Mr Lee Van Rensburg
October 2015

Flexion extension axis

Centre capitellum to anteroinferior medial
epicondyle
J Shoulder Elbow Surg (2012) 21, 1006-1012
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
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Kinematic study
Did not separate LCL from LUCL
Found
 LCL important ulnohumeral stabilizer
 LCL stabilizes radial head
 Varus
 External rotation
 Ulno humeral stability independent of forearm rotation
JSES 1996;5:103-12

Concept ‘Y’ to LCL complex

Previous studies


Instability release superior band
No instability if release posterior band
Varus
External rotation
J Shoulder Elbow Surg 2002;11:53-9.)

Release of anterior band
increased laxity
Varus
 External rotation

Varus
External rotation
J Shoulder Elbow Surg 2002;11:53-9.)

Released anterior band


Then release posterior band


Laxity
Instability
If release anterior capsule and
Varus band
anterior

External rotation
effectively leave a LUCL, still tethers
ulna
J Shoulder Elbow Surg 2002;11:53-9.)

Important where LCL complex
injured

1. Humeral epicondylar bony avulsion – 8%
 Paediatric



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2. LCL Sleeve avulsion, bare epicondyle – 52%
3. Mid substance tear – 29%
4. Soft tissue ulnar avulsion – 5%
5. Bony ulnar avulsion – 1%
6. Combined – 6%
J Shoulder Elbow Surg 2003;12:391-6

Common extensor origin

Completely avulsed 66%
 Bare epicondyle

Dislocations worse than fracture
dislocations

Look at degree of displacement
J Shoulder Elbow Surg 2003;12:391-6

Approach dictated by injury

Beware superficial fascia may be
intact

Incise superficial fascia


‘Bomb’ gone off
Avulsion of CEO and LCL

Mass repair suture anchors
 5.5 twin fix,
 2 fibrewire

Axis of rotation middle of capitellum
Early movement
Ensure sound repair

If LCL Shredded midsubstance

Internal brace
 Anchor into middle capitellum
 Anchor supinator crest
 tie one set of sutures of fibrewire to each
other
?
Internal brace medial side

Kocher interval

Split -- Anconeus - ECU
Elevate anconeus on ulna to
expose supinator crest and lateral
face of proximal ulna
Palpate tubercle of supinator ridge
Expose supracondylar ridge
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

2 cm anterior and posterior
J Bone Joint Surg Am, 2000 May 01;82(5):724-724

2 drill holes in ulna



1st near tubercle on the supinator
crest
2nd - 1.25 cm at base of annular
ligament
Pass suture through two points
and offer up to lateral
epicondyle – isometric point


Usually more anterior than think
Remember needs to be tight in
extension (PLRI in ext)
J Bone Joint Surg Am, 2000 May 01;82(5):724-724
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
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Drill entry hole in lateral
epicondyle, widen for graft
Connect 2 exit holes ant and
post supracondylar ridge
Auto/ allo graft




Palmaris
Plantaris
Hamstring
15-16 cm gives 3 ply graft
J Bone Joint Surg Am, 2000 May 01;82(5):724-724

Humeral fixation
Several options
 One or both limbs of graft into isometric
point
 Stich two limbs together and pull with ‘Yoke’
stitch through tunnel anterior to
supracondylar ridge
 Free end of the graft just reaches the tunnel
– 2 ply to, pass free end back through
tunnels into ulna again or suture back onto
itself for 3 ply
 Tension 40 degrees flexion and full
pronation

J Bone Joint Surg Am, 2000 May 01;82(5):724-724
2000
2000
J Bone Joint Surg [Br] 2005;87-B:54-61.
2 strand
1 strand
Proximal
1 strand
Distal
No significant difference
J Shoulder Elbow Surg 2002;11:60-4