Traumatic Valgus Instability of the Elbow: Pathoanatomy and Results of Direct Repair

Author(s): Richard MJ, Aldridge JM III, Wiesler ER, Ruch DS

Source: J Bone Joint Surg 90:2416-22, 2008.

Summary:

The anterior bundle of medial collateral ligament is the primary restraint to valgus stress between 20° and 120° of elbow flexion.  Repetitive valgus stress places the elbow at risk for chronic attenuation of the medial collateral ligament injury in throwing athletes.  There are a few reports on acute medial collateral ligament injury or rupture in the athlete.  The purpose of the present study is to describe the pathoanatomy of the acute medial collateral ligament rupture and to report the results of direct repair in this setting. 

Between 1996 and 2006, ten collegiate athletes and one college pitching coach presented with acute rupture of the medial collateral ligament of the elbow and no history of dislocation.  The examination consistently demonstrated a large hematoma involving the medial aspect of the elbow and the proximal aspect of the forearm.  All elbows had gross valgus instability without a firm end point.  The mean time between the injury and repair was twenty days.  Operative findings uniformly demonstrated avulsion of the superficial layer of the flexor pronator muscles with distal retraction.  The underlying medial collateral ligament was consistently avulsed in a sleeve-like manner from the denuded medial epicondyle.  In nine elbows, the medial collateral ligament was directly repaired to its origin with transosseous sutures.  In two elbows, suture anchors were used.  The ulnar nerve was transposed anteriorly in all patients.  Postoperatively, the elbows were placed in a hinged orthosis for six weeks.  The patients were released to throwing at a mean of nineteen weeks postoperatively.  Full, active range of motion was achieved in ten of the eleven patients.  The remaining patient, a baseball pitcher, had a 20° flexion contracture.  The mean DASH score at the time of the latest follow-up was six (range two to twelve). 

This study has several limitations.  The authors comment on the fact that all patients were managed operatively.  The series was small and there was no comparison group of patients who were managed non-operatively.  While the authors observed good results in association with the operative treatment of this injury, it is unknown whether the operative treatment is superior to non-operative treatment.  Nonetheless, this does suggest that there is smaller subset of athletes who acutely rupture their medial ligament (as opposed to chronic attenuation).  In this population, early surgical repair seems logical and appears effective.