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Review Topic
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Introduction
  • A rare elbow injury that predominately affects throwing athletes
  • Epidemiology
    • location
      • predominantly involves the epiphyseal plate
      • fractures lines may propagate to be either transverse or oblique in orientation
  • Pathophysiology
    • mechanism of injury
      • three commonly accepted theories
        • olecranon posteriomedial impingement 
        • triceps traction force
        • valgus extension overload 
  • Associated injuries with throwing movements
    • ulnar collateral ligament tears
    • medial epicondyle avulsion fracture
Presentation
  • Symptoms
    • posteromedial olecranon pain of the throwing arm
      • improves with rest
      • worse with throwing movements
  • Physical exam
    • inspection
      • mild swelling over olecranon
      • localized tenderness
    • motion
      • valgus instability stress test
        • may indicate associated UCL injury
Imaging
  • Radiographs  
    • recommended views
      • AP, lateral, oblique views of elbow
    • optional views
      • valgus stress views
      • contralateral elbow for comparison 
    • findings
      • physeal widening, delayed fusion, or fragmentation
      • widening of the medial joint space with UCL injuries
  • CT  
    • views
      • best seen on lateral views
    • findings
      • typical fracture pattern
        • originates from the articular surface 
        • runs toward the dorsal-proximal direction
  • MRI 
    • indications
      • suspected UCL tear
    • views
      • coronal T2 fat-saturated views
    • findings
      • T-sign indicative of UCL tears  
Treatment
  • Nonoperative
    • short-term administration of NSAIDS, rest +/- temporary splinting
      • indications
        • first-line treatment 
      • modalities
        • initial 4-6 weeks of rest or splinting
        • progressive ROM exercises
        • avoiding valgus loading forces (e.g. throwing)
        • electrical bone stimulation may also be considered
  • Operative
    • open internal fixation
      • indications
        • delayed fracture union 
      • modalities
        • large compression screw  
        • tension band wire 
 

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Questions (4)
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(SAE07SM.23) Figure 7 shows the CT scan of a 22-year-old professional baseball pitcher who has had elbow pain for the past 6 months despite rest from throwing. Management should consist of Review Topic

QID: 8685
FIGURES:
1

cast immobilization for 6 weeks.

8%

(8/105)

2

brief immobilization followed by rest for 6 weeks.

25%

(26/105)

3

internal fixation with a compression screw.

43%

(45/105)

4

internal fixation with a tension band wire.

18%

(19/105)

5

bone stimulation.

6%

(6/105)

L 4

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(SBQ07SM.23) A 19-year-old college baseball player has posterior elbow pain despite non-operative treatment for 9 months. He developed acute worsening of pain and inability to throw. His imaging is shown in Figure A. What is the next most appropriate step in management? Review Topic

QID: 1408
FIGURES:
1

Elbow arthroscopy

1%

(7/849)

2

Open removal of osteophytes

0%

(3/849)

3

Ulnar nerve transposition

0%

(1/849)

4

Internal fixation with a compression screw

95%

(806/849)

5

Cast immobolization, followed by gradual return to strengthening program

3%

(25/849)

L 1

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