- Email: [email protected]
Bony overuse injuries about the elbow
BONY OVERUSE INJURIES ABOUT THE ELBOW RICHARD B. JONES, MD and ROBERT H. MILLER III, MD
Elbow injuries are becoming increasingly common, especially among racquet and throwing sport athletes. Treatment of overuse injuries of the elbow continues to evoh,e. The purpose of this report is to discuss some of the more common bony overuse injuries of the elbow including osteochondritis dissecans of the capitellum, olecranon stress fractures, and valgus extension overload. Other less common entitites include osteochondritis dissecans of the trochlea and medial epicondyle injuries. Diagnosis, current treatment recommendations, and rehabilitation are discussed. KEY WORDS: osteochondritis dissecans, valgus extension overload, olecranon Copyright © 2001 by W.B. Saunders Company
Bony overuse injuries of the elbow are often complex and usually contain some soft tissue c o m p o n e n t to their pathology. They are most often caused by repetitive stresses, such as those experienced by throwing athletes, racquet sport athletes, and gymnasts. Tullos et al ~reported that 50% of professional pitchers experienced shoulder or elbow s y m p t o m s significant enough for them to cease pitching at various times in their careers. The most common bony overuse injuries about the elbow are osteochondritis dissecans of the capitellum, olecranon stress fractures, and valgus extension overload. Other less c o m m o n disorders include osteochondritis dissecans of the trochlea and fracture of the medial epicondyle.
OSTEOCHONDRITIS DISSECANS OF THE CAPITELLUM Osteochondritis dissecans of the capitellum was first described in 1929 by Panner, 2 who believed it to be analogous to Perthes disease of the hip. The disorder has long been identified in adolescent and young adult athletes involved in repetitive activities, such as throwing, or activities that place the u p p e r extremity in a weight-bearing position, such as gymnastics. Osteochondritis dissecans of the capitellum is a localized lesion in which a segment of the articular surface, including the cartilage and subchondral bone, is involved. The cause of osteochondritis dissecans is still uncertain, although microtrauma, genetic factors, and ischemic events have been implicated. 3-" Overuse-related changes in the immature elbow can be considered in the following 2 groups: osteochondritis of the capitellum (Panner's disease) and osteochondritis dissecans of the elbow. Panner's disease occurs in children 4 to 8 years old and involves the entire ossific nucleus of the capitellum. 2 It often is a self-limited problem, leading to
reossification and resolution with time. -~,5-7 On the other hand, osteochondritis dissecans typically occurs in patients aged 10 years and older and involves only a portion of the capitellum. It also may be associated with permanent deformity of the joint surface. Some believe these are simply a continuum of the same process, but others believe they are separate clinical entities. -~," Diagnosis
The most c o m m o n s y m p t o m is an insidious onset of progressive pain, usually in the lateral aspect of the elbow of tile dominant arm. ~." Pain usually is activity-related and often improves with rest. Tenderness may be elicited with palpation over the lateral elbow at approximately the radiocapitellar joint. Patients often have a loss of extension of the elbow as well. Popping, catching, or grinding may be present, indicating the possibility of a loose body. Symptoms may be reproduced by asking the patient to pronate and supinate the forearm with the elbow in full extension, which causes compression of the radiocapitellar joint2 Standard anteroposterior and lateral radiographs of the elbow usually are sufficient to evaluate the lesion. These often show the characteristic radiolucency or rarefaction of the lateral or central portion of the capitellum (Fig 1). Loose bodies may be seen in advanced cases, as well as h y p e r t r o p h y of the radial head. Other views, such as 45 ° obliques, may also be helpful. Computed tomography and magnetic resonance imaging (MRI) (Fig 2) are useful in defining the osseous extent of the lesion. Reported early changes include a low-signal intensity in Tl-weighted images and no abnormalities on T2-weighted images. Later stages may show intervening fluid on T2-weighted images, indicating detachment of the fragment. ~ Treatment
From the University of Tennessee--Campbell Clinic, Department of Orthopaedic Surgery, Memphis, TN. Address reprint requests to Richard B. Jones, MD, University of Tennessee--Campbell Clinic, Department of Orthopaedic Surgery, 910 Madison Ave, 5th Floor, Memphis, TN 38103-3433. Copyright © 2001 by W.B. Saunders Company
1048-6666/01/1101-0007535.00/0 doi:10.1053/otor.2001.18701
Treatment of osteochondritis dissecans of the capitellum depends on several factors, including tile symptoms, radiographic appearance, tile age of the patient, and the status of the articular fragment (detached or attached). Although true Panner's disease usually resolves with rest and inactivity, 2.'~," tile treatment of osteochondritis disse-
Operative Techniques in Orthopaedics, Vol 11, No 1 (January), 2001: pp 55-62
55
nondisplaced fragment; and grade 5 lesions have a displaced fragment with subsequent loose bodies. The treatment recommended by Baumgarten et aP includes observation or drilling of grade 1 lesions, excision of affected cartilage to a stable rim and abrasion chondroplasty of grade 2 lesions, removal of the osteochondral fragment and abrasion chondroplasty of grade 3 and 4 lesions, and abrasion chondroplasty and search for loose bodies in grade 5 lesions. At an average 48-month follow-up, 4 of their 17 patients still had pain, 14 had resumed their preinjury level of activity, and flexion contractures were decreased from an average 19° preoperatively to 5° at follow-up. Also, 8 of 17 had some flattening of the radial head on radiographs but no other degenerative changes. Ruch et al "~ reported good results with arthroscopic debridement and early range of motion in 12 patients with an average age of 14.5 years. At an average follow-up of 3.2 years, flexion contractures improved from an average 23 ° to 10°. All patients had remodeling of the capitellum, but 5 had radial head enlargement. Eleven patients were highly satisfied with their results with no limitation of activities. Jackson et al 4 reported their results with arthroscopic or open debridement of lesions, drilling, and excision of loose bodies in 10 female gymnasts aged 10 to 17 years. At an average follow-up of 2.9 years, all showed reossification of the defects. All had improvement in symptoms, but only 1 of the 10 returned to competitive gymnastics. Any benefit from arthroscopic or open fixation of fragments is controversial. Fixation devices have included
Fig 1. Radiographic appearance of osteochondritis dissecans of the capitellum.
cans must be individualized. Lesions with intact articular cartilage often can be treated with rest and protection of the elbow for approximately 6 weeks, xS,",l"A hinged brace can be used to maintain range of motion after a short period of immobilization. When pain has resolved, a gradually progressive physical therapy program is begun, including stretching and strengthening as well as sportspecific exercises. Patients usually return to full activity within 3 to 6 months. Lesions should be followed up radiographically for the next few years. Arthroscopy is tile mainstay of surgical treatment. Baumgarten et aP described an arthroscopic classification system of osteochondritis dissecans of the capitellum and outlined treatment recommendations. Grade 1 lesions have smooth but soft ballotable articular cartilage (Fig 3); grade 2 lesions have fibrillations or fissuring of the articular cartilage; grade 3 lesions have exposed bone with a fixed osteochondral fragment; grade 4 lesions have a loose, 56
Fig 2. MRI appearance of osteochondritis dissecans of the capitellum. JONES AND MILLER
radial nerves. The arthroscopy cannula is passed with a blunt trocar along the same course as the needle, just proximal and anterior to the radiocapitellar articulation. The arthroscope is inserted through this cannula with inflow through the arthroscope. This portal allows examination of the coronoid process of the ulna and the trochlear ridge. An anteromedial portal can be established with the Wissinger rod technique or under direct arthroscopic vision through the anterolateral portal. An 18-gauge spinal needle can be inserted through tile anticipated anteromedial portal site 2 cm distal and 2 cm anterior to the medial epicondyle into tile joint while confirming satisfactory position arthroscopically. After the skin is incised and the fascia is reached with a hemostat, a blunt trocar is inserted following the same course as the needle, heading toward tile center of the joint. With the cannula in the anterolateral portal, the arthroscope can be switched to the anteromedial portal to view the radioulnar and radiocapitellar articulations and the amlular ligament. Extending the elbow shows more of the capitellum, and pronating and supinating the forearm exposes more of the radial head. Placing varus stress on tile joint allows tile articular surface of the capitellum to be seen better. The direct lateral portal is very useful for viewing osteochondritis dissecans lesions.
Fig 3. Arthroscopic appearance of grade 3 osteochondritis dissecans of the capitellum.
Kirschner wires, absorbable screws, and variable pitch screws, but most reports indicate no advantage to this procedure.5,7,.~ The arthroscopic approach to treatment of osteochondritis dissecans of the capitellum should include thorough inspection of tile lesion as well as tile entire elbow.
Arthroscopic technique. The procedure begins with distention of the elbow joint. An 18-gauge spinal needle is inserted at the direct lateral portal and aimed directly toward the center of the joint. The needle passes between the olecranon, radial head, and distal humerus. Care must be taken to avoid extending too far anteriorly and entering the soft tissues in the antecubital fossa. A 50- to 60-mL syringe and connective tubing are used to distend the elbow with fluid. Free backflow of fluid confirms proper intra-articular location of the needle. Then the joint is maximally distended with 25 to 35 mL of fluid to displace the neurovascular structures anteriorly in the antecubital fossa and to increase the space available in the anterior aspect of the joint. With the first needle in place and distention maintained, a second 18-gauge spinal needle is inserted through the anterolateral portal 3 cm distal and 1 cm anterior to the lateral epicondyle. This needle is aimed toward the center of the joint, and again free backflow of the solution confirms an intra-articular location. The needle is removed and the skin is incised with the tip of a no. 11 blade by pulling the skin against the cutting edge. A mosquito hemostat is used to dissect bluntly d o w n to the fascia to minimize the chance of injury to cutaneous or BONY OVERUSE INJURIESABOUT THE ELBOW
Direct lateral portal. The 4.0-mm scope is left with tile inflow in the anteromedial portal to maintain joint distention whereas the smaller 2.7-ram scope is used to examine the structures through the direct lateral portal. This portal is made proximal and posterior to the radiocapitellar articulation, just posterior to the previously established anterolateral portal. If a second working portal is required, it is placed approximately 1 cm distally, approximating the articulation. This can be used instead of an anterolateral portal. A blunt trocar is used to carefully enter the joint to avoid scuffing tile articular cartilage. The concavity of tile radial head articulating on the convex capitellum is examined. The lens is turned to look anteriorly and tile elbow is moved gently through flexion and extension to examine the surface of the capitellum, looking for chondromalacia and any chondral defects producing instability and incongruence. The scope is now swept back posteriorly to examine tile articulation between tile olecranon and the trochlea. Small loose bodies may hide in this area. A normal bare area exists in tile olecranon articulation at the site of the physeal scar. Tile articulation can be followed proximally to view the posteromedial olecranon tip. Through this direct lateral portal the entire extent of the lesion should be identified with a probe. If the lesion is firmly attached and involves a substantial part of tile articular surface in a preadolescent patient, the lesion is drilled with a 0.062 Kirschner wire to stimulate local healing. If tile fragment is loose, it can be elevated with a small osteotome and removed with an arthroscopic grasper. The remaining crater is then debrided with a small curette or arthroscopic burr d o w n to healthy bleeding bone, and the articular edges are debrided to stable cartilage. Once the fragment is removed, an arthroscopic examination of the entire elbow should be performed as described above. Any loose bodies should be removed with an arthroscopic 57
grasper. Large fragments may require a small arthrotomy for excision or reduction and internal fixation. Postoperatively, an aggressive physical therapy program is begun, including immediate active range of motion exercises and isometric strengthening. A posterior splint can be used immediately after surgery for pain relief, but should not be used more than a few days. Light throwing usually can be resumed as early as 6 to 8 weeks, but this depends on the procedure performed, t~
OLECRANON STRESS FRACTURES Stress fractures of the olecranon in throwers were initially described by Waris ~2 in 1946. The following 3 types of olecranon stress fractures have been described: stress fracture of the physis in adolescent gymnasts, tip fracture of the olecranon, and fracture of the olecranon itself. ~x~4 The third type has been divided into 2 groups according to the configuration of the fracture line. A transverse fracture generally is considered to be caused by a traction force from the triceps, while an oblique fracture line is believed to result from a valgus extension overload that causes the posteromedial olecranon to impact the medial wall of the olecranon fossa and the lateral edge of the coronoid to impinge in the intercondylar notch to resist the valgus stress. This repeated impingement is believed to cause an oblique stress fracture. ~
Diagnosis Olecranon tip fractures and stress fractures are not the same clinical entity even though both occur in throwers. Patients with tip fractures usually have acute pain in the elbow after a particularly hard throw, while patients with stress fractures usually have a longer history of chronic pain that recurs when throwing is resumed after a period of rest. Tenderness can be elicited over the olecranon in most patients with either fracture, but pain also may occur over the medial collateral ligament (MCL). Pain with valgus stress may be present with stress fractures, MCL injury, or posteromedial osteophytes. Veltri et a l " described a useful test, the "milking maneuver," to differentiate MCL injuries from olecranon injuries. With the patient's elbow flexed more than 90 °, the examiner grasps the thumb of the affected arm to apply a valgus stress on the MCL, while using the opposite hand to palpate the olecranon and the MCL. Pain over the MCL during this maneuver indicates injury to the ligament and not the olecranon, because the olecranon is not engaged in the fossa when the elbow is flexed more than 90 ° . Patients may also have a nonspecific loss of elbow motion. Radiographic evaluation usually is necessary to determine the type of fracture. Radiographically, tip fractures involve as much as a third of the olecranon, whereas stress fractures occur in the middle third (Fig 4). If the fracture is not visible on initial films, bone scanning (Fig 5A), computed tomography (Fig 5B), or MRI (Fig 5C) may be indicated. Recognition of physeal injuries in adolescents may be more difficult. By the age of 12 years, the olecranon physis is narrow (rarely wider than 5 ram) with serpiginous, congruent borders. With a physeal fracture the physis may appear widened or fragmented with sclerotic bor58
Fig 4. Radiographic appearance of olecranon stress fracture.
ders. Comparison radiographs of the opposite elbow may be helpful.
Treatment Because nonunion and formation of loose bodies can occur after olecranon tip fractures, surgical excision usually is recommended. 17 Fractures through the body generally can be treated conservatively with 6 to 8 weeks of activity restriction, during which stretching and range of motion exercises are continued. Strength and endurance programs, such as swimming, can be begun after this time, but no heavy strength training activities are permitted until bony healing is evident clinically and radiographically, which may require 8 to 12 weeks. At this time, a light throwing program can be initiated. Complete recovery may take 3 to 6 months. Safran 17 outlined a general nonoperative treatment protocol for overuse injuries about the elbow using the acronym PRICEMM. The elbow is protected from further injury, rested, iced, compressed with an elastic bandage, and elevated. Medications (nonsteroidal anti-inflammatory drugs) are used for inflammation, and modalities such as iontophoresis are used. If these measures fail to provide relief, surgical treatment is indicated. Techniques described for olecranon fractures include drilling perpendicularly across the fracture site, ~s open reduction and internal fixation with or without bone grafting, L~,~',2" and percutaneous placement of a 6.5-ram cannulated screw. Most undisplaced olecranon stress fractures can be treated with percutaneous 6.5-ram screws, 100 to 110 mm long. For displaced physeal fractures in adolescents, open reduction and internal fixation with bone grafting have been r e c o m m e n d e d because of the frequency of fibrous nonunion. 21,22 An untreated physeal fracture or nonunion may lead to incomplete fusion of the physis, which has been reported to increase the risk of fracture in adults. 2~ Technique of internal fixation of olecranon stress fracture. The fracture is approached posteriorly with an incision paralleling the lateral border of the olecranon. Oblique fractures can be fixed with screws inserted perpendicular to the fracture line. ~s Transverse fractures are fixed with a JONES AND MILLER
: ~
.'
i
LEFT
Postoperative Care
LRTERRL
17 Itnb 1~q7 aS. 14~B~
6.5-mm intramedullarypin (Fig 6). If a supplemental tension band wire is needed, a hole is drilled tranversely across the distal fragment, and a no. 18 stainless steel wire is passed through the aponeurosis of the triceps, around the olecranon, and brought distally and obliquely across the fracture site. It is passed through the drill hole in the distal fragment and passed obliquely again over the fracture site. The 2 ends are then twisted together until the construct is tight.
"'+:~';'~'~+-
Postoperatively, a posterior splint is worn for 7 to 10 days, then, gentle range of motion exercises are begun. A hinged brace is used for 4 to 6 weeks. When radiographic signs of healing are present and there is no tenderness, a light throwing program is begun. This can begin as early as 6 to 8 weeks, but typically begins at 10 to 12 weeks. Strengthening exercises are started and progressed to throwing without restrictions.
VALGUS EXTENSION OVERLOAD Valgus extension overload syndrome is a spectrum of injuries with soft tissue and bony components that include ulnar collateral ligament injury, flexor pronator injury, radiocapitellar overload, and posteromedial impingement. King et a123 initially described olecranon impingement as caused by medial elbow stress, cubitus valgus, and a narrowed olecranon fossa from bony hypertrophy. It is currently thought that the mechanism of injury occurs in the acceleration phase of pitching when excessive valgus stress applied to the elbow causes wedging of the olecranon in the olecranon fossa. This subsequently causes osteophyte production at the posterior and posteromedial aspects of the tip of the olecranon, eventually leading to chondromalacia or loose body formation. 24-2s Whether treatment of this condition is open or arthroscopic, Andrews 25 stressed the importance of treating the "true offending symptomatic lesion" or the posteromedial osteophyte.
Diagnosis Patients typically have pain in the elbow with forced extension and valgus strain as in the acceleration phase of pitching. Examination may elicit specific points of tenderhess. Tenderness posteromedially along the tip of the olecranon is common, as is pain with valgus stress in extension and forced extension of the elbow. 2" A flexion contracture of the elbow may be present. Wilson et al 2" reported that pitchers gradually become ineffective, making it 2 or 3 innings before a gradual loss of control begins. This often is manifested as an early release, causing them to throw high. Radiographs should include anteroposterior, lateral, and, in throwers, axial views. The elbow should be flexed approximately 110° and with the arm lying on the cassette the beam should be angled at 45 ° to the ulna. This gives the best view of the olecranon as it articulates with the
Fig 5. Olecranon stress fracture as seen on (A) bone scan, (B) computed tomography scan, and (C) MRI.
midline 3 cm proximal to the olecranon tip. Care must be taken with the use of any instruments medially to avoid injury to the ulnar nerve. First, a full-radius resector is used to excise soft tissue and hypertrophic synovium from the posterior compartment to fully expose the extent of the osteophytes. Then a 0.25-in osteotome can be introduced through the posterior portal. Approximately 5 to 10 m m of the tip of the olecranon should be removed with the osteotome. The fragment can then be levered out with a grasper. A 4-ram round burr is used to contour the remaining olecranon tip. A full-radius resector can then be used to smooth the olecranon edges. Any "kissing lesions" of chondromalacia present on the corresponding olecranon fossa should be debrided as well.
2
""
"-L
.,.
Fig 6. Intramedullaryfixation of olecranon fracture. trochlea and puts the medial aspect of the olecranon on profile, which may show a posteromedial osteophyte (Fig 7). Occasionally, oblique views are helpful in identifying loose bodies or osteophytes. Computed tomography, MRI, or arthrotomography also are useful for showing articular cartilage defects, osteophytes, or loose bodies, but are not necessary in all patients.
Treatment Conservative treatment is tried before any surgical intervention is undertaken. The rehabilitation program focuses on diminishing pain and inflammation about the posterior elbow region and improving eccentric strength and control of the elbow flexors to control the forceful elbow extension that occurs during the deceleration phase of pitching. If conservative treatment fails, arthroscopic or open surgical intervention is indicated. This is typically done arthroscopically because of less soft tissue dissection and the chance for earlier, more aggressive rehabilitation. After routhle arthroscopic examination of the joint, a direct lateral portal can be established as previously described. Accessory portals include the straight posterior and posterolateral portals.
Straight posterior portal, A straight posterior portal is made under direct vision with the arthroscope in the direct lateral portal. The posterior toral is created in the 60
Posterolateral portal. The posterolateral portal can be established under arthroscopic guidance with the arthroscope in the direct lateral portal and the lens directed posteriorly or with the arthroscope in the posterior portal. An 18-gauge needle is inserted 3 cm proximal to the olecranon tip and just lateral to the triceps tendon, aimed superiorly, and satisfactory position is confirmed. The skin is excised and a small hemostat is used to spread d o w n to the capsule. A blunt trocar is used to enter the joint. The arthroscopic view through this portal includes the olecranon fossa, olecranon tip, and posterior trochlea and a portion of the posterior band of the ulnar collateral ligament. Osteophytes are typically located on the posterior and posteromedial tip of the olecranon. Loose bodies frequently gravitate to the posterior compartment.
Postoperative Care Range of motion is begun immediately after surgery. Swelling and inflammation are controlled with ice and compressive dressings. Light strength training and functional activities are started at approximately 2 weeks and progressed over the next 6 to 8 weeks. By 8 to 12 weeks, sport-specific activities are resumed. ~,-~"
OSTEOCHONDRITIS THE TROCHLEA
D I S S E C A N S OF
Osteochondritis dissecans of the trochlea is rare, and only a few cases have been reported in the literature. 3~,32 The patients reported have been adolescents with chronic elbow pain usually with actMty and occasional joint crepitance. Radiographs showed a lytic area in the trochlea with sclerotic borders. In 1 patient the lesion was in the medial articular eminence or the region separating the trochlea from the capitellum. MRI appearance was similar to that of osteochondritis dissecans of the capitellum. Surgical exploration in 1 patient found a lesion consisting of necrotic tissue without overlying cartilage. No loose bodies were found. It was theorized that the lesion resulted from vascular insults from repetitive microtrauma22
P H Y S E A L F R A C T U R E OF THE M E D I A L EPICONDYLE Fractures of the medial epicondylar physis can occur in skeletally immature athletes, although this is a relatively
JONES AND MILLER
Fig 7. Valgus extension overload. Posteromedial osteophyte is visible on anteroposterior (A) and lateral (B) views.
u n c o n l m o n overuse injury a b o u t the elbow. These fi'actures can be caused by repeated valgus stress, a fall, or repetitive violent forearm flexor muscle contractions as in p itching. ~7.~,~ Children with this injury usually have medial elbow pain with throwing. T h r o w i n g accuracy and distance are often affected. Point tenderness m a y be elicited over the medial epicondyle, and a flexion contracture usually is present. Radiographically, the epicondylar physis m a y a p p e a r widened or fragmented, w.~-~ A c o m p a r i s o n view of the opposite elbow is m a n d a t o r y . The a m o u n t of displacem e n t should be critically assessed in a throwing athlete, because laxity of the ulnar collateral ligament m a y result. Treatment d e p e n d s on stability of the fragment, w.s".-~r which can be evaluated by the gravity stress test. This consists of an anteroposterior radiograph taken with the patient supine to allow the weight of the arm to cause a valgus stress on the ulnar collateral ligament. If the fragm e n t m o v e s distally and the joint gaps open medially, the elbow is considered unstable, w If the fragment is stable, rest and immobilization are a p p r o p r i a t e treatment, with a gradual return to throwing at 6 to 8 weeks. Unstable elbows, especially in the d o m i n a n t arm of a throwing athlete, should be treated by open reduction and internal fixation through a medial approach. The ulnar nerve can be left in place, and the fragment can be fixed with a BONY OVERUSE INJURIES ABOUT THE ELBOW
cancellous screw or Kirschner wire. w.24 Postoperatively, a posterior splint is applied. This can be changed to a hinged brace at 1 to 2 weeks and range of motion should be progressed over the next 4 weeks until full motion is obtained. T h r o w i n g usually is resumed at about 6 weeks.
CONCLUSION Most elbow injuries in athletes are chronic, overuse injuties that result from intrinsic or extrinsic overload, most c o m m o n l y osteochondritis dissecans of the capitellum, olecranon stress fractures, and valgus extension overload. Other less c o m m o n disorders are osteochondritis dissecans of the trochlea and fracture of the medial epicondyle. Initial treatment of most overuse injuries of the elbow consists of cessation of the aggravating activity. Surgical treatment, generally arthroscopic, is reserved for unstable or recalcitrant injuries.
REFERENCES 1. Tt.llos HS, Erwin WD, Woods GW, et al: Unusual lesions of the
pitching arm. Clin Orthop 88:169-182, 1972 2. Panner HJ: A peculiar affection of tile capitellum humeri resembling Calv,5-Perthes disease of the hip. Acta Radiol 10:234-242, 1927 3. Baumgarten TE, Andrews JR, Satterwhite YE: The arthroscopic classification and treatment of osteochondritis dissecans of the capitellure. Am J Sports Med 26:520-523, 1998
61
4. Jackson DW, SiMno N, Reiman P: Osteochondritis in the female gymnast's elbow. Arthroscopy 5:129-136, 1989 5. Peterson RK, Savoie FH Ill, Field LD: Osteochondritis dissecans of the elbow. AAOS lnstr Course Lect 48:393-398, 1999 6. Schenck RC, Goodnight JM: Current concepts review: osteochondritis dissecans. J Bone Joint Surg 78A:156-160, 1996 7. McManama GB, Micheli LJ, Berry MV, et al: The surgical treatment of osteochondritis of tile capitellum. Am J Sports Med 13:11-21, 1985 8. Takahara IVl, Shundo M, Kondo M, et al: Early detection of osteochondritis dissecans of the capitellum in young baseball players: Report of three cases. J Bone Joint Surg 80A:892-897, 1998 9. Pavlov H, Torg JS, Jacobs B, et al: Nonunion of olecranon epiphysis: two cases in adolescent baseball pitchers. AJR Am J Roentgenol 136:819-820, 1981 10. Ruch DS, Cory JW, Poehling GG: The arthroscopic management of osteochondritis dissecans of the adolescent elbow. Arthroscopy 14: 797-803, 1998 11. Azar FIVl,Wilk KE: Nonoperative treatment of the elbow in throwers. Op Tech Sports Med 4:91-99, 1996 12. Waris W: Elbow injuries of javelin-throwers. Acta Chit Scand 93:563575, 1946 13. Brukner P: Stress fractures of timeupper limb. Sports IVied 26:415-424, 1998 14. Nuber GW, Diment MT: Olecranon stress fractures in throwers: A report of two cases and a review of the literature. Clin Orthop 278:58-61, 1992 15. Suzuki K, Minami A, Suenaga N, et al: Oblique stress fracture of time olecranon in baseball pitchers. J Shoulder Elbow Surg 6:491-494, 1997 16. Veltri DM, O'Brien SJ, Field LD, et al: The milking maneuver: A new test to evaluate time MCL of time elbow in time throwing athlete. Presented at time 10m Open IVleeting of the American Shoulder and Elbow Surgeons, New Orleans, LA, 1994 17. Safran MR: Elbow injuries in athletes. Clin Orthop 310:257-277, 1995 18. Kvidera DJ, Pedegana LR: Stress fracture of timeolecranon: Report of two cases and review of time literature. Orthop Rev 12:113-116, 1983 19. Banas MP, Lewis RA: Nonunion of an olecranon epiphyseal plate stress fracture in an adolescent. Orthopedics 18:1111-1112, 1995
62
20. Maffulli N, Chart D, Aldreige M]: Overuse injuries of tile olecranon in young gymnasts. J Bone Joint Surg 74B:305-308, 1992 21. Kovach J 11, Baker BE, Mosher JP: Fracture-separation of time olecranon ossification center in adults. Am J Sports Med 13:105-111, 1985 22. Orava S, Hulko A: Delayed unions and nonunions of stress fractures in athletes. Am J Sports IVied 16:378-382, 1988 23. King JW, Brelsford H J, Tullos HS: Analysis of the pitching arm of the professional baseball pitcher. Clin Orthop 67:116-123, 1969 24. Andrews JR, Jelsma RD, Joyce ME, et al: Open surgical procedures for injuries to tile elbow in throwers. Op Tech Sports Med 4:109-113, 1996 25. Andrews JR: Bony injuries about tile elbow in the throwing athlete. AAOS Instr Course Lect 34:323-331, 1985 26. Wilson FD, Andrews JR, Blackburn TA, et al: Valgus extension overload in time pitching elbow. Am J Sports Med 11:83-88, 1983 27. Martin DS, Baumgarten TE: Elbow injuries in the throwing athlete: Diagnosis and treatmenL Op Tech Sports Med 4:100-108, 1996 28. Moskal MJ, Savoie FH 111, Field LD: Arthroscopic treatment of posterior elbow impingement. AAOS Instr Course Lect 48:399-404, 1999 29. Rettig AC: Elbow, forearln, and wrist injuries in tile athlete. Sports Med 25:115-130, 1998 30. Wilk KE, Arrigo CA, Andrews JR, et al: Rehabilitation following elbow surgery in the throwing athlete. Op Tech Sports Med 4:114132114199, 1996 31. Chan D, Aldridge MJ, Maffulli N, et al: Chronic stress injuries of the elbow in young gymnasts. Br J Radiol 64:1113-1118, 1991 32. Vanthournout I, Rudelli A, Valenti P, et al: Osteochondritis dissecans of the trochlea of tile humerus. Pediatr Radiol 21:600-601, 1991 33. Nyska M, Peiser J, Lukiec F, et al: Avulsion fracture of the medial epicondyle caused by arm wrestling. Am J Sports Med 20:347-350, 1992 34. Gore RM, Rogers LF, Bowerman J, et al: Osseous manifestations of elbow stress associated with sports activities. AJR Am J Roentgenol 134:971-977, 1980 35. Smith FM: Medial epicondyle injuries. JAMA 142:396-402, 1950 36. Woods GW, Tullos KS, King JW: The throwing arm: Elbow injuries. Am J Sports Med 1:43-47, 1973 (suppl) 37. Woods GW: Elbow instability and medial epicondyle fractures. Am J Sports Med 5:23-30, 1977
JONES AND MILLER
Elbow injuries are becoming increasingly common, especially among racquet and throwing sport athletes. Treatment of overuse injuries of the elbow continues to evoh,e. The purpose of this report is to discuss some of the more common bony overuse injuries of the elbow including osteochondritis dissecans of the capitellum, olecranon stress fractures, and valgus extension overload. Other less common entitites include osteochondritis dissecans of the trochlea and medial epicondyle injuries. Diagnosis, current treatment recommendations, and rehabilitation are discussed. KEY WORDS: osteochondritis dissecans, valgus extension overload, olecranon Copyright © 2001 by W.B. Saunders Company
Bony overuse injuries of the elbow are often complex and usually contain some soft tissue c o m p o n e n t to their pathology. They are most often caused by repetitive stresses, such as those experienced by throwing athletes, racquet sport athletes, and gymnasts. Tullos et al ~reported that 50% of professional pitchers experienced shoulder or elbow s y m p t o m s significant enough for them to cease pitching at various times in their careers. The most common bony overuse injuries about the elbow are osteochondritis dissecans of the capitellum, olecranon stress fractures, and valgus extension overload. Other less c o m m o n disorders include osteochondritis dissecans of the trochlea and fracture of the medial epicondyle.
OSTEOCHONDRITIS DISSECANS OF THE CAPITELLUM Osteochondritis dissecans of the capitellum was first described in 1929 by Panner, 2 who believed it to be analogous to Perthes disease of the hip. The disorder has long been identified in adolescent and young adult athletes involved in repetitive activities, such as throwing, or activities that place the u p p e r extremity in a weight-bearing position, such as gymnastics. Osteochondritis dissecans of the capitellum is a localized lesion in which a segment of the articular surface, including the cartilage and subchondral bone, is involved. The cause of osteochondritis dissecans is still uncertain, although microtrauma, genetic factors, and ischemic events have been implicated. 3-" Overuse-related changes in the immature elbow can be considered in the following 2 groups: osteochondritis of the capitellum (Panner's disease) and osteochondritis dissecans of the elbow. Panner's disease occurs in children 4 to 8 years old and involves the entire ossific nucleus of the capitellum. 2 It often is a self-limited problem, leading to
reossification and resolution with time. -~,5-7 On the other hand, osteochondritis dissecans typically occurs in patients aged 10 years and older and involves only a portion of the capitellum. It also may be associated with permanent deformity of the joint surface. Some believe these are simply a continuum of the same process, but others believe they are separate clinical entities. -~," Diagnosis
The most c o m m o n s y m p t o m is an insidious onset of progressive pain, usually in the lateral aspect of the elbow of tile dominant arm. ~." Pain usually is activity-related and often improves with rest. Tenderness may be elicited with palpation over the lateral elbow at approximately the radiocapitellar joint. Patients often have a loss of extension of the elbow as well. Popping, catching, or grinding may be present, indicating the possibility of a loose body. Symptoms may be reproduced by asking the patient to pronate and supinate the forearm with the elbow in full extension, which causes compression of the radiocapitellar joint2 Standard anteroposterior and lateral radiographs of the elbow usually are sufficient to evaluate the lesion. These often show the characteristic radiolucency or rarefaction of the lateral or central portion of the capitellum (Fig 1). Loose bodies may be seen in advanced cases, as well as h y p e r t r o p h y of the radial head. Other views, such as 45 ° obliques, may also be helpful. Computed tomography and magnetic resonance imaging (MRI) (Fig 2) are useful in defining the osseous extent of the lesion. Reported early changes include a low-signal intensity in Tl-weighted images and no abnormalities on T2-weighted images. Later stages may show intervening fluid on T2-weighted images, indicating detachment of the fragment. ~ Treatment
From the University of Tennessee--Campbell Clinic, Department of Orthopaedic Surgery, Memphis, TN. Address reprint requests to Richard B. Jones, MD, University of Tennessee--Campbell Clinic, Department of Orthopaedic Surgery, 910 Madison Ave, 5th Floor, Memphis, TN 38103-3433. Copyright © 2001 by W.B. Saunders Company
1048-6666/01/1101-0007535.00/0 doi:10.1053/otor.2001.18701
Treatment of osteochondritis dissecans of the capitellum depends on several factors, including tile symptoms, radiographic appearance, tile age of the patient, and the status of the articular fragment (detached or attached). Although true Panner's disease usually resolves with rest and inactivity, 2.'~," tile treatment of osteochondritis disse-
Operative Techniques in Orthopaedics, Vol 11, No 1 (January), 2001: pp 55-62
55
nondisplaced fragment; and grade 5 lesions have a displaced fragment with subsequent loose bodies. The treatment recommended by Baumgarten et aP includes observation or drilling of grade 1 lesions, excision of affected cartilage to a stable rim and abrasion chondroplasty of grade 2 lesions, removal of the osteochondral fragment and abrasion chondroplasty of grade 3 and 4 lesions, and abrasion chondroplasty and search for loose bodies in grade 5 lesions. At an average 48-month follow-up, 4 of their 17 patients still had pain, 14 had resumed their preinjury level of activity, and flexion contractures were decreased from an average 19° preoperatively to 5° at follow-up. Also, 8 of 17 had some flattening of the radial head on radiographs but no other degenerative changes. Ruch et al "~ reported good results with arthroscopic debridement and early range of motion in 12 patients with an average age of 14.5 years. At an average follow-up of 3.2 years, flexion contractures improved from an average 23 ° to 10°. All patients had remodeling of the capitellum, but 5 had radial head enlargement. Eleven patients were highly satisfied with their results with no limitation of activities. Jackson et al 4 reported their results with arthroscopic or open debridement of lesions, drilling, and excision of loose bodies in 10 female gymnasts aged 10 to 17 years. At an average follow-up of 2.9 years, all showed reossification of the defects. All had improvement in symptoms, but only 1 of the 10 returned to competitive gymnastics. Any benefit from arthroscopic or open fixation of fragments is controversial. Fixation devices have included
Fig 1. Radiographic appearance of osteochondritis dissecans of the capitellum.
cans must be individualized. Lesions with intact articular cartilage often can be treated with rest and protection of the elbow for approximately 6 weeks, xS,",l"A hinged brace can be used to maintain range of motion after a short period of immobilization. When pain has resolved, a gradually progressive physical therapy program is begun, including stretching and strengthening as well as sportspecific exercises. Patients usually return to full activity within 3 to 6 months. Lesions should be followed up radiographically for the next few years. Arthroscopy is tile mainstay of surgical treatment. Baumgarten et aP described an arthroscopic classification system of osteochondritis dissecans of the capitellum and outlined treatment recommendations. Grade 1 lesions have smooth but soft ballotable articular cartilage (Fig 3); grade 2 lesions have fibrillations or fissuring of the articular cartilage; grade 3 lesions have exposed bone with a fixed osteochondral fragment; grade 4 lesions have a loose, 56
Fig 2. MRI appearance of osteochondritis dissecans of the capitellum. JONES AND MILLER
radial nerves. The arthroscopy cannula is passed with a blunt trocar along the same course as the needle, just proximal and anterior to the radiocapitellar articulation. The arthroscope is inserted through this cannula with inflow through the arthroscope. This portal allows examination of the coronoid process of the ulna and the trochlear ridge. An anteromedial portal can be established with the Wissinger rod technique or under direct arthroscopic vision through the anterolateral portal. An 18-gauge spinal needle can be inserted through tile anticipated anteromedial portal site 2 cm distal and 2 cm anterior to the medial epicondyle into tile joint while confirming satisfactory position arthroscopically. After the skin is incised and the fascia is reached with a hemostat, a blunt trocar is inserted following the same course as the needle, heading toward tile center of the joint. With the cannula in the anterolateral portal, the arthroscope can be switched to the anteromedial portal to view the radioulnar and radiocapitellar articulations and the amlular ligament. Extending the elbow shows more of the capitellum, and pronating and supinating the forearm exposes more of the radial head. Placing varus stress on tile joint allows tile articular surface of the capitellum to be seen better. The direct lateral portal is very useful for viewing osteochondritis dissecans lesions.
Fig 3. Arthroscopic appearance of grade 3 osteochondritis dissecans of the capitellum.
Kirschner wires, absorbable screws, and variable pitch screws, but most reports indicate no advantage to this procedure.5,7,.~ The arthroscopic approach to treatment of osteochondritis dissecans of the capitellum should include thorough inspection of tile lesion as well as tile entire elbow.
Arthroscopic technique. The procedure begins with distention of the elbow joint. An 18-gauge spinal needle is inserted at the direct lateral portal and aimed directly toward the center of the joint. The needle passes between the olecranon, radial head, and distal humerus. Care must be taken to avoid extending too far anteriorly and entering the soft tissues in the antecubital fossa. A 50- to 60-mL syringe and connective tubing are used to distend the elbow with fluid. Free backflow of fluid confirms proper intra-articular location of the needle. Then the joint is maximally distended with 25 to 35 mL of fluid to displace the neurovascular structures anteriorly in the antecubital fossa and to increase the space available in the anterior aspect of the joint. With the first needle in place and distention maintained, a second 18-gauge spinal needle is inserted through the anterolateral portal 3 cm distal and 1 cm anterior to the lateral epicondyle. This needle is aimed toward the center of the joint, and again free backflow of the solution confirms an intra-articular location. The needle is removed and the skin is incised with the tip of a no. 11 blade by pulling the skin against the cutting edge. A mosquito hemostat is used to dissect bluntly d o w n to the fascia to minimize the chance of injury to cutaneous or BONY OVERUSE INJURIESABOUT THE ELBOW
Direct lateral portal. The 4.0-mm scope is left with tile inflow in the anteromedial portal to maintain joint distention whereas the smaller 2.7-ram scope is used to examine the structures through the direct lateral portal. This portal is made proximal and posterior to the radiocapitellar articulation, just posterior to the previously established anterolateral portal. If a second working portal is required, it is placed approximately 1 cm distally, approximating the articulation. This can be used instead of an anterolateral portal. A blunt trocar is used to carefully enter the joint to avoid scuffing tile articular cartilage. The concavity of tile radial head articulating on the convex capitellum is examined. The lens is turned to look anteriorly and tile elbow is moved gently through flexion and extension to examine the surface of the capitellum, looking for chondromalacia and any chondral defects producing instability and incongruence. The scope is now swept back posteriorly to examine tile articulation between tile olecranon and the trochlea. Small loose bodies may hide in this area. A normal bare area exists in tile olecranon articulation at the site of the physeal scar. Tile articulation can be followed proximally to view the posteromedial olecranon tip. Through this direct lateral portal the entire extent of the lesion should be identified with a probe. If the lesion is firmly attached and involves a substantial part of tile articular surface in a preadolescent patient, the lesion is drilled with a 0.062 Kirschner wire to stimulate local healing. If tile fragment is loose, it can be elevated with a small osteotome and removed with an arthroscopic grasper. The remaining crater is then debrided with a small curette or arthroscopic burr d o w n to healthy bleeding bone, and the articular edges are debrided to stable cartilage. Once the fragment is removed, an arthroscopic examination of the entire elbow should be performed as described above. Any loose bodies should be removed with an arthroscopic 57
grasper. Large fragments may require a small arthrotomy for excision or reduction and internal fixation. Postoperatively, an aggressive physical therapy program is begun, including immediate active range of motion exercises and isometric strengthening. A posterior splint can be used immediately after surgery for pain relief, but should not be used more than a few days. Light throwing usually can be resumed as early as 6 to 8 weeks, but this depends on the procedure performed, t~
OLECRANON STRESS FRACTURES Stress fractures of the olecranon in throwers were initially described by Waris ~2 in 1946. The following 3 types of olecranon stress fractures have been described: stress fracture of the physis in adolescent gymnasts, tip fracture of the olecranon, and fracture of the olecranon itself. ~x~4 The third type has been divided into 2 groups according to the configuration of the fracture line. A transverse fracture generally is considered to be caused by a traction force from the triceps, while an oblique fracture line is believed to result from a valgus extension overload that causes the posteromedial olecranon to impact the medial wall of the olecranon fossa and the lateral edge of the coronoid to impinge in the intercondylar notch to resist the valgus stress. This repeated impingement is believed to cause an oblique stress fracture. ~
Diagnosis Olecranon tip fractures and stress fractures are not the same clinical entity even though both occur in throwers. Patients with tip fractures usually have acute pain in the elbow after a particularly hard throw, while patients with stress fractures usually have a longer history of chronic pain that recurs when throwing is resumed after a period of rest. Tenderness can be elicited over the olecranon in most patients with either fracture, but pain also may occur over the medial collateral ligament (MCL). Pain with valgus stress may be present with stress fractures, MCL injury, or posteromedial osteophytes. Veltri et a l " described a useful test, the "milking maneuver," to differentiate MCL injuries from olecranon injuries. With the patient's elbow flexed more than 90 °, the examiner grasps the thumb of the affected arm to apply a valgus stress on the MCL, while using the opposite hand to palpate the olecranon and the MCL. Pain over the MCL during this maneuver indicates injury to the ligament and not the olecranon, because the olecranon is not engaged in the fossa when the elbow is flexed more than 90 ° . Patients may also have a nonspecific loss of elbow motion. Radiographic evaluation usually is necessary to determine the type of fracture. Radiographically, tip fractures involve as much as a third of the olecranon, whereas stress fractures occur in the middle third (Fig 4). If the fracture is not visible on initial films, bone scanning (Fig 5A), computed tomography (Fig 5B), or MRI (Fig 5C) may be indicated. Recognition of physeal injuries in adolescents may be more difficult. By the age of 12 years, the olecranon physis is narrow (rarely wider than 5 ram) with serpiginous, congruent borders. With a physeal fracture the physis may appear widened or fragmented with sclerotic bor58
Fig 4. Radiographic appearance of olecranon stress fracture.
ders. Comparison radiographs of the opposite elbow may be helpful.
Treatment Because nonunion and formation of loose bodies can occur after olecranon tip fractures, surgical excision usually is recommended. 17 Fractures through the body generally can be treated conservatively with 6 to 8 weeks of activity restriction, during which stretching and range of motion exercises are continued. Strength and endurance programs, such as swimming, can be begun after this time, but no heavy strength training activities are permitted until bony healing is evident clinically and radiographically, which may require 8 to 12 weeks. At this time, a light throwing program can be initiated. Complete recovery may take 3 to 6 months. Safran 17 outlined a general nonoperative treatment protocol for overuse injuries about the elbow using the acronym PRICEMM. The elbow is protected from further injury, rested, iced, compressed with an elastic bandage, and elevated. Medications (nonsteroidal anti-inflammatory drugs) are used for inflammation, and modalities such as iontophoresis are used. If these measures fail to provide relief, surgical treatment is indicated. Techniques described for olecranon fractures include drilling perpendicularly across the fracture site, ~s open reduction and internal fixation with or without bone grafting, L~,~',2" and percutaneous placement of a 6.5-ram cannulated screw. Most undisplaced olecranon stress fractures can be treated with percutaneous 6.5-ram screws, 100 to 110 mm long. For displaced physeal fractures in adolescents, open reduction and internal fixation with bone grafting have been r e c o m m e n d e d because of the frequency of fibrous nonunion. 21,22 An untreated physeal fracture or nonunion may lead to incomplete fusion of the physis, which has been reported to increase the risk of fracture in adults. 2~ Technique of internal fixation of olecranon stress fracture. The fracture is approached posteriorly with an incision paralleling the lateral border of the olecranon. Oblique fractures can be fixed with screws inserted perpendicular to the fracture line. ~s Transverse fractures are fixed with a JONES AND MILLER
: ~
.'
i
LEFT
Postoperative Care
LRTERRL
17 Itnb 1~q7 aS. 14~B~
6.5-mm intramedullarypin (Fig 6). If a supplemental tension band wire is needed, a hole is drilled tranversely across the distal fragment, and a no. 18 stainless steel wire is passed through the aponeurosis of the triceps, around the olecranon, and brought distally and obliquely across the fracture site. It is passed through the drill hole in the distal fragment and passed obliquely again over the fracture site. The 2 ends are then twisted together until the construct is tight.
"'+:~';'~'~+-
Postoperatively, a posterior splint is worn for 7 to 10 days, then, gentle range of motion exercises are begun. A hinged brace is used for 4 to 6 weeks. When radiographic signs of healing are present and there is no tenderness, a light throwing program is begun. This can begin as early as 6 to 8 weeks, but typically begins at 10 to 12 weeks. Strengthening exercises are started and progressed to throwing without restrictions.
VALGUS EXTENSION OVERLOAD Valgus extension overload syndrome is a spectrum of injuries with soft tissue and bony components that include ulnar collateral ligament injury, flexor pronator injury, radiocapitellar overload, and posteromedial impingement. King et a123 initially described olecranon impingement as caused by medial elbow stress, cubitus valgus, and a narrowed olecranon fossa from bony hypertrophy. It is currently thought that the mechanism of injury occurs in the acceleration phase of pitching when excessive valgus stress applied to the elbow causes wedging of the olecranon in the olecranon fossa. This subsequently causes osteophyte production at the posterior and posteromedial aspects of the tip of the olecranon, eventually leading to chondromalacia or loose body formation. 24-2s Whether treatment of this condition is open or arthroscopic, Andrews 25 stressed the importance of treating the "true offending symptomatic lesion" or the posteromedial osteophyte.
Diagnosis Patients typically have pain in the elbow with forced extension and valgus strain as in the acceleration phase of pitching. Examination may elicit specific points of tenderhess. Tenderness posteromedially along the tip of the olecranon is common, as is pain with valgus stress in extension and forced extension of the elbow. 2" A flexion contracture of the elbow may be present. Wilson et al 2" reported that pitchers gradually become ineffective, making it 2 or 3 innings before a gradual loss of control begins. This often is manifested as an early release, causing them to throw high. Radiographs should include anteroposterior, lateral, and, in throwers, axial views. The elbow should be flexed approximately 110° and with the arm lying on the cassette the beam should be angled at 45 ° to the ulna. This gives the best view of the olecranon as it articulates with the
Fig 5. Olecranon stress fracture as seen on (A) bone scan, (B) computed tomography scan, and (C) MRI.
midline 3 cm proximal to the olecranon tip. Care must be taken with the use of any instruments medially to avoid injury to the ulnar nerve. First, a full-radius resector is used to excise soft tissue and hypertrophic synovium from the posterior compartment to fully expose the extent of the osteophytes. Then a 0.25-in osteotome can be introduced through the posterior portal. Approximately 5 to 10 m m of the tip of the olecranon should be removed with the osteotome. The fragment can then be levered out with a grasper. A 4-ram round burr is used to contour the remaining olecranon tip. A full-radius resector can then be used to smooth the olecranon edges. Any "kissing lesions" of chondromalacia present on the corresponding olecranon fossa should be debrided as well.
2
""
"-L
.,.
Fig 6. Intramedullaryfixation of olecranon fracture. trochlea and puts the medial aspect of the olecranon on profile, which may show a posteromedial osteophyte (Fig 7). Occasionally, oblique views are helpful in identifying loose bodies or osteophytes. Computed tomography, MRI, or arthrotomography also are useful for showing articular cartilage defects, osteophytes, or loose bodies, but are not necessary in all patients.
Treatment Conservative treatment is tried before any surgical intervention is undertaken. The rehabilitation program focuses on diminishing pain and inflammation about the posterior elbow region and improving eccentric strength and control of the elbow flexors to control the forceful elbow extension that occurs during the deceleration phase of pitching. If conservative treatment fails, arthroscopic or open surgical intervention is indicated. This is typically done arthroscopically because of less soft tissue dissection and the chance for earlier, more aggressive rehabilitation. After routhle arthroscopic examination of the joint, a direct lateral portal can be established as previously described. Accessory portals include the straight posterior and posterolateral portals.
Straight posterior portal, A straight posterior portal is made under direct vision with the arthroscope in the direct lateral portal. The posterior toral is created in the 60
Posterolateral portal. The posterolateral portal can be established under arthroscopic guidance with the arthroscope in the direct lateral portal and the lens directed posteriorly or with the arthroscope in the posterior portal. An 18-gauge needle is inserted 3 cm proximal to the olecranon tip and just lateral to the triceps tendon, aimed superiorly, and satisfactory position is confirmed. The skin is excised and a small hemostat is used to spread d o w n to the capsule. A blunt trocar is used to enter the joint. The arthroscopic view through this portal includes the olecranon fossa, olecranon tip, and posterior trochlea and a portion of the posterior band of the ulnar collateral ligament. Osteophytes are typically located on the posterior and posteromedial tip of the olecranon. Loose bodies frequently gravitate to the posterior compartment.
Postoperative Care Range of motion is begun immediately after surgery. Swelling and inflammation are controlled with ice and compressive dressings. Light strength training and functional activities are started at approximately 2 weeks and progressed over the next 6 to 8 weeks. By 8 to 12 weeks, sport-specific activities are resumed. ~,-~"
OSTEOCHONDRITIS THE TROCHLEA
D I S S E C A N S OF
Osteochondritis dissecans of the trochlea is rare, and only a few cases have been reported in the literature. 3~,32 The patients reported have been adolescents with chronic elbow pain usually with actMty and occasional joint crepitance. Radiographs showed a lytic area in the trochlea with sclerotic borders. In 1 patient the lesion was in the medial articular eminence or the region separating the trochlea from the capitellum. MRI appearance was similar to that of osteochondritis dissecans of the capitellum. Surgical exploration in 1 patient found a lesion consisting of necrotic tissue without overlying cartilage. No loose bodies were found. It was theorized that the lesion resulted from vascular insults from repetitive microtrauma22
P H Y S E A L F R A C T U R E OF THE M E D I A L EPICONDYLE Fractures of the medial epicondylar physis can occur in skeletally immature athletes, although this is a relatively
JONES AND MILLER
Fig 7. Valgus extension overload. Posteromedial osteophyte is visible on anteroposterior (A) and lateral (B) views.
u n c o n l m o n overuse injury a b o u t the elbow. These fi'actures can be caused by repeated valgus stress, a fall, or repetitive violent forearm flexor muscle contractions as in p itching. ~7.~,~ Children with this injury usually have medial elbow pain with throwing. T h r o w i n g accuracy and distance are often affected. Point tenderness m a y be elicited over the medial epicondyle, and a flexion contracture usually is present. Radiographically, the epicondylar physis m a y a p p e a r widened or fragmented, w.~-~ A c o m p a r i s o n view of the opposite elbow is m a n d a t o r y . The a m o u n t of displacem e n t should be critically assessed in a throwing athlete, because laxity of the ulnar collateral ligament m a y result. Treatment d e p e n d s on stability of the fragment, w.s".-~r which can be evaluated by the gravity stress test. This consists of an anteroposterior radiograph taken with the patient supine to allow the weight of the arm to cause a valgus stress on the ulnar collateral ligament. If the fragm e n t m o v e s distally and the joint gaps open medially, the elbow is considered unstable, w If the fragment is stable, rest and immobilization are a p p r o p r i a t e treatment, with a gradual return to throwing at 6 to 8 weeks. Unstable elbows, especially in the d o m i n a n t arm of a throwing athlete, should be treated by open reduction and internal fixation through a medial approach. The ulnar nerve can be left in place, and the fragment can be fixed with a BONY OVERUSE INJURIES ABOUT THE ELBOW
cancellous screw or Kirschner wire. w.24 Postoperatively, a posterior splint is applied. This can be changed to a hinged brace at 1 to 2 weeks and range of motion should be progressed over the next 4 weeks until full motion is obtained. T h r o w i n g usually is resumed at about 6 weeks.
CONCLUSION Most elbow injuries in athletes are chronic, overuse injuties that result from intrinsic or extrinsic overload, most c o m m o n l y osteochondritis dissecans of the capitellum, olecranon stress fractures, and valgus extension overload. Other less c o m m o n disorders are osteochondritis dissecans of the trochlea and fracture of the medial epicondyle. Initial treatment of most overuse injuries of the elbow consists of cessation of the aggravating activity. Surgical treatment, generally arthroscopic, is reserved for unstable or recalcitrant injuries.
REFERENCES 1. Tt.llos HS, Erwin WD, Woods GW, et al: Unusual lesions of the
pitching arm. Clin Orthop 88:169-182, 1972 2. Panner HJ: A peculiar affection of tile capitellum humeri resembling Calv,5-Perthes disease of the hip. Acta Radiol 10:234-242, 1927 3. Baumgarten TE, Andrews JR, Satterwhite YE: The arthroscopic classification and treatment of osteochondritis dissecans of the capitellure. Am J Sports Med 26:520-523, 1998
61
4. Jackson DW, SiMno N, Reiman P: Osteochondritis in the female gymnast's elbow. Arthroscopy 5:129-136, 1989 5. Peterson RK, Savoie FH Ill, Field LD: Osteochondritis dissecans of the elbow. AAOS lnstr Course Lect 48:393-398, 1999 6. Schenck RC, Goodnight JM: Current concepts review: osteochondritis dissecans. J Bone Joint Surg 78A:156-160, 1996 7. McManama GB, Micheli LJ, Berry MV, et al: The surgical treatment of osteochondritis of tile capitellum. Am J Sports Med 13:11-21, 1985 8. Takahara IVl, Shundo M, Kondo M, et al: Early detection of osteochondritis dissecans of the capitellum in young baseball players: Report of three cases. J Bone Joint Surg 80A:892-897, 1998 9. Pavlov H, Torg JS, Jacobs B, et al: Nonunion of olecranon epiphysis: two cases in adolescent baseball pitchers. AJR Am J Roentgenol 136:819-820, 1981 10. Ruch DS, Cory JW, Poehling GG: The arthroscopic management of osteochondritis dissecans of the adolescent elbow. Arthroscopy 14: 797-803, 1998 11. Azar FIVl,Wilk KE: Nonoperative treatment of the elbow in throwers. Op Tech Sports Med 4:91-99, 1996 12. Waris W: Elbow injuries of javelin-throwers. Acta Chit Scand 93:563575, 1946 13. Brukner P: Stress fractures of timeupper limb. Sports IVied 26:415-424, 1998 14. Nuber GW, Diment MT: Olecranon stress fractures in throwers: A report of two cases and a review of the literature. Clin Orthop 278:58-61, 1992 15. Suzuki K, Minami A, Suenaga N, et al: Oblique stress fracture of time olecranon in baseball pitchers. J Shoulder Elbow Surg 6:491-494, 1997 16. Veltri DM, O'Brien SJ, Field LD, et al: The milking maneuver: A new test to evaluate time MCL of time elbow in time throwing athlete. Presented at time 10m Open IVleeting of the American Shoulder and Elbow Surgeons, New Orleans, LA, 1994 17. Safran MR: Elbow injuries in athletes. Clin Orthop 310:257-277, 1995 18. Kvidera DJ, Pedegana LR: Stress fracture of timeolecranon: Report of two cases and review of time literature. Orthop Rev 12:113-116, 1983 19. Banas MP, Lewis RA: Nonunion of an olecranon epiphyseal plate stress fracture in an adolescent. Orthopedics 18:1111-1112, 1995
62
20. Maffulli N, Chart D, Aldreige M]: Overuse injuries of tile olecranon in young gymnasts. J Bone Joint Surg 74B:305-308, 1992 21. Kovach J 11, Baker BE, Mosher JP: Fracture-separation of time olecranon ossification center in adults. Am J Sports Med 13:105-111, 1985 22. Orava S, Hulko A: Delayed unions and nonunions of stress fractures in athletes. Am J Sports IVied 16:378-382, 1988 23. King JW, Brelsford H J, Tullos HS: Analysis of the pitching arm of the professional baseball pitcher. Clin Orthop 67:116-123, 1969 24. Andrews JR, Jelsma RD, Joyce ME, et al: Open surgical procedures for injuries to tile elbow in throwers. Op Tech Sports Med 4:109-113, 1996 25. Andrews JR: Bony injuries about tile elbow in the throwing athlete. AAOS Instr Course Lect 34:323-331, 1985 26. Wilson FD, Andrews JR, Blackburn TA, et al: Valgus extension overload in time pitching elbow. Am J Sports Med 11:83-88, 1983 27. Martin DS, Baumgarten TE: Elbow injuries in the throwing athlete: Diagnosis and treatmenL Op Tech Sports Med 4:100-108, 1996 28. Moskal MJ, Savoie FH 111, Field LD: Arthroscopic treatment of posterior elbow impingement. AAOS Instr Course Lect 48:399-404, 1999 29. Rettig AC: Elbow, forearln, and wrist injuries in tile athlete. Sports Med 25:115-130, 1998 30. Wilk KE, Arrigo CA, Andrews JR, et al: Rehabilitation following elbow surgery in the throwing athlete. Op Tech Sports Med 4:114132114199, 1996 31. Chan D, Aldridge MJ, Maffulli N, et al: Chronic stress injuries of the elbow in young gymnasts. Br J Radiol 64:1113-1118, 1991 32. Vanthournout I, Rudelli A, Valenti P, et al: Osteochondritis dissecans of the trochlea of tile humerus. Pediatr Radiol 21:600-601, 1991 33. Nyska M, Peiser J, Lukiec F, et al: Avulsion fracture of the medial epicondyle caused by arm wrestling. Am J Sports Med 20:347-350, 1992 34. Gore RM, Rogers LF, Bowerman J, et al: Osseous manifestations of elbow stress associated with sports activities. AJR Am J Roentgenol 134:971-977, 1980 35. Smith FM: Medial epicondyle injuries. JAMA 142:396-402, 1950 36. Woods GW, Tullos KS, King JW: The throwing arm: Elbow injuries. Am J Sports Med 1:43-47, 1973 (suppl) 37. Woods GW: Elbow instability and medial epicondyle fractures. Am J Sports Med 5:23-30, 1977
JONES AND MILLER