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Medial Collateral Ligament Reconstruction: Salvage of Instability From Osseous Deficiency

Introduction The relationship of olecranon spur removal and medial ulnar collateral ligament injury was first recognized by Andrews. It is well known that valgus instability resulting from excessive removal of the medial corner of the olecranon is extremely difficult, if not impossible, to correct. To date, articular deficiency of the medial corner of the olecranon process has been thought not to be amenable to surgical correction.…

Ulnar Collateral Ligament Reconstruction: Complications and Salvage

Introduction Elbow ulnar collateral ligament (UCL) reconstruction is a successful treatment for overhead athletes with UCL injuries. Although excellent results can be expected in approximately 85% of patients, there is a rather high complication rate. Cain et al. reported complications in 20% of patients undergoing UCL reconstruction. Complications after UCL reconstruction can be divided into four main categories: 1 ulnar nerve dysfunction 2 infection 3 fracture 4…

Medial Collateral Ligament Reconstruction: MCL Insufficiency

Introduction The medial ulnar collateral ligament (MCL) of the elbow is the primary stabilizer to valgus stress and is most commonly injured in the overhead-throwing athlete. Ulnar collateral ligament insufficiency is surgically managed with MCL reconstruction, or “Tommy John surgery,” named for the first professional pitcher treated by Dr. Frank W. Jobe in 1974. First described in a javelin thrower in 1946, MCL injury is now…

Articular Injuries in the Athlete

Introduction Activities such as throwing, lifting, and gymnastics generate large stresses across the elbow joint, which can result in a multitude of pathologies. In skeletally immature athletes, these stresses, combined with the developing bony anatomy and unique physeal biomechanics, lead to distinct injury patterns. In the past, macrotrauma, such as fractures and dislocations, were common in this age group, but recently there has been a paradigm…

The Thrower’s Elbow

Introduction Throwing places unique demands on the elbow, resulting in predictable injury patterns. In the late cocking and early acceleration phases of throwing, valgus torques are estimated to reach 64 N-m and angular velocities of 5000 degrees per second as the elbow extends from 110 to 20 degrees of flexion. Appreciation of the elbow anatomy and biomechanics relevant to throwing assists the clinician in diagnostic and…

Elbow Tendinopathies: Triceps Tendon Rupture and Snapping

Anatomy of the Triceps Tendon The triceps muscle is composed of three muscle heads, hence its name. The lateral, long, and medial heads of the triceps have a common insertion, the triceps tendon proper, on the posterior part of the olecranon. The medial, and stronger, lateral triceps expansion onto the extensor tendon fascia and the lateral side of the olecranon inserts over a footprint measuring 466 mm…

Elbow Tendinopathies: Chronic Biceps Ruptures

Introduction Distal biceps tendon ruptures are relatively rare injuries, with a reported incidence of about one per 100,000 persons per year. Most injuries occur in male laborers and athletes, with a peak incidence in the fourth and fifth decades. Several risk factors have been identified for distal biceps tendon rupture including smoking, mechanical impingement or overuse, and fluoroquinolone use. Early repair is preferred as delayed repair…

Elbow Tendinopathies: Acute Distal Biceps Tendon Ruptures

Introduction Injuries to the distal biceps tendon were at one time thought to be rare. Presently, however, these injuries are relatively common. This increase in the identification of distal biceps tendon injuries is multifactorial and likely due to improved patient and physician awareness, increased understanding of the injury, better reporting, improved physical examination maneuvers, and superior imaging techniques. As such, surgeons should be familiar with the…

Managing Surgical Failure in Tennis Elbow

Introduction Surgical intervention is not commonly required to treat epicondylitis, and nonoperative management is usually successful in about 90% of patients. Similarly, when surgery is performed, a 90% success rate is typically reported, interestingly, regardless of the surgical technique. a a References . On the other hand, when surgical intervention is not successful, there are few reports of subsequent management. Hence there is relatively little known…

Medial Epicondylitis/Tendinosis

Introduction As with the lateral elbow we prefer the term tendinosis to epicondylitis as the problem is in the common flexor tendons not the epicondyle. The histopathology (see Chapter 59 ) has no inflammatory cells. Medial elbow tendinosis is less common than lateral elbow tendinosis by a factor of 1 : 5. Indications As with lateral epicondylitis, the indications for surgery are pain that limits daily activity and/or…

Percutaneous Ultrasound Tenotomy Treatment of Epicondylitis

Introduction Over the last several years one of the most significant changes in the practice of managing epicondylar tendinopathy has been the introduction of ultrasound (US)-guided treatment. This in turn prompted the development of a percutaneous ultrasonic treatment of the pathology, which has the simplicity of a cortisone injection but the effectiveness of a surgical procedure, without the cost or morbidity. Rationale US-guided intervention for musculoskeletal…

Lateral Epicondylitis/Tendinosis

Introduction The term tendinosis is preferred to epicondylitis as this is more descriptive of the true pathology. Epicondylitis (tendinosis) occurs at least five times more commonly on the lateral than on the medial aspect of the joint. The selection factors to determine the candidates for surgery are similar for each process, yet there are some distinct features with regard to the surgical technique. Thus, medial epicondylitis…

Healing and Wound Problems

Introduction The importance of wound problems following elbow trauma should not be underestimated. The thin posterior soft tissue envelope places the elbow at risk for significant wound healing problems and potential infection. Soft tissue damage and swelling that occur from the initial injury, surgical intervention, and early mobilization further exacerbate this issue. Wound complications range from minor problems that can be managed in the outpatient setting…

Heterotopic Ossification

Introduction The term heterotopic ossification (HO) refers to the presence of mature lamellar bone tissue outside of the bones that form the skeleton. HO and ectopic bone are terms that are used interchangeably for this type of bone formation. Conceptually, heterotopic bone is different from periarticular calcifications, which are deposits of calcific material without mature bone tissue; these amorphous globular deposits (referred to in this text…

Elbow Stiffness: Rehabilitation After Surgical Contracture Release

Introduction The basic science and surgical procedures to restore motion in patients with elbow stiffness have been thoroughly reviewed in the previous three chapters. Unfortunately, recurrence of stiffness is not uncommon, maintenance of the range of motion (ROM) achieved in surgery is difficult, and the rehabilitation program after contracture release is paramount for the final outcome of any of the procedures discussed previously. In general, improvements…

Elbow Stiffness: Arthroscopic Contracture Release

Introduction Restoration of elbow motion in patients with stiffness is commonly attempted arthroscopically. The reader should refer to Part 2 for an in-depth review of arthroscopic elbow surgery. Chapter 21 reviews the arthroscopic management of the arthritic elbow, and many of the concepts summarized here overlap with that particular chapter. In this chapter, we will provide a more concise review of contracture release when performed arthroscopically.…

Extrinsic Contracture: Lateral and Medial Column Procedures

Introduction Of the numerous potential causes for elbow stiffness, the causes and pathophysiologic mechanisms dictate treatment and affect prognosis. An extensive treatment of these mechanisms and classification have been addressed in Chapter 53 . As discussed previously, extrinsic contracture typically involves only the soft tissues around the elbow, sparing the joint space ( Fig. 54.1 ). Posttraumatic stiffness is one of the most frequent causes of…

Elbow Stiffness: Basic Science and Overview

Introduction Loss of joint motion is a common complication of elbow trauma. Posttraumatic elbow stiffness is seen after major but also trivial injuries. Dealing with posttraumatic elbow stiffness is a challenging task for the orthopedic surgeon as it often involves young high–functional demand patients. The last few years have seen an expansion in our understanding of the basic science behind the development of posttraumatic elbow stiffness.…

Chronic Unreduced Elbow Dislocation

Introduction Instability is a major problem at the elbow and some forms of the problem are reviewed in Chapter 32, Chapter 35, Chapter 36, Chapter 41, Chapter 49 . Chronic unreduced dislocation discussed herein is very uncommon in the United States and is principally seen in and discussed in the literature from Third World nations. Since the last edition of this book, little has changed regarding…

Nonunion of the Olecranon and Proximal Ulna

General Considerations Nonunion of proximal ulna fractures is relatively uncommon with current osteosynthesis techniques. One 2008 series reported 2 of the 62 cases (3%) with olecranon fractures who had nonunions after fixation by tension band wiring techniques. Although this problem is perhaps less common today than in the past, it continues to challenge the orthopedic surgeon. Olecranon and proximal ulna fracture nonunion can result in profound…