Radiographic comparison of adolescent athletes with elbow osteochondritis dissecans to ulnar collateral ligament injuries and controls

Osteochondritis dissecans in children: location-dependent differences (part II: ankle and elbow)

The classic terminology "osteochondritis dissecans (OCD)" describes a pathologic alteration, centered at the osteochondral junction, involving the subchondral bone and/or its cartilaginous precursor, with risk for lesion instability and disruption of adjacent articular cartilage. Among children and young adults, these sites of osteochondrosis can be a cause of chronic joint pain and are most often found within the knee, the ankle, and the elbow joints. While Part I of this review series focused on shared key definitions, pathophysiologic principles, and imaging considerations, as well as unique differences between lesions at different locations within the knee joint, the current Part II article is devoted to lesions that involve the ankle and elbow joints. Following the outline of the Part I article, an evidence-based literature review on location-specific pathophysiology, imaging considerations, findings of lesion instability, and treatment selection considerations will be discussed for lesions involving the talar dome, capitellum, and humeral trochlea.

Osteochondritis Dissecans of the Capitellum: Influence of Activity on Lesion Location Within a Zone of Propensity

BACKGROUND

There may be an association between repetitive stress on the elbow and capitellar osteochondritis dissecans (COCD). The influence of activity on the characteristics or specific location of the lesion within a capitellar zone of propensity remains unclear.

PURPOSE/HYPOTHESIS

The purpose of this study was to evaluate COCD in gymnasts and baseball players compared with a non-upper extremity (non-UE) sport COCD cohort. It was hypothesized that activity would influence presentation and lesion location and characteristics.

STUDY DESIGN

Cross-sectional study, Level of evidence, 3.

METHODS

Consecutive patients presenting with COCD treated in a tertiary sports medicine practice between March 2006 and March 2021 were reviewed. Demographic and imaging lesion characteristics were recorded. The sagittal inclination angle position of the lesion center relative to the humeral shaft was recorded. Intra- and interrater reliability was confirmed (intraclass correlation coefficient, 0.808; intraclass correlation coefficient, 0.824, respectively). Participants were analyzed by activity.

RESULTS

A total of 126 elbows were identified: 68 in gymnasts, 31 in baseball players, and 27 in patients with no history of UE sports. The mean age of the participants was 12.5 years (range, 8-18 years). All (100%) unilateral cases of osteochondritis dissecans (OCD) in baseball players occurred in the dominant throwing arm, compared with less hand-dominance correlation in gymnasts (64%) and non-UE athletes (67%). Significantly, 14 of the 20 (70%) patients with bilateral OCD were gymnasts (P = .036). In non-UE athletes, lesions occurred at a mean sagittal inclination angle of 52.7° (±13.8°), with a mean lateral containment of 4.7 (±2.1) mm. In gymnasts, lesions occurred more posteriorly at 41.2° (±14.9°), with a lateral containment of 3.6 (±1.9) mm. In baseball players, COCDs occurred at 55.1° (±11.9°), with a lateral containment of 2.5 (±1.6) mm. These more posterior lesion positions in gymnasts (P = .001) and lesser lesion containment noted in gymnasts (P = .015) and baseball players (P < .001) were significant.

CONCLUSION

Compared with COCD lesions in adolescents with no history of UE sports, gymnastics participation (impact weightbearing) correlated with a higher rate of bilateral lesion formation and a more posterior (extended) lesion position. Baseball participation (resulting in valgus shear forces in the elbow) resulted in a sagittal position similar to non-UE lesions, but more lateral and with less containment.

Elasticity of the Forearm Flexor-Pronator Muscles as a Risk Factor for Medial Elbow Injuries in Young Baseball Players: A Prospective Cohort Study of 314 Players

BACKGROUND

Young baseball players with medial elbow injuries are known to have high forearm flexor-pronator muscle elasticity; however, the causal relationship between forearm muscle elasticity and the occurrence of medial elbow injuries remains unclear.

PURPOSE/HYPOTHESIS

The purpose of this study was to determine whether the forearm flexor-pronator muscle elasticity is a risk factor for medial elbow injury in young baseball players. It was hypothesized that high flexor carpi ulnaris (FCU) elasticity would be a risk factor for medial elbow injuries.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Young baseball players (aged 9-12 years) with no history of elbow injuries underwent examination during which the strain ratios (SRs) of the pronator teres, flexor digitorum superficialis, and FCU muscles were measured using ultrasound strain elastography as an index of elasticity. Additionally, the participants completed a questionnaire assessing age, height, weight, months of experience as a baseball player, position in baseball, number of training days per week, number of throws per day, and elbow pain during throwing; then the range of motion of the shoulder and hip internal/external rotation were measured. One year after the baseline measurements, the occurrence of new medial elbow injuries was evaluated. Multivariate logistic regression analysis was subsequently conducted to determine risk factors for medial elbow injuries. Cutoff points for significant SR values obtained from the multivariate logistic regression analysis were calculated using the receiver operating characteristic curve.

RESULTS

Of the 314 players, 76 (24.2%) were diagnosed with medial elbow injury. Multivariate logistic regression analysis showed that a 0.1 increase in the SR of the FCU muscle (odds ratio [OR], 1.211; 95% CI, 1.116-1.314) and number of throws per day (OR, 1.012; 95% CI, 1.001-1.022) were significantly associated with medial elbow injuries. Receiver operating characteristic curve analyses revealed that the optimal cutoff for the SR of the FCU muscle was 0.920 (area under the curve, 0.694; sensitivity, 75.0%; specificity, 56.7%).

CONCLUSION

Increased FCU elasticity is a risk factor for medial elbow injury. Evaluation of the FCU elasticity may be useful in identifying young baseball players at high risk of medial elbow injuries and may facilitate prevention of medial elbow injury. As shown by the results of multivariate logistic regression analysis, FCU elasticity itself may be useful in identifying young baseball players at high risk of elbow injuries. However, we believe that other factors, such as the number of pitches per day, need to be considered to improve its accuracy.

Osteochondritis Dissecans of Smaller Joints: The Elbow

This review presents the current understanding of the etiology, pathogenesis, and how to diagnose and treat osteochondritis dissecans (OCD) at the elbow joint followed by an analysis of particular characteristics and outcomes of the treatment. OCD is seen in patients with open growth plates (juvenile OCD [JOCD] and in adults [AOCD] with closed growth plates [adult OCD). The etiology at smaller joints remains as unclear as for the knee. Mechanical factors (throwing activities [capitulum] seem to play an important role. Clinical symptoms are unspecific. Thus, imaging techniques are most important for the diagnosis. In low-grade and stable lesions, treatment involves rest and different degrees of immobilization until healing. When surgery is necessary, the procedure depends on the OCD stage and on the state of the cartilage. With intact cartilage, retrograde procedures are favorable while with damaged cartilage, several techniques are used. Techniques such as drilling and microfracturing produce a reparative cartilage while other techniques reconstruct the defect with osteochondral grafts or cell-based procedures such as chondrocyte implantation. There is a tendency toward better results when reconstructive procedures for both the bone and cartilage are used. In addition, comorbidities at the joint have to be treated. Severe grades of osteoarthritis are rare.

Elbow Overuse Injuries in Pediatric Female Gymnastic Athletes: Comparative Findings and Outcomes in Radial Head Stress Fractures and Capitellar Osteochondritis Dissecans

BACKGROUND

Radial head stress fractures (RHSFs) and capitellar osteochondritis dissecans (COCD) are rare but may be seen in gymnasts. The purpose of this study was to compare the clinical and radiographic characteristics and the outcomes of RHSF and COCD in pediatric and adolescent gymnastic athletes.

METHODS

Classical gymnasts and competitive tumblers ≤18 years of age presenting with RHSF or COCD over a 5-year period were reviewed. Radiographic characteristics, clinical characteristics, and patient-reported outcomes were compared.

RESULTS

Fifty-eight elbows (39 with COCD and 19 with RHSF) were studied; the mean patient age was 11.6 years. Gymnastic athletes with RHSF competed at a higher level; of the athletes who competed at level ≥7, the rate was 95% of elbows in the RHSF group and 67% of elbows in the COCD group. The RHSF group presented more acutely with more valgus stress pain than those with COCD (p < 0.01) and demonstrated increased mean valgus angulation (and standard deviation) of the radial neck-shaft angle (13° ± 3.8° for the RHSF group and 9.3° ± 2.8° for the COCD group; p < 0.01) and decreased mean proximal radial epiphyseal height (3.7 ± 0.6 mm for the RHSF group and 4.2 ± 1.5 mm for the COCD group; p < 0.01). At a minimum of 2 years (range, 2.0 to 6.3 years), the RHSF group reported fewer symptoms; the QuickDASH (abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire) score was 1.75 ± 3.84 points for the RHSF group and 7.45 ± 7.54 points for the COCD group (p < 0.01). Those at a high level (≥7) were more likely to return to gymnastics independent of pathology, with the RHSF group reporting higher final activity levels with the mean Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) score at 26.0 ± 7.5 points compared with the COCD group at 23.6 ± 5.7 points (p < 0.05). Of the 9 patients with bilateral COCD, only 3 (33%) returned to gymnastics.

CONCLUSIONS

RHSF with features similar to the more familiar COCD lesion may present in gymnastic athletes. Those with RHSF may present more acutely with a high competitive level and may have a better prognosis for return to competitive gymnastics than those with COCD.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fracture obliquity is a predictor for loss of reduction in supracondylar humeral fractures in older children

Supracondylar humeral fractures in older children have different biomechanical characteristics and surgical outcomes when compared to the same fractures in younger children. We aimed to analyze the fracture's architecture in a large group of older children and investigate the correlation between patients' variables, fracture patterns, fixation techniques and the rate of loss of reduction (LOR). A retrospective review study was conducted. We collected the records of 240 consecutive patients aged 8-14 years that sustained Gartland type 2/3 supracondylar humeral fractures between 2004 and 2014 and were operated at our hospital. We excluded patients with intra-articular or pathological fractures. Following the radiographical analysis and chart review, we conducted a multivariable regression analysis. Fracture obliquity on the sagittal plane ( > 20°) occurred in 33% of the cases and was found to be the only factor related to LOR (P = 0.01). Gartland type 3 fractures and more than two lateral pin configuration did not correlate to fixation failure (P = 0.69 and 0.14, respectively). The incidence of flexion-type fractures (5.8%) was found to be higher than in the total pediatric population. The sagittal oblique supracondylar humeral fracture is common and is related to fixation instability and LOR. This pattern needs to be considered when investigating different pin configurations, complication rates, and biomechanical properties. Subclassifying Gartland type 2/3 supracondylar humeral fractures as 'oblique' or 'transverse' might offer more comprehensive information about the anticipated operative results, lead to applying more stable pin constructs to these fractures and allow improved outcomes following surgical fixation.

Failure of Surgery for Osteochondral Injuries of the Elbow in the Pediatric and Adolescent Population

PURPOSE OF REVIEW

With an increase in single-sport specialization, elbow injuries have become increasingly common in the pediatric and adolescent population. Osteochondritis dissecans (OCD) of the capitellum frequently requires intervention yet can be difficult to treat given high patient activity demands. The purpose of this paper is to review treatment options, understand failure rates, and provide strategies for successful revision surgery.

RECENT FINDINGS

Patients at high risk for the development of this condition are involved in high-demand upper extremity activity such as baseball or gymnastics. Treatment options include non-operative management, drilling, fixation, loose body removal/microfracture, osteochondral autograft, and osteochondral allograft. Cartilage preservation procedures (i.e., osteochondral autograft) have a significant advantage in terms of clinical and radiographic healing compared with fixation or microfracture. Capitellar OCD lesions afflict a large number of adolescent athletes today and will likely continue increasing in number from sports-related injuries. It is critical to recognize and treat these lesions in a timely and appropriate fashion to optimize clinical outcomes. When faced with failure of healing, surgeons must critically analyze reasons for failure including post-operative compliance, return to high-demand sporting activity, fixation of non-viable fragments, utilization of microfracture, alignment, and concomitant pathology.