Elbow Injuries in the Adolescent Thrower

Purpose of Review

With an increasing rate of adolescent elbow injuries, especially in throwing athletes, the purpose of this review is to investigate the current literature regarding the diagnosis, treatment, and non-operative and operative outcomes of medial epicondyle fractures, ulnar collateral ligament repair, osteochondritis dissecans of the elbow, and olecranon stress fractures.

Recent Findings

Acceptable outcomes with both non-operative and operative treatments of medial epicondyle fractures have been reported, with surgical indications continuing to evolve. Unstable osteochondritis dissecans lesions, especially in patients with closed growth plates, require operative fixation, and emerging open and arthroscopic techniques including lesion debridement, marrow stimulation, autograft transfer, and allograft transplantation are described with good outcomes. Ulnar collateral repair has emerged as an exciting treatment option for an avulsion of either end of the ligament in young throwing athletes, with faster rehabilitation times than traditional ulnar collateral ligament reconstruction. Olecranon stress fractures are increasing in prevalence, and when a non-operative treatment course is unsuccessful, athletes have a high return-to-play rate after percutaneous cannulated screw placement.

Summary

With proper indications, non-operative and operative treatment modalities are reported with a high return-to-play and acceptable clinical outcomes for common elbow injuries, including medial epicondyle fractures, ulnar collateral ligament repair, osteochondritis dissecans of the elbow, and olecranon stress fractures, in adolescent throwing athletes. Further research is needed to better define treatment algorithms, surgical indications, and outcomes.

     

A missed medial humeral epicondyle fracture with incarcerated fragment in the elbow joint and ulnar nerve palsy: A rare case report

Medial epicondyle fracture associated with incarcerated intra‐articular fragment and ulnar nerve palsy is uncommon and frequently missed. We report a case of 13‐year‐old boy with incarcerated medial epicondyle fracture fragment in ulnohumeral joint and ulnar nerve palsy, which was managed successfully by open reduction internal fixation and ulnar nerve transposition.     

Effect of Perineural Dextrose Injection on Ulnar Neuropathy at the Elbow: A Randomized,Controlled, Double-Blind Study

ObjectiveTo compare perineural dextrose injection efficacy in the treatment of ulnar neuropathy at the elbow with a control group.DesignProspective double-blind randomized control study.SettingTraining and research hospital.ParticipantsThe study was completed with 40 patients with ulnar neuropathy at the elbow.InterventionNormal saline (0.9% sodium chloride) was injected in patients in the control group (n=20; mean age=38.1±10.7 years; median duration of symptoms=4.5 months), and 5% dextrose was injected in patients in the dextrose group (n=20; mean age=43.6±13.5 years; median duration of symptoms=5 months), perineurally under ultrasound guidance twice at 2-week intervals. Ultrasound-guided perineural injection of 1 cc each was administered into the ulnar nerve, 2 cm and 4 cm distal to the medial epicondyle, at the level of the medial epicondyle, and 2 cm and 4 cm proximal to the medial epicondyle. The amount of total fluid injected was 5 cc.Main Outcome Measure(s)At baseline and weeks 2, 4, and 12, the patients were evaluated with the Visual Analog Scale for pain and the Disabilities of the Arm Shoulder and Hand questionnaire for disability. Electrophysiological evaluation was performed with ulnar nerve conduction studies, and the ulnar nerve cross-sectional area was measured on ultrasonography.ResultsThe improvements in pain, disability, ulnar motor nerve velocity, and ulnar nerve cross-sectional area in the dextrose group were superior to those in the control group, especially at weeks 4 and 12 (P<.001, using independent samples t tests).ConclusionPerineural 5% dextrose may be an effective alternative therapy for those with ulnar neuropathy at the elbow for up to the 12th week.     

Medical diagnosis of cubital tunnel syndrome ameliorated with thrust manipulation of the elbow and carpals

Abstract

This case report describes the effectiveness of thrust manipulation to the elbow and carpals in the management of a patient referred with a medical diagnosis of cubital tunnel syndrome (CuTS). The patient was a 45-year-old woman with a 6-week history of right medial elbow pain, ulnar wrist pain, and intermittent paresthesia in the ulnar nerve distribution. Upon initial assessment, she presented with a positive elbow flexion test and upper limb neurodynamic test with ulnar nerve bias. A biomechanical assessment of the elbow and carpals revealed a loss of lateral glide of the humerus on the ulna and a loss of palmar glide of the triquetral on the hamate. After the patient received two thrust manipulations of the elbow and one thrust manipulation of the carpals over the course of four sessions, her pain and paresthesia were resolved. This case demonstrates that the use of thrust manipulation to the elbow and carpals may be an effective approach in the management of insidious onset CuTS. This patient was successfully treated with thrust manipulation when joint dysfunction of the elbow and wrist were appropriately identified. This case report may shed light on the examination and management of insidious onset CuTS.     

High-Velocity Thrust Technique for Traumatic Onset Lateral Elbow Pain

Abstract

A 35 year-old male presented to physical therapy following a fall onto his outstretched right hand. He developed pain and dysfunction in the right lateral epicondyle region. The patient was assessed and received a physical therapy diagnosis of abducted ulna syndrome. The patient was treated with a high-velocity, low-amplitude manipulation technique to the humeroulnar joint. This technique coincided with a restoration in the patient's normal function, along with an elimination of painful symptoms. This case study suggests that a high-velocity, low-amplitude manipulation technique performed by a physical therapist may play an important role in the successful treatment of traumatically induced lateral epicondyle pain.     

关节镜下微创治疗18例胫骨平台骨折合并前交叉韧带胫骨止点撕脱骨折的疗效观察

目的 探讨关节镜下微创治疗胫骨平台骨折合并前交叉韧带(ACL)胫骨止点撕脱骨折的手术效果.方法 选择2016年7月-2019年7月上海市宝山区罗店医院骨科和锦州医科大学附属第三医院骨二科收治的18例胫骨平台骨折合并ACL胫骨止点撕脱骨折的患者.利用关节镜进行关节腔检查、处理合并症、复位骨折及微创内固定,采用膝关节功能H...     

Maisonneuve injury with no fibula fracture: A case report

BACKGROUNDAnkle syndesmosis injury is difficult to diagnose accurately at the initial visit. Missed diagnosis or improper treatment can lead to chronic complications. Complete syndesmosis injury with a concomitant rupture of the interosseous membrane (IOM) is more unstable and severe. The relationship between this type of injury and Maisonneuve injury, in which the syndesmosis is also injured, has not been discussed in the literature previously.CASE SUMMARYA 16-year-old patient sustained left medial malleolar fracture, and the associated inferior tibiofibular syndesmotic instability was overlooked. After open reduction and internal fixation of the medial malleolar fracture, inferior tibiofibular syndesmosis diastasis with IOM rupture was detected by auxiliary imaging. Secondary surgical intervention was performed to reduce anatomically and fix with two trans-syndesmosis screws. Twelve weeks later, the screws were removed. At the 6-mo follow-up, the patient gained full range of motion of the ankle.CONCLUSIONComplete syndesmosis injury with IOM rupture should be considered Maisonneuve-type injury. Open reduction and internal fixation could obtain good outcomes.     

The ultrasonographic and electrodiagnostic findings of ulnar neuropathy at the elbow

OBJECTIVE: To evaluate and compare the morphologic changes of the ulnar nerve at the elbow, using ultrasonography, between patients with cubital tunnel syndrome and retrocondylar compression syndrome determined with electrodiagnosis. DESIGN: Prospective study using electrodiagnosis and ultrasonography. SETTING: An outpatient rehabilitation clinic in a tertiary university hospital in South Korea. PARTICIPANTS: Thirteen patients (8 men, 5 women; mean age, 48.2y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: In the electrodiagnostic study, we used the inching technique to localize the ulnar nerve lesion at the elbow. In the ultrasonography study, we measured the length of the swollen ulnar nerve and the ratio of the nerve diameter between the proximal end of the medial epicondyle to the elbow joint level and the tip of medial epicondyle to the elbow joint level. RESULTS: The mean length of the swollen ulnar nerve segment in retrocondylar compression syndrome (2.58+/-0.58cm) was significantly longer than that of cubital tunnel syndrome (1.64+/-0.31cm). The mean ratio of the nerve diameter between the proximal end of medial epicondyle and the elbow joint level was significantly larger in retrocondylar compression syndrome (1.52+/-0.25) than that of cubital tunnel syndrome (1.06+/-0.06). CONCLUSIONS: Ultrasonography detected the morphologic changes and the extent of the ulnar nerve lesion at the elbow, and it can become a screening and follow-up imaging modality in patients with ulnar neuropathy at the elbow.     

肘后外侧小切口及有序骨折复位固定治疗儿童肱骨髁上骨折

【目的】探讨经肘后外侧小切口有序骨折复位治疗儿童肱骨髁上骨折的临床疗效。【方法】1999～2007年,对76例手法复位失败、无合并神经、血管损伤的儿童肱骨髁上骨折采用肘后外侧小切口手术,术中采取有序的骨折复位方法,先复位固定肱骨远端外侧柱,后复位固定肱骨远端内侧柱。术后患肢石膏托外固定2～3周并进行功能锻炼。【结果】全部病例均获随访,平均随访时间4年（1～6年）。按Flynn标准对术后肘关节功能恢复情况进行评价,其中优61例,良15例,优良率为100％,无肘内翻发生。【结论】肘后外侧小切口及有序骨折复位固定适用于闭合复位不满意但不伴有明显神经、血管损伤的儿童肱骨髁上骨折,本术式具有解剖关系简单,对组织损伤小,出血少等优点;便于骨折复位、固定,能有效防止骨折远端内移、内旋、内倾及预防肘内翻畸形发生。     

Lateral epicondyle osteotomy approach for coronal shear fractures of the distal humerus: Report of three cases and review of the literature

BACKGROUNDCoronal shear fractures of the distal humerus are rare injuries and are technically challenging to manage. Open reduction and internal fixation (ORIF) has become the preferred treatment because it provides anatomical reduction, stable internal fixation, and early motion, but the optimal surgical approach remains controversial.CASE SUMMARYWe report three cases of coronal shear fractures of the distal humerus treated successfully by ORIF via a novel surgical approach, in which lateral epicondyle osteotomy was performed based on the extended lateral approach. We named the novel surgical approach the lateral epicondyle osteotomy approach. All patients underwent surgical treatment and were discharged successfully. All patients had excellent functional results according to the Mayo elbow performance score. The average range of motion was 118° in flexion/extension and 172° in pronation/ supination. Only case 2 had a complication, which was implant prolapse.CONCLUSIONWe demonstrated that the lateral epicondyle osteotomy approach in ORIF is effective and safe for coronal shear fractures of the distal humerus.     

Floating elbow combining ipsilateral distal multiple segmental forearm fractures: A case report

BACKGROUNDFloating elbow along with ipsilateral multiple segmental forearm fracture is a rare and high-energy injury, although elbow dislocation or fracture of the ulna and radius may occur separately.CASE SUMMARYWe report the case of a 37-year-old woman with open (IIIA) fracture of the right distal humerus with multiple shaft fractures of the ipsilateral radius and ulna with a history of falling from a height of almost 20 m from a balcony. After providing advanced trauma life support, damage control surgery was performed to debride the arm wound and temporarily stabilize the right upper limb with external fixators in the emergency operating room. Subsequently, one-stage internal fixation of multiple fractures was performed with normal values of biochemical indicators and reduction in limb swelling. The patient achieved good outcome at the 7 mo follow-up.CONCLUSIONOne- or two-stage treatment must be performed according to the type of injury; we efficiently used the “damage control principle.”     

手术治疗后交叉韧带胫骨止点撕脱性骨折

目的探讨膝关节后内侧入路手术内固定治疗手术后交叉韧带胫骨止点撕脱性骨折的临床效果。方法对15例交叉韧带胫骨止点撕脱性骨折患者行膝后倒＂L＂形小切口显露,解剖复位骨折,予以中空螺钉及带线锚钉内固定。术后随访6个月,收集骨折复位、愈合及关节稳定性、活动度以及Lysholm膝关节功能评分标准评估膝关节功能恢复情况。结果术后8~13周均骨性愈合,未见位移。术后6个月,有2例后抽屉试验弱阳性,1例轻度屈膝受限,无伸膝受限,Lysholm膝关节功能评分（92.0±2.4）分。结论膝后内侧入路中空螺钉及带线锚钉内固定治疗后交叉韧带胫骨止点撕脱性骨折操作简单、安全、效果可靠。     

Evaluation of the isometry of different points of the patella and femur for medial patellofemoral ligament reconstruction

BackgroundThe location of patellar and femoral fixation of the graft in medial patellofemoral ligament reconstructions has been widely discussed. This study aimed to assess the distances between different patellar and femoral fixation points to identify the least anisometric pairs of points.MethodsTen cadaver knees were attached to an apparatus that simulated an active range of motion of 120°, with three metallic markers fixed onto the medial side of the patella, and seven markings onto the medial epicondyle. The examined points included the proximal patella pole (1), the patellar center (3), the midpoint between points 1 and 3 (2), a point directly on the epicondyle (6), points 5 mm anterior (5) and posterior (7) to the epicondyle, points 5 mm anterior to point 5 (4) and 5 mm posterior to point 7 (8), and points 5 mm proximal (9) and distal (10) to the epicondyle. The distances between patella and femur points were measured by a photogrammetry system at 15° intervals.FindingsThe pair of points that exhibited the lowest average variability in distance, and hence was the most isometric, was the patella center combined with the anterior to the medial femoral epicondyle. The pairs of points that exhibited the highest average variability in distance, and hence were the least isometric, were the ones located distal or posterior to the medial femoral epicondyle, with less influence by the patellar location.InterpretationSurgeons should avoid positioning the graft distally or posterior to the epicondyle due to the increase in anisometry.     

肱骨远段内固定物及假体设计与其解剖学参数的关系

背景:制约肱骨远段骨折治疗及内固定物、假体设计和改进的一个重要因素是该部位的解剖学形态,肱骨远段解剖学参数的测定对肱骨远段畸形矫正、内固定物固定和假体置换时有较大的应用意义。目的:测量肱骨远端相关角度及肱骨远端相关结构宽度或深度相关17项解剖学指标,验证其与内固定物及假体置入和骨的适配性,验证其特点与内固定物及假体力学性能的关系。设计:重复测量,对比观察。单位:江苏省南通大学附属医院。材料:实验于2005-10/2006-02在江苏省南通大学附属医院创伤研究室完成,随机抽取成人54对防腐尸体肱骨标本(由南通大学医学院人体解剖教研室提供),肘关节畸形、退行性病变者给予排除,其中男30对、女24对。方法:剔除所有肱骨标本附着的软组织,利用游标卡尺(精度0.01mm,上海量具刃具厂生产)、分规、量角器对肱骨远端数项解剖学指标进行测量。①肱骨远端相关角度的测量:测量的项目包括肱骨远端前倾角、肱骨滑车外旋角、肱骨小头前倾角、肱骨滑车前倾角、肱骨髁体角、肱骨内外髁中心连线内旋角。②肱骨远端相关结构宽度或深度测量:测量项目包括肱骨滑车前端横径、肱骨滑车下端横径、肱骨滑车矢状径、内上髁至外上髁最大宽度、滑车最内侧缘至小头最外侧缘宽度、鹰嘴窝宽度、鹰嘴窝深度、内上髁宽度、尺神经沟深度、肱骨小头宽度、肱骨小头矢径等。主要观察指标:肱骨远端相关角度及肱骨远端相关结构宽度或深度测量结果。结果:①肱骨远端相关角度:男、女性肱骨远端前倾角分别是(35.62±5.21)°,(36.22±5.29)°,肱骨滑车外旋角分别是(5.22±1.15)°,(5.46±1.33)°,肱骨小头前倾角分别为(48.35±8.78)°,(49.65±9.12)°,肱骨滑车前倾角分别为(33.08±7.15)°,(34.45±7.52)°,肱骨髁体角分别为(80.12±5.22)°,(80.17±5.45)°,肱骨内外髁中心连线内旋角分别为(3.14±0.62)o,(3.32±0.68)°,男女之间的测量数据无显著差别(P>0.05)。②肱骨远端相关结构宽度或深度:本组标本中,男、女性肱骨滑车前端横径分别为(21.40±4.21),(21.12±4.34)mm,肱骨滑车下端横径分别为(23.54±4.52),(23.31±4.43)mm,肱骨滑车矢径分别是(23.91±4.85),(23.55±4.63)mm,内上髁至外上髁最大宽度分别是(58.23±6.44),(55.32±6.55)mm,滑车最内侧缘至小头最外侧缘宽度分别是(45.36±5.21),(42.15±5.03)mm,鹰嘴窝宽度分别是(24.56±4.25),(25.34±4.42)mm,鹰嘴窝深度分别是(13.43±2.52),(12.95±2.13)mm,内上髁宽度分别是(14.35±3.32),(13.02±2.96)mm,尺神经沟深度分别是(8.53±2.96),(7.90±2.54)mm,肱骨小头宽度分别是(18.05±2.87),(16.51±2.75)mm,肱骨小头矢径分别是(19.59±3.84),(19.12±3.55)mm。男女之间肱骨远端相关结构宽度或深度的测量数据差异无显著性意义(P>0.05)。结论:进行肱骨远段内固定物置入和假体置换以及畸形矫正时,要适合肱骨远端各项解剖参数,以期肘关节功能有良好恢复。     

Treatment of lower part of glenoid fractures through a novel axillary approach: A case report

BACKGROUNDBased on the location and size of the fracture block, open reduction and internal fixation can be employed or assisted for shoulder arthroscopy in the treatment of glenoid fractures. However, the treatment of lower part of glenoid fractures through a novel axillary approach has not been reported so far. CASE SUMMARYA 22-year-old right-handed man was transferred to our outpatient clinic because of right shoulder injury during a traffic accident. X-ray examination after admission suggested the fracture of the lower part of the right glenoid and an ipiselial proximal humeral fracture. Three-dimensional (3D) computed tomography (CT) further suggested that the size of the fracture block of the lower part of the right glenoid was 3.4 mm × 16.2 mm. The patient was diagnosed as the fracture of the lower part of the glenoid, also known as bony Bankart lesion without shoulder dislocation. After general anesthesia, the patient was surgically treated with the open reduction internal fixation through a novel axillary approach. 3D CT and shoulder joint function were reexamined at 12 mo of follow-up, showing acceptable recovery.CONCLUSIONThis case report describes a novel axillary approach adopted in an open reduction with cannulated screw and wire anchor internal fixation. After a follow-up for more than 12 mo, 3D CT and shoulder joint function examinations display a good recovery.     

手术治疗肘关节恐怖三联征8例报告

目的:回顾分析8例肘关节恐怖三联征的手术治疗过程和随访过程,加深对肘关节恐怖三联征概念的认识,并报告临床治疗体会.方法:2006年8月-2010年12月收治的肘关节恐怖三联征患者共8例.桡骨头骨折按Schatzker法分类Ⅰ型3例,Ⅱ型4例,Ⅲ型1例.尺骨冠状突骨折按O' Driscoll法分型Ⅰ型4例Ⅱ型4例.8例均行手术内固定,用2.0 mm双头加压螺钉及指骨小钛板固定尺骨冠状突和桡骨小头,并用空心带齿垫圈螺钉或锚钉修复内外侧副韧带.术后屈肘90°中立位石膏固定2周后拆除,开始肘关节屈伸和前臂旋转功能锻炼.结果:8例患者均获随访,随访时间5～24个月,骨折均愈合,关节稳定,其中1例发生骨化性肌炎,2例劳累后有轻微疼痛.根据Mayo肘关节功能评分:优6例(＞90分),良1例(85分),可1例(65分).结论:解剖复位、坚强可靠的内固定手术和适时的康复训练是治疗肘关节恐怖三联征的有效手段.     

The Changing Face of Professional Education

Abstract

The purpose of this paper is to review the literature pertaining to subacromial impingement syndrome and lateral epicondylalgia (LE) in tennis players. The mechanisms of joint and muscular imbalances that lead to functional impingement of the shoulder joint may impair the stabilization and power function of the shoulder resulting in overcompensation of the wrist extensors during the tennis swing. This may contribute to microtrauma at the soft tissue structures at the lateral epicondyle thus causing symptoms of LE. Recent interest in the regional interdependence model as well as case studies published in the literature suggests that the relationship of proximal or distal joints should not be overlooked. Compensatory strategies at the distal upper extremity due to changes at the shoulder may overload smaller muscles in the forearm which cannot safely handle the extra stress, especially under repetitive conditions. Conditions of the shoulder and elbow that were previously considered to be independent, specifically subacromial impingement syndrome and lateral epicondylalgia, need to be critically reexamined in the context of regional interdependence given the potential association between the conditions. Specific studies examining the muscle and joint characteristics of the shoulder and elbow are needed as they relate to subacromial impingement syndrome and LE. Anatomic adaptations and biomechanical alterations in the upper extremity could result in abnormal stress loads and microtrauma at the shoulder and lateral elbow.