The elbow is formed by the junction of the humerus (upper arm bone), and radius and ulna (forearm bones). These three bones articulate to form the elbow joint, which is held and supported by muscles and strong ligaments called the lateral ligament (on the outer side) and ulnar collateral ligament (on the inner side). Injury to these ligaments cause elbow instability and dislocation of the joint. Recurrent or chronic elbow instability is characterized by repeated looseness of the joint and feeling that it may move out of place. Other symptoms include catching, clicking or locking of the elbow. It may also be associated with a fracture of the ulna bone.
Recurrent or chronic elbow instability may be caused by trauma, falling on an outstretched arm or repeated stress as seen in sports activities that involve overhead movement of the arm.
When you present to the clinic with elbow instability, your doctor will review your medical history, perform a detailed physical exam and order imaging studies (X-ray and MRI scan) to diagnose recurrent elbow instability.
Non-surgical treatment with bracing, NSAIDs, activity modification and physical therapy may be all that you need to manage your instability. However, extreme stress and tearing of the ligaments may require surgery, where your surgeon repairs the ligament and fixes the elbow fracture with pins or screws or replaces and reconstructs the damaged ligament with a tissue graft.
The elbow is a hinge joint made up of 3 bones – humerus, radius and ulna. The bones are held together by ligaments to provide stability to the joint. Muscles and tendons move the bones around each other and help in performing various activities. Elbow dislocation occurs when the bones that make up the joint are forced out of alignment.
Elbow dislocations usually occur when a person falls onto an outstretched hand. Elbow dislocations can also occur from any traumatic injury such as motor vehicle accidents. When the elbow is dislocated you may have severe pain, swelling, and lack of ability to bend your arm. Sometimes you cannot feel your hand or may have no pulse in your wrist because arteries and nerves run along your elbow may be injured.
To diagnose elbow dislocation your doctor will examine your arm. Your doctor will check the pulses at the wrist and will evaluate the circulation to the arm. An X-ray is necessary to determine if there is a break in the bone. An arteriogram, an x-ray of your artery can be helpful to know if the artery is injured.
An elbow dislocation is a serious injury and therefore requires immediate medical attention. At home, you may apply an ice pack to the elbow to ease pain and swelling. However, it is important to see your doctor for help. You can also check if the arteries and nerves are injured or remain intact. You can feel your pulse by pressing tips of your fingers at the base of your wrist. They should turn white or blanch and a pink color should come back in 3 seconds. To check for nerves, first bend your wrist up and move your fingers apart and then touch your thumb to your little finger. You can also check for numbness all over your hand and arm. If you have problem with any of these tests you need to see your doctor right away.
You doctor will put your dislocated elbow back in place by pulling down your wrist and levering your elbow. This procedure is known as reduction. As it is a painful procedure you may be given medications to relieve your pain before the procedure. After the reduction, you may have to wear a splint to immobilize your arm at the elbow. After few days, you may also need to do gentle motion exercises to improve the range of motion and strength.
Elbow dislocations may be prevented if you avoid falling on outstretched arm or avoid situations that may cause falls such as walking at night or walking on slippery floors.
The ulnar collateral ligament (UCL), also called medial collateral ligament, is located on the inside of the elbow and connects the ulna bone to the humerus bone. It is one of the main stabilizing ligaments in the elbow especially with overhead activities such as throwing and pitching. When this ligament is injured or torn, it can end a professional athlete’s career unless surgery is performed.
The common symptoms associated with a UCL tear are as follows:
- Pain on inner side of the elbow
- Unstable elbow joint
- Numbness in the little finger or ring finger
- Decreased performance in activities such as throwing baseballs or other objects
Ulnar collateral ligament tear is usually caused by repetitive overhead throwing such as in baseball. The stress of repeated throwing on the elbow causes microscopic tissue tears and inflammation. With continued repetition, eventually the UCL can tear preventing the athlete from throwing with significant speed. If untreated, it can end an athlete’s professional career. UCL tear may also be caused by direct trauma such as with a fall, car accident, or work injury. Other causes include any activity that requires repetitive overhead motion of the arm such as tennis, pitching sports, fencing, and painting.
UCL tear should be evaluated by an orthopedic specialist for proper diagnosis and treatment. Your physician will perform the following:
- Medical history
- Physical examination including a valgus stress test to assess for elbow instability
Other tests such as X-rays and MRI scans may be ordered to confirm the diagnosis.
Your physician will recommend conservative treatment options to treat the symptoms associated with UCL injury unless you are a professional or collegiate athlete. In these cases, if the patient wants to continue in their sport, surgical reconstruction is performed.
Conservative treatment options that are commonly recommended for non-athletes include the following:
- Activity restrictions
- Ice compression
- Physical therapy
- Pulsed ultrasound to increase blood flow to the injured ligament and promote healing
- Professional instruction
If conservative treatment options fail to resolve the condition and symptoms persist for 6-12 months, your surgeon may recommend ulnar collateral ligament reconstruction surgery. UCL reconstruction surgery repairs the UCL by reconstructing it with a tendon from the patient’s own body (autograft) or from a cadaver (allograft). It is also referred to as Tommy John Surgery. The most frequently used tissue is the palmaris longus tendon in the forearm. The basic steps for UCL reconstruction surgery include the following:
- The surgery is performed in an operating room under regional or general anesthesia
- Your surgeon will make an incision over the medial epicondyle area
- Care is taken to move muscles, tendons, and nerves out of the way
- The donor tendon is harvested from either the forearm or below the knee
- Your surgeon drills holes into the ulna and humerus bones
- The donor tendon is then inserted through the drilled holes in a figure 8 pattern
- The tendon is attached to the bone surfaces with special sutures
- The incision is closed and covered with sterile dressings
- Finally a splint is applied with the elbow flexed at 90 degrees.
After surgery your surgeon will give you guidelines to follow, depending on the type of repair performed and the surgeon’s preference. Common post-operative guidelines include:
- Elevate your arm above heart level to reduce swelling
- Wear an immobilizing splint or cast for 1-3 weeks
- Apply ice packs to the surgical area to reduce swelling
- Keep the surgical incision clean and dry. Cover the area with plastic wrap when bathing or showering
- Physical therapy will be ordered for strengthening and stretching exercises after the removal of the splint or cast Professional athletes can expect a strenuous strengthening and range of motion rehabilitation program for 6-12 months before returning to their sport
- Eating a healthy diet and not smoking will promote healing
Risks and complications
As with any major surgery there are potential risks involved.
The majority of patients suffer from no complications following UCL Reconstruction surgery; however, complications can occur and include:
- Limited range of motion
- Nerve damage causing numbness, tingling, burning or loss of feeling in the hand and forearm area
- Cubital Tunnel Syndrome
- Elbow instability