Avulsion Fracture Of Medial Epicondyle Research Articles

Adolescent medial epicondyle trash lesion clinic radiological evaluation and treatment

<p class="abstract">Elbow injures in children accounts for 10% of all fractures, ranges from simple sprain to elbow fracture dislocation. Ligamentous injury accounts for 2-3% only and are mostly sports related seen in overhead athletes. Trash lesions (the radiological appearances seemed harmless) around the elbow are reported in children under 10 years which are high energy trauma with initial normal looking X-rays. These are osteochondral or physical injures presenting with soft tissue swelling without any fractures. A high index of suspicion, early additional imaging such as MRI, CT scan, ultrasound examination and aggressive surgical care are usually necessary for prompt diagnosis and successful treatment of these injuries before complications arise. We presented a case of an elbow injury in a 15 year old girl, following a fall on her outstretched hand with initial normal findings in her X-rays. 3 months following the injury she had persisting pain and instability with ulnar nerve impingement symptoms. Her elbow CT scan, nerve conduction study confirmed the avulsion fracture of medial epicondyle with ulnar nerve neuritis and cubital tunnel syndrome. Valgus stress test proved the extent of additional medial instability. Medial epicondyle avulsion fractures are always challenging for fixation. The retracting UCL forces prevents healing and were prone for failure with non-operative splinting once instability is defined. Attempted fixation can also result in failure of fixation. Our case study highlights the possibility of such trash lesion in adolescent and also the modified technique of ulnar collateral ligament (UCL) reconstruction in a cost effective manner.</p>

Diagnosis and management of medial epicondyle avulsion fracture in a 27-year-old female: A case report

ObjectiveThe purpose of this case report is to describe the diagnosis and management of an adult patient presenting with a rarely reported avulsion fracture of the medial epicondyle of the humerus. Clinical presentationA 27-year-old female sought care following an injury sustained when the elbow gave out on an attempted back flip. The clinical assessment found an indication of elbow fracture with a diagnosis of medial epicondyle avulsion fracture made on radiographic examination. Intervention and outcomeFollowing in-house imaging, the patient was referred for an orthopedic consultation. An MRI was ordered and revealed numerous internal joint derangements. The orthopedist prescribed a hinged brace and followed up in 4 weeks. Physical therapy was ordered by the surgeon with follow-up again in 4 more weeks. ConclusionMedial epicondyle avulsion fractures are extremely rare in adults, and in this case, were accompanied by extensive internal joint derangements in the elbow. Chiropractors should be able to diagnose this condition from x-ray and can be of assistance with rehabilitation therapies.

Medial Elbow Pain - Recreational Athlete

HISTORY: 22-year female recreational athlete with history of left elbow pain following a fall on outstretched arm during a running/cutting activity. She noted immediate local pain of 7/10 on VAS and swelling of the medial elbow and forearm. She was unable to fully extend the elbow. PHYSICAL EXAMINATION: Edema was noted at the medial elbow, extending into the medial forearm. Palpation of soft tissues, tendon and bony structures revealed significant point tenderness at the medial joint space and at the medial epicondyle. Limited active ROM with extension was noted due to pain. Valgus stress test was positive, with significant discomfort upon moderate loading. Due to significant pain complaints, further physical examination was suspended and clinician progressed to point-of-care ultrasound imaging of the medial elbow complex DIFFERENTIAL DIAGNOSIS: 1. Medical Collateral ligament sprain 2. Medial Collateral ligament disruption 3. Common Flexor Tendon Pathology 4. Pronator Teres Strain 5. Medial epicondyle avulsion fracture 6. Biceps tendon pathology TESTS AND RESULTS: Bilateral ultrasound Imaging of the medial elbow complex revealed disruption of the ligamentous fibers of the UCL anterior band at the joint line. A large hypoechoic gap in the UCL is present, denoting the presence of significant fluid. Gravity valgus stress loading revealed a joint gap of 0.76cm compared to 0.38cm of the uninvolved side. FINAL WORKING DIAGNOSIS: Full thickness tear of the anterior bundle of the medial collateral ligament TREATMENT AND OUTCOMES: Since the athlete did not participate in overhead throwing activities, conservative management approach was selected. ROM was limited 0-100 degrees initially to full ROM at 4 weeks post injury. Strengthening was initiated with initial emphasis on core and shoulder musculature, progressed to elbow and forearm musculature, including the flexor/pronator group as an active stabilizer against valgus forces. Patient was symptom-free at 4 months following injury, and ultrasound imaging revealed reduced valgus joint gapping. This case presentation illustrates the utility of ultrasound imaging in diagnosing MCL pathology, especially when physical examination is limited due to patient discomfort, and further illustrates the successful conservative management of a full thickness MCL tear.

Medial Elbow Pain - Young Baseball Pitcher

HISTORY: A 14-year, 2-month old male right-handed baseball pitcher presented with chronic right medial elbow pain over 18 months, with no inciting injury/trauma. Initially he had mild right medial epicondylitis on magnetic resonance imaging (MRI) which resolved with rest and physical therapy. Still his right elbow pain recurred when throwing, ultimately failing conservative measures. Our collaborating orthopaedist then referred him to us for ultrasound and nonsurgical management. At his initial visit with us, he reported no pain at rest. He last had elbow pain one month earlier while doing lighter outfield (non-pitching) throws. PHYSICAL EXAMINATION: Afebrile with normal blood pressure and pulse. Normal muscle bulk and appearance for his age. Focused right elbow examination showed normal range of motion and no pain with flexion/extension. No locking or swelling. He did have laxity of his right elbow with valgus stress. DIFFERENTIAL DIAGNOSIS: 1. Valgus extension overload. 2. Osteochondritis dissecans. 3. Olecranon stress fracture. 4. Medial epicondyle avulsion fracture. 5. Medial apophysitis. 6. Medial epicondylitis. 7. Ulnar collateral ligament (UCL) sprain or tear. 8. Ulnar neuritis/subluxation. TESTS AND RESULTS: Initial MRI 18 months prior showed no UCL injury, but rather fluid at the flexor pronator mass consistent with medial epicondylitis. New MRI showed a partial right UCL tear at the proximal insertion. No full tear, fracture, or other connective tissue injury. Under ultrasound, laxity of the right UCL and pathology consistent with the partial UCL tear was seen, with no fracture, loose bodies, or epicondylitis. FINAL WORKING DIAGNOSIS: Partial UCL tear at the right elbow. TREATMENT AND OUTCOMES: We injected platelet rich plasma (PRP) under ultrasound to the pathologic site of the right UCL. The boy then proceeded with our 12-week PRP rehabilitation protocol tailored to throwing athletes. At 8 weeks post-injection, ultrasound showed interval healing with reduced laxity of the right UCL. At 16 weeks post-injection, ultrasound revealed virtually complete healing with no laxity of the right UCL. The boy eventually returned to throwing full pitching distance without pain, emphasizing the potential utility of PRP injection in pediatric/adolescent athletes with musculoskeletal injuries.

Classification of Olecranon Stress Fractures in Baseball Players

Background: Although the onset mechanism of an olecranon stress fracture (OSF) due to a throwing disorder is believed to involve valgus extension overload, olecranon posteromedial impingement, or triceps traction force, this issue is still debated in the literature. Purpose: To establish a classification system for the different types of OSFs to improve diagnosis and clarify the onset mechanism. Study Design: Case series; Level of evidence, 4. Methods: A total of 200 baseball players (198 male, 2 female; mean age, 16.1 years; age range, 13-27 years) who were diagnosed with an OSF from January 1987 to July 2012 were studied. Combined disorders as well as the direction and form of the fracture line were analyzed on plain radiographs, computed tomography, and magnetic resonance imaging. Furthermore, the presence or absence of ulnar collateral ligament (UCL) injuries and avulsion fractures of the lower pole of the medial epicondyle was determined by imaging findings to calculate the combined percentage of OSFs. In addition, the prevalence of OSFs was evaluated among patients who were evaluated between April 2008 and March 2011 for throwing elbow disorders. Results: There were 5 types of OSFs identified in the new classification system: physeal, classic, transitional, sclerotic, and distal. The physeal type was further separated into stages 1 to 4 based on severity. The mean age for each type identified was as follows: physeal, 14.1 years; classic, 18.6 years; transitional, 16.9 years; sclerotic, 18.0 years; and distal, 19.6 years. A concomitant UCL injury and/or medial epicondyle avulsion fracture was diagnosed in 71% to 95% of cases, depending on the OSF type. Among baseball-related elbow disorders, the incidence of OSFs was 5.4%. Conclusion: This study presents a new classification system for the different types of OSFs based on the origin and direction of the fracture plane. This new system was strongly influenced by the age at symptom onset. Such information is essential for successful open reduction and internal fixation by ensuring that fixation pressure is perpendicular to the fracture plane, which will avoid the recurrence of stress fractures. In addition, the prevalence of UCL injuries suggests that it is a major risk factor for the development of OSFs.

October Image Quiz: Medial epicondyle avulsion fracture

Journal of Orthopaedics for Physician Assistants 2(4):p 10, Fall 2014. | DOI: 10.2106/JBJS.JOPA.15.00052

Intra-Apophyseal Avulsion Fracture of Medial Epicondyle in a Adolescent Baseball Player

Overuse elbow injuries in young throwing athletes are generally defined as ‘Little Leaguer’s elbow’. Repetitive submaximal valgus forces on the medial epicondylar apophysis in such athletes can result in apophyseal separation or chronic apophyseal fragmentation, which would usually take over more than a year to heal. We report of a unique case of a 13-year-old male baseball pitcher who, due to the traction of the medial collateral ligament, presented with an acute intra-apophyseal avulsion fracture of the medial epicondyle. The fracture was successfully healed using a long arm cast, and correct union was confirmed by 3 dimensional computed tomography at 8 weeks post-trauma. This acute avulsion fracture is a variant of Little Leaguer’s elbow and should be distinguished in terms of diagnosis and treatment from common lesion such as chronic fragmentation of the medial epicondylar apophysis.

Non-Articular Displaced Medial Epicondyle Avulsion Fracture in a High School Baseball Pitcher: A Case Review

Non-Articular Displaced Medial Epicondyle Avulsion Fracture in a High School Baseball Pitcher: A Case Review

Acute, avulsion fractures of the medial epicondyle while throwing in youth baseball players: A variant of Little League elbow

The young throwing athlete is susceptible to medial elbow injury due to valgus overload. We hypothesized that this injury can occur during the throwing motion with an acute episode of medial elbow pain resulting in an inability to effectively participate in throwing activities. In addition, appropriate treatment of acute, medial epicondyle avulsion fractures in baseball players can result in an asymptomatic elbow with subsequent return to play within a year of injury. A case series of all youth baseball players with medial epicondyle avulsion fractures that occurred while throwing were identified. We studied several variables, including demographics, adherence to USA Baseball youth pitching recommendations, clinical history, radiographic findings, treatment, and outcome. Eight skeletally immature baseball players, who were a mean age of 13 years (range, 11-15 years), presented with medial epicondyle fractures that occurred while throwing. All 8 players experienced sudden pain during throwing, and all 5 players with appropriate age and position qualifications did not conform to the USA Baseball youth pitching recommendations. Anteroposterior radiographs documented average fracture displacement of 5.1 mm (range, 2.5-10 mm). Five of 8 players had 5 mm or less of displacement and were selected for nonoperative treatment. Three of 8 players had more than 5 mm of displacement and underwent open reduction and internal fixation. All players were able to return to play at an average of 7.6 months (range, 4-10 months). Medial epicondyle avulsion fractures can occur with a characteristic acute presentation while throwing in youth baseball players. Prevention may be possible when conforming to established USA Baseball youth pitching recommendations. Once an acute medial epicondyle avulsion fracture occurs, these injuries may be managed using published treatment algorithms, with successful return to play in less than 1 year.

Elbow Disorders in the Young Athlete

Elbow injuries in the pediatric athlete are common. Elbow injuries result from macrotrauma or microtrauma. Examples of macrotrauma include elbow dislocations and medial epicondyle fractures. Examples of microtrauma or repetitive overuse injuries include medial epicondyle apophysitis and osteochondritis dissecans of the capitellum. Elbow injuries occur in patterns unique to the skeletally immature patient. For example, lateral sided disorders of the elbow such as Panner’s disease and osteochondritis dissecans of the capitellum result from compressive forces on the elbow whereas medial-sided elbow injuries, including medial epicondyle apophysitis, medial epicondyle avulsion fracture, and ulnar collateral ligament tears, result from tension forces on the elbow. Excessive baseball throwing causes many microtrauma overuse elbow injuries. In addition, the trend for young throwing athletes to train year round in only one sport also increases the risk of overuse injury. Prompt recognition and treatment of elbow injuries in the young athlete is key to prevent potential long-term disability and deformity. Unfortunately, in some cases, surgical treatment of elbow injuries in the young athlete is only palliative.

Elbow Pain in a Youth Baseball Pitcher

HISTORY: An 11-year-old baseball pitcher sustained a right elbow injury while pitching in the first inning. He had pitched all season without difficulty. After feeling well during his normal warm-up, on the 15th pitch, he felt a pop in his elbow during the acceleration phase. He developed pain and swelling in the right elbow immediately and was unable to continue pitching. He was seen the following day where he had limited range of motion of his right elbow secondary to pain and swelling. PHYSICAL EXAMINATION: Positive effusion, no ecchymosis. Tenderness over the medial epicondyle and flexor/pronator mass. 10 degrees to 80 degrees, active; 0 degrees to 90 degrees, passive. Severely tender medially with minimal valgus stress. Neurovascular exam was normal. DIFFERENTIAL DIAGNOSIS: Osteochondritis dissecans Panner's disease Flexor/pronator common tendon avulsion Medial epicondyle avulsion fracture UCL tear Medial epicondyle apophysitis TEST AND RESULTS: AP, lat at 90 degrees flexion and oblique radiographs: Small eggshell fleck of bone from medial epicondyle, ossification center unfused. No joint effusion seen. MRI: Medial epicondyle avulsion with 2 mm gap. Common flexor and UCL origins intact on the avulsed fragment. Radial collateral ligament intact. FINAL WORKING DIAGNOSIS: UCL avulsion fraction of the medial epicondyle TREATMENT AND OUTCOMES: Immobilization in posterior splint with no throwing activities. Operative repair of avulsed UCl performed 14 days post injury.Complete avulsion of UCL with small eggshell of cortical bone from the medial epicondyle with 4 mm displacement.Follow-up: Ten days post-op, patient was doing well. ROM was 20 – 100 degrees with full supination and pronation. Ulnar nerve function was intact. Repeat AP, lat and oblique radiographs at 10 days, six weeks and 12 weeks showed healing of avulsion fragment of cortical bone to medial epicondyle. Rehabilitation: Immediately post-op: Patient was placed in a splint at 60 degrees flexion. Ten days post-op: The patient started a home program of elbow flexion and extension isometrics at 60 degrees with gentle hand exercises. One month post-op: Gentle concentric exercises were initiated. Six weeks post-op: Patient was advanced to elbow flexion and extension between 0 and 145 degrees, out of splint. Splint was discontinued except at school. No sports participation. Two months post-op: Discontinuation of brace at all times. PREs, shoulder and scapular stabilization exercises were advanced. Ten weeks post-op: Functional exercises; reactive, oscillating blade device; the upper body cycle and tricep PREs were added. Twelve weeks post-operation: Light batting practice.

ELBOW INJURY-FOOTBALL

HISTORY A 15 year old freshman high school football player presented within 24 hours of injuring his right arm in a football game. While playing as a nose tackle, he was chop blocked. He fell and supported his body with his right arm with the elbow in extension. Immediately after the injury, he experienced numbness of the fourth and fifth digits of the right hand, which resolved in a few seconds. He did not experience any popping or buckling sensation during the injury. No manipulation or reduction of the elbow was attempted prior to the office visit. No previous elbow injuries. He is right hand dominant. PHYSICAL EXAMINATION Examination revealed a moderate right elbow effusion. No ecchymosis. The medial epicondyle and origin of the flexor pronator mass were tender to palpation. There is restricted flexion and extension (30–100 degrees) secondary to pain. Pronation and supination were painful. Valgus and varus stress at 0 and 30 degrees of elbow flexion without instability. No wrist or shoulder pain with passive or active range of motion. Right upper extremity was neurovascularly intact. DIFFERENTIAL DIAGNOSIS supracondylar fracture. elbow dislocation. radial head fracture. capitellum fracture. coronoid process fracture. medial epicondyle fracture. TESTS AND RESULTS AP/lateral/capitellum x-rays: Angulated radial head fracture. Approximately 30 degrees of apex ulnar angulation. Radial capitellar joint space widened almost 1 cm on lateral side. Avulsion fracture of medial epicondyle. FINAL/WORKING DIAGNOSIS Right elbow dislocation equivalent with radial head fracture. TREATMENT AND OUTCOME Open reduction and internal fixation of radial head fracture. Physical therapy – active and active-assisted ROM right elbow and forearm. Unlocked brace. Patient initially improved without problems. Then, 4 weeks post surgery developed decreased elbow flexion/extension as well as pronation/supination range of motion. Possible intra-articular loose body. Continue physical therapy. Follow-up in two weeks. Arthroscopy if no improvement in two weeks.