UvA-DARE (Digital Academic Repository) Radial head fracture: a potentially complex injury Kaas, L. Link to publication

Transcription

1 UvA-DARE (Digital Academic Repository) Radial head fracture: a potentially complex injury Kaas, L. Link to publication Citation for published version (APA): Kaas, L. (2012). Radial head fracture: a potentially complex injury General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam ( Download date: 18 Sep 2018

2 Chapter 7 Ulnar collateral ligament injury Denise Eygendaal, Laurens Kaas Evidence Based Orthopedics, 1 st edition. M. Bhandari (ed.) Wiley-Blackwell, Oxford; 2012: Page

3 84 Chapter 7 CASE SCEnARIO A 23 year old professional athlete (baseball pitcher) has been complaining about his right elbow for 6 months. The pain is medial sided and the onset of the symptoms was gradual. A wrong pitch 5 months ago has severely increased the pain, resulting in an inability to pitch. At physical examination there is a slight extension deficit of 10, a positive moving valgus test and a positive milking test. 1 This test can identify partial tears of the ulnar collateral ligament (UCL) by extending the elbow from the fully flexed position, while the examiner exerts a valgus moment by grasping the thumb and resisting extension. The patient has no neurovascular symptoms. RELEVAnT AnATOMy Stability of the elbow is attained by dynamic and static constraints. Static or passive constraints are provided by both the bones and the soft tissues of the elbow. The role of the muscles as dynamic constraints is becoming increasingly clear and is probably larger than previously postulated. The relative role of the osseous and soft tissue restraints are shown in table I. The ulnar collateral ligament consists of an anterior and a posterior bundle, and a transverse ligament (also known as the Cooper ligament). The anterior and posterior bundles originate from a broad anteroinferior surface of the medial humeral epicondyle. The anterior bundle inserts the base of the coronoid process of the ulna and the posterior bundle inserts the medial part of the semilunar notch of the ulna. The mean length of the anterior UCL is 27.1 mm and that of posterior UCL 24.2 mm, the mean widths are about 4.7 mm and 5.3 mm respectively. The function of these ligaments is to restrain valgus stress, during extension (anterior bundle) and during flexion (posterior bundle). Studies reveal that the anterior medial collateral ligament can be subdivided into three regions or bands according to their function (see figure 1). 2-4 IMPORTAnCE OF THE PRObLEM Injury to the UCL was first recognized in 1946 in javelin throwers. 5 The injury has since become well recognized in baseball pitchers and other overhead throwing athletes. However, Extended 90 elbow flexion MCL Soft tissue, capsule Osseous articulation Table 1: Relative contribution to valgus stress resistance (%). 37

4 UCL instability of the elbow 85 Figure 1. The UCL complex consists of an anterior (1) and a posterior(2) bundle, and a transverse ligament. 3 (reproduced with permission) exact numbers or incidence of this injury in athletes or in the general population are not known. The three most common causes of UCL injury are elbow dislocation, chronic attenuation in athletes or acute valgus injury. The elbow joint is the second most commonly dislocated major joint after the shoulder. In children it is the most commonly dislocated joint. 6 The incidence of this dislocation is estimated to be 6/100,000 in the general population, usually in the posterior or posterolateral direction. 7 Josefsson 8 showed that elbow dislocation induced injury in the lateral as well as the medial ligamentous structures, whereas O Driscoll 9 demonstrated that the joint could be dislocated experimentally with preservation of the medial ligaments. During dislocation ligamentous injury occurs in a lateral to medial circle. In stage 1, the radial collateral ligament is disrupted; in stage 2, the other lateral ligamentous structures as well as the anterior and posterior capsule are disrupted. In stage 3, disruption of the UCL can be partial with disruption of the posterior bundle only (3A) or complete (3B). 9 The UCL can therefore be disrupted after dislocation of the elbow joint. Persistent valgus instability after conservative treatment of elbow dislocation has been described in up to 50%. It is related to degenerative changes of the elbow joint after an average follow-up of 9 years. 10 7

5 86 Chapter 7 TOP 5 QuESTIOnS Diagnosis 1. Is UCL insufficiency a frequently encountered problem in general orthopedic practice? 2. As the clinical instability of the elbow is underestimated in most cases, what is de gold standard for the evaluation of the UCL? Treatment 3. Should (professional) athletes with an acute injury of the UCL always be treated surgically? 4. What are the surgical treatment options? Prognosis 5. Does surgical reconstruction of the UCL prevent accelerated degeneration of the elbow joint? QuESTIOn 1: IS ucl InSuFFICIEnCy A FREQuEnTLy EnCOunTERED PRObLEM In GEnERAL ORTHOPEDIC PRACTICE? Case clarification The patient was treated in an upper limb unit specializing in sports medicine. In a general orthopedic practice with a small number of sports-related injuries or post-traumatic deformities of the elbow, the incidence is low. In those situations the doctor s delay due to unfamiliarity with UCL injury can be an issue. Finding the evidence - Cochrane Database: No reviews available. - PubMed: No reports on incidence of UCL injury of the elbow in the general population or in throwing athletes. Findings There are no scientific reports on the incidence of UCL injury in throwing athletes or the general population. One study found an incidence of UCL lesions in 33% of 490 baseball players who underwent rehabilitation for any kind of injury of the upper extremity. 11 As previously mentioned, persistent valgus instability after conservatively treated elbow dislocations has been described in up to 50% of the cases. 10 In up to 54% of the patients with a radial head fracture a UCL lesion is diagnosed with MRI, although the incidence of clinical relevant UCL injuries is much lower (1-8%) Orthopedic surgeons should think

6 UCL instability of the elbow 87 of UCL insufficiency in patients with medial sided elbow pain especially in athletes and in patients with posttraumatic conditions of the elbow as a posterolateral dislocation. Recommendations - UCL insufficiency of the elbow has been mainly reported in athletes and in patients with post-traumatic conditions of the elbow as a postero-lateral dislocation, although the incidence in the general (or athlete) population is unknown. [Overall quality very low] QuESTIOn 2: AS THE CLInICAL InSTAbILITy OF THE ELbOw IS underestimated In MOST CASES, what IS DE GOLD STAnDARD FOR THE EVALuATIOn OF THE ucl? Case clarification In the case described above, the history was very suggestive for UCL injury. Apparently this athlete had ruptured the UCL 5 months ago, but this injury had subsided; after a new event, the chronic rupture of UCL became symptomatic again. Physical examination revealed a positive milking maneuver; the MRI with arthrogram (MRA) revealed a detachment of the UCL on the humeral side. Current opinion Anteropostererior, lateral and axillary views of the elbow are assessed for degenerative changes, such as joint space narrowing, ossification of the UCL and loose bodies. A small bony avulsion fragment might be identified when a UCL bony avulsion exists. 7 Finding the evidence - Cochrane Database: No reviews available - PubMed: 7 reports on MRA in UCL pathology. 2 reports on CTA in UCL pathology. Quality of the evidence - Level IV: 6 case series. - Level V: 2 expert opinion. Findings Dynamic radiographs under valgus load have been described in the past as a useful diagnostic tool; however mild valgus laxity has been observed in uninjured overhead athletes and dynamic radiographs in symptomatic elbows seems to be inconsistent. 16, 17 Another imaging modality is CT with arthrogram (CTA), with a sensitivity of 86% and a specificity of 91%. 18 However, the preferred imaging technique for UCL injuries of the elbow is MRA.

7 88 Chapter 7 MRI is capable of identifying full thickness tears, MRA improves the diagnosis of partial tears. 17, Another advantage of MRI/MRA is the ability to identify associated pathology, such as medial epicondylitis and chondral lesions. Sensitivity of MRA is reported to be up to 97% in detecting UCL injury, including partial undersurface UCL tears, with a specificity of up to 100%. 18, 23, 24 No comparative studies between CTA and MRA are currentlu available. Recommendations - MRA is the preferred imaging technique for detection of UCL injuries of the elbow. [Overall quality very low] QuESTIOn 3: SHOuLD (PROFESSIOnAL) ATHLETES with An ACuTE InjuRy OF THE ucl ALwAyS be TREATED SuRGICALLy? Case clarification Treatment of UCL of the elbow injuries is based on the patients athletic demands and the degree of UCL injury. Initial conservative treatment consists of rest, anti-inflammatory measures and physical therapy. Finding the evidence - Cochrane Database: No reviews on conservative treatment of UCL available - PubMed: 1 report on conservative treatment of UCL injury of the elbow Quality of the evidence - Level IV: 1 case series. Findings Rettig et al. 25 was the first to report on the results of conservative treatment in throwing athletes. Phase I of the conservative treatment consisted of rest and modalities to treat symptoms for 2 to 3 months. If pain free, the athlete began with phase II which consisted of muscle strengthening and throwing. Thirteen of 31 athletes (42%) returned to same level of play, with an average return of 24 weeks after injury after conservative treatment. This rehabilitation period is shorter compared to the rehabilitation period after UCL reconstruction. No history or physical examination features are predictive for athletes who will respond to no non-operative treatment.

8 UCL instability of the elbow 89 Recommendations - reatment of UCL of the elbow injuries is based on the patients athletic demands and the degree of UCL injury. [Overall quality very low] QuESTIOn 4: what ARE THE SuRGICAL TREATMEnT OPTIOnS? Current opinion Persistent symptomatic UCL instability after initial conservative treatment is an indication for reconstruction. Finding the evidence - Cochrane Database: 0 reviews available on results of UCL reconstruction. - PubMed: 17 reports available on results of UCL reconstruction. Quality of the evidence - Level I: 2 systematic reviews. - Level IV: 14 case series. - Level V: 1 expert opinion. Findings The first successful UCL reconstruction was performed in 1974 by Dr. Frank Jobe and colleagues. They published their initial results in throwing athletes in 1986, using the palmaris longus tendon as an autograft, with detachment of the flexor-pronator musculature, submuscular transposition of the ulnar nerve and a figure-of-eight graft fixation technique. In this fixation technique the autograft is placed through two drill holes in the ulna and three in the medial epicondyle in a figure-of-eight fashion, going through the posterior humeral cortex and suturing the graft to itself. 26 Several modifications of this original technique have been introduced over the past 35 years. Muscle splitting instead of detachment and abandoning the obligatory ulnar nerve transposition, improved clinical results and decreased the complication rate. 27, 28 The introduction of the docking technique by Rohrbough et al. 29 allows easier graft passing, tensioning and fixation. It uses the same ulnar tunnels as in the Jobe technique, but the humeral tunnels are created with one single inferior tunnel, with two small superior and one anterior exit tunnels. The graft is positioned in the inferior tunnel, and tensioned with sutures that exit the superior tunnels. The graft is fixated by tying the sutures over a bony bridge. Another graft fixation technique is interference screw fixation, where one or both graft endings are fixed with a bioabsorbable interference screw. 23, 30 Different autografts have been described: the palmaris longus tendon, plantaris tendon, hamstrings tendon, tendon 7

9 90 Chapter 7 allografts or triceps tendon can be used. 27, 30 Ulnar decompression or transposition can be indicated in patients with symptoms of ulnar nerve irritation, which is present in over 40% of the patients with UCL insufficiency. 16 Additional diagnostic arthroscopy can be performed if intra-articular pathology is suspected. 23, 29 After surgery a long arm cast is applied for 1-2 weeks to allow wound healing. Some authors use an additional hinged brace during mobilization for 2-6 weeks. Strengthening exercises (with or without brace) are initiated after 4-6 weeks. Throwing is usually allowed after 2-5 months. Return to competition varies between when ready to 12 months after surgery. 23, The original report on UCL reconstruction by Jobe et al. reported excellent results in 63%. 26 With the improvement of the surgical technique, success rates increased: 74-95% of all athletes returned to their previous level of injury or higher. 16, 34, 36 Previous surgery for UCL insufficiency is associated with poorer results. 16, 17 The most frequent reported complication is a transient ulnar neuropathy, which occurs in 1-21% of the patients, with a mean of 6%. About 1% of the patients experience graft site complications. 27 In this case UCL reconstruction is advised, if conservative treatment under supervision of a specialized physiotherapist for 3 months, is not successful. Recommendations - Symptomatic UCL insufficiency is indication for reconstruction. Reconstruction of a non-symptomatic UCL injury is not indicated. [Overall quality very low] - The preferred surgical techniques are the docking technique or interference screw fixation. [Overall quality very low] - Injury to the UCL of the elbow was once a career-ending-injury in overhead athletes, UCL reconstruction have made return to previous of higher level of athlete participation in sports likely to occur. [Overall quality very low] QuESTIOn 5: DOES SuRGICAL RECOnSTRuCTIOn OF THE ucl PREVEnT ACCELERATED DEGEnERATIOn OF THE ELbOw joint? Current opinion Persistent valgus instability can be related to accelerated degeneration of the elbow joint. The question whether surgical reconstruction of the UCL can prevent accelerated degeneration of the elbow has not been answered yet. Finding the evidence - Cochrane Database: No reviews available on prevention of degeneration with UCL reconstruction. - PubMed: No reports available on prevention of degeneration with UCL reconstruction.

10 UCL instability of the elbow 91 Findings Symptomatic UCL insufficiency is indication for reconstruction; a reconstruction of UCL to prevent further damage to the joint in the future is not indicated. Reconstruction of a non-symptomatic UCL injury is not indicated. 10 Recommendations - A reconstruction of the UCL to prevent further damage to the joint in the future is not indicated. [Overall quality very low] SuMMARy OF RECOMMEnDATIOnS - UCL insufficiency of the elbow has been mainly reported in athlete s and in patients with posttraumatic conditions of the elbow as a postero-lateral dislocation, although the incidence in the general (or athlete) population is unknown. - The preferred imaging technique for detection of UCL injuries of the elbow is MRI with arthrography. - Treatment of UCL of the elbow injuries is based on the patients athletic demands and the degree of UCL injury. - Symptomatic UCL insufficiency is indication for reconstruction. Reconstruction of a non-symptomatic UCL injury is not indicated. - The preferred surgical techniques are the docking technique or interference screw fixation. - Injury to the UCL of the elbow was once a career-ending-injury in overhead athletes, UCL reconstruction have made return to previous of higher level of athlete participation in sports likely to occur. - A reconstruction of the UCL to prevent further damage to the joint in the future is not indicated. 7 COnCLuSIOnS Research on diagnosis and treatment of UCL injury should continue to find higher levels of evidence. Prospective studies to determine preferable diagnostic technique, best graft fixation techniques and long term results of conservative and surgical treatment are in demand.

11 92 Chapter 7 REFEREnCE LIST (1) Veltri DM, O Brien SJ, Field LD, Altchek DW, Warren RF. The milking maneuvre. In: 10th Open Meeting of the American Shoulder and Elbow Surgeons, New Orleans, (2) Callaway GH, Field LD, Deng XH, Torzilli PA, O Brien SJ, Altchek DW, et al. Biomechanical evaluation of the medial collateral ligament of the elbow. J Bone Joint Surg Am 1997 Aug; 79(8): (3) Regan WD, Korinek SL, Morrey BF, An KN. Biomechanical study of ligaments around the elbow joint. Clin Orthop Relat Res 1991 Oct; (271): (4) Eygendaal D, Olsen BS, Jensen SL, Seki A, Sojbjerg JO. Kinematics of partial and total ruptures of the medial collateral ligament of the elbow. J Shoulder Elbow Surg 1999 Nov; 8(6): (5) Waris W. Elbow injuries in javelin throwers. Acta Chir Scand 1946; 93: (6) Linscheid RL, Wheeler DK. Elbow dislocations. JAMA 1965 Dec 13; 194(11): (7) Josefsson PO, Nilsson BE. Incidence of elbow dislocation. Acta Orthop Scand 1986 Dec; 57(6): (8) Josefsson PO, Johnell O, Wendeberg B. Ligamentous injuries in dislocations of the elbow joint. Clin Orthop Relat Res 1987 Aug; (221): (9) O Driscoll SW, Morrey BF, Korinek S, An KN. Elbow subluxation and dislocation. A spectrum of instability. Clin Orthop Relat Res 1992 Jul; (280): (10) Eygendaal D, Verdegaal SH, Obermann WR, van Vugt AB, Poll RG, Rozing PM. Posterolateral dislocation of the elbow joint. Relationship to medial instability. J Bone Joint Surg Am 2000 Apr; 82(4): (11) Han KJ, Kim YK, Lim SK, Park JY, Oh KS. The effect of physical characteristics and field position on the shoulder and elbow injuries of 490 baseball players: confirmation of diagnosis by magnetic resonance imaging. Clin J Sport Med 2009 Jul; 19(4): (12) Itamura J, Roidis N, Mirzayan R, Vaishnav S, Learch T, Shean C. Radial head fractures: MRI evaluation of associated injuries. J Shoulder Elbow Surg 2005 Jul; 14(4): (13) van Riet RP, Morrey BF, O Driscoll SW, van Glabbeek F. Associated injuries complicating radial head fractures: a demographic study. Clin Orthop Relat Res 2005; 441: (14) Kaas L, Turkenburg JL, van Riet RP, Vroemen J, Eygendaal D. Magnetic resonance imaging findings in 46 elbows with a radial head fracture. Acta Orthopaedica 2010; 81(3): (15) Morrey BF. Current concepts in the treatment of fractures of the radial head, the olecranon, and the coronoid. Instr Course Lect 1995; 44: (16) Conway JE, Jobe FW, Glousman RE, Pink M. Medial instability of the elbow in throwing athletes. Treatment by repair or reconstruction of the ulnar collateral ligament. J Bone Joint Surg Am 1992 Jan; 74(1): (17) Thompson WH, Jobe FW, Yocum LA, Pink MM. Ulnar collateral ligament reconstruction in athletes: muscle-splitting approach without transposition of the ulnar nerve. J Shoulder Elbow Surg 2001 Mar; 10(2): (18) Timmerman LA, Schwartz ML, Andrews JR. Preoperative evaluation of the ulnar collateral ligament by magnetic resonance imaging and computed tomography arthrography. Evaluation in 25 baseball players with surgical confirmation. Am J Sports Med 1994 Jan; 22(1): (19) Cotten A, Jacobson J, Brossmann J, Pedowitz R, Haghighi P, Trudell D, et al. Collateral ligaments of the elbow: conventional MR imaging and MR arthrography with coronal oblique plane and elbow flexion. Radiology 1997 Sep; 204(3): (20) Munshi M, Pretterklieber ML, Chung CB, Haghighi P, Cho JH, Trudell DJ, et al. Anterior bundle of ulnar collateral ligament: evaluation of anatomic relationships by using MR imaging, MR arthrography, and gross anatomic and histologic analysis. Radiology 2004 Jun; 231(3):

12 UCL instability of the elbow 93 (21) Kijowski R, Tuite M, Sanford M. Magnetic resonance imaging of the elbow. Part II: Abnormalities of the ligaments, tendons, and nerves. Skeletal Radiol 2005 Jan; 34(1): (22) Kaplan LJ, Potter HG. MR imaging of ligament injuries to the elbow. Radiol Clin North Am 2006 Jul; 44(4): , ix. (23) Azar FM, Andrews JR, Wilk KE, Groh D. Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med 2000 Jan; 28(1): (24) Schwartz ML, al-zahrani S, Morwessel RM, Andrews JR. Ulnar collateral ligament injury in the throwing athlete: evaluation with saline-enhanced MR arthrography. Radiology 1995 Oct; 197(1): (25) Rettig AC, Sherrill C, Snead DS, Mendler JC, Mieling P. Nonoperative treatment of ulnar collateral ligament injuries in throwing athletes. Am J Sports Med 2001 Jan; 29(1): (26) Jobe FW, Stark H, Lombardo SJ. Reconstruction of the ulnar collateral ligament in athletes. J Bone Joint Surg Am 1986 Oct; 68(8): (27) Vitale MA, Ahmad CS. The outcome of elbow ulnar collateral ligament reconstruction in overhead athletes: a systematic review. Am J Sports Med 2008 Jun; 36(6): (28) Purcell DB, Matava MJ, Wright RW. Ulnar collateral ligament reconstruction: a systematic review. Clin Orthop Relat Res 2007 Feb; 455: (29) Rohrbough JT, Altchek DW, Hyman J, Williams RJ, III, Botts JD. Medial collateral ligament reconstruction of the elbow using the docking technique. Am J Sports Med 2002 Jul; 30(4): (30) Eygendaal D. Ligamentous reconstruction around the elbow using triceps tendon. Acta Orthop Scand 2004 Oct; 75(5): (31) Paletta GA, Jr., Wright RW. The modified docking procedure for elbow ulnar collateral ligament reconstruction: 2-year follow-up in elite throwers. Am J Sports Med 2006 Oct; 34(10): (32) Koh JL, Schafer MF, Keuter G, Hsu JE. Ulnar collateral ligament reconstruction in elite throwing athletes. Arthroscopy 2006 Nov; 22(11): (33) Nissen CW. Effectiveness of interference screw fixation in ulnar collateral ligament reconstruction. Orthopedics 2008 Jul; 31(7): 646. (34) Savoie FH, III, Trenhaile SW, Roberts J, Field LD, Ramsey JR. 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. Am J Sports Med 2008 Jun; 36(6): (35) Bowers AL, Dines JS, Dines DM, Altchek DW. Elbow medial ulnar collateral ligament reconstruction: clinical relevance and the docking technique. J Shoulder Elbow Surg 2010 Mar; 19(2 Suppl): (36) Gibson BW, Webner D, Huffman GR, Sennett BJ. Ulnar collateral ligament reconstruction in major league baseball pitchers. Am J Sports Med 2007 Apr; 35(4): (37) Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. Am J Sports Med 1983 Sep; 11(5):