Nonunion of olecranon epiphysis: two cases in adolescent baseball pitchers

Retrograde headless compression screw fixation of olecranon stress fractures in throwing athletes: a novel technique

Background

An olecranon stress fracture (OSF) is a rare injury most commonly seen in high-level overhead throwing athletes with no clear consensus on surgical treatment. The most common surgical treatment described in the literature is cannulated screw fixation but there have been high rates of reported hardware irritation and need for subsequent hardware removal.

Hypothesis/Purpose

This study describes a novel surgical technique in the treatment of OSFs in high-level throwing athletes using retrograde headless compression screws. We hypothesized that patients would have excellent outcomes and decreased rates of hardware irritation postoperatively.

Methods

A retrospective review of competitive-level throwing athletes who sustained OSFs that were treated operatively using a novel technique using retrograde cannulated headless compression screws to avoid disruption of the triceps tendon. Postoperative outcome measures obtained included the Disabilities of the Arm, Shoulder and Hand score, Mayo Elbow Performance Score, Simple Elbow Test score, Single Assessment Numerical Evaluation score, Visual Analog Scale, arch of motion, and time to return to sport as well as level returned to. Radiographs were obtained routinely at 2-week, 6-week, 12-week, 6-month, 1-year, and 2-year follow-up.

Results

Five of 5 patients who met inclusion criteria were available for final follow-up. Mean age at time of surgery was 20 years (range 17-24). Mean follow-up was 17 months (range 4-33). All patients were baseball players, 4 of which were pitchers and 1 position player. All patients were able to return to sport at the same level or higher at a mean of 5.8 months (range 3-8). Postoperatively, mean arch of motion was 138°, Visual Analog Scale score was 0, Single Assessment Numerical Evaluation score was 90, Disabilities of the Arm, Shoulder and Hand score was 2.0, Mayo Elbow Performance Score was 100, and Simple Elbow Test score was 12. There was no incidence of hardware removal.

Conclusion

This study presents a novel surgical technique in the treatment of OSFs in high-level throwing athletes. The results presented demonstrate that this technique is safe and effective for getting athletes back to play quickly without any complications of hardware irritation which has previously shown to be a significant problem in prior literature.

Number of Months of Baseball in the Previous Year and Preseason Olecranon Tenderness: Risk Factors for Shoulder and Elbow Injuries in High-School Baseball Players

OBJECTIVE

To identify risk factors for shoulder and elbow injuries in high-school baseball position players and pitchers in the preseason history and physical examination.

DESIGN

Retrospective cohort study.

SETTING

Community high-school baseball.

PARTICIPANTS

Three hundred seventy-one male baseball players' mean age 15.0 ± 1.8 years.

OUTCOME MEASURES

A preseason history and physical examination was performed on all athletes. Injury information was collected by weekly self-report and athletic trainer injury logs throughout the season. Comparisons between injured and noninjured players were performed using t tests and χ 2 analyses. Binary logistic regression models were developed to identify risk factors for injury.

RESULTS

Seventy-six injuries were recorded over the season. In univariate analysis, the injured group had greater months of baseball participation ( P = 0.007) and shoulder visual analog scale for the past year ( P = 0.003). The injured group also had more olecranon tenderness ( P < 0.0001, odds ratio [OR] 2.9) and decreased elbow arc of motion. All other factors were not significantly different ( P > 0.05). In multivariable logistic regression, months per year of baseball participation was the only factor significantly associated with injuries ( P = 0.010, OR = 1.21).

CONCLUSIONS

Baseball players who developed arm injuries during a season were more likely to play more months of baseball and report shoulder pain in the previous year. The presence of preseason olecranon tenderness was associated with nearly triple the risk of injury during the season. Every additional month of baseball participation in the previous year was associated with a 1.2× increased odds of injury. The presence of glenohumeral internal rotation deficit was not a predictor of injury.

Elbow Imaging: Variants and Asymptomatic Findings

One of the key principles in the interpretation of radiology images is the ability to differentiate between normal and abnormal findings. This article provides a comprehensive overview of normal structures and anatomical variants occurring around the elbow including potential diagnostic pitfalls. We discuss frequently observed anatomical variants found in routine clinical practice associated with osseous, ligamentous, musculotendinous, and neurovascular structures at the elbow that may simulate pathology or predispose to symptoms under specific circumstances.

Olecranon Stress Fracture

Olecranon stress fractures are a rare upper extremity fracture that primarily affects throwing athletes. The incidence of olecranon stress fractures are increasing owing to the number of patients playing and the volume of engagement in competitive sports, especially in the pediatric population. However, olecranon stress fractures can present a challenge from a management and a rehabilitation perspective owing to their vague presentation, thereby affecting how these patients are diagnosed and managed. Therefore, it is imperative to further evaluate the disease process, diagnosis, and treatment of this condition to best manage our patients.

Stress Fractures of the Elbow in the Throwing Athlete: A Systematic Review

Background:

Stress fractures of the elbow are rare in throwing athletes and present a challenge from both a management and rehabilitation perspective. Although the incidence of stress fractures of the elbow is increasing, there is a lack of data in the literature focused on throwers.

Purpose:

To evaluate studies regarding the management and outcomes of stress fractures of the elbow in throwing athletes.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review was conducted by searching the Scopus, PubMed, and Cochrane Library electronic databases to identify studies reporting on the management and outcomes of stress fractures in overhead-throwing athletes. Management data included nonoperative and operative modalities, and outcome data included return to play, encompassing the timing and level of activity. Studies were excluded if the stress fracture of the elbow was not a result of a sport injury attributed to throwing or if the study failed to report whether an athlete returned to play.

Results:

Fourteen studies met the inclusion criteria and were included in this analysis. There were 52 patients in total (50 male, 2 female) with a mean age of 19.7 years (range, 13-29.1 years). The olecranon was the most common location of the stress fracture (51 patients; 98.1%), followed by the distal humerus (1 patient; 1.9%). The majority of patients (n = 40; 76.9%) were treated operatively. Of the 40 patients who were treated surgically, 14 (35.0%) underwent a period of conservative treatment preoperatively that ultimately failed because of persistent nonunion or continued elbow pain. A total of 50 patients (96.2%) returned to sport either at or above their preinjury level. Of the 2 patients (3.8%) who did not return to sport, 1 did not return because of continued elbow pain postoperatively, and the other was lost to follow-up. Complications occurred in 9 patients (17.3%), all of whom were treated surgically.

Conclusion:

On the basis of this systematic review, the majority of elbow stress fractures were treated operatively and approximately one-third after a period of failed nonoperative management. The return-to-sport rate was high. Further, higher level studies are needed to optimize management and return-to-sport rates in this population.

Olecranon physeal nonunion in the adolescent athlete: identification of two patterns

BACKGROUND

This study aimed to present the outcomes of patients undergoing surgical management of persistent, symptomatic olecranon physes.

METHODS

Consecutive patients undergoing surgical management for symptomatic persistent olecranon physeal abnormalities were reviewed. Preoperative data, intraoperative findings, and postoperative clinical outcomes including physical examination findings, radiographs, complications, and reoperations were analyzed.

RESULTS

A total of 13 elbows in 12 patients (100% male; average age, 18 ± 4 years) were identified. All patients were pitchers at the high-school or college level. Two unique radiographic patterns were identified: distal persistent olecranon physis (n = 9), identified by an irregular sclerotic lucency at the site of the olecranon physis; and proximal persistent olecranon physis (n = 4), identified by a radiolucency exiting proximal to the triceps insertion at the site of an accessory ossification center that failed to unite. Surgical management included débridement, autograft bone grafting, and internal fixation. There were 3 reoperations (1 for infection, 2 for painful hardware). All patients achieved successful radiographic union (average, 8 ± 2 weeks). At an average follow-up of 4.4 ± 1.2 years, the average postoperative Disabilities of the Arm, Shoulder, and Hand score was 1.1 ± 1.6; the Mayo Elbow Performance Score was 98.5 ± 2.4; the American Shoulder and Elbow Surgeons score was 99.3 ± 0.4; and average Likert score for satisfaction was 9.95 ± 0.2. At final follow-up, there were no significant differences in strength, motion, or stability in comparing the operative with the nonoperative elbow (P > .05 for all).

CONCLUSIONS

Two unique patterns of olecranon physeal abnormalities in young, overhead throwing athletes have been identified. Open reduction with internal fixation is clinically and radiographically successful in obtaining union and symptom resolution in these patients.

Cartilage degeneration at symptomatic persistent olecranon physis in adolescent baseball players

Background. Elbow overuse injuries are common in adolescent baseball players, but symptomatic persistent olecranon physis is rare, and its pathogenesis remains unclear. Purpose. To examine the histopathological and imaging findings of advanced persistent olecranon physis. Methods. The olecranon physes of 2 baseball pitchers, aged 14 and 15 years, were examined by preoperative magnetic resonance imaging (MRI), and surgical specimens were examined histologically. Results. T2-weighted MRI revealed alterations in the intrachondral signal intensity possibly related to collagen degeneration and increased free water content. Histological findings of specimens stained with hematoxylin-eosin showed complete disorganization of the cartilage structure, hypocellularity, chondrocyte cluster formation, and moderately reduced staining. All these findings are hallmarks of osteoarthritis and are suggestive of cartilage degeneration. Conclusion. Growth plate degeneration was evident in advanced cases of symptomatic persistent olecranon physis. These findings contribute to understanding the pathogenesis of this disease.

Classification of Olecranon Stress Fractures in Baseball Players

BACKGROUND

Although the onset mechanism of an olecranon stress fracture (OSF) due to a throwing disorder is believed to involve valgus extension overload, olecranon posteromedial impingement, or triceps traction force, this issue is still debated in the literature.

PURPOSE

To establish a classification system for the different types of OSFs to improve diagnosis and clarify the onset mechanism.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 200 baseball players (198 male, 2 female; mean age, 16.1 years; age range, 13-27 years) who were diagnosed with an OSF from January 1987 to July 2012 were studied. Combined disorders as well as the direction and form of the fracture line were analyzed on plain radiographs, computed tomography, and magnetic resonance imaging. Furthermore, the presence or absence of ulnar collateral ligament (UCL) injuries and avulsion fractures of the lower pole of the medial epicondyle was determined by imaging findings to calculate the combined percentage of OSFs. In addition, the prevalence of OSFs was evaluated among patients who were evaluated between April 2008 and March 2011 for throwing elbow disorders.

RESULTS

There were 5 types of OSFs identified in the new classification system: physeal, classic, transitional, sclerotic, and distal. The physeal type was further separated into stages 1 to 4 based on severity. The mean age for each type identified was as follows: physeal, 14.1 years; classic, 18.6 years; transitional, 16.9 years; sclerotic, 18.0 years; and distal, 19.6 years. A concomitant UCL injury and/or medial epicondyle avulsion fracture was diagnosed in 71% to 95% of cases, depending on the OSF type. Among baseball-related elbow disorders, the incidence of OSFs was 5.4%.

CONCLUSION

This study presents a new classification system for the different types of OSFs based on the origin and direction of the fracture plane. This new system was strongly influenced by the age at symptom onset. Such information is essential for successful open reduction and internal fixation by ensuring that fixation pressure is perpendicular to the fracture plane, which will avoid the recurrence of stress fractures. In addition, the prevalence of UCL injuries suggests that it is a major risk factor for the development of OSFs.

The value of using radiographic criteria for the treatment of persistent symptomatic olecranon physis in adolescent throwing athletes

BACKGROUND

Previously published reports present a variety of nonoperative and operative treatments for a persistent olecranon physis. However, the radiographic indication for the operative treatment is not clear.

HYPOTHESIS

Our radiographic classification of persistent olecranon physis is helpful in formulating treatment decisions.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Sixteen male baseball players with persistent olecranon physis were retrospectively evaluated. The mean age at first presentation was 14.7 years (range, 12-17 years). The lesion was classified into 2 stages based on radiographic appearance. Stage I demonstrated widening of the olecranon epiphyseal plate when compared with the contralateral elbow on the lateral view. Sclerotic change indicated stage II. All patients underwent nonoperative treatment for at least 3 months. Follow-up radiographs were taken at 1-month intervals. Operative treatment was provided to the patients whose condition had failed to improve after nonoperative treatment.

RESULTS

Of the 16 patients, 12 had stage I lesions and 4 had stage II lesions. Nonoperative management produced healing in 91.7% of patients with stage I lesions and none of the patients with stage II lesions.

CONCLUSION

Our radiographic classification of persistent olecranon physis is useful for treatment decision making. In addition, our results demonstrated that sclerotic change is a high predictive indicator of the need for operative treatment.

Imaging of sports injuries in children and adolescents

Sports injuries may be unique in childhood and adolescence due to the inherent weakness of the growing skeleton at specific sites, mainly the cartilaginous parts. Many injuries are predictable based on the known mechanism of injury encountered in certain sports. There are two distinct patterns of injury in sports; acute, and chronic or overuse. Imaging plays an important role in the diagnosis and management of these entities. Radiologists should be familiar with the advantages and limitations of the various imaging modalities when evaluating the injured young athlete. The present review focuses on the radiological findings and appropriate imaging approach in injuries that are typically or most commonly encountered in the skeletally immature athletes.

Juvenile and adolescent elbow injuries in sports

Elbow injuries in skeletally immature athletes continue to increase as juvenile and adolescent athletes participate in organized athletics at earlier ages and with greater intensity. Specialization in specific sports at younger ages has led to an increase in injuries related to repetitive microtrauma. As a result, the spectrum of injuries commonly seen in skeletally immature athletes has increased at a time when long-term outcomes and less invasive interventions with biologic principles are gaining greater attention. Optimal treatment of these injuries requires a knowledge of the complex developmental and radiographic anatomy, the pathophysiology and natural history, and the indications and expected outcomes for conservative and operative management.

Valgus extension overload syndrome and stress injury of the olecranon

Basic science studies have improved our understanding of the pathomechanics for valgus extension overload and olecranon stress fractures. These disorders result from repetitive abutment of the olecranon into the olecranon fossa combined with valgus torques, resulting in impaction and shear along the posteromedial olecranon. The patient history and physical examination are similar for each disorder. Imaging studies including plain radiographs, computed tomography, MRI or bone scan may be necessary for accurate diagnosis. Clinical and basic science support mandatory and careful assessment of the medial collateral ligament when valgus extension overload is identified and limited debridement of the olecranon when surgery is indicated. For stress fractures that fail nonoperative management, treatment with internal fixation provides good results.

Ganglion cyst and olecranon physis nonunion in a baseball pitcher: unique treatment after conservative therapy fails

Although ganglion cysts and stress fractures occur at many joints, the presence of both disorders at the same joint is rare. In this unusual case, a 30-year-old professional pitcher had been treated conservatively for presumed olecranon bursitis in his right (throwing) arm, but, when therapy failed, he sought additional care. A thorough workup and subsequent surgery revealed a ganglion cyst and nonunion of a stress fracture of the olecranon physis. The ganglion cyst had its origin at the fracture site, and both cyst and bone fragment were excised. The patient had a full recovery and was able to resume pitching as an instructor 18 months after surgery.

Imaging of elbow injuries in the child and adult athlete

Because of the often complex and sometimes poorly remembered history of trauma to the elbow, imaging beyond conventional plain film radiographs is often needed. Usually, this consists of high-resolution MR imaging to evaluate the articular cartilage, supporting ligaments, and tendons about the elbow. Sonography, however, can also be used, especially when there is a targeted clinical question as to the presence of epicondylitis, or to provide guidance for diagnostic or therapeutic injections.

Stress fractures of the upper extremity

Stress fractures are common injuries in the athletic population. Although much of the published literature has focused on lower extremity stress injuries, these injuries also occur in the upper extremities. Stress injuries of bone result from repetitive loads smaller than would be required to cause an acute fracture. As bone is repetitively stressed, it behaves like any solid substance. If deformity occurs within its elastic range, it returns to its original configuration. If stressed into its plastic range, permanent deformity occurs, and microfractures propagate, causing structural failure and complete fracture of the involved bone. High clinical suspicion is required for diagnosis because of historical and physical features can be vague. Plain radiographs are often inconclusive, but bone scans and MR imaging usually help elucidate the diagnosis. Most upper extremity stress injuries will heal with nonoperative management. In rare situations these injuries can progress to nonunion, which requires surgical correction.

Common elbow problems in the athlete

Because of the popularity of sports participation, sports physical therapists must recognize in the athlete the many clinical conditions that occur about the elbow. The purpose of this paper is to present the most common elbow problems that an athlete may encounter and to provide information to facilitate recognition of elbow pathology. This information is essential before initiating treatment. An attempt is made to include sprains, strains, neuropathies, dislocations, fractures, contusions, vascular insults, and skin problems in the distal humerus, elbow, and proximal forearm of both the immature and mature athlete. Comprehension of the mechanism of injury aids clinical evaluation and rehabilitation and enhances early return to activity.