Helping Surgeons Keep Up with Elbow Ligament Injuries

Continuing education takes many different forms and approaches for the health care professional. In this article, orthopedic surgeons are brought up-to-date on the diagnosis and treatment of lateral collateral ligament (LCL) injuries of the elbow. After reading the information on this condition, each surgeon can take a short exam in order to earn continuing education credits.

The article presented many facets of management of an elbow lateral collateral ligamentous injury. It was designed to create understanding, reflection, and thought on the part of the surgeon treating these kinds of problems. The authors made use of patient photos, X-rays, drawings of the soft tissue anatomy (muscles and ligaments), and even photographs of dissected cadavers showing specific locations of muscles, nerves, tendons, and ligaments.

Topic areas discussed included functional anatomy, etiology (cause), classification (how to describe the extent of injury), clinical examination and findings, as well as diagnostic imaging. The second half of the article addressed surgical considerations for reconstructive surgery and post-operative care.

The two main causes of lateral collateral ligament (LCL) damage are injury (e.g., torn or stretched joint capsule and/or ligaments) and dislocation (e.g., fall on the outstretched arm). Chronic, recurrent dislocation is referred to as instability and requires surgery. The surgeon uses tendon grafts to restore elbow joint stability and tries to return normal motion of the bones of the forearm.

The authors lead the reader through the details of the complex anatomy and coordination of all the soft tissues of the elbow. These are required to move the elbow and forearm through its full motion. This concept is referred to as functional anatomy. An understanding of functional anatomy is important because the surgeon will be called upon to return the patient's anatomy to as normal as possible. The goal is to help the patient once again regain full, smooth, and coordinated motion, strength, and function.

Based on the findings of the physical examination, X-rays (plain and stress radiographs), and MRIs, the surgeon will decide what is the best way to repair or reconstruct the anatomy to achieve these goals of restoration just described. There are many key factors to think about when planning the surgical procedure.

For example, the surgeon evaluates whether there are any fractures that must be addressed. Are there other soft tissues (besides the LCL) that are torn or damaged? What was the patient's anatomy like before the injury? There are always variations in shape, symmetry, and position of bone and soft tissues from person to person.

The surgeon must decide: is this going to be a repair procedure or reconstructive surgery? Studies have not been done to compare results of these two approaches. Therefore, the surgeon does not have evidence-based research on which to base his or her decisions in these matters. There are some studies reported. There just isn't enough evidence to support one approach over another.

Repair techniques becomes another area of surgical decision-making. What type of sutures should be used (bone anchors with nonabsorbable sutures are preferred by many surgeons). Should the sutures be placed through tunnels that require drilling through the bone? Even the position the arm is placed in during surgery becomes an important consideration.

Likewise, reconstruction techniques are being investigated. A table representing study results from 1991 to the present date is provided. Type of reconstruction, graft type, outcomes, and complications reported for 12 different studies are summarized for the reader's consideration.

And finally, a focus on postoperative protocols (i.e., how to treat the patient after surgery) concludes this continuing education document. Another table is presented summarizing treatment after surgery for the 12 studies mentioned above.

Elbow immobilization in a splint or brace was common for anywhere from one to six weeks. Position of the elbow in the device was reported and also varied from 45 degrees of elbow flexion up to 90 degrees with either full or slight forearm pronation (palm down position). Range-of-motion activities, progression through strengthening exercises, and return to sports (usually six months after surgery) were also reported for these 12 studies.

Anyone interested in the diagnosis, treatment, and follow-up for patients with recurrent lateral instability of the elbow due to lateral collateral ligament damage of the elbow will find this article of interest. Those who want to gain some continuing education credits can earn up to two credits.

References: Lee M. Reichel, MD, et al. Elbow Lateral Collateral Ligament Injuries. In The Journal of Hand Surgery. January 2013. Vol. 38A. No. 1. Pp. 184-201.