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Acute Rupture of the Medial Collateral Ligament of the Elbow Requiring Reconstruction

A fifty-three-year-old male laborer sustained an injury to the right elbow when he stepped in a rut and fell, attempting to break the fall with the right hand. There was immediate. severe pain in the right elbow, and an acute valgus deformity was noted. With the aid of a fellow employee, the valgus deformity was corrected, and the patient was seen in an emergency room shortly thereafter. Anteroposterior and lateral radiographs of the right elbow showed no fracture, dislocation, or subluxation. A long posterior splint was applied to the arm, and the patient was referred to our care. On examination two days after injury, the right elbow was swollen and ecchymotic, with blisters medially and in the antecubital area. The ulnar collateral-ligament complex was not stressed on the first examination. The arm was immobilized in the long posterior splint for sixteen days, after which the patient started a program of active exercise under the supervision of a physiotherapist. On subsequent examinations, the patient was noted to have persistent valgus instability of the elbow that prevented minor forceful use of the extremity. A radiograph made with valgus stress applied to the forearm and with the elbow in 30 degrees of flexion showed significant medial instability (Fig. I). Three months after the injury. the anterior oblique ligament was reconstructed using the tendon of the palmaris longus muscle. The tip of the medial epicondyle was osteotomized and the flexor origin was retracted. A valgus force was applied to the elbow, and no medial collateral ligament was seen. Two communicating drill-holes were placed in the area of the medial epicondyle and two were placed medial to the coronoid process. The palmaris longus tendon was then woven through the drill-holes, pulled taut, and sutured to itself (Fig. 2). The medial epicondyle and flexor mass were reattached using a staple. A long posterior plaster splint was applied to the arm with the elbow in 90 degrees of flexion. After four weeks of immobilization. the patient started a physiotherapy program involving active exercise. He regained a full range of motion as well as stability of the elbow, and he returned to performing heavy labor. Twelve months postoperatively. radiographs made with valgus stress applied to the forearm showed no opening of the medial side of the elbow (Fig. 3).