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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