Sonography of the scapholunate ligament in four cadaveric wrists: correlation with MR arthrography and anatomy

OBJECTIVE: The objective of our study was to sonographically characterize the dorsal aspect of the scapholunate ligament in cadaveric wrists using arthrography, MR arthrography, and anatomic correlation as the gold standard. MATERIALS AND METHODS: The dorsal aspect of the scapholunate ligament in four cadaveric wrists was evaluated on sonography without knowledge of the findings from standard arthrography, MR arthrography, and anatomic sectioning. The sonographic findings were compared with the findings from other modalities. The criteria for an abnormal scapholunate ligament included an abnormal contrast communication between the radiocarpal and midcarpal joints on arthrography and a discontinuity of the dorsal aspect of the scapholunate ligament that was documented both on MR arthrography and at anatomic sectioning. RESULTS: Arthrography, MR arthrography, and anatomic sectioning showed the dorsal aspect of the scapholunate ligament to be normal in one specimen and abnormal in three specimens. On sonography, the normal scapholunate ligament was hyperechoic between the scaphoid and lunate bones. In the three cases of abnormality, a normal scapholunate ligament was not visualized, and an abnormal hypoechogenicity was present. CONCLUSION: The dorsal aspect of the scapholunate ligament can be depicted on sonography; abnormality is present in patients in whom the normally hyperechoic fibrillar ligament is hypoechoic or absent.     

Sonography of the medial collateral ligament of the elbow: a study of cadavers and healthy adult male volunteers

OBJECTIVE: We assessed the ability of high-resolution sonography to reveal the size and echogenicity of the anterior bundle of the normal medial collateral ligament of the elbow in cadavers and uninjured male volunteers. MATERIALS AND METHODS: The anterior bundle of the medial collateral ligament in five cadaveric elbows was imaged and injected with contrast material by experienced musculoskeletal radiologists using a 12-MHz linear array transducer. Immediate ligament dissection was performed. The bilateral ligaments in 30 healthy 21- to 34-year-old male volunteers were imaged with gravitational stress. Of these, five randomly selected subjects also received approximately 5 lb (11.3 kg) of applied stress. RESULTS: Contrast material was injected directly into all five cadaveric ligaments. The anterior bundle of the medial collateral ligament in all 30 asymptomatic male volunteers was hyperechoic in comparison with surrounding muscle and had a fibrillar pattern and fanlike shape. Its mean dimensions were 2.6 +/- 0.31 x 2.2 +/- 0.47 x 4.0 +/- 0.88 mm on the right and 2.6 +/- 0.36 x 2.1 +/- 0.42 x 4.0 +/- 0.86 mm on the left, in longitudinal short, transverse short, and transverse long axes, respectively. Differences in ligament measurements in sidedness, stress application, and hand dominance did not approach statistical (Bonferroni corrected, p > 0.01) or clinical (all differences, <0.2 mm) significance. CONCLUSION: Radiologists can accurately use sonography to identify and measure the size of the anterior bundle of the normal medial collateral ligament of the elbow. These baseline parameters for the normal ligament may prove useful when evaluating the injured ligament.     

High-resolution ultrasound anatomy of extrinsic carpal ligaments

PURPOSE: Carpal ligaments can be classified as intrinsic and extrinsic. Extrinsic ligaments are often involved in carpal instability. The purpose of this article is to describe the sonographic appearance of extrinsic carpal ligaments on high-resolution ultrasound (HRUS) using magnetic resonance arthrography (MR arthrography) as a reference standard. MATERIALS AND METHODS: We studied both wrists in 18 healthy volunteers (ten men, eight women, age range 18-58 years, mean age 34 years) with a Philips iU22 US scanner equipped with a high-resolution linear-array broadband transducer (5-17 MHz). The scans were performed along the long axis of the extrinsic dorsal and ventral ligaments to assess their course, thickness and structure. Ten subjects were also studied with MR arthrography of the wrist. RESULTS: In all patients, the ligament components could be appreciated as thin fibrillar hyperechoic structures. The course of seven extrinsic carpal ligaments and their relationships with surrounding articular structures could be studied. The radioscapholunate and the ulnar collateral ligaments were not visible on US. MR arthrography depicted all ligaments except for the ulnar collateral, which was never visualised. CONCLUSIONS: The results obtained are consistent with those reported in the literature. HRUS provides good anatomical detail of the extrinsic carpal ligaments, but the role of US in planning the treatment of carpal instability disorders is yet to be demonstrated.     

Anterior bundle of ulnar collateral ligament: evaluation of anatomic relationships by using MR imaging, MR arthrography, and gross anatomic and histologic analysis

PURPOSE: To evaluate the gross and microscopic anatomy and the magnetic resonance (MR) imaging and MR arthrographic appearance of the anterior bundle of the ulnar collateral ligament (UCL) of the elbow. MATERIALS AND METHODS: The origin and insertion of the anterior bundle of the UCL, the bundle's relationship to the overlying flexor tendons, and the presence of a layered configuration were assessed through inspection and dissection of an elbow specimen. T1-weighted spin-echo MR imaging and MR arthrography in standard imaging planes and a coronal oblique plane were performed in eight other elbow specimens. Additional MR arthrography was performed in four specimens by using the coronal plane with the elbow in 20 degrees of flexion. The specimens were then cut in planes corresponding to those of the MR images. Histologic analysis of two specimens was performed. RESULTS: The anterior bundle of the UCL appeared as a low-signal-intensity structure on T1-weighted spin-echo MR and MR arthrographic images. It consisted of a uniform layer of parallel collagen fibers attaching proximally to the base of the medial epicondyle of the humerus and distally to the medial aspect of the coronoid process of the ulna (sublime tubercle). A layer of synovium separated the anterior bundle from the more superficial tendon of the flexor digitorum superficialis muscle. MR imaging-anatomic comparison in four (50%) specimens revealed separation between the anterior bundle of the UCL and the sublime tubercle. Results of histologic analysis of two of these specimens confirmed insertion of the anterior bundle of the UCL 3 and 4 mm distal to the articular margin. Ligamentous degeneration was detected in only one of these specimens. CONCLUSION: There is variability in the distal insertion of the anterior bundle, and this suggests that caution should be exercised in the diagnosis of its partial detachment from the sublime tubercle of the ulna.     

Sonography of injury of the ulnar collateral ligament of the elbow—initial experience

Objective The purpose of this study is to describe the sonographic appearance of injuries of the ulnar collateral ligament (UCL) of the elbow.Design and patients Eight non-professional male baseball pitchers, ages 13–35 years, with medial elbow pain and clinical suspicion of ulnar collateral ligament injury, were referred for imaging. All eight underwent sonography of the affected and contralateral asymptomatic elbow, and six also underwent MR imaging. Neither valgus stress nor power Doppler was used during the sonographic examinations. Time from onset of symptoms to imaging was 1.5 weeks to 6 months. Three patients had surgical confirmation of their injuries, with time from imaging to surgery of 2 days to 9 months.Results In four patients, the UCL was ruptured, manifest sonographically in three cases as discontinuity of the normally hyperechoic ligament with anechoic fluid in the gap and in one case as non-visualization of the ligament with heterogeneous echogenicity in the expected location of the ligament. Two adolescent patients had avulsions of the UCL from the medial epicondyle, with sonographic demonstration of the avulsed echogenic bony fragment in both cases. One patient had a mild sprain, manifest as mild thickening and decreased echogenicity of the ligament sonographically compared with the contralateral normal elbow, with mild surrounding hypoechoic edema. The eighth patient had a small partial tear of the deep surface of the distal aspect of the ligament, visualized as a hypoechoic focus between the deep surface of the ligament and its ulnar attachment.Conclusion Tears of the ulnar collateral ligament are manifested sonographically as non-visualization of the ligament or alteration of the normal morphology.     

Biomechanical evaluation of a new ulnar collateral ligament reconstruction technique with interference screw fixation

BACKGROUND: Techniques for ulnar collateral ligament reconstruction have evolved. HYPOTHESIS: Ulnar collateral ligament reconstruction with interference screw fixation restores elbow kinematics and failure strength to that of the native ligament. STUDY DESIGN: Controlled laboratory study. METHODS: Of 10 matched pairs of cadaveric elbows, one underwent kinematic testing under conditions of an intact, released, and reconstructed ligament. Single 5-mm diameter bone tunnels were created at the isometric anatomic insertion sites on the medial epicondyle and sublime tubercle. Graft fixation was achieved with 5 x 15 mm soft tissue interference screws. The reconstructed and contralateral intact elbows were then tested to failure. RESULTS: Average stiffness for intact elbows (42.81 +/- 11.6 N/mm) was significantly greater than for reconstructed elbows (20.28 +/- 12.5 N/mm). Ultimate moment for intact elbows (34.0 +/- 6.9 N.m) was not significantly different from reconstructed elbows (30.6 +/- 19.2 N.m). Release of the ulnar collateral ligament caused a significant increase in valgus instability. Reconstruction restored valgus stability to near that of the intact elbow. CONCLUSIONS: With this reconstruction method, failure strength was comparable with that of the native ligament and physiologic elbow kinematics were reliably restored. Clinical Relevance: This technique returns elbow kinematics to near normal, with less soft tissue dissection and risk of ulnar nerve injury and ease of graft insertion, tensioning, and fixation.     

Iliotibial band friction syndrome: MR imaging findings in 16 patients and MR arthrographic study of six cadaveric knees.

PURPOSE: To define magnetic resonance (MR) imaging findings in patients with the iliotibial band friction syndrome (ITBFS) and to correlate these findings with anatomic features defined at magnetic resonance (MR) arthrography in cadavers. MATERIALS AND METHODS: The anatomic relationship of the iliotibial tract (ITT) to the lateral recesses of the knee joint and the lateral femoral epicondyle was investigated with MR arthrography at full extension and at 30 degrees and 60 degrees of knee flexion in six cadaveric knees. Seventeen MR imaging studies in 16 patients with ITBFS were evaluated. RESULTS: In the cadaveric study, no interference of the lateral synovial recess with the lateral femoral epicondyle at full extension and at 30 degrees and 60 degrees of knee flexion was observed. In all specimens, correlation of MR images with macroscopic and microscopic sections revealed no primary bursa between the lateral femoral epicondyle and the ITT. In clinical studies, MR imaging findings of poorly defined signal intensity abnormalities or circumscribed fluid collections were located in a compartmentlike space confined laterally by the ITT and medially by the meniscocapsular junction, the lateral collateral ligament, and the lateral femoral epicondyle. CONCLUSION: MR imaging accurately depicts the compartmentlike distribution of signal intensity abnormalities in patients with ITBFS.     

MRI of the reconstructed ulnar collateral ligament

OBJECTIVE: We are often asked to evaluate the postoperative elbow using MRI. In this article, we present both the normal appearance of the reconstructed ulnar collateral ligament (UCL) and a spectrum of UCL graft abnormalities at MR arthrography. CONCLUSION: The UCL is the primary medial stabilizer of the elbow during flexion and is susceptible to injury, particularly in overhead throwing athletes. In the setting of UCL injury, ligament reconstruction is the principal surgical procedure available to restore stability and function and to relieve pain with activity. We have found MR arthrography useful in assessing the reconstructed UCL.     

The lateral elbow ligaments. A correlative radiographic study

Knowledge of the lateral elbow ligaments' normal anatomic relationships to osseous structures, as seen on standard radiographs, can facilitate the interpretation of arthrograms and an understanding of fracture mechanisms. We dissected fresh cadaveric elbows to isolate the entire lateral ulnar collateral and annular ligaments as well as their sites of osseous origin and insertion. We obtained radiographs of each ligament after painting them with a special radiopaque tantalum powder cyanoacrylic preparation. The resulting study allowed radiographic depiction of these important soft tissue structures in relation to the attendant osseous anatomy.     

Relationship of ulnar collateral ligament strain to amount of medial olecranon osteotomy.

Athletes at risk for valgus extension overload are also at risk for tears of the anterior bundle of the ulnar collateral ligament. Some athletes develop ligament tears after procedures for valgus extension overload such as posteromedial olecranon osteotomy. The amount of posteromedial olecranon that can be resected before ulnar collateral ligament strain, and risk of injury, increases is unknown. We dissected and mounted five fresh-frozen human cadaveric elbows to allow strain gauge monitoring of the ulnar collateral ligament with varying valgus stress, elbow flexion angle, and medial osteotomy. The average strain to failure was 11.96%+/-6.51%, corresponding to a load of 347.71+/-46.42 N. The maximum tensile force recorded at failure was 416.24 N. Three-way repeated-measures analysis of variance revealed no significant change in strain with change in the amount of osteotomy for a given applied load and angle of flexion. On the basis of these data, we conclude that the effect of medial olecranon osteotomy on ulnar collateral ligament strain may be small. Small sample size, elderly specimens, and the variables inherent in the experimental setup and mathematical modeling make it difficult to extrapolate these results to in vivo behavior of the anterior ulnar collateral ligament. Further work is needed before definitive guidelines for olecranon osteotomy can be formulated.     

Pisotriquetral joint: assessment with MR imaging and MR arthrography

PURPOSE: To evaluate magnetic resonance (MR) imaging and MR arthrographic findings in the pisotriquetral joint (PTJ) and their contribution to assessment of PTJ osteoarthritis. MATERIALS AND METHODS: Images of 22 fresh human cadaveric PTJs were obtained with both conventional and arthrographic MR techniques. The MR appearances of all intraarticular and periarticular structures were analyzed and correlated with anatomic slices. Two readers graded visibility of anatomic structures and severity of joint abnormalities. Differences in the visibility ratings at standard MR imaging and at MR arthrography were calculated. Association between the type of pisiform insertion of ligament or muscle with cartilaginous abnormalities of the PTJ was assessed. The association between cartilaginous lesions and osteoarthritic changes was calculated. RESULTS: The tendon sheath, the fibrous capsule, and cartilaginous surfaces were better visualized at MR arthrography than at MR imaging. Pisohamate and pisometacarpal ligaments were slightly better seen on MR arthrograms. Tendons, muscles, and retinacular structures were well demonstrated at both conventional MR and MR arthrography. Cartilaginous lesions and osteophytes were easily identified and were detected more often in the pisiform bone than in the triquetral bone. Communication of the PTJ with the radiocarpal joint was noted in 18 (82%) of 22 wrists. CONCLUSION: MR imaging and/or MR arthrography allows visualization of all anatomic structures of the PTJ. MR arthrography improves visualization of findings of osteoarthritis.     

Ligamentous and tendinous anatomy of the intermetacarpal and common carpometacarpal joints: evaluation with MR imaging and MR arthrography.

PURPOSE: The purpose of this work was to demonstrate the normal ligamentous and tendinous anatomy of the intermetacarpal (IMC) and common carpometacarpal (CCMC) joints with MRI and MR arthrography. METHOD: MR images of 22 wrists derived from fresh human cadavers were obtained before and after arthrography. The MR imaging features of the ligaments and tendons about the CCMC and IMC joints and the joints themselves were analyzed in a randomized fashion and correlated with those seen on anatomic sections. RESULTS: Six CCMC ligaments were visualized. The dorsal and palmar CCMC ligaments and the pisometacarpal ligament were best visualized in the sagittal plane. The radial and ulnar CCMC collateral ligaments and the capito-third metacarpal ligament were best visualized in the coronal plane. Three main IMC ligaments were observed: a dorsal and a palmar ligament and an interosseous ligament complex. All three ligaments were best visualized in the axial plane. Four tendinous insertions to the metacarpal bases were evident. CONCLUSION: The anatomy of the ligaments and tendinous insertions about the second to fifth IMC and the CCMC joints is well demonstrated by MR imaging and MR arthrography. MR arthrography does not significantly improve the visualization of these complex structures.     

Avulsion of the medial epicondyle after ulnar collateral ligament reconstruction: imaging of a rare throwing injury

OBJECTIVE: The objective of this article is to report and describe the clinical and imaging features of an avulsion fracture of the medial epicondyle after ulnar collateral ligament (UCL) reconstruction. CONCLUSION: Avulsion fracture of the medial epicondyle is a rare complication of UCL reconstruction with distinct radiographic and MRI findings.     

MR imaging findings of lateral ulnar collateral ligament abnormalities in patients with lateral epicondylitis.

OBJECTIVE: The purpose of this paper was to use MR imaging to determine whether a relationship exists between lateral epicondylitis and abnormalities of the lateral ulnar collateral ligament. SUBJECTS AND METHODS: The study group comprised 35 consecutive patients who were referred for MR imaging to rule out lateral epicondylitis. On MR imaging, "lateral epicondylitis" was defined as increased signal intensity of the extensor tendons close to their insertion on the lateral epicondyle. The severity of the lateral epicondylitis was graded as mild, moderate, or severe. The origin of the lateral collateral ligamentous complex was characterized, and the lateral ulnar collateral ligament was graded as normal, thickened, partially torn, or torn. Eleven patients underwent elbow surgery after the initial MR examination. RESULTS: In 15 patients, MR imaging revealed characteristics of mild lateral epicondylitis. In 13 of these patients, the lateral ulnar collateral ligament was normal; one patient showed a thickened ligament; and one patient had a thinned ligament. In 11 patients, MR imaging showed features of moderate lateral epicondylitis. In eight of these patients, the lateral ulnar collateral ligament was thickened, and in the remaining three patients the ligament was normal. All nine patients with severe lateral epicondylitis showed abnormalities of the lateral ulnar collateral ligament on MR imaging. In one of these patients the lateral ulnar collateral ligament was thickened, in three patients we saw a partial tear, and in the remaining five patients we saw a complete tear of the ligament. CONCLUSION: In our study, MR imaging features of lateral epicondylitis were often associated with thickening and tears of the lateral ulnar collateral ligament.     

MR arthrography of elbow: evaluation of the ulnar collateral ligament of elbow

 Objective. The purpose of this study was to evaluate ulnar collateral ligament (UCL) injury of the elbow in throwing athletes by MRI and MR arthrography. Design. Ten elbows of throwing athletes were examined on both plain MRI and MR saline arthrography and the injuries subsequently surgically proven. Spin-echo (SE) T1-weighted and fast SE T2-weighted coronal images were obtained. Results. The UCL was unclear in all ten cases on T1-weighted MRI. In five cases an avulsion fracture was also found on T1-weighted MRI. On T2-weighted MRI, abnormal high-intensity areas were identified in or around the UCL. On T2-weighted MR arthrography images, extracapsular high-intensity areas, which represent extracapsular leakage, were found in four of five cases with avulsion fracture. At surgery, all these four cases showed avulsion fractures with instability; the other case had a fracture but it was stable and adherent to the humerus. On T2-weighted MR arthrography images, an extracapsular high-intensity area was found in one of the five cases without avulsion fracture. At surgery this patient had a complete tear of the UCL itself. Conclusion. MR arthrography provided additional information for evaluating the degree of UCL injury.     

MR imaging,MR arthrography,and specimen correlation of the posterolateral corner of the knee: an anatomic study

OBJECTIVE: We sought to evaluate the anatomy of the posterolateral aspect of the knee with anatomic dissection, MR imaging, MR arthrography, and sectional anatomy. MATERIALS AND METHODS: We assessed the posterolateral corner of the knee during dissection of one gross anatomic specimen. MR imaging and MR arthrography were performed in seven additional knee specimens. T1-weighted spin-echo MR images were obtained in the standard imaging planes as well as in the coronal oblique plane. The specimens underwent T1-weighted spin-echo MR imaging after administration of intraarticular contrast material and were sectioned into planes corresponding to those of the MR images. RESULTS: At anatomic dissection, the following posterolateral structures were identified: the arcuate ligament (medial and lateral limbs), fabellofibular ligament, popliteofibular ligament, popliteus tendon and its two posterior attachments to the lateral meniscus, fibular collateral ligament, direct and anterior arms of the tendon of the long head of the biceps femoris muscle, and direct and anterior arms of the tendon of the short head of the biceps femoris muscle. Correlation of MR imaging and anatomic findings showed that the popliteofibular ligament and oblique popliteal ligament were found in 57% and 100% of specimens, respectively. At least one of the two limbs of the arcuate ligament was identified in 71% of specimens. The fabellofibular ligament was not identified on MR images in any of the specimens. The anteroinferior and posterosuperior popliteomeniscal fascicles were identified in all specimens. CONCLUSION: The posterolateral corner of the knee comprises complex and variable anatomic structures. Recognition of these variations is important in the assessment of MR images of the knee.     

Arthrography in javelin throwers with medial elbow pain

In 18 javelin throwers from all parts of Sweden, referred to our Section of Sports Medicine because of medial elbow pain, an arthrography was performed to study intra-articular changes. In 11 of the throwers the pain occurred suddenly at the moment a throw was being executed and in 7 there was a gradual increase of pain during training and competition. In the clinical examination 1 week to 72 months after the onset of the symptoms there was a tenderness over the medial collateral ligament in all subjects. No elbow was unstable. On the plain radiographic examination a small calcification was seen at the site of the ligament in 3 cases. The arthrography revealed a leakage of contrast into the soft tissue at the site of the ligament in 10 elbows, and a local synovitis was seen in 16 elbows. We conclude that the medial elbow pain in javelin throwers is caused by a partial injury to the medial collateral ligament and a secondary local inflammation.     

Magnetic resonance (MR) imaging of the shoulder, elbow, and wrist

Thorough knowledge of small structures in the joints is becoming important as the resolution of magnetic resonance (MR) imaging has improved during the past decade. The author discusses the MR anatomy and pathology of three representative structures in the joints of the upper extremities: the labral-ligamentous complex of the shoulder, ulnar collateral ligament(UCL) of the elbow, and triangular fibrocartilage complex(TFCC) of the wrist. The labral-ligamentous complex is composed of the anterior labrum and three glenohumeral ligaments. Because of their similar MR appearance, the labral sulcus is difficult to differentiate from traumatic detachment of the labrum, even with the aid of MR arthrography. Insertion of the UCL to the medial condyle in the growing elbow presents different MR appearances according to age. Acute and chronic UCL tears are commonly seen in elbows with medial tension overload and are well depicted with three-dimensional Fourier transform(3DFT) gradient-echo images. 3DFT images are the most suitable for observation of the TFCC as well. Since abnormally high signals of the articular disc suggestive of tear are often seen in asymptomatic subjects, MR imaging may not reliably be used to differentiate clinically significant tears from asymptomatic defects. In this review article, the author emphasizes developmental anatomy and normal variations in the interpretation of MR images.     

The effectiveness of diagnostic imaging methods for the assessment of soft tissue and articular disorders of the shoulder and elbow

There are no clear guidelines for diagnostic imaging of articular and soft tissue pathologies of the shoulder and elbow. Several methods are used, including magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA) and ultrasound (US). Their cost-effectiveness is still unclear. We performed a meta-analysis of the relevant literature and discussed the role of MR imaging of the shoulder and elbow compared with other diagnostic imaging modalities. For the shoulder impingement syndrome and rotator cuff tears, MRI and US have a comparable accuracy for detection of full-thickness rotator cuff tears. MRA and US might be more accurate for the detection of partial-thickness tears than MRI. Given the large difference in cost of MR and US, ultrasound may be the most cost-effective diagnostic method for identification of full-thickness tears in a specialist hospital setting (Evidence level 3). Both MRA and CT arthrography (CTA) are effective methods for the detection of labrum tears. More recently, multidetector CTA has offered the advantages of thinner slices than with MRA in a shorter examination time. Still, MRA has the advantage towards CTA to directly visualize the affected structures with a better evaluation of extent and location and to detect associated capsuloligamentous injuries. For the elbow pathologies, plain MRI or MRA have the advantage towards CTA to detect occult bone injuries. CTA is better for the assessment of the thin cartilage of the elbow. Both US and MRI are reliable methods to detect chronic epicondylitis; US is more available and far more cost-effective (Evidence level 2). MRA can differentiate complete from partial tears of the medial collateral ligament. US or MRI can detect partial and complete biceps tendon tears and/or bursitis. MRI can provide important diagnostic information in lesions of the ulnar, radial, or median nerve.     

Upper extremity injuries in the paediatric athlete

Injuries to the upper extremity in paediatric and adolescent athletes are increasingly being seen with expanded participation and higher competitive levels of youth sports. Injury patterns are unique to the growing musculoskeletal system and specific to the demands of the involved sport. Shoulder injuries include sternoclavicular joint injury, clavicle fracture, acromioclavicular joint injury, osteolysis of the distal clavicle, little league shoulder, proximal humerus fracture, glenohumeral instability and rotator cuff injury. Elbow injuries include supracondylar fracture, lateral condyle fracture, radial head/neck fracture, medial epicondyle avulsion, elbow dislocation and little league elbow. Wrist and hand injuries include distal radius fracture, distal radial physeal injury, triangular fibrocartilage tear, scaphoid fracture, wrist ligamentous injury thumb metacarpalphalangeal ulnar collateral ligament injury, proximal and distal interphalangeal joint injuries and finger fractures. Recognition of injury patterns with early activity modification and the initiation of efficacious treatment can prevent deformity/disability and return the youth athlete to sport.