thrower's elbow
TRANSCRIPT
TheThrower’sElbowAaronVenouziou,MD
Orthopaedic SurgeonSt.Luke’sHospital
Thessaloniki
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Anatomy
Complexhingejoint
3individualarticulations
• Ulnohumeral
• Radiocapitelar
• ProximalRadioulnar
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Anatomy
2mainligamentouscomplexes
• MCL(medialcollateralligament)
anteriorbundleposteriorbundletransversebundle
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Anatomy
2mainligamentouscomplexes
• LCL(lateralcollateralligament)
annularradialcollaterallateralulnarcollateralaccessorylateralcollateral
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Biomechanics
Ulnohumeral Joint<20o />120o
VALGUS VARUS
MCL20o - 120o
LCL20o - 120o
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Pathomechanics
Overheadthrowing
90mph
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Pathomechanics
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Pathomechanics
tensileloads compressiveloads
shearloads
extremelyhighvalgusstresses
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PathomechanicsTensileload
s
64Nmofvalgustorque
Tensilestrengthofthe
UCLisonly34Nm
Medialsidepathology
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Pathomechanics
Tensileload
s
Medialsidepathology
• MCL
• Flexortendons
• Ulnarnerve
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Pathomechanics
shearloads
Posteriorsidepathology
• Valgusextensionoverloadsyndrome
• Posteromedialimpingement
• Inflammation
• Chondropathy
• Osteophyte /spurformation
• Loosebodies
• Olecranon stressfractures
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Pathomechanicscom
pressiveloads
Lateralsidepathology
• OCD
• Radiocapitellar
arthropathy
500N
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ElbowUCLInjury
• Attenuationtocompleterupture• Medialelbowpain• Painduringaccelerationphase• Lossofvelocity,accuracy• POPsensationinacutecases• Ulnarnervesymptoms• Painw/palpationoverMCL(50o-70o flexion)
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ElbowUCLInjury
UCLexamination
• Valgusstresstest
• 30o ofelbowflexion
• Openingofthemedialjointspace+/- pain
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ElbowUCLInjury
UCLexamination
• Milkingmaneuver
• 90o elbowflexion
• Grabbingtheaffectedthumbwiththeoppositehandpassedundertheaffectedarm
• Pullingtostressthemedialelbow
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ElbowUCLInjury
UCLexamination
• Movingvalgusstresstest
• ShoulderinABDandER
• Theexaminerholdsthethumbandsupportstheelbow
• Elbowflexion-extension+valgusstress
• Painbetween80oand120o=>positivetest
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ElbowUCLInjury
UCLimaging
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ElbowUCLInjury
UCLinjury/tear
• Usuallydonotrespondtoconservativetreatment
Surgicaltreatmentindications:• Acuteruptures• Instability• Chronicpain
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• Jobe etal.JBJSAm1986TommyJohnprocedureFreetendongraftFigure- eightfashionthroughbonetunnels63%returntosports(10outof16athletes)31%postopulnarnervecomplication
UCLreconstruction
Hamstringstendongrafts
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• Surgicalapproach
UCLreconstruction
Medialskinincision ProtectMABC
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• ModifiedJobe Technique
UCLreconstruction
Release+/- transpositionofUN MusclesplittingthroughFCU
Smith,Altchek etal.AJSM1996
Noneuropathies
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Dockingtechnique
• Altchek etal.AJSM1996
• Rohrboughetal.AJSM200295%(31pts)returntosports
• Azar etal.AJSM201079%(78pts)returntosports
UCLreconstruction
15-20mm tunneldepth
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• Bonetunnels
UCLreconstruction
centralorlateraltothemidpointoftheepicondyle
30o inthesagittalplane
15o inthecoronalplane
anteriorandposterioraspectsofthesublimetubercle
Byram,Ahmadetal.AJSM2013
bonebridgeof6to8mm
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Oct.2014
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ValgusExtensionOverloadSyndrome
• Posteromedialimpingement
• Chondropathy
• Osteophyteformation
• Loosebodies
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ValgusExtensionOverloadSyndrome
• Posteriorelbowpain
• Lossoffullextension
• Crepitus/locking
• Armbartest
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ValgusExtensionOverloadSyndrome
Imaging
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ValgusExtensionOverloadSyndrome
Imaging
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ValgusExtensionOverloadSyndrome
VEOSyndromeTreatment
• Openvs.arthroscopicdebridement
• Reddyetal.Arthroscopy200085%returntosports(55athletes)
• Blonna etal.AJSM201091%returntosports(24athletes)
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OsteoChondritis Dissecans
• Radiocapitellar jointtenderness
• 15o to20o extensionlag
• Activecompressiontest
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OsteoChondritis Dissecans
Treatment
• Openvs.arthroscopic• Fragmentfixation• Removalofloosecartilage• Abrasionchondroplasty• Microfractures• Mosaicplasty
• 70-90%returntosports• Rushetal.Arthroscopy1998• Baumgarten etal.AJSM1999
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Conclusions
Elbowinjuriesaretheresultofbiomechanicalforcesontheelbowduringthrowingmotion
tensileforces mediallycompressiveforces laterallyshearforces posteriorly
Prognosisforreturntocompetitionisverygood
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