Elbow injuries in the young athlete--an orthopedic perspective

Fracture-Separation of the Medial Humeral Epicondyle Caused by Arm Wrestling: A Systematic Review

Background:

Arm wrestling is a popular sport in which various injuries have occurred, even in children.

Purpose:

To analyze reported fracture-separation of the medial humeral epicondyle (MHE) caused by arm wrestling to determine its mechanism and provide a current overview.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

The PubMed and Web of Science databases were searched using the terms “arm wrestling” and “humeral fracture” or “medial humeral epicondyle fracture”; and “sports” and “humeral fracture” or “medial humeral epicondyle fracture,” following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The inclusion criteria were English full-text articles on arm wrestling–induced MHE fracture that described patient characteristics and presented appropriate images. Studies with a lack of appropriate images or detailed description of the injury situation were excluded. The patient characteristics were evaluated, and the ratios of treatment selection and outcomes were evaluated using the chi-square test.

Results:

Included were 27 studies with a total of 68 patients, all boys with a mean age of 14.6 ± 1.24 years (based on n = 65, with 3 patients excluded from this calculation as no definitive age was provided). Boys aged 14 to 15 years accounted for 72% (49/68) of the cases. Fracture occurred suddenly during arm wrestling in 63 boys, while the other 5 boys experienced antecedent medial elbow pain. The match status at the time of injury, provided for 46 patients, was varied. In 31 boys with known match details, injury occurred when a participant suddenly added more force to change the match status. Eight patients displayed anterior and/or proximal displacement of the MHE fragment. Treatment was nonoperative in 25 patients and operative in 38 patients (n = 63, excluding 5 unknown patients). In 35 patients followed up for ≥3 months (mean, 17.6 ± 12.3 months), outcomes were not significantly different between the operative and nonoperative groups.

Conclusion:

MHE fracture-separation caused by arm wrestling occurred mostly in boys aged 14 to 15 years regardless of the match status. The likely direct cause is forceful traction of the attached flexor-pronator muscles. A relative mechanical imbalance during adolescence may be an underlying cause. A sudden change from concentric to eccentric contraction of the flexor-pronator muscles increases the likelihood of fracture occurrence.

Clinical Outcomes and Return to Play in Youth Overhead Athletes After Medial Epicondyle Fractures Treated With Open Reduction and Internal Fixation

Background:

There is limited literature regarding outcomes after operative treatment of displaced medial epicondyle avulsion fractures in adolescent athletes. Most studies have had a relatively small sample size and have not assessed return to play of the overhead athlete.

Purpose:

To examine return to play and outcomes of youth overhead athletes who underwent open reduction and internal fixation (ORIF) with screw fixation.

Study Design:

Case series; Level of evidence, 4.

Methods:

Charts and radiographs were queried between January 2003 and June 2018 for young overhead athletes (age, <17 years) who underwent ORIF for displaced medial epicondyle fracture. Patients with open fracture or concomitant injury were excluded. Radiographs from postoperative follow-up visits were examined for radiographic union. Eligible patients were asked to provide responses to the American Shoulder and Elbow Surgeons Standardized Assessment Elbow questionnaire and Kerlan-Jobe Orthopaedic Clinic questionnaires as well as questions regarding return to play.

Results:

Overall, 29 patients were included in the study; the mean age at surgery was 14.7 years (range, 12.9-16.5 years). There were 25 baseball players, 3 football quarterbacks, and 1 tennis player. Of the 23 patients with available images at least 3 months after surgery, 96% demonstrated radiographic union at last follow-up. Imaging for the 1 patient with nonunion was taken 3 months after ORIF, and it is unknown if he eventually had union. All patients (100%) were successfully contacted to complete questionnaires at a mean follow-up of 4.8 years (range, 1.0-13.5 years). The mean KJOC score was 93.0, and the mean scores for the American Shoulder and Elbow Surgeons Elbow questionnaire were 8.9, 35.6, and 9.8 for pain, function, and satisfaction, respectively. One overhead athlete did not return to play, while the other 28 returned at a mean 7 months after surgery. No patient underwent revision ORIF, 1 underwent hardware removal, and 1 underwent ulnar nerve transposition. No players underwent ulnar collateral ligament reconstruction after primary ORIF of the medial epicondyle.

Conclusion:

ORIF of displaced medial epicondyle fractures is a reliable and successful procedure in adolescent overhead athletes with high demands, with relatively low risk of major complications, reinjury, or reoperation.

Osteochondritis dissecans of the elbow

Capitellar osteochondritis dissecans (OCD) can be a significant problem in adolescent overhead athletes. The cause is likely multifactorial secondary to repetitive stresses, biomechanical mismatch, and a tenuous vascular supply of the capitellum. Recent literature reveals that the prevalence is likely higher than previously thought. This, in conjunction with increased levels of athletic competition in children at younger ages, has fed the recent interest in this topic. The literature continues to show that non-operative treatment is still successful for stable lesions. Unstable lesions, therefore, have been the focus of the new literature regarding operative management and outcomes. The aim of this paper is to provide a summary of current literature and an up-to-date approach to the diagnosis, evaluation, and treatment of osteochondritis dissecans of the capitellum.

Common medial elbow injuries in the adolescent athlete

Recently there has been increased year-round sports participation among children and adolescents with limited to no rest periods. This has led to increases in pediatric repetitive stress injuries, once considered a rarity. Whether in the throwing athlete or in the athlete that experiences repetitive axial loading; increased medial tension and overload syndromes can lead to stress reactions and fractures. This occurs in the developing athlete due to the bone being weaker than the surrounding tendons and ligaments. The medial elbow is a high stress area and is susceptible to many conditions including apophysitis , avulsion fractures and ulnar collateral ligament disruption. Valgus stress can cause injury to the medial elbow which can lead to increased lateral compression, Panner's disease and osteochondral lesions of the capitellum and olecranon. The purpose of this manuscript is to review common elbow disorders in the adolescent population, outline management and highlight important features of rehabilitation.