Elbow Collateral Ligament/Biceps

a.Collateral Ligament/Biceps

What is a Distal Biceps Rupture?
A distal biceps rupture occurs when the biceps tendon tears away from its attachment to the radius, a bone in the forearm. The biceps tendon is responsible for turning the palm face up and for flexing the elbow. Unlike the shoulder, there is only one attachment site for the biceps tendon in the forearm. Therefore, patients with Distal biceps ruptures will have significant loss of strength in rotation of the forearm and elbow flexion.

What causes a Distal Biceps Rupture?
Distal biceps ruptures generally result from heavy lifting, particularly with the elbows bent to around 90 degrees. Tendonitis, or inflammation of the portion of the muscle which attaches to the bone, may precede the rupture.

What are the symptoms?
Often, the patient feels a ‘pop’ in the elbow, followed by immediate pain and swelling. A bruise forms over the lower arm and elbow. There will be an immediate loss of strength. When the swelling subsides, a deformity will be present in the arm. Because the biceps muscle is under tension, it will retract up into the arm if its distal attachment ruptures. This causes the muscle to appear hollowed out in the lower part of arm, and balled up in the upper part.

How is a Distal Biceps Rupture diagnosed?
Distal biceps ruptures are diagnosed on clinical exam. Tenderness is present in the forearm where the tear occurred. The arm is swollen and painful, and a defect is seen in the lower portion of the muscle. X-rays are normal. MRI will confirm the tear.

How is it treated?
Non-operative

Because of the loss of strength, which is associated with these tears, non-operative treatment is recommended for only those patients who are unable to undergo surgery.

Operative
The surgeon will make an incision just below the crease in the elbow and locate the end of the torn tendon. He will then trim this to fresh, healthy tissue and suture the tip. The attachment site is exposed, and a socket created in the bone. The tendon is inserted into the socket and is held in place using a screw, button or both.

b. Ulnar Collateral Ligament Rupture (UCL)

What is an Ulnar Collateral Ligament Rupture?
The Ulnar collateral ligament, also known as the medial collateral, or ‘Tommy John’ ligament, helps to stabilize the elbow joint. It does so by connecting the ulna, a bone in the forearm, to the humerus, or arm bone. When this ligament is stretched, or injured, the bones of the elbow may separate during intense activities, such as throwing. This causes pain on the inside of the elbow.

What causes an Ulnar Collateral Ligament Rupture?
Trauma is the main cause of ulnar collateral ligament tears. These occur with direct blows to the outside of the elbow, or with elbow dislocations. In throwing athletes, repetitive use may lead to stretching of the ligament. When the ligament is stretched too far, it no longer functions. Throwing related tears of the UCL occur with overuse, or when the muscles that stabilize the elbow joint are fatigued.

What are the symptoms?
Patients will complain of pain over the attachment site of the ulnar collateral ligament on the ulna. There may be swelling in the joint, bruising, and loss of elbow motion. In tears that occur suddenly, a ‘pop’ may be heard or felt. Throwing athletes will complain of loss of velocity and control.

How is a UCL tear diagnosed?
A tear is diagnosed on physical exam. The surgeon will press on the ligament and reproduce pain. Swelling or motion loss can be identified in the elbow. A milking maneuver or moving stress test designed to test the ligament causes pain. X-rays are usually normal, but in severe case, a stress x-ray of the elbow may show widening of the joint. An MRI may show the tear, particularly if it occurs in the setting of trauma or if there is fluid in the joint. For tears occurring without trauma, such as those in throwers, the ligament may appear normal on MRI. Adding dye to the joint prior to the MRI will increase the likelihood that a tear will be identified.

How is it treated?

Non-operative
Most patients can be treated non-operatively with rest, ice, anti-inflammatory medications and physical therapy. A brace or sling may be prescribed for comfort. Activity may be resumed when normal range of motion and strength return.

Operative
For throwing athletes who wish to continue their careers, surgery is recommended. The surgeon will reconstruct a new ligament using a tendon found in the forearm. The tendon is removed, and tunnels are drilled on both sides of the elbow where the old ligament attached. The tendon is routed through those tunnels, and sewn to itself, or held in place with screws. A splint is applied initially, and physical therapy is begun to preserve motion at the elbow joint.

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