Elbow Impingement And Stress Fractures In Throwers
11/11/2016Elbow Impingement and StressFractures in ThrowersJohn Conway, MDBen Hogan SportsMedicineFort Worth, TexasElbow Impingement and StressFractures in ThrowersI, John Conway MD, have relevant financialrelationships to be discussed, directly or indirectly,referred to or illustrated with or without recognitionwithin the presentation as follows:Arthrex Inc. - RoyaltiesMy full disclosure is in the AOSSM Final ProgramBook and in the AAOS DatabaseElbow Impingement1. Posterior-Lateral1. RC Plica2. Lateral Gutter Plica3. Proximal Lateral Band2. PosteriorTip Spur / FragmentationFossa Spur, LB, Fibrosis3. Posterior-Medial / VEOPM Tip Spur / FragmentationPM Trochlea OCL, LBPlicaTrochleaChondromalaciaPosterior Osteophyte1
11/11/2016Posterior-Lateral Impingement1. Radius-capitellar Plica(Meniscus)Anterior / PosteriorRH Chondromalacia2. Lateral Gutter PlicaProximal / DistalLateral Ulna / TrochleaChondromalaciaPalpationAnt & Post RC marginsDistal lateral gutterProximal lateral gutterPassive FlexionPronation Test ( 25-50%)Active Flex-Pron TestActive Flex-Sup TestMRA: 3mm, irregular, edemaRadius-Capitellum PlicaPain, Snapping,Catching, LockingFindingsHypertrophyFrayed marginsInflammationLateral capitellum andradial m PlicaPain, Snapping,Catching, LockingFindingsCapitellumRHHypertrophyFrayed marginsInflammationLateral capitellum andradial headchondromalacia2
11/11/2016Lateral Gutter PlicaPain, Snapping,Catching, LockingFindingsHypertrophyFrayed marginsInflammationLateral ulna andtrochleachondromalaciaLateral Gutter PlicaPain, Snapping,Catching, LockingFindingsHypertrophyFrayed marginsInflammationLateral ulna andtrochleachondromalaciaMUCL Insufficiency EffectMUCL insufficiency that increased valgus laxityincreased the radiocapitellar contact pressures andreduced the resistance of the elbow to valgus loading.This may contribute to the symptomatic entrapment ofthe plica.Duggan JP et al JSES 20113
11/11/2016Arthroscopic ResectionPreserve theacononeus musclefasciaMini-Shavers (3mm)Removes less fasciaAllows better access tothe UH joint, the RCjoint and the lateralmargin of the radialheadDirect PosteriorLateral PortalPosteriorLateralPortalMid Radio‐CapitellarPortalAlso include Anterior MedialPortal for anterior lateralmechanical symptomsArthroscopic ResectionPreserve theacononeus musclefasciaMini-Shavers (3mm)Removes less fasciaAllows better access tothe UH joint, the RCjoint and the lateralmargin of the radialhead4 mm serrated shaverPL Impingement OutcomesClarkArthroscopy1988Commandre et al JSMPF1988Akagi et alJSES1998Antuna et alArthroscopy2001Awaya et alAJR2001Ruch et alJSES2006Kim et alAJSM4
11/11/2016PL Impingement OutcomesAntuna et al Arthroscopy 200114 Patients50% Flex Pron test93% Chondromalacia86% ExcellentKim et al AJSM 200612 Patients25% Flex Pron test58% Chondromalacia92% ExcellentRajeev et al JOS 2015600 Patients with lateral pain121 Patients / 50 Athletes40% RT Comp SportProximal Lateral BandBand-like structureRunning from the deep lateraltriceps surface to the lateral marginof the trochlea rimProximal lateral gutterTender, sometimes snapsOften painful on:Deep flexion pressFull extension pressFossaRimPlicaBandPlicaBandFossaRimProximal Lateral BandBand-like structureRunning from the deep lateraltriceps surface to the lateral marginof the trochlea rimProximal lateral gutterTender, sometimes snapsOften painful on:Deep flexion pressFull extension pressGymnasts, golfers and boxersFossaRimPlicaBandPlicaBandFossaRim5
11/11/2016Proximal Lateral BandBand-like structureFossaRimRunning from the deep lateraltriceps surface to the lateral marginof the olecranon fossa rimPlicaBandProximal lateral gutterTender, sometimes snapsOften painful on:PlicaBandDeep flexion pressFull extension pressGymnasts, golfers and boxers3 mm Scope DPLView distal to proximalFossatoresect the PL BandRimPosterior ImpingementHyperextensionmechanismPain on extensionSometimes lockingand catching31 yo MLB OF2D / 3D thin sectionCT imagingPosterior-Medial Impingement“ exfoliation ofcartilage loosebodies ”GE Bennett Am J Surg 1959OverloadMedial TensionLateral CompressionValgus ExtensionDon Slocum AJSM 1978VEO in thePitching Elbow“ wedgingeffect of theolecranon intothe olecranonfossa.”FD Wilson, JR AndrewsMEAJSM 19836
11/11/2016MUCL Insufficiency EffectMUCL insufficiency that increased valgus laxity alters boththe contact pressure and area on the PM olecranon &partially explains the development of PM olecranonosteophytes.MUCL Insufficiency EffectMUCL insufficiency that increased valgus laxity causes anincreaseAndpitchersin totalwithcontactconcomitantpressureUCLOon the“mayPMhavetrochlea,a lowerwhiledecreasingratefor return”the followingoverall contactMUCLareareconstructionand shifting the contactOshbar et al CORR 2012area medially.Posterior-Medial ImpingementMost common diagnosis(78%) requiring surgicaltreatment in baseballplayersAndrews, Timmerman AJSM 1995Most common diagnosis(51%) requiringarthroscopic treatment inathletesReedy et al Arthroscopy 20007
11/11/2016Posterior-Medial Impingement1. Posterior-medialGutter Synovitis / PlicaMay occur without other PIpathologyUsually resolves withoutsurgeryMay respond to injectionRarely treat with synovectomyTrochleaPosterior-Medial Impingement2. OlecranonStress ReactionStress FracturePosterior-medial TipProximal-transverseProcessExostosis FormationFragmentation (LB)IncidenceIncidence 24%135 Asymptomatic Pros18-21 yo22-25 yo26-29 yo30-35 yo12%19%36%50%Conway AOSSM 20008
11/11/2016Posterior-Medial Impingement3. Posterior-medialTrochleaChondromalaciaSubchondral edema /insufficiency fractureOsteochondralcollapseMarginal exostosesPosterior-Medial Impingement3. Posterior-medialTrochleaChondromalaciaSubchondral edema /insufficiency fractureOsteochondralcollapseMarginal exostosesPosterior-Medial Impingement3. Posterior-medialTrochleaChondromalaciaSubchondral edema /insufficiency fractureOsteochondralcollapseMarginal exostoses9
11/11/2016Posterior-Medial Impingement3. Posterior-medialTrochleaChondromalaciaSubchondral edema /insufficiency fractureOsteochondralcollapseMarginal exostosesMRIMRI ScanModerate to highsignal in the PMtrochlea hyalinecartilage and forsome, thesubchondral boneFocal OC defects ina fewMRI ScanCohen SB, et al Arthroscopy 2011Resect What?Old Schoolthought saidresect theentireolecranon tipNew Schoolsays don’tremove anyof thenormalolecranonmargin10
11/11/2016Extent of ResectionKamineni JBJS 2003Kinematic Study3mm increments:Stepwise incr. valgusangulationChallenges rationale forremoval of anynormal boneKamineni JBJS 2004Biomechanical Study3mm increments: 6 mm resection incr.MUCL strainConcluded resection 3mm may jeopardizeMUCL functionOlecranon FragmentationThe Goalof treatmentis therestorationof thenormalcontour ofthe posteriormedialolecranon1.2.3.Trochlea Chondromalacia11
11/11/2016Trochlea Arthroscopic Treatment2.1.TrochleaSupine RHPProne LHPArthroscopic Treatment3.Supine RHP12
11/11/2016Outcomes - Return to PlayArthroscopic ResectionRossenwasser AANAJordan AOSSMWardJHSurgAndrews AJSMFideler opy919293959798001183%74%78%73%74%95%85%78%Second Surgery @ 2 yearsAll ProceduresFideler JSES 97Andrews AJSM 95BartzAOSSM 9926%41%17%UCL ReconstructionFideler JSES 97Andrews AJSM 95BartzAOSSM 9910%25%8%Rehabilitation ConsiderationsFull extension splint for24 hoursHigher rate of postMUCL reconstructionstiffness with scopeIrrigate and fully extendelbow to evacuatehemarthrosis beforefinal ligament fixation.Don’t shorten MUCLimmobilization periodunless micro-fractureperformed – then limitmotion or CPM to 10-50 (or 40-100 ) for 10 daysMake motion recoverythe first priority butdon’t be aggressive.Bernas et al. AJSM 200913
11/11/2016PearlsSafety First!Experience / KnowledgeReasonable expectationsStrategic preoperative planningSupine position BESTSee well / Use retractorsExtension SplintThank youElbow Stress FracturesME ApophysisPM TrochleaCapitellum RimLateral cleOlecranonApophysisSt ReactionOblique MidTransProximalTip14
11/11/2016More informationOlecranon Stress FracturesOsbahr DC, Bedi A, Conway JESports Medicine of Baseball, Chapter 23Dines JM, ElAttrache NS, Yocum LA, Altchek DW,Andrews J, Wilk KE, Eds., Lippincott Williams &Wilkins. 2012; pages 249-260.Adaptionist’s ParadigmForm is related to functionBones adapt to their mechanicalenvironment over time leading to apredictable relationship between structureand functionWolff J, 1892Pearson OM, YrBk Phys Anthrop 2004Wolff’s Law1) Bone is deposited and reabsorbed to achieve optimumbalance between strength and weight2) Trabecular bone is formed during growth anddevelopment in orientations that line up with the directionof the principle mechanical stresses that act on the bone3) Both phenomena occur through self regulatingmechanisms that respond to mechanical forces acting onbone tissueWolff J, 1892Pearson OM, YrBk Phys Anthrop 200415
11/11/2016Young’s ModulusStress and StrainYield PointBreak PointYoung’sModulusBone and Tissue BalanceTissue BreakdownStressTissue RepairRemodeling CapacityBone and Tissue Balance16
11/11/2016Excessive Stress in BoneStress ReactionPeri-trabecular andperiostealinflammation andedemawith or w/o periostealnew bone formationStress FractureTabecular and corticalfracture linesStress Fracture / ReactionInsufficiency FractureNormal stress onabnormal boneFatigue FractureAbnormal stress onnormal bonePresentationMust considerit to look for itBone painmeans bonestressChange in activityGradual onsetVaguely localizedLate presentationProgressivecomplaintsPop on onset rarePain at rest rare17
11/11/2016PresentationMust considerit to look for itBone painmeans bonestressPain on palpationwell localizedPain on bone stressvalgus, extension,torsionPain on percussionPain on vibrationDifferential DiagnosisTumorInfectionInflammatory ArthritisPeripheral neuropathymedian & radial n.Proximal neuropathyradiculitis & TOSMust considerother causesfor vaguepain – or riskmissing thereal problemPlain RadiographsOften normalBeam opathyPeriosteal new boneEndosteal thickeningCortical radiolucencyLinear sclerosisFracture lineMarginalfragmentation18
11/11/2016Adaptive ChangesCortical and trabecularhypertrophyCanal and fossanarrowingProtective26 yo RHPDegenerative31 yo RHPTraction anddegenerativeexostosis formationPlain Radiographs3 Phase Bone ScanPositive earlyAll 3 phases positivewith fractureFindings resolve inorder with healing4 Stage ZwasGrading ScaleOlecranon tip stress fracture19
11/11/2016MR ImagingFalse negative or Delayedpositive, especially forolecranon tip and sublimetubercle stress fracturesSequence dependantMarrow / periosteal edemaFracture line4 Stage Grading ScaleBone Stress Injury in the ElbowUlnaFractureReactionSublime tubercleUlna metaphysisOlecranon processmid and proximalOlecranon apophysisOlecranon tipAccelerationBone Stress Injury in the ElbowHumerusFractureReactionCapitellum marginCapitellum bodyPost-med TrochleaMedial epicondyleBallRelease20
11/11/2016Mid and Distal HumerusPeriostitisHumeral Shin SplintsTPBS & MRIdiagnostic2 Fx GroupsUnder 30 years oldOver 30 years old4 risk factorsMid and Distal HumerusUnder age 30No prodromal sxSingle hard throwChange in activity?Spiral, btfly fragmentConsider pathologicalfracture27 y/o RHPwww.flicker.comMid and Distal HumerusOver age 30Prolonged time frompitchingLack of regularexerciseProdromal symptoms27 y/o RHPwww.flicker.com21
11/11/2016Medial epicondylePrimarily seen inadolescentsStress reaction andfracture seen in MEfollowing UCLRBone tunnelsInterference ScrewCapitellumCentral Stress ReactionMRI shows central edemaAssociated with UCLinsufficiency (VO)CapitellumRim Stress FractureDescribed in 1980 (Gore)Lateral column lossTreat with rest or excisionUCLPosterior-medial TrochleaPosterior ImpingementCompression / ShearChondromalaciaStress reaction - EdemaSubchondralinsufficiency fractureFocal Osteo-necrosis(SON)22
11/11/2016Sublime TubercleEnthesopathicNew bone formationSublime tuberclechanges are verycommon and seen inup to 75% of pitchersSublime TubercleStress reaction iscommon in HS andcollegeFracture morecommon in youngthrowersAv Age 17 years oldSublime TubercleMost fail to heal or haveassociated UCLinsufficiency23
11/11/2016Poor Prognostic IndicatorsOlder ageProlonged or recurrentsymptomsSclerotic marginsFracture displacementMUCL abnormal on MRIContrast w/in fractureSublime Tubercle Case #116yo HS junior, draftable, playingSore all summer, WU difficultTender over ST, MVST X-rays ST stress fracture 0.5 mm RLMRIBone Growth Stim. 2 months2 months BGSSublime Tubercle Case #217 yo HS juniorAche 2 months thenSudden painX-rays ST stress fracture 0.5 mm RLMRIORIF with bone graft3 months post‐op24
11/11/2016Sublime Tubercle Case #319 yo college soph6 months vague pain thenSudden painX-rays ST stress fracture1.5 mm RLMRI UCL chronic tearUCLR with DANE TJUCL and ST InsufficiencyOptionsDistal DockingButtonReally wide tunnelsDistal DockingInterference ScrewButton (Endo, Biceps)CombinedOlecranon ProcessAdolescentApohyseal delayed closureApohyseal nonunionApopyseal avulsionAdultFour types25
11/11/2016AdolescentPersistent Olecranon Physis16 published reports:Athletes between 13 – 16/17 years53 individual casesLargest series: 16 baseball playersSports:Gymnastics, Baseball, Javelin, Tennis,Badminton, Diving, WrestlingTreatment recommendationsRestSurgeryTension band / PinsTension band / ScrewsScrewsMost recommend autogenous bone graftNone recommend bone growth stim.26
11/11/2016MaterialsOver 12 years31 athletes with olecranon injuries(Age 9 – 20 years)Oblq. Stress Fx in mature skeleton7Displ. Avulsion Fx thru physis2Delayed closure of physis22MaterialsAll malesSport Baseball21Gymnastics 1Group 1 SurgeryGroup 2 No SurgeryGroup 1- Surgery16 Athletes (15 baseball, 1 gymnast)Av Age Onset15 2 years (15 4)(12 10 – 16 10)Av Age Surg15 10 years(14 6 – 16 11)Av Duration8 months(11 months 15 YO)27
11/11/2016Group 2- No Surgery6 Athletes (all baseball players)Av Age Onset14 7 years(13 0 to 15 6)Av Duration2 monthsMethodsHistory and ExaminationComparison X-raysAlgorithm (age at first visit) 14 0 (n 2)No surgery14 0 – 15 11Discussion 16 0 (n 8)SurgeryDiscussionDuration of symptomsResponse to conservative careComparative radiographic appearanceSequential radiographic changesReview of literature and experienceRisk / benefitFamily / Patient preference28
11/11/2016Contra-lateral PhysisGroup 1Av.Group 294% ClosedRange 50 – 100%RHP 15 4Av. 62% ClosedRange20 – 100%LHP 15 2Group 1 - TreatmentGroup 1 - TreatmentInternal fixationSingle 6.5 mm screwDouble 4.0 mm screws15 (baseball)1 (gymnastics)GraftLocal autogenous graftHardware removalAv Post-opFirst 6 only50% patients20 weeks29
11/11/2016Group 1 - TreatmentPre-op1 week16 weeksLHP15 1 yearsRadiographic Follow-upPost-operative studies at:0, 1, 6 weeks then every 6 weeks untilbony union documented1 week6 weeks12 weeksGroup 2 - TreatmentAgeweeks121613 8Right30
11/11/2016Results - Time to ClosureGroup 1Av. 9 Weeks ( 2 Mo)7/15 Closed at 6 weeks15/16 Closed at 12 weeks1/16 UnknownGroup 2Av. 25 Weeks ( 6 Mo)4/6 Closed at 10 months2/6 UnknownResults - Return to SportGroup 194% 15 / 16 Total14 / 15 Baseball9 / 15 College2 / 15 DraftedGroup 280% (4 / 5 Total)One lost to Follow-upResults - Return to Sport1 GymnastSymptomsFull activity6 weeks (age 15 1)5 weeksJr. Olympic Nat’l Championships (4 mo)High BarStill RingsAll AroundGoldBronzeBronze31
11/11/2016Effect of Graft / HW RemovalNoneConclusionsNon-operative Treatment is effective foryounger adolescent athletes withpersistence of the olecranon physisOperative Treatment without bone graft isrecommended for the older adolescentathlete with a persistent olecranon physisOlecranonAdult - ClassificationStress Injury4 Adult TypesFractureReaction1 MetaphysealStr. Reaction2 Oblique Midolecranon Fx3 Transverseproximalolecranon Fx4 Olecranon TipFxNakaji Knee Surg STA 2006; Schickendantz AJSM 200232
11/11/2016Furushima Classification1. Proximal Ulna Str ReactionCause Valgus and TorsionX-rays NormalMRI Diffuse edemaT2 Fat SatNon-operative careComplete rest 6 wks orRelative restBudget throwing, changepositions, BGSSchickendantz AJSM 20022. Mid-oblique Str FractureCause Valgus and TorsionX-rays Normal or fractureMRI Edema VariesLocation Mid-olecranonFracture lineruns proximal-medial todistal-lateralProx‐medDist‐lat33
11/11/20162. Mid-oblique Str FractureNon-operative careShort duration sxNo fx line or sclerosisPlay based on symptomsProx‐medHigher recurrence rateFollow: X-ray and MRIDist‐latSx resolve with x-rays2. Mid-oblique Str FractureOperative care7.0 mm screw4.5 mm screwT‐BandPlateChronic conditionFailed non-operativeX-ray Fx line / sclerosisFixation MethodsScrewsT-bands, PlatesScrew Fixation OptionsLongitudinalSingle vs PairedWith T-band wireOblique andtothe fx linePaired 4.0mmscrewsProbably more failures with longitudinalscrew fixation placement34
11/11/2016Screw Fixation – Case 1Longitudinal FixationFracture persistedOblique FixationFracture healedPaired 4.0mm screwsPerpendicular to fx lineFollow with 2mm, 3 plane CTPre and Post-opMinor League PitcherORIF with Axial screwFailed unionScrew Fixation – Case 1Longitudinal FixationFracture persistedOblique FixationFracture healedPaired 4.0mm screwsPerpendicular to fx lineExchange for fully threaded screwsDirection: From Proximal, Lat, and DorsalTo Distal, Med, and VolarScrew Fixation – Case 2Conservative careFracture persistedOblique FixationFracture healedPaired 4.0mm screwsPerpendicular to fx lineVeryclose totheCollegePitchersubchondralplateFailed unionExchange for fully threaded screwsDirection: From Proximal, Lat, and DorsalTo Distal, Med, and Volar35
11/11/20163. Transverse Prox Str FractureCause Torsion, VEOUCL insufficiencyX-rays Normal orfractureMRIEdema VariesLocation Prox olecranonFracture lineruns Transverse3. Transverse Prox Str FractureSingle screwScrew and T-bandPaired screwsAnte gradeSmaller fragmentAnte gradeRetro gradeRetro gradeLarger fragmentTransverse Prox Stress Fracture36
11/11/2016Transverse Prox Stress FractureTransverse Prox Stress FractureFailed Fixation3 Months Postop37
11/11/2016Failed Fixation4. Post-Med Tip Str FractureCause VEO, Posterior ImpUCL insufficiencyX-rays Normal, Exostosis,Fracture, Loose BodiesEdema Varies,Often False NegativeLocation PM TipMRIFracture lineruns Transverse orObliqueRadial Head Stress FractureSalter Harris Type 3RareNot an Os RHOften unrecognized 90% GymnastsAge 8 – 11Best followed withfluoroscopyContrast MRI38
11/11/2016Radial Head Stress FractureSalter Harris Type 3RareNot an Os RHOften unrecognized 90% GymnastsAge 8 – 11Best followed withfluoroscopyRadial Head Stress FractureSalter Harris Type 3RareNot an Os RHOften unrecognized 90% GymnastsAge 8 – 11Best followed withfluoroscopyXRadial Head Stress FractureSalter Harris Type 3RareNot an Os RHOften unrecognized 90% GymnastsAge 8 – 11Best followed withfluoroscopy39
11/11/2016Radial Head Stress FractureSalter Harris Type 3RareNot an Os RHOften unrecognized 90% GymnastsAge 8 – 11Best followed withfluoroscopyRadial Head Stress FractureSalter Harris Type 3RareNot an Os RHOften unrecognized 90% GymnastsAge 8 – 11Best followed withfluoroscopyRadial Head Stress FractureSalter Harris Type 3RareNot an Os RHOften unrecognized 90% GymnastsAge 8 – 11Best followed withfluoroscopy40
11/11/2016Radial Head Stress FractureSalter Harris Type 3RareNot an Os RHOften unrecognized 90% GymnastsAge 8 – 11Best followed withfluoroscopyRadial Head Stress FractureN 19 gymnastsAge 8 – 11Level 8 to elite6 required ORIFAll healed and 5/6returned to sportSummary – Stress FracturesOverall10 different typesHumerusUlnaOlecranon46FractureReaction541
11/11/2016Thank You42
Nov 05, 2016 · Nov 05, 2016 · Posterior-Lateral 1. RC Plica 2. Lateral Gutter Plica 3. Proximal Lateral Band 2. Posterior . PM Tip Spur / Fragmentation PM Trochlea OCL, LB Plica Trochlea Chondromalacia Posterior Osteophyte. 11/11/2016 2 Posterior-Lateral Impingement 1. Radius-capitellar Plica (Meniscus) . Full extension
Module 4 Special Tests for Impingement. At the end of this module the learner will be able to: Identify and describe shoulder impingement syndrome, with specific focus on Neer's three stages of shoulder impingement. Describe the mechanism of injury for both anterior and posterior shoulder impingement.
tion protocol as in preceding studies [3, 5, 8, 9]. Hand fractures are categorized into three different groups: (i) phalangeal fractures, (ii) metacarpal fractures or carpal fractures, and (iii) scaphoid fractures. Multiple fractures in the phalangeal bones sustained during the same frac-tu
Feb 15, 2019 · PTOT-12.2: Elbow Fracture Post-ORIF 582 PTOT-12.3: Elbow Nonspecific 592 PTOT-12.4: Elbow Neuropathy 604 PTOT-12.5: Elbow Tendinopathies 616 PTOT-12.6: Hand Fractures post ORIF 627 PTOT-12.7: Hand Fractures – Nonsurgical 637 PTOT-12.8: Hand- Post Dupuytren’s Release 646 PTOT-12.9: Hand Tendinopathies 656
The OptiLock Periarticular Plating System is intended for fixation of fractures and osteotomies. The System is intended for buttressing multifragment distal femur fractures including: supracondylar, intra-articular and extra- articular condylar fractures, fractures in normal or osteopenic bone and nonunions and malunions.
1. Proximal fractures (proximal short and long nails only) 2. Diaphyseal fractures Proximal Long, (antegrade/retrograde nails) 3. Open and closed fractures 4. Comminuted fractures 5. Nonunions and malunions 6. Pathologic fractures CONTRAINDICATIONS 1. Distal fracture involving the olecranon fossa 2. Bone shaft having excessive bow or deformity 3.
ELBOW FRACTURE (Epicondyle) Description Contact sports, such as football, hockey, and An epicondyle elbow fracture is a broken bone (fracture) in the elbow involving the attachment of the forearm muscles to the arm bone (humerus). This usually occurs in children. These fractures result f
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