Clinical concepts for treatment of the elbow in the adolescent overhead athlete

Injuries to the adolescent elbow are common because of the repetitive overuse inherent in many overhead sport activities. The management of these patients is greatly facilitated through a greater understanding of the demands placed on the upper extremity kinetic chain during these overhead activities as well as a detailed examination and rehabilitation for the entire upper extremity kinetic chain. Particular emphasis on improving rotator cuff strength and muscular endurance, along with scapular stabilization, is a critical part of elbow rehabilitation in these patients. In addition, the use of a strategic and progressive interval sport return program is necessary to minimize reinjury and return the adolescent overhead athlete to full function.

Skeletal age assessment from elbow radiographs. Review of the literature

Skeletal age is important to evaluate remaining growth. In 50% of normal children and adolescents, skeletal age does not differ from chronological age. During puberty, skeletal age is an important tool when performing a lower limb epiphysiodesis or when treating (conservatively or surgically) patients with spinal deformities. Skeletal age alone is not enough and should be assessed together with other clinical and radiological findings such as standing and sitting heights, Risser sign, Tanner stages and annual growth rate. Puberty starts at 11 years of skeletal age and ends at 13 years of skeletal age in girls; in boys, puberty starts two years later (13 years of skeletal age) and then ends at a skeletal age of 15. Most current clinical and radiographic markers do not help paediatric orthopaedic surgeons to clearly distinguish maturity levels prior to Risser I. Sauvegrain et al. developed a method to assess skeletal age by using elbow radiographs (AP and lateral projections). Between 11 and 13 years of skeletal age in girls and between 13 and 15 years of skeletal age in boys, the olecranon apophysis is characterised by a clear morphological development. This method is a reliable tool to assess skeletal age during puberty because significant morphological changes in the elbow happen every six months.

Juvenile and adolescent elbow injuries in sports

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

[Measurement of the carrying angle of the elbow in 2,000 children at ages six and fourteen years]

OBJECTIVES

It is important to know the carrying angles of both elbows in the evaluation of deformities which may be seen after treatment of distal humerus fractures. This study was performed to determine the basal values of the carrying angle in specific age groups.

METHODS

The carrying angles of both elbows were measured with the use of a goniometry in 2000 students of randomly selected primary schools in Sivas and its nearby districts. Measurements were performed in those who completed the ages of six (500 girls, 500 boys) and 14 (500 girls, 500 boys) years, with the elbow in full extension and forearm in supination. The mean carrying angles of dominant and non-dominant elbows were analyzed in eight groups.

RESULTS

The mean angles measured from dominant arms were significantly greater than those of the contralateral side in both sexes and age groups (p<0.05). The mean angles of both elbows were greater in girls than those of the corresponding elbows in boys at six years of age, while vice versa was the case at 14 years of age; however, these differences did not reach significance (p>0.05). Finally, both boys and girls at 14 years of age had significantly greater angles in dominant and non-dominant elbows compared to corresponding sex and elbow side in six-year groups (p<0.001).

CONCLUSION

Our results are consistent with the literature data showing that the carrying angle increases with age and that it is always greater on the dominant side.

A new look at the sequential development of elbow-ossification centers in children

The pattern and sequence of ossification of the six secondary ossification centers around the elbow in the child were mainly derived from studies done >30 years ago. This series reexamined the sequence and pattern based on a cross-sectional study of the elbow radiographs of 1,577 Chinese children with elbow injuries; age range, from newborn to 17 years. The ratio of girls to boys was 1:2. Each child had a radiograph of the normal and the injured elbow giving a total of 3,154 radiographs. A percentile chart of ossification was constructed for each of the ossification centers in both sexes for easy reference. No differences in the timing and ossification pattern were found between the right and left elbow or between the normal and injured elbow in this study. The sequence of ossification in both boys and girls was found to be the same (i.e., the capitulum first, followed by the radial head, medial epicondyle, olecranon, trochlea, and last, the lateral epicondyle). The ages at which 50% of the girls were found to have positive radiologic ossification for each of these centers were ages 1, 5, 5, 9, 9, and 10 years, respectively. In boys, with the exception of the capitulum, an average delay of 2 years was found in each of the ossification centers, although the sequence remained similar.

MR imaging of the normal developmental anatomy of the elbow

Growth and ossification of the elbow are complex. Interpreting MR images of the elbow in children requires a knowledge of the elbow's developmental changes. This article discusses the basic principles of growth and development of the distal humerus, proximal radius, and ulna. The signal characteristics of cartilage and marrow in the immature skeleton are described. Technical factors related to imaging of growth cartilage are outlined, and specific challenges during imaging of the pediatric elbow are emphasized. The changing MR appearance of the elbow due to ossification and physeal closure is described. The article also explains several pitfalls encountered.

Radiology of the elbow in children

Elbow injuries are common in children. Correct management depends on a correct diagnosis. Most elbow injuries can be diagnosed by standard radiographs, but the variability of the developing secondary ossification centers which appear at different ages renders the diagnosis difficult. The normal development of the pediatric elbow should be learned by everyone who treats children's elbow injuries.

The shoulder and elbow in Apert's syndrome

Nine children with Apert's syndrome were studied and found to have progressive bony dysplasia in the shoulder and elbow. The children showed loss of joint motion and radiographic abnormalities including subluxation and flattening of the humeral head with irregularities of the glenoid. The elbow showed flattening and subluxation of the radial head in radiographs and a positive click on physical examination. The limitation of motion and the presence of bony defects were progressive, suggesting that Apert's syndrome is a progressive generalized dysplasia.

[Age-related changes in large joints and long tubular bones of the upper extremity in children (echographic data)]

Two hundred and ten children at the age of 17 days up to 15 years have been examined. Echocameras, working in the grey scale regime have been used. At examination of the arm, forearm, brachial, elbow and radiocarpal joints in the children the most informative are longitudinal echographic approaches. At examination of the brachial bone head in the children older than 10 years only the anterior longitudinal approach is informative. To perform the echographic investigation of various elements of the locomotor apparatus of the upper extremities in children older than 9-10 years is difficult. The echographic reveal of additional nuclei of ossification and synostosis stages of the long tubular bones of the upper extremities in children often coincide in time with roentgenological data.

The development of centres of ossification of bones forming elbow joints in young swine

Epiphyseal centres of ossification in the bones forming the elbow joints of pigs between one day and 15 weeks of age were examined radiographically, macroscopically, mesoscopically and microscopically. Thoracic limbs from 39 pigs were perfused with India ink or silicone rubber injection compound and the bones were dissected free of soft tissues. The humerus, ulna and radius were fixed in formalin or ethyl alcohol and then cleared by the modified Spalteholz technique. Bones were radiographed, examined grossly, and then cut into slabs for mesoscopical evaluation. Foci considered to be calcifying within cartilaginous anlage were selected for microscopical examination. It was concluded that the epiphyseal centre of ossification develops at different times in different sites in the bones forming the elbow joint. Centres of ossification are initiated when foci of chondrocytes adjacent to one side of a cartilage canal undergo hypertrophy and the inter-territorial matrix becomes calcified. Osteogenesis then proceeds in the calcified focus, presumably with osteoprogenitor cells that originate within the cartilage canals. Subsequently, each epiphyseal centre of ossification enlarges by one of two methods. Firstly, the layer of cartilage adjacent to the centre undergoes endochondral ossification, thus allowing for the circumferential growth of the epiphyseal centre of ossification. Secondly, foci of calcification develop adjacent to the ends of cartilage canals near the epiphyseal centre of ossification and eventually the focus of calcification coalesces with the developing epiphyseal centre of ossification, thus establishing a new ossification front. Endochondral ossification continues at the periphery of the mass of bone. Mesoscopical examination is more useful than radiographical evaluation for identifying small foci of calcification which precede epiphyseal centres of ossification.

Avulsion of the triceps tendon

Avulsion of the triceps tendon is a rare injury. The clinical examination, including a test for complete rupture of the tendon, radiographic findings, characteristics of the normal maturation of the olecranon, and the surgical treatment of this injury are reviewed.

Aging in the musculoskeletal system of rhesus monkeys: I. Passive joint excursion

In order to describe ontogenetic change in the musculoskeletal system of rhesus monkeys, 126 Macaca mulatta from Cayo Santiago, ranging in age from 7 months to 21 years, were examined under anesthesia. Passive joint excursions were measured at the wrist, elbow, shoulder, hip, and knee. Mean ranges of excursion at these joints differed significantly between age groups and by sex. The potential for most movements appeared to decrease approximately 25 degrees over the first two decades of the macaque life span, and males generally showed less potential for movement than females in all age groups. These results are similar to those obtained for humans and are consistent with patterns of positional behavior, trauma, and osteoarthritis observed in this rhesus monkey population. Thus, to fully describe the locomotor strategy of rhesus monkeys, age- and sex-related variation in locomotor anatomy and functional capacity must be considered.

[Diagnostics and therapy of osseous elbow lesions in the growing skeleton]

Osseous elbow lesions in the growing skeleton often involve problems of diagnosis, indication and therapy which are essentially different from those occurring in adult persons. Beyond its task to prove or to exclude a fracture line, X-ray diagnosis also has to search systematically for discernible soft tissue modifications (adipoid signs) or for disturbed correlations of positions and axes. When adopting an indication for conservative or surgical treatment, it has to be considered that rotation faults are not compensated during the further growth of bones and that an insufficient reposition of an epiphysis fracture causes a tendency towards an increase of the joint deformity when the bone is growing. The treatment of a bone fracture aims not only at a good elbow joint function which can be achieved even by a conservative, insufficient reposition, but also at an exact reposition and a reliable fixation during the short healing time. In most cases, the latter is only possible by means of fine metal implants (drilling wires and screws for little fragments which, by way of exception, do not touch the epiphyseal cartilage). This is the only way to avoid joint deformations and defective positions in adolescents which can promote the formation of destructive arthroses in adults. As opposed to fractures in adult persons, the functional result is not deteriorated by an additional immobilization for a period of three to four weeks effected in order to guarantee the so-called "minimal osteosynthesis".