Elbow Pain Research Articles

Biologic Treatment for the Elbow Tendinopathy

Although elbow tendinopathy is the one of common diseases causing elbow pain, ideal nonoperative treatment to provide long-term satisfaction has not been introduced. Recently, there is significant interest in biological treatment to facilitate the healing environment and tissue proliferation in elbow tendinopathy. Biological agents such as platelet-rich plasma (PRP) or stem cells are likely to be established as one of the nonoperative treatment methods that can have long-term therapeutic effects in the future, given their theoretical basis. Despite many previous studies using biological agents such as PRP and stem cells in the elbow, its beneficial effect on elbow tendinopathy is controversial. Thus, the purpose of this review is to provide an evidence-based summary of the biologic agent for treating elbow tendinopathy and to identify areas where further research is warranted.

A Network Meta-Analysis of Randomized Controlled Trials Directed at Treating Lateral Epicondylalgia

Abstract Background: Lateral epicondylosis is the most prevalent cause of lateral elbow pain, occurring in 4 per 1000 patients. The aim of most treatments is to reduce inflammation even with histological evidence demonstrating that lateral epicondylosis is a non-inflammatory condition. Objective: To determine the relative merits of the different regimens used to diminish lateral epicondylosis pain using a mixed treatment comparison/network meta-analysis (NMA). Methods: A thorough literature search was performed. The eligibility criteria for this mixed treatment comparison were: randomized controlled clinical trials; human subjects; working age population (16 to 70 years); the outcome measure was an objective pain assessment; measured at a 1- to 3-month follow-up. The NMA were performed using the GeMTC user interface for automated NMA utilizing a Bayesian Hierarchical Model of random effects. The evaluation of confidence in the findings from NMA was performed using a semi-automated platform called CINeMA (Confidence in Network Meta-Analysis). Results: The model suggests that articulation technique is the most effective measure for decreasing lateral epicondylalgia followed by topical nitrates, acupuncture, kinesiology taping and low-level laser therapy, respectively. Muscle energy technique, local corticosteroid injection, prolotherapy and counterforce bracing displayed a trend toward being less effective than placebo. Conclusions: The results suggest that the most effective modalities for improving lateral epicondylalgia are those that decrease muscle tone and those that improve circulation, while measures meant to decrease inflammation appear to be of no or limited benefit.

Arthroscopic Lateral Collateral Ligament Complex Reconstruction for Posterolateral Rotatory Instability of the Elbow, the Operative Technique

Posterolateral rotatory instability is concerning pathology in patients with recalcitrant lateral elbow pain. An arthroscopic technique can be used to perform reconstruction of lateral collateral ligament for eradicating the instability and also to manage concomitant lesions in a simultaneous operation. Similar to the modified Brostrӧm procedure using an inferior extensor retinaculum to augment the lateral collateral ligament for lateral ankle instability, in our Technical Note, we use anconeus muscles and annular ligament to augment the lateral collateral ligament for elbow instability during the reconstruction, allowing all tissue to heal with the bone by using a knotless technique.

A Review of Musculoskeletal Embolization to Treat Pain Outside of the Knee.

Chronic inflammation leading to musculoskeletal pain has garnered interest in the past decade with the success of genicular artery embolization for knee pain secondary to osteoarthritis. Outside the knee joint, musculoskeletal embolization has been applied to other anatomical locations, mainly shoulder pain secondary to adhesive capsulitis and elbow pain secondary to lateral epicondylitis. The success of these early trials and other case reports highlights the efficacy of musculoskeletal embolization and its future potential.

A student-centred design approach for reducing musculoskeletal disorders in India through Six Sigma methodology with ergonomics concatenation

Classroom-related musculoskeletal disorders (CMSDs) rates in low- and middle-income countries (LMICs) are increasing despite the ever-collective interest in occupational health and safety (OHS) and succeeding developments over time. To explore the problem (i.e., OHS) with its proposed solutions, this study integrated the Six Sigma methodology with ergonomics principles to eliminate the CMSDs. Participants were 478 students from India as a country amongst the LMICs. The age range, mean, and standard deviation were 17–37, 20.28, and 2.348 for male students and 17–26, 19.57, and 2.163 for female students, respectively (units in years). The study found that students are prone to high risks of getting CMSDs due to prolonged usage of poorly designed furniture. The CMSDs results are as follows: fatigue joint and muscle pain (71%), shoulder and neck tension (70%), headache (63%), neck pain (53%), back pain (51%), legs’ joints pain (46%), shoulders and muscles pain (42%), elbow pain (42%), sleeplessness (insomnia) (40%) and hand pain (39%). The proposed solutions include the two ergonomically designed students’ desks; students’ requirements and anthropometric measurements consideration; occupational health and safety workshops and/or seminars preparation; administration interventions; behavioural (personal) interventions, and other engineering interventions.

Successful Treatment with Emicizumab of Patient with Type 2N Normandy and Severe Hemophilia a

It is unusual to have both Type 2N VWD and severe hemophilia A. Type 2N (Normandy) von Willebrand Disease (VWD) is an uncommon recessive disorder resulting in a defect in the binding site of von Willebrand Factor (VWF) with factor VIII. Factor VIII plasma levels are low due to rapid clearance. Our patient has severe hemophilia A (factor VIII <1%; Inversion 22) with no history of inhibitors and is heterozygous for a known pathogenic mutation (c2560C>T; p. Arg854Trp) Type 2N “Normandy”. He benefited from the use of HEMLIBRA® (Emicizumab-kxwh, Genentech) a humanized bispecific monoclonal antibody with a long half-life independent of VWF interaction.The patient was diagnosed at 11 months old with excessive bleeding from his frenulum and began episodic standard factor VIII. He had 10 bleeds including knees, arms and hamstring before starting prophylaxis at 3 yrs. of age. On ADVATE 50 units/kg/dose twice a week he had nose bleeds, soft tissue bleeds, and joint bleeds. At 11 yrs. of age, the nose bleeds increased daily. VWD testing revealed VWF activity 25%, VWF Antigen 42%, Factor VIII <1% and Normal Multimers with Type 2 Normandy genotype. ALPHANATE® (Anti-hemophiliac factor/von Willebrand factor complex (human), Grifols) prophylaxis was started to address mucosal bleeding however the right elbow synovitis progressed to right elbow contracture and bone cyst on MRI. He returned briefly to ADVATE® 50 units/kg MWF to every other day prophylaxis with continued intermittent bleeding in right elbow joint. With the diagnosis of Type 2N, and the availability of VONVENDI ® (Recombinant von Willebrand factor, Takeda), he was placed on ADYNOVATE® (Antihemophilic Factor Recombinant PEGylated, Takeda) daily and VONVENDI® every 3rd day starting at 14 yrs. old. The combination of ADYNOVATE® every 12-24 hours with VONVENDI® daily to every other day improved his acute bleeding episodes including his nose bleeds (Half-life ADONYVATE®+VONVENDI® 9.25 hr. vs. Half-life ADVATE® 5.5 hr.). The patient continued to participate in high-risk activities such as playing on trampoline which contributed to his injuries but his family felt the treatment was better than previous therapies.After considering the treatment burden of 2 types of factors more than 5 times a week and progression of synovitis in right elbow joint, the patient was started on HEMLIBRA® with weekly subcutaneous injections. Four weeks of loading dose (3 mg/kg/dose) was followed by once per week prophylaxis at standard dosing 1.5 mg/kg weekly. The first bleeding episode on HEMLIBRA® was reported after tooth restoration October 2019. After receiving both ADYNOVATE® and VONVENDI® pre-op, he developed swelling with suspected hematoma at the angle of his jaw about 4 days post-op treated successfully with ADYNOVATE® /VONVENDI®. In April 2020, he had right elbow pain stereotypic of a joint bleeding episode after yard work which was treated successfully with ADYNOVATE® /VONVENDI®. No report of severe nosebleeds.To our knowledge this is the first example of successful use of HEMLIBRA® in a patient with Type 2N VWD and severe hemophilia A. It is unclear why the ALPHANATE® was not clinically effective however the combination of VONVENDI® and ADYNOVATE® provided improved hemostasis with frequent infusions and high cost before the start of HEMLIBRA®. HEMLIBRA once a week has significantly reduced the treatment burden and improved bleeding prevention. The genotype of this patient is unusual however this approach may be successful in other types of VWD that result in significant bleeding phenotype. [Display omitted] DisclosuresBryant: Novo Nordisk: Consultancy, Honoraria; Bristol Myers Squib: Consultancy, Honoraria; Hema Biologics: Consultancy, Honoraria. Carr: Genentech: Speakers Bureau; Bayer: Speakers Bureau; Medexus: Speakers Bureau.

Association Between Musculoskeletal Pain and Psychological Stress Responses in High School Baseball Players: A Cross-sectional Study.

Background:Musculoskeletal pain could represent a psychological stressor in adolescent athletes. However, few epidemiological studies have investigated this association.Purpose:To assess the relationship between musculoskeletal pain (shoulder, elbow, wrist, and low back) and psychological stress responses in high school baseball players.Study Design:Cross-sectional study.Methods:Participants comprised male Japanese high school baseball players who had completed a questionnaire as part of their annual medical evaluation in 2016. Experiences of shoulder, elbow, wrist, and low back pain during the previous season were investigated. Pain severity was graded as 1 (mild, playing without interference), 2 (moderate, playing with interference), or 3 (severe, could not play because of pain). The Stress Response Scale–18 was used to measure stress response: low, medium, rather high, and high. Prevalence rates of shoulder, elbow, wrist, and low back pain and their association with psychological stress responses were investigated using univariate and multivariable analyses.Results:A total of 944 players (223 pitchers and 721 fielders) were included in this study. Their mean age was 16.1 ± 0.6 years, and 66% were high school juniors, while 33.6% were seniors. In pitchers, the prevalence rates during the previous year of severe (grade 3) interference with playing because of elbow, shoulder, wrist, and low back pain were 21.5% (n = 48), 19.3% (n = 43), 3.6% (n = 8), and 18.4% (n = 41), respectively, whereas in fielders, the respective prevalence rates were 17.1% (n = 123), 17.9% (n = 129), 6.7% (n = 48), and 19.3% (n = 139). After adjusting for confounding factors (playing on a top-performing team, high school grade level, and all other sites of musculoskeletal pain), the authors found significant associations in pitchers between severe experiences of elbow pain and low back pain and medium to high psychological stress responses (odds ratio, 2.64 [95% CI, 1.32-5.39], P = .006 and odds ratio, 2.32 [95% CI, 1.12-4.89], P = .024, respectively). No significant associations were seen between musculoskeletal pain and psychological stress responses in fielders.Conclusion:In the current study, elbow and low back pain were associated with stronger psychological stress responses compared with other musculoskeletal pain in high school baseball pitchers.

Changes in Medial Elbow Joint Space When Elbow Valgus Stress Is Applied at Different Limb Positions and Loads In Vivo.

Background:Ulnar collateral ligament (UCL) injury is a common sports injury among overhead-throwing athletes and causes medial elbow pain and instability. UCL injury is generally diagnosed based on symptoms, physical findings, and image evaluation. To standardize the method for evaluating elbow valgus instability, more information is needed regarding changes in the medial elbow joint space (JS) in healthy elbows.Purpose/Hypothesis:The purpose of this study was to measure the JS during the application of elbow valgus stress at different elbow flexion angles and loads and to clarify the presence of defensive muscle contractions during elbow valgus stress. It was hypothesized that the JS will differ according to different limb positions and loads and that defensive contractions will occur when elbow valgus stress is >90 N.Study Design:Controlled laboratory study.Methods:Elbow joints on the nondominant side were examined in 20 healthy male university students (mean age, 21 ± 0.2 years) at 30°, 60°, and 90° of elbow flexion. To create valgus stress on the elbow, loads of 30, 60, 90, 120, and 150 N were applied with a Telos stress device and with gravity stress on the forearm. The medial JS was measured ultrasonographically during the application of elbow valgus stress. Electrodes were attached to the pronator teres muscle, and defensive muscle contractions were measured using electromyography during the application of elbow valgus stress. Repeated-measures analysis of variance and paired t tests were used to compare the JS at each elbow angle and each valgus stress load, and the Bonferroni method was used as a post hoc test.Results:At 30° of elbow flexion, the JS was significantly higher at 30 N versus 0 N and at 60 N versus 0 or 30 N (P ≤ .018 for all). At 60° of flexion, the JS was significantly higher at 30 N versus 0 N, at 60 N versus 0 and 30 N, and at 90 N versus 0, 30, and 60 N (P ≤ .024 for all). At 90° of elbow flexion, the JS was significantly higher at 30 N versus 0 N and at 60 N versus 0 and 30 N (P ≤ .028 for all). Defensive muscle contraction did not occur at any elbow flexion angles at elbow valgus stress ≤60 N.Conclusion:The lack of muscular contraction at elbow valgus stress ≤60 N may reflect the function of the medial collateral ligament.Clinical Relevance:Elbow valgus stress ≤60 N allows for the evaluation of the joint opening.

Wrist flexion and extension strength in patients with work-related chronic elbow pain: the isokinetic effort factor and its implications.

The validity of isokinetic strength findings relating to forearm muscles in patients with chronic elbow pain and/or epicondylitis is not well established. Furthermore, given the nature of this disorder, ensuring maximal effort in performing the tests is an essential prerequisite. The isokinetic-based DEC parameter (defined as the difference between high- and low-velocity eccentric-to-concentric ratios of a given muscle) has been shown to efficiently detect maximal effort. The purpose of this study was therefore to assess the validity of isokinetic strength tests in patients with chronic elbow pain and/or epicondylitis. A cohort consisting of 44 male patients with chronic elbow pain (average evolution time, 262 ± 193.04 days) was recruited. The wrist extensor and flexor concentric and eccentric isokinetic strength of the involved and uninvolved sides was measured. The involved-uninvolved and flexor-extensor (F/E) ratios, as well as the DEC (eccentric-concentric difference), were computed based on peak moment values. Work disability and relapse within the first year were registered. In maximal performers, associations between deficits, F/E ratios, work disability, and symptom relapse were explored applying multiple comparisons. Of the patients, 68.2% met the maximal-effort criteria, with the involved-side muscles being significantly weaker than their uninvolved-side counterparts in most cases. Although the mean deficit in this group was not associated with either work disability or relapse, patients with a relapse of symptoms within the first year had a significantly higher F/E ratio than those without relapse. In patients presenting with chronic elbow pain who perform at the maximal level of effort, high wrist F/E strength ratios may predict symptom relapse.

116 Canadian Community Paediatricians' Perspectives of Sport Medicine in Residency and in Practice

Abstract Primary Subject area Community Paediatrics Background Participation by children and adolescents in organized sports and recreational sporting activities is increasingly popular in Canada. Although the health and psychosocial benefits of sports for children are significant, participation in sports confers an increased risk of injury, resulting in a considerable burden of visits to emergency departments and primary care offices. Despite the frequency of sport-related injuries, there are documented gaps in sport and exercise medicine (SEM) education in paediatric training, leading to many practicing paediatricians feeling uncomfortable in managing these issues. Objectives We sought to describe Canadian community paediatricians’ perspectives about SEM in training and practice. This descriptive, cross-sectional cohort study of practicing Canadian community paediatricians was designed to assess: i) self-reported practice profiles with respect to sport issues; ii) perceptions of SEM training during paediatric residency; and iii) comfort level with management of sport injuries. Design/Methods To address these questions, a cross-sectional electronic survey of Canadian community paediatricians was conducted between February and March 2020. A survey was emailed to full members of the community paediatrics section of the Canadian Paediatric Society (CPS) (n=370) by CPS administrative staff. Participants were asked about musculoskeletal (MSK)/sport issues seen, how they manage these cases, their comfort level with diagnosis and management of sport injuries (on a 5-point Likert scale), and their perceptions of MSK/SEM training during paediatric residency. Results The response rate was 23.0% (85/370). A quarter of respondents (20/85; 23.4%) reported seeing MSK/sport issues very often; a third (27/85; 31.7%) were comfortable managing these patients on their own. Almost all respondents did not feel that they had received adequate SEM training during paediatric residency (81/85; 95.3%). Respondents were most comfortable managing concussion, rating their comfort 4.17/5 on a 5-point scale (95% CI=3.96-4.38), and Osgood-Schlatter’s disease 3.86/5 (95% CI=3.60-4.11). Participants were uncomfortable managing acromioclavicular joint separations 1.81/5 (95% CI=1.58-20.6) and elbow pain 2.65/5 (95% CI=2.40-2.90). Regression analysis indicated that only the frequency of MSK/sport-related visits was associated with provider comfort level (p &amp;lt; 0 .001). Conclusion Most Canadian community paediatricians do not manage many patients with sport-related issues and are not comfortable managing these patients on their own. They feel that SEM training during their paediatric residency inadequately prepared them for practice. Incorporating more SEM training into paediatric residency programs may increase comfort level with MSK/sport issues and change referral patterns and practice patterns amongst community paediatricians.

Players' satisfaction with daily pitching performance could predict shoulder and elbow injuries in high-school baseball pitchers: a prospective time-to-event study.

Hypothesis and BackgroundThe relationship between baseball pitchers’ satisfaction with their performance and the incidence of shoulder and elbow injuries is unclear. We hypothesized that self-evaluated satisfaction with pitching performance before an injury and incidence of shoulder and elbow injuries are related.MethodsBaseline data on baseball experience, height, weight, elbow and shoulder range of motion, and shoulder muscle strength of high-school baseball pitchers were collected. During the season, all participants completed a self-recorded questionnaire regarding satisfaction scores, presence of shoulder and/or elbow pain, and pitching limitations due to shoulder and/or elbow pain experienced daily to determine when injuries occurred and record the satisfaction scores. The optimal satisfaction score cutoff value was determined through receiver operating characteristic curve analysis; participants were categorized into satisfied and unsatisfied groups. Statistical tests were performed to evaluate the differences between the groups, obtain the time-to-event curves, and calculate the hazard ratios for the incidence of injury.ResultsOverall, 108 participants aged 15-17 years were enrolled and divided into satisfied (88) and unsatisfied (20) groups. The injury incidence rate was 10.2% and 50.0% in the satisfied and unsatisfied groups, respectively. High-school baseball pitchers with low satisfaction had a significantly increased risk of shoulder and elbow injuries; these players had a 7.3-times greater risk of injuries and 1.9-times earlier occurrence of injuries than pitchers who were satisfied with their performance.ConclusionDaily evaluation of players’ self-satisfaction could predict shoulder and elbow injuries in high-school baseball pitchers.

Atypical Presentation of Haemophilus influenzae Septic Arthritis: A Case Report.

IntroductionSeptic arthritis is a destructive form of acute arthritis that requires expeditious recognition. as delayed treatment yields significant morbidity and mortality.Case ReportA 40-year-old male presented to the emergency department with right elbow pain. Examination revealed tachycardia, swelling, redness, tenderness, and decreased range of motion of the right humeroulnar joint. Synovial fluid analysis was consistent with an inflammatory etiology, but blood and joint cultures ultimately revealed Haemophilus influenzae.DiscussionThis case highlights the importance of trusting clinical findings over laboratory evidence in patients with suspected septic arthritis.

Ulnar Groove Plasty Guided by a 3D Printing Technique for Moderate to Severe Cubital Tunnel Syndrome Caused by Elbow Osteoarthritis.

BackgroundThe purpose of this study was to explore the feasibility of ulnar groove plasty guided by a three-dimensional (3D) printing technique for treatment of moderate to severe cubital tunnel syndrome (CuTS) caused by elbow osteoarthritis.Material/MethodsPatients with moderate to severe CuTS secondary to osteoarthritis of the elbow were enrolled in our hospital from April 2015 to March 2018. Based on a previously proposed “elbow canal index”, a 1: 1 model of the elbow joint was printed using CT image data collected preoperatively. After computer-aided measurement, the standard for enlargement of the ulnar nerve groove was calculated and a personalized “trial model” was created by 3D reconstruction. After intraoperative exposure of the ulnar nerve sulcus, the proliferative osteoid was burred with a grinding drill, and the cubital enlargement was verified by the trial model. The ulnar nerve was decompressed and reincorporated into the enlarged cubital canal, and the Osborne ligament was zig-zag elongated and reconstructed.ResultsNone of the patients reported experiencing medial elbow instability, medial elbow pain, ulnar nerve subluxation, flexor-pronator weakness, or incision infection. There was significant improvement of the motor nerve conduction velocity, sensory nerve conduction velocity, two-point discrimination of the little finger, grip strength, pinch strength of the thumb and index finger, VAS score, and DASH score in this study (P<0.001).ConclusionsUlnar groove plasty guided by a 3D printing technique may be another effective treatment of moderate to severe CuTS caused by elbow osteoarthritis.

Relationship Between Pitch Volume and Subjective Report of Injury in High School Female Fast-Pitch Softball Pitchers.

The relationship between pitch volume and injury is well-represented within baseball literature. However, the impact of softball pitch volume on injury epidemiology is limited. The purpose was to determine if increased pitch volumes in high school-aged softball pitchers are related to increased rates of subjectively reported pain/injury. We hypothesized that pitchers with increased volumes would have higher pain/injury rates. Cross-sectional study. Level 4. A total of 28 female softball pitchers (aged 14-18 years) completed an online survey of questions pertaining to pitching history, pitch volume, and subjective report of pain or injury in the back, shoulder, and elbow. An independent-samples t test was used to (1) compare pitch volumes in those who reported pain in individual body regions (shoulder, elbow, back) compared with those who did not; (2) compare pitch volumes in those who reported pain in 0 or 1 of the regions of interest compared with 2 or 3 regions; and (3) compare the reported percentage of the past year that players reported playing through pain in players who averaged >85 compared with <85 pitches per game. Chi-square analysis was used to compare those who pitched either >85 or <85 pitches per game with regard to frequency of shoulder pain, elbow pain, back pain, seeking of medical attention, and actual injury diagnosis. Type I error was set at α = 0.05. Weekly and yearly pitch counts were higher in those reporting pain or injury (YES) than those who did not (NO) in the shoulder (pitches per week: NO = 219 ± 35; YES = 429 ± 101; P = 0.027) (pitches per year: NO = 8876 ± 946; YES = 19,195 ± 4944; P = 0.022) and back (pitches per week: NO = 188 ± 16; YES = 426 ± 90; P = 0.014) (pitches per year: NO = 8334 ± 793; YES = 18,252 ± 4340; P = 0.027). Similar results were observed for those with pain or injury reported in 2 or 3 regions compared with 0 or 1 regions (pitches per week: NO = 220 ± 38; YES = 414 ± 95; P = 0.039) (pitches per year: NO = 8765 ± 1010; YES = 18,661 ± 4623; P = 0.028). Those reporting shoulder pain or injury also reported higher pitch counts per game (NO = 71.4 ± 5.2; YES = 83 ± 4; P = 0.049), and those reporting back pain also reported playing more games per week (NO = 2.7 ± 0.2; YES = 5.2 ± 1.1; P = 0.034). Those with pitch counts of >85/game were more than twice as likely to see a physician regarding pain/injury (P = 0.027) and reported playing through pain a higher percentage of the year (>85, 49.3% ± 10%; <85, 25.2% ± 6%; P < 0.05). High pitching volumes commonly prevalent in high school-aged softball pitchers may be associated with increased pain/injury and appear related to cumulative volume. This study provides recommendations for cumulative pitch volume guidelines in softball pitchers.

A Woman With Painful Elbow

A 71-year-old woman presented to the emergency department with right elbow pain after a fall. On physical examination, she was conscious and had pain well-localized to the posterior aspect of the elbow without any open wounds or swelling. She was unable to extend her elbow. Other physical examinations were unremarkable. Radiography (Figure 1) and point-of-care ultrasound of the right elbow were performed (Figure 2, Figure 3, Video).Figure 2Point-of-care ultrasound (short-axis view) of the olecranon fossa demonstrating 3 different echogenic bands within the joint fluid, separating into fatty material (arrowhead), serous joint effusion (anechoic collection), and sediment of red blood cells (asterisk). This trilevel appearance of lipohemarthrosis is called the “parfait sign.” O, olecranon fossa.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Point-of-care ultrasound (long-axis view) along the sagittal plane showing an elevated posterior fat pad sign (arrowhead) with heterogeneous echotexture consistent with lipohemarthrosis in the olecranon fossa. O, olecranon fossa.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Occult olecranon fracture with elevated posterior fat pad sign and lipohemarthrosis. Point-of-care ultrasound of the right elbow demonstrated an elevated posterior fat pad sign with lipohemarthrosis. Occult olecranon fracture was diagnosed by computed tomography (Figure 4). The patient was discharged with a splint and started rehabilitation on a 1-week follow-up. Geriatric elbow fractures are not uncommon in the ED after low-energy falls. Diagnosis can sometimes be difficult with radiography because of overlapping bones or inappropriate radiographic positions. Point-of-care ultrasound is an ideal and practical tool for rapidly evaluating traumatic elbow injury.1Okumura Y. Maldonado N. Lennon K. et al.Point-of-care ultrasound: sonographic posterior fat pad sign: a case report and brief literature review.J Emerg Med. 2017; 53: 98-101Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Findings of elevated posterior fat pad sign and lipohemarthrosis on point-of-care ultrasound are highly sensitive predictors of intraarticular elbow fractures.2O'Dwyer H. O'Sullivan P. Fitzgerald D. et al.The fat pad sign following elbow trauma in adults: its usefulness and reliability in suspecting occult fracture.J Comput Assist Tomogr. 2004; 28: 562-565Crossref PubMed Scopus (47) Google Scholar, 3Rabiner J.E. Khine H. Avner J.R. et al.Accuracy of point-of-care ultrasonography for diagnosis of elbow fractures in children.Ann Emerg Med. 2013; 61: 9-17Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 4Costa D.N. Cavalcanti C.F. Sernik R.A. Sonographic and CT findings in lipohemarthrosis.AJR Am J Roentgenol. 2007; 188: W389Crossref PubMed Scopus (12) Google Scholar Lipohemarthrosis is defined as “2 or 3 different echogenic bands seen within the joint fluid,” separating into fatty material, serous joint effusion, and sediment of red blood cells.1Okumura Y. Maldonado N. Lennon K. et al.Point-of-care ultrasound: sonographic posterior fat pad sign: a case report and brief literature review.J Emerg Med. 2017; 53: 98-101Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar This trilevel appearance is sometimes called the “parfait sign.” Treatment of nondisplaced elbow fractures involves immobilization for a duration of 1 week. https://www.annemergmed.com/cms/asset/2b8d4b36-a95f-43b2-8942-70edc14a2430/mmc1.mp4Loading ... Download .mp4 (0.86 MB) Help with .mp4 files VideoPoint-of-care ultrasound (short-axis view) of the right elbow revealing a trilevel area of joint fluid within the olecranon fossa, known as lipohemarthrosis (asterisk) (visible from 00:00 to 00:04); long-axis view in the same region presented an elevated posterior fat pad sign (arrowhead) (visible from 00:04 to 00:09).

Outcomes after Elbow Ulnar Collateral Ligament Reconstruction with the Docking Plus Technique in 162 Athletes (129)

Objectives:This retrospective case series examined 162 athletes who underwent ulnar collateral ligament (UCL) reconstruction (UCLR) from 2015-2018. All cases were by a single surgeon at a high volume center using the Docking Plus Technique. We previously reported outcomes in 324 athletes from 2005-2014 with 88% of patients reporting a Conway score of good or excellent. The purpose of this study was to determine if patients undergoing UCLR with the docking plus technique are able to return to sport and to better characterize the athletes needing this procedure. Our hypothesis was that our cohort would largely be able to return to their previous level of play and be mostly college level pitchers.Methods:Patients who underwent UCLR at our institution from 2015-2018 were identified and surveyed. We were able to reach a total of 162 patients by telephone for a survey. They were surveyed for subjective and objective outcomes and for background demographic information including information about their athletic careers before and after UCLR.Results:Of our 162 respondents, 150 (93%) returned to the same level of play or higher (excellent on Conway classification). 9 did not return to competitive play (6%) while 3 returned to a lower level of play. 5 of those who did not return to competitive play had their surgery senior year of college. Most athletes were in college at the time of surgery (61%), followed by high school (32%). 2 athletes were in middle school, the rest were playing professionally. Baseball pitchers compromised the majority of our respondents (75%). Catchers were 9% of respondents and infielders/outfielders were 3% each. Other athletes participated in cheerleading, lacrosse, track, volleyball, gymnastics, wrestling, and football, though these were far less common. The mean and median ages of survey respondents was 19 (12-31). 61% described an acute “pop” leading to their elbow pain while 39% endorses no acute event but chronic elbow pain leading to presentation. Of the 61% presenting with an acute rupture, 40% endorsed an “acute on chronic,” presentation. 58% of baseball players played more than just baseball in high school while 41% had specialized in just baseball. The average return to competitive play was 12 months, with a range of 4-24. The range for pitchers was 9-24 with an average of around.Conclusions:Overall, our results mirror those of previous studies. 93% of our patients returned to the same level of competition or higher after undergoing UCLR with the docking plus technique. Most of those who did not return were college seniors who graduated. Our typical patient was a college baseball pitcher around 19 years old. Return to play with our set rehab protocol was around 1 year, though faster for non-pitchers. The docking plus technique provides reliable treatment for chronic or acute UCL tears in athletes.

Perineural injection as an alternative treatment of resistant lateral elbow pain

Abstract Background Lateral elbow pain (LEP) or lateral epicondylitis (LE) is a common problem affecting both males and females. Multiple therapeutic modalities are used with different outcomes. Objective The current study aimed at description of the effectiveness of a newly introduced modality, Perineural Injection (PNI) therapy in comparison to the already used therapeutic ultrasound (TUS) as a conventional modality in the treatment of resistant LEP (LE). Patients and methods This is a longitudinal interventional study. Thirty patients of both sexes aged between 21 to 62 years old who had LE were randomly allocated into two groups (15 each). In PNI group, 5% buffered dextrose was injected subcutaneously around the lateral epicondyle once weekly for 8 weeks. In TUS group, continuous US was used 3 sessions per week for 4 weeks. Tenderness grading scale, visual analogue scale (VAS), Patient- Rated Tennis Elbow Evaluation Questionnaire (PRTEE) score, and ultrasonographic evaluation were used before and 12 weeks after treatment. Results In both groups, there was a high significant clinical improvement at 12th week after treatment. However, the improvement was better in the PNI group than the TUS group. By US evaluation at 12th week after treatment, there was a significant decrease in hypoechoic areas and disturbed fibrillar pattern in PNI group compared to before therapy (p &amp;lt; 0.001 and = 0.025) respectively. But in TUS group, there was decrease in hypoechoic areas and tendon thickness compared to before treatment (p = 0.02 and 0.026) respectively. Conclusion Both PNI and TUS therapies for LE gave clinical improvement for pain, functional limitations and some ultrasonographic findings (as echogenity, fibrillar pattern and tendon thickness). However, PNI therapy gave better outcome as compared to TUS.

Medial Epicondyle Apophyseal Avulsion Fractures in Youth Throwers: A Severe Variant of Little League Elbow (132)

Objectives:Medial epicondyle apophyseal avulsion fractures sustained during throwing represent an understudied, severe variant of medial epicondyle apophysitis, or ‘Little League elbow’. The current study sought to characterize presenting features, treatment options, and clinical results of a large cohort of pre-adolescent and adolescent patients who presented with these fractures.Methods:Skeletally immature athletes with medial epicondyle apophyseal avulsion fractures sustained during throwing from 2003-2017 at a tertiary-care pediatric referral center were identified. Exclusion criteria were fractures sustained during non-throwing activity or prior elbow fracture. Medical records and radiographic images were reviewed for study variables. Treatment decisions were made independently by fellowship-trained pediatric orthopaedic surgeons or sports medicine physicians on a case-by-case basis. Patients treated with open reduction and internal fixation (ORIF) were compared to those treated non-operatively, and all fracture patients were compared to a larger control group of patients diagnosed with medial epicondyle apophysitis/Little League elbow with no fracture.Results:During the study period, a total of 317 patients were diagnosed with Little League elbow due to medial epicondyle apophyseal overuse injury, 50 of whom (16%) sustained a discreet, radiographically confirmed epicondyle fracture sustained during a single throw. Median age of the fracture cohort at presentation was 13.1 years (range 8 years – 16 years). Forty-nine fracture patients (98%) were male baseball pitchers and one (2%) was a male football quarterback. Fracture patients had significantly higher median BMI (21.3 kg/m2 vs. 19.2kg/m2, p=0.004) than the apophysitis control group, but there was no significant difference in age. Of the 37 patients with documentation regarding pre-injury symptoms, 31 patients (84%) described pre-existing medical elbow pain prior to their acute injury, while 6 (16%) denied pain prior to the inciting throw. Of the 12 patients (24%) with documented shoulder exams at presentation, 5 (42%) demonstrated glenohumeral internal rotation deficit (GIRD). Twenty-three patients (46%) were treated with ORIF (22 single screw fixation; 1 suture anchor fixation), while 27 (54%) were treated non-operatively. Median fracture displacement was significantly greater in operative patients than non-operative patients (5.0mm vs. 3.0mm, p=<.001), with all ‘minimally displaced’ (<4mm) fractures undergoing non-operative treatment (Figure 1). Multivariable analysis determined that for each additional mm of displacement, the odds of surgical intervention increased by 6.4 times (OR=6.36; 95% CI=1.83-22.07; p=.004), when controlling for age and BMI. All patients returned to their throwing sport (RTS) at a median of 12.8 weeks post-diagnosis, but 13 (26%) developed recurrent elbow pain, with no significant difference in in RTS time or recurrence rate between treatment cohorts. Nine of twenty-two (41%) screw ORIF patients underwent secondary implant removal, with no significant difference in this rate between those with or without a washer.Conclusions:Medial epicondyle apophyseal avulsion fractures in youth throwers represent a severe variant of Little League elbow, constituting approximately 16% of cases within the condition’s spectrum. These fractures may be effectively treated with either non-operative measures, particularly minimally displaced fractures <4mm, or ORIF, though >40% of operative patients may require implant removal. A large majority of patients reported medial elbow pain prior to fracture, suggesting this severe presentation of Little League elbow may be preventable.

Pulseless pink hand syndrome

Supracondylar humerus fracture is one of the most common elbow injuries in children, comprising 60% of all the elbow injuries in children. An elbow or forearm fracture should be suspected in a child with elbow pain or failure to use the upper extremity after a fall. The fracture typically occurs through the weak metaphyseal bone proximal to the fossae. A careful examination of the entire arm should be performed, and any area with tenderness or swelling should have radiograph as multiple fracture (such as supracondylar fracture and a radius/ulna fracture) are not uncommon. A thorough motor, sensory and vascular examinations should be performed, difficult in pediatric group but should be attempted and recorded accurately. Assessment of vascular status in supracondylar fracture of humerus is important as up to 20% of displaced fractures present with vascular compromise. Here we present a case report of 7-year-old girl who sustained extension type supracondylar humerus fracture with pulseless pink hand. Urgent manipulation was undertaken but it was unsuccessful, a posterior stab incision was taken to reduce the fracture fragments using bone spike. To our knowledge, there are various methods and flow charts regarding the treatment of the vascular compromise which accompany various associated risks and complications with no specific protocol.

S2153 A Case of Proton Pump Inhibitor Causing Systemic Drug-Induced Lupus

Introduction: Drug induced lupus erythematosus (DILE) is a well documented autoimmune phenomenon that can be triggered by exposure to certain medications. Presented here is a case of systemic drug induced lupus erythematosus from a proton pump inhibitor (PPI), which represents a fairly uncommon reaction to this medication. Case Description/Methods: A 63 year old female with history of gastroesophageal reflux disease (GERD) presented to clinic complaining of typical heartburn pain and globus sensation for which she was prescribed pantoprazole. After 2 weeks of daily use, she developed pain and swelling of bilateral metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints, photosensitive malar rash, patchy alopecia, ‘gnawing’ diffuse abdominal pain (different than GERD symptoms), and oral ulcers. Her pantoprazole was stopped, and 2 weeks later her symptoms resolved. Review of the her medical record revealed that she had prior exposure to 2 other PPI's in the past that both were associated with development of similar symptoms. Use of omeprazole caused pain and swelling of her right MCP joints, and several years later use of esomeprazole caused severe pain and swelling of the left elbow. In both cases, discontinuation of her PPI caused resolution of symptoms. Her labs were notable for positive anti histone antibody and negative ANA, dsDNA, RF, anti CCP. Discussion: DILE has three basic variants; systemic, subacute cutaneous, and chronic cutaneous. The type of drug induced lupus and severity of symptoms is strongly associated with the specific drug of exposure. PPI's are most associated with subacute cutaneous DILE, although this remains an overall rare adverse reaction. Subacute cutaneous DILE presents with formation of annular or papulosquamous skin lesions and mild (if any) systemic symptoms. Our case is more consistent with systemic DILE. Review of literature reveals few case reports of systemic DILE from PPI use. Systemic DILE presents with multi-system involvement with constitutional symptoms, myalgias, arthralgias, and serositis. Symptoms resolve with withdrawal of the agent. The case above clearly demonstrates this illness script through multiple exposures to PPI. Classic SLE is ruled out in this case due to this temporal relationship with drug exposure, as well as her antibody profile positive for anti-histone and negative for other SLE-associated antibodies. This case highlights the importance of considering atypical drug reactions, even when prescribing relatively common medications.