Working Diagnosis:
Complete proximal lateral collateral ligament and distal ulnar collateral ligament tears.
Partial tears of flexor and extensor tendons at origin.

Treatment:
She was subsequently referred to Orthopedic Surgery who recommended surgical repair of ulnar collateral ligament and extensor tendon. The operation was performed two months after her initial injury, and she was immobilized in splint for 30 days post operatively. She was then transitioned into a hinged elbow brace one month after surgery allowing 40-100 degrees ROM. At this time, she was also enrolled into physical therapy for a progressive range of motion protocol.

Outcome:
Three months postoperatively, she began performing low intensity gymnastics consisting of limited weight bearing and strain on the elbow. She continued with physical therapy achieving full active and passive range of motion but has not regained sensation in the ulnar distribution. She continues to follow with orthopedic surgery but it is unclear if she will be able to return to her prior level of gymnastic competition.

Author's Comments:
Proper diagnosis of FOOSH (Fall On Outstretched Hand) injuries are critical when taking care of athletes due to the implications regarding rehabilitation and return to sport. Recommendations for surgical or non-surgical treatment depends on which structures are damaged. If there is concern for a ligamentous injury in the elbow, the Axial T2 fat saturation MRI sequence is best for visualization of the ligaments (1).

While most common FOOSH injuries involve the wrist or forearm, injuries involving the elbow can also be seen. Rotation on impact, joint subluxation, and energy displacement increase the risk of elbow injury (2). Following an elbow dislocation, it is especially important to rule out the "Terrible Triad" injury of the elbow which consists of posterior dislocation, along with radial head and coronoid process fractures. This has historically poor outcome and prognosis for rehabilitation and return to sport (3).

Considerations for non-surgical or surgical management depends on both imaging findings as well as desired post recovery function (3). Non-operative treatment often includes pain management, rest, and physical therapy with graduation progression of load bearing. It can be pursued if there are no fractures, no complete ligament or tendon tears (partial tears are grade dependent), and no neurovascular compromise. If surgery is warranted, stability and rest compromise the initial management, followed by postoperative physical therapy focusing on range of motion and gradual progression of load bearing. Return to play is often determined by the severity of injury, resolution of symptoms, and progression with physical therapy.

Editor's Comments:
The ulnar collateral ligament (UCL) extends from the medial epicondyle to the sublime tubercle and is composed of three bundles: the anterior-oblique, posterior-oblique, and the transverse bundle. The anterior-oblique bundle of the UCL works with the flexor-pronator mass, flexor carpi ulnaris, and joint capsule to provide the soft tissue valgus stabilization of the elbow joint. Of these three structures, the UCL, and specifically the anterior-oblique bundle of the UCL, is the primary restraint to valgus force at the elbow. Though commonly within the differential for overuse elbow pain in overhead throwing sports, acute and overuse injuries of the UCL can be seen in javelin throwers, tennis, gymnastics, football, wrestling, and during elbow dislocations (4). There are multiple surgical techniques for UCL reconstruction, but the modified Jobe's technique and the docking techniques are the most common with the most robust long term follow up data. The modified Jobe's UCL reconstruction utilizes a flexor pronator mass splitting or elevation approach with anteriorly directed humeral epicondyle tunnels to avoid ulnar nerve irritation, a common post operative complaint in UCL reconstruction. In comparison the docking techniques utilizes a single humeral tunnel to decrease the risk of humeral fracture from tunneling and improve UCL tensioning. Both techniques have shown stability comparable to a native UCL when the elbow is flexed greater than 90 degrees but there is a decline in stability in flexion less than 90 degrees with both. (5, 6)

References:
1. Bucknor, Matthew D., et al. "Elbow Imaging in Sport: Sports Imaging Series." Radiology, 18 Mar. 2016,pubs.rsna.org/doi/full/10.1148/radiol.2016150501.
2. "Elbow - MRI." The Radiology Assistant : Elbow - MRI, radiologyassistant.nl/musculoskeletal/elbow-mri.
3. Erickson, Brandon. "Medial Ulnar Collateral Ligament Injury (Valgus Instability)." Orthobullets, www.orthobullets.com/shoulder-and-elbow/3079/medial-ulnar-collateral-ligament-injury-valgus-instability.
4. Chang, E, et al. Comparison of Surgical Techniques for Ulnar Collateral Ligament Reconstruction in Overhead Athletes. J Am Acad Orthop Surg 2016;24(3):135-149.
5. Lyle Cain E, et al. Outcome of Ulnar Collateral Ligament Reconstruction of the Elbow in 1281 Athletes: Results in 743 Athletes with Minimal 2 year follow up. American Journal of Sports Medicine. 2010;38(12):2426-2434.
6. Erickson B, et al. Treatment of Ulnar Collateral Ligament Tears of the Elbow: Is Repair a Viable Option? Orthopaedic Journal of Sports Medicine 2017;5(1):2325967116682211.

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