Acute-subacute Ulnar Collateral Ligament Tear

Acute-subacute Ulnar Collateral Ligament Tear

Authors, Editors, Case Information Author: Daniel Bister, BS Affiliation: Medical Student, University of Miami Miller School of Medicine Co Author(s): Jean Jose, D.O. Professor of Clinical Radiology, Orthopedic Surgery and PMNR Medical Director Radiology, Lennar Foundation Medical Center Director of Imaging, UHealth Sports Medicine Pedro Ferrer, M.D. Interventional Radiology Fellow, Jackson Memorial Hospital / University of Miami Senior Editor: Timothy Yu, MD Clinical Vignette: A 16-year-old right-hand dominant male high school wrestler presented with 2 weeks of right elbow pain, stiffness, and instability after a wrestling injury. His exam was notable for anteromedial swelling, medial epicondyle tenderness, pain with valgus stress, and decreased elbow range of motion and strength with intact neurovascular function. Type of Probe Used: High-frequency linear array 10-18 MHz real-time grayscale and color Doppler Unlabeled Long Axis View of the UCL Anterior Bundle Unlabeled long-axis view of the right medial elbow with probe aligned parallel to the UCL from the medial epicondyle to the sublime tubercle. Labeled Long Axis View of the UCL Anterior Bundle Labeled long-axis view of the right medial elbow with probe aligned parallel to the UCL from the medial epicondyle to the sublime tubercle. Full-thickness tear of the anterior bundle of the UCL with partial-thickness tear of the posterior bundle. Disrupted ligament fibers show loss of normal hyperechoic fibrillar pattern replaced by a hypoechoic defect. Landmarks: ME - Medial Epicondyle ST - Sublime Tubercle Unlabeled Long Axis View of the UCL Unlabeled long-axis view of the right medial elbow with probe oriented parallel to the UCL from the medial epicondyle proximally to the sublime tubercle distally. Labeled Long Axis View of the UCL Labeled long-axis view of the right medial elbow with probe oriented parallel to the UCL from the medial epicondyle proximally to the sublime tubercle distally, redemonstrating abnormal ligament morphology with disruption of anterior bundle fibers. A hypoechoic gap within the ligament substance confirms fiber discontinuity consistent with acute traumatic injury. Landmarks: UCL - Ulnar collateral ligament, ME - Medial Epicondyle Unlabeled Long Axis View of the UCL 2 Unlabeled long-axis view of the right medial elbow with probe oriented parallel to the UCL from the medial epicondyle proximally to the sublime tubercle distally. Labeled Long Axis View of the UCL 2 Labeled long-axis view of the right medial elbow with probe oriented parallel to the UCL from the medial epicondyle proximally to the sublime tubercle distally, demonstrating a hypoechoic cleft with periligamentous edema. Landmarks: ST - Sublime Tubercle, ME - Medial Epicondyle, CFT - Common Flexor Tendon, UCL - Ulnar Collateral Ligament Unlabeled Long Axis View of the UCL Dynamic Stress Unlabeled long-axis view of the right medial elbow with the probe oriented parallel to the anterior bundle of the ulnar collateral ligament under dynamic valgus stress using the milking maneuver. Labeled Long Axis View of the UCL Dynamic Stress Labeled long-axis view of the right medial elbow with the probe oriented parallel to the anterior bundle of the ulnar collateral ligament under dynamic valgus stress using the milking maneuver. Joint space widening of greater than 1 mm compared to the contralateral elbow. Landmarks: ME - Medial Epicondyle, [Brackets] - Ulnohumeral Joint Space Gapping Unlabeled Short Axis view of the Right Medial Elbow Unlabeled short-axis view of the right medial elbow with the probe oriented perpendicular to the ulnar nerve, at the level of the cubital tunnel. Cross-sectional fascicles are visible with evidence of perineural edema. Labeled Short Axis view of the Right Medial Elbow Labeled short-axis view of the right medial elbow with the probe oriented perpendicular to the ulnar nerve, at the level of the cubital tunnel. Cross-sectional fascicles are visible with evidence of perineural edema. Interpretation Image Interpretation: Ultrasound of the right medial elbow demonstrated a full-thickness tear of the anterior bundle of the UCL with partial-thickness tear of the posterior bundle. Disrupted ligament fibers showed loss of normal compact hyperechoic fibrillar pattern replaced by a hypoechoic defect with periligamentous edema and likely hemorrhage consistent with acute-subacute injury. Mild widening of medial ulnohumeral joint space with valgus stress was limited by guarding. Perineural edema of the ulnar nerve at the cubital tunnel was also identified. Teaching Pearl: UCL injuries are not limited to overhead athletes. Contact and wrestling athletes can sustain acute complete tears without any history of overhead throwing. Male wrestlers have among the highest NCAA UCL injury rates. Dynamic ultrasound with valgus stress is a rapid bedside tool to confirm medial elbow instability typically using a Telos device or wrist weight to obtain stress views. While a bulk of the literature has been performed at 30 degrees flexion, compelling arguments are made for flexion angles closer to 45-50 degrees, particularly in throwing athletes. Always compare the symptomatic and contralateral elbow during the same exam. An injured stress delta (ISD) greater than or equal to 1.4 mm increase in joint space (sensitivity 86%, specificity 87%) or a side to side comparison with stressed delta delta (SDD - injured stress delta minus contralateral stress delta) of 1 mm (sensitivity 96 %, specificity 81%) is diagnostic for UCL insufficiency in throwing athletes. References: 1. Cho MJ, Chai JW, Kim DH, et al. Ultrasonographic differential diagnosis of medial elbow pain. Ultrasonography. 2024;43(5):299-313. Nicolette GW, Gould HP, Ahmad CS, et al. Medial ulnar collateral ligament injuries in contact athletes. Curr Rev Musculoskelet Med. 2023;16:28-36. 2. Sutterer BJ, Boettcher BJ, Payne JM, Camp CL, Sellon JL. The role of ultrasound in the evaluation of elbow medial ulnar collateral ligament injuries in throwing athletes. Curr Rev Musculoskelet Med. 2022; 15(6): 535–546. 3. Roche SWJ, et al. Sonographic assessment of ulnohumeral joint instability. Sonography. 2024;11(4). 4. Roedl JB, Gonzalez FM, Zoga AC, Morrison WB, Nevalainen MT, Ciccotti MG, et al. Potential Utility of a Combined Approach with US and MR Arthrography to Image Medial Elbow Pain in Baseball Players. Radiology. 2016;279(3):827-37.
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