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Little League Elbow

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Topic updated on 03/27/16 1:27pm
Introduction
  • Generic adolescent term for medial elbow injury
    • can refer to a continuous spectrum of injuries to medial side of the elbow including
      • medial epicondyle stress fractures
      • ulnar collateral ligament (UCL) injuries
      • flexor-pronator mass strains
  • Epidemiology
    • demographics
      • younger patients are more likely to have apophysitis or avulsion injuries, rather than UCL sprains
  • Pathophysiology
    • mechanism
      • associated with throwing curveballs
    • pathoanatomy
      • due to repetitive valgus loading with throwing causing repetitive microtrauma to the immature skeleton 
      • causes tension overload of the medial structures 
  • Risk factors 
    • Greater than 80 pitches per game 
    • More than 8 months of competitive pitching per year
    • Fastball speed > 85mph 
    • Continued pitching despite arm fatigue/pain
    • Participating in showcases
Presentation
  • Symptoms
    • elbow pain in throwing arm
    • decreased throwing speed, accuracy, and distance
  • Physical exam
    • tenderness to palpation about medial elbow
    • pain with valgus stress
    • instability with valgus stress notes more severe involvement
      • should be checked in varying degrees of elbow flexion to extension
Imaging
  • Radiographs 
    • recommended views
      • AP/lateral elbow
    • findings
      • may show physeal widening   
      • may show fragmentation or avulsion of the medial epicondyle
  • MRI
    • will show increased edema of the medial epicondyle apophysis 
    • can be used to confirm UCL insufficiency 
Treatment
  • Nonoperative
    • rest, activity modifications, PT
      • indication
        • is the mainstay of treatment
      • technique
        • coach and parent education is critical to limit number of innings pitched per week
        • use minimal immobilization to maintain elbow ROM
  • Operative 
    • ORIF of medial epicondyle
      • indication
        • for medial epicondyle avulsion fractures
    • UCL reconstruction
      • indication
        • for UCL disruption and insufficiency
Technique
  • Pediatric UCL reconstruction
    • similar to adult treatment
    • commonly using palmaris longus autograft
Complications
  • Ulnar nerve neuropathy
  • Continued pain and instability
  • Loss of motion
  • Inability to return to same level of play

 

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Qbank (3 Questions)

TAG
(OBQ12.151) A 12-year-old baseball pitcher describes progressive worsening of medial elbow pain on his throwing side. Examination reveals normal elbow range of motion. He is tender over the medial elbow to palpation. A dynamic ultrasound of his elbow shows no evidence of medial widening with valgus stress. His radiograph is shown in Figure A and an MRI is shown in Figure B. What is the most likely cause of his symptoms? Topic Review Topic
FIGURES: A   B        

1. Displaced medial epicondyle avulsion fracture
2. Medial apophysitis
3. Medial ulnar collateral ligament tear
4. Valgus extension overload with olecranon osteophytes
5. Ulnar neuritis

PREFERRED RESPONSE ▶
TAG
(OBQ09.129) A 10-year-old little league pitcher has the triad of medial elbow pain in his throwing arm, decreased throwing effectiveness, and decreased throwing distance. What is the pathogenesis of the condition that is most likely to be occuring in this patient? Topic Review Topic

1. Acute fragmentation of the entire capitellar ossific nucleus
2. Rupture of the anterior band of the anterior bundle of the ulnar collateral ligament
3. Repetitive contraction of the flexor-pronator mass stresses the chondro-osseous origin, leading to apophysitis
4. Microtraumatic vascular insufficiency of the capitellum from chronic compressive and rotatory forces
5. Repetitive triceps contraction during extension

PREFERRED RESPONSE ▶
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