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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
    • 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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Questions (4)
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(SAE07PE.83) A 6-year-old Little League pitcher has had pain in the right elbow for the past 2 weeks. Examination reveals mild lateral elbow joint tenderness with full range of motion and no effusion or collateral laxity. A radiograph is shown in Figure 38. Initial management should consist of Review Topic

QID: 6143
FIGURES:
1

cessation of throwing activities.

93%

(41/44)

2

a long arm cast for 3 months.

0%

(0/44)

3

a corticosteroid injection into the elbow joint.

0%

(0/44)

4

excision of the fragment.

0%

(0/44)

5

arthroscopic drilling of the lesion.

2%

(1/44)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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? Review Topic

QID: 4511
FIGURES:
1

Displaced medial epicondyle avulsion fracture

10%

(565/5424)

2

Medial apophysitis

86%

(4651/5424)

3

Medial ulnar collateral ligament tear

2%

(95/5424)

4

Valgus extension overload with olecranon osteophytes

1%

(51/5424)

5

Ulnar neuritis

0%

(16/5424)

ML 2

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PREFERRED RESPONSE 2

(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? Review Topic

QID: 2942
1

Acute fragmentation of the entire capitellar ossific nucleus

1%

(45/3277)

2

Rupture of the anterior band of the anterior bundle of the ulnar collateral ligament

8%

(261/3277)

3

Repetitive contraction of the flexor-pronator mass stresses the chondro-osseous origin, leading to apophysitis

79%

(2593/3277)

4

Microtraumatic vascular insufficiency of the capitellum from chronic compressive and rotatory forces

11%

(349/3277)

5

Repetitive triceps contraction during extension

0%

(11/3277)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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