Elbow injuries

"Transcranial Direct Current Stimulation (tDCS) in managing pain and recovery: A clinical case of radial capitellum fracture"

INTRODUCTION

The management of pain and functional recovery following a radial capitellum fracture poses a significant clinical challenge, especially in individuals whose professions, such as physiotherapy, demand optimal joint functionality. Transcranial Direct Current Stimulation (tDCS) emerges as a potential non-pharmacological intervention for pain management, necessitating exploration in the context of orthopedic injuries.

CASE PRESENTATION

A 41-year-old male physiotherapist presented with a MASON 2 radial capitellum fracture following a fall, experiencing notable pain (NPRS 6/7) and functional impairment (DASH 45/100, PRTEE 43/100). Conservative management, involving immobilization and potential surgical consideration, was employed, followed by tDCS for pain management. Post-tDCS, significant improvements were observed in pain and functional scores (NPRS to 0, DASH to 14.2, PRTEE to 7), alongside enhancements in range of motion and muscle strength.

CLINICAL DISCUSSION

The application of tDCS showcased notable efficacy in pain reduction and functional improvement, highlighting its potential in augmenting pain management strategies post-fracture. However, the variability in responses and lack of standardized application protocols necessitate further research to optimize its clinical utility. The balance between immobilization for fracture healing and mobilization for preventing stiffness and facilitating recovery was pivotal in managing the fracture and ensuring functional improvement.

CONCLUSIONS

This case underscores the potential of tDCS in managing pain and facilitating functional recovery in radial capitellum fractures, warranting further exploration and standardization of its application in clinical practice. The integrated, patient-centric approach, involving interdisciplinary collaboration and personalized care, was crucial in ensuring positive outcomes and provides a framework for managing similar orthopedic cases.

Scapular muscles strength in college baseball players with and without a history of UCL injury

BACKGROUND

Ulnar collateral ligament (UCL) injuries are common in overhead athletes and have increased in prevalence among baseball pitchers of all ages. The purpose of this study was to examine the difference between the strength of five scapular stabilizing muscles in college baseball pitchers with and without a history of UCL surgery. Data on a pitcher with a recent diagnosis of a Grade I UCL sprain was also included as a case study.

METHODS

Thirty-nine college baseball pitchers, eight pitchers with a history of UCL surgery, volunteered to participate. Each participant completed a self-guided warm-up and then the strength of five scapular stabilizing muscles were assessed using a hand-held dynamometer. Station one tested latissimus dorsi and serratus anterior while the middle trapezius, lower trapezius, and rhomboids were assessed at station two. To determine the difference between groups Mann-Whitney U tests were performed with a significance level of P≤0.05.

RESULTS

The results showed no significant difference in muscle strength for all five muscle strength tests between the two groups. Although not statistically significant, the injured group averaged greater strength than the non-injured group for all five muscles tested.

CONCLUSIONS

The results of this study indicated there was no difference is scapular stabilizing muscle strength between college baseball pitchers with and without a history of UCL surgery. This may be due to proper rehabilitation and rest following the UCL injury. More research is needed to determine the role of scapular stabilizing muscle strength on elbow and UCL injury in college baseball players.

Repair of the Ulnar Collateral Ligament of the Elbow: Rehabilitation Following Internal Brace Surgery

Injuries to the elbow in athletes who play overhead sports, especially in baseball pitchers, continue to increase in frequency. The anterior band of the ulnar collateral ligament (UCL), the primary restraint to valgus stress, is commonly injured from throwing. Historically, such injuries have been treated with surgical reconstruction techniques, using a tendon autograft. A recently developed UCL repair procedure with an internal brace, utilizing collagen tape, is gaining popularity. The primary goal of this surgery is to enhance elbow joint stability while the ligament is healing and to allow earlier return to sport after UCL reconstruction. The rehabilitation program following UCL repair with internal brace progresses through a different time frame than after UCL reconstruction. The purpose of this commentary, based on our experience with more than 350 cases, including 79 patients with at least a 1-year postsurgical follow-up, was to describe and provide the rationale for the rehabilitation process following UCL repair with internal brace. J Orthop Sports Phys Ther 2019;49(4):253-261. doi:10.2519/jospt.2019.8215.

Diagnosis and treatment of triceps tendon injuries: a review of the literature

OBJECTIVE

To elucidate mechanism of injury, nonoperative protocols, surgical techniques, rehabilitation schedules, and return to sports guidelines for partial and complete triceps tendon injuries.

DATA SOURCES

The PubMed and OVID databases were searched in 2010 and peer-reviewed English language articles in 2011.

MAIN RESULTS

After a fall on an outstretched hand, direct trauma on the elbow, or lifting against resistance, patients often present with pain and weakness of extension. Examination may reveal a palpable tendon gap, and radiographs may reveal a Flake sign. Acute partial injuries have positive outcomes with immobilization in 30-degree flexion for 4 to 6 weeks. Primary repair for complete rupture can restore normal extensor function after 3 to 4 months. Reconstruction returns normal extensor function up to 4 years. Most authors support postoperative immobilization for 2 to 3 weeks at 30- to 40-degree flexion, flexion block bracing for an additional 3 weeks, and unrestricted activity at 6 months. Athletes may be able to return to sports after 4 to 5 weeks of recovery from a partial injury, but return may be delayed if operative tendon repair is performed.

CONCLUSIONS

Acute partial triceps tendon injuries may be managed conservatively at first and should be repaired primarily if this fails or if presentation is delayed. Reconstruction should first use the anconeus rotation technique. If the anconeus is devitalized, the Achilles tendon may be the allograft of choice.

Posteromedial elbow impingement: magnetic resonance imaging findings in overhead throwing athletes and results of arthroscopic treatment

PURPOSE

The purpose of this study was to define the magnetic resonance imaging (MRI) pattern and assess the results of arthroscopic treatment of posteromedial elbow impingement in overhead throwers.

METHODS

Over an 8-year period, 9 throwing athletes diagnosed with posteromedial elbow impingement were retrospectively identified. All patients had either a noncontrast or direct arthrogram-MRI study that was reviewed by a single, fellowship-trained musculoskeletal radiologist blinded to the clinical diagnosis. Arthroscopic treatment included debridement of posteromedial synovitis, loose body removal, and excision of the olecranon spur. All patients underwent a physical examination and completion of the Andrews-Carson scale at a mean of 68 months (range, 25 to 112 months).

RESULTS

All patients were male, with a mean age of 21.0 years (range, 17 to 34 years). The dominant arm was affected in all patients. The mean length of symptoms before surgery was 9 months (range, 5 to 24 months). At MRI, a reproducible pattern of pathology was noted. All patients had pathology at the articular surfaces of the posterior trochlea and the anterior, medial olecranon. The findings ranged from abnormal edema-like signal in the hyaline cartilage to cartilage defects and subjacent, subchondral bone marrow edema. Findings at surgery included posteromedial synovitis and olecranon spurring in all patients and loose bodies in 3 patients. On the basis of the Andrews-Carson scale, the subjective and objective outcome was considered excellent in 7 patients and good in 2.

CONCLUSIONS

Posteromedial elbow impingement is a source of disability in the overhead throwing athlete. Correlation of history and physical examination with imaging findings is essential to confirm the diagnosis. This study indicates that MRI identifies a reproducible pattern of pathology in throwing athletes with this disorder. These MRI findings correlate highly with arthroscopic evaluation. Arthroscopic debridement, olecranon spur excision, and loose body removal allow return to throwing sports and reliable subjective and objective results in carefully selected patients.

A Review of Epidemiology of Paediatric Elbow Injuries in Sports

The elbow is a common site of orthopaedic injury in the paediatric population. The number of these injuries continues to rise following increased levels of participation in paediatric recreational and competitive sport. Injuries to the paediatric elbow can be classified as either overuse or acute. Delineating injury patterns to the elbow in children can be challenging, given the cartilaginous composition of the distal humerus and the multiple secondary ossification centres that appear and unite with the epiphysis at defined ages. Pitching in baseball, serving in tennis, spiking in volleyball, passing in American football and launching in javelin-throwing can all produce elbow pathology by forceful valgus stress, with medial stretching, lateral compression and posterior impingement. In children and adolescents, the epiphyseal plate is weaker than the surrounding ligaments, predisposing them to epiphyseal plate injuries. On the other hand, post-pubescent or skeletally mature athletes are more prone to tendinous or ligamentous injury. Injuries may cause significant impact on the athlete, parents and healthcare system. With the exception of baseball, there are few prospective cohort studies on the epidemiological trends of childhood elbow injuries in other sports. This paper aims to describe the epidemiological trends in paediatric elbow injuries related to sports, suggests prevention strategies and discusses the scope for further research. A web-based search of existing articles pertaining to paediatric elbow injuries in sports was performed. The implications of acute and overuse injuries and the possibility of permanent damage should be understood by parents, coaches and the athletes. Proper understanding of the intrinsic and extrinsic risk factors that could lead to elbow injuries is thus required. Measures to prevent elbow injuries should include proper coaching, warm-up, officiation, legislation, medical expertise and protective gear. There are still many opportunities for prospective studies and other research projects among young athletes in various sports. Current studies will serve as a baseline for future research to assess the success of specific interventions in reducing the incidence of elbow injury in the paediatric athlete. Further epidemiological studies in various sports will help expand our knowledge and prevent potential disability and deformity in the paediatric elbow.

Musculoskeletal injuries in tennis

Tennis is popular in the United States, with millions participating in the sport. Unlike many other sports, young, middle-aged, and elderly persons are actively playing tennis. Most injuries that are seen are secondary to overuse. Faulty stroke mechanics are often involved in the development of specific injuries seen in tennis players. Fortunately, most injuries respond to conservative treatment and do not require surgery. Most players are able to return to their previous level of activity after appropriate treatment.

Multidetector computed tomography in acute joint fractures

Conventional radiography plays an essential diagnostic role in the primary evaluation of acute joint trauma. In complex fractures, however, computed tomography (CT) is an imaging modality often used second to radiography. As a result of technical breakthroughs in the field, multidetector CT (MDCT) allows faster imaging and better temporal, spatial, and contrast resolution compared with conventional single-slice spiral CT. MDCT with multiplanar reformation is helpful in disclosing fracture patterns, particularly in complex joint fractures, where they reveal occult fractures and show the exact number of fracture components and their degree of displacement.

Finger flexor tendon forces are a complex function of finger joint motions and fingertip forces

In vivo tendon forces provide a view inside the musculoskeletal system revealing muscle function and potential injury etiologies. The studies presented here measured the in vivo tendon force of the flexor digitorum superficialis of the long finger during open carpal tunnel release surgery in ten adult patients. Forces were measured during passive movement of the finger, isometric pinch, and dynamic tapping of the finger. The tendon forces during passive movement of the finger were the largest with the finger fully extended. During isometric pinch, tendon force was linearly related to fingertip force, and was on average 3.3 times larger than the fingertip force. During dynamic activities, however, the relationship between tip and tendon force was nonlinear and often remained elevated when the finger was moving but with no applied force. Tendon forces were the highest with the isometric finger pinch. In conclusion, tendon force is a completed function of both fingertip load and motion of the joints that the tendons cross. A comparison of these results with others published in the literature indicated that rehabilitation processes need to incorporate a systems approach rather than rely on one specific physiologic relationship to minimize finger flexor tendon forces.

Molecular composition and pathology of entheses on the medial and lateral epicondyles of the humerus: a structural basis for epicondylitis

OBJECTIVES

To improve the understanding of epicondylitis by describing the normal structure and composition of the entheses associated with the medial and lateral epicondyles and their histopathology in elderly cadavers.

METHODS

Medial and lateral epicondyles were obtained from 12 cadavers. Six middle aged cadavers (mean 47 years) were used to assess the molecular composition of "normal" entheses from people within an age range vulnerable to epicondylitis. Cryosections of epicondylar entheses were immunolabelled with monoclonal antibodies against molecules associated with fibrocartilage and related tissues. A further six elderly cadavers (mean 84 years) were used for histology to assess features of entheses related to increasing age.

RESULTS

Tendon entheses on both epicondyles fused with those of the collateral ligaments and formed a more extensive structure than hitherto appreciated. Fibrocartilage (which labelled for type II collagen and aggrecan) was a constant feature of all entheses. Entheses from elderly subjects showed extensive microscopic damage, hitherto regarded as a hallmark of epicondylitis.

CONCLUSIONS

Fibrocartilage is a normal feature and not always a sign of enthesopathy. Furthermore, pathological changes documented in patients with epicondylitis may also be seen in elderly people. The fusion of the common extensor and flexor tendon entheses with those of the collateral ligaments suggests that the latter may be implicated as well. This may explain why pain and tenderness in epicondylitis may extend locally beyond the tendon enthesis and why some patients are refractory to local treatments.