Article

MR imaging of ligament injuries to the elbow

January 2004
Magnetic Resonance Imaging Clinics of North America 12:221-232, v-vi

DOI:10.1016/j.mric.2004.02.006

Authors:

MR imaging is a highly valuable tool in the evaluation of ligamentous injuries of the elbow. Proper coil selection, patient positioning, and pulse sequence parameters are essential for optimization of image quality. Clinical evaluation of ligamentous injuries is often difficult and visualization at surgery may be limited. MR imaging can demonstrate not only ligamentous pathology but abnormalities in the adjacent osseous and soft tissue structures, making it an important aid to clinical management. In skeletally immature patients, MR imaging can demonstrate injury not only to the ligaments but to the physes and apophyses, making it useful in the evaluation of the pediatric elbow.

Using Stress Ultrasonography to Understand the Risk of UCL Injury Among Professional Baseball Pitchers Based on Ligament Morphology and Dynamic Abnormalities

Article

Full-text available

Aug 2018

Background Ulnar collateral ligament (UCL) injury of the elbow is a common and debilitating problem seen frequently among elite baseball pitchers. Ultrasound is a useful diagnostic tool in evaluating UCL injuries. Hypothesis Evaluation with stress ultrasound of the elbow to measure the morphology of the UCL and the ulnohumeral joint space gapping is indicative of higher risk of UCL injury among professional baseball pitchers. Study Design Cohort study; Level of evidence, 2. Methods Ultrasound imaging was used to assess the medial joint laxity of the elbow of 70 asymptomatic professional baseball pitchers during spring training. Medial joint laxity and UCL morphology were assessed with OsiriX imaging software under 2 conditions—gravity valgus load and 5.5 lb of valgus load per a handheld dynamometer—with the shoulder in the maximal cocking position and the elbow in 90° of flexion. Two trials of resting position, elbow gapping, and UCL thickness were collected, measured, and averaged for data analysis. Intra- and interrater reliabilities were established and maintained, with intraclass correlation coefficients in the acceptable range for all measures (0.84-0.99). One-way analysis of variance was used to compare dominant variables between those pitchers who sustained a subsequent UCL injury and those who did not. A receiver operating curve was used to identify pitchers who, based on elbow gapping measures (by cut score), were at high risk versus low risk for UCL injury. Results Players who went on to injure the UCL (n = 7) displayed a significantly wider opening under 5.5 lb of applied stress (6.5 ± 1.2 vs 5.3 ± 1.2 mm, P = .01) when compared with pitchers without UCL injury history (n = 63); they also presented a trend toward wider dominant arm resting joint opening (4.9 ± 1.2 vs 4.0 ± 1.1 mm, P = .07). Professional pitchers with valgus stress ulnohumeral joint gapping ≥5.6 mm (area underneath the curve, 0.77; P = .02) of the dominant arm were at a 6-times greater risk of sustaining a UCL tear requiring reconstruction within a season. Conclusion Our data suggest that ultrasound evaluation of UCL morphology may be indicative of pitchers who are at risk of sustaining UCL injury and that it may improve player assessment.

Dirsek ve El Bileği MRG: Teknik Özellikler ve Normal Anatomi

Article

Jul 2014

Can Cevikol

Overuse and Traumatic Injuries of the Elbow

Article

Full-text available

Nov 2009

MR imaging is a useful modality for evaluating athletes presenting with elbow pain. Osteochondral injuries and ligamentous injuries are well seen on MR imaging. Ligamentous injuries may be associated with clinical instability syndromes, the secondary signs of which may be evident on MR images. Enthesopathies and distal biceps tendon injuries are common clinical problems that may be seen in both professional and recreational athletes. Nerve compression syndromes may be investigated using MR imaging; however, the usual aim of imaging is to exclude an underlying space-occupying lesion. This article reviews the basic anatomy of the elbow joint and discusses the common osteochondral injuries, ligamentous injuries, instability syndromes, and tendinous pathologies at the elbow joint. The role of imaging in compressive neuropathies is briefly discussed.

Dirseğin Patolojik Değişiklikleri

Article

Jul 2014

Berna Dirim

MRI of the Annular Ligament of the Elbow: Review of Anatomic Considerations and Pathologic Findings in Patients With Posterolateral Elbow Instability

Article

Full-text available

Dec 2014

Objective: The annular ligament is one of the major stabilizers of the proximal radioulnar joint. However, it is one of the least studied structures in the lateral elbow because of imaging challenges and low pathologic incidence. This article will examine the anatomy of the annular ligament, its biomechanics, and its functional importance. Eight surgically proven cases of annular ligament abnormality in patients with posterolateral and nursemaid elbow, along with the associated findings, are presented. Conclusion: Adequate understanding of the anatomy and familiarity with the associated injuries that can be seen in annular ligament displacement or rupture will improve detection of annular ligament abnormality.

MRI of the Elbow: Techniques and Spectrum of Disease: AAOS Exhibit Selection

Article

Full-text available

Jul 2013
J BONE JOINT SURG AM

Magnetic resonance imaging (MRI) of the elbow allows for high-resolution evaluation of osseous and soft-tissue structures, including ligaments, tendons, nerves, and muscles. Multiple imaging techniques and pulse sequences exist. The purpose of this article is to update orthopaedic surgeons on current MRI techniques and illustrate the spectrum of elbow pathology detectable by MRI. We searched MEDLINE with use of the keywords "MRI" and "elbow" for studies less than five years old evaluating MRI techniques. These papers, our experience, and textbooks reviewing elbow MRI provided the information for this article. We discuss the essentials and applications of the following techniques: (1) conventional, non-gadolinium-enhanced MRI; (2) gadolinium-enhanced MRI; and (3) magnetic resonance arthrography. The classic MRI appearances of occult fractures, loose bodies, ulnar collateral ligament injuries, lateral collateral ligament complex injuries, biceps tendon injuries, triceps tendon injuries, lateral epicondylitis, medial epicondylitis, septic arthritis, osteomyelitis, osteochondritis dissecans, compression neuropathies, synovial disorders, and various soft-tissue masses are reviewed. MRI is a valuable, noninvasive method of elbow evaluation. This article updates orthopaedic surgeons on the various available MRI techniques and facilitates recognition of the MRI appearances of the most commonly seen pathologic elbow conditions.

Correlation of Joint Space Widening on Valgus Stress Magnetic Resonance Imaging With Level of Play and Innings Pitched in Professional Pitchers

Article

Full-text available

Nov 2023

Background Previous studies have described various techniques and confirmed the clinical utility of valgus stress radiography and stress ultrasound in overhead athletes. The addition of valgus stress and a high-resolution anatomic assessment of the elbow with magnetic resonance imaging (MRI) in the active throwing position (flexed elbow valgus external rotation [FEVER] view) can add valuable diagnostic or prognostic information in throwing athletes. Purpose/Hypothesis The purpose of this study was to evaluate findings on MRI and subsequent performance in professional throwing athletes. It was hypothesized that joint space widening in the FEVER view would be predictive of performance and the risk of subsequent injuries. Study Design Cross-sectional study; Level of evidence, 3. Methods All pitchers on 2 Major League Baseball teams who consented to participate during their preseason screening in 2019 and 2020 underwent standard and FEVER MRI, and performance data from the following season were recorded, including injuries, mean throwing velocity, number of innings pitched, strikeout percentage, walk percentage, weighted on-base average, and level of play reached (not signed, minor league, or major league). Categorical variables were compared using the Fisher exact test or chi-square test, and continuous variables were compared using the Kruskal-Wallis test, as appropriate. Ordered logistic regression was used to determine the independent factors predicting performance. Results A total of 91 players underwent preseason imaging, and all players had subsequent performance data available. Multivariate analysis revealed that when controlling for age, mean velocity, history of injuries, presence of symptoms, and history of ulnar collateral ligament reconstruction, increased absolute joint space widening was predictive of a lower level of play (β = −0.63; P = .042). Univariate analysis demonstrated a significant correlation between relative joint space widening and level of play reached (β = −0.54; P = .034). Relative joint space widening remained a significant predictor of level of play (β = −0.87; P = .012) on multivariate analysis. Multivariate analysis also showed that both absolute joint space widening (β = −13.50; P = .012) and relative joint space widening (β = −13.60; P = .026) were predictive of the number of innings pitched in the subsequent season. Conclusion The present study demonstrates that findings on MRI with valgus stress correlated with the level of play reached and number of innings pitched in professional throwing athletes.

Techniques of Musculoskeletal System Imaging

Article

Full-text available

Mar 2022

Musculoskeletal models endow an opportunity to study the movement of the upper limb in vivo. The solid foundation of musculoskeletal model design is inherited from musculoskeletal parameters. Some of these parameters are tendon and muscle fiber length, pennation angle, and muscle volume. It is possible to extract these parameters based on cadaver. However, it is time-consuming and gives a generic statement about the function of the musculoskeletal system, but this is not enough to get accurate data and timely for each patient. Medical imaging has revolutionized visualization of the internal structure of the body in real time and in vivo. It is worth using medical imaging because it is impossible to imagine in real time what is inside the body unless surgery is performed; it is possible to see internal structure through cadaver dissection, but not in vivo. There are several kinds of medical imaging tools, which have been used in musculoskeletal system analysis such as Ultrasonography (US), Magnetic Resonance Imaging (MRI), Diffusion Tensor Imaging (DTI) and Computer Tomography (CT) scans. The work proposed aims to present principle, development and challenges of different medical imaging tools of musculoskeletal system methods. The results of this study show that the choice of imaging device for the musculoskeletal system depends mainly on the motivation, target and the strong points that present in the medical imaging devices.

Article

Full-text available

Oct 2021

The elbow is a complex joint whose biomechanical function is granted by the interplay and synergy of various anatomical structures. Articular stability is achieved by both static and dynamic constraints, which consist of osseous as well as soft-tissue components. Injuries determining instability frequently involve several of these structures. Therefore, accurate knowledge of regional anatomy and imaging findings is fundamental for a precise diagnosis and an appropriate clinical management of elbow instability. This review focuses particularly on the varied appearance of overuse-related elbow injuries at CT-arthrography.

Nonoperative Treatment of Elbow Ulnar Collateral Ligament Injuries With and Without Platelet-Rich Plasma in Professional Baseball Players: A Comparative and Matched Cohort Analysis

Article

Oct 2019
AM J SPORT MED

Background Recent studies evaluating nonoperative treatment of elbow ulnar collateral ligament (UCL) injuries augmented with platelet-rich plasma (PRP) have shown promising results. To date, no comparative studies have been performed on professional baseball players who have undergone nonoperative treatment with or without PRP injections for UCL injuries. Hypothesis Players who received PRP injections would have better outcomes than those who did not receive PRP. Study Design Cohort study; Level of evidence, 3. Methods The Major League Baseball (MLB) Health and Injury Tracking System identified 544 professional baseball players who were treated nonoperatively for elbow UCL injuries between 2011 and 2015. Of these, 133 received PRP injections (PRP group) before starting their nonoperative treatment program, and 411 did not (no-PRP group). Player outcomes and a Kaplan-Meier survival analysis were compared between groups. In addition, to reduce selection bias, a 1:1 matched comparison of the PRP group versus the no-PRP group was performed. Players were matched by age, position, throwing side, and league status: major (MLB) and minor (Minor League Baseball [MiLB]). A single radiologist with extensive experience in magnetic resonance imaging (MRI) interpretation of elbow injuries in elite athletes analyzed 243 MRI scans for which images were accessible for tear location and grade interpretation. Results Nonoperative treatment of UCL injuries resulted in an overall 54% rate of return to play (RTP). Players who received PRP had a significantly longer delay in return to throwing ( P < .001) and RTP ( P = .012). The matched cohort analysis showed that MLB and MiLB pitchers in the no-PRP group had a significantly faster return to throwing ( P < .05) and the MiLB pitchers in the no-PRP group had a significantly faster RTP ( P = .045). The survival analysis did not reveal significant differences between groups over time. The use of PRP, MRI grade, and tear location were not statistically significant predictors for RTP or progression to surgery. Conclusion In this retrospective matched comparison of MLB and MiLB pitchers and position players treated nonoperatively for a UCL tear, PRP did not improve RTP outcomes or ligament survivorship, although there was variability with respect to PRP preparations, injection protocols, time from injury to injection, and rehabilitation programs. MRI grade and tear location also did not significantly affect RTP outcomes or progression to surgery.

Imaging the Postsurgical Upper Limb

Article

Jun 2019
RADIOL CLIN N AM

Ligaments injuries check-up and assessment of their healing potential in simple posterolateral elbow dislocation: about 25 cases

Article

Full-text available

May 2019
EUR J ORTHOP SURG TR

Introduction Elbow dislocation can lead to instability and stiffness of the elbow. The main goal of this study was to list the initial elbow ligaments injuries caused by simple posterolateral elbow dislocations. The secondary goals were to assess ligament healing 2 months after the initial dislocation, to research a correlation between ligaments injuries and clinical course, and to search for predictive factors of instability. Patients and methods Patients who had simple posterolateral elbow dislocation for the first time between January 2015 and May 2016 were included. Each patient had an MRI scan of their traumatised elbow on the day of the dislocation and then again 2 months later. The assessment was performed thanks to a clinical examination and calculation of functional recovery scores. The Mann–Whitney U test was used to research a correlation between the healing of ligaments injuries and clinical course. Results Twenty-five patients were included in the study. The initial MRI scans showed 70% and 54% ligament rupture, respectively, for the anterior band (ant MCL) and the posterior band (post MCL) of the medial collateral ligament (MCL), as well as 79% for the ulnar (ULCL) and 50% for the radial (RLCL) lateral collateral ligaments. The healing rate 2 months after dislocation was fairly low from 18% for the ULCL up to 41% for the anterior band of the MCL. No correlation was found between the ligament healing noticeable on MRI scans and clinical course. No elbow instability was diagnosed during the 4-month follow-up. Conclusion Elbow dislocation is particularly damaging for ligaments. There is no predominance on medial or lateral ligament for rupture. The low healing rate 2 months after the initial dislocation could be explained by performing a follow-up MRI scan too early.

Emergency and Trauma of the Elbow

Article

Jul 2017

The elbow is a joint composed of three different articulations all included in the same synovial capsule, with a complex anatomy that allows two kinds of motion: flexion-extension and pronation and supination. Stabilization of the elbow is provided by osseous and ligamentous structures. When assessing the elbow in the traumatic setting, the mechanism of injury determines the pattern of osseous and ligamentous lesion, with potential important implications on elbow instability. The role of the radiologist in the assessment of the traumatic elbow requires an understanding of the most common injury mechanisms in traumatic elbow injuries. This knowledge facilitates the detection of potential secondary occult bone and soft tissue injuries that could lead to chronic instability. We analyze the acute patterns of injury of the osseous, ligamentous, musculotendinous, and neurovascular structures, with a focus on the most commonly used classifications of fractures and fracture-dislocations. We also discuss the therapeutic management of these injuries, with mention of the most frequently used surgical techniques and the commonly expected posttreatment findings. Finally, we review the repetitive microtrauma patterns of injury of the elbow joint structures and the most common pitfalls in the interpretation of elbow imaging.

Elbow MRI Findings Do Not Correlate With Future Placement on the Disabled List in Asymptomatic Professional Baseball Pitchers

Article

Full-text available

Apr 2017

Background Injury rates among professional baseball players may reach as high as 5.8 per 1000 encounters, with pitchers being most vulnerable on account of the excessive biomechanical load on the upper extremity during the throwing motion. Anatomically, the shoulder is the most common site of pitching-related injury, accounting for 30.7% of injuries, closely followed by the elbow at 26.3%. Characteristic valgus loading imparts a predictable constellation of stresses on the joint, including medial tension, lateral compression, and posterior medial shearing. The degenerative cohort of tissue changes that result are readily detected on magnetic resonance imaging (MRI). It is not yet known whether such findings predict future placement on the disabled list (DL) in asymptomatic Major League pitchers. Hypothesis Abnormal soft tissue and osseous changes detected on MRI of the throwing elbow in asymptomatic professional pitchers will impart an increased risk of subsequent transfer to the DL in the season after MRI. Study Design Retrospective cohort study. Level of Evidence Level 3. Methods The study aimed to examine a potential association between the total number of innings pitched (approximate lifetime valgus load) and the typical MRI degenerative changes, hypothesizing a rejection of the null hypothesis. A total of 26 asymptomatic professional pitchers from a single Major League Baseball (MLB) organization and its various minor league affiliates underwent MRI of their dominant elbow from 2003 to 2013 as a condition of their contract signing or trade. Twenty-one of those pitchers played at the Major League level while 5 played with the team’s minor league affiliates including both the AA and AAA levels. Asymptomatic was defined as no related stints on the DL due to elbow injury in the 2 seasons prior to MRI. A fellowship-trained musculoskeletal radiologist reevaluated the studies after being blinded to patient name, injury history, and baseball history. A second investigator collected demographic data; this included total career number of innings pitched and any subsequent DL reports for each subject while remaining blinded to the MRI results. Results The mean age at the time of MRI was 29.6 years (range, 19-39 years). The mean number of innings pitched was 1111.7. Of the 26 pitchers, 13 had scar remodeling of the anterior bundle of the ulnar collateral ligament (UCL). Of those, 4 had partial-thickness tears of the anterior bundle of the UCL, ranging from 10% to 90% of the total thickness. Twelve had articular cartilage loss within the posteromedial margin of the ulnohumeral joint, and 12 had posteromedial olecranon marginal osteophytes. Seven pitchers had degeneration of the common extensor tendon origin, 10 had degeneration of the flexor pronator mass, 9 had insertional triceps tendinosis, 2 had enthesopathic spurs at the sublime tubercle, 3 had osteochondral intra-articular bodies, and 2 subjects had joint effusions. In the year after MRI, 6 pitchers were placed on the DL for elbow-related injuries. There was no robust correlation between any single MRI finding and subsequent transfer to the DL, and no statistically significant correlation between number of innings pitched and MRI findings, although some trends were observed for both. Conclusion MRI findings in asymptomatic MLB pitchers were not associated with placement on the DL within the subsequent year. While a trend was observed with olecranon osteophytes and subsequent DL placement (P = 0.07), this finding did not reach statistical significance. Furthermore, there was no robust correlation between the number of innings pitched with the presence of any of the aforementioned degenerative changes on MRI. Clinical Relevance The characteristic structural transformation that occurs in the throwing elbow of professional pitchers is predictable and readily detectable on MRI. However, this study suggests that these changes are not predictive of near-term placement on the DL in those who are asymptomatic. Abnormal findings on MRI, even high-grade partial UCL tears, do not correlate with near-term placement on the DL, mitigating their potential negative impact on signing decisions.

Imaging of the Elbow in Overhead Athletes

Chapter

Mar 2016

When it comes to imaging of the injured athlete’s elbow, there is a vast array of image modalities to choose from, including conventional radiographs, ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), and arthrography (CTA, MRA). Choosing the appropriate imaging technique is of vital importance for quick diagnosis and adequate treatment. This chapter will discuss the role of each image modality in the diagnostic workup for pathology around the elbow commonly encountered in overhead athletes. Specific conditions of the elbow will be discussed in detail with a focus on image findings.

Radiologic Case Study

Article

May 2013
ORTHOPEDICS

A 13-year-old girl presented with right ankle pain, swelling, and the inability to bear weight after falling at home and twisting her ankle. Radiograph (Figure 1 ) and computed tomography scan (Figure 2 ) were obtained.

Imaging Diagnosis and Prognostication of Hamstring Injuries

Article

Full-text available

Sep 2012
AM J ROENTGENOL

David A. Rubin

Objective: Hamstring injuries are common in sports. Although management and outcomes are sport specific, clinical evaluation alone is a poor guide for treatment planning and prognostication. Cross-sectional imaging has added value in these cases. Conclusion: Specifically, the location (tendon attachment, classic or intramuscular myotendinous junction, or extramuscular portion of the tendon), specific muscles involved, and anatomic extent are factors that can influence the immediate treatment, expected convalescent period, and risk of recurrence in these athletes.

High-Resolution Ultrasound in the Diagnosis of Upper Limb Disorders

Article

Oct 2008
ANN PLAS SURG

The purpose of this study is to determine the reliability of high-resolution ultrasound (HRUS) in the diagnosis of upper limb disorders compared with the initial clinical opinion. We prospectively studied 178 patients referred for HRUS examination (47.2% hand, 34.8% wrist, and 18% elbow examinations) by recording the clinical opinion, the specific ultrasound diagnosis, and the final diagnosis, as established by surgery (79.9%) or follow-up (20.1%). HRUS examination was highly reliable in diagnosing cystic lesions, synovial disease, ligament injury and foreign bodies (100%), and slightly less reliable for solid lesions (82.1%) and nerve, bone, and tendon disorders (97%, 91.7%, 86.5%, respectively). HRUS examination resulted in significantly more correct diagnoses (92.1%) than the clinical opinion (70.8%) (McNemar test, P = 0.001). The agreement between the HRUS diagnosis and the clinical opinion was slight (Kappa test, k = 0.16). HRUS examination is more reliable than clinical examination in diagnosing upper limb disorders.

The Postoperative Elbow, Wrist, and Hand

Chapter

Jan 2008

Posterior translation of the radial head in magnetic resonance imaging of lateral epicondylitis: a cross-sectional study

Preprint

Full-text available

May 2022

Background: Disruption of the lateral collateral ligament complex (LCLC) causes posterolateral rotatory instability (PLRI). This is usually post-trauma but may also result from lateral epicondylitis. The present study examined the amount of posterior translation of the radial head related to LCLC injury, Common extensor tendon (CET) injury, and Baker classification in patients with lateral epicondylitis. Methods: We retrospectively evaluated the findings for patients with lateral epicondylitis of the humerus who underwent surgery at our institution between April 2016 and July 2021. Fifteen elbows with preoperative coronal and sagittal MR images were included. We evaluated posterior translation of the radial head on sagittal elbow MRI and compared it according to LCLC and CET lesion classifications in lateral epicondylitis. Results: Mean patient age was 49 years. All patients received single or multiple steroid injections before surgery. In the LCLC classification, four, nine, and two lesions were classified as LCLC0, LCLC1, and LCLC2, respectively. The mean radio-humeral distance (RHD) values for the LCLC lesions were 0.65 mm in LCLC0, 2.46 mm in LCLC1, 2.22 mm in LCLC2. RHD was significantly greater in LCLC1 than in LCLC0. In the CET classification, five, six, and four lesions were classified as CET1, CET2, and CET3, respectively. The mean RHD values for the CET lesions were 1.33 mm in CET1, 2.68 mm in CET2, 1.48 mm in CET3. Conclusions: Posterior translation of the radial head on MRI in patients with lateral epicondylitis is greater in cases with LCLC lesions than in those with normal findings.

5G-Enabled IIoT Framework Architecture Towards Sustainable Smart Manufacturing

Article

Full-text available

Mar 2022

With the rapid growth of advanced technologies in the manufacturing sector, a revolution in manufacturing systems is underway and smart manufacturing and its sustainability is becoming the key components towards the fourth industrial revolution. In this context, the IIoT (industrial internet of things), represents a bridge between the digital and physical environment by providing an interactive relation between smart devices and machines also through data sharing. Therefore, it creates a working environment where decisions are made in real-time. The huge data amount generated through the manufacturing system, the high reliability, low latency, and high connectivity demands of IIoT-enabled intelligent manufacturing system requires an advanced wireless transmission technology that goes far beyond the 3rd and 4th generation mobile network. 5G is the most appropriate communication technology for this new IIoT enabled smart manufacturing system’s requirements. Based on the requirements of sustainable smart manufacturing and the characteristics of the 5G wireless communication, this paper proposes a 5G-enabled IIoT framework architecture towards a sustainable smart manufacturing environment, that will allow the support of manufacturers and smart factories in the industrial 4.0 revolution. This is by improving while enhancing efficiency, process and product quality, and sustainability in the whole manufacturing system. Besides, the security threats and challenges of the 5G-IIoT enabled smart manufacturing are also analyzed.

Acute Ligament Injuries of the Elbow

Article

Aug 2021

Ulnar collateral, radial collateral, lateral ulnar collateral, and annular ligaments can be injured in an acute trauma, such as valgus stress in athletes and elbow dislocation. Recognizing normal anatomy in magnetic resonance imaging and ultrasonography studies is important to identify ligamentous abnormalities in these imaging modalities.

MRI of the Elbow: How to Do It

Article

Aug 2021

The diagnostic cascade for elbow complaints starts with the physical examination and radiographs that already can clarify or rule out many causes. Depending on the suspected pathology, additional imaging is necessary. Magnetic resonance imaging (MRI) has the advantage of accurately demonstrating a broad spectrum of diseases. The main indication for noncontrast MRI of the elbow is chronic epicondylitis. For magnetic resonance (MR) arthrography, it is suspected chondral and osteochondral abnormalities. Indirect MR arthrography is an option when direct arthrography is not practicable. MR arthrography of the elbow with traction is feasible, with promising results for the assessment of the radiocapitellar cartilage.

Elbow: Anatomy and MRI Optimization

Chapter

Oct 2021

The elbow is formed by the articulations between the distal humerus, proximal ulna, and proximal radius. This complex joint produces motion of a synovial hinge joint and a pivot joint providing humans with a distinct evolutionary advantage: the ability to throw. However, such movement places great mechanical force upon the small joint, necessitating reinforcement by the adjacent ligaments, tendons, muscles, and fascial planes that function in concert to stabilize the elbow. This chapter will review conventional elbow anatomy and common anatomic variations. This is followed by a discussion of MR imaging optimization, with a review of patient positioning, protocols, technical parameters, and study selection.

The Conservative Treatment of Ulnar Collateral Ligament Injuries

Chapter

May 2021

Nonoperative treatment is often the first step in management of ulnar collateral ligament (UCL) injuries, though numerous patient factors and degree of UCL injury influence treatment decisions. Clinical history, injury mechanism, physical exam, and imaging guide treatment decisions. Patient education, injury prevention strategy, and creating realistic patient expectations are emphasized as important aspects of nonoperative treatment. Treatment modalities reduce elbow pain and inflammation prior to initiating active rehabilitation. Rehabilitation for UCL injury involves global conditioning of the entire kinetic chain with correction of modifiable UCL injury risk factors. When ready, athletes should undergo a supervised progressive throwing program that emphasizes proper throwing mechanics. The outcomes of nonoperative management of UCL injury are satisfactory in well-selected patients with UCL injury features optimal for healing.

Soft Tissue Injury to the Elbow

Chapter

Jan 2008

Exam and Imaging of the Throwing Elbow

Article

May 2020
OPER TECHN SPORT MED

The throwing motion involves the entirety of the kinetic chain from the lower extremities to the fingertips. This activity subjects the elbow joint in particular to tremendous forces which risk overwhelming the static and dynamic stabilizers which protect the joint. Failure of these structures results in a predictable pattern of injuries common to overhead throwers, which can serve as a framework for the clinician caring for overhead throwing athletes. An understanding of the anatomy and biomechanics of the elbow coupled with a thorough history, comprehensive physical examination of the entirety of the kinetic chain, and judicious imaging studies allows the clinician to accurately diagnose and optimally manage elbow injury in the overhead throwing athlete.

Ulnar Collateral Ligament Evaluation and Diagnostics

Article

Jul 2020
CLIN SPORT MED

The overhead throwing motion subjects the elbow to a predictable pattern of forces, including medial tension, lateral compression, and posterior shear, that in turn result in a predictable pattern of injuries. Careful history taking, thorough physical examination, and judicious diagnostic imaging allow clinicians to correctly diagnose ulnar collateral ligament (UCL) injury. Athletes with UCL injury complain of acute or chronic medial elbow injury, resulting in decreased throwing effectiveness, with loss of control and/or velocity. Magnetic resonance imaging is the gold standard for diagnosis, but stress ultrasound rapidly is becoming an important adjunct, particularly in diagnostically challenging situations.

Valgus stress ultrasound for medial ulnar collateral ligament injuries in athletes: is ultrasound alone enough for diagnosis?

Article

Mar 2020

Background: We hypothesized that valgus stress ultrasound would be useful for both identifying medial ulnar collateral ligament (MUCL) tears and assessing the severity of the tears. Hence, we performed valgus stress ultrasound of the elbow in athletes with MUCL injuries, confirmed by magnetic resonance imaging (MRI), to determine whether ultrasound can be used as a diagnostic tool. Methods: Stress ultrasound and MRI data from 146 athletes with medial elbow pain were compared prospectively. MRI findings for MUCL injuries were classified into 3 levels as follows: low-grade partial tear (≤50%), high-grade partial tear (>50%), and complete tear. The degree of joint laxity on stress ultrasound was evaluated by measuring joint gapping after applying a 2.5-kg load to the wrist. Joint gapping was measured at 30° and 90° of elbow flexion for the dominant arm and nondominant arm, and the differences between the dominant and nondominant arms were determined. Results: A higher degree of MUCL injury on MRI was associated with greater joint gapping in the medial elbow on stress ultrasound. At 30° of elbow flexion, the cutoff value for complete MUCL rupture was 0.5 mm (P < .001), with a sensitivity and specificity of 88.1% and 61.5%, respectively. At 90° of elbow flexion, the cutoff value for complete MUCL rupture was 1.0 mm (P < .001), with a sensitivity and specificity of 81.0% and 66.4%, respectively. Conclusion: Stress ultrasound can be used to diagnose complete MUCL tears in athletes when joint gapping is greater than 0.5 mm at 30° of elbow flexion and greater than 1 mm at 90° of elbow flexion.

Optimization of MRI Protocol for the Musculoskeletal System

Article

Full-text available

Jan 2020

Magnetic resonance imaging (MRI) is an essential modality for the diagnosis of musculoskeletal system defects because of its higher soft-tissue contrast and spatial resolution. With the recent development of MRI-related technology, faster imaging and various image plane reconstructions are possible, enabling better assessment of three-dimensional musculoskeletal anatomy and lesions. Furthermore, the image quality, diagnostic accuracy, and acquisition time depend on the MRI protocol used. Moreover, the protocol affects the efficiency of the MRI scanner. Therefore, it is important for a radiologist to optimize the MRI protocol. In this review, we will provide guidance on patient positioning; selection of the radiofrequency coil, pulse sequences, and imaging planes; and control of MRI parameters to help optimize the MRI protocol for the six major joints of the musculoskeletal system.

Principles of Surgical Evaluation and Techniques for the Elbow in the Overhead Athlete

Chapter

May 2019

Appropriate orthopedic management of elbow pathologies in the athlete requires thoughtful history-taking, thorough physical examination, and well-selected diagnostic imaging. Obtaining a thorough history of an overhead athlete should include past injuries and treatments to the elbow as well as the remainder of the kinetic chain (shoulder, core, hips, and legs). Physical examination of such athletes should involve evaluation of the neck/cervical spine, both shoulder girdles (clavicles with associated joints, scapulae, and glenohumeral joints), both elbows, and the remainder of the kinetic chain, including inspection, palpation, range of motion, strength and sensation testing, as well as special provocative maneuvers. Diagnostic imaging may begin with plain radiographs but will often require advanced modalities such as ultrasound, computed tomography, and magnetic resonance imaging. This thorough evaluation will allow the clinician to confirm the suspected diagnosis as well as thoroughly exclude alternative or potential concomitant diagnoses. This chapter will review the surgical management of five elbow pathologies common among overhead throwing athletes: ulnar collateral ligament injury, medial elbow tendinopathy/epicondylitis, lateral elbow tendinopathy/epicondylitis, distal biceps injury, and distal triceps injury.

Correlation of MRI to Arthroscopy in the Elbow: Thrower's Elbow and Ulnar Collateral Ligament Injury

Article

Dec 2017
SPORTS MED ARTHROSC

One cannot overstate the importance of a thorough history and physical examination, supplemented with directed imaging, to help pinpoint the exact cause of the athlete's elbow pain. Although plain radiographs should not be overlooked, advanced imaging plays a critical role in diagnosis and management of pathology in the thrower's elbow, including computed tomography, magnetic resonance imaging, and stress ultrasound. By judiciously combining these elements, the clinician can appropriately manage these injuries in order to successfully return the athlete to their preinjury level of play.

Case 102

Chapter

Jan 2007

This is a 5-year-old boy who fell off a trampoline and injured his left elbow. Radiographs, including stress views, were negative for fracture or effusion (not shown).

Isolated coronoid fracture: Assessment by magnetic resonance imaging for concomitant injuries

Article

May 2016

Background: Ligamentous injury associated with isolated coronoid fracture had been sparingly reported. Concealed or unclear fractures and ligamentous or articular cartilage lesions are promptly acknowledged by magnetic resonance imaging (MRI) but cannot be entirely pictured in regular radiological assessments. In isolated coronoid fracture, the fragment size is very small and due to the complex anatomy surrounding the coronoid radiographic imaging may not be sufficient. The purpose of this study was to evaluate the incidence of combined osteochondral and ligamentous injuries by magnetic resonance imaging (MRI) in 24 patients with an isolated coronoid fracture. Materials and methods: In a retrospective study conducted at tertiary hospital between 2009 and 2011, elbow radiographs (anteroposterior and lateral views), computed tomography scan images, and MRI in the sagittal, coronal, axial, oblique, and coronal oblique planes were collected and reviewed. Musculoskeletal radiologist with subspecialty training in musculoskeletal MR interpretation and a fellowship-trained shoulder and elbow surgeon evaluated the MRI. Results: The incidence of associated injuries revealed torn lateral collateral ligament (LCL) in all 24 patients (100%) while 15 patients (62.5%) had common extensor muscle tears. Seven of 24 elbows (29.2%) showed medial collateral ligament (MCL) tear, and 13 of 16 patients (81.3%) with anteromedial facet fracture had MCL attached to the fragment. Five of 24 (20.8%) cases had contusions on the radial head. On the distal humeral side, 15 patients had bone contusions on the posterior inferior of the trochlear on sagittal view. The ligament affections of the LCL were confirmed intraoperatively and repaired. Conclusion: LCL injury was consistent in all isolated coronoid fracture. The forces resulting in the injury appear similar to varus distraction forces acting in the knee leading to distraction injuries of the lateral structures of the knee joint. As concurrent osteochondral injuries and ligamentous injuries are not rare, magnetic resonance analysis serves as an excellent tool for analysis of the ligamentous injuries preoperatively and aids in surgical planning.

Elbow

Chapter

Jan 2008

Injury to the myotendinous, ligamentous, osseus, and nervous structures of the elbow can result from acute macrotrauma or recurrent microtrauma. Acute macrotrauma primarily results from direct impact of the elbow with the ground, collision of an outstretched hand with the ground, or high intensity movement involving the elbow joint in an unconditioned individual. Recurrent or chronic repetitive microtrauma to the elbow is usually the result of either eccentric overuse of the extensors of the forearm or repetitive valgus stress overload, as occurs with overhead throwing or work-related tasks. In these settings, the ability of MRI to achieve superb soft tissue contrast is of particular utility. It can evaluate for and distinguish between myotendinous, ligamentous, osseus, cartilaginous, and nervous etiologies in the athlete who presents with nonspecific symptoms.

The Role of Ultrasound in Sports Medicine

Chapter

Jan 2016

The use of ultrasound in musculoskeletal imaging and, in particular, sports medicine has dramatically increased with the technical advances of the last 20 years. These improvements allow detailed evaluation of the structures of the musculoskeletal system including tendons, ligaments, muscles, nerves, joints, cartilage, and bursae. In addition to its wide availability, portability, and lower cost, the greatest advantages of ultrasound, particularly in the musculoskeletal system, are the ability to perform dynamic imaging as well as the opportunity to interact with the patient and correlate symptoms with sonographic findings. The real-time nature of ultrasound provides a unique evaluation of structures in their dynamic state, thereby identifying pathology that may be demonstrated only when the patient performs certain motions.

Imaging of Sports Ligamentous Injuries of the Elbow

Article

Nov 2013
SEMIN MUSCULOSKEL R

Ligamentous injuries of the elbow are common in sports. The diagnosis is usually based on a combination of the assessment of the mechanism of injury during the sporting activity and physical examination. Imaging with radiographs and MR imaging has an important diagnostic role, particularly when the clinical presentation is unclear and to evaluate for other important potential associated injuries such as myotendinous injuries, fractures, dislocations, and osteochondral lesions. Treatment includes conservative and surgical measures depending on the severity of the instability and associated injuries. We provide a detailed review of sports-related injuries of the medial and lateral collateral ligament complexes of the elbow with an emphasis on imaging manifestations of disease and a discussion of the anatomy, biomechanics, and treatment options.

The Aging Athlete: Part 2, "Boomeritis" of the Upper Extremity

Article

Full-text available

Sep 2012
AM J ROENTGENOL

Objective: The purpose of this review is to describe the upper extremity injuries that frequently accompany aging, the typical clinical presentations, and the differential diagnoses with an emphasis on the injury most likely encountered with each presentation. Conclusion: Expectation of continued participation in exercise and sports activities by the baby boomer population has presented new challenges to the medical field. The concepts behind factors that predispose older athletes to certain pathologic conditions that affect the muscles, tendons, and bones of the upper extremity must be understood.

Injuries of the Elbow and the Current Treatment of Tendon Disease

Article

Full-text available

Sep 2012
AM J ROENTGENOL

Objective: Overuse and traumatic injuries of the elbow are common, occurring in both athletes and nonathletes. This article will discuss the commonly encountered soft-tissue and osseous pathologic abnormalities around the elbow and their imaging appearance on MRI and ultrasound. Conclusion: The current treatment of tendon disease of the elbow is reviewed, with a focus on platelet-rich plasma injection.

Ulnar Collateral Ligament Reconstruction in Throwing Athletes: A Review of Current Concepts: AAOS Exhibit Selection

Article

Apr 2012
J BONE JOINT SURG AM

Isolated ulnar collateral ligament (UCL) injury from repetitive throwing was first described by Waris in 1946 in javelin throwers1. Although these injuries were once considered career-ending for athletes, a surgical technique pioneered by Jobe in 1974 facilitated successful return to competition2. Since that time, modifications of the original procedure have resulted in improved clinical results. The present article provides a comprehensive review of current concepts related to UCL injury in throwing athletes, including a review of relevant anatomy and biomechanics, the mechanism of UCL injury and associated elbow pathology, and the evolution of UCL reconstruction procedures and clinical outcomes. The UCL is composed of three bundles: anterior, posterior, and oblique; the oblique bundle is commonly termed the transverse ligament3,4 (Fig. 1). Gross anatomical studies have demonstrated that the anterior bundle is easily distinguished from the underlying joint capsule5,6. The anterior bundle consists of two separate histological layers: the deeper layer is composed of collagen bundles contained within the capsule, and the shallower layer is a distinct ligamentous structure superficial to the capsule7. The anterior bundle originates from the anteroinferior edge of the medial humeral epicondyle and inserts onto the sublime tubercle of the ulna. There is a distinct ridge on the sublime tubercle that divides the anterior bundle into two equally sized bands, the anterior and posterior bands5,6 (Fig. 2). The area of the origin of the anterior bundle on the medial humeral epicondyle is 45.5 ± 9.3 mm2, whereas the insertion on the sublime tubercle is much broader, measuring 127 ± 35.7 mm2 (Fig. 3)6. Fig. 1 Anatomy of the ulnar collateral ligament. (Reproduced from: Conway JE, Jobe FW, Glousman RE, Pink M. Medial instability of the elbow in …

Magnetic resonance imaging findings in 46 elbows with a radial head fracture

Article

Full-text available

Jun 2010
ACTA ORTHOP

Radial head fractures are common, and may be associated with other injuries of clinical importance. We present the results of a standard additional MRI scan for patients with a radial head fracture. PATIENTS AND METhods: 44 patients (mean age 47 years) with 46 radial head fractures underwent MRI. 17 elbows had a Mason type-I fracture, 23 a Mason type-II fracture, and 6 elbows had a Mason type-III fracture. Associated injuries were found in 35 elbows: 28 elbows had a lateral collateral ligament lesion, 18 had capitellar injury, 1 had a coronoid fracture, and 1 elbow had medial collateral ligament injury. The incidence of associated injuries with radial head fractures found with MRI was high. The clinical relevance should be investigated.

3T MR Imaging of the Musculoskeletal System (Part II): Clinical Applications

Article

Mar 2006
Magn Reson Imag Clin N Am

R. Richard Ramnath

The gain in SNR that is afforded by 3T MR imaging systems has tremendous clinical applications in the musculoskeletal system. The potential for demonstrating and enhancing the visibility of normal osseous, tendinous, cartilaginous, and ligamentous structures is exciting. Furthermore, harnessing this added signal to increase spatial resolution may improve our diagnostic abilities in various joints dramatically. Radiologists have enjoyed great success in assessing joint disease with current MR imaging field strengths; however, many intrinsic joint structures remain poorly evaluated, which leads to a golden opportunity for 3T MR imaging. The articular cartilage of the knee, the glenoid labrum of the shoulder, the intrinsic ligaments and TFC of the wrist, the collateral ligaments of the elbow, the labrum and articular cartilage of the hip, and the collateral ligaments of the ankle have been evaluated suboptimally on 1 .5T systems using routine nonarthrographic MR images. Because of the enhanced SNR, the higher spatial resolution, and the greater CNR of intrinsic joint structures at higher field strengths, 3T MR imaging has the potential to improve diagnostic abilities in the musculoskeletal system vastly, which translates into better patient care and management. The author's 2 years of clinical experience with musculoskeletal MR imaging on 3T systems has met and exceeded his expectations, and has bolstered the confidence of his orthopedic surgeons in his diagnoses. As coil technology advances and as the use of parallel imaging becomes more available in the extremities, the author expects to see even more dramatic improvements in image quality.

Imaging of the Elbow: A Review of Imaging Findings in Acute and Chronic Traumatic Disorders of the Elbow

Article

Apr 2006
J HAND THER

Matthew A Frick

Traumatic injuries of the elbow are frequent in patients of all ages but are particularly common in young children and adolescents engaged in normal play and athletic competition. Injury may result primarily due to direct trauma or may be secondary to transmission of forces through the elbow following a fall on an outstretched hand. In middle-aged and older individuals, chronic repetitive injuries tend to predominate. In all patients, radiographs remain the initial imaging study of choice. Many patients, however, may need advanced cross-sectional imaging (i.e. MRI, CT, or ultrasound) either at presentation or during the course of their treatment and follow-up. This article reviews the imaging appearance of common acute and chronic traumatic disorders of the elbow.

Reprint of Imaging of the Elbow: A Review of Imaging Findings in Acute and Chronic Traumatic Disorders of the Elbow

Article

Jan 2006
J HAND THER

Matthew A Frick

MR imaging of the elbow in baseball pitchers

Article

Mar 2008

Baseball pitcher throwing biomechanics are important to understanding the pathophysiology and magnetic resonance (MR) imaging appearances of injuries in baseball pitchers. Baseball pitchers experience repetitive excessive valgus forces at the elbow. Typical injuries are secondary to medial joint distraction, lateral joint compression, and rotatory forces at the olecranon. MR imaging is useful for evaluation of the elbow in baseball pitchers.

Kinetics of Baseball Pitching with Implications About Injury Mechanisms

Article

Full-text available

Mar 1995
AM J SPORT MED

Elbow and shoulder kinetics for 26 highly skilled, healthy adult pitchers were calculated using high-speed motion analysis. Two critical instants were 1) shortly before the arm reached maximum external rotation, when 67 N-m of shoulder internal rotation torque and 64 N-m of elbow varus torque were generated, and 2) shortly after ball release, when 1090 N of shoulder compressive force was produced. Inability to generate sufficient elbow varus torque may result in medial tension, lateral compression, or posteromedial impingement injury. At the glenohumeral joint, compressive force, joint laxity, and 380 N of anterior force during arm cocking can lead to anterior glenoid labral tear. Rapid internal rotation in combination with these forces can produce a grinding injury factor on the labrum. After ball release, 400 N of posterior force, 1090 N of compressive force, and 97 N-m of horizontal abduction torque are generated at the shoulder; contribution of rotator cuff muscles in generating these loads may result in cuff tensile failure. Horizontal adduction, internal rotation, and superior translation of the abducted humerus may cause subacromial impingement. Tension in the biceps tendon, due to muscle contraction for both elbow flexion torque and shoulder compressive force, may tear the anterosuperior labrum.

Ulnar collateral ligament in the growing elbow: MR imaging of normal development and throwing injuries

Article

Full-text available

Sep 1994

To study the magnetic resonance (MR) imaging appearance of the ulnar collateral ligament (UCL) and its insertion into the medial epicondyle. Sixteen normal and 20 symptomatic elbows were examined with a 1.5-T unit. Normal elbows were imaged with axial T2*-weighted three-dimensional Fourier transform sequences. Symptomatic elbows were imaged with coronal T1-, T2-, and T2*-weighted and/or short-inversion-time inversion-recovery sequences. In normal immature elbows, the ulnar periosteum was seen as an extension of the UCL, and its enthesis had signal intensity characteristics that differed from those of the mature ligament. In symptomatic elbows imaged before epiphyseal fusion, segmentation and subchondral bone resorption of the ossification center were seen with or without a capsular tear. After epiphyseal fusion, a full-thickness or a partial UCL tear at the site of its insertion, with or without subcortical bone resorption, was seen. The MR imaging characteristics of the developing elbow differ from those of the mature elbow. MR imaging is useful in assessing UCL damage.

MR imaging findings of lateral ulnar collateral ligament abnormalities in patients with lateral epicondylitis

Article

Full-text available

Dec 1999

The purpose of this paper was to use MR imaging to determine whether a relationship exists between lateral epicondylitis and abnormalities of the lateral ulnar collateral ligament. The study group comprised 35 consecutive patients who were referred for MR imaging to rule out lateral epicondylitis. On MR imaging, "lateral epicondylitis" was defined as increased signal intensity of the extensor tendons close to their insertion on the lateral epicondyle. The severity of the lateral epicondylitis was graded as mild, moderate, or severe. The origin of the lateral collateral ligamentous complex was characterized, and the lateral ulnar collateral ligament was graded as normal, thickened, partially torn, or torn. Eleven patients underwent elbow surgery after the initial MR examination. In 15 patients, MR imaging revealed characteristics of mild lateral epicondylitis. In 13 of these patients, the lateral ulnar collateral ligament was normal; one patient showed a thickened ligament; and one patient had a thinned ligament. In 11 patients, MR imaging showed features of moderate lateral epicondylitis. In eight of these patients, the lateral ulnar collateral ligament was thickened, and in the remaining three patients the ligament was normal. All nine patients with severe lateral epicondylitis showed abnormalities of the lateral ulnar collateral ligament on MR imaging. In one of these patients the lateral ulnar collateral ligament was thickened, in three patients we saw a partial tear, and in the remaining five patients we saw a complete tear of the ligament. In our study, MR imaging features of lateral epicondylitis were often associated with thickening and tears of the lateral ulnar collateral ligament.

Posterolateral rotatory instability of the Elbow

Article

Apr 1991

Recurrent posterolateral rotatory instability of the elbow is an apparently undescribed clinical condition that is difficult to diagnose. We treated five patients, ranging in age from five to forty years, who had such a lesion and in whom the instability could be demonstrated only by what we call the posterolateral rotatory-instability test. This test involves supination of the forearm and application of a valgus moment and an axial compression force to the elbow while it is flexed from full extension. The elbow is reduced in full extension and must be subluxated as it is flexed in order to obtain a positive test result (a sudden reduction of the subluxation). Flexion of more than about 40 degrees produces a sudden palpable and visible reduction of the radiohumeral joint. The elbow does not subluxate without provocation. The cause for this condition, we think, is laxity of the ulnar part of the lateral collateral ligament, which allows a transient rotatory subluxation of the ulnohumeral joint and a secondary dislocation of the radiohumeral joint. The annular ligament remains intact, so the radio-ulnar joint does not dislocate. Operative repair of the lax ulnar part of the lateral collateral ligament eliminated the posterolateral rotatory instability, as revealed intraoperatively in our five patients.

Elbow Subluxation and Dislocation: A Spectrum of Instability

Article

Jul 1992
CLIN ORTHOP RELAT R

After sequential releases of the ligaments and capsules of 13 fresh autopsy specimen elbows, external rotation and valgus moments with axial forces resulted in posterior dislocations in 12 of the 13 with the anterior medial collateral ligament (AMCL) intact. Kinematic displacements measured with a three-dimensional electromagnetic tracking device showed that dislocation involved posterolateral rotation of 34[degrees]-50[degrees] and 5[degrees]-23[degrees] valgus at about 80[degrees] flexion. Dislocation is the final of three sequential stages of elbow instability resulting from posterolateral rotation, with soft-tissue disruption progressing from lateral to medial. In each stage, the pathoanatomy correlated with the pattern and degree of instability. Testing for valgus stability of the elbow during simulated active flexion revealed no significant increase (-0.3[degrees]-2.4[degrees]) in valgus laxity after reduction compared with the intact specimens (p > 0.05, [beta] = 0.1, [delta] = 2.5[degrees]). In no case did the digitized AMCL origin-to-insertion distance increase beyond normal during the dislocation (p < 0.01). The mechanism of dislocation during a fall on the outstretched hand would involve the body "rotating internally" on the elbow, which experiences an external rotation/valgus moment as it flexes. Posterior dislocations should therefore be reduced in supination. If valgus stability in pronation is demonstrated, the AMCL can be assumed to be intact, and rehabilitation in a hinged cast-brace with the elbow in full pronation can be commenced immediately. (C) Lippincott-Raven Publishers.

Anatomy of the ulnar part of the lateral collateral ligament of the elbow

Article

Jan 1992
CLIN ANAT

The lateral ulnar collateral ligament (LUCL) of the elbow has been illustrated variably in anatomy texts. The purpose of this investigations was to determine the percentage of specimens in which this structure is present, and to describe its anatomy and function. The LUCL was identified as part of the lateral capsulo-ligamentous complex in 17 of 17 fresh frozen cadaver elbows (P <.0001). The LUCL originates on the lateral epicondyle, blends with the fibers of the annular ligament as it arches superficial to it, then curves to insert on the tubercle of the supinator crest of the ulna. It is distinct at its insertion, but not at its origin where its fibers blend with those of the common extensor origin. The insertion is exposed in the interval created between (the deep surface of) the fascia of the supinator and its muscle fibers. The insertion can be palpated by applying a varus stress to the elbow. Cutting the ulnar fibers permitted posterolateral rotatory subluxation of the ulno-humeral joint and varus subluxation of the elbow. © 1992 Wiley-Liss, Inc.

Functional Anatomy of the Ligaments of the Elbow

Article

Dec 1985

Dissections of 10 fresh cadaver specimens revealed an important insertion of the posterior portion of the lateral collateral ligament to the ulna at the crista supinatoris. The humeral origin of the medial ligament attachments was found to lie posterior to the axis of elbow flexion; in this position a cam effect is created so that ligament tension varies with elbow flexion. The three-dimensional distance between the origin and the insertion of the anterior portion of the medial collateral ligament was found to increase slightly from extension to approximately 60 degrees of flexion; thereafter, it remained nearly constant. The distance of the posterior portion increased by about 9 mm from 60 degrees to 120 degrees of flexion. The flexion axis was shown to pass through the origin of the lateral collateral ligament, so the length of this structure was not changed during elbow flexion.

Ulnar collateral ligament Injury in baseball pitchers: MR imaglng evaluation

Article

Dec 1992

The ulnar collateral ligament (UCL) provides stability to the medial aspect of the elbow during valgus stress. Trauma to this ligament may result from repetitive forceful throwing. Diagnosis of UCL injury has been based on clinical findings of medial joint pain and valgus instability, as direct imaging of this structure has not been available. Eleven baseball pitchers with clinical evidence of UCL injury were evaluated with magnetic resonance (MR) imaging. Surgical correlation was obtained in six patients, four of whom underwent UCL reconstruction. MR imaging findings in UCL injury included laxity, irregularity, poor definition, and increased signal intensity within and adjacent to the UCL. These findings reflect the presence of hemorrhage and/or edema within the UCL due to repeated microtears, which eventually lead to weakening and possible disruption of the UCL. Optimization of spatial resolution, signal-to-noise ratio, and other technical factors is critical for evaluation of the UCL due to its small size. MR imaging is useful in documenting the presence and severity of injury to the UCL and in distinguishing this entity from other causes of elbow pain.

MR imaging of the elbow

Article

Sep 1992

B J Murphy

Of 27 patients who underwent magnetic resonance (MR) imaging of the elbow, 11 underwent elbow arthroscopy and/or an open surgical procedure. Surgical findings were compared with those from MR imaging. Five healthy volunteers also underwent MR imaging to demonstrate anatomic relationships. Transchondral fracture (osteochondritis dissecans) was identified in three of the 11 patients and was proved at surgery. Loose bodies were suspected at MR imaging in the three patients but were found in only two. One complete avulsion of the ulnar collateral ligament (UCL) and four cases of intact, thickened UCLs were identified at MR imaging and surgery. Loose bodies from the olecranon tip were found in three patients at surgery but were seen on MR images in only two. MR imaging depicted olecranal osteophytes in three cases, which were confirmed at surgery. Two complete avulsions of the biceps tendon and one partial triceps tendon tear were identified with MR imaging and proved at surgery. A postoperative soft-tissue infection and a synovial cyst were also seen at MR imaging and surgery. These results suggest that MR imaging is useful in the evaluation of the elbow.

Biomechanical Study of Ligaments Around the Elbow Joint

Article

Nov 1991

The ligamentous contribution to elbow joint stability is a product of morphology and biologic parameters of each of the collateral ligaments. Better understanding of these characteristics is of paramount importance for successful ligament reconstruction in the surgery for joint replacement and traumatic injury. Two experiments were performed. In the first, the arc of elbow flexion where the individual ligament was either taut or slack was measured; in the second, the structural properties of each collateral ligament were determined by using bone-ligament-bone preparations. The anterior medial collateral ligament (AMCL) and radial collateral ligament (RCL) were taut throughout most of the entire arc of flexion. The posterior medial collateral ligament (PMCL) was taut only when the elbow was in a flexed position. Among the collateral ligaments, the AMCL was the strongest and stiffest with an average failure load of 260 N. The palmaris longus tendon, the most frequently used graft for elbow ligament reconstruction, was similar in strength (357 N).

Valgus stability of the elbow

Article

Sep 1987

The valgus stabilizers of the elbow have been identified anatomically, but their relative importance has not been quantified. The purpose of this study was to analyze the acute changes of the torque-displacement curve to valgus stress following (a) section of the posterior portion of the medial collateral ligament; (b) excision of the radial head; (c) prosthetic replacement of the radial head; and (d) excision of the anterior portion of the medical collateral ligament. Thirty cadaver specimens underwent load-displacement testing in three positions: 0 degrees, 45 degrees, and 90 degrees of flexion. The anterior portion of the medial collateral ligament was the primary stabilizer of the elbow to valgus stress. The relative contribution of the posterior ligament was minimal. After excision of the radial head alone, the slope of the load-displacement curve decreased an average of 30%. Silicone rubber radial head replacement did not significantly improve the stability to valgus stress after radial head excision.

Articular and ligamentous contributions to the stability of the elbow joint

Article

Sep 1983
AM J SPORT MED

This preliminary study of four elbow specimens investigates the relationship of articular geometry and ligamentous structures in providing stability to the elbow joint. A technique is presented that describes the constraining features of varus-valgus and distraction in extension and at 90 degree of elbow flexion. Valgus stability is equally divided among the medial collateral ligament, anterior capsule, and bony articulation in full extension; whereas, at 90 degrees of flexion the contribution of the anterior capsule is assumed by the medial collateral ligament which provides approximately 55% of the stabilizing contribution to valgus stress. Varus stress is noted to be resisted primarily by the anterior capsule (32%) and the joint articulation (55%) with only a small (14%) contribution from the radial collateral ligament. At 90 degrees of flexion, little change is noted in the contribution to the radial collateral ligament (9%), but the anterior capsule offers only 13%, with the remaining stability (75%) arising from the joint articulation. In extension, the soft tissue resistance to distraction is provided minimally by either the radial (5%) or the medial (5%) collateral ligaments, and thus primarily originates from the anterior capsule (85%). At 90 degrees of flexion, however, the capsule offers virtually no resistance to distraction (8%). The radial collateral ligament contributes 10% of the stability, while the medial collateral ligament accounts for 78% of the resistance to distraction in this position. Too few specimens have been studied to form any conclusions for direct clinical applications at this time. However, the technique provides a reliable tool with additional studies for different positions and loading conditions underway. These efforts should disclose useful information that might be applied to the management of chronic elbow instability, radial head or olecranon fracture, the design and implantation of elbow prostheses, or provide a rationale for other reconstructive procedures.

Wilson FD. Valgus extension overload in the pitching elbow. Am J Sports Med 1983;

Article

Mar 1983
AM J SPORT MED

Five baseball pitchers, three college and two profes sional, with an average age of 24 years, exhibited pain between the acceleration phase and follow- through phase of the pitching motion. This caused the players to be unable to continue at the level of com petition necessary to play. A significant osteophyte on the posteromedial aspect of the olecranon process was identified in all pitchers. This caused impingement with the articular wall of the olecranon fossa and often created an area of chondromalacia. The more com monly identified posterior osteophyte was present in all cases. However, if just this posterior osteophyte is removed, the described lesion will be missed, with resultant persistent disability. Surgical excision of the posteromedial osteophyte through a relatively atraumatic posterolateral ap proach allowed early return of function without mor bidity. With an average follow up of 1 year, all of the pitchers returned for one full season at maximum effectiveness.

Ulnar collateral ligament injury in the throwing athlete: Evaluation with saline-enhanced MR arthrography

Article

Nov 1995

To determine whether magnetic resonance (MR) arthrography of the elbow can demonstrate precisely an ulnar collateral ligament (UCL) abnormality in the throwing athlete. Forty college-level and professional throwing athletes (age range, 18-40 years) underwent saline-enhanced MR arthrography of their injured elbows. MR findings were compared with the surgical findings. Saline-enhanced MR arthrography was positive in 24 of 26 individuals with UCL tear confirmed at the time of surgery. Eighteen (95%) of 19 complete UCL tears and six (86%) of seven partial UCL tears were diagnosed with MR arthrography. Two false-negative findings and no false-positive findings were obtained. Saline-enhanced MR arthrography of the elbow is a new application of a previously described technique used in the shoulder. It is useful for demonstration of subtle and gross UCL abnormalities in the throwing athlete.

Arthroscopic Assessment of the Medial Collateral Ligament Complex of the Elbow

Article

Jul 1995
AM J SPORT MED

The extent that the medial collateral ligament complex could be visualized by arthroscopy was determined in 10 fresh cadaveric elbows from 10 individuals. We carefully exposed the medial collateral ligament complex through a muscle-splitting incision before performing arthroscopy. The anterior and posterior bundles were identified and marked by placing 4.0 nylon sutures deep to the bundles to aid in arthroscopic visualization. A portion of the anterior bundle was visible in only one elbow and in that elbow only the most anterior 25% of the anterior bundle was seen. Attempts to visualize the anterior bundle through additional portals were unsuccessful. Varying the flexion angle of the cadaveric elbow from 0 degrees to 130 degrees also failed to improve visualization. Conversely, the entire posterior bundle, including humeral and ulnar insertion sites, could be seen in all 10 specimens using the posterior portals. We also noted that direct pressure was placed on the ulnar nerve in all specimens when the arthroscope or any arthroscopic instrument was advanced into the posteromedial gutter in contact with the posterior bundle because of its proximity immediately adjacent to the ulnar nerve. The inability to reliably see the anterior bundle and the humeral or ulnar insertion sites of this ligament may limit the value of the arthroscope when assessing medial collateral ligament injuries. Additionally, great care should be taken when using the arthroscope or other instruments in the posteromedial gutter because the ulnar nerve lies immediately adjacent to the thin posterior bundle and capsule.

Undersurface Tear of the Ulnar Collateral Ligament in Baseball Players: A Newly Recognized Lesion

Article

Jan 1994
AM J SPORT MED

Seven patients were diagnosed with an undersurface tear of the deep capsular layer of the anterior bundle of the ulnar collateral ligament. Preoperatively, all of the patients had tenderness over the anterior bundle of the ulnar collateral ligament and pain with valgus stressing of the elbow. Six of the seven patients had a normal magnetic resonance imaging scan, with one magnetic resonance imaging scan showing degeneration within the ligament. All of the patients had a negative computed tomography arthrogram for extracapsular contrast extravasation. A consistent finding in five of the seven patients was a leak of contrast around the edge of the humerus or ulna, although the contrast was contained within the joint. At arthroscopic evaluation, all of the patients demonstrated medial elbow instability as valgus stress was applied across the elbow joint in 70 degrees of flexion. All of the patients underwent open medial elbow surgery, where the ulnar collateral ligament was visualized and found to be intact externally. But when the anterior bundle was incised, there was a detachment of the undersurface of the ligament at the ulna or the humerus. Cadaveric dissections were performed to define the anatomy of the insertion sites and to confirm that this lesion was not an anatomic variant. A tear of the deep layer of the ulnar collateral ligament can result in symptomatic instability that is difficult to diagnose with conventional preoperative testing. This lesion of the anterior bundle of the ulnar collateral ligament has not been previously reported, and in our series it was associated with persistent medial elbow pain in throwing athletes.

Preoperative Evaluation of the Ulnar Collateral Ligament by Magnetic Resonance Imaging and Computed Tomography Arthrography: Evaluation in 25 Baseball Players with Surgical Confirmation

Article

Jan 1994
AM J SPORT MED

A prospective study was completed on 25 baseball play ers with medial side elbow pain. They were evaluated preoperatively with both computed tomography arthro gram and magnetic resonance imaging examinations of the elbow to assess the ulnar collateral ligament. At surgery, 16 of 25 patients had an abnormal ulnar col lateral ligament and 9 patients had a normal ulnar col lateral ligament. The computed tomography arthrogram detected abnormalities in 12 of the 14 patients with ulnar collateral ligament tearing (sensitivity, 86%). The mag netic resonance imaging scan indicated abnormalities in 8 of 14 patients (sensitivity, 57%). The specificity of the computed tomography arthrogram was 91 % and the magnetic resonance imaging was 100%. A newly described "T-sign" was seen on the com puted tomography arthrogram in the patients with an undersurface tear of the ulnar collateral ligament. This represented the dye leaking around the detachment of the ulnar collateral ligament from its bony insertion but remaining contained within the intact superficial layer of the ulnar collateral ligament and capsule. Both the computed tomography arthrogram and the magnetic resonance imaging scan were accurate in di agnosing a complete tear of the ulnar collateral ligament preoperatively in all cases. The main advantage of the computed tomography arthrogram was in evaluating the partial undersurface tear.

MR arthrography of elbow: Evaluation of the ulnar collateral ligament of elbow

Article

Nov 1996

The purpose of this study was to evaluate ulnar collateral ligament (UCL) injury of the elbow in throwing athletes by MRI and MR arthrography. Ten elbows of throwing athletes were examined on both plain MRI and MR saline arthrography and the injuries subsequently surgically proven. Spin-echo (SE) T1-weighted and fast SE T2-weighted coronal images were obtained. The UCL was unclear in all ten cases on T1-weighted MRI. In five cases an avulsion fracture was also found on T1-weighted MRI. On T2-weighted MRI, abnormal high-intensity areas were identified in or around the UCL. On T2-weighted MR arthrography images, extracapsular high-intensity areas, which represent extracapsular leakage, were found in four of five cases with avulsion fracture. At surgery, all these four cases showed avulsion fractures with instability; the other case had a fracture but it was stable and adherent to the humerus. On T2-weighted MR arthrography images, an extracapsular high-intensity area was found in one of the five cases without avulsion fracture. At surgery this patient had a complete tear of the UCL itself. MR arthrography provided additional information for evaluating the degree of UCL injury.

Kinematics of the lateral ligamentous constraints of the elbow joint

Article

Sep 1996
J SHOULDER ELB SURG

Thirty osteoligamentous elbow joint specimens were included in a study of the lateral collateral ligament complex (LCLC). The morphologic characteristics of the LCLC were examined, and then three-dimensional kinematic measurements were undertaken after selective ligament dissections were performed. Isolated sectioning of the annular ligament (AL) or the lateral ulnar collateral ligament (LUCL) induced only minor laxity to the elbow joint with a maximum of 2.2 degrees and 4.4 degrees during forced varus and external rotation (supination), respectively. Transsection of the lateral collateral ligament (LCL) caused a maximal laxity of 15.4 degrees and 22.8 degrees during forced varus and external rotation (supination), respectively. Combined ligament dissections showed that total transection of the LCLC at the ulnar or the humeral insertion was important for joint laxity. Total transection of the LCLC at the humeral or the ulnar insertion induced a maximal laxity of 24.5 degrees and 37 degrees during forced varus and external rotation (supination), respectively. This study suggests the AL and the LUCL are of minor importance as constraints when cut separately, whereas the LCL is a significant preventer of elbow joint laxity. The LCLC was observed to be a complex structure of ligamentous fibers rather than discreet bands. The LCLC forms a ligamentous constraint between the lateral humeral epicondyle and the ulna, stabilizing the elbow joint and forming a base for radial head stability and rotation.

Medial elbow pain in the throwing athlete: MR imaging evaluation

Article

Apr 1997

Translational injuries in posterior elbow dislocation

Article

Mar 1997

We describe a new plain radiographic finding in posterior elbow dislocation: a defect in the nonarticular posterior surface of the capitellum caused by impaction of the radial head during dislocation. The defect was visible on a lateral view unobscured by overlying bony structures in the unreduced state and confirmed on both an axial view after reduction and by magnetic resonance imaging. We propose that this lesion is analogous to the Hill-Sachs/Bankart lesion complex seen in translational glenohumeral injury.

Posterolateral rotatory instability of the elbow: Usefulness of MR imaging in diagnosis

Article

Aug 1997

To evaluate the efficacy of magnetic resonance (MR) imaging in the assessment of the normal and abnormal ulnar band of the lateral collateral ligament for diagnosis of posterolateral rotatory instability. In nine symptomatic patients and nine asymptomatic subjects, MR imaging was performed with three-dimensional gradient-recalled and fast spin-echo sequences. The nine patients had clinical symptoms suggestive of subtle elbow instability. The components of the lateral collateral ligament were identified; tears of the ulnar band were noted in all symptomatic patients. The anterior fibers of the lateral collateral ligament, including the annular ligament, were intact. All symptomatic patients subsequently underwent surgical exploration and reconstruction. Positive clinical findings were demonstrated at examination performed while the patients were under anesthesia. All tears of the ulnar band were confirmed. With use of appropriate pulse sequences, MR imaging is an effective tool in the preoperative, noninvasive diagnosis of posterolateral rotatory instability.

Biomechanical evaluation of the medial collateral ligament of the elbow

Article

Sep 1997

Unlabelled: Anatomical dissection and biomechanical testing were used to study twenty-eight cadaveric elbows in order to determine the role of the medial collateral ligament under valgus loading. The medial collateral ligament was composed of anterior, posterior, and occasionally transverse bundles. The anterior bundle was, in turn, composed of anterior and posterior bands that tightened in reciprocal fashion as the elbow was flexed and extended. Sequential cutting of the ligament was performed while rotation caused by valgus torque was measured. The anterior band of the anterior bundle was the primary restraint to valgus rotation at 30, 60, and 90 degrees of flexion and was a co-primary restraint at 120 degrees of flexion. The posterior band of the anterior bundle was a co-primary restraint at 120 degrees of flexion and a secondary restraint at 30 and 90 degrees of flexion. The posterior bundle was a secondary restraint at 30 degrees only. The reciprocal anterior and posterior bands have distinct biomechanical roles and theoretically may be injured separately. The anterior band was more vulnerable to valgus overload when the elbow was extended, whereas the posterior band was more vulnerable when the elbow was flexed. The posterior bundle was not vulnerable to valgus overload unless the anterior bundle was completely disrupted. The intact elbows rotated a mean of 3.6 degrees between the neutral position and the two-newton-meter valgus torque position. Cutting of the entire anterior bundle caused an additional 3.2 degrees of rotation at 90 degrees of flexion, where the effect was greatest. Clinical relevance: Physical findings in a patient who has an injury of the anterior bundle may be subtle, and an examination should be performed with the elbow in 90 degrees of flexion for greatest sensitivity. As the anterior bundle is the major restraint to valgus rotation, reconstructive procedures should focus on anatomical reproduction of that structure. Parallel limbs of tendon graft placed from the inferior aspect of the medial epicondyle to the area of the sublimis tubercle will simulate the reciprocal bands of the anterior bundle. Temporary immobilization with the elbow in flexion may relax the critically important anterior band of the reconstruction during healing.

Imaging of Posttraumatic and Soft Tissue Dysfunction of the Elbow

Article

Feb 2000

Hollis G Potter

The inherent obliquity of the elbow produces a challenge to the radiologist. In the treatment of elbow trauma, comprehensive evaluation includes detection of bone, cartilage, ligament, and tendon injury. In most cases, plain radiographs remain the initial imaging mainstay for evaluation of the elbow, followed by properly performed magnetic resonance imaging with thin (1.5-2 mm) sections and appropriate pulse sequencing to provide differential contrast between subchondral bone, cartilage, and joint fluid. Vigilant attention to imaging technique obviates the need for additional intraarticular contrast agent, which converts the magnetic resonance imaging to an invasive procedure and, in many cases, increases the cost. The advent of magnetic resonance angiography has provided an important noninvasive diagnostic means to detect associated vascular injury. In addition, computed tomography imaging, particularly with concomitant three-dimensional reformations, provides comprehensive fracture assessment. Postprocessing capabilities include rotation of three-dimensional models and subtraction programs that may be useful in disclosing subtle fracture components. Finally, ultrasound increasingly is being accepted as an important imaging modality by which to detect tendinous and soft tissue injury and has the distinct advantage of being able to impart dynamic load to muscle tendon units.

Ligamentous Stabilizers Against Posterolateral Rotatory Instability of the Elbow

Article

Dec 2001

The lateral ulnar collateral ligament, the entire lateral collateral ligament complex, and the overlying extensor muscles have all been suggested as key stabilizers against posterolateral rotatory instability of the elbow. The purpose of this investigation was to determine whether either an intact radial collateral ligament alone or an intact lateral ulnar collateral ligament alone is sufficient to prevent posterolateral rotatory instability when the annular ligament is intact. Sequential sectioning of the radial collateral and lateral ulnar collateral ligaments was performed in twelve fresh-frozen cadaveric upper extremities. At each stage of the sectioning protocol, a pivot shift test was performed with the arm in a vertical position. Passive elbow flexion was performed with the forearm maintained in either pronation or supination and the arm in the varus and valgus gravity-loaded orientations. An electromagnetic tracking device was used to quantify the internal-external rotation and varus-valgus angulation of the ulna with respect to the humerus. Compared with the intact elbow, no differences in the magnitude of internal-external rotation or maximum varus-valgus laxity of the ulna were detected with only the radial collateral or lateral ulnar collateral ligament intact (p > 0.05). However, once the entire lateral collateral ligament was transected, significant increases in internal-external rotation (p = 0.0007) and maximum varus-valgus laxity (p < 0.0001) were measured. None of the pivot shift tests had a clinically positive result until the entire lateral collateral ligament was sectioned. This study suggests that, when the annular ligament is intact, either the radial collateral ligament or the lateral ulnar collateral ligament can be transected without inducing posterolateral rotatory instability of the elbow.

MR imaging of ligament injuries to the elbow

Abstract

No full-text available

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