Sports related injuries of the elbow. Dr. B. The, MD, PhD Upper Limb Unit Amphia Hospital Breda

Transcription

1 Sports related injuries of the elbow Dr. B. The, MD, PhD Upper Limb Unit Amphia Hospital Breda

2 A short intro

3 Work at hand

4 Thrower s elbow First report 1941 (Bennet, JAMA) a possible complication from repetitive overhead throwing a generic dead arm Premature retirement for the afflicted pitchers

5 Thrower s elbow In the 60 s and 70 s reported incidence approached 50% 67% of pitchers found to have degenerative elbow disease

6 Thrower s elbow The term medial elbow-stress syndrome was coined: Sequential failure of Musculature UCL Capsule Joint

7 Thrower s elbow Conservative treatment First attempts at surgical treatment Non-anatomical reconstructions Direct repairs Discouraging results

8 Thrower s elbow 1974: first UCL reconstruction A wary surgeon (Frank Jobe) A top-level athlete (Tommy John, LA Dodgers) A revolution in surgical treatment

9 Thrower s elbow These days 85% success rate (return to preinjury level of play for at least one year) 1 in 9 pitchers (major league)

10 Thrower s elbow Valgus extension overload syndrome: Valgus in late cocking phase Extension in acceleration phase Results in Compression lateral compartment Shear stress posterior compartment Tensile overload medially

11 Thrower s elbow What happens posteriorly?

12 Thrower s elbow Valgus stress in UCL insufficiency leads to posteromedial impingement. Posteromedial impingement results in osteophytes and pain.

13 Thrower s elbow Removing these painful osteophytes results in increased tensile overload at the UCL! After resection, 25% of pitchers requires UCL reconstruction True causal relation? Confounding by indication?

14 Thrower s elbow Clinical presentation Medial elbow pain Chronic / episodic rather than acute Rarely reported by patient as instability problem Diminished accuracy, velocity, stamina Ulnar nerve symptoms (mainly sensory) 40%

15 Thrower s elbow Physical diagnostics Valgus stress test Milking manoeuvre Moving valgus Pain Instability (compare contralateral)

16 Thrower s elbow Case: Applying valgus stress induces lateral sided pain. What s going on? Beware of radiocapitellar pathology Additional physical diagnostics? Is an MCL insufficiency mandatory? Theory dictates the MCL to be the primary valgus stabiliser

17 Thrower s elbow Imaging Why X rays? Medial side Lateral side Posterior side Soft tissue

18 Thrower s elbow Imaging Why X rays? Why Ultrasound? Why CT (arthro)? Why MRI?

19 Thrower s elbow MRI: the holy grail? True or false: a key advantage is that LUCL injuries are readily identifiable on MRI. The LUCL is notoriously problematic to visualise on MRIs

20 Thrower s elbow MRI: the holy grail? True or false: MRI is a valuable tool to assess ligamentous injury after elbow dislocations False it hardly ever aids injury classification, decision-making or determining of prognosis. Which imaging modalities are more usefull?

21 Thrower s elbow Diagnostic arthroscopy? Chondral lesions / loose fragments Why are these findings relevant when considering surgical stabilisation?

22 Surgery

23 Surgery

24 Surgery

25 What do you see?

26 Distal biceps Usually male patients 50 yrs old Physically active Eccentric loading leads to rupture

27 Distal biceps Ecchymosis Pain anterior side Weakness / pain most pronounced with: Active. Passive.

28 Distal biceps Hook test (but also palpate for differences in caliber or tension) Resisted supination, passive end-range pronation Do these sign help to differentiate between complete or partial tears?

29 Distal biceps When dealing with longer standing cases Are there any differences?

30 Distal biceps Distal biceps tendon ruptures are commonly treated surgically. Well-known complications include neurapraxia of the lateral antebrachial cutaneous nerve (and proximal radioulnar synostosis).

31 Surgical landmarks Anterior approach for distal biceps tendon rupture repair: Lateral antebrachial cutaneous nerve Lacertus fibrosus (bicipital aponeurosis) Henry s leash Radial tuberosity (which side of the radial shaft?)

32 Remember the PIN Aiming a guide pin vs PIN Most safe: aiming at a right angle to the shaft, ulnarly Least safe: aiming distally, radially. True or false: when a patient still retains wrist extension, a true PIN palsy is not present False: ECRB/ECRL are innervated by the radial nerve (proximal to branching off of the PIN)

33 Remember the PIN Aiming a guide pin vs PIN Most safe: aiming at a right angle to the shaft, ulnarly Least safe: aiming distally, radially. True or false: when a patient still retains PIP/DIP extension, a true PIN palsy is not present. False: MCP extension is a pure PIN function, PIP/DIP can be extended using the intrinsics.

34 Single or double incision technique? Double perhaps more biomechanically sound? Was reported to have increased risk for heterotopic ossification, but perhaps not so much with muscle splitting technique. Overall very good results with normalisation of ROM, strength and functional scores comparable with healthy controls / contralateral limb, regardless of the technique.

35 What do you see?

36 OCD Osteochondritis dissecans: usually skeletally immature patients involved in sports such as gymnastics or throwing. Affects only a segment of the capitellum (as opposed to Panner s disease) Poor prognosis if left untreated

37 Panner s disease AVN capitellar ossification centre. Usually under 10 yrs Sclerosis (or fragmentation) of the entire ossification centre Good prognosis with conservative treatment

38 Practical application: Stable vs Probably stable: Open physis unstable Normal range of movement Grade I radiological appearance (flattening or lucency)

39 Stable vs unstable Probably unstable: Closed physis, OR ROM impairment >20 degrees, OR Grade II / III radiological appearance (fragmentation, dislocation) By these criteria the vast majority is unstable at presentation

40 Stable lesions Conservative measures No throwing, no gymnastics untill complete healing (how to assess?) Success of conservative therapy is guided by clinical rather than radiological signs Progression, persistence or recurrence of symptoms at 6 months warrants re-evaluation, possibly surgical intervention.

41 Operative treatment ICRS II/III: in situ fixation, with or without autologous bone ICRS IV: removal of lesion, debridement, microfracture treatment. Consider Autologous osteochondral grafting in large lesions.

42 Lateral epicondylitis Lateral epicondylitis Is most common between the ages 35 and 50 years Is primarily located in the extensor carpi radialis brevis origin (a watershed area), but can also affect the extensor digitorum communis origin Presents as angiofibroblastic hyperplasia at histological examination

43 What else to consider? Differential diagnosis for lateral-sided elbow pain include: Radial tunnel syndrome Location of tenderness? Provocation? EMG? MRI? Other? Conservative treatment? Surgical options?

44 What else to consider? Differential diagnosis for lateral-sided elbow pain include: Radial tunnel syndrome LUCL injury Plica, synovitis Osteochondral pathology Cervical root compression C6 (or C5) How to differentiate with physical exam?

45 Combined pathology is common Therefore, physical history is aimed at: Confirming the tennis elbow Detecting concommitant pathology

46 Treatment options Conservative issues: Corticosteroid injections: good, bad or ugly?

47 Conservative treatment chance of success? Negative predictors: Manual labor Dominant arm High base-line pain levels Poor coping mechanisms

48 Operative treatment Nirschl release and related techniques: Easy to perform Easy to mess up

49 Operative treatment Arthroscopic techniques Successful and relatively safe Demanding technique, but intra-articular pathology can be treated simultaneously. Is it time and cost-effective?

50 Secondary trouble Surgery for lateral epicondylitis according to Nirschl puts the ulnar collateral ligament at risk Repeat injection therapy may do so as well (but is usually more impressive due to subcutaneous tissue necrosis and discoloration).

51 How different is medial epicondylitis? Background, etiology, histopathology is similar. Different differential diagnosis

52 How different is medial epicondylitis? Background, etiology, histopathology is similar. Different differential diagnosis MCL-a Ulnohumeral degeneration Snapping triceps Ulnar neuropathy or instability

53 Medial epicondylitis Treatment influenced by the vicinity of ulnar nerve (and MACN). Safety of injection therapy, arthroscopic treatment? Concommitant ulnar neuropathy much more frequent

54 In the office Medial epicondylitis commonly affects the origins of the pronator teres and flexor carpi radialis muscles. Resisted pronation at least as sensitive as resisted wrist flexion?

55 In the office Case: Patient has had 3 cortisone injections to treat medial epicondylitis. He has been diagnosed with radiocapitellar osteoarthritis, but never suffered any complaints on the lateral side in the past. Initial pain relief had been almost complete, but symptoms seems to recurr with increasingly shorter painfree intervals. Now, his symptoms are worst than ever. They include a painful click on the medial side of the elbow and a gradual increase in pain on the lateral side of the elbow, which seems to be deeper as if originating from within the joint.. What s going on?

56 Beware of the deep The anterior band of the ulnar collateral ligament is deep to the pronator teres and flexor carpi radialis origins and is the primary valgus stabiliser of the elbow.

57 Bedankt voor jullie aandacht!