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Functional anatomy of the medial ligamentous
complex of the elbow. Its role in anterior
posterior instability
Impact Factor: 1.33 · DOI: 10.1007/s00276-001-0301-x · Source: PubMed



Pierre Mansat
University Hospital, Toulouse, FRANCE

Available from: Pierre Mansat
Retrieved on: 23 August 2015

Rongières E-mail: rongieres. The cutaneous incision was . Vaysse1 and J. The main question that exists in ligamentous injuries. 2. Its role in anterior posterior instability M. 16 . is whether or not repair of the medial ligamentous complex should be done. Material and methods We studied 35 fresh frozen cadaver elbows from 15 men and 10 women aged 40 to 86 years (average age 71 years). Akhavan2. F-31059 Toulouse cedex. because recent studies only describe an anterior bundle and a posterior bundle. 10 other elbows were dissected and used for the ligamentous section studies which were performed subcutaneously. France Received July 27. were dissected and resected. Posterior subluxation was obtained after an anterior capsulotomy medial epicondylectomy did not compromise the stability of the elbow after a complete section of the insertion of the deep fibers of the anterior bundle. All elbows in the study had mobility which was near to normal without operative scarring and without instability on initial tests.Collateral ligaments . 24 ] and the specific roles of the medial and lateral ligamentous complexes in elbow stability in the postero-anterior plane [3-13 . Mansat2.Original articles Functional anatomy of the medial ligamentous complex of the elbow. which are fundamental for postero -anterior stability of the elbow. superficial and deep. removing skin and subcutaneous tissue. France 2 Service de Chirurgie Orthopédique et Traumatologique. B écue 1 1 Laboratoire d'anatomie appliquée. passing between the muscles and the capsulo-ligamentous plane. Rongières 1. 133 route de Narbonne.m@chu-toulouse. but controversies still exist. M. 15 other elbows were excluded because they showed scarring or stiffness. F31062 Toulouse cedex. 15 . 10 -13 . H. Description of different ligamentous bundles of the collateral ulnar ligament This study was done with 25 elbows. Mansat2. We describe an intermediate bundle in two layers. P. Our goal was to precisely describe each ligamentous complex. The cadavers were studied within four days after death. Section of the anterior bundle lead to posterior subluxation of the elbow at 30-100° flexion in both supination and pronation. The goal of this study was to define the role of the medial ligamentous complex of the elbow in elbow instability and to describe the anatomy of the complex in 35 fresh-frozen cadaver elbows. The descriptive anatomy of the collateral ligg. concerning the description of the ligaments in the lateral plane [1. All classic descriptions include three bundles anterior. 8. We documented medial ligamentous complex anatomy and compared our results to those in the literature.Elbow joint . P.Pathomechanics Correspondence to: M. 18 ]. 1999 / Accepted in final form July 06. above all in the English literature. The medial epicondylar mm. intermediate and posterior by a cadaver study. and the anterior bundle of the medial ligamentous complex. of the elbow has been well known since the 19th century [22 ]. 2001 Key words: Instability . which disagrees with current literature. Université Paul Sabatier. We found two bundles at the level of the anterior portion and termed them superficial and deep. either associated with fractures or not. the transverse bundle being ulno-ulnar. Hôpital Purpan. Elements thus required for stability of the elbow are integrity of the articular surface of the humerus and the ulna. 25 elbows were dissected in order to describe the different bundles of the medial ligament complex and to precise the positions of the elbow that placed each in tension section of the different ligamentous bundles was done to study the role of each in elbow stability. especially the medial plane. Faculté de Médecine Abstract Abstract The question remains unanswered regarding the role of repair of medial ligament injuries associated with subluxation of the elbow and non-reconstructable radial head fracture and whether or not this will decrease the risk of chronic instability and cubitus valgus. Place du Docteur Baylac. 2.Functional anatomy .

a. Results The medial ligamentous complex (ulnar collateral ligament) It was composed of three primary bundles. anterior. posterior bundle . centered on the medial ligamentous plane. of Cooper. and an accessory bundle also called the arciforme bundle. 1 Drawing. On 10 elbows which were not dissected After section of the capsulo-ligamentous structures through a cutaneous approach. An analysis of tensioning of different bundles in different degrees of flexion and extension of the elbow from 0 to 140 degrees was performed in order to appreciate the role of each bundle and stability of the elbow. Medial ligamentous complex of the elbow (in elbow flexion). intermediate and posterior. The anterior bundle (Figs. distal to the joint line and elevated from distal to proximal. anterior bundle b. we performed an X-ray analysis of the postero-anterior stability of the elbow. the lig. 1-3) Fig. intermediate bundle (in French) a+b. Analysis of ligamentous factors in postero-anterior stability of the elbow On 25 dissected elbows After section of different ligamentous complexes. The fibers of the different muscles were cut transversely. anterior bundle for O'Driscoll c. disinserting their fibers from the capsule plane with dissection scissors in order to not injure the fibrous ligamentous structures. actually called the transverse bundle.. or as was in the past. one centimeter proximal to it and eight centimeters below it. and from the flexor carpi ulnaris to the flexor carpi radialis mm. The distribution of the different bundles of the medial ligamentous complex was studied and compared to the data of the literature.centered on the medial epicondyle. two centimeters long. the postero-anterior stability of the elbow was analyzed visually with photographs after flexion and extension.

The posterior bundle (Figs. 3) was demonstrated well after medial epicondylectomy. 3 Medial ligamentous complex of the elbow (in elbow flexion). a. Resection of the medial epicondyle. deep ground of the intermediate bundle b. and ended on the medial border of the coronoid process. superficial and deep. located immediately deep to and behind the anterior bundle.Fig. The intermediate bundle was tight in extension but its maximal tension was between 30° and 90° of flexion and it appeared lightly slackened beyond 120° of flexion. 2) . It was tight in extension and appeared relaxed after 90° of flexion. Several superficial fibers were prolonged to the medial border of the ulna. 1. and terminated on the medial border of the coronoid process. fused with the superficial layer. medial epicondyle resected to see the deep ground of the intermediate bundle It was weak and very thin. The superficial layer inserted on the anterior aspect and on the inferior border of the medial epicondyle. It was composed of two layers. The deep layer (Fig. It inserted in a fan shape from the junction of the medial epicondyle and trochlea up to the cartilaginous edge of the trochlea of the humerus. The intermediate bundle (Figs. 1-3) This was a thick fibrous layer flattened from front to back. It took origin from the anterior aspect of the medial epicondyle and ended on the medial border of the coronoid process. just behind the anterior bundle. deep to the tendon of the brachialis.

anterior bundle b. medial epicondyle It was fan shaped. posterior bundle ME. Its very oblique orientation in front and outside and the predominance of its fibers in the frontal plane would be the proof. Posterior subluxation was obtained after anterior capsulotomy. This might be because the medial epicondylar origin of the ligament is more of a ventral capsular reinforcement than an actual part of the ulnar collateral lig. a. semi -circularly on the medial border of the olecranon. had to resect the medial epicondyle [16 ]. 8. and a posterior band. It was completely relaxed in extension and tightened after 60° of flexion. 2 Medial ligamentous complex of the elbow (in elbow flexion). Study of postero-anterior stability of the elbow Dissected elbows The stability of the elbow was not compromised after section of the anterior bundle and/or posterior bundle of the medial ligamentous complex. and we add here the description in two planes (superficial and deep) of the middle or intermediate bundle (older literature) or the anterior bundle (English literature) of the ulnar collateral lig. Our study agrees with the descriptive anatomy of elbow ligaments published by classical French authors [22]. intermediate bundle (in French) a+b. Section of the intermediate bundle was followed by a posterior subluxation from 30° to 100° of elbow flexion. but the work of Callaway [4] made the opposite point in separating the anterior bundle into an anterior band (the most important for stability). anterior bundle for O'Driscoll c. This was recently described in literature with an anatomic study. 24 ]. including histology14]. that which we confirm. Discussion The majority of anatomic treatises in the English literature ignore the anterior bundle within the medial ligamentous complex [1.Fig. . in order to show this bundle. 2. 10-13 . but the concept was clearly established in the anatomic work of O'Driscoll who. We can reclassify our anterior bundle and intermediate bundle into one single actual anterior bundle to correspond to the English description.) [15 ]. It inserted proximally on the posterior inferior portion of the medial epicondyle (beneath and behind the intermediate bundle) and ended distally. in supination and in pronation. A medial epicondylectomy only compromised the stability of the elbow after complete section of the insertion of the deep fibers (dissection technique of O'Driscoll. Non dissected elbows The isolated section of the medial capsulo-ligamentous complex did not disturb the postero-anterior instability of the elbow.

and qualified them as secondary stabilizers (especially the wrist extensors). the authors propose a classification of postero-anterior instabilities of the elbow in three stages Stage 1 Postero-lateral subluxation Stage 2 Perched position (or posterior subluxation of the elbow) Stage 3 Posterior subluxation 3a Without rupture of the medial intermediate bundle 3b With rupture of the intermediate bundle. 7. MI. 14. 7. then completed by the injury to the medial complex without rupture to the intermediate bundle (Stage 3a) or with rupture of the intermediate bundle (3b). underlines the importance of the stabilizing role of muscular elements. The muscular tension of the elbow has a fundamental role but this has not been defined. then continuing further into a new hyperextension completing the posterior subluxation. The intricacy of the static and dynamic elements makes the analysis of their specific roles very complex.D. 8. 16. the comparison is not easy. 16. extending in a circumferential fashion to the postero-anterior capsule (Stage 2). capsulo-ligamentous and muscular. The theory based on the importance of medial lesions does not explain postero-lateral subluxations [15. USA) for his help in the translation. The clinical examination and a radiological exam under general anesthesia confirm the diagnosis It is question of axial compression of the elbow in slight flexion in valgus and supination (lateral pivot shift test). Acknowledgements: Thanks to M. References . and a lateral lesion was present in only 18 cases. Roux. (Detroit.The different tensions of the ligamentous bundles with flexion and extension are known [12. After studying cadavers compared to the clinical lesion. H. based on the importance of lesions of the lateral structures. 4. 19]. The mechanism of valgus does not appear to be necessary but it was present in the clinical situation. but this still must be defined. 7. Josefsson [9] found a medial lesion in all cases of his series of 31 subluxations explored surgically. 12. Our study is in agreement with the last theory with several exceptions. For him the isolated section of the lateral (radial) collateral lig. According to Schwab [20 ]. only gave a minimal instability or none at all. 16 ] and the disagreement existing in our series regarding the mechanism of subluxation in the dissected elbows and in the non -dissected elbows. a clinical entity above all encountered after surgical treatment of epicondylar pain (with disinsertion of the lateral ligamentous complex) or after posterior subluxation of the elbow. but our methodology being different. The stabilization factors of the elbow are multiple [1. 5. R. Pre-requisites for this stability are the integrity of the articular surfaces and the intermediate bundle of the medial and lateral ligamentous complexes. Osborne [18] underlined the role of repair laterally in the treatment of recurrent subluxations of the elbow.. The mechanism of posterior subluxation of the elbow was a subject of controversy in the literature [1. The beginning of the injury being rupture of the intermediate bundle of the lateral ligamentous complex (Stage 1). 19].-P. based on the importance of injury to the medial structures and the role of flexion. followed by a slight flexion that ruptures the posterior bundle. 13. The humero-ulnar articulation appears to be the chief element of postero -anterior stability of the elbow. supination and slight flexion explains best the different stages of postero -anterior instability of the elbow. Two theories disagree regarding the role of hyperextension. Additionally the disagreement existing in the literature about the importance of surgical repair of the intermediate bundle [9. hyperextension leads to injury to the intermediate bundle of the medial (ulnar) collateral lig. valgus and slight flexion [16]. 12 . 12. Variations in tension are explained by the approximation or separation of the points insertions of the different bundles with flexion and extension. 13. 16]. although authors have often since confirmed his theory [5. Also we were not able to obtain a distinction between stages 3a and 3b. 8. 13. thought to be an axial compression in supination. Joly. with passage of the coronoid behind the trochlea. Injury to the lateral ligamentous complex extending circumferentially to the medial side after axial compression of the elbow in valgus. The clinical signs were lateral pain with a feeling of instability without true subluxation. A biomechanical study evaluated the stabilizing role of the lateral epicondylar mm. 17]. More recently O'Driscoll and Morrey [15 . These different stages occur according to the same mechanism. They are osteo -cartilaginous. Desroques for their tecnical help and support for iconography and Joseph Failla M. 16 ] defined postero-lateral subluxation of the elbow. 19].

Cohen MS. Am J Sports Med 11 315-319 12. Inoue H (1999) Anatomic relation between the medial collateral ligament of the elbow and the humero-ulnar joint axis. Williams PL (1995) Gray's anatomy. Johnell O. Cotterill P (1965) Recurrent dislocation of the elbow. Mansat Ch. Morrey BF (1985) The elbow and its disorders. Martin BF (1958) The annular ligament of the superior radial ulnar Joint. function and biomechanics. Korinek S. Callaway GH. Akhavan H. An KN (1985) Functional anatomy of the ligaments of the elbow. J Bone Joint Surg 79-A 1223-1231 5. Rev Chir Orthop 58. Torzilli PA. Churchill Livingstone. arthrologie. An KN (1983) Articular and ligamentous contributions to the stability of the elbow joint. pp 490 -501 23. I 257-264 20. Woods GW. An K (1992) Elbow subluxation and dislocation a spectrum of instability. Clin Orthop 218 186-190 22. Senda M. Habernek H. J Bone Joint Surg 48-B 340-346 19. Basmajian JV. Dalstra M. Clin Orthop 146 42-52 21. pp 393 -397 3. O'Driscoll SW. Doin. Nielsen S (1987) Experimental elbow instability after trans-section of the medial collateral ligament. Bennett JB. pp 414-432. Tulbios HS (1980) Biomechanics of elbow instability the role of the medial collateral ligament. New York. suppl. Shigeyama Y. J Bone Joint Surg 79-A 225-233 6. Hastings H (1997) Rotary instability of the elbow. 4. B égué T (1999) Functional anatomy of the lateral collateral ligament complex of the elbow.1. J Shoulder Elbow Surg 6 528-533. Hannouche D. Clin Orthop 201 84-90 14. The anatomy and role of the lateral stabilizers. Testut L (1899) Traité d'anatomie humaine ostéologie. O'Brien SJ. pp 502-522 13. Sneppen O (1996) Kinematics of the lateral ligamentous constraints of the elbow joint. Wendeberg B (1987) Surgical versus non -surgical treatment of ligamentous injuries following dislocations of the elbow joint. J Shoulder Elbow Surg 5 333-341 18. Morrey BF. Surg Radiol Anat 21 187-191 9. Morrey BF. Williams & Wilkins. Am J Sports Med 22 667-673 24. Vardon J. Rieunau G. Sojberg JO. Mansat M (1972) Luxation récidivante du coude. J Anat 175 203-212 7. Gay R. Timmerman LA. Berg EE. Josefsson PO. Ovesen J. Morrey BF. O'Driscoll SW. myologie. Martinez Ch. An KA (1992) Origin of the medial ulnar collateral ligament. DeHoll D (1997) Radiography of the medial elbow ligaments. Bull Assoc Anat 79 3 2. Combes JM. pp 7-42. Altchek DW. 38 th ed. Combelles R (1995) Anatomie descriptive et fonctionnelle des ligaments latéral et médial du coude. Warren RF (1997) Biomechanical evaluation of the medial collateral ligament of the elbow. Olsen BS. Baltimore. Ortner F (1992) The influence of anatomic factors in elbow joint dislocation. Paris. Morrey BF. Ochi N. pp 43-62. J Hand Surg 17A 164-168 16. J Bone Joint Surg 69-A 605-608 10. Clin Orthop 274 226-230 8. Slonecker CE (1989) Grant's method of anatomy A clinical problem-solving approach. WB Saunders Co. Philadelphia. Osborne G. Ogura T. Schwab GH. Field ID. Gentz C. Anatomy. Fuss FK (1991) The ulnar collateral ligament of the human elbow joint. Clin Orthop 280 186-197 17. J Shoulder Elbow Surg 8 6-10 15. pp 640-646 Surg Radiol Anat 23: 301-305 . A prospective randomized study. Deng XH. Andrews JR (1994) Histology and arthroscopy anatomy of the ulnar collateral ligament of the elbow. J Anat 52 473-482 11. Hashizume H. Sojberg JO.

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