Post-traumatic recurrent ulnar nerve dislocation at the elbow: a rare case report

Introduction and importance

Several authors have also made reference to a less prevalent condition known in elbow as ulnar nerve subluxation. However, this particular condition tends to manifest primarily in young individuals who engage in professional sports or activities involving extensive use of the forearm. A more severe form of ulnar nerve subluxation, which is ulnar nerve dislocation, gives rise to a characteristic dislocation and relocation of the nerve at the elbow during flexion and extension of the forearm. Due to the rarity of this condition in clinical settings and its predominant occurrence as subluxation in younger patients, there are instances where traumatic ulnar nerve dislocation can be overlooked and misdiagnosed with two commonly encountered pathological conditions as ulnar nerve entrapment or medial epicondylitis.

Case presentation

The authors present a 51-year-old male with chronic pain when moving his right forearm following a fall that caused a direct force injury to his elbow. The patient was misdiagnosed and treated as medial epicondylitis and early-stage ulnar nerve entrapment. However, the symptoms did not improve for a long time. The authors performed the ulnar nerve anterior transposition surgery using the subcutaneous transposition technique and the result is very good without any pain.

Clinical discussion

The ulnar nerve can naturally be subluxed or dislocated if Osborne's ligament is loose or when there are anatomical variations in the medial epicondyle. In some case, this ligament can be ruptured by trauma. The symptoms of ulnar instability are caused by friction neuritis. Dynamic ultrasound of the ulnar nerve in two positions show clearly this condition.

Conclusion

Post-traumatic ulnar nerve dislocation is a rare condition, and the recurrent characteristic of it leads to neuritis or neuropathy. The condition can be overlooked or misdiagnosed as medial epicondylitis or early-stage ulnar nerve entrapment. The nerve transposition surgery will give good result.

Return to Sport and Clinical Outcomes Following Osteochondral Autograft Transplantation in Baseball Players and Gymnasts With Unstable Osteochondritis Dissecans: A Critically Appraised Topic

CLINICAL SCENARIO

Osteochondritis dissecans (OCD) of the capitellum is a condition occurring at the elbow and often seen in both baseball players and gymnasts due to the repetitive loading of the radiocapitellar joint. Treatment options for OCD vary and are dependent on lesion presentation, elbow motion, and growth plate maturity. OCD lesions categorized as unstable can be treated with an osteochondral autograft transplantation surgery (OATS).

FOCUSED CLINICAL QUESTION

In an adolescent population, what are the return to sport rates and clinical outcomes following OATS in baseball players and gymnasts with unstable OCD lesions?

SUMMARY OF KEY FINDINGS

Three articles met the inclusion criteria for this appraisal, and all indicate an OATS procedure should be considered in the management of unstable OCD lesions. Return to play outcomes were favorable for both baseball players and gymnasts. Self-reported patient function and elbow extension all improved following an OATS.

CLINICAL BOTTOM LINE

An OATS procedure is a favorable option for the management of OCD lesions of the elbow in baseball players and gymnasts.

STRENGTH OF RECOMMENDATION

There is level B evidence to support return to sport and clinical outcomes in baseball players and gymnasts following an OATS procedure. This score is directly related to the quality of evidence that currently exists on the topic.

Thrombosis of the Brachial Artery After Closed Elbow Dislocation

Posterior dislocation of the elbow joint is the second commonest large joint dislocation that can be experienced due to various traumatic incidents. Although it may be associated with fractures and vascular lesions, in this case report, we describe a patient who encountered a posterolateral elbow dislocation following a fall on their arm with an extended elbow. This dislocation was followed by delayed thrombosis of the brachial artery, necessitating a revascularization surgery. For optimal patient care, physicians should remain vigilant, being cautious about potential vascular injuries both before and after performing a closed reduction of the elbow joint. The suspicion of vascular injury should be even more pronounced when bony lesions or open injuries are present. Effective management of such cases requires a collaborative effort between orthopedic and vascular surgeons. The preferred surgical approach involves the utilization of a saphenous graft, with the essential prerequisite of achieving a stable elbow joint before proceeding with revascularization.

Relationship between Standing Trunk Extension Angle and Medial Elbow Injuries in Young Baseball Pitchers

Purpose: The purpose of this study was to investigate the relationship between the standing trunk extension angle and medial elbow injuries. Subjects and methods: The study participants were 90 male baseball pitchers (10−12 years) belonging to youth baseball teams. Pitching elbow injuries were evaluated by an orthopedic surgeon using ultrasound scans and physical examination findings. A single optical three-dimensional motion analysis system was used for the trunk extension measurements, with three-dimensional coordinates captured. The overall, upper, and lower trunk angles were then analyzed. Results: Trunk extension angle during standing trunk extension was significantly smaller among participants who were positive for medial elbow injuries on ultrasound scans (positive: 71.4° ± 10.3°; negative: 75.7° ± 9.2°; t = 2.05, p < 0.05). The upper trunk extension angle was significantly smaller than the lower trunk extension angle among participants who were positive for medial elbow injuries on physical examination (upper: 33.0° ± 6.9°; lower: 41.2° ± 8.2°; t = −2.42, p < 0.05). Conclusions: Trunk extension angle during standing trunk extension is associated with medial elbow injuries. Evaluating the trunk extension angle as multiple segments rather than a single rigid body is valuable.

Hip Abductor Strength Asymmetry: Relationship to Upper Extremity Injury in Professional Baseball Players

BACKGROUND

Hip strength is an important factor for control of the lumbo-pelvic-hip complex. Deficits in hip strength may affect throwing performance and contribute to upper extremity injuries.

HYPOTHESIS

Deficits in hip abduction isometric strength would be greater in those who sustained an upper extremity injury and hip strength would predict injury incidence.

STUDY DESIGN

Prospective cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Minor League baseball players (n = 188, age = 21.5 ± 2.2 years; n = 98 pitchers; n = 90 position players) volunteered. Hip abduction isometric strength was assessed bilaterally with a handheld dynamometer in side-lying position, expressed as torque using leg length (N·m). Hip abduction strength asymmetry was represented by [(trail leg/lead leg) × 100]. Overuse or nontraumatic throwing arm injuries were prospectively tracked. Poisson regression models were used to estimate relative risk ratios associated with hip asymmetry; confounders, including history of prior overuse injury in the past year, were included.

RESULTS

Hip abduction asymmetry ranged from 0.05% to 57.5%. During the first 2 months of the season, 18 players (n = 12 pitchers) sustained an upper extremity injury. In pitchers, for every 5% increase in hip abduction asymmetry, there was a 1.24 increased risk of sustaining a shoulder or elbow injury. No relationship between hip abduction strength and injury was observed for position players.

CONCLUSION

Hip abduction asymmetry in pitchers was related to subsequent upper extremity injuries. The observed risk ratio indicates that hip abduction asymmetry may contribute a significant but small increased risk of injury.

CLINICAL RELEVANCE

Hip abduction muscle deficits may affect pitching mechanics and increase arm stress. Addressing hip asymmetry deficits that exceed 5% may be beneficial in reducing upper extremity injury rates in pitchers.

Increased Elbow and Olecranon Injury History in Professional Pitchers With Increased Elbow Flexion at Ball Release

BACKGROUND

Elbow flexion at late portions of the pitch has been associated with increased elbow varus torque, a kinetic surrogate associated with injury risk. Direct examinations of injury incidence with elbow flexion angles have not been conducted in professional pitchers.

PURPOSE

To compare elbow and shoulder injury incidence among professional baseball players stratified by degree of elbow flexion at ball release (BR).

STUDY DESIGN

Descriptive laboratory study.

METHODS

Professional pitchers (N = 314) were instructed to pitch between 8 and 12 fastballs while being evaluated using motion capture technology. Upper extremity injury incidence was recorded upon interview. Pitchers were subsequently subdivided into 3 groups based on increasing elbow flexion at BR. Analysis of variance was used to compare participant characteristics and kinematic and peak kinetic variables. An odds ratio (OR) was calculated to determine the risk of having a previous upper extremity injury based on the degree of elbow flexion at BR.

RESULTS

A total of 116 pitchers (132 documented injuries) had a previous upper extremity injury, with elbow injury (76 injuries; 57.6%) being the most common. Evaluation of kinetic values showed that pitchers with the smallest elbow flexion at BR had significantly less peak elbow flexion torque than did those with greatest elbow flexion at BR (3.8 ± 0.5 vs 4.1 ± 0.6 %weight × height; P = .003). Pitchers who demonstrated a greater than average degree of elbow flexion at BR when pitching were more likely to have a history of elbow injury (OR, 1.97; 95% CI, 1.14-3.40; P = .015) and olecranon spur formation or stress fracture (OR, 5.79; 95% CI, 1.25-26.85; P = .025).

CONCLUSION

Pitchers with greater elbow flexion at BR had significantly higher odds of previous injury of the elbow and olecranon. Increasing elbow flexion has been shown to place the medial elbow in a position to carry a greater amount of load, which may be exacerbated during the final moments of the pitching motion. Professional pitchers can consider decreasing elbow flexion at BR as a potential, modifiable risk factor for elbow injury, in particular for olecranon spur formation and fracture.

CLINICAL RELEVANCE

This study attempts to associate injury incidence with a modifiable, kinematic variable for an at-risk population.

Risk Factors of Shoulder and Elbow Injuries in Baseball: A Scoping Review of 3 Types of Evidence

Background

Shoulder and elbow overuse injuries are the most common problems in baseball players. No scoping review has compared the findings from different types of evidence.

Purpose

To map the broad evidence from 3 types of evidence (epidemiological, biomechanical, and narrative) on potential risk factors for shoulder and elbow injuries in baseball and identify gaps in the existing literature to guide future research.

Study Design

Scoping review.

Methods

Eight electronic databases were searched from inception to May 14, 2020. Any peer-reviewed papers that investigated or discussed potential risk factors for shoulder and elbow injuries in baseball were included.

Results

A total of 302 studies (107 epidemiological studies, 85 biomechanical studies, and 110 narrative reviews) were included. Risk factors were categorized into 9 domains: sports profiles, physical characteristics/functions, pitching mechanics, performance, behavioral, psychosocial, biological and developmental, injury/sports profiles, and environmental factors. Studies were consistent in supporting limited shoulder range of motion (ROM) and player positions (pitchers or catchers) as risk factors for shoulder injuries. For elbow injuries, the majority of the included studies suggested that being pitchers or catchers and working with higher ball velocity can be risk factors.

Conclusion

Findings were consistent in some risk factors, such as limited shoulder ROM and positions. However, findings were inconsistent or limited for most factors, and substantial research gaps were identified. Research assessing those factors with inconsistent or limited evidence in the current literature were recognized to be priorities for future studies.

A Novel Variant of Type II Monteggia Equivalent Fracture-Dislocation in Children: A Case Report

Monteggia fracture-dislocations are extremely rare in children. By definition, it is an ulnar shaft fracture with proximal radioulnar joint dislocation. Throughout the years, various equivalents of this entity have been described. In this report, we present a unique case of a type II Monteggia fracture equivalent with an ipsilateral fracture of the proximal radius and olecranon in a child. The patient was a 12-year-old male who presented with a history of a fall on an outstretched hand. The diagnosis was made based on the clinical examination and plain radiographs. We describe the management of this unique fracture and discuss the possible mechanism of injury. We have highlighted a rare combination of injuries. It is crucial to investigate the condition properly in order to avoid missing the diagnosis and to prevent poor outcomes and further unnecessary revision surgeries.

Successful Nonoperative Treatment of Osteochondritis Dissecans of the Humeral Capitellum in a Young Baseball Player with Advanced Skeletal Maturity

Background:

Osteochondritis dissecans (OCD) of the humeral capitellum presents most typically in adolescent athletes who perform repetitive overhead activities. Earlier studies have demonstrated that conservative treatment of OCD is appropriate for patients with an open capitellar growth plate from the standpoint that spontaneous healing can be expected.

Case:

A 12-year-old male baseball player with two years of experience with a local team participated in our medical check that included screening for capitellar OCD using ultrasonography. The subject experienced elbow pain when throwing, and ultrasonographic elbow examination indicated OCD of the capitellum, detected as irregularity of the subchondral bone of the capitellum. The initial radiograph, taken with the elbow at 45° of flexion, identified new bone formation in the lateral aspect of the OCD lesion; however the epiphyseal lines of the capitellum and lateral epicondyle were closed. We advised the patient to stop heavy use of the elbow, e.g., throwing and batting, and started conservative treatment in anticipation of spontaneous healing. Physiotherapy focusing on the shoulder girdle, core, and hip and lower limb stretches were performed to resolve general tightness. The OCD lesion had healed completely 12 months after the start of conservative treatment.

Discussion:

Conservative treatment for young baseball players might be worth considering if lateral new bone formation within the OCD lesion is detected on radiographic findings, even if the epiphyseal lines of the capitellum and lateral epicondyle are closed.

Pitch break and performance metrics remain unchanged in pitchers who returned to the same level of play after ulnar collateral ligament reconstruction in Major League Baseball pitchers

BACKGROUND

The ulnar collateral ligament is commonly injured in overhead-throwing athletes, particularly baseball pitchers. Pitch movement (break) is a critical aspect to pitching performance. The primary purpose of this study was to determine the changes in pitch velocity, pitch break, angle of break, and pitch performance metrics before and after ulnar collateral ligament reconstruction (UCLR) in Major League Baseball (MLB) pitchers. The secondary purpose was to determine changes in pitch performance metrics before and after UCLR. We hypothesized that pitch break and pitch performance metrics would be unchanged following UCLR.

MATERIALS AND METHODS

This was a retrospective case-series study of pitchers who had undergone primary UCLR between 2008 and 2014. Velocity, horizontal movement (Hmov), and vertical movement (Vmov) of each pitch were collected from the PITCHf/x system for each pitcher 12-24 months before surgery, 12-24 months after surgery, and 24-36 months after surgery. Overall break was calculated by taking the Pythagorean sum of Hmov and Vmov. Angle of break was determined by taking the inverse tangent of Vmov divided by Hmov. Repeated-measures analysis of covariance was performed to determine differences in pitch velocity, movement, angle of movement, and performance metrics between preoperative and postoperative time frames. Performance metrics included balls, strikes, swings, fouls, swings and misses, ground balls, line drives, pop-ups, fly balls, and home runs. Covariates included age at surgery, time from MLB debut to surgery, innings pitched as a starter, innings pitched as a reliever, and total pitches thrown.

RESULTS

In a cohort of 46 pitchers who underwent UCLR between 2008 and 2014, pitch velocity, movement, and angle were not significantly changed with respect to preoperative or postoperative time frames. In addition, postoperative time frames had clinically insignificant differences in pitch performance metrics.

CONCLUSION

Pitch break and performance metrics are not significantly affected in pitchers who return after UCLR.

Surgical outcomes of coronal shear fractures of the distal humerus in the elderly

BACKGROUND

The purpose of this study is to evaluate the clinical outcomes of the elderly with coronal shear fractures (CSFs) of the distal humerus who had undergone open reduction and internal fixation (ORIF).

METHODS

Between April 2002 and March 2019, eight elderly patients (76.3 ± 5.1 years)with CSFs of the distal humerus were investigated retrospectively. Postoperative complications, the range of motion (ROM) of the elbow joint, and functional elbow scoring (Mayo elbow performance score; MEPS) were assessed.

RESULTS

The mean follow-up duration was 23.6 ± 13.9 months. CSFs were treated by a buried implantable headless screw or Kirshner wires or bioresorbable screw with/without lateral locking plates. There were no superficial or deep infections, or elbow joint instability. Seven patients obtained fracture healing, but one patient showed non-union. Osteochondritis dissecans was present in one patient. Three patients showed step-off deformity (> 2 mm) of the articular surface. Two patients displayed a collapse of the fractured articular surface. A patient with severe comminution of both the capitellum and the trochlear showed the collapse of the whole articular surface with osteonecrosis of the capitellum and trochlea. Mean the range of motion of the elbow were flexion, 116.3±12.7° and extension, -28.8±14.1°. The mean MEPS was 78.8±10.2 points, representing patients who scored an excellent (n=1), good (n=3), and fair (n=4).

CONCLUSION

ORIF yielded satisfactory outcomes for theelderly with noncomminuted CSF of the distal humerus. However, the cases with comminuted articular fragment or complex posterior fractures were still challenging.

The ulnar collateral ligament loading paradox between in-vitro and in-vivo studies on baseball pitching (narrative review)

Ulnar collateral ligament (UCL) weakening or tears occur in 16% of professional baseball pitchers. To prevent players from sustaining a UCL injury, it is important to understand the relationship between the UCL properties and elbow stabilizers with the load on the UCL during pitching. In-vitro studies showed that the ultimate external valgus torque of 34 Nm would rupture the UCL, which is in apparent conflict with the reported peak valgus torques in pitching (40–120 Nm). Assuming both observations are correct, the question rises why ‘only’ 16 out of 100 professional pitchers sustain a UCL rupture. Underestimation of the effect of other structures in in-vivo studies is most likely the explanation of this mismatch because the calculated in-vivo torque also includes possible contributions of functional and structural stabilizers. In-vitro studies show that the flexor-pronator mass has the potential to counteract valgus torque directly, whereas the elbow flexor-extensor muscles combined with the humeroradial joint might have an indirect effect on valgus torque by increasing the joint compression force. Accurate experimental electromyography data and a more detailed (musculoskeletal)mechanical model of the elbow are needed to investigate if and to what extent the structural and functional stabilizers can shield the UCL during pitching.

Fifteen-minute consultation: Assessing the child with an elbow injury

This article aims to provide a concise summary of the key considerations when assessing a child with an elbow injury. Elbow injuries are common with acute elbow trauma, accounting for 2%-3% of all visits to the emergency department. This article will cover history, examination and key X-ray findings, along with a brief guide to management. It is hoped this article will help healthcare professionals who assess children with elbow injuries. Our work is applicable to those both in the hospital and community setting.

Early Sport Specialization Linked to Throwing Arm Function and Upper Extremity Injury History in College Baseball Players

BACKGROUND

Evidence suggests that shoulder and elbow injuries account for 31% to 37% of all National Collegiate Athletic Association (NCAA) baseball injuries, and up to 69% of NCAA baseball injuries are the result of noncontact and overuse mechanisms. Early sport specialization may contribute to the high rates of upper extremity injuries in college baseball players.

HYPOTHESIS

Higher specialization by age 13 years would be associated with worse subjective throwing arm function and a greater history of shoulder and elbow injury.

STUDY DESIGN

Cohort study.

LEVEL OF EVIDENCE

Level 2.

METHODS

Survey data were collected from college baseball players (N = 129) during midseason of the spring 2019 baseball season. Participants were stratified in low, moderate, and high specialization groups based on a 3-criteria sports specialization questionnaire. Participants' throwing arm function was measured using the Functional Arm Scale for Throwers and the Kerlan-Jobe Orthopaedic Clinic shoulder and elbow questionnaires. Participants' history of a shoulder or elbow injury that resulted in missing ≥2 weeks of baseball activity at any point in their baseball career was also collected.

RESULTS

The high specialization group reported worse subjective throwing arm function on the Functional Arm Scale for Throwers questionnaire than the low (P = 0.03) and moderate (P = 0.01) specialization groups. The high specialization group was over 5 times more likely to report a history of shoulder injury than the moderate (odds ratio [OR] = 5.42; 95% CI [1.71, 17.2]; P = 0.004) and low (OR = 5.20; 95% CI [1.87, 14.5]; P = 0.002) specialization groups, and over 3 times more likely to report a history of elbow injury than the moderate specialization group (OR = 3.77; 95% CI [1.05, 13.6]; P = 0.04).

CONCLUSION

College baseball players that were highly specialized by age 13 years reported worse subjective throwing arm function and were more likely to have a history of upper extremity injury than players that were moderate or low specialization.

CLINICAL RELEVANCE

Early specialization in baseball may be detrimental to long-term upper extremity health in college baseball players.

Regional Interdependence and the Role of the Lower Body in Elbow Injury in Baseball Players: A Systematic Review

BACKGROUND

Elbow injuries are exceedingly common in baseball players. Previous studies have identified that upper extremity strength and range of motion deficits pose a risk for these injuries, but few studies have examined the effect of lower extremity deficits. Given the role of the lower extremity in the kinetic chain of the baseball throwing motion, lower body deficits may affect the kinematics of the upper extremity and play a role in the elbow injury of baseball players.

PURPOSE

To systematically review the current literature investigating the association of trunk and lower extremity deficits with elbow pain or injury in baseball players.

STUDY DESIGN

Systematic review.

METHODS

A systematic review of the literature was performed according to the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines to identify and analyze all previous studies focused on the association of elbow pain and/or injury with functional deficits of the trunk and lower extremities.

RESULTS

A total of 14 studies met inclusion criteria, examining a range of baseball players extending from youth to professional athletes. One of the 14 studies examined other types of overhead throwing athletes alongside baseball players. Lower extremity-related risk factors for elbow pain and injury in these athletes were found and stratified per level of play. Factors included specific hip range of motion, lower extremity injury or pain, balance, and foot arch posture. Associations were also found with lower extremity injury and noncompliance with primary prevention programs.

CONCLUSION

Specific lower extremity deficits were found to be independent risk factors for elbow pain and injury in throwing athletes at certain levels of play. Additionally, prevention programs designed to correct deficits in identified risk factors were effective in reducing the incidence of elbow injury in youth athletes. These results highlight the potential of screening and subsequent intervention to reduce the incidence of elbow injury in certain subsets of baseball players.

Training With Lighter Baseballs Increases Velocity Without Increasing the Injury Risk

Background:

Pitch velocity has become an increasingly popular metric by which pitchers are graded and compared. Training programs that utilize weighted balls have been effective in increasing velocity but at the cost of an increased injury risk. No studies have evaluated training with lighter baseballs with regard to increasing pitch velocity and the injury risk.

Purpose/Hypothesis:

The purpose of this study was to determine whether a training program utilizing lighter baseballs could increase fastball velocity without increasing the injury risk to participants. We hypothesized that a training program with lighter baseballs would increase fastball velocity but not increase the injury risk.

Study Design:

Case series; Level of evidence, 4.

Methods:

All baseball pitchers who participated in a 15-week program at a single location, with the same coaches, and aimed to improve pitching mechanics and increase velocity were included. The training program was broken down into 3 phases, and each participant went through the same program. Lighter baseballs (3 and 4 oz) and standard baseballs (5 oz) were utilized as part of the training program. Weighted (heavier) balls were not used. Velocity was measured at 4 time points throughout the program with the pitcher throwing 5 fastballs using a standard 5-oz ball at maximum velocity (sessions 3, 10, 17, and 25). Injuries for all players were recorded throughout the entire program.

Results:

A total of 44 male pitchers aged 10 to 17 years (mean age, 14.7 ± 1.8 years) completed the training program and were available for analysis. No pitcher sustained a shoulder or elbow injury during the course of the training program. Fastball velocity increased by a mean of 4.8 mph (95% CI, 4.0-5.6 mph) (P < .001). Overall, 43 of 44 players (98%) had an increase in fastball velocity over the course of the program.

Conclusion:

A 15-week pitching training program with lighter baseballs significantly improved pitching velocity without causing any injuries, specifically to the shoulder or elbow. Lighter baseballs should be considered as an alternative to weighted baseballs when attempting to increase a pitcher’s velocity.

Low return-to-sports rate after elbow injury and treatment with radial head arthroplasty

BACKGROUND

The aim of this study was to analyze sports participation after radial head arthroplasty among recreational athletes.

METHODS

A total of 57 recreational athletes (mean age, 49 years; age range, 18-79 years) treated with radial head arthroplasty for non-reconstructible radial head fractures were included in this retrospective study. The return-to-sports rate and the time to return to sports were analyzed. The clinical and radiologic outcomes were compared between patients who returned to sports (group 1) and those who did not (group 2).

RESULTS

After a mean follow-up period of 8.4 years (range, 2.5-16.4 years), 30 of 57 patients (53%) had returned to sports. The mean sports frequency significantly decreased from 5.2 ± 5.0 h/week to 2.2 ± 2.9 h/week after surgery (P < .001). In group 1, 83% of patients returned to the same sports activity whereas 17% changed to a less demanding sports activity. The mean time to return to sports was 158 days (range, 21-588 days). Patients who returned to sports had a significantly better Mayo Elbow Performance Score (MEPS) (84 ± 19 points vs. 63 ± 20 points, P < .001); Disabilities of the Arm, Shoulder and Hand score (16 ± 17 vs. 46 ± 22, P < .001); and arc of flexion (114° ± 32° vs. 89° ± 36°, P = .007). A secondary radial head prosthesis (P = .046) and MEPS lower than 85 points (P = .001) were associated with a significantly lower return-to-sports rate. No differences regarding radiographic changes were found between the 2 groups (P ≥ .256).

CONCLUSION

The return-to-sports rate after radial head replacement is low. A secondary radial head prosthesis and a worse clinical outcome (MEPS < 85 points) significantly increase the risk of not returning to sports after radial head arthroplasty.

Shoulder and elbow injuries in soccer goalkeepers versus field players in the National Collegiate Athletic Association, 2009-2010 through 2013-2014

OBJECTIVES

Examination of the incidence of shoulder and elbow injuries in the collegiate soccer player population is limited, as is comparison between goalkeepers and field players. We hypothesized that goalkeepers would have a higher incidence of shoulder and elbow injuries than field players. Furthermore, we sought to determine the incidence of shoulder and elbow injuries among National Collegiate Athletic Association (NCAA) soccer players, and to determine injury risk factors.

METHODS

The NCAA Injury Surveillance Program database was analyzed for injuries to NCAA men's and women's soccer players during the 2009-2010 through 2013-2014 academic years. The incidence of injury was calculated per 10,000 athletic exposures (AE) for goalkeepers versus field players, activity, and injury characteristics, and compared using univariate analysis and risk-ratios to determine injury risk factors.

RESULTS

While the overall incidence of shoulder and elbow injuries in soccer players was 2.7/10,000AE [95% CI 2.62-2.78], the incidence among goalkeepers was 4.6-fold higher (8.3 vs. 1.8/10,000AE, p < 0.0001). Goalkeepers had significantly higher incidences of injury in practice (21.3-fold) and in the preseason (16.1-fold) than field players. Women goalkeepers were disproportionately affected, with injury incidences 7.7-fold higher than women field players, and 1.9-fold higher than male goalkeepers. Acromioclavicular joint injuries, rotator cuff tears/sprains, and elbow and shoulder instability constituted the majority of the goalkeeper injuries.

CONCLUSIONS

Shoulder and elbow injuries in NCAA soccer players are significantly more common in goalkeepers than field players. Incidence varies widely by position and injury, with a number of associated risk factors. Soccer players sustaining these injuries, along with their coaches and medical providers, may benefit from this injury data to best manage expectations and outcomes. Soccer governing bodies may use this to track injury incidence and response to preventative measures.

Prospective outcome assessment of arthroscopic arthrolysis for traumatic and degenerative elbow contracture

BACKGROUND

The purpose of this study was to evaluate the efficacy of arthroscopic elbow release for both traumatic and degenerative contractures from intraoperative recording through the recovery time until final follow-up.

METHODS

The study is based on 54 consecutive patients with extrinsic elbow contracture (traumatic in 31 and degenerative in 23) treated with arthroscopic arthrolysis by a single surgeon in 2011-2015. Range of motion (ROM) and the Mayo Elbow Performance Score (MEPS) were recorded preoperatively; intraoperatively; following release; and in the 1st, 3rd, 8th, 12th, and 26th weeks and at 2 years postoperatively.

RESULTS

Significant improvements were noted in extension, flexion, and range of motion, measured both intraoperatively and at all follow-up visits. The greatest improvement in the range of motion was achieved at the time of surgery (from 89° ± 28° to 131° ± 14°, P < .001); it then decreased at 1 week to 103° ± 22° (P < .001) and slowly recovered to reach 124° ± 22° after 2 years. This was better than the preoperative value (P < .001) but worse than the intraoperative value (P = .002). A similar pattern was observed in both traumatic and degenerative contractures. The MEPS improved from 73 ± 12 preoperatively to 93 ± 14 at the final evaluation (P < .001). The ROM and MEPS results at every follow-up were comparable for both traumatic and degenerative contractures. ROM improved regardless of the severity of contracture.

CONCLUSIONS

Arthroscopic elbow arthrolysis was similarly efficient in ROM restoration in both traumatic and degenerative contractures and regardless of the severity of contracture. After early deterioration, the achieved gain slowly recovers over a period of 6 months but may not recover to the ranges achieved during arthroscopy.

Relationship of Glove Arm Kinematics With Established Pitching Kinematic and Kinetic Variables Among Youth Baseball Pitchers

Background:

While the kinematics of the pitching arm, trunk, and pelvis have been described and studied, glove arm kinematics remain an understudied portion of the pitching motion. Baseball pitchers seek to achieve maximum ball velocity in a fashion that does not place the arm at risk of injury.

Purpose:

To assess the relationship between glove arm shoulder horizontal abduction and elbow flexion and pitching arm kinematics and kinetics among youth pitchers to determine whether recommendations can be made toward a safer pitching motion.

Study Design:

Descriptive laboratory study.

Methods:

Thirty-three right-handed youth male baseball pitchers (mean ± SD: age, 13.6 ± 2.0 years; height, 169.4 ± 14.3 cm; weight, 63.5 ± 13.0 kg; experience, 7.3 ± 3.0 years) threw 3 fastballs to a catcher while kinematic data were collected with an electromagnetic tracking system. The Spearman rank-order test was used to identify relationships between glove arm horizontal abduction and glove arm elbow flexion and various kinematics and kinetics found at maximum shoulder external rotation (MER) and ball release for the fastest fastball delivered by each participant.

Results:

At MER, there were significant relationships found between a more flexed glove arm elbow and increased pitching arm elbow valgus force (r_s[31] = –0.52, P = .002), increased pitching arm shoulder anterior force (r_s = –0.39, P = .024), and decreased hip velocity (r_s[31] = –0.45, P = .009). Additionally, there were significant relationships between greater glove arm horizontal abduction at MER and increased pitching arm humeral velocity (r_s[31] = 0.52, P = .002) and increased trunk rotational velocity (r_s[31] = 0.40, P = .022) at MER.

Conclusion:

A more extended glove arm elbow and more horizontally abducted glove arm shoulder at MER could prove to be more advantageous for performance and possibly be a safer motion for the baseball thrower.

Clinical Relevance:

The orthopaedic community can dictate safer biomechanics when communicating with pitchers, trainers, and pitching coaches.

Competitive bass anglers: a new concern in sports medicine

OBJECTIVE

Competitive bass angling involves sport fishing against other anglers while targeting a species of fish known as the black basses. Due to the rapidly growing popularity of high school competitive bass angling in Alabama and the nature of the casting motion similar to that of overhead athletes, we sought to examine the prevalence of sports type injuries in this population.

METHODS

In spring 2016, an anonymous survey was distributed across two large scale competitive high school fishing tournaments, allowing for a broad sampling of anglers throughout the state of Alabama. Survey items included demographic information, relevant past medical history, and various pains associated with the shoulder, elbow and wrist. Results were recorded and analyzed electronically using Microsoft Excel and IBM SPSS statistical software.

RESULTS

A total of 257 surveys were recorded. The response rate was 61%. The mean age of participating anglers was 15 ± 1.61 years. The majority (42%) of anglers fished year round. On average, anglers casted nearly 1,000 more times while competing versus fishing recreationally. Approximately 15% of anglers experienced shoulder, elbow, and wrist pain. The most common factors associated with pain included higher tournament cast counts, number of competitive years, number of tournaments/year, number of tournaments, and use of light weight lures.

CONCLUSION

A large portion of high school competitive anglers experience upper extremity pain. Knowledge of angling factors associated with pain allow for the creation of a modifiable routine to help reduce pain in affected anglers and prevent pain in healthy anglers.

Performance and Injury Characteristics of Pitchers Entering the Major League Baseball Draft After Ulnar Collateral Ligament Reconstruction

BACKGROUND

Ulnar collateral ligament (UCL) reconstruction (UCLR) has been studied and shown to be a successful procedure for returning overhead athletes to sport. Many studies of Major League Baseball (MLB) players have shown high levels of return to play with successful statistical performance. No study has followed professional advancement of drafted pitchers who underwent UCLR as amateurs when compared with drafted pitchers who did not undergo the procedure before selection in the MLB draft.

HYPOTHESIS

There would be no difference in professional advancement, statistical performance, or injury rate between the UCLR and control groups.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Thirty-eight pitchers with a UCLR as an amateur and 114 controls were identified in the MLB draft between 2006 and 2010. Highest level of professional baseball achieved was collected from all players, as well as statistical performance metrics including velocity, wins, earned run average (ERA), and walks and hits per inning pitched (WHIP). Additional data on future injuries were analyzed for days on the disabled list (DL), risk of being placed on the DL, and DL assignment for elbow injury.

RESULTS

Thirteen of 38 UCLR pitchers reached the major league level (34.2%) compared with 29 of 114 (25.4%) control pitchers, which was not statically significant (P = .295). The UCLR and control groups were similar for average velocity, peak velocity, innings pitched, games, games started, innings per game, ERA, WHIP, wins, losses, saves, batters faced, and innings pitched per year, as well as hits, runs, home runs allowed, strikeouts, batters walked, and batters struck per inning. The UCLR group had a significantly increased rate of DL assignment when compared with controls (86.8% vs 64.0%; P = .008); however, days on DL (152.8 vs 135.6; P = .723) and DL assignment for elbow injury (45.5% vs 43.8%; P = .877) were similar.

CONCLUSION

There was no difference in the rate of professional advancement among pitchers drafted by the MLB who had undergone UCLR as amateurs compared with controls. Both groups had similar statistical performance. Pitchers in the UCLR group had an increased risk of DL assignment but no increase in the number of days on DL or risk of DL placement for elbow injury.

Optimal management of ulnar collateral ligament injury in baseball pitchers

The ulnar collateral ligament stabilizes the elbow joint from valgus stress associated with the throwing motion. During baseball pitching, this ligament is subjected to tremendous stress and injury if the force on the ulnar collateral ligament during pitching exceeds the physiological limits of the ligament. Injuries to the throwing elbow in baseball pitchers result in significant time loss and typically surgical intervention. The purpose of this paper is to provide a review of current information to sports medicine clinicians on injury epidemiology, injury mechanics, injury risk factors, injury prevention, surgical interventions, nonsurgical interventions, rehabilitation, and return to play outcomes in baseball pitchers of all levels.

Hegemann's disease and fishtail deformity: aetiopathogenesis, radiographic appearance and clinical outcome

PURPOSE

A systematic review regarding clinical studies on Hegemann's disease and fishtail deformity was performed with the aims to: (1) formulate the most up-to-date theory on aetiology in order to better define these conditions, (2) summarise the most frequent radiographic descriptions on radiographs and (3) give an overview of different treatment options.

METHODS

A systematic review of studies to date on Hegemann's disease and fishtail deformity was performed. Studies were eligible if: (1) the article provides a description of Hegemann's disease or fishtail deformity, (2) original data of at least one patient was available, (3) the article was written in English, German or Dutch and (4) a full manuscript was available. Animal studies, reviews and expert opinions were not included.

RESULTS

We included a total of 22 articles: seven regarding Hegemann's disease including eight patients and 15 regarding fishtail deformity including 58 patients.

CONCLUSIONS

Fishtail deformity and Hegemann's disease seem to be a spectrum of vascular disorders of the distal humerus, varying from a benign mild vascular disorder to a complete avascular necrosis after fractures. Additional imaging is advised to confirm the presence of a fishtail deformity, intra-articular loose bodies and signs of osteoarthritis to decide if, and what, operative treatment is needed. As long as no clear aetiology for both diseases exist and the clinical symptoms and radiographic appearance are difficult to distinguish, both entities should preferably be named as 'vascular disturbance of the trochlear growth plate' to overcome confusing definitions and discussions.

Is Tommy John Surgery Performed More Frequently in Major League Baseball Pitchers From Warm Weather Areas?

Background:

Medial ulnar collateral ligament (UCL) reconstruction is a common procedure performed on Major League Baseball (MLB) pitchers with symptomatic UCL insufficiency, frequently due to overuse. Warm weather climates afford youth pitchers the opportunity to throw year-round, potentially placing them at risk for overuse elbow injuries.

Purpose/Hypothesis:

To determine whether the proportion of MLB pitchers who underwent medial UCL reconstruction and who pitched competitive youth baseball in warm weather areas is higher than those from cold weather areas. The hypothesis was that MLB pitchers from warm weather areas were more likely to undergo UCL reconstruction than pitchers from cold weather areas.

Study Design:

Descriptive epidemiological study.

Methods:

All MLB pitchers with symptomatic UCL deficiency who underwent UCL reconstruction as of June 1, 2014, were evaluated. The state/country where they played high school baseball was identified from online reference websites. Warm and cold weather areas were defined by latitude distance from the equator and mean annual temperatures. A chi-square test was used to compare the proportion of MLB pitchers from warm versus cold weather areas who underwent UCL reconstruction. The study was 99.6% powered to detect a 100% effect size (eg, 1% vs 2%) and 71.4% powered to detect a 50% effect size (eg, 1% vs 1.5%) with setting α = .05.

Results:

A total of 247 pitchers were identified who had undergone UCL reconstruction; 139 (56.3%) pitched high school baseball in warm weather areas, 108 (43.7%) pitched in cold weather areas. A significantly higher proportion of pitchers who underwent UCL reconstruction (2.2% [95% CI, 1.9%-2.6%]) were from warm weather areas compared with cold weather areas (0.94% [95% CI, 0.78%-1.1%]) (P < .0001). Warm weather pitchers had a mean (±SD) age of 27.6 ± 0.6 years and had played 4.0 ± 0.6 seasons in MLB at the time of surgery, while cold weather pitchers were aged 28.4 ± 0.8 years and had played 5.0 ± 0.9 seasons in MLB (P = .089 and P = .047, respectively).

Conclusion:

MLB pitchers who played high school baseball in warm weather climates have undergone medial UCL reconstruction more frequently and earlier in their MLB careers than pitchers who played in cold weather areas.

Analysis of pitching velocity in major league baseball players before and after ulnar collateral ligament reconstruction

BACKGROUND

Ulnar collateral ligament (UCL) reconstructions are relatively common among professional pitchers in Major League Baseball (MLB). To the authors' knowledge, there has not been a study specifically analyzing pitching velocity after UCL surgery. These measurements were examined in a cohort of MLB pitchers before and after UCL reconstruction.

HYPOTHESIS

There is no significant loss in pitch velocity after UCL reconstruction in MLB pitchers.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between the years 2008 to 2010, a total of 41 MLB pitchers were identified as players who underwent UCL reconstruction. Inclusion criteria for this study consisted of a minimum of 1 year of preinjury and 2 years of postinjury pitch velocity data. After implementing exclusion criteria, performance data were analyzed from 28 of the 41 pitchers over a minimum of 4 MLB seasons for each player. A pair-matched control group of pitchers who did not have a known UCL injury were analyzed for comparison.

RESULTS

Of the initial 41 players, 3 were excluded for revision UCL reconstruction. Eight of the 38 players who underwent primary UCL reconstruction did not return to pitching at the major league level, and 2 players who met the exclusion criteria were omitted, leaving data on 28 players available for final velocity analysis. The mean percentage change in the velocity of pitches thrown by players who underwent UCL reconstruction was not significantly different compared with that of players in the control group. The mean innings pitched was statistically different only for the year of injury and the first postinjury year. There were also no statistically significant differences between the 2 groups with regard to commonly used statistical performance measurements, including earned run average, batting average against, walks per 9 innings, strikeouts per 9 innings, and walks plus hits per inning pitched.

CONCLUSION

There were no significant differences in pitch velocity and common performance measurements between players who returned to MLB after UCL reconstruction and pair-matched controls.

Rate of return to pitching and performance after Tommy John surgery in Major League Baseball pitchers

BACKGROUND

Medial ulnar collateral ligament (UCL) reconstruction is a common procedure performed on Major League Baseball (MLB) pitchers in the United States.

PURPOSE

To determine (1) the rate of return to pitching (RTP) in the MLB after UCL reconstruction, (2) the RTP rate in either the MLB and minor league combined, (3) performance after RTP, and (4) the difference in the RTP rate and performance between pitchers who underwent UCL reconstruction and matched controls without UCL injuries.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Major League Baseball pitchers with symptomatic medial UCL deficiency who underwent UCL reconstruction were evaluated. All player, elbow, and surgical demographic data were analyzed. Controls matched by age, body mass index, position, handedness, and MLB experience and performance were selected from the MLB during the same years as those undergoing UCL reconstruction. An "index year" was designated for controls, analogous to the UCL reconstruction year in cases. Return to pitching and performance measures in the MLB were compared between cases and controls. Student t tests were performed for analysis of within-group and between-group variables, respectively.

RESULTS

A total of 179 pitchers with UCL tears who underwent reconstruction met the inclusion criteria and were analyzed. Of these, 148 pitchers (83%) were able to RTP in the MLB, and 174 pitchers were able to RTP in the MLB and minor league combined (97.2%), while only 5 pitchers (2.8%) were never able to RTP in either the MLB or minor league. Pitchers returned to the MLB at a mean 20.5 ± 9.72 months after UCL reconstruction. The length of career in the MLB after UCL reconstruction was 3.9 ± 2.84 years, although 56 of these patients were still currently actively pitching in the MLB at the start of the 2013 season. The revision rate was 3.9%. In the year before UCL reconstruction, pitching performance declined significantly in the cases versus controls in the number of innings pitched, games played, and wins and the winning percentage (P < .05). After surgery, pitchers showed significantly improved performance versus before surgery (fewer losses, a lower losing percentage, lower earned run average [ERA], threw fewer walks, and allowed fewer hits, runs, and home runs) (P < .05). Comparisons between cases and controls for the time frame after UCL reconstruction (cases) or the index year (controls) demonstrated that cases had significantly (P < .05) fewer losses per season and a lower losing percentage. In addition, cases had a significantly lower ERA and allowed fewer walks and hits per inning pitched.

CONCLUSION

There is a high rate of RTP in professional baseball after UCL reconstruction. Performance declined before surgery and improved after surgery. When compared with demographic-matched controls, patients who underwent UCL reconstruction had better results in multiple performance measures. Reconstruction of the UCL allows for a predictable and successful return to the MLB.

Assessment of Injuries During Brazilian Jiu-Jitsu Competition

Background:

Brazilian jiu-jitsu (BJJ) is a unique style of martial arts with rapid growth in the United States and internationally. Although studies have examined injuries in other martial arts and combat sports, to date, no published medical study has examined injuries in BJJ competitions.

Purpose:

(1) To estimate the incidence of injuries in BJJ competitions and (2) to identify and describe the types and mechanisms of injuries associated with competitive BJJ.

Study Design:

Descriptive epidemiology study.

Methods:

Injury data were obtained from records of on-site medical coverage at 8 statewide BJJ tournaments in Hawaii, USA, between 2005 and 2011.

Results:

The identified injury incidence on the day of matches was 9.2 per 1000 exposures (46 injuries out of 5022 exposures, ie, match participations). Orthopaedic injuries were the most common and accounted for 78% of all injuries (n = 36), followed by costochondral or rib injuries (n = 7) and lacerations requiring medical care (n = 3). The elbow was found to be the joint most commonly injured during BJJ competitions, with the arm bar being the most common mechanism. We propose that this BJJ-specific injury mechanism, the “arm bar,” be recognized as another mechanism of hyperextension injury to the elbow in sports.

Conclusion:

Comparison of the BJJ injury data with injury data reported for judo, taekwondo, wrestling, and mixed martial arts showed that BJJ competitors were at substantially lower risk of injury compared with these other sports. With orthopaedic injuries being most common and the elbow being the area most vulnerable to injury in BJJ, it is important that participants, referees, and physicians be properly educated about the unique mechanisms of injury that can occur, particularly to the elbow.

Coronoid fractures of the elbow

Coronoid fractures of the ulna are relatively uncommon, yet critical injuries to recognize. They often occur in association with elbow dislocations and play an important role in elbow instability. Historic recommendations are to fix all large coronoid fracture fragments, as well as small fracture fragments associated with instability. There is little data regarding management of small coronoid fracture fragments. The coronoid process acts as a bony buttress to prevent posterior dislocation and has three soft tissue insertions which lend stability as well: the anterior joint capsule of the elbow, the brachialis muscle and the medial ulnar collateral ligament. Injured patients often present with swelling, tenderness and limited range of motion. After obtaining a detailed history and performing a careful physical examination, plain radiographs should be obtained. If present, dislocations are reduced and post-reduction stability is assessed. If the elbow is unstable, management usually consists of a combination of bony and soft-tissue repairs often including coronoid process repair. Loss of motion is the most common complication of these injuries. The current recommendation is to repair virtually all coronoid fractures associated with instability.