The Journal of Bone and Joint Surgery (American). 2008;90:2416-2422.
doi:10.2106/JBJS.G.01448
© 2008 The Journal of Bone and Joint Surgery, Inc.
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Traumatic Valgus Instability of the Elbow: Pathoanatomy and Results of Direct Repair

Marc J. Richard, MD1, J. Mack Aldridge, III, MD2, Ethan R. Wiesler, MD3 and David S. Ruch, MD4

1 Division of Orthopaedic Surgery, Duke University Medical Center, 3609 Southwest Durham Drive, Durham, NC 27707. E-mail address: marc.richard{at}duke.edu
2 Division of Orthopaedic Surgery, Duke University Medical Center, 3116 N. Duke Street, Durham, NC 27704
3 Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157
4 Division of Orthopaedic Surgery, Duke University Medical Center, Box 3466, Durham, NC 27710
Investigation performed at Duke University Medical Center, Durham, and Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Background: The medial collateral ligament provides valgus stability to the elbow. The purpose of the present study was to describe the pathoanatomy of acute traumatic medial collateral ligament ruptures and to report the rationale and results of direct repair.

Methods: Between 1996 and 2006, eleven athletes presented with acute rupture of the medial collateral ligament of the elbow and no history of dislocation. Three patients had received steroid injections for the treatment of medial epicondylitis, but none had a history of medial elbow insufficiency. All patients demonstrated gross valgus instability on clinical examination and medial joint space widening on valgus stress radiographs. Complete avulsion of the medial collateral ligament from its humeral origin was documented with magnetic resonance imaging in all patients. Operative findings uniformly demonstrated avulsion of the flexor-pronator muscles with distal retraction. The underlying medial collateral ligament was avulsed in a sleeve-like fashion from the denuded medial epicondyle. The ligament was directly reattached to its footprint. The avulsed flexor-pronator tendon was repaired to the residual tendon with use of interrupted figure-of-eight nonabsorbable sutures. All patients were followed for a minimum of sixteen months with serial clinical examinations, radiographs, and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

Results: Full active range of motion was achieved in ten patients; the remaining patient had a 20° flexion contracture. Three patients had acute ulnar nerve palsies at the time of the injury, and all three recovered complete motor and sensory function by six months after the injury. Nine of the eleven patients returned to competitive college athletics between four and six months. The mean DASH score at the time of the most recent follow-up was 6.

Conclusions: Direct repair of an acute traumatic medial collateral ligament avulsion of the elbow reliably restores valgus stability, even in throwing athletes.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.


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Letters to the Editor:

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Traumatic Valgus Instability of the Elbow: Pathoanatomy and Results of Direct Repair
Sunil Gurpur Kini, MBBS,M.S(Ortho),D.N.B(Ortho)
JBJS Online, 25 Nov 2008 [Full text]
Drs. Richard and Ruch respond to Dr. Kini
Marc J. Richard, MD, et al.
JBJS Online, 25 Nov 2008 [Full text]