Elbow Injuries in the Adult Athlete. Tamara A. Scerpella, MD Professor, Orthopedic Surgery University of Wisconsin

Transcription

1 Elbow Injuries in the Adult Athlete Tamara A. Scerpella, MD Professor, Orthopedic Surgery University of Wisconsin

2 Acute Elbow Dislocation Fracture Distal humerus Olecranon Radial head Distal Biceps Rupture Ulnar Collateral Ligament Tear

3 Acute Elbow Dislocation Fracture Distal humerus Olecranon Radial head Distal Biceps Rupture Ulnar Collateral Ligament Tear

4 Chronic (Throwing) Lateral Epicondylitis Valgus Extension Overload Ulnar neuritis UCL laxity Flexor pronator mass injury Posteromedial impingement Olecranon stress fracture Osteochondral Lesions (capitellum)

5 Elbow Dislocation 10-25% of all elbow injuries 6-8 cases / 100,000 (2nd to shoulder)

6 Elbow Anatomy Bony Stability Primary Bony Stabilizers (~50%) Ulnohumeral joint Coronoid and olecranon Secondary stabilizers Radial head (static)

7 Elbow Anatomy Soft Tissue Stabilizers Primary Ligamentous Stabilizers Radial Collateral Lig UCL, anterior band Secondary stabilizers flexor-pronator, common extensors (dynamic)

8 Elbow Dislocation - Mechanism 80-90% posterior or posterolateral Fall on outstretched arm è posterior or posterolateral Fall on flexed elbow è anterior Hyperlaxity predisposes (gymnasts) Direction = ulna displacement

9 Elbow Dislocation - Posterior

10 Elbow Dislocation -Posterior

11 Elbow Dislocation - Diagnosis

12 Elbow Dislocation - Treatment Immediate / On-Field one reduction attempt Splint / X-ray if unsuccessful (possible fracture) Sedation / Anesthesia prolonged or complex (with fracture)

13 Elbow Dislocation - Reduction Anterior

14 Elbow Dislocation - Treatment Post-reduction: NV exam; Xray to r/o fracture; assess stability

15 Immobilize THEN Mobilize Soft tissue rest Early mobilization to restore ROM Mehlhoff et al 1988

16 Surgical Indications Unstable after reduction Even if flexed, pronated Significant soft-tissue damage Repair: LCL complex first UCL if still unstable common extensor, flexorpronator avulsions

17 Associated Fractures Coronoid Radial Head Distal Humerus Olecranon Terrible Triad: Radial Head, Coronoid & Elbow Dislocation

18 Associated Fracture - Coronoid Anterior dislocation Type 1: avulsion fx Type 2: < 50% Type 3: > 50% Elbow stability significantly compromised Valgus instability (UCL insertion) Treatment: ORIF

19 Acute Elbow Dislocation Fracture Distal humerus Olecranon Radial head Distal Biceps Rupture Ulnar Collateral Ligament Tear

20 Radial Head Fracture FOOSH Diagnosis: tenderness, effusion X-ray: fat pad sign Treatment based upon displacement: >2mm = ORIF Non-op: immobilize 3-5 days only Rapid mobilization to prevent extension loss

21 Distal Biceps Rupture Rare in young athlete Forcible extension while actively flexing FB, weight-lifting Diagnosis: Ecchymosis Deformity -retraction Treatment: Surgical repair

22 Ulnar Collateral Ligament Rupture - Acute Painful pop while throwing Localized swelling Laxity to valgus stress MR-arthrogram is diagnostic

23 Case 20 y.o. M LHD collegiate pitcher Acute onset medial elbow pain in left arm Felt a pop during a pitch Immediate pain Decreased velocity and control Swelling medial elbow X 2 weeks tingling in ring and small finger Resolved when swelling subsided

24 Case Physical Exam Mild swelling medial elbow TTP just distal to medial epicondyle 1+ laxity on valgus stress at 30 and 90 degrees Pain with moving valgus stress test 2 pt discrimination normal in ulnar nerve distribution

25 Case

26 Case UCL reconstruction using palmaris longus

27 Chronic Injury (Throwing) UCL Chronic Tear - attenuation Valgus Extension Overload UCL laxity Flexor pronator mass injury Posteromedial impingement Olecranon stress fracture Ulnar neuritis Lateral Epicondylitis Osteochondritis Dissecans (capitellum)

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29 Ulnar (Medial) Elbow Overuse Overhead throwing: tremendous valgus stress concentrates on medial side Medial elbow problems predominate 97% of elbow c/o in baseball pitchers Also football, volleyball, tennis, javelin, gymnastics Chronic, overuse most common Acute UCL tears may occur

30 Valgus Extension Overload Medial tensile forces Lateral compressive forces Posterior shear stresses Result: UCL laxity flexor pronator mass injuries neuritis of the ulnar nerve posterior impingement olecranon stress fractures

31 Chronic UCL Laxity - Pathogenesis 3 bundles: anterior, posterior, transverse Anterior: strongest, primary valgus restraint at <90 Posterior: restraint at >60 Valgus forces > Intrinsic Tensile force of UCL = microtearing of UCL Additional stress: bad mechanics poor flexibility inadequate conditioning Result: attenuation and ultimate rupture of UCL

32 Chronic UCL Laxity - Presentation Symptoms medial pain in late-cocking, early acceleration +/- ulnar n sxs Can throw only 50-75% of normal level Exam: valgus force at degrees flexion (ant band) milking maneuver at > 90 deg (post band) Flexion contracture: result of repeated attempts at healing and stabilization, don t need full extension to throw Pain with wrist flexion or tenderness over flexor mass origin suggests flexor/pronator mass injury.

33 Valgus Instability - Exam Milking maneuver Valgus stress test ~15 o and full pronation

34 Valgus Instabilty - Exam Moving valgus stress test 90 degrees abduction, full ER Full flexion to extension maintaining a constant valgus stress pain/apprehension o 100% sensitive and 75% specific for UCL attenuation/tear (O Driscoll AJSM 05)

35 UCL Tear - Imaging XRAY: changes c/w chronic instability: calcification/ossification of ligament MRI: ligamentous avulsions, partial injuries, midsubstance tears, surrounding soft tissues CT Arthrography: undersurface tears Similar to MRI with gadolinium Timmerman, Andrews (1994) MRI, CT arthrography with arthroscopy correlation Equivalent ability to detect full-thickness tears

36 Chronic UCL Tear Nonoperative Treatment 2-4 weeks rest, NSAIDS, PT Corticosteroid injections NOT recommended After acute inflammation gone - supervised flexibility, strengthening program target FCU, pronator teres, FDS After full ROM / strength regained - begin throwing, conditioning program (~ 3 mos) Early treatment can stop progression of instability ~50% athletes returning to preinjury level

37 Chronic UCL Injury Surgery Indications: competitive athletes with acute, complete UCL rupture chronic sxs with failure of 3-6 mos nonoperative tx Surgery - repair or reconstruct UCL Direct repair - acute ligamentous avulsions Reconstruction - chronic instability with attenuation, midsubstance tears palmaris longus, plantaris, Achilles, hamstrings PL avg load to failure 357N (Ant UCL 260N) Morrey et al.

38 UCL Reconstruction Ulnar nerve transposition ONLY if nerve symptoms!

39 Post-op Rehabilitation Brief immobilization (7-10 d) - then active shoulder, elbow, wrist ROM 4-6 weeks: PREs wrist/forearm 6 weeks: PREs elbow Valgus stress avoided until 4 months 2-3 months: RTC strengthening emphasized 3-4 months: throwing program - light tossing 6 months: lobbing ball 60 ft with easy windup 7 months: 50% max velocity 8-9 months: pitchers 70% max months: full activity

40 Results- Surgical Reconstruction Jobe et al: reconstruction with ulnar transposition 10/16 (63%) preinjury function (11-19 months) 1 to lower level, 5 retired High incidence of ulnar n complications 5/16 2 reoperated 1 transposition, 1 neurolysis 3 paresthesias that resolved Conway et al: 14 direct repair, 56 reconstruction direct: 71% G/E, 50% return to play by 9 mos recon: 80% G/E, 68% to preinjury by 12 mos 40% preop ulnar sx, 22% postop - 8 req transposition

41 Jobe et al (1997): reconstruction without transposition 83 athletes (54 pro, 18 college, 11 rec) 94% G/E results avg RTP 13 mos 3 with ulnar paresthesias, 1 with neuropathy all resolved by 6 months

42 Valgus Extension Overload Chronic UCL laxity Compressive lateral forces = synovitis, osteochondral lesions at radiocapitellar joint Posterior impingement (olecranon osteophytes)

43 Posterior Impingement Posteromedial olecranon osteophytes, chondromalacia Posterior pain with valgus/extension (late acceleration phase)

44 Posterior Impingement Non-operative Treatment Rest, ice, NSAIDS Functional strengthening elbow, forearm Dynamic stabilizers Stretching - isotonic, isokinetic, isometric exercises begun As strength improves - plyometric exercises (flexor/pronator mass); interval throwing program

45 Posterior Impingement Surgical Treatment Indications: failed non-op tx symptomatic spurs or loose bodies Elbow arthroscopy - good results, low complication rates undersurface tears of UCL can be seen but must be addressed open Reconstruction of UCL reserved for pts who have failed all above treatment

46 Ulnar Neuritis Associated with UCL laxity Pain / numbness / tingling Later: weakness / atrophy Treatment: decompression / transposition

47 Flexor Pronator Injury Medial Epicondylitis = Golfer s Elbow repetitive valgus forces = chronic inflammatory changes X less common than lateral Pronator teres, FCR, FCU PT highest activity in acceleration phase FCU overlies UCL at 120 o Decrease in FCU activity with UCL instability Microtears between PT and FCR origins inflammatory and fibrotic granulation tissue

48 Medial elbow pain, insidious, worse with throwing Physical exam tender flexor-pronator origin pain with wrist flexion, forearm pronation XR - normal / traction spurs, UCL Ca++ MRI - Presentation signal musculotendinous origin EMG/NCV - evaluate for ulnar neuropathy 60% have ulnar neurapraxia

49 Rest, ice, NSAIDS Steroid injections (tendon attenuation with repeat injections) Splinting or counterforce bracing PT - wrist flexor/pronator stretching, then progressive isometrics; PREs >90% success Treatment - Nonoperative

50 Treatment - Surgical >6 months of non-op PT Debride inflamed tissue, repair tendon Postop rehab: Brief immobilization (7-10d) Passive, active elbow weeks - PREs RTP - 4 months 95% success Ulnar neuropathy=poor prognosis

51 Lateral Epicondylitis

52 Lateral Epicondylitis - Treatment

53 Summary Throwing / racquet athlete = medial-sided problems Flexor pronator tendinosis / medial epicondylitis UCL laxity Posterior Impingement Ulnar neuritis Many respond to non-operative Rx