Elbow Injuries in the Adult Athlete - American College of ...forms.acsm.org/16tpc/PDFs/11 Scerpella.pdf · Elbow Injuries in the Adult Athlete Tamara A. Scerpella, MD Professor, Orthopedic
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Elbow Injuries in the Adult Athlete Tamara A. Scerpella, MD Professor, Orthopedic Surgery University of Wisconsin
Acute
• Elbow Dislocation • Fracture
– Distal humerus – Olecranon – Radial head
• Distal Biceps Rupture • Ulnar Collateral Ligament Tear
Acute
• Elbow Dislocation • Fracture
– Distal humerus – Olecranon – Radial head
• Distal Biceps Rupture • Ulnar Collateral Ligament Tear
Chronic (Throwing)
• Lateral Epicondylitis • Valgus Extension Overload
– Ulnar neuritis – UCL laxity – Flexor pronator mass injury – Posteromedial impingement – Olecranon stress fracture
• Osteochondral Lesions (capitellum)
Elbow Dislocation
• 10-25% of all elbow injuries • 6-8 cases / 100,000 (2nd to shoulder)
Elbow Anatomy – Bony Stability
• Primary Bony Stabilizers (~50%) – Ulnohumeral joint – Coronoid and olecranon
• Secondary stabilizers – Radial head (static)
Elbow Anatomy – Soft Tissue Stabilizers
• Primary Ligamentous Stabilizers – Radial Collateral Lig – UCL, anterior band
• Secondary stabilizers – flexor-pronator, common
extensors (dynamic)
Elbow Dislocation - Mechanism Direction = ulna displacement
• 80-90% posterior or posterolateral
• Fall on outstretched arm è posterior or posterolateral
• Fall on flexed elbow è anterior
• Hyperlaxity predisposes (gymnasts)
Elbow Dislocation - Posterior
Elbow Dislocation -Posterior
Elbow Dislocation - Diagnosis
Elbow Dislocation - Treatment • Immediate / On-Field –
one reduction attempt – Splint / X-ray if
unsuccessful (possible fracture)
• Sedation / Anesthesia – prolonged or complex (with fracture)
Elbow Dislocation - Reduction Anterior
Elbow Dislocation - Treatment • Post-reduction:
– NV exam; Xray to r/o fracture; assess stability
Immobilize THEN Mobilize • Soft tissue rest • Early mobilization
to restore ROM
Mehlhoff et al 1988
Surgical Indications • Unstable after reduction
– Even if flexed, pronated • Significant soft-tissue
damage • Repair:
– LCL complex first – UCL if still unstable – common extensor, flexor-
pronator avulsions
Associated Fractures • Coronoid • Radial Head • Distal
Humerus • Olecranon • Terrible Triad:
Radial Head, Coronoid & Elbow Dislocation
Associated Fracture - Coronoid
• Anterior dislocation • Type 1: avulsion fx • Type 2: < 50% • Type 3: > 50%
– Elbow stability significantly compromised
– Valgus instability (UCL insertion)
– Treatment: ORIF
Acute
• Elbow Dislocation • Fracture
– Distal humerus – Olecranon – Radial head
• Distal Biceps Rupture • Ulnar Collateral Ligament Tear
Radial Head Fracture • FOOSH • Diagnosis:
tenderness, effusion • X-ray: fat pad sign • Treatment based
upon displacement: >2mm = ORIF
• Non-op: immobilize 3-5 days only
• Rapid mobilization to prevent extension loss
Distal Biceps Rupture • Rare in young athlete • Forcible extension
while actively flexing • FB, weight-lifting • Diagnosis:
– Ecchymosis – Deformity -retraction
• Treatment: – Surgical repair
Ulnar Collateral Ligament Rupture - Acute
• Painful pop while throwing
• Localized swelling • Laxity to valgus
stress • MR-arthrogram is
diagnostic
Case
• 20 y.o. M LHD collegiate pitcher • Acute onset medial elbow pain in left arm • Felt a “pop” during a pitch
– Immediate pain – Decreased velocity and control
• Swelling medial elbow X 2 weeks • tingling in ring and small finger
– Resolved when swelling subsided
Case
• Physical Exam – Mild swelling medial elbow – TTP just distal to medial epicondyle – 1+ laxity on valgus stress at 30 and 90
degrees – Pain with moving valgus stress test – 2 pt discrimination normal in ulnar nerve
distribution
Case
• UCL reconstruction using palmaris longus
Case
Chronic Injury (Throwing) • UCL Chronic Tear - attenuation • Valgus Extension Overload
– UCL laxity – Flexor pronator mass injury – Posteromedial impingement – Olecranon stress fracture – Ulnar neuritis
• Lateral Epicondylitis • Osteochondritis Dissecans (capitellum)
Ulnar (Medial) Elbow Overuse
• Overhead throwing: – tremendous valgus stress – concentrates on medial side
• Medial elbow problems predominate – 97% of elbow c/o in baseball pitchers
• Also football, volleyball, tennis, javelin, gymnastics
• Chronic, overuse most common • Acute UCL tears may occur
Valgus Extension Overload • Medial tensile forces • Lateral compressive
forces • Posterior shear stresses • Result:
– UCL laxity – flexor–pronator mass
injuries – neuritis of the ulnar nerve – posterior impingement – olecranon stress fractures
Chronic UCL Laxity - Pathogenesis
• 3 bundles: anterior, posterior, transverse – Anterior: strongest, primary valgus restraint at <90 – Posterior: restraint at >60
• Valgus forces > Intrinsic Tensile force of UCL = microtearing of UCL
• Additional stress: – bad mechanics – poor flexibility – inadequate conditioning
• Result: attenuation and… ultimate rupture of UCL
Chronic UCL Laxity - Presentation
• Symptoms – medial pain in late-cocking, early acceleration – +/- ulnar n sxs – Can throw only 50-75% of normal level
• Exam: • valgus force at 20-30 degrees flexion (ant band) • “milking maneuver” at > 90 deg (post band) • Flexion contracture: result of repeated attempts
at healing and stabilization, don’t need full extension to throw
• Pain with wrist flexion or tenderness over flexor mass origin suggests flexor/pronator mass injury.
Valgus Instability - Exam
• Milking maneuver
• Valgus stress test ~15o and full pronation
Valgus Instabilty - Exam • Moving valgus stress
test – 90 degrees abduction,
full ER – Full flexion to extension
maintaining a constant valgus stress
• pain/apprehension • Usually @ 70-120o
– 100% sensitive and 75% specific for UCL attenuation/tear (O’Driscoll AJSM ’05)
UCL Tear - Imaging • XRAY: changes c/w chronic instability:
calcification/ossification of ligament • MRI: ligamentous avulsions, partial injuries,
midsubstance tears, surrounding soft tissues • CT Arthrography: undersurface tears
– Similar to MRI with gadolinium • Timmerman, Andrews (1994) – MRI, CT
arthrography with arthroscopy correlation – Equivalent ability to detect full-thickness tears
Chronic UCL Tear – Nonoperative Treatment
• 2-4 weeks rest, NSAIDS, PT • Corticosteroid injections NOT recommended • After acute inflammation gone - supervised
flexibility, strengthening program – target FCU, pronator teres, FDS
• After full ROM / strength regained - begin throwing, conditioning program (~ 3 mos)
• Early treatment can stop progression of instability
• ~50% athletes returning to preinjury level
Chronic UCL Injury – Surgery • Indications:
– competitive athletes with acute, complete UCL rupture – chronic sxs with failure of 3-6 mos nonoperative tx
• Surgery - repair or reconstruct UCL • Direct repair - acute ligamentous avulsions • Reconstruction - chronic instability with
attenuation, midsubstance tears – palmaris longus, plantaris, Achilles, hamstrings – PL – avg load to failure 357N (Ant UCL – 260N)
• Morrey et al.
UCL Reconstruction
Ulnar nerve transposition ONLY if nerve symptoms!
Post-op Rehabilitation • Brief immobilization (7-10 d) - then active shoulder,
elbow, wrist ROM • 4-6 weeks: PREs wrist/forearm • 6 weeks: PREs elbow • Valgus stress avoided until 4 months • 2-3 months: RTC strengthening emphasized • 3-4 months: throwing program - light tossing • 6 months: lobbing ball 60 ft with easy windup • 7 months: 50% max velocity • 8-9 months: pitchers 70% max • 12-18 months: full activity
Results- Surgical Reconstruction
• Jobe et al: reconstruction with ulnar transposition – 10/16 (63%) preinjury function (11-19 months) – 1 to lower level, 5 retired – High incidence of ulnar n complications – 5/16
• 2 reoperated – 1 transposition, 1 neurolysis • 3 paresthesias that resolved
• Conway et al: 14 direct repair, 56 reconstruction – direct: 71% G/E, 50% return to play by 9 mos – recon: 80% G/E, 68% to preinjury by 12 mos – 40% preop ulnar sx, 22% postop - 8 req transposition
• Jobe et al (1997): reconstruction without transposition – 83 athletes (54 pro, 18 college, 11 rec) – 94% G/E results – avg RTP 13 mos – 3 with ulnar paresthesias, 1 with neuropathy
– all resolved by 6 months
• Chronic UCL laxity • Compressive lateral
forces = synovitis, osteochondral lesions at radiocapitellar joint
• Posterior impingement (olecranon osteophytes)
Valgus Extension Overload
Posterior Impingement • Posteromedial olecranon osteophytes, chondromalacia
• Posterior pain with valgus/extension (late acceleration phase)
• Rest, ice, NSAIDS • Functional strengthening elbow, forearm
– Dynamic stabilizers • Stretching - isotonic, isokinetic, isometric
exercises begun • As strength improves - plyometric
exercises (flexor/pronator mass); interval throwing program
Posterior Impingement Non-operative Treatment
• Indications: – failed non-op tx – symptomatic spurs or loose bodies
• Elbow arthroscopy - good results, low complication rates – undersurface tears of UCL can be seen but
must be addressed open • Reconstruction of UCL reserved for pts
who have failed all above treatment
Posterior Impingement Surgical Treatment
Ulnar Neuritis • Associated with UCL laxity • Pain / numbness / tingling • Later: weakness / atrophy • Treatment: decompression / transposition
Flexor Pronator Injury Medial Epicondylitis = “Golfer’s
Elbow” • repetitive valgus forces = chronic
inflammatory changes • 10-20 X less common than lateral • Pronator teres, FCR, FCU
– PT highest activity in acceleration phase
– FCU overlies UCL at 120o
– Decrease in FCU activity with UCL instability
• Microtears between PT and FCR origins – inflammatory and fibrotic granulation
tissue
• Medial elbow pain, insidious, worse with throwing
• Physical exam – tender flexor-pronator origin – pain with wrist flexion, forearm pronation
• XR - normal / traction spurs, UCL Ca++ • MRI - signal musculotendinous origin • EMG/NCV - evaluate for ulnar neuropathy
– 60% have ulnar neurapraxia
Presentation
• Rest, ice, NSAIDS • Steroid injections (tendon attenuation
with repeat injections) • Splinting or counterforce bracing • PT - wrist flexor/pronator stretching, then
progressive isometrics; PREs • >90% success
Treatment - Nonoperative
• >6 months of non-op PT • Debride inflamed tissue, repair tendon • Postop rehab:
– Brief immobilization (7-10d) – Passive, active elbow ROM – @4-6 weeks - PREs – RTP - 4 months
• 95% success • Ulnar neuropathy=poor prognosis
Treatment - Surgical
Lateral Epicondylitis
Lateral Epicondylitis - Treatment
Summary
• Throwing / racquet athlete = medial-sided problems – Flexor pronator tendinosis / medial
epicondylitis – UCL laxity – Posterior Impingement – Ulnar neuritis
• Many respond to non-operative Rx
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