1. Mr Lee Van Rensburg October 2015

2. J Shoulder Elbow Surg (2012) 21, 1006-1012  Flexion extension axis  Centre capitellum to anteroinferior medial epicondyle

3. JSES 1996;5:103-12  Kinematic study  Did not separate LCL from LUCL  Found  LCL important ulnohumeral stabilizer  LCL stabilizes radial head  Varus  External rotation  Ulno humeral stability independent of forearm rotation

4. J Shoulder Elbow Surg 2002;11:53-9.)  Concept ‘Y’ to LCL complex  Previous studies  Instability release superior band  No instability if release posterior band Varus External rotation

5. J Shoulder Elbow Surg 2002;11:53-9.)  Release of anterior band increased laxity  Varus  External rotation Varus External rotation

6. J Shoulder Elbow Surg 2002;11:53-9.)  Released anterior band  Laxity  Then release posterior band  Instability  If release anterior capsule and anterior band  effectively leave a LUCL, still tethers ulna Varus External rotation

7.  Important where LCL complex injured  1. Humeral epicondylar bony avulsion – 8%  Paediatric  2. LCL Sleeve avulsion, bare epicondyle – 52%  3. Mid substance tear – 29%  4. Soft tissue ulnar avulsion – 5%  5. Bony ulnar avulsion – 1%  6. Combined – 6% J Shoulder Elbow Surg 2003;12:391-6

8.  Common extensor origin  Completely avulsed 66%  Bare epicondyle  Dislocations worse than fracture dislocations  Look at degree of displacement J Shoulder Elbow Surg 2003;12:391-6

9.  Approach dictated by injury  Beware superficial fascia may be intact  Incise superficial fascia  ‘Bomb’ gone off  Avulsion of CEO and LCL

10.  Mass repair suture anchors  5.5 twin fix,  2 fibrewire  Axis of rotation middle of capitellum Early movement Ensure sound repair

11.  If LCL Shredded midsubstance  Internal brace  Anchor into middle capitellum  Anchor supinator crest  tie one set of sutures of fibrewire to each other Internal brace medial side ?

12. J Bone Joint Surg Am, 2000 May 01;82(5):724-724  Kocher interval  Split -- Anconeus - ECU  Elevate anconeus on ulna to expose supinator crest and lateral face of proximal ulna  Palpate tubercle of supinator ridge  Expose supracondylar ridge  2 cm anterior and posterior

13. J Bone Joint Surg Am, 2000 May 01;82(5):724-724  2 drill holes in ulna  1 st near tubercle on the supinator crest  2 nd - 1.25 cm at base of annular ligament  Pass suture through two points and offer up to lateral epicondyle – isometric point  Usually more anterior than think  Remember needs to be tight in extension (PLRI in ext)

14. J Bone Joint Surg Am, 2000 May 01;82(5):724-724  Drill entry hole in lateral epicondyle, widen for graft  Connect 2 exit holes ant and post supracondylar ridge  Auto/ allo graft  Palmaris  Plantaris  Hamstring  15-16 cm gives 3 ply graft

15. J Bone Joint Surg Am, 2000 May 01;82(5):724-724  Humeral fixation  Several options  One or both limbs of graft into isometric point  Stich two limbs together and pull with ‘Yoke’ stitch through tunnel anterior to supracondylar ridge  Free end of the graft just reaches the tunnel – 2 ply to, pass free end back through tunnels into ulna again or suture back onto itself for 3 ply  Tension 40 degrees flexion and full pronation

16. J Bone Joint Surg [Br] 2005;87-B:54-61. 2000

17. J Shoulder Elbow Surg 2002;11:60-4 No significant difference 2 strand 1 strand Proximal 1 strand Distal