7: Elbow Trauma, Fracture, and Reconstruction 1 Under- 4 The valgus load creates stress 3 These two muscles help dissemi- 2 Orthopaedic Knowledge Update: Shoulder and Elbow 4 The UCL receives dynamic support from the sur- The throwing motion creates substantial energy and Clinical Evaluation primary responsibility for valgusranges stress of throughout flexion the tight and during extension; extension,during and the flexion. the anterior posterior band band is is tight rounding musculature. Theprimary flexor dynamic carpi contributor to ulnaristhe valgus is elbow, stabilization the and of secondary the stabilizer. flexor digitorum superficialis is a A specific, detailedstanding elbow patient pathology historydominance in is and a the vital throwing duration,symptoms to intensity, athlete. should and be Arm under- location notedity of as that well as elicits theoccur symptoms at type rest, of (for with activ- activities example,throwing?). of does daily living, Information the or only pain with should be elicited as to History nate the substantial forcesthrowing across motion the and elbowrelationship thereby during has the protect implications theaging for UCL. UCL preventing injuries. Their and man- subsequent forces that are mediatedthe by elbow. structures Angular about velocitiesond as have high as been 3,000° observederation per at sec- phase the elbow oftranslates during the into the accel- 64 throwingtensile N/m motion. strength of of This valgusstabilizers the velocity of UCL torque. the is Because elbowor also only the are 34 minimizing important N/m, injury. for the avoiding other standing these forces increases thethe ability to relationships understand about among the elbow. the conditions that occur about the other aspectscur of the on elbow:stresses tensile the forces occur oc- medialreaches in extension, aspect, the and compressionally, olecranon primarily shear forces at occur fossa the and later- daver radiocapitellar as joint. compressive study the Aincreased recent elbow 67% ca- found after the that UCL was lateral transected. contact pressures Within the anterior oblique ligament, the 1 James Hammond, DO, ATC Brian J. Cole, MD, MBA Throwing-Related Elbow Anatomy and Biomechanics Introduction © 2013 American Academy of Orthopaedic Surgeons Dr. Cole or anfrom immediate Arthrex family and member DJ hasbureau Orthopaedics; received or is royalties has a madeserves member paid as of presentations a on a paidthrex, behalf speakers’ consultant Carticept, of to Genzyme; Biomimmetic, or is Allosource,received an and research employee DePuy; of or andthrex, Zimmer, Smith Ar- has institutional & support Nephew,mond and nor from DJ any Orthopaedics. Regentis, immediate Neitherof family Dr. Ar- member value Ham- has from received orcial anything has company stock or or institutionsubject stock of related this options directly chapter. held or in indirectly a to commer- the The medial ormost clinically ulnar relevant collateral anatomicof structure ligament in the (UCL) the elbow throwing isposed athlete. the of The the UCLtransverse anterior is ligaments. oblique, a Thethe posterior complex anterior strongest com- oblique ligament oblique, of ligament and portant the is complex stabilizer and to thelete. valgus most The im- stress anterior oblique in ligamentdial the originates throwing in epicondyle. the ath- me- insertion of A the anterior recentextends oblique distal ligament evaluation found toously that of the it unnamed sublime ridge thespecimens. tubercle and ulnar along was present a on previ- all skeletal Overhead throwing imparts substantialbow stress and to can the causeclinical el- unique studies injuries. have Biomechanical elucidatedthese and the injuries causative and factorsment have in strategies allowed to preventioncondition evolve. is and facilitated The treat- byvers, diagnosis specific and of radiography examination is maneu- annosis. useful elbow for Prevention confirming strategies, thepitch such diag- counts, as have the beenof monitoring developed injury of in to young decreasehave athletes. the contributed Evolving risk to surgicalcertain changes strategies conditions in in techniques the for throwing treating athlete. Elbow Injuries and the Throwing Athlete Chapter 40 anterior band and the posterior band alternately have 7: Elbow Trauma, Fracture, and Reconstruction 2 ytnens vrol h pcnyewt normal with epicondyle the stress. only valgus moving indicated over as from tenderness epicondylitis, differentiated by medial be with associated should pain pain testing, by indicated resistance as associ- injury, with flexor-pronator Pain a noted. nerve with be ated el- should of with testing symptoms Evidence hyperflexion or bow sign, pathology. Tinel positive nerve a subluxation, ulnar for sessed rhpei nweg pae hudradEbw4 Elbow and Shoulder Update: Knowledge Orthopaedic be to reported is test stress specificity. valgus 75% with moving 100%, the ( of re- 120° the and ity thumb when 70° intense the between most is on is elbow the pulling typically Pain at by constant. created reached mains motion of torque is range the a rotation through while taken external pulled is elbow is of The thumb shoulder. limit patient’s the the and until begins position, test same stress the valgus in moving pa- elbow The the the 90°. and beyond on supinated flexed The forearm pulling injury. the by with are UCL thumb performed tient’s also and is test instability maneuver valgus stress milking assess sensitivity valgus to moving the used the lacks milking The and injury. test chronic maneuver a This subtle identify reliably athlete. more to often needed throwing typ- is is a instability also flexion the is in of but mass 30° assessed, and flexor-pronator 0° ically the at Re- stress of Valgus determined. done. testing be strength should the sisted of ligament length the oblique along epi- anterior or medial there the tenderness at and proximally injury condyle, occurs avulsion usually acute UCL An the elbow. of medial the on is athlete full of throwers. lack in a common evaluated; determined. be is be should extension should motion or of pain lateral, range the medial, The of the dif- character and side-to-side location posterior any exact identify The to ference. observed insight an- be carrying provide patient’s should can The gle elbow. an they the about during but stresses elbow, overlook into the to of easy evaluation are observations General Examination Physical on play play- curveball, other than the frequently ers. or more pitch more fastball and are teams, the for more players throw pitch skilled to safe However, relatively ages. likely a all considered of is athletes on the and stress valgus generate less elbow generates slider the changeup greatest and the fastball and deter- the force, the greatest be elbow, generates the should at curveball stress schedule The throwing per thrown mined. the pitches of and number the outing, late pitches, of cocking, through). types follow The early or during deceleration, (windup, motion acceleration, throwing cocking, occur the important symptoms in is point which It shoulder. the the determine especially to joints, pain other or in paresthesias, symptoms, mechanical associated 7: Section ain ihssetdULijr hudb as- be should injury UCL suspected with patient A yial,tefcso h xmnto nathrowing a in examination the of focus the Typically, 5 lo rua rcue n Reconstruction and Fracture, Trauma, Elbow 6 iue1 Figure .Tesensitiv- The ). n fteUL eetsuyfudta signal surgery require that to UCL likely found high-grade most rehabilitation or were predict study complete tear to a recent used with patients be A outcomes; can MRI UCL. on thicken- the intensity chronic of and mass, avul- ing flexor-pronator injury, the UCL in- of be elbow, a sion the can dissecans, about osteochondritis MRI diagnoses cluding several defects. space, confirm osteochondral to joint used of or loss bodies, osteophytes, loose of evidence for sessed ieoeig noeigo oeta mhsbeen has mm 3 than diagnostic. more of joint considered opening medial a an identify opening; to Valgus line used be views. can axillary radiographs the stress and in radiocapitellar, radiographs plain lateral, are AP, studies imaging initial The Imaging aiyaogoeha hoigahee swl as well as athletes throwing UCL overhead in differences among found case laxity or have studies studies case Several small reports. are studies injury, available UCL most defining but for described been have amination iue1 Figure lrsngah n yai lrsngahcex- ultrasonographic dynamic and Ultrasonography htgahsoigtemvn agsstress valgus moving the showing Photograph motion. et Dou test. 03Aeia cdm fOtoadcSurgeons Orthopaedic of Academy American 2013 © b le-hea 7 h aigah a eas- be can radiographs The d e d ro = arrow d ire 8 c in of tions ( iue2 Figure ). 7: Elbow Trauma, Fracture, and Reconstruction 3 2 18 A 42% return-to-sport rate 16 17 An excellent result was defined as 19 Elbow Injuries and the Throwing Athlete Orthopaedic Knowledge Update: Shoulder and Elbow 4 Another study reported an 83% return to the Chapter 40: 7 The commonly described docking technique also In the original Jobe technique for reconstructing the resection of a portionminiopen, of or the arthroscopic diseasedhas means. been tendon accomplished, If by pain open, thea relief strength can surgical be deficit goal expected, may but remain. UCL Injury The initial management of athrowing UCL athlete injury in should anincludes overhead be a 6-week nonsurgical. periodas The of rest strengthening regimen from ofThe throwing athlete as the should well be flexor-pronatorexamination asymptomatic musculature. and before have throwing a activitiesthat normal are resumed. time, At thechanics and athlete offset shouldtrunk stress rotation, optimize from reduced throwing shoulder theincreased external me- medial rotation, elbow and elbow. flexion Late valgus have stress at been the shown elbow. to increase uses a muscle-splittingtunnels approach in the and ulna.in two the Only humerus, converging one and primaryhumerus two tunnel smaller to is holes facilitate are drilled tendon drilled suture graft in passage. the is OneThe passed limb into second of the limblength the tunnel and of in tension, the sectioned theand to humerus. tendon the docked appropriate graft in length, each the is limb humeral assessed ofbridge socket. for after the The final sutures tendontechnique tensioning. from led graft to The are a21 use athletes good tied of (90%). or over excellent the a outcome docking in bone 19 of UCL, a figure-of-8bone tendon tunnels and graftnique sutured was required back woven takedown ontoand through of itself. exposure the of This flexor-pronatorof the tech- the mass posterior tunnels. An humeral ulnarperformed. cortex nerve The transposition for always substantial one was led morbidity to of modification the ofof exposure this new technique techniques. andsists The of development a modified muscle-splitting Jobeity approach to technique to decrease the con- morbid- flexor-pronatormeral musculature, tunnel a change direction,only in and if hu- the ulnar patientmeral nerve has tunnel preoperative transposition symptoms. is Theulnar directed hu- nerve somewhat injury anteriorly withdissection to graft necessary avoid passage for andthe exposure. decrease biomechanical the Themodified strength outcomes Jobe resulting and technique havecomparison from become with the using any standardto-sport other the for rate technique. was Aletes. reported 93% for return- overhead throwing ath- a return to previousa level of good play result for waslower at least defined level 1 as for year, at a and daily least return batting 1 to practice. year throwing A or 92% at the rate a ability of to return throw to at the pre- previous levelfollow-up after of a modified throwing Jobe technique at was used. a minimum 2-year was reported for overhead24.5-week throwing follow-up. athletes at a mean . Ultrasound- 14 (arrow) yle d on c omplete avulsion of the UCL c 9,10 On MRI, increased signal is seen 12 Surgical intervention typically involves 15 from the humeral epi MRI showing a 11 Nonsurgical treatments have high success rates. 13 Arthroscopy has been used as a diagnostic tool pri- Conditions Causing Medial Elbow Pain Figure 2 © 2013 American Academy of Orthopaedic Surgeons Medial Epicondylitis Medial epicondylitis iscondylitis less and common usuallywrist than occurs flexion lateral and as epi- forcefulquet a pronation sport, result during or golf, overhead ofited a throwing. repetitive over rac- Pain the typically medial isforearm elbow elic- and flexion exacerbated and bymarily resisted pronation. clinical, The butported diagnosis ultrasonography to and be is useful. MRI pri- are re- side-to-side differences betweenand the nonthrowing athletes’ arms. throwing marily for closelystress; evaluating a 1 jointpartial-thickness to line tear, opening and 2 4 with cate to mm 10 a mm of ofviewed full-thickness joint opening from indi- line tear. thestressed The opening anterolateral at 65° portal, ulnohumeral indicate to and 70°pronated. a of joint the elbow flexion joint is with is the forearm The componentsprogram of include a NSAIDs, flexibilityguided typical exercises, physical ice, nonsurgical and therapy.been treatment used. Steroid The injectionsprove use have pain of relief iontophoresis also in was a found comparative to study. im- in the flexor musculardyle. origin about the medial epicon- guided autologousscores blood on the injectionPhase visual led analog scales. and to modified Nirschl improved Pain 7: Elbow Trauma, Fracture, and Reconstruction 4 urn eosrcin la ev transposition reconstruction. of nerve time the at ulnar done be re- should reconstruction, injury UCL a with quiring associated symptoms nerve ulnar sd 9o 2ptet 8% a necletresult. excellent an had (86%) patients was 22 technique at- of this humeral 19 after the used, follow-up on 3-year medial technique At the docking tachment. sublime in the a at hole with used the tubercle, is drill at screw single interference hole An a drill epicondyle. and single a tubercle uses sublime technique new relatively xeso neaiain hnvlu teso the on stress terminal valgus of loss When fossa. osteo- some examination. the which has on within commonly at extension impinge also point patient olecranon elbow the The the the as is from and this phytes release ball extension; during reaches elbow the at pain rhpei nweg pae hudradEbw4 Elbow and Shoulder Update: Knowledge Orthopaedic under- olec- who posterior had osteophytes. players 65% ranon that re- baseball found A surgery professional elbow extension. went 72 reaches elbow of the view as the fossa within impinge olecranon posterior osteophytes which medial in commonly, con- athletes and, common throwing overhead relatively in a dition is overload extension Valgus Overload Extension Valgus or Impingement Posteromedial trans- nerve ulnar weeks. isolated 12 with approximately play is to position return The activities. to throwing rehabili- time to return appropriate graduated with a pro- and success tation This great position. had subcutaneous has a cedure into nerve ulnar suc- the transposing be involves typically can treatment modification, Surgical activity cessful. and observed. splint- NSAIDs, night be ice, of ing, use can the subluxation including measures, nerve Nonsurgical ulnar of and/or test, evidence hyperflexion elbow the positive at a sign tunnel, Tinel cubital positive a throw- examination, with physical distribution occur On can ing. nerve symptoms ulnar nerve Night Ulnar the occur. nerve. can into the on paresthesias stress and increase pain can also or injury triceps, medial UCL thickened a osteo- subluxation, and/or nerve adhesions phytes, and of nerve presence the The cre- neuritis. on can induce compression stress and friction, valgus traction, substantial ate A neuritis. insufficiency ulnar UCL with have patients of 40% Approximately specimens. UCL a intact of In sim- that stability construct. to to the ilar led with of technique this epicondyle, end study, each on medial biomechanical on holes the screws drill and interference single tubercle same sublime the the uses technique Another 11.5- an at technique. docking reported was the graft with palmaris was quadrupled used a throwing after follow-up of month level injury 7: Section la Neuritis Ulnar odtosCuigPseirEbwPain Elbow Posterior Causing Conditions eea ehiuscnb aeoie shbi.A hybrid. as categorized be can techniques Several lo rua rcue n Reconstruction and Fracture, Trauma, Elbow 23 tltstpclyrpr posterior report typically Athletes 20 22 3 fteptethas patient the If 21 oei ee fnn ainswounderwent who patients nine overload. of extension valgus out- of seven excellent treatment an arthroscopic cu- in reported the study enters recent nerve come ulnar A as- the tunnel. medial as to bital the osteophyte taken resecting the of when be pect injury must be nerve care ulnar must addition, avoid of In resection Care minimize olecranon. working. and normal osteophytes for remove a to and portal taken viewing accom- for posterior portal be central posterolateral the can a is of procedure using olecranon portion plished medial arthroscopic a the The of resect portion proce- removed. to a open and used an tip, is In olecranon osteotome fashion. normal done an open be of or dure, can excision arthroscopic procedure any an The in whether done. and be to UCL, be should as the can olecranon at debate that seen is olecranon is of there strain amount increased the before to excised as conflict ies ocsa xeso lohv enipiae nthis in implicated been have also condition. extension triceps substantial valgus at a The forces undergoes extension. elbow approaches the and or as load sub- stress is increased a transverse olecranon to of The that ject injury. to as overload similar extension injury described of valgus mechanism a primarily with oblique, are fractures aei hoesadohrtrwn athletes. throwing in other described been and have throwers olecranon javelin the of fractures Stress Fracture Stress Olecranon r h newn sepyeecso ae had later excision reconstruction. osteophyte UCL requiring underwent instability valgus in- who play- UCL baseball of professional ers symptoms of exacerbate percent Twenty-five or jury. shear olecra- unmask by posteromedial can the non impingement of Overresection increases for- effect. osteophyte mass then elbow induces which the as stress mation, fossa This the on extension. olec- impinge posteromedial reaches to the it to cause and stress el- ranon transfer in the may laxity UCL to subtle the Any stabilization extension. secondary during particularly provides olecranon bow, the fossa of in its engagement forces in and valgus athlete, substantial throwing endures the elbow medial The impinge- repeated. posteromedial be not with should patients and particu- ment in not is helpful at injection larly throwing Intra-articular symp- to level. if return earlier cannot recommended the patient is the rest or el- persist of the toms period the at longer stress during A minimize bow. corrected to be program throw- throwing must to interval return mechanics gradual Pitching a ing. allow interval an to by program followed throwing restrictions throwing of days 14 be- relationship the reveal significant can osteophyte. radiographs posterior a be Plain diagnoses. is must these tween there UCL Care concomitant elbow. because a is injury posteromedial there whether re-creates the determine test to positive taken in elbow the a pain and extension, flexion to the of taken 30° to quickly 20° is at applied is elbow ugcltetetsol ecrflyconsidered. carefully be should treatment Surgical to 10 and rest with begins treatment Nonsurgical 03Aeia cdm fOtoadcSurgeons Orthopaedic of Academy American 2013 © 25,26 23 These Stud- 24 7: Elbow Trauma, Fracture, and Reconstruction 5 31 ). The lesion It appears that the Figure 3 29,30 Elbow Injuries and the Throwing Athlete Orthopaedic Knowledge Update: Shoulder and Elbow 4 Chapter 40: Treatment starts with nonsurgical measures, includ- Typically, the athlete has elbow pain during activity. The initial imaging is with plain radiographs. The Conditions Causing Lateral Elbow Pain ing a periodactivities. of NSAIDs relative and rest ice maysurgical and be cessation measures used as of appear needed.tients throwing to Non- but be may require successful asfor long in surgical as treatment most 4 include months. pa- nal open The reduction fixation, options and bone inter- grafting,ternal and fixation open reduction withniques and bone in- grafting. includescrews, The and fixation a tension-band tech- combinationwiring. of The screws available wiring, and studiesreports tension-band are and largely compression limited small to case case studies. Capitellar Osteochondritis Dissecans Osteochondritis dissecans (OCD) isthe a subchondral local disorder bonefragmentation of of that articular resultsbone. cartilage in and It its separationfrom is underlying Panner and disease, important whichis to occurs in idiopathic, differentiate younger patients, without this usually surgical intervention. condition is OCDthe typically elbow self-limiting, occurs in adolescents at andtive who overhead are improves high-demand, throwingnot repeti- completely athletes. understood. Genetic Theply, factors, repetitive pathogenesis blood trauma, sup- is andbeen a implicated. The vulnerable underlying epiphysisdation bone have and undergoes can degra- destabilize theably overlying a cartilage. combination of Prob- factorsby contributes which to the the lesion process is created. The pain isprogresses insidious if in the onset, activitycult is is to continued. localize relieved The and by paintion. often rest, is is Occasionally, accompanied the diffi- and by symptomscatching loss are of or mechanical, mo- locking with ofmon the finding elbow on joint. examinationdiocapitellar The joint. is Crepitus most tenderness can com- over bejoint elicited the with in ra- the pronation lateral of and motion supination, of andcompression 15° there test, is to the loss elbow 30°.patient is actively In pronates fully the and extendedcontracts supinates active while the the the radiocapitellar forearm muscles and reproduces about the the athlete’s elbow. symptoms. A positive test standard AP view in90° full of extension flexion and showflattening lateral typical views of capitellar in radiolucency the and joint surface ( highest rates ofunderwent successful union bone wereThose in grafting undergoing patients fixation with who alone66% had failure or an rate. approximately A withouta recent persistent fixation. study olecranon foundhad physis that a those and 100% with evidence failure of rate sclerosis with nonsurgical measures. commonly occurscapitellum. in the Ingrade anterolateral I the lesion aspect is Minami a of translucent cystic classification the shadow in system, the mid- a Surgical 27 28 Posterior elbow pain typically develops during the The treatment of an olecranon stress fracture is Some experts recommend early surgical treatment to On physical examination, the athlete may have ten- © 2013 American Academy of Orthopaedic Surgeons years from adolescence throughoccurs the late teens. at Thephase pain terminal of throwing, extension andphysical it examination can in may be be relieved the benign;the with motion elbow rest. is follow-through is The normal, stable,tion. and Plain there is radiographs no revealolecranon tenderness a that to persistent may palpa- physis beon in wider the the on the contralateralsclerosis involved about side side. the than physis Theretient’s that age. is may unexpected T2-weighted be forthe MRI the evidence physis, pa- may but show of this edema finding about is not diagnostic. The persistent olecranon physisnon is stress similar fracture to andlete’s an may posterior olecra- be elbow responsibletwo pain. for ossification centers: The an the ath- olecranontransverse posterior to center physis the is has longitudinal oriented tributes axis to of longitudinal the growth; ulnaanterior a second and at center con- the issurface more olecranon but tip, not contributing toters to longitudinal fuse the growth. and create These joint aproximately two single cen- age physis that 14 persistsboys. years until This ap- in physis girls cancess and become of age sclerotic closing during and 16 can the years be pro- in as wide as 5 mm. Persistent Olecranon Physis derness over the physis (ifranon, it or is the open), posteromedial thebe olecranon. posterior elicited Symptoms olec- by may forceful extensiontriceps of muscle the testing. elbow Typically, the ortension resisted patient has than less in ex- graphs may the show a contralateralif sclerotic line the elbow. of condition Plain remodeling isbe fracture chronic. radio- beneficial If to the obtainside physis radiographs is to of open, detect the itreveal any contralateral may physeal increased widening. uptakeedema A within in bone scan the thethe will bone fracture area. line. and MRI MRI allowUCL also will injury characterization is is beneficial show of suspected. if an associated somewhat controversial. Nonsurgical measuresrest require from throwingThe and return to possibly anuntil temporary symptoms interval splinting. have throwing subsided program andevidence is there of is delayed fracture radiographic healing.be As restricted a for result,may as throwing respond long can as tohas 6 not bone months. been stimulators, well Stress but defined. fractures thisreduce treatment the time to resumption of throwing. treatment also is recommendedment if nonsurgical is manage- band unsuccessful. wiring with Tension-band acompression compression wiring, screw, screw and the tension- alone useor have of 7.3-mm a been cannulated described.used. compression A A screw 6.5- recentture typically case after is report fixation describedgrafting in a ultimately a persistent was required college frac- for pitcher, healing. in which bone 7: Elbow Trauma, Fracture, and Reconstruction 6 te rao h oy h igoi oeie sfa- intrave- gadolinium. an- is or administered in arthrographically sometimes nously of diagnosis lesion addition The the OCD body. by an cilitated the of of these those area lesion; to under other fluid unstable similar or an are fluid suggests findings as of surface stable ring articular is peripheral the lesion A the MRI. and on intact whether seen is determine surface to key articular is The decision the assessed. loca- treatment be size, a can making the lesion to the and of ra- MRI, stability plain on and on tion, detected found be not can changes diographs Early lesions. these ing rhpei nweg pae hudradEbw4 Elbow and Shoulder Update: Knowledge Orthopaedic le- III grade subchon- a split its in a present and are has lesion sion. bodies loose lesion the and between II bone, zone dral grade clear a or capitellum, line lateral or dle 7: Section iue3 Figure R a eoetemdlt fcoc o evaluat- for choice of modality the become has MRI 32 lo rua rcue n Reconstruction and Fracture, Trauma, Elbow Pra AP h arti the arthros normal tively d whi ispla c hthereisa d c orp hwn C fthe of OCD showing iograph mn.Su ement. c ular c riaei inta is artilage c c mlt rgetwt su with fragment omplete halesionoftenhasarela- c opi c appearan c t. c c e ptlu in apitellum b e c ause b tle rgetto n oso lo oino oethan more radiographic of with motion elbow closed, 20°. of is un- loss an physis and In fragmentation the capitellar motion. lesion, elbow open good stable A an the and of bone, healing. radiolucency by subchondral or nonsurgical flattening characterized localized plate, for is le- growth Advanced capacity lesion healing. less of stable rate have higher a sions have physes lar lcmn,mroigteotosue nteke and knee and allograft, the osteochondral in Mosaicplasty, used joints. re- other options cartilage the for mirroring exist been placement, options have screws Several Herbert used. and Pull- successfully grafting, methods. bone different wires, through preparation out achieved bed be can and lesion excision can fragment also ( wire after Kirschner used a with be trephination base subchondral or the Microfracture 50% of surface. than capitellar less involving the be lesion of can contained nonsurgical débridement a if Simple for effective described. or been proce- bodies have surgical dures Several loose unsuccessful. been or has treatment lesion unstable an n ae f8%t 91%. to heal- 88% have of flattening rates or ing lucency capitellar with Patients eln.Pthcut ntal hudb monitored. be should initially of counts evidence has Pitch athlete and the asymptomatic, healing. interval if is months motion, An 6 good studies. at has initial initiated is the program is with throwing inter- MRI compared 3-month progressing. approximately and not an val is at or needed as healing ensure repeated is to strength. lesion intervals and the 6-week that motion at assessed optimize are to Radiographs ther- implemented physical is and apy used, Anti- activity. are with throwing medications begins without inflammatory rest treatment elbow The of option. months 6 an are regimens cal iue4 Figure iue4 Figure ugclmngmn sidctdi h ain has patient the if indicated is management Surgical C ein r mnbet eln,adnonsurgi- and healing, to amenable are lesions OCD 36 .Fxto farltvl ag,unfragmented large, relatively a of Fixation ). Arthros mi 03Aeia cdm fOtoadcSurgeons Orthopaedic of Academy American 2013 © c rofra c opi c ture. c mg hwn nODlso after lesion OCD an showing image 34,35 hs ihoe capitel- open with Those 33 7: Elbow Trauma, Fracture, and Reconstruction 7 Am J J Bone apitellar joint after c io d the ra d )an A ( 2004;86-A(10):2268-2274. d Elbow Injuries and the Throwing Athlete 2011;39(9):1936-1941. ial hea d Orthopaedic Knowledge Update: Shoulder and Elbow 4 Chapter 40: The anterior bandfresh-frozen of cadaver specimens. the The53.0 UCL mm, mean and was length the was ulna evaluated mean was in length 29.2 of mm. 10 mens the The and footprint ridge had on was a the present mean in measurement all of speci- 24.5 mm. Sheppard JE, Schickendantz MS:of Quantitative the analysis medial ulnarand collateral its relationship ligament to ulnar the footprint ulnar sublime tubercle. Sports Med flexor-pronator mass to elbowJoint valgus Surg stability. Am evaluation of a new ulnar collateral ligament recon- 1. Farrow LD, Mahoney AJ, Stefancin JJ, Taljanovic MS, 2. Park MC, Ahmad CS: Dynamic contributions of the 3. Ahmad CS, Lee TQ, ElAttrache NS: Biomechanical Annotated References Summary The elbow ofstress during a the phases throwing of theto throwing athlete the motion. correct The endures diagnosis key isbow substantial to region, analyze the obtain condition a byamination detailed el- history, maneuvers, apply and specific obtain ex- studies. appropriate Nonsurgical measures imaging canspecific be phases successful of during thesurgical techniques disease have improved process, patient outcomes. andthroscopic Ar- procedures advances have an in increasing rolemany in conditions, treating with acceptable outcomesto-play rates. and Postoperative return- management isspecific stepwise and to restorestrength to optimal the mechanics, affected muscle flexibility, groups. and overing the ra c a c Fig- ). B a( c images showing an anterolateral pli c opi c tionofthepli c rese Arthros ). The goal is to adequately release the synovial Nonsurgical measures should be initially considered, Figure 5 © 2013 American Academy of Orthopaedic Surgeons ure 5 plica so thatThe it examination no is longercomplete. snaps repeated over to Postoperativerange the ensure of radial management the motion head. terval and release throwing allows advancement program is of typicallyand strength. is early can started An advance at as in- tomatic. 8 long weeks as the patient remains asymp- Radiocapitellar plica, firstsnapping described elbow, essentially asplica is a that a snaps cause hypertrophic overelbow of the synovial moves edge from a flexion of to thediagnosis extension. radial includes The head intra-articular differential as looseity, the bodies, lateral instabil- epicondylitis, andtriceps subluxation over of the the medial medial ditions can epicondyle. be Some ruled of outbow on these the examination con- basis of typicallystability, location. full The is motion, el- otherwise andmay normal benign, have strength. tenderness The with posterior patient and to centered the lateral over epicondyle are the not joint. informative, Plain andon radiographs MRI. the usually plica frequently is missed including relativeIntra-articular rest, steroid NSAIDs, injectionsattempt and have to been relieve gentle inflammation usedgical and motion. in decrease pain. treatment an Sur- yielded with good results. an The snappingcan arthroscopic of be the procedure replicated plica typically onlows has the arthroscopic surgeon examination to and locate al- the area to be released ( autograft transplantation have beenatively used large to OCD treatwhich a lesion there rel- or is an loss uncontained of lateral lesion column (in support). Radiocapitellar Plica 7: Elbow Trauma, Fracture, and Reconstruction 8 eto 7: Section rhpei nweg pae hudradEbw4 Elbow and Shoulder Update: Knowledge Orthopaedic 2 akG,LeS,LeM:Dansi au fultra- of value Diagnostic MY: Lee SM, Lee GY, Park 12. arthroscopic the of Evaluation DW: Altchek LD, Field 11. Ishigaki H, Kashiwa T, Ogino M, Takahara J, Sasaki 10. .Nzra N chn M ictiM,OKn PL, O’Kane MG, Ciccotti JM, McShane LN, Nazarian 9. .KmN,Mo G oS,Mo J hiJW, Choi WJ, Moon SM, Ko SG, Moon NR, Kim 8. .Topo H oeF,YcmL,Pn M Ul- MM: Pink LA, Yocum FW, Jobe WH, Thompson 7. .ODicl W atnR,SihA:Te“moving The AM: Smith RL, Lawton SW, O’Driscoll 6. com- Kinetic al: et JW, Loftice DS, Kingsley GS, Fleisig 5. .Dga PJ,OaeeU,AeadrJ,NbePC, Noble JW, Alexander UC, Osadebe Jr, JP Duggan 4. oorpyfrciia eilepicondylitis. medial Rehabil Med clinical Phys for sonography elbow. the of 1996;24(2):177-181. test instability valgus col- 84-A(4):525-531. in players. laxity baseball elbow medial lege and ul- ligament the of collateral assessment nar Ultrasonographic Y: Kanauchi D, pitchers. baseball 227(1):149-154. asymptomatic league in the elbow of the major band of anterior ligament the collateral of ulnar US Dynamic MI: Harwood uyi aealpaes au o rdcigrehabili- predicting in- for ligament Value outcome. collateral tation players: ulnar baseball of in imaging jury MR JY: Park 152-157. a oltrllgmn eosrcini athletes: in nerve. the reconstruction of ulnar transposition without ligament approach Muscle-splitting collateral nar agssrs et o eilclaea iaettears ligament collateral elbow. the medial of for test” stress valgus pitchers. 2006;34(3):423-430. and baseball change-up, collegiate curveball, in slider fastball, the among parison eradrcntuto ncnatpesrsi h lat- 2011;20(2):226-233. elbow. the the ligament in of pressures collateral compartment contact eral ulnar on reconstruction of and impact tear The DM: Lintner tuto ehiu ihitreec ce fixation. Med screw Sports interference J Am with technique struction eaiepeitv au 0.Ti td reinforced study This 90%. > and value value, predictive predictive sensitiv- negative positive had a accuracy, epicondylitis with specificity, medial ity, elbows of 21 diagnosis of clinical assessment ultrasonographic An injury higher-grade a with severe those surgery. less and required a MRI, who had on patients treatment injury The nonsurgical surgery. to required nonsurgi- responded 27 After MRI. of treatment, with cal evidence evaluated clinical were injury with UCL players baseball Thirty-nine t a obe fe C rneto n etrdaf- late restored simulate and reconstruction. transection lax- to UCL ter valgus after torque average doubled The was N/m phase. ity release 5.25 the and and load cocking valgus N/m a 1.75 under tested of were specimens cadaver Six lo rua rcue n Reconstruction and Fracture, Trauma, Elbow mJSot Med Sports J Am hudrEbwSurg Elbow Shoulder J u Radiol J Eur 2003;31(3):332-337. 2008;89(4):738-742. oeJitSr Am Surg Joint Bone J 2011;80(3):e422-e426. hudrEbwSurg Elbow Shoulder J 2005;33(2):231-239. Radiology mJSot Med Sports J Am mJSot Med Sports J Am 2001;10(2): 2002; 2003; Arch 6 giad L hmesH orlto fthrowing of Correlation H: Chambers AL, Aguinaldo 16. epi- Medial DA: Connell H, Jones KE, Ali SP, Suresh 15. Maartmann- DH, Ochiai DM, Rodin RP, Nirschl 14. imaging resonance Magnetic AA: Smet De R, Kijowski 13. 8 anE r nrw R ua R ta:Otoeof Outcome al: et JR, Dugas JR, Andrews Jr, EL Cain 18. Mieling JC, Mendler DS, Snead C, Sherrill AC, Rettig 17. 0 aet AJ,Wih W h oiiddcigpro- docking modified The RW: Wright Jr, GA Paletta 20. Elbow DW: Altchek DM, Dines JS, Dines AL, Bowers 19. ehnc ihebwvlu odi dl baseball adult in load valgus pitchers. elbow with mechanics 939. discussion in- 40(11):935-939, treatment? blood effective autologous an guided jection ultrasound Is condylitis: 31(2):189-195. study. double-blinded, randomized, placebo-controlled phosphate A epicondylitis: sodium acute for dexamethasone Iontophoretic of Group: administration Study DEX-AHE-01-99 C; Moe epicondylitis. medial Radiol with patients in findings n18 tlts eut n73ahee ihmini- with athletes 743 in follow-up. elbow Results 2-year mum the athletes: of 1281 reconstruction in ligament collateral ulnar 29(1):15-17. athletes. throwing ligament collateral in ulnar injuries of treatment Nonoperative P: in -erflo-pi lt throwers. elite in Med reconstruc- follow-up ligament 2-year collateral tion: ulnar elbow for cedure Surg technique. bow docking the Clini- and reconstruction: relevance ligament cal collateral ulnar medial 2426-2434. advldtn lrsngah o igoigme- to- diagnosing moved for epicondylitis. and dial ultrasonography examination validating physical the ward of value the r eels ucpil oebwvlu hnthose than valgus slot. elbow arm to higher a susceptible pitch- with less Sidearm were flexion. external elbow ers in- shoulder increased mound. reduced valgus and indoor rotation, elbow rotation, trunk an with late at associated cluded most pitchers variables baseball The adult evalu- to 69 used ate was analysis motion Three-dimensional hstcnqei cetbefrULreconstruction. UCL for result. acceptable a excellent is or using good technique a technique This had docking recon- 90% graft, modified UCL three-strand underwent a who with athletes struction overhead 21 Of and months. months, 11.6 4.4 was was competition to throwing aver- return to The average return 83%. the was to function time of age level re- previous of rate to under- The turn graft patients transposition. nerve All gracilis re- subcutaneous technique. or went Jobe UCL longus modified underwent the palmaris whom using a of with most minimum construction 2-year patients, a 942 for on collected were data Prospective 2006;34(10):1594-1598. 03Aeia cdm fOtoadcSurgeons Orthopaedic of Academy American 2013 © 2005;34(4):196-202. mJSot Med Sports J Am 001(,suppl):110-117. 2010;19(2, mJSot Med Sports J Am mJSot Med Sports J Am 2009;37(10):2043-2048. mJSot Med Sports J Am rJSot Med Sports J Br hudrEl- Shoulder J 2010;38(12): mJSports J Am Skeletal 2003; 2001; 2006; 7: Elbow Trauma, Fracture, and Reconstruction 9 2010; Rinsho 2008;36(5): 2009;37(2): J Bone Joint J Bone Joint Am J Sports Med Am J Sports Med Am J Sports Med Am J Sports Med Elbow Injuries and the Throwing Athlete 1979;14(8):805-810. 2007;89(6):1205-1214. 1993;75(2):272-275. Orthopaedic Knowledge Update: Shoulder and Elbow 4 Chapter 40: In a retrospective reviewthe of humeral 106 capitellum, patients withsurgical treatment OCD was of fragment nonsurgicalbone or removal, grafting, or mosaicplasty fragmenteral with plugs femoral fixation from condyle. the Lesionsor lat- with were unstable classified at assponded well stable 7.2-year to nonsurgical follow-up. measures,sions and Stable responded unstable to le- lesions surgical intervention. re- Retrospective review of 176humeral patients capitellum with OCD found53% of that the of 90.5% stage ofsures. II stage lesions Mean I healed time12.3 and with months nonsurgical to for stage mea- healing Ireturn-to-throwing and rates was II were lesions, 14.9 respectively,spectively. 78.6% and months and 52.9%, and re- In aphysis retrospective in analysis 16classified male as of stage baseballthe I persistent players, (a contralateral the olecranon widened elbow)sion). lesions physis or Nonsurgical compared were treatment stage with wasthose II successful with in (radiographic a 92% of le- stagesion. I lesion but none with a stage II le- OCD of the capitellumanatomy, was clinical reviewed, presentation, including diagnostic patho- studies,surgical non- and surgicalprogram. treatments, and a rehabilitation Retrospective review ofcapitellum 39 who patients with wererecommendation OCD treated that of nonsurgically patients with the ledundergo an to advanced surgical lesion intervention the becauserates of and poor healing management. evidence of progression with nonsurgical 868-872. Classification, treatment, anddritis outcome dissecans of of the osteochon- humeralSurg capitellum. Am tent physis in an adult: A case report. Surg Am sui N: The valuetreatment of of using persistent radiographicin symptomatic criteria olecranon for adolescent the physis 2010;38(1):141-145. throwing athletes. cases of osteochondritis dissecans ofSeikei the Geka elbow. tis dissecans of the capitellum. 38(9):1917-1928. Nonoperative treatment forof osteochondritis dissecans the298-304. capitellum. sui N: Conservativethe treatment humeral for capitellum. osteochondrosis of 36. Takahara M, Mura N, Sasaki J, Harada M, Ogino T: 31. Matsuura T, Kashiwaguchi S, Iwase T, Enishi T, Ya- 32. Minami M, Nakashita K, Ishii S, et al:33. Twenty-five Baker CL III, Romeo AA, Baker CL Jr: Osteochondri- 34. Mihara K, Tsutsui H, Nishinaka N, Yamaguchi K: 35. Matsuura T, Kashiwaguchi S, Iwase T, Takeda Y, Ya- Am 1986; 2003;12(1): Arthroscopy Am J Sports Med Am J Sports Med 1992;278:58-61. Int J Sports Med 2007;35(12):2039-2044. 1997;6(5):491-494. J Shoulder Elbow Surg 2012;40(1):218-221. Clin Orthop Relat Res Am J Sports Med A collegiate pitcherwas with successfully an treated nonsurgically olecranonrence but stress on had return fracture a to recur- gical full treatment activity. Seven with months aposterior after single sur- elbow cannulated pain screw, with hefixation had bullpen was throwing. with Revision smaller repeat screw. screw After an fixation intervalpatient and throwing a program, returned second the 17-month to follow-up. pitching without symptoms at After unsuccessful nonsurgical treatment,with nine patients posteromedial impingementcopy followed underwent by arthros- rehabilitationing and an program. interval throw- The68-month follow-up. results were excellent at a mean Twenty-two athletes underwentwith a UCL hybrid reconstruction which variation an interference ofon screw the the is ulna docking used to technique avoidtechnique. in the Nineteen a in fracture patients single risk had of andid tunnel the excellent two-tunnel result, patients as avulsions. requiring revision for sublime tubercle stress fracture ofJ the Shoulder Elbow olecranon Surg in baseball pitchers. rence of an olecranonafter stress percutaneous fracture internal in fixation: an A elite case pitcher report. 7(4):210-213. throwers: A report of twoerature. cases and a review of the lit- J Sports Med mad CS: Clinical outcomesto of treat the ulnar DANE collateral TJ ligamentbow. insufficiency technique of the el- olecranon in javelin throwers. non physis in baseballative players: management. Results following oper- 1993;21(6):836-839, discussion 839-840. gery in professional baseball players. 1995;23(4):407-413. MG: Posteromedial elbow impingement:onance Magnetic imaging res- findings inand overhead throwing results athletes 2011;27(10):1364-1370. of arthroscopic treatment. of the ulnar nerve in the athlete. 59-62. 27. Suzuki K, Minami A, Suenaga N, Kondoh M: Oblique 28. Stephenson DR, Love S, Garcia GG, Mair SD: Recur- 26. Nuber GW, Diment MT: Olecranon stress fractures in 21. Dines JS, ElAttrache NS, Conway JE, Smith W, Ah- 25. Hulkko A, Orava S, Nikula P: Stress fractures of the 29. Charlton WP, Chandler RW: Persistence of the olecra- 23. Andrews JR, Timmerman LA: Outcome of elbow sur- 24. Cohen SB, Valko C, Zoga A, Dodson CC, Ciccotti 22. Rettig AC, Ebben JR: Anterior subcutaneous transfer 30. Skak SV: Fracture of the olecranon through a persis- © 2013 American Academy of Orthopaedic Surgeons 7: Elbow Trauma, Fracture, and Reconstruction 10 rhpei nweg pae hudradEbw4 Elbow and Shoulder Update: Knowledge Orthopaedic 7: Section lo rua rcue n Reconstruction and Fracture, Trauma, Elbow 03Aeia cdm fOtoadcSurgeons Orthopaedic of Academy American 2013 ©