Review Question - QID 7590

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Valgus Extension Overload (Pitcher's Elbow) QID: 7590 (SAE11OS.2)

QID 7590 (Type "7590" in App Search)

Figures 2a and 2b are the MR arthrograms of a 19-year-old college baseball pitcher who injured his throwing elbow during a game 5 days ago when he felt a pop. Immediately after the throw he reported significant discomfort with pitching and noted that he could not achieve his normal velocity or accuracy in location with his subsequent pitches. On further questioning, he admits to increasing medial elbow pain over the last few seasons with pitching. Examination reveals medial elbow swelling and somewhat diffuse tenderness to palpation medially. Valgus stress at 30 degrees of flexion and resisted wrist flexion produced discomfort. He notes some tingling in his fourth and fifth fingers but Tinel's test posterior to the medial epicondyle is unremarkable. Radiographs of the elbow show no fracture. Because the patient wishes to return to competitive throwing, what is the next step in management?

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Ulnar nerve transposition

41/1397

Ulnar collateral ligament reconstruction

89%

1240/1397

Long arm cast for a medial epicondyle fracture

19/1397

Open reduction and internal fixation of the medial epicondyle

40/1397

Elbow arthroscopy and excision of a posteromedial olecranon osteophyte

41/1397

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This high level throwing athlete has a full-thickness injury to the ulnar collateral ligament and is most likely to be able to return to competitive throwing with an ulnar collateral ligament reconstruction. There is no radiographic evidence of a medial epicondyle fracture. The clinical presentation and lack of a posteromedial olecranon osteophyte makes valgus extension overload unlikely, and therefore, makes arthroscopic osteophyte excision a suboptimal choice. Whereas ulnar nerve pathology can coexist with an ulnar collateral ligament injury, isolated ulnar nerve transposition without addressing the ligament injury is not warranted in this patient. Initial nonsurgical management with activity modification and physical therapy is appropriate for partial-thickness injury to the ulnar collateral ligament in a non-throwing athlete, and in athletes whose sporting activity places them at low risk.

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