0:01

With that as background, let's turn our attention

0:03

to the major ligaments about the elbow.

0:08

We're gonna start medially.

0:10

I tend to call this the medial collateral.

0:14

Ligament is complex

0:15

and do not call it the ulnar collateral.

0:19

Ligament is complex

0:20

because of the existence on the lateral side

0:24

of a lateral ulnar collateral ligament.

0:27

So basically, if we look at the medial collateral ligament

0:31

as complex, there are three bundles,

0:34

and I've listed them here

0:36

for you on the slide shown on the right, the anter bundle,

0:40

which is the most important one,

0:42

and we'll be spending a lot

0:43

of time talking about it, is shown here.

0:46

It runs from the medial epicondyle, the distal humerus

0:50

to the sublime tubercle.

0:52

Now, it doesn't stop at the sublime tubercle,

0:55

as I'm gonna show you in a minute,

0:57

but that is the initial site of attachment as it reaches.

1:02

As it reaches the ulnar.

1:04

The posterior bundle is shown back here.

1:06

It too runs from the medial epicondyle,

1:09

but now to the Elon, it is intimate with the cubital tunnel

1:14

of the ulnar region.

1:17

And then and less important is a transverse bundle that runs

1:22

between the two bundles.

1:23

The anter posterior bundle, it functionally appears

1:27

to be less important than we will not be speaking

1:29

about it today.

1:31

So to give you an idea of what the anterior bundle

1:35

of the medial collateral ligament is complex,

1:38

this is a beautiful image as well as this section

1:42

through it in the coronal plane.

1:45

You will note here that it is generally dark,

1:47

although it expands slightly

1:49

and has intermediate signal at its humeral attachment

1:55

as it extends down, particularly in young people,

1:59

it has a very tight attachment to that sublime tubercle.

2:04

Now it doesn't end there, as I'm gonna show you in a moment.

2:07

It continues further down inferiorly.

2:09

Here is what it looks like in the section.

2:12

You can see slightly larger at the top, narrowing down,

2:16

attaching to the sublime tubercle.

2:19

Now, what has been pointed out in the literature,

2:22

and I show you pictures from the first article

2:25

that discussed this now more than a decade ago,

2:28

that there is also a medial collateral ligament ridge

2:33

or sublime ridge.

2:35

So as you look at the footprint of that anterior bundle,

2:38

it doesn't start but up here just at the tubercle,

2:41

it goes all the way down over a long region,

2:46

often triangular in shape.

2:48

Now you can see that here in the specimen

2:50

and what it looks like

2:52

and how far down it may go,

2:54

you can see it also in the bottom two images.

2:57

This will become important

2:58

To us as we talk later on about these partial detachments

3:03

that may involve the anterior bundle

3:06

of the medial collateral ligament as complex, particularly

3:10

in baseball pitchers.

3:12

Now, if you look at the function

3:14

of the medial collateral ligament as complex,

3:17

these are stabilizers to valgus stress.

3:20

Which bundle becomes more important as

3:23

that stabilizer depends upon the degree of flexion

3:26

and extension of the elbow.

3:29

If in fact we are dealing

3:30

with increasing extension shown in this

3:33

particular illustration.

3:35

Here it is the anter bundle that becomes taught

3:39

and is an important, more important restraint.

3:43

If we do the opposite experiment

3:45

and look at increasing flex shown on the left,

3:49

it is the posterior bundle that in fact becomes tense

3:53

and becomes the more important stabilizer to valgus stress.

3:58

Now I just added a note here

4:00

because I'm not gonna show you images of this,

4:03

but there are now two bands

4:06

of tissue anterior posterior,

4:08

that have been identified within the anterior bundle.

4:12

And I'll take this moment

4:13

to just point out the confusion in terminology, bundles

4:17

and bands and fingers

4:19

and things of that sort described to, uh,

4:22

to ligaments and tendons.

4:24

We talked about important bands in the Glen Humeral joint.

4:28

Now we're talking about important bundles

4:31

that occur in the elbow joint that may contain bands.

4:35

I think Anan should make this terminology less confusing

4:39

because it makes it a bit difficult for us to try

4:42

to figure out should we talk about bands

4:44

or bundles as we move from one joint to another.

4:50

I wanted to show you another important aspect

4:52

of the nar attachment of the anterior bundle

4:56

of the medial collateral ligamentous complex.

4:59

And I'm using some illustrations taken from an article

5:03

that some of our foes did when they were

5:05

with us in San Diego a number of years ago

5:09

that here we're looking at that anterior bundle

5:12

as it come down and attaches to the sublime tubercle

5:16

that we talked about.

5:17

Here's the articular cartilage you can see of the ra,

5:22

uh, of the o.

5:24

And you can see here the sub chondral bone plate.

5:27

The attachment of the anterior bundle

5:29

to the supplying cubicle is generally very tight

5:33

in younger people,

5:35

but in older people it that ligament may peel away

5:39

for a certain distance.

5:41

In younger people, there is a recess between that bundle

5:46

and the articular cartilage

5:48

and then a little bit of the subc chondral bone plate.

5:51

But if that recess becomes larger

5:54

and extends lower down than the subc

5:57

Bone plate, it may indicate a significant

6:00

partial detachment.

6:02

So that is why we pay attention tomography

6:05

and some of our baseball pitchers trying to decide if

6:09

that recess is extending too far.

6:13

Inferiorly as shown in this particular baseball pitcher

6:17

who had symptoms in this area of the elbow.

6:21

We'll get back to that point a little bit later.

6:25

The posterior bundle

6:26

of the medial collateral ligament is complex, forms

6:30

the floor of the cubital tunnel, so it's easy

6:33

to identify it.

6:34

If you find the ulnar nerve,

6:36

you can find this particular bundle

6:38

of tissue passing just deep to it.

6:42

This then the posterior bundle.

6:45

Now we have generally used the routine imaging planes

6:49

to study the ligaments of the elbow,

6:51

but recently of view has been described that I think is a,

6:56

a good view described by Pamela Lund from Arizona

7:00

and her associates.

7:02

She, she and, uh,

7:04

her associate called this the fever view flexed elbow

7:08

valgus external rotation.

7:10

The picture shows how,

7:12

and this is positioned in the scanner,

7:15

you can see the imaging plane,

7:17

which is oriented along the axis of that anterior bundle.

7:22

And this is showing beautifully what you can see

7:25

with slight widening as you might expect

7:29

in the elbow joint.

7:31

Now these measurements do become important.

7:34

Uh, some people regard a measurement of 2.5

7:37

or three millimeters with stress testing as being abnormal.

7:41

So in this case, we're dealing

7:43

with a borderline width of that joint.

7:46

There is a little bit of abnormal signal at the humeral

7:49

attachment of the anterior bundle.