± 183.06 mm2 [64.73 ± 6.51 %], p < 0.001). Conclusion: The fibula osteotomy provides the greatest articular visibility of the lateral tibial plateau compared to the lateral epicondyle osteotomy of the femoral LCL and PLT attachments. This small benefit should be critically balanced against the considerably greater soft tissue damage caused by the fibula osteotomy. The lateral femoral epicondyle osteotomy including the LCL and PLT increases lateral articular visualization without risk to neurovascular or posterolateral soft tissue structures and represents an important extended approach to treat comminuted lateral plateau fractures.

scholarly journals Quantitative and Qualitative Analyses of the Lateral Ligamentous Complex and Extensor Tendon Origins of the Elbow: An Anatomic Study

2020 ◽  
Vol 8 (10) ◽  
pp. 232596712096137
Author(s):  
David L. Bernholt ◽  
Samuel I. Rosenberg ◽  
Alex W. Brady ◽  
Hunter W. Storaci ◽  
Randall W. Viola ◽  
...  
Keyword(s):  
Lateral Collateral Ligament ◽  
Joint Line ◽  
Anatomic Reconstruction ◽  
Annular Ligament ◽  
Lateral Side ◽  
Collateral Ligament ◽  
Measuring Device ◽  
Lateral Epicondyle ◽  
Radial Collateral Ligament ◽  
Bony Landmarks

Background: The lateral collateral ligament complex of the elbow is important in preventing posterolateral rotary instability of the elbow. Understanding the quantitative anatomy of this ligamentous complex and the overlying extensor musculature can aid in the surgical treatment of problems affecting the lateral side of the elbow. Purpose: To perform qualitative and quantitative anatomic evaluations of the lateral elbow ligamentous complex and common extensor muscle origins with specific attention to pertinent osseous landmarks. Study Design: Descriptive laboratory study. Methods: A total of 10 nonpaired, fresh-frozen human cadaveric elbows (mean age, 42.2 years; all male) were utilized. Quantitative analysis was performed using a 3-dimensional coordinate measuring device to quantify the location of pertinent bony landmarks, tendons, and ligament footprints of the lateral side of the elbow. Results: The extensor carpi radialis brevis was the only humeral footprint found to cross the radiocapitellar joint line, extending a mean 5.9 mm (95% CI, 4.7-7.0) distal to the joint line. With the elbow in full extension, the lateral ulnar collateral ligament (LUCL) humeral footprint was found 7.1 mm (95% CI, 4.7-9.4) anterior and 9.8 mm (95% CI, 8.4-11.2) distal to the lateral epicondyle and 8.6 mm (95% CI, 7.5-9.7) proximal to the radiocapitellar joint line, while the radial collateral ligament humeral footprint was found 6.6 mm (95% CI, 5.5-7.8) anterior and 5.6 mm (95% CI, 4.0-7.2) distal to the lateral epicondyle and 12.7 mm (95% CI, 11.4-14.0) proximal to the radiocapitellar joint line. The center of the ulnar attachment of the LUCL was found 1.4 mm (95% CI, 0.7-2.1) anterior and 2.4 mm (95% CI, 1.2-6.0) proximal to the supinator tubercle and 24.4 mm (95% CI, 22.7-26.1) distal to the radiocapitellar joint line. The center of the ulnar attachment of the annular ligament was found to be 17.3 mm proximal to the supinator tubercle. Conclusion: The current study provides measured distances of LUCL and radial collateral ligament attachments in reference to clinically relevant landmarks, which can potentially aid surgeons in performing more anatomic reconstruction or repair of the lateral ligamentous complex of the elbow.

Dorsal and Volar Surgical Approaches to the Metacarpophalangeal Joint: A Comparative Anatomic Study

2017 ◽  
Vol 22 (03) ◽  
pp. 297-302
Author(s):  
Eitan Melamed ◽  
Nicholas Calotta ◽  
Ricardo Bello ◽  
Richard M Hinds ◽  
John T Capo ◽  
...  
Keyword(s):  
Surface Area ◽  
Articular Surface ◽  
Insertion Site ◽  
Proximal Phalanx ◽  
Extensor Tendon ◽  
Joint Surface ◽  
Surgical Approaches ◽  
Collateral Ligament ◽  
Volar Approach ◽  
A1 Pulley

Background: We compared 3 surgical approaches to the MP joint: a dorsal extensor tendon–splitting approach, a dorsal extensor tendon–reflecting parasagittal approach, and the volar A1 pulley approach. We quantitatively compared each of these approaches by measuring the amount of articular cartilage exposed on the base of the proximal phalanx. We hypothesize that visualization of the articular cartilage of the proximal phalangeal base is enhanced with the volar approach. Methods: The MP joints of the 32 available digits were randomly assigned to 1 of 3 surgical approaches: extensor tendon splitting (A), extensor tendon reflecting (B), or volar approach (C). After each approach, the visible articular surface of the base of the proximal phalanx was stained with methylene blue. The MP joints were then disarticulated, and the proximal phalanges were digitally mapped using a 3-dimensional digitizer. Three-dimensional computer software was used to analyze and calculate the dyed exposed surface area and total surface area of each specimen. Results: The mean % exposed joint surface area for the dorsal extensor splitting, dorsal extensor reflecting and volar approaches were 62%, 67% (over the dorsal side of the proximal phalanx) and 54% (over the volar side of the proximal phalanx), respectively. Multiple linear regression showed statistical significance for a smaller percentage of articular surface area exposed with the volar approach. However, this was not clinically significant. A significant association was found between location in the small finger and greater % exposed joint surface, compared to approaches in the index finger. In all volar approach specimens, the collateral insertion site was visible, but not in the dorsal approach specimens. Conclusions: Knowledge of the limits of each exposure is essential for planning the most appropriate surgical approach. The A1 pulley approach provided greater access to the volar 50% of the joint and collateral ligament insertion without violating the extensor mechanism. The amount of joint surface visualized through all 3 approaches was not significantly different. However, based on the accessibility to the collateral ligament insertion site among three different approaches, we recommend the volar A1 pulley approach for treatment of avulsion fractures of the base of the proximal phalanx. For other injuries of the MP joint, including the intra-articular proximal phalanx base fractures, and metacarpal head fractures, the dorsal approaches are still indicated.

Avulsion Fracture of the Ulnar Sublime Tubercle in Overhead Throwing Athletes

2002 ◽  
Vol 30 (3) ◽  
pp. 426-431 ◽  
Author(s):  
John P. Salvo ◽  
Louis Rizio ◽  
John E. Zvijac ◽  
John W. Uribe ◽  
Keith S. Hechtman
Keyword(s):  
Magnetic Resonance Imaging ◽  
Magnetic Resonance ◽  
Avulsion Fracture ◽  
Ulnar Collateral Ligament ◽  
Resonance Imaging ◽  
Ligament Injuries ◽  
Collateral Ligament ◽  
Avulsion Fractures ◽  
The Sublime

Background Injuries to the ulnar collateral ligament are relatively common in throwing athletes and result from either acute traumatic or repeated valgus stress to the elbow. Avulsion fracture of the sublime tubercle of the ulna is a rarely reported site of ulnar collateral ligament injury. Purpose We retrospectively reviewed our cases of ulnar collateral ligament injuries to study avulsion fractures of the sublime tubercle of the ulna. Study Design Case series. Methods Data, including radiographs and magnetic resonance imaging scans, were obtained by review of hospital and office records and by follow-up examination. Of 33 consecutive patients treated for ulnar collateral ligament injuries, 8 had avulsion fractures of the sublime tubercle of the ulna. All eight were male baseball players with dominant arm involvement, an average age of 16.9 years, and an average follow-up of 23.6 months. Results Six of eight patients had failure of nonoperative treatment and required surgical repair. Two of the six underwent ulnar collateral ligament reconstruction and four had direct repair of the sublime tubercle avulsion with bioabsorbable suture anchors. At last follow-up, all eight had returned to their preinjury level of activity. No patient had residual medial elbow pain or laxity. Conclusions Diagnosis of sublime tubercle avulsion fracture is made with history, physical examination, and radiographic studies. Magnetic resonance imaging can help identify an avulsion fracture not visible radio-graphically and can help determine whether direct repair or reconstruction is needed.

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