Review Question - QID 216851

This patient has an elbow condition commonly referred to as "little league elbow." Initial treatment is rest, physical therapy and activity modification.

Little league elbow represents a spectrum of injuries that can occur to the medial elbow in young-adolescent throwers. This can include stress fractures of the medial epicondyle, injury to the flexor-pronator mass and ulnar collateral ligament injuries (UCL). With an open physis, apophysitis and bony avulsion injuries are more common than injuries to the UCL. These typically occur due to repetitive valgus loading that overloads the medial elbow. Most commonly, these injuries occur in young pitchers who are throwing too frequently or too many pitches per game. Radiographs are often normal, but may demonstrate physeal widening of the medial epicondyle. It can be beneficial to compare radiographs of the injured elbow to the contralateral elbow to determine if there is, in fact, any widening. MRI is more sensitive and shows edema of the medial epicondyle apophysis and can differentiate between bony/physeal injury and ligament injury. Initial management is rest, refraining from throwing and physical therapy to strengthen the dynamic stabilizers about the elbow, improve shoulder and elbow range of motion, and improve core strength.

Gottschalk et al. reviewed pediatric medial epicondyle fractures, noting that many occur with an elbow dislocation, for which one must be suspicious. They note that recommended treatment of true medial epicondyle fractures with displacement should focus on early fixation and mobilization but nondisplaced fractures or stress fractures can be treated nonoperatively. They conclude that outcomes are usually good in these injuries if proper indications are followed.

Osbahr et al. reviewed acute avulsion fractures of the medial epicondyle associated with throwing in youth baseball players. They note that the valgus stress during throwing places these athletes at high risk and found that those who did not follow USA baseball throwing recommendations were more likely to sustain injuries. Ultimately, they concluded that once identified, if published management algorithms are followed these patients usually make an uneventful recovery to sport, although it can take up to 1 year.

Figure A is an AP radiograph demonstrating medial epicondyle physeal widening. Figure B is a T2 MRI sequence demonstrating an apophyseal injury of the medial epicondyle physis.

Incorrect Answers:
Answer 2: Ulnar collateral ligament reconstruction is not indicated in the setting of a little league elbow, as the ligament remains competent.
Answer 3: Elbow arthroscopy would not be indicated in this patient but could be used in patients with capitellar osteochondral lesions.
Answer 4: Open reduction and internal fixation is an option in cases of medial epicondyle fractures with displacement.
Answer 5: Immobilization in a long-arm cast for 6 weeks would be inappropriate as it would only promote elbow stiffness.