7/16/2015. Elbow Injuries in the Adolescent Athlete. Cara Smith, PT, CHT

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1 Elbow Injuries in the Adolescent Athlete Cara Smith, PT, CHT 1

2 Objectives Describe the anatomy and structural biomechanics of the elbow joint. Discuss the factors that distinguish the adolescent athlete from the adult athlete. Recognize the signs and symptoms associated with common injuries of the pediatric elbow. Bony Anatomy Distal humerus Medial: trochlea; medial epicondyle Lateral: capitulum; lateral epicondyle Anterior: radial fossa; coronoid fossa Posterior: olecranon fossa Proximal radius Radial head Radial neck Proximal ulna Olecranon Greater sigmoid notch Coronoid process Radial notch 2

3 Articulations Humeroulnar Joint Distal humerus: trochlea Proximal ulna: trochlear notch Hinge joint (one degree of freedom) Flexion and extension Articulations Humeroradial Joint Distal humerus: capitulum Proximal radius: fovea of the radial head Radius only articulates with a portion of the capitulum during extension; contact increases with elbow flexion Flexion/extension Supination/pronation 3

4 Articulations Proximal Radioulnar Joint Proximal Radius: radial head Proximal Ulna: radial notch Supination/pronation In conjunction with the distal radioulnar joint Muscular Anatomy Elbow flexion Primary Brachialis Biceps brachii Brachioradialis Secondary Pronator teres Extensor carpi radialis longus Flexor carpi radialis Supination Biceps brachii Supinator 4

5 Muscular Anatomy Elbow extension Primary Triceps Anconeus Secondary Flexor carpi ulnaris Extensor carpi ulnaris Pronation Pronator teres Pronator quadratus Capsuloligamentous Support Anterior Joint Capsule Loose anteriorly and posteriorly to allow full elbow flexion and extension Limited role in joint stability Most lax at 80 degrees of flexion 5

6 Capsuloligamentous Support Medial (Ulnar) Collateral Ligament Complex Restrain valgus forces throughout full elbow flexion and extension Anterior bundle Largest component of the MCL Main ligamentous stabilizer to valgus force with elbow extension Posterior bundle Less defined than the anterior bundle Taught with elbow flexion Transverse bundle Spans the insertion of the anterior and posterior bundles Little to no role in stabilizing the elbow Capsuloligamentous Support Lateral Collateral Ligament Complex Restrain varus forces on the elbow Radial collateral ligament Taut throughout elbow flexion and extension Lateral ulnar collateral ligament Taut in extreme flexion Accessory lateral collateral ligament Annular ligament Envelops the radial head Prevents inferior subluxation 6

7 Ulnar Nerve Innervation Radial Nerve Median Nerve Cubitus Valgus (Carrying Angle) Trochlea causes the ulna to deviate laterally Normal Males: 5 8º Females: 10 15º 7

8 Elbow Injuries Why are kids so unique? 8

9 Child vs. Adolescent vs. Young Adult Child Terminates with the appearance of all secondary centers of ossification Adolescent Ends when all secondary centers have fused Increase in physical strength avulsions physeal separations AVN Young adult Ossification centers have fused, final muscular development is achieved Muscle avulsions are more common that bony avulsions Elbow Ossification Centers Site Age at Appearance Age Epiphysis Unites Capitulum 18 months 14 years Radial head 5 years 16 years Medial epicondyle 5 years 15 years Trochlea 8 years 14 years Olecranon 10 years 14 years Lateral epicondyle 12 years 16 years Alcid, et. al,

10 Fractures Faster healing times versus adults Kids heal faster under plaster» Dr. Pete Carter Remodeling can occur at the site of the fracture and allow some malunion deformities to correct spontaneously Salter Harris Fracture Scale 10

11 Supracondylar Fractures Most common elbow fracture between ages 5 10 years of age Mechanism of injury Fall on outstretched hand Can be non displaced vs displaced Risk of injury to the nerves Treatment of Supracondylar Fractures Non displaced Cast immobilization Elbow flexion Neutral forearm rotation Displaced Reduction and pinning vs. ORIF Followed by cast immobilization 11

12 Medial Epicondyle Fractures Apophyseal injuries No effect on the longitudinal growth of the humerus Occur most commonly around age 11 Mechanism of injury Valgus strain or rotational injury Treatment Cast immobilization with elbow flexion and forearm pronation May require pinning/internal fixation based on amount of displacement Radial Neck Fractures Most commonly occur after the age of 9 Mechanism of injury: Valgus stress with a longitudinal force on an outstretched arm Treatment Non operative cast immobilization Operative Closed reduction (+/ pins/nails) Open reduction (+/ internal fixation) 12

13 Humeroulnar Dislocation Ulna and radius dislocate posteriorly Mechanism of injury Hyperextension forces with elbow in extension Position Perched Complete Treatment Closed reduction Reduction and ligamentous repair Little League Elbow Medial epicondyle apophysitis Apophysis can be avulsed due to pull of the common flexor/pronator group and strain of the UCL Cause Repetitive valgus strain on the elbow Usually occurs in kids 9 12 y/o 13

14 Little League Elbow Presentation Insidious onset of medial elbow pain Pain with throwing activities; may see a decline in performance (decreased velocity, distance, etc.) Treatment Activity restrictions; rest Gradual return to throwing The bony fragment can get lodged in the joint, requiring surgical removal Osteochondritis Dissecans Interruption of the blood supply to the epiphysis that leads to bony necrosis Repetitive microtrauma, axial compression Usually occurs between years of age Most common site Capitellum Lateral and central portions Compression forces on the radiocapitellar joint from throwing, serving in tennis, or weight bearing in gymnastics 14

15 Osteochondritis Dissecans Presentation Insidious onset lateral elbow pain, tenderness, and swelling Occurs during activity and increases over time Can lead to loss of motion with advanced lesions Treatment Stable lesions Activity restrictions; rest Unstable lesions or presence of closed physes Surgical intervention Panner s Disease Must differentiate from OCD Occurs in children ages 4 8 years Avascular necrosis of the capitellum Presentation Insidious onset lateral elbow pain Treatment Rest from activity (allows for revascularization and reossification) 15

16 Uncommon in kids The UCL complex is stronger than the physis Occur after the medial epicondyle apophysis is closed (~ 15 y/o) Not just a baseball problem Volleyball, tennis, golf, wresting, gymnastics, football Can be an acute injury or a chronic issue Acute Traumatic valgus load Must rule out medial epicondyle or olecranon avulsion fracture Chronic Repetitive microtrauma Ulnar Collateral Ligament Injuries Treatment Acute Most commonly treated surgically Chronic Non operative REST No throwing for a minimum of 3 months and then gradual return Operative Considered only after failed non operative treatment Ulnar Collateral Ligament Injuries 16

17 THANK YOU References Alcid J, Ahmad C, Lee T. Elbow anatomy and structural biomechanics. Clin Sports Med. 2003; 23: Thompson JC. Netter s Concise Atlas of Orthopaedic Anatomy. New Jersey: Icon Learning Systems, Lockard M. Clinical Biomechanics of the Elbow. J Hand Ther. 2006; 19:72 81 Neumann D. Kinesiology of the Musculoskeletal System. St. Louis, MO: Elsevier/Mosby, Gill T, Micheli L. The immature athlete common injuries and overuse syndromes of the elbow and wrist. Clin Sports Med. 1996; 15(2): Zellner B, May MM. Elbow injuries in the young athlete an orthopedic perspective. Pediatr Radiol. 2013; 43(1): S129 S134. Kramer D. Elbow pain and injury in young athletes. J Pediatr Orthop. 2010; 30(2): S7 S12. Leahy I, Schorpion M, Ganley T. Common medial elbow injuries in the adolescent athlete. J Hand Ther. 2015; 28: Mulligan E. Elbow and Shoulder Injuries and Rehabilitation for Management of the Young Athlete

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