Medial Tension Injuries True Little League Elbow

Medial tension injuries are the most common entities associated with Little League elbow. Young throwers typically present with the classic history triad of medial elbow pain, decreased throwing effectiveness, and de

FIGURE 5.3. (A) Anterior view of the elbow demonstrating medial and lateral forces placed on the elbow structures during the throwing motion. (B) Posterior view of the elbow showing forces typically placed on the elbow structures during the late cocking and acceleration phases. The valgus load can cause impingement at the postero-medial ulnohumeral articulation and lead to osteophyte formation.

FIGURE 5.3. (A) Anterior view of the elbow demonstrating medial and lateral forces placed on the elbow structures during the throwing motion. (B) Posterior view of the elbow showing forces typically placed on the elbow structures during the late cocking and acceleration phases. The valgus load can cause impingement at the postero-medial ulnohumeral articulation and lead to osteophyte formation.

Valgus stress

Valgus stress

Valgus

Valgus

creased throwing distance. The physical examination includes a complete evaluation of the upper extremity from the neck down to the hand.

Medial Epicondylar Osteochondrosis (Stress Injury)

The physical examination reveals point tenderness at the medial epicondyle and pain with resisted flexion and pronation, as well as with valgus stress at 25° of elbow flexion. Often there is a flexion contracture of less than 15°. The radiographs show fragmentation and widening of the medial epicondylar physis. If uncertainty exists, a bone scan or magnetic resonance imaging (MRI) may be helpful in identifying an injury.

The treatment is always nonoperative and includes 4 to 6 weeks of relative rest (wrist and elbow range of motion are maintained), ice massage, and nonsteroidal anti-inflammatory medication or acetaminophen until tenderness of the medial epicondyle subsides. After the symptoms resolve, a gradual return to throwing is begun using a supervised interval-throwing program. Anytime a young thrower is seen for elbow complaints, a proper evaluation of throwing technique by a trained throwing coach or therapist is mandatory to assure that he or she is using proper mechanics.

Medial Epicondylar Avulsion

Examination demonstrates point tenderness at the medial epicondyle and exacerbation of pain with resisted wrist flexion and pronation; valgus stress at 25° is frequently found. In patients with a complete medial epicondylar avulsion, a medial aspect hematoma can be seen on inspection, and grating can be noted with range of motion if the fragment is in the joint.

Radiographs may show widening of the medial epi-condyle and, in the case of complete avulsion, there will be displacement of the medial epicondyle from its actual posteromedial position in the humerus. Avulsion fractures are commonly displaced into the normal position of the trochlear ossification center. Because the medial epi-condylar nucleus appears before the trochlear center, any radiograph showing the presence of a trochlear center and no medial epicondylar center indicates a dislocated avulsion fracture of the medial epicondyle. The medial epi-condyle is extra-articular, and no fat pad sign will be visible. If there is any question concerning the presence or position of an apophyseal or epiphyseal growth center in any of these entities, a contralateral elbow series should be obtained for comparison. Tomograms, computed tomography (CT) scans, and MRI are rarely needed for evaluation of medial epicondylar avulsions. If injury to the ligament is of concern, a CT arthrogram or contrast-enhanced MRI may be used to diagnose undersurface medial collateral ligament (MCL) tears, and MRI is the study of choice for suspected complete MCL tears.16-18

The treatment of medial epicondylar avulsion is based on the amount of fragment displacement. This treatment guideline is used for young throwing athletes who continue to place high demands on their elbows through future sports participation, and greater amounts of displacement may be acceptable for nonoperative treatment in a nonathletic child. For minimal displacement (<2 mm), a posterior splint is applied with the elbow flexed slightly less than 90° to relax the flexor-pronator group for 2 to 3 weeks. After 2 weeks, range of motion exercises are begun and are advanced as tolerated by the patient. At 6 weeks, radiographs are taken to assess healing. The athlete can start an interval-throwing program at 8 weeks if the fracture has healed and is painless. A full return to competition is permitted at 12 weeks.

When there is significant displacement (>2mm), open reduction and internal fixation are recommended. In ad dition, a relative indication for open reduction and internal fixation is the presence of ulnar nerve dysfunction.19,20

The operation is performed through a medial incision centered over the medial epicondyle. The fragment is usually displaced anterior and distally and is reduced to its posteromedial location by holding it with a towel clip while flexing and pronating the forearm. The fixation is achieved with one or more cannulated 3.0-mm AO screws, depending on the fragment size (Fig. 5.4). The ulnar nerve is identified and protected throughout the procedure. It is important to preserve the medial antebrachial cutaneous nerve during the superficial dissection to avoid bothersome neuromas. After the completion of the procedure, the elbow is splinted for 2 weeks. Range of motion is started after 2 weeks and rehabilitation continues as described above for minimally displaced avulsion fractures.

Other Associated Entities

Ulnar neuritis is less common in young throwers than in adult throwers. Subluxation of the nerve can contribute to the problem, but be aware that 30% of the adolescent population has asymptomatic subluxation.21 Players often relay a history of numbness and tingling in the ring and long fingers, weakness and clumsiness of the hand after throwing, and a snapping sensation in the elbow during the acceleration phase. Examination may demonstrate sensory changes in the ulnar distribution, possible muscle atrophy, and a positive Tinel's sign at the cubital tunnel. An electromyographic (EMG) study confirms the diagnosis. Treatment of ulnar neuritis is nonoperative, consisting of rest, nonsteroindal anti-inflammatory medication, immobilization in a sling or splint for 2 to 3 weeks, if necessary, followed by a gradual return to a throwing program. Recurrence is common and is usually due to underlying medial collateral ligament laxity or

FIGURE 5.4. (A) Anteroposterior radiograph of a displaced medial epicondyle fracture. (B) Postoperative radiograph shows fracture fixation with a single screw after open reduction and internal fixation.

poor throwing mechanics, both of which increase valgus stresses that place the nerve on stretch. Symptomatic subluxation without underlying laxity in young players can be treated with ulnar nerve transposition with good results.22

Other manifestations of medial tension stresses are medial prominence overgrowth, which is a cosmesis problem, and delayed closure of the medial epicondylar growth plate, which is more of a radiological finding than a functional problem.19

Medial collateral ligament injuries in young players are rare but, when present, they should be treated with repair or reconstruction based on the tear sites.5 If the injury is treated surgically, the postoperative splint is removed at 2 weeks and a valgus-stress-preventing brace is applied for 4 weeks. At this time, rehabilitation begins.

Complications associated with the medial tension injuries are loss of motion, specifically the final 5° to 10° of extension, ligament ossification, and valgus instability. In medial epicondylar avulsions that have been treated surgically, painful retained hardware should be removed after the fracture has healed.

Cure Tennis Elbow Without Surgery

Cure Tennis Elbow Without Surgery

Everything you wanted to know about. How To Cure Tennis Elbow. Are you an athlete who suffers from tennis elbow? Contrary to popular opinion, most people who suffer from tennis elbow do not even play tennis. They get this condition, which is a torn tendon in the elbow, from the strain of using the same motions with the arm, repeatedly. If you have tennis elbow, you understand how the pain can disrupt your day.

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