Epidemiology of Elbow Dislocations in High School Athletes

Primary Care Considerations for the Adolescent Wrestler

PURPOSE OF REVIEW

Adolescent wrestlers undergo intense physical combat. While guidelines are effective in keeping the sport safer, concerns specific to the adolescent wrestler may be missed at primary care visits without knowledge of the unique challenges faced by these athletes. The following review highlights important characteristics of the adolescent wrestler which are of interest to primary care providers.

RECENT FINDINGS

Recommendations for concussion management are evolving to gradual return-to-sport after physician clearance rather than total sport removal. Prolonged skin-to-skin contact also places athletes at greater risk of dermatologic infections, which often require removal from competition, treatment, and/or coverage. Finally, adolescent nutritional literature recommends limiting pre-match weight loss to 3-5% body weight due to noted kidney damage that may result from larger deficits. Adolescent wrestlers are more prone to acute injuries than chronic overuse injuries, with most injuries occurring above the trunk. Primary care providers should consider obtaining imaging to rule out severe injuries or referring to specialist providers. Current guidelines for skin infections require frequent pre-match skin checks and mandatory waiting periods when certain infections are identified. However, the primary care provider is well-equipped for more in-depth skin examination, discussion of skin hygiene, and appropriate treatment of skin infections. Athletes attempting to meet lower weight classes may put themselves at risk of acute kidney damage, under-fueling, and eating disorders. Current guidelines attempt to mitigate excessive weight changes in the adolescent wrestler during competition season, but primary care providers should emphasize healthier methods of weight fluctuation and look for indicators of physiological or psychological effects.

Mid- to long-term functional outcome and return to sport after elbow dislocation in bouldering: a clinical retrospective cohort study

INTRODUCTION

Traumatic elbow dislocations are among the most common injuries in sport climbing. They occur most frequently in bouldering (a climbing discipline with strong upward trend often performed indoors) due to the typical low-height backward fall into crashpads. There is still no data about the functional outcome and return to sport of this typical bouldering injury.

MATERIALS AND METHODS

All Patients with elbow dislocations due to a bouldering associated fall between 2011 and 2020 were identified retrospectively in our level I trauma centre. Trauma mechanisms, injury types and therapies were obtained. Follow-up was performed with an online questionnaire including sports-related effects, return to sport and the Elbow Self-Assessment Score (ESAS).

RESULTS

30 patients with elbow dislocations after bouldering accidents were identified. In 22 (73.3%) patients the injury was a simple dislocation. The questionnaire was completed by 20 patients. The leading mechanism was a low-height fall into crashpads. Surgical procedures were performed in every second patient. 18 patients (90%) reported return to bouldering after 4.7 ± 2.1 months. 12 patients (66.7%) regained their pre-injury level. Mid-/Long-term follow-up (mean 105 ± 37.5 months) showed excellent results in ESAS score (97.2 ± 3.9 points). Persistent limited range of motion or instability was reported by only 3 patients (15%).

CONCLUSION

Most athletes are able to return to bouldering but only two thirds regain their pre-injury performance level in this demanding upper-extremity sport. The unique low-height trauma mechanism may create a false sense of security. Specific awareness and safety features should be placed for climbing athletes to reduce elbow injuries.

Estimates of Golf-Related Upper Extremity Injuries in the United States: A 10-Year Epidemiology Study (2011-2020)

BACKGROUND

Golf is one of the most popular sports in the United States (US) and is played by participants of all ages and skill level. Given the popularity and sport-specific demands on the upper torso, golf poses a considerable risk for upper extremity (UE) injuries. Therefore, the aim of the current study was to (1) determine the incidence rate of UE golf injuries presenting to emergency departments (EDs) in the US, (2) determine the most commonly injured body parts and mechanisms of injury, and (3) compare current injury epidemiology with previous trends in the literature.

HYPOTHESIS

Male sex, bimodal age extremes (young and elderly), and utilization of golf carts (vs walking) are associated with a higher incidence of golf-related UE injuries.

STUDY DESIGN

Descriptive epidemiology study.

LEVEL OF EVIDENCE

Level 3.

METHODS

The National Electronic Injury Surveillance System (NEISS) is a statistically validated injury surveillance system that collects data from ED visits as a representative probability sample of hospitals in the US. We queried the NEISS for the years 2011 to 2020 to examine the following variables for golf-related UE injuries: sociodemographic, diagnosis, body part, and mechanism of injury.

RESULTS

From 2011 to 2020, there were a total of 1862 golf-related UE injuries presenting to participating EDs, which correlates to an estimated 70,868 total injuries. Overall, male golf players were disproportionately affected (69.2%) versus female golf players (30.8%) and the most commonly injured age groups were those aged >60 and 10 to 19 years. The most common injuries included fractures (26.8%), strains/sprains (23.4%), and soft tissue injuries (15.9%). The joints injured most frequently were the shoulder (24.8%), wrist (15.6%), and joints in the hand (12.0%). The most common mechanisms of injury were cart accidents (44.63%), falling/tripping (29.22%), and golf club swinging/mechanics (10.37%).

CONCLUSION

Golf-related UE injuries can be acute or due to chronic overuse. Male athletes >60 years of age were the population most commonly presenting to the ED with a golf-related injury. Further, the shoulder, forearm, and wrist were most commonly injured. These findings are consistent with previous epidemiological trends in the literature. Interventions to reduce the incidence of injury should be sport-specific and focus primarily on equipment and golf cart safety and swing modification to optimize the biomechanical function of the UEs.

CLINICAL RELEVANCE

Our findings indicate that golf-related injury prevention programs should target UE injuries, particularly among young (<19) and older (>60 years) golfers with poor swing mechanics.

Elbow Dislocations in the National Football League: Epidemiology and Management

Background Currently, it is not known how the combined osseous and ligamentous injury of a traumatic elbow dislocation in a National Football League (NFL) athlete affects management and return to play. In this study, we aimed to describe the epidemiology, management, and return to play for elbow dislocations in NFL athletes. Methodology This is a descriptive observational study. A retrospective review of all elbow dislocations between 2000 and 2014 (15 seasons) was performed using the NFL Injury Surveillance System (NFLISS). Results Over 15 NFL seasons, 82 elbow dislocations were recorded in the NFLISS. Among players who reported surgery (n = 5), players missed an average of 73.8 days of play. Among those who did not report surgery, players missed an average of 36.1 days. The overall incidence was 0.26 dislocation events per 10,000 athlete exposures. The majority of these injuries occurred during regular-season games, in defensive linebackers and linemen, during tackling contact with another player, and most commonly on a running play. Conclusions This study demonstrates that an elbow dislocation is not a career-ending or season-ending injury in an NFL cohort. Information regarding incidence, positions affected, whether surgical management is utilized, and return to play will help players who sustain and physicians who treat these injuries in elite football athletes understand the impact of their injuries.

An Update on Simple Elbow Dislocations: A Protocol for Early Return to Sport in High School Wrestlers

ABSTRACT

The principles and management of simple elbow dislocations have evolved over time. In the past, a conservative approach of immobilization and slow rehabilitation were used. More modern treatments emphasize an understanding of the soft tissues about the elbow joint and prescribe an aggressive approach to regaining motion. Elbow stiffness is a common effect of the injury. We outline our treatment principles in a series of high school wrestlers with simple elbow dislocation. The ultimate goal is to return to sport in a safe but early timeframe. We recommend a brief period of immobilization with close follow-up and no motion restrictions after immobilization is removed. This review and case series emphasize the importance of aggressive but safe return to sport in high school wrestlers with an elbow dislocation.

THE NONOPERATIVE REHABILITATION OF A TRAUMATIC COMPLETE ULNAR COLLATERAL LIGAMENT TEAR OF THE ELBOW IN A HIGH SCHOOL WRESTLER: A CASE REPORT

Background and Purpose

Injuries frequently occur in competitive wrestling, with the elbow joint representing about 25% of all injuries. Specific to the elbow, the ulnar collateral ligament (UCL) can be injured traumatically from takedowns in wrestling. In athletes with complete UCL tears, surgical management is often recommended with nonoperative management resulting in less favorable outcomes. The purpose of this case report is to present a nonoperative criterion-based rehabilitation program for a high school wrestler with a complete UCL tear of the elbow.

Case Description

A 17-year-old male wrestler presented to outpatient physical therapy with a complete UCL tear sustained from falling on an outstretched hand during a wrestling match. He presented with limited elbow range of motion (ROM), medial elbow instability, and weakness of the involved shoulder and forearm musculature. A three staged criterion-based rehabilitation protocol was developed for this subject based on specific criteria, including pain, elbow ROM, arm strength, and functional outcomes.

Outcomes

The subject was treated for nine visits over six weeks, and demonstrated improvements in all strength tests of the involved upper extremity, with elbow flexion strength improving the most by 58%. Return to sport (RTS) tests were used to assess the subject's ability to return to practice. At approximately eight weeks after initial injury, the subject was able to return to full participation in competitive wrestling with no reports of elbow pain or instability.

Discussion

Through the utilization of a criterion-based rehabilitation protocol for the nonoperative management of an UCL injury, this high school wrestler was able to safely progress back to wrestling without pain or instability in an accelerated time frame. Previously, no detailed rehabilitation guidelines for nonoperative management of UCL injuries in contact sports have been described. Additionally, few studies exist which report on the inclusion of RTS testing following an injury to the UCL of the elbow, as RTS testing is optimal for determining readiness for sport.

Level of Evidence

4, Case Report.

The Demographics of Fractures and Dislocations Across the Entire United States due to Common Sports and Recreational Activities

BACKGROUND

There exists little nationwide data regarding fracture and dislocation patterns across a wide variety of sporting activities for all ages and sexes.

HYPOTHESIS

Participant demographics (age and sex) will vary with regard to fracture and joint dislocation sustained during sport-related activities.

STUDY DESIGN

Descriptive epidemiology study.

LEVEL OF EVIDENCE

Level 3.

METHODS

The National Electronic Injury Surveillance System All Injury Program data 2005 through 2013 were accessed; 18 common sports and recreational activities in the United States were selected. Statistical software was used to calculate the numbers of fractures and dislocations, and incidence was calculated using US Census Bureau data. Multivariate logistic regression analysis determined the odds ratios (ORs) for the occurrence of a fracture or dislocation.

RESULTS

A fracture occurred in 20.6% and a joint dislocation in 3.6% of the emergency department visits for sports-related injuries; annual emergency department visit incidence was 1.51 for fractures and 0.27 for dislocations (per 1000 people). Most of the fractures occurred in football (22.5%). The OR for fracture was highest for inline skating (OR, 6.03), males (OR, 1.21), Asians, whites, and Amerindians compared with blacks (OR, 1.46, 1.25, and 1.18, respectively), and those older than 84 years (OR, 4.77). Most of the dislocations occurred in basketball (25.7%). The OR for dislocation was highest in gymnastics (OR, 4.08), males (OR, 1.50), Asians (OR, 1.75), and in those aged 20 to 24 years (OR, 9.04). The most common fracture involved the finger, and the most common dislocation involved the shoulder.

CONCLUSION

Inline skating had the greatest risk for fracture, and gymnastics had the greatest risk for joint dislocation.

CLINICAL RELEVANCE

This comprehensive study of the risks of sustaining a fracture or dislocation from common sports activities across all age groups can aid sports health providers in a better understanding of those sports at high risk and be proactive in prevention mechanisms (protective gear, body training).

Elbow Injuries in National Collegiate Athletic Association Athletes: A 5-Season Epidemiological Study

Background:

Little research has focused on the rates and patterns of elbow injuries in National Collegiate Athletic Association (NCAA) student-athletes.

Purpose:

To describe the epidemiological patterns of elbow injuries in NCAA athletes during 5 seasons over the academic years 2009 through 2014 using the NCAA Injury Surveillance Program (NCAA-ISP) database.

Study Design:

Descriptive epidemiology study.

Methods:

A voluntary convenience sample of NCAA varsity teams from 11 sports was examined to determine the rates and patterns of elbow injuries. Rates and distributions of elbow injuries were identified within the context of sport, event type, time in season, mechanism, time lost from sport, surgical treatment, and injury type. Rates of injury were calculated as the number of injuries divided by the total number of athlete-exposures (AEs). An AE was defined as any student participation in 1 NCAA-sanctioned practice or competition with an inherent risk of exposure to potential injury. Injury rate ratios (IRRs) and injury proportion ratios (IPRs) were then calculated to compare the rates within and between sports by event type, season, sex, mechanism, surgical treatment, and time lost from sport. Comparisons between sexes were made using only sports data that had both male and female samples.

Results:

Overall, 373 elbow injuries were reported in the NCAA-ISP data set during the 2009-2010 through 2013-2014 academic years among 11 varsity sports. The overall rate of injury was 1.76 per 10,000 AEs. The rate of elbow injuries in men was 0.74 per 10,000 AEs, while women experienced injuries at a rate of 0.63 per 10,000 AEs. In sex-comparable sports, men were 1.17 times more likely to experience an elbow injury compared with women. Men’s wrestling (6.00/10,000 AEs) and women’s tennis (1.86/10,000 AEs) were the sports with the highest rates of elbow injuries by sex, respectively. The top 3 highest injury rates overall occurred in men’s wrestling, baseball, and tennis. Elbow injuries were 3.5 times more likely to occur during competition compared with practice. Athletes were 0.76 times less likely to sustain an elbow injury during the preseason compared with in-season. Contact events were the most common mechanism of injury (67%). For sex-comparable sports, men were 2.41 times more likely than women to have contact as their injury mechanism (95% CI, 0.78-7.38). The majority of athletes missed less than 24 hours of participation time (67%), and only a minority (3%) of patients with elbow injuries went on to have surgical intervention. Elbow ulnar collateral ligament injuries were most common (26% of total injuries).

Conclusion:

Analysis of the study data demonstrated a significant rate of elbow injuries, 1.76 injuries per 10,000 AEs in NCAA collegiate athletes. Higher injury rates can be expected in males within sex-comparable sports. Elbow injuries are most common in the setting of competitions and most commonly occur secondary to contact-type mechanisms. Injuries were more likely to occur during in-season play. The majority of injuries required less than 24 hours of time away from sport and did not require surgical intervention.

Epidemiology of Upper Extremity Soccer Injuries Among High School- and College-Aged Players in the United States: An Analysis of the 1999-2016 NEISS Database

BACKGROUND:

Although lower extremity injuries are more common than upper extremity injuries in high school- and college-aged soccer players, upper extremity injuries may be equally severe. The epidemiology of upper extremity injuries is poorly characterized in this population.

HYPOTHESIS:

Upper extremity injuries are an important contributor to soccer-related morbidity among high school- and college-aged players.

STUDY DESIGN:

Descriptive epidemiology study.

LEVEL OF EVIDENCE:

Level 3.

METHODS:

The National Electronic Injury Surveillance System (NEISS) is a nationally representative sample of 100 hospital emergency departments (EDs). Each record contains demographic and injury information. Records from 1999 to 2016 were analyzed, including patients between the ages of 14 and 23 years with a soccer-related injury sustained at school or during an athletic event.

RESULTS:

A total of 1,299,008 high school- or college-aged patients presented to the ED for a soccer-related injury from 1999 to 2016, of which 20.4% were in the upper extremity. Patients were predominantly male (58.0%) and high school-aged (81.4%). Males constituted a greater proportion of upper extremity injuries when compared with other injury locations (63.5% male for upper extremity). Upper extremity injuries were more likely to be fractures (43.7% vs 13.9%) and dislocations (7.1% vs 3.4%) and less likely to be strains/sprains (27.8% vs 56.6%). Males suffered more shoulder dislocations (81.8% males among patients with shoulder dislocation vs 57.8% among those with other injuries), finger dislocations (72.0% vs 58.0%), upper arm fractures (74.9% vs 57.6%), and forearm fractures (68.3% vs 57.3%).

CONCLUSION:

Upper extremity injuries are frequent in high school- and college-aged soccer players presenting to the ED. Efforts to reduce soccer-related injuries should include strategies targeting the upper extremity, perhaps reducing the incidence of high-energy falls.

CLINICAL RELEVANCE:

Efforts to reduce soccer-related injuries should include strategies targeting upper extremity injuries, particularly among males and college-aged players.

Epidemiology of Elbow Ulnar Collateral Ligament Injuries Among Baseball Players: National Collegiate Athletic Association Injury Surveillance Program, 2009-2010 Through 2013-2014

BACKGROUND

Injuries to the ulnar collateral ligament (UCL) of the elbow are of major concern in baseball; however, the epidemiology of these injuries among National Collegiate Athletic Association (NCAA) athletes is poorly described.

PURPOSE

To determine the incidence of UCL injuries in NCAA baseball and investigate the risk factors involved.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

All UCL injuries for academic years 2009-2010 through 2013-2014 were extracted from the NCAA Injury Surveillance Program database. The incidence was calculated for different positions, activity, time in game, competition status, and injury characteristics and compared via injury risk ratios to determine risk factors for injury occurrence. The NCAA provides sampling weights based on division and year. For all other injury characteristic analysis, unweighted data were used.

RESULTS

Over the course of the 2009-2010 to 2013-2014, 20 UCL injuries were reported in the NCAA Injury Surveillance Program over 177,992 athletic exposures (AEs) for an overall incidence of 1.12 per 10,000 AEs (95% CI, 0.63-1.62). Eighty-five percent occurred during throwing, and 100% were new injuries. Of the injuries sustained during games, 28.6% occurred early (warm-up through third inning) and 71.4% late (fourth inning or later), with a risk ratio of 1.3 for late-game injuries (95% CI, 0.24-6.44). Of those injured, 45.0% were able to return to play by the next season, while the remainder were out for at least 7 days. Injury was season ending for 15% of athletes (0.17 per 10,000 AEs), and 15% of athletes required surgery.

CONCLUSION

UCL injury is a potentially season-ending, even career-ending, injury among NCAA baseball players. Additionally, while more injuries occurred later in games, the current study revealed no significant difference in injury rates with respect to time in game. Last, the authors found a higher reported rate of extensive time away from sport after UCL injury than previously published studies on this patient population.

Football-Related Pediatric Extremity Fractures and Dislocations: Size Matters

Football remains a popular sport in the United States despite sometimes significant injuries, such as fractures and dislocations, occurring. The objective of this study was to evaluate pediatric extremity fractures and dislocations related to football. A retrospective review was conducted at a level 1 pediatric trauma center to identify patients who were treated specifically for American football-related injuries (International Classification of Diseases, Ninth Revision, code E007.0). All patients with football-related injuries presenting to the emergency department during a 6-year period (2007-2012) were reviewed for inclusion in the study. Patients with only fractures or dislocations involving the extremities were analyzed. Exclusion criteria included patients older than 18 years, non-football-related sports-related injuries, and patients presenting to non-emergency department health care facilities. Demographic information was collected in addition to type of injury, body mass index, and type of treatment. A total of 193 patients with 96 fractures and 7 dislocations were included. More than two-thirds of all fractures occurred in the lower extremities, with tibia (17.0%) and femoral shaft (14.2%) fractures being the most common. Thirty-five percent of the fractures and dislocations required operative treatment. No statistically significant correlations were identified pertaining to age, race, and timing of the injuries in the season. Regarding body mass index, underweight patients were associated with 3.6 times greater odds of sustaining a fracture when compared with patients who were not underweight (P=.006). Underweight patients may be at a higher risk for fractures or dislocations. Identifying at-risk children may result in improved patient and coach education, potentially leading to better preventive measures and fewer injuries. [Orthopedics. 2018; 41(4):216-221.].

Treatment strategy and long-term functional outcome of traumatic elbow dislocation in childhood: a single centre study

PURPOSE

Traumatic elbow dislocation (TED) is the most common injury of large joints in children. There is an ongoing debate on the optimal treatment for TED. We aimed to assess the functional outcome after operative and nonoperative treatment of TED.

METHODS

We analysed the medical records of patients with TED treated at the University Children's Hospital, Basel, between March 2006 and June 2015. Functional outcome was assessed using the Mayo Elbow Performance Score (MEPS) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) Sport and Music Module score. These scores were compared between nonoperatively and operatively treated patients.

RESULTS

A total of 37 patients (mean age 10.2 years, 5.2 to 15.3) were included. Of these, 21 (56.8%) children had undergone nonoperative treatment, with 16 (43.2%) patients having had operative treatment. After a mean follow-up of 5.6 years (1.2 to 5.9), MEPS and QuickDASH Sport and Music Module scores in the nonoperative group and operative group were similar: MEPS: 97.1 points (SD 4.6) versus 97.2 points (SD 2.6); 95% confidence interval (CI)-2.56 to 2.03); p = 0.53; QuickDASH Sport and Music Module score: 3.9 points (SD 6.1) versus 3.1 points (SD 4.6); 95% CI 2.60 to 4.17; p = 0.94. We noted no significant differences regarding the long-term functional outcome between the subgroup of children treated operatively versus those treated nonoperatively for TED with accompanying fractures of the medial epicondyle and medial condyle.

CONCLUSION

Functional outcome after TED was excellent, independent of the treatment strategy. If clear indications for surgery are absent, a nonoperative approach for TED should be considered.

LEVEL OF EVIDENCE

Level III - therapeutic, retrospective, comparative study.

Elbow Dislocation and Subluxation Injuries in the National Collegiate Athletic Association, 2009-2010 Through 2013-2014

Background

Examination of the incidence of elbow dislocation and subluxation injuries in the collegiate athlete population is limited.

Purpose

To determine the incidence of elbow dislocation and subluxation injuries in the National Collegiate Athletic Association (NCAA) and investigate the risk factors involved.

Study Design

Descriptive epidemiology study.

Methods

All elbow subluxation and dislocation injuries from the 2009-2010 through 2013-2014 academic years in the NCAA Injury Surveillance Program database were extracted. The incidence was calculated for different injuries, sports, activity, time in game, competition status, and injury characteristics. Such differences were compared by use of risk ratios to determine risk factors for injury.

Results

The overall incidence of elbow instability injuries was 0.04 per 10,000 athlete-exposures (AEs). Elbow dislocations were more common, with 553 injuries (82.2%, 0.03/10,000 AEs), while elbow subluxations were the minority, with 119 injuries (17.8%, 0.01/10,000 AEs). Men's wrestling had the highest incidence of elbow instability (1.08/10,000 AEs), more than women's gymnastics (0.74), men's football (0.11), and women's volleyball (0.06). All injuries occurred via a contact mechanism, and 99.2% were new injuries. Sixty-nine percent of injuries kept athletes sidelined for more than 2 weeks. Injuries were 3 times more likely to occur in competition (0.08/10,000 AEs) than practice (0.03/10,000 AEs). Injuries sustained during competition were 1.4 times more likely to occur early in the match than late.

Conclusion

Elbow instability injuries are an infrequent but serious source of disability for select NCAA athletes, with a number of associated risk factors. Athletes sustaining these injuries, along with their coaches and medical providers, may benefit from these return-to-play data to best manage expectations and outcomes.

Elbow Dislocations in Contact Sports

Elbow dislocations are more common in athletes than in the general population. Simple elbow dislocations should be managed with early range of motion and early return to sport, even with high-level contact athletes. Patients with instability on examination or with complex elbow dislocations may require surgical intervention. Overall, the outcomes after simple elbow dislocations are excellent and athletes should be able to return to play without significant limitations.