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Current Reviews in Musculoskeletal Medicine

Erschienen in:

27.01.2020 | Injuries in Overhead Athletes (J Dines and C Camp, Section Editors)

Review of Anatomy of the Medial Ulnar Collateral Ligament Complex of the Elbow

verfasst von: Mark E. Cinque, Mark Schickendantz, Salvatore Frangiamore

Erschienen in: Current Reviews in Musculoskeletal Medicine | Ausgabe 1/2020

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Abstract

Purpose of Review

The importance of both the static and dynamic stabilizers of the medial elbow for the throwing athlete has been demonstrated in recent studies. Furthermore, recent anatomic studies have demonstrated the insertion of the anterior bundle (UCL) to be more distal and elongated, which has implications for surgical reconstruction of the UCL. The purpose of this review is to highlight recent anatomic and biomechanical studies evaluating the anatomy and reconstructions of the medial elbow.

Recent Findings

Recent literature has highlighted the crucial role of the dynamic stabilizers in resisting valgus force, especially during the throwing motion. The dynamic stabilizers of the medial elbow include the flexor pronator mass, specifically the flexor carpi ulnaris (FCU) and flexor digitorum superficialis (FDS). The clinical importance of these findings cannot be under stated, as unrecognized dynamic stabilizer injury can lead to increased stress on a native or reconstructed UCL in the throwing athlete.

Summary

The medial ulnar collateral ligament complex of the elbow has a crucial role in providing both static and dynamic elbow stability. Most notably, the anterior bundle (UCL) provides the primary resistance to valgus and rotational stresses, especially during throwing motion. An understanding of the humeral and ulnar footprints and their relationships with surrounding structures is necessary to restore the native isometry of the medial complex of the elbow during UCL reconstruction. The flexor pronator musculature plays an essential role in dynamic stability, and the intimate relationship of the FCU and FDS with the ulnar insertion of the UCL should be considered to optimize recovery and outcomes with repair or reconstruction.

•• Camp CL, Tubbs TG, Fleisig GS, Dines JS, Dines DM, Altchek DW, et al. The relationship of throwing arm mechanics and elbow varus torque: Within-Subject Variation for Professional Baseball Pitchers Across 82,000 Throws. Am J Sports Med. 2017;45:3030–5 Purpose: To describe the within-subject relationship between elbow varus torque and arm slot and arm rotation in professional baseball pitchers. Methods: A total of 81 professional pitchers performed 82,000 throws while wearing a motusBASEBALL sensor and sleeve. These throws represented a combination of throw types, such as warm-up/catch, structured long-toss, bullpen throwing from a mound, and live game activity. Variables recorded for each throw included arm slot (angle of the forearm relative to the ground at ball release), arm speed (maximal rotational velocity of the forearm), arm rotation (maximal external rotation of the throwing arm relative to the ground), and elbow varus torque. Linear mixed-effects models and likelihood ratio tests were used to estimate the relationship between elbow varus torque and arm slot, arm speed, and arm rotation within individual pitchers. Results: All 3 metrics—arm slot (χ²= 428,P< .001), arm speed (χ²= 57,683,P< .001), and arm rotation (χ²= 1392,P< .001)—were found to have a significant relationship with elbow varus torque. Within individual athletes, a 1-N m increase in elbow varus torque was associated with a 13° decrease in arm slot, a 116°/s increase in arm speed, and an 8° increase in arm rotation. Conclusion: Elbow varus torque increased significantly as pitchers increased their arm rotation during the arm cocking phase, increased the rotational velocity of their arm during the arm acceleration phase of throwing, and decreased arm slot at ball release. Thus, shoulder flexibility, arm speed, and elbow varus torque (and likely injury risk) are interrelated and should be considered collectively when treating pitchers. CrossRef

Dodson CC, Altchek DW. Ulnar collateral ligament reconstruction revisited: the procedure I use and why. Sports Health. 2012;4:433–7.CrossRef

Udall JH, Fitzpatrick MJ, McGarry MH, Leba TB, Lee TQ. Effects of flexor-pronator muscle loading on valgus stability of the elbow with an intact, stretched, and resected medial ulnar collateral ligament. J Shoulder Elb Surg. 2009;18:773–8.CrossRef

Alcid JG, Ahmad CS, Lee TQ. Elbow anatomy and structural biomechanics. Clin Sports Med. 2004;23(503–517):vii.

•• Frangiamore SJ, Moatshe G, Kruckeberg BM, Civitarese DM, Muckenhirn KJ, Chahla J, et al. Qualitative and quantitative analyses of the dynamic and static stabilizers of the medial elbow: an anatomic study. The American Journal of Sports Medicine. 2018;46:687–94 Purpose: To perform qualitative and quantitative anatomic evaluations of the medial elbow-UCL complex with specific attention to pertinent osseous and soft tissue landmarks. Methods: Ten nonpaired, fresh-frozen human cadaveric elbows (mean age, 54.1 years [range, 42–64 years]; all male) were utilized for this study. Quantitative analysis was performed with a 3-dimensional coordinate measuring device to quantify the location of pertinent bony landmarks and tendon and ligament footprints on the humerus, ulna, and radius. Results: The anterior bundle of the UCL attached 8.5 mm (95% CI, 6.9–10.0) distal and 7.8 mm (95% CI, 6.6–9.1) lateral to the medial epicondyle, 1.5 mm (95% CI, 0.5–2.5) distal to the sublime tubercle, and 7.3 mm (95% CI, 6.1–8.5) distal to the joint line on the ulna along the ulnar ridge. The flexor digitorum superficialis (FDS) ulnar tendinous insertion was closely related and interposed within the anterior bundle of the UCL, overlapping with 45.6% (95% CI, 38.1–53.6) of the length of the anterior bundle of the UCL. The flexor carpi ulnaris (FCU) attached 1.9 mm (95% CI, 0.8–2.9) posterior and 1.3 mm (95% CI, 0.6–3.2) proximal to the sublime tubercle and overlapped with 20.9% (95% CI, 7.2–34.5) of the area of the distal footprint of the anterior bundle of the UCL. Conclusion: The anterior bundle of the UCL had consistent attachment points relative to the medial epicondyle and sublime tubercle. The ulnar limb of the FDS and FCU tendons demonstrated consistent insertions onto the ulnar attachment of the anterior bundle of the UCL. These anatomic relationships are important to consider when evaluating distal UCL tears both operatively and nonoperatively. Excessive stripping of the sublime tubercle should be avoided during UCL reconstruction to prevent violation of these tendinous attachments. CrossRef

Lin F, Kohli N, Perlmutter S, Lim D, Nuber GW, Makhsous M. Muscle contribution to elbow joint valgus stability. J Shoulder Elb Surg. 2007;16:795–802.CrossRef

Park MC, Ahmad CS. Dynamic contributions of the flexor-pronator mass to elbow valgus stability. J Bone Joint Surg Am. 2004;86-a:2268–74.CrossRef

•• Camp CL, Jahandar H, Sinatro AM, Imhauser CW, Altchek DW, Dines JS. Quantitative anatomic analysis of the medial ulnar collateral ligament complex of the elbow. Orthop J Sports Med. 2018;6:2325967118762751 Purpose: To quantify the anatomy of the MUCLC, including the anterior bundle (AB), posterior bundle (PB), and transverse ligament (TL). Methods: Ten unpaired, fresh-frozen cadaveric elbows underwent 3-dimensional (3D) digitization and computed tomography with 3D reconstruction. Ligament footprint areas and geometries, distances to key bony landmarks, and isometry were determined. A surgeon digitized the visual center of each footprint, and this location was compared with the geometric centroid calculated from the outline of the digitized footprint. Results: The mean surface area of the AB was 324.2 mm², with an origin footprint of 32.3 mm²and an elongated insertional footprint of 187.6 mm²(length, 29.7 mm). The mean area of the PB was 116.6 mm²(origin, 25.9 mm²; insertion, 15.8 mm²), and the mean surface area of the TL was 134.5 mm²(origin, 21.2 mm²; insertion, 16.7 mm²). The geometric centroids of all footprints could be predicted within 0.8 to 1.3 mm, with the exception of the AB insertion centroid, which was 7.6 mm distal to the perceived center at the apex of the sublime tubercle. While the PB remained relatively isometric from 0° to 90° of flexion (P= .606), the AB lengthened by 2.2 mm (P< .001). Conclusions: Contrary to several historical reports, the insertional footprint of the AB was larger, elongated, and tapered. The TL demonstrated a previously unrecognized expansive soft tissue insertion directly onto the AB, and additional analysis of the biomechanical contribution of this structure is needed. PubMedPubMedCentral

• Dugas JR, Ostrander RV, Cain EL, Kingsley D, Andrews JR. Anatomy of the anterior bundle of the ulnar collateral ligament. J Shoulder Elbow Surg. 2007;16:657–60 The purpose of this project was to study the anatomy of the anterior bundle of the ulnar collateral ligament and provide anatomic measurements not previously described. Thirteen fresh-frozen cadaver elbows were dissected. A 3-dimensional, electromagnetic, digitizing device was used to measure several anatomic parameters of the anterior bundle of the ulnar collateral ligament. The width of the ligament was not uniform, increasing distally toward the insertion. The average area of the origin was 45.5 mm², and the average area of the insertion was 127.8 mm². The edge of the insertion was separated from the ulna articular margin by an average of 2.8 mm. The study provides quantitative data describing the anatomy of the anterior bundle of the ulnar collateral ligament. This information may prove useful in surgical techniques designed to reproduce the anatomy and biomechanics of the elbow after injury. CrossRef

10.

Farrow LD, Mahoney AP, Sheppard JE, Schickendantz MS, Taljanovic MS. Sonographic assessment of the medial ulnar collateral ligament distal ulnar attachment. J Ultrasound Med. 2014;33:1485–90.CrossRef

11.

•• Lall AC, Beason DP, Dugas JR, Cain EL Jr. The effect of humeral and ulnar bone tunnel placement on achieving ulnar collateral ligament graft isometry: A Cadaveric Study. Arthroscopy. 2019;35:2029–34 Purpose: To assess simulated ulnar collateral ligament (UCL) graft length change, using surgically dissected anatomic landmarks, between multiple combinations of humeral and ulnar bone tunnels. Methods: Three equidistant humeral and ulnar tunnels were created at each UCL footprint of 10 cadaveric elbows. Suture was passed between 9 possible tunnel combinations for each elbow and affixed to an isometry gauge. Each elbow was moved through an arc of 0, 30, 60, 90, and 120 for each tunnel combination. Changes in isometry gauge spring displacement (and, in effect, tension) were recorded. Results: There was an overall significant effect (P< .0001) of tunnel placement at all degrees of flexion. Pairwise comparisons revealed increases in displacement between the central and posterior tunnel positions of the medial epicondyle, with significant differences (P> .0009) occurring when paired with both the central and posterior aspect of the sublime tubercle. Significant differences (P< .0001) were noted between the anterior and posterior humeral tunnel positions. Conclusions: Simulated UCL graft isometry is dependent upon optimal bone tunnel placement. No significant differences were noted between ulnar tunnel locations when paired with any given humeral tunnel. Conversely, deviation anterior or posterior from the centroid of the UCL footprint on the medial epicondyle significantly affected isometry at all degrees of flexion recorded with the greatest amount of displacement occurring with pairi4ng of posterior tunnels on both the humeral and ulnar footprints. CrossRef

12.

Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. Am J Sports Med. 1983;11:315–9.CrossRef

13.

•• Erickson BJ, Fu M, Meyers K, Camp CL, Altchek DW, Coleman SH, et al. The middle and distal aspects of the ulnar footprint of the medial ulnar collateral ligament of the elbow do not provide significant resistance to valgus stress: a biomechanical study. Orthop J Sports Med. 2019;7, 2325967118825294 Purpose: The purpose of this study was to determine the contribution of each part of the UCL footprint to the elbow valgus stability provided by the UCL. It was hypothesized that the distal two-thirds of the ulnar UCL footprint would not contribute significantly to valgus stability provided by the UCL. Methods: Fifteen cadaveric arms were dissected to the capsuloligamentous elbow structures and potted. A servohydraulic load frame was used to place 5 N m of valgus stress on the intact elbow at 30°, 60°, 90°, and 120° of flexion. The UCL insertional footprint was measured and divided into thirds (proximal, middle, and distal). One-third of the UCL footprint was elevated off the bone (leaving the ligament in continuity), and the elbow was retested at the same degrees of flexion. This was repeated until the entire UCL footprint on the ulna was sectioned. Each elbow was randomized for how the UCL would be sectioned (sectioning the proximal, then middle, and then distal third or sectioning the distal, then middle, and then proximal third). Ulnohumeral joint gapping (millimeters) was recorded with a 3-dimensional motion capture system using physical and virtual markers. Two-group comparisons were made between each sectioned status versus the intact condition for each flexion angle. Results: When the UCL was sectioned from distal to proximal, none of the ligaments failed prior to complete sectioning. When the UCL was sectioned from proximal to distal, 3 of the 6 ligaments failed after sectioning of the proximal third, while 2 more failed after the proximal and middle thirds were sectioned. Of the specimens with the distal third of the ligament sectioned first, no significant differences were found between intact, distal third cut, and distal plus middle thirds cut at all flexion angles. Conclusion: The middle and distal thirds of the insertional footprint of the UCL on the ulna did not significantly contribute to gap resistance at 5 N m of valgus load. The proximal third of the footprint is the primary resistor of valgus load.

14.

Beckett KS, McConnell P, Lagopoulos M, Newman RJ. Variations in the normal anatomy of the collateral ligaments of the human elbow joint. J Anat. 2000;197(Pt 3):507–11.CrossRef

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Eygendaal D, Valstar ER, Sojbjerg JO, Rozing PM. Biomechanical evaluation of the elbow using roentgen stereophotogrammetric analysis. Clin Orthop Relat Res. 2002:100–5.

16.

• Farrow LD, Mahoney AJ, Stefancin JJ, Taljanovic MS, Sheppard JE, Schickendantz MS. Quantitative analysis of the medial ulnar collateral ligament ulnar footprint and its relationship to the ulnar sublime tubercle. Am J Sports Med. 2011;39:1936–41 Background: The medial ulnar collateral ligament is the major soft tissue restraint to valgus displacement of the elbow. Currently, little has been published regarding the medial ulnar collateral ligament's ulnar footprint. Hypothesis: The medial ulnar collateral ligament has a long attachment onto the ulna and the anatomy of the footprint is consistent. Methods: The authors studied the morphologic characteristics of the ulnar footprint of the medial ulnar collateral ligament in 10 fresh-frozen cadaveric specimens, 100 osseous specimens, and with 3-dimensional computed tomography in an additional 10 osseous specimens. They measured the length of the anterior band's ulnar attachment and the entire ligament length. They also measured the length of the osseous ridge, which extends distally from the sublime tubercle in both osseous specimens and on computed tomography. Results: The mean length of the medial ulnar collateral ligament was 53.9 mm and the mean length of the ulnar soft tissue footprint was 29.2 mm. The authors identified an osseous ridge that extended distally from the sublime tubercle to just medial to the ulnar insertion of the brachialis muscle tendon. This osseous ridge was present in all osseous and fresh-frozen cadaveric specimens. The mean length of this osseous ridge was 24.5 mm. Conclusion: The medial ulnar collateral ligament has a long attachment along the proximal ulna. The ligament attaches to a previously undescribed ridge of bone located on the medial aspect of the proximal ulna, the medial ulnar collateral ligament ridge. This ridge is present in all skeletal specimens.CrossRef

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Regan WD, Korinek SL, Morrey BF, An KN. Biomechanical study of ligaments around the elbow joint. Clin Orthop Relat Res. 1991:170–9.

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Floris S, Olsen BS, Dalstra M, Sojbjerg JO, Sneppen O. The medial collateral ligament of the elbow joint: anatomy and kinematics. J Shoulder Elb Surg. 1998;7:345–51.CrossRef

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Armstrong AD, Ferreira LM, Dunning CE, Johnson JA, King GJ. The medial collateral ligament of the elbow is not isometric: an in vitro biomechanical study. Am J Sports Med. 2004;32:85–90.CrossRef

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Bryce CD, Armstrong AD. Anatomy and biomechanics of the elbow. Orthop Clin North Am. 2008;39:141–154, v.CrossRef

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Morrey BF, An KN. Functional anatomy of the ligaments of the elbow. Clin Orthop Relat Res. 1985:84–90.

22.

•• Safran M, Ahmad CS, Elattrache NS. Ulnar collateral ligament of the elbow. Arthroscopy. 2005;21:1381–95 Recent advances in the diagnosis and treatment of the overhead athlete’s elbow has led the medical community to understand that the ulnar collateral ligament (UCL) of the elbow is more commonly injured than originally thought. Injury can result in secondary symptoms and problems in other regions of the elbow. Sports requiring an overhead motion, such as throwing a ball, hitting a ball overhead, or serving a tennis ball, impart a valgus stress on the elbow that is resisted by the UCL. Throwing sidearm or hitting a forehand in tennis, squash, or racquetball may also impart a valgus stress to the elbow. Repeated or excessive valgus stress places a force on the UCL that may result in injury to the ligament. Injury to the UCL may result in problems in other areas of the elbow, including the ulnar nerve, the flexor-pronator musculotendinous unit, the radiocapitellar joint and the posterior compartment of the elbow, in addition to being a cause of loose bodies within the elbow. This article reviews the anatomy, biomechanics, and pathophysiology of injury to the UCL and injuries to the other structures that result from UCL injury. Also reviewed are patient history, examination techniques, tests that help confirm the diagnosis of UCL injury, and treatment of the injured UCL. CrossRef

23.

Callaway GH, Field LD, Deng XH, Torzilli PA, O'Brien SJ, Altchek DW, et al. Biomechanical evaluation of the medial collateral ligament of the elbow. J Bone Joint Surg Am. 1997;79:1223–31.CrossRef

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Mullen DJ, Goradia VK, Parks BG, Matthews LS. A biomechanical study of stability of the elbow to valgus stress before and after reconstruction of the medial collateral ligament. J Shoulder Elb Surg. 2002;11:259–64.CrossRef

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Sojbjerg JO, Ovesen J, Nielsen S. Experimental elbow instability after transection of the medial collateral ligament. Clin Orthop Relat Res. 1987:186–90.

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Remaley DT, Fincham B, McCullough B, Davis K, Nofsinger C, Armstrong C, et al. Surface electromyography of the forearm musculature during the windmill softball pitch. Orthop J Sports Med. 2015;3:2325967114566796.CrossRef

Titel: Review of Anatomy of the Medial Ulnar Collateral Ligament Complex of the Elbow
verfasst von: Mark E. Cinque
Mark Schickendantz
Salvatore Frangiamore
Publikationsdatum: 27.01.2020
Verlag: Springer US
Erschienen in: Current Reviews in Musculoskeletal Medicine / Ausgabe 1/2020
Elektronische ISSN: 1935-9748
DOI: https://doi.org/10.1007/s12178-020-09609-z

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