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Elbow injuries and the throwing athlete

Elbow injuries and the throwing athlete. Michael J. Kissenberth MD Orthopaedic Surgery, Sports Medicine SHCC, Greenville Hospital System. First Question. What sport do you play?. Most sport related elbow injuries are caused by repetitive microtrauma….

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Elbow injuries and the throwing athlete

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  1. Elbow injuries and the throwing athlete Michael J. Kissenberth MD Orthopaedic Surgery, Sports Medicine SHCC, Greenville Hospital System

  2. First Question What sport do you play?

  3. Most sport related elbow injuries are caused by repetitive microtrauma…

  4. And the underlying pathology is directly related to the biomechanicsof the sport.

  5. Second Question • Where does it hurt? • Anterior • Medial • Posteromedial • Posterior • Lateral

  6. Third Question 3. When does it hurt?

  7. 1st Critical Instant Andrews

  8. 2nd Critical Instant Andrews

  9. Restraint to Valgus Torqueat 90 Degrees FlexionUCL 54%RC Articulation 33%Capsule 10%

  10. Medial Tension ME injury Sigmoid rim fx FP mass injury UCL lesions UN neuritis Lateral Compression RC joint injury Synovitis Effects of Valgus Torque

  11. History • Medial Pain • Late Cocking, Early Acceleration • Recurrent Symptoms • Pop on Single Throw • Swelling, Stiffness • Lost Performance!!!

  12. Previous Treatment • Lost Playing Time • Rehabilitation • Injections • Diagnostic Studies • Surgery (VEO)

  13. Examination • Medial Swelling • Motion Loss • UCL Tender • Valgus Stress Painful • Valgus Laxity • Associated Findings

  14. Kids • ME Apophysitis • ME Fragmentation • ME Avulsion

  15. ME Apophysitis With Fragmentation Without Fragmentation

  16. 14 y/o BB Player No prior symptoms “Pop!”

  17. FP Muscles - UCL FPM The flexor pronator muscles provide varus torque UCL ME Ulna Flesig AJSM 95, Werner JOPST 93

  18. Decreased FCR activity in throwers with an UCL injury

  19. FPM / ME Injury

  20. Pronator Muscle Tear 27 y/o RHP Conjoined Tendon

  21. Severe FPM / ME Think UCL Injury!!!

  22. Rarely inject FPM Deep Massage Modalities Rehabilitation Repair ME

  23. Treatment Relative / Active Rest Ice, NSAID Local Modalities Prevent Atrophy Treat Associated Conditions NO Steroid Injections!!!

  24. Treatment Strengthen FCU, FDS Trunk, Scapula, Cuff Stab. PNF, Plyometrics Sport Specific Exercise Review Throwing Mechanics Interval Throwing Program

  25. Direct Repair

  26. UCL Complex • Anterior Bundle • Strongest portion • Insertion on sublime tubercle • 18 mm posterior to coronoid tip • Origin is inferior and posterior to rotation axis • Tighter in flexion

  27. Milking Maneuver UCL Tests Static Valgus Stress

  28. Moving VST O’Driscoll Likely best test

  29. Modified UCL Recon

  30. 6 – 8 Millimeter Bridge

  31. Three Incision Harvest

  32. Docking Procedure

  33. Avulsion Fracture Sublime Tubercle Glajchen AJR 1998

  34. Rehabilitation Initial Immobilization Relieve PainResolve Arm SwellingRecover Range of MotionPrevent Muscle Atrophy Restore Aerobic ConditionMaintain/develop core stability

  35. Toss 4 - 5 MonthsMound 6 - 8 MonthsGame 11 - 12 Months Prevent Shoulder Injury

  36. Ulnar Nerve Injury ME

  37. Ulnar Nerve Injury Fibrosis Compression Tension UN subluxation Elbow valgus laxity

  38. Non-operative Care • Night Splint • NSAIDs • Oral Steroids • Activity Modification • Desensitization / Soft tissue release

  39. Decompression 4 3 2 1 ME

  40. Fascia Sling ME

  41. Lateral CompressionInjuries Rad-Cap arthrosis Stress fracture OCD Lateral synovium

  42. Kids – Lateral Elbow • Panner’s Disease • <10 yo, self limited • OCD Capitellum • Progressive!!!

  43. Panner’s Disease • OCD capitellum • 5-10yo • Self limited • Tx conservatively • Rest, ice, nsaids • Gradual RTP. Must be able to throw without sx

  44. Posterior blood supply peds lateral elbow Repetitive injury to epiphysis may alter blood flow = osteochondrosis

  45. Osteochondritis Dissecans • Age 9 - 16 Years Old • Progressive • Remove loose bodies

  46. Loose Body

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