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Published byTrevor Brooks Modified over 7 years ago
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Ulnar Collateral Ligament Injuries in Throwing Athletes
Nicholas Sablan, MD Tidewater Orthopaedic Associates
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Outline Biomechanics of Pitching Anatomy Exam Imaging
Nonsurgical Management Surgical Management Prevention
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Biomechanics of Pitching
Every Pitch approaches maxium torque on UCL complex Valgus forces at elbow (64Nm) can exceed the tensile strength of UCL (32Nm) Fleisig, AJSM 1995 Fatigue of dynamic stabilizers
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Anatomy Three parts Anterior Bundle Posterior Bundle
Transverse Ligament Anterior bundle primary stabilizer to valgus stress from arc Morrey, AJSM 1983 Feltner, IJSB 1987
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Functional Anatomy Humeral Origin lies posterior to axis of elbow flexion Ligament tension varies with flexion Distance between anterior bundle origin and insertion increases slightly from 0 to 60 degrees
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History Medial elbow pain Early acceleration/late cocking phase
Chronic episodic with decreased accuracy/velocity/control most common Sometimes acute “pop” Ulnar nerve symptoms
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Physical Examination Tenderness ROM Flexor Pronator Mass Ulnar Nerve
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Stability Tests Valgus Stress test (Jobe) Milking Test (O’Brien)
Moving Valgus test
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Imaging Plain Radiographs Stress Radiographs Ultrasound
MRI +/- Arthrogram
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Plain Radiographs Arthritic Changes Bony Avulsions
Olecranon osteophytes Calcifications
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Stress Radiographs Average opening pitcher 0.32mm
>0.5mm diagnostic ? Telos stress device
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Ultrasound Noninvasive “Real” time Injections Stress testing
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MRI Assess Flexor Pronator origin Sensitivity 57% Specificity 100%
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MRI: T SIGN Dye leak down the sublime tubercle
UCL attaches 2.8 mm from articular surface
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Nonsurgical Management of PartialTears
No throwing minimum 6 weeks mild symptoms, 8-12 weeks moderate severity Therapy focused on: Pitching mechanics Shoulder kinematics Shoulder motion deficits Core strength Scapular stabilizers
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Nonoperative management
Once pain free and kinetic chain deficits addressed PRP injections?
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Nonsurgical management Rettig et al, AJSM 2001
31 throwing athletes with UCL injuries 30 month f/u Supervised rehab program Phase I: rest 2-3 months, therapy Phase II: throwing progression 41% return to level of play at average 24 weeks No significant difference in duration, acuity of symptoms, or age of patient b/w those able to play/unable
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Surgical Management Acute or chronic complete tear of UCL
Partial tears after “failure of conservative Rx” (Functional inability to throw secondary to medial elbow pain Usually not necessary to operate on UCL injuries if athlete has no future in baseball or retiring (casual high school athlete?)
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Goals of Surgical Treatment
Reconstruct UCL Role for repair? Treat Associated joint pathology Ulnar nerve
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Graft choices Ipsilateral Palmaris Contralateral gracilis Allograft
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Reconstruction of the UCL in Athletes Jobe, et al. JBJS, 1986
Reconstruction in 16 athletes Lift off common flexor bundle Routine Ulnar nerve transposition 68% return to previous play High incidence of ulnar nerve complications
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Muscle Splitting Approach to UCL Altchek et al AJSM 1996
Safe zone between braches of median and ulnar nerve 22 patients No ulnar neuropathy
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Modified UCL reconstruction
Muscle Splitting (protect MABC) Selective ulnar nerve transposition Fixation techniques?
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UCL Reconstruction Outcomes ASMI Modified TJ
Muscle Splitting Ulnar nerve transposition 82% return to play
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Docking Technique Flexor mass divided Reduced # bone tunnels
Graft “docked” into medial epicondyle 90% return to play Highest peak load to failure
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Dane TJ Interference screw on ulna Docking technique on humerus
86% return to play
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Postoperative Management
Splint for 1 week ROM brace with therapy Throwing program at 4 months Return to competitive throwing 9-12 months
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Complications Ulnar Nerve Fracture Stiffness Heterotopic ossification
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Prevention Year Round Sport
Pitch Counts (USA baseball Medical Advisory Committee) Curve Balls?
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Thank You!
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