ELBOW INJURY-FOOTBALL

Abstract

HISTORY A 17 year-old senior football player presented to clinic 1.5 weeks after a backyard pick up game in which he fell on his outstretched left arm. The patient immediately felt a pop in his left elbow. He had swelling and bruising to the medial aspect of his elbow. He had pain with any motion of the elbow joint. After his visit, the patient was diagnosed with an elbow contusion and allowed to participate fully in football practice, secondary to minimal swelling and tenderness over the medial aspect of the elbow and full active range of motion (ROM). No laxity was noted. The patient proceeded to practice football all week and continued to have pain, greatest with flexion. His trainer noted decreased strength in the left arm. There was no repeat injury. The patient presented the second time, 2.5 weeks after the initial injury, secondary to decreased strength, tenderness over the medial aspect of the elbow, and effusion. PHYSICAL EXAM Examination 2.5 weeks after injury revealed no effusion or bruising over the left elbow. There was pain to palpation over the medial epicondyle extending 2cm distal along the ulna. He was lacking full extension by 5–10 degrees. Flexion was to 130 degrees. The pain increased with valgus stress. At 0 degrees he had opening to valgus stress. He had full pronation and supination. Strength was decreased in flexion. Triceps, brachialradialis, and bicep reflexes are symmetric compared to the right side at 2/2. Radial pulse and capillary refill were normal. DIFFERENTIAL DIAGNOSIS Ulnar collateral ligament tear. Medial epicondylar apophysitis (skeletally immature athlete). Medial epicondylar physeal fracture (skeletally immature athlete). Flexor-pronator muscle tear. TESTS AND RESULTS Left elbow lateral and Anteroposterior view radiographs: reveal no bony abnormalities. MRI of left elbow: 1. Avulsion and separation of the ossification center of the medial epicondyle. 2. Associated high-grade injury of the common/pronator tendon with evidence of an intrasubstance tear of the flexor carpi radialis muscle. 3. High-grade injury and tear of the anterior and posterior bands of the ulnar collateral ligament. 4. Grade 2 osseous contusion of the capitellum and olecranon. 5. Small joint effusion. 6. Overlying soft tissue swelling. FINAL WORKING DIAGNISIS Ulnar collateral ligament tear with associated flexor-pronator muscle/tendon damage secndary to high-grade extension injury with valgus stress. TREATMENT AND OUTCOMES 1. Surgical repair of the medial elbow ligament (ulnar collateral) was only necessary due to fact that the flexor tendons were intact and the ulnar collateral ligament had avulsed from the ulna with a bone fragment. a. One week following surgery, the patient was doing well. He continued in a hinged elbow brace between 30–90 degrees. The patient began ROM following this visit to the surgeon. b. Post op one month, the patient was doing well with increasing ROM while in the hinged elbow brace. Following this visit, the patient was allowed to start full active and passive ROM with supination and pronation while in the brace. The patient was allowed to begin isometric exercises around the elbow but was not allowed to do any strengthening. c. Post op visit at 3 months following surgery, the patient was doing well and released to full activity. He would not return to football that season (secondary to the end of the season approaching). He would not need to wear the hinged elbow brace while doing cheerleading. d. No contact sports estimated for 3 months from time of surgery.