Ulnar Collateral Ligament Percutaneous Tenotomy
Other Names
- UCL Tenotomy
- UCL Needle Tenotomy
Background
Key Points
- Percutaneous needle tenotomy involves repeatedly fenestrating the diseased ligament under ultrasound with the goal of promoting a healing response
- Procedure uses a high frequency, linear transducer in long axis
- The anterior band of the UCL is most often injured
- Carefully identify the ulnar nerve in order to avoid fenestration of the nerve
Anatomy of the Ulnar Collateral Ligament
- Responsible for medial stabilization of the elbow joint
- Thick triangular band with anterior and posterior portions, connected by a small intermediate portion
- Anterior bundle: attaches from medial epicondyle to coronoid process
- Most commonly associated with injury in the overhead athlete (baseball, tennis, etc)
Indications
Contraindications
- Absolute
- Anaphylaxis to injectates
- Overlying cellulitis, skin lesion or systemic infection
- Relative
- Can be treated with less invasive means
- Tendon tear or rupture
- Hyperglycemia or poorly controlled diabetes
- Lack of symptom improvement with previous injection
Procedure
Equipment
- Sterile prep (including chloraprep, chlorhexadine, iodine, etc)
- Ultrasound with sterile probe cover
- Gloves
- Needle
- Local anesthesia: typically 21-25 gauge, 1.5 inch
- Tenotomy: 18-20 gauge, 1.5 to 3 inch needle
- Syringe: 5-10 mL
- Gauze
- Ethyl Chloride
- Bandage
- Injectate
- Local anesthetic
- Corticosteroid/ injectate
Ultrasound Findings
- Best visualized in long axis with high frequency linear transducer
- Common ultrasound findings
- Discontinuous or heterogenous appearing fiber pattern of the ligament
- With or without hypoechoic swelling associated with the injury
- Note, the common flexor tendon can also be injured
- Consider dynamic valgus stress testing of the UCL
- This can be used to help assess the competency of the ligament
- Can distinguish partial and full thickness tears[3]
Technique: Long Axis, In-Plane
- Patient Position
- Patient is supine
- Arm is abducted, externally rotated
- Probe Position, Needle Orientation
- Long axis to the UCL
- Needle is in plane distal-to-proximal
- Target
- The entire length of the UCL
- Emphasis on area of pathology
- Pearls and Pitfalls
- You must identify ulnar nerve prior to beginning procedure
- Be aware of patients with prior ulnar nerve or UCL surgery
- Dynamic evaluation is helpful when evaluating for UCL stability
- Consider additional needling of the proximal enthesis to create bleeding at the medial epicondyle
Aftercare
- Council patient on increased pain immediately following the procedure
Complications
- Skin: Subcutaneus fat atrophy, skin atrophy, skin depigmentation
- Painful local reaction
- Infection
- Hyperglycmia
- Nerve or blood vessel injury
- Tendon rupture
- Frequency unknown
- Ulnar Nerve Injury
- Frequency unknown
See Also
References
- ↑ Image courtesy of https://www.drahmadsportsmedicine.com/, "UCL Biomechanics"
- ↑ 2.0 2.1 2.2 Malanga, Gerard, and Kenneth Mautner. Atlas of ultrasound-guided musculoskeletal injections. McGraw-Hill, 2014.
- ↑ De Smet, AA, Winter TC, Thomas MB, Bernhardt DT. Dynamic sonography with valgus stress to assess elbow ulnar collateral ligament injury in baseball pitchers. Skelet Radiol. 2002;31(11):671–676.
Created by:
John Kiel on 21 September 2023 18:43:16
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Last edited:
21 September 2023 19:10:06
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