William M Isbell

In This Chapter

Distal biceps tendon rupture

Surgery—biceps tendon repair Triceps tendon rupture

Surgery—triceps tendon repair

Ruptures of the tendons of the elbow joint are relatively rare. Rupture of the distal biceps tendon accounts for most of these injuries. The distal biceps tendon is ruptured most commonly in the dominant extremity of patients in their 40s to 60s and is more common in men than women.1 The mechanism of injury is thought to occur from traumatic extension of a flexed elbow with a maximally contracted biceps. Degradation or degeneration of the tendon may play some role in its rupture. Other theories that have been advanced for the cause of biceps rupture have included hypovascularity of the tendon, mechanical failure of the tendon, and impingement of the surrounding structures on the tendon leading to its failure.2

Compared to the number of patients presenting with biceps rupture, the number of patients with triceps rupture is small. The largest number of triceps tendon ruptures has been reported in professional football players.3 The mechanism of injury involves an eccentric load to a contracting triceps. Several risk factors have been identified for this injury including anabolic steroids, renal dialysis, lupus, and hyperparathyroidism.4-8 Tendinosis of the triceps tendon is thought to play some role, with the weakened tendon often progressing from a partial tear to a complete rupture.

BICEPS RUPTURE

Clinical Features and Evaluation

Patients who present to the orthopedic clinic after sustaining a rupture of the biceps tendon often complain of feeling a sudden pop at the elbow. Frequently, there is the onset of significant swelling and pain, followed by a reduction in pain and increasing ecchymosis. These patients may or may not have a palpable defect at the elbow. There is detectable weakness with resisted supination and flexion of the elbow. In some patients, with resisted elbow flexion, the muscle belly may be seen retracting prox-imally forming a mass in the arm much larger than that of the contralateral biceps (Fig. 36-1). Plain radiographs are usually obtained but have a limited role in making the diagnosis. MRI is helpful to determine the location of the tear as well as the degree to which the tendon is torn. It is also useful to evaluate for tendinosis and the quality of the ruptured tissue.

Relevant Anatomy

The biceps muscle lies in the anterior compartment of the arm.

Its proximal origin of the short head is at the coracoid, and its proximal origin of the long head is intra-articular at the glenoid. The distal biceps tendon attaches at the radial tuberosity, the most common site of its rupture. It is innervated by the musculocutaneous nerve, which originates at cervical roots 5, 6, and

7. The biceps is the strongest supinator of the forearm. This supination force increases as the elbow is flexed. With the brachialis, the biceps acts as an elbow flexor as well. When the elbow is flexed with a supinated forearm, the biceps is more active than when the forearm is in a pronated position.9

Treatment Options

Treatment of injuries of the distal biceps tendon depends on the degree to which the tendon is torn and whether it is acutely or chronically ruptured. There is no universally established treatment for partial ruptures of the biceps tendon. If some tendon remains attached, frequently the initial treatment is conservative. In the initial phase, reducing swelling and re-establishing range of motion are paramount. The patient gradually progresses to strengthening once the pain has subsided and motion has been regained. If there is persistent pain and weakness, the partially ruptured tendon is debrided and reattached anatomically to the radial tuberosity. Simple debridement of the tendon has not been shown to effectively reduce pain following partial ruptures.10

The results of surgical repair of acute, complete ruptures of the biceps are far more favorable than those of chronic repairs, as one might expect. However, not all patients require repair of a completely ruptured tendon. Low demand and elderly patients

INTRODUCTION

• Distal biceps tendon ruptures are more common than triceps ruptures.

• In athletes, triceps tendon ruptures are most commonly seen in professional football players, particularly linemen.

• Nonoperative treatment of a complete distal biceps tear results in significant loss of supination strength, while nonoperative treatment of a complete triceps tendon tear results in loss of elbow extension strength.

• Partial tears of both biceps and triceps ruptures can be treated nonoperatively. If pain and/or weakness persist, surgical repair is undertaken.

Biceps Rupture Image Elderly

Figure 36-1 Patient flexing the elbows after right distal biceps tendon Figure 36-2 Tendon of ruptured distal biceps taken out through a rupture, showing retraction of the affected muscle belly into arm. transverse incision in the flexion crease of the elbow.

Figure 36-1 Patient flexing the elbows after right distal biceps tendon Figure 36-2 Tendon of ruptured distal biceps taken out through a rupture, showing retraction of the affected muscle belly into arm. transverse incision in the flexion crease of the elbow.

without significant pain are often treated conservatively for these ruptures, especially if it involves the nondominant arm. However, in most patient populations, the benefit of greater strength and function make acute repair the best choice. The primary reason to fix these complete tears is the restoration of supination strength.

Many techniques have been described for the repair of distal biceps ruptures using a single or a double incision. The most commonly used technique is that of Boyd and Anderson, using two incisions for the anatomic repair. Single-incision techniques have been shown to have higher incidences of posterior interosseous nerve complications, but newer techniques using suture anchors have shown some promise in reducing these complications.11

Surgery

Biceps Tendon Repair (Modified Boyd-Anderson12)

In the case of an acute rupture, a transverse incision is made over the flexion crease of the elbow. Dissection is carried down to the level of the ruptured tendon. Careful attention is made to retract the lateral antebrachial cutaneous nerve laterally. The ruptured tendon is bluntly freed from any adhesions or scar. Its end is tagged with two nonabsorbable locking stitches (Fig. 36-2). A tunnel is created between the radius and ulna with blunt dissection. A curved clamp can aid in this dissection. With the curve of the clamp going medially around the radius, a small pos-terolateral incision is made at the tip of the clamp. Through this incision, the radial neck and tuberosity are exposed while keeping the forearm in maximal pronation, thereby protecting the posterior interosseous nerve. Once the radial tuberosity is exposed, a trough is created in the tuberosity with a bur. Three holes are drilled in the radius adjacent to the trough. The tagged tendon is then passed through the interval between the radius and ulna once again with a curved clamp pointing away from the ulna and following the curve of the radius (Fig. 36-3). The suture limbs are then passed through the trough and out the holes in the radius and tied over the top of the bony bridge. The incisions are then closed in two layers, and the elbow is placed into a well-padded posterior splint.

Chronically ruptured biceps tendons may be repaired directly, provided that the tendon of the biceps has not retracted significantly or that the muscle itself has not shortened significantly. It is recommended that these repairs be performed through two incisions to reduce the risk of injury to the radial nerve. If the native tendon is significantly retracted or if the quality of the chronically ruptured tendon is poor, the repair may be augmented with either autograft or allograft tendon. The semitendinosus is a good choice for this augmentation because of its similarity in size to that of a native biceps tendon.

Postoperative Rehabilitation

The patient's arm is immobilized in 90 degrees of flexion for 2 weeks. At the time of suture removal, the patient is placed into a hinged elbow brace. Range of motion is progressed to full over the next 4 weeks. At 6 to 8 weeks postoperatively, gentle strengthening of the biceps is begun. Any aggressive strengthening is avoided until at least 12 weeks postoperatively. The patient is allowed to return to competitive activities when full

Figure 36-3 Posterolateral incision with tagged biceps tendon pulled into position to be anchored into the radial tuberosity.

range of motion is obtained and strength is close to that of the opposite side, somewhere around 4 to 6 months postoperatively.

Results

The results of nonoperative treatment of distal biceps ruptures have been shown to result in a loss of as much as 50% of supination strength at the elbow. Morrey et al have shown a return of 97% of flexion strength and 95% of supination strength in patients who had repairs of distal biceps ruptures.13 D'Alessandro et al14 showed similar excellent results in a group of 10 athletes who underwent distal biceps repair. All the athletes in this group returned to full unlimited activity, with the only deficit seen being a decrease in endurance of 20% compared with the opposite side in functional testing. The repair of chronic ruptures has shown less favorable results. Weakness following chronic repair has been reported as high as 50%15 (similar to that of nonoperative repair) and as little as 13% in other cases.16

TRICEPS RUPTURE

Clinical Features and Evaluation

Patients with distal triceps tendon ruptures often present with a history of a direct blow to the elbow or forced elbow flexion while the triceps was contracted. Oftentimes, these patients have a history of corticosteroid injections for presumed olecranon bursitis.4 There are usually pain and swelling at the elbow with some limitation of range of motion and weakness with resisted extension. In patients with a complete rupture, there is usually a palpable defect in the distal triceps. Using a modification of the T. Campbell Thompson Test for Achilles tendon ruptures, the elbow may be flexed over the examination table and the triceps muscle belly squeezed, resulting in no elbow extension when the triceps tendon is torn.17 Lateral radiographs of the elbow may show a small piece of bone pulled off with the triceps tendon. Occasionally there is a large piece of bone similar to that of an olecranon fracture. Magnetic resonance imaging is useful to delineate between partial and complete tears as well as to localize the tear itself (Fig. 36-4).

Figure 36-4 Magnetic resonance imaging showing a rupture of the triceps tendon off the olecranon.

Relevant Anatomy

The triceps is named for its three heads. The origin of the lateral head is the posterolateral aspect of the humerus, the origin of the long head is the infraglenoid tubercle of the scapula, and the medial head originates from the spiral groove of the humerus. The insertion of the triceps is the olecranon. The function of the triceps is to extend the elbow, and the long head aids in shoulder adduction and arm extension. The innervation of the triceps is the radial nerve, which originates at cervical roots 6, 7, and 8.

Treatment Options

There is no consensus regarding what percentage of the triceps tendon must be torn before repair is warranted. In general, most partial tears of the tendon may initially be treated conservatively. Treatment focuses on swelling reduction, pain relief, and restoration of range of motion. Contact athletes may return to play after partial tears in a hinged brace with an extension block. However, there are reported cases of complete ruptures of partial tears following a return to contact sports.3

Complete ruptures of the triceps tendon have been shown to cause significant disability, not only in athletes, but also in chronically ill patients in whom the triceps is very important for transfers and mobilization.5 There have been reports of repairs of both acute and chronic ruptures of the triceps tendon. The cornerstone of the surgical treatment of these ruptures is repair of the tendon to the bone of the olecranon. Occasionally large bony avulsions of the triceps are treated like an olecranon fracture with screw or tension band fixation.

Surgery

Triceps Tendon Repair

The repair is accomplished through a posterior approach to the elbow with a direct midline incision, curving around the tip of the olecranon. Dissection is carried through the subcutaneous tissue to the triceps muscle and tendon below (Fig. 36-5). The dissection medially is done carefully to prevent injury to the ulnar nerve (in chronic cases, the nerve may be encapsulated in scar requiring decompression and transposition). Once the torn tendon is dissected free, a nonabsorbable suture is placed through the tendon with a locking stitch. Two bone tunnels are drilled in the olecranon. These may be placed parallel to or crossing each other. The sutures are then tied down through these bone tunnels while the elbow is in extension (Fig. 36-6). Particular attention is made not to place the knot medially

Figure 36-5 A complete rupture of the distal triceps mobilized for repair.

Figure 36-4 Magnetic resonance imaging showing a rupture of the triceps tendon off the olecranon.

Figure 36-6 Distal triceps rupture being repaired through drill holes in the olecranon.

(adjacent to the ulnar nerve) to prevent irritation or too superficially, which will cause pain when resting the elbow on a hard surface. The incision is closed in two layers. The elbow is immobilized in a well-padded posterior splint in 45 degrees of flexion.

Postoperative Rehabilitation

After repair of a distal triceps rupture, the arm is immobilized in 45 degrees of flexion for 2 weeks. At the time of suture removal, the elbow is put into a hinged elbow brace and active and passive range-of-motion exercises are begun. At 6 weeks postoperatively, gentle strengthening is begun. Aggressive resistive strengthening is avoided until 3 months postoperatively. Athletes may return to competitive play between 4 and 6 months postoperatively if range of motion has returned and strength is similar to that of the opposite side. Additional protection for contact athletes may be provided by a hinged elbow brace.

Results

Excellent results have been reported with both early and delayed repairs of complete ruptures of the triceps. In the largest series reported, 10 of 11 professional football lineman who had early repair of a complete rupture of the triceps returned to play at least 1 year of football following repair. All the players were found to have full range of motion, no pain, and no discernible weakness 1 year following repair. Ten players with partial tears were identified. The tears of one of these players progressed to a complete tear when he returned to play. The remaining nine players were able to finish out their season with a partial tear. Six of these players healed their partial tears and required no further intervention, and three players underwent repair of partial tears in the off season.3

CONCLUSIONS

Ruptures of the tendons about the elbow may be uncommon injuries, but they will be encountered in a sports medicine practice. Complete ruptures of both the distal biceps tendon and the triceps tendon are best treated with early anatomic repair followed by early restoration of range of motion and delayed strengthening. Partial ruptures of either of these tendons may be initially treated conservatively with pain and swelling reduction and restoration of motion. However, in highly active patients, these partial tears may continue to be symptomatic or progress to complete tears, requiring repair.

REFERENCES

1. Friedmann E: Rupture of the distal biceps brachii tendon: Report on 13 cases. JAMA 1963;184:60-63.

2. Siler JG III, Parker LM, Chamberland PD, et al: The distal biceps tendon: Two potential mechanisms involved in its rupture—Arterial supply and mechanical impingement. J Shoulder Elbow Surg 1995; 4:149-156.

3. Mair SD, Isbell WM, Gill TJ, et al: Triceps tendon ruptures in professional football players. Am J Sports Med 2004;32:431-434.

4. Lambert MI, St. Clair Gibson A, Noakes TD: Rupture of the triceps tendon associated with steroid injections. Am J Sports Med 1995;23:778.

5. Mankin HJ: Rickets, osteomalacia, and renal osteodystrophy. J Bone Joint Surg Am 1974;56:101, 352-386.

6. Martin JR, Wilson CL, Matthews WH: Bilateral rupture of ligament patellae in case of disseminated lupus erythematosus. Arthritis Rheum 1958;6:548-552.

7. Preston FS, Adicaff A: Hyper parathyroidism with avulsion of three major tendons: Report of a case. N Engl J Med 1962;266:968-971.

8. Sallender JL, Ryan GM, Borden GA: Triceps tendon rupture in weight lifters. J Shoulder Elbow Surg 1984;7:151-153.

9. Basmajian JV Latif A: Integrated actions and functions of the chief flexors of the elbow: A detailed electromyographic analysis. J Bone Joint Surg Am 1957;39:1106-1118.

10. Bourne MH, Morrey BF: Partial rupture of the distal biceps tendon. Clin Orthop 1985;193:189-194.

11. Ozyurekoglu T, Tsai TM: Ruptures of the distal biceps brachii tendon: Results of three surgical techniques. Hand Surg 2003;8:65-73.

12. Boyd HD, Anderson LD: A method for reinsertion of the distal biceps brachii tendon. J Bone Joint Surg Am 1961;43:1041-1043.

13. Morrey BG, Askew LJ, An KN, Dobyns JH: Rupture of the distal tendon of the biceps brachii: A biomechanical study. J Bone Joint Surg Am 1985;67:418-421.

14. D'Alessandro DF, Shields CL Jr, Tibone JE, Chandler RW: Repair of distal biceps tendon ruptures in athletes. Am J Sports Med 1993;21:114-119.

15. Boucher PR, Morton KS: Rupture of the distal biceps brachii tendon. J Trauma 1967;7:626-632.

16. Hang DW Bach BR Jr, Bojchuk J: Repair of chronic distal biceps brachii tendon rupture using free autogenous semitendinosis tendon. Clin Orthop 1996;323:188-191.

17. Viegas SF: Avulsion of the triceps tendon. Orthop Rev 1990; 19:533-536.

In This Chapter

Little leaguer's elbow Medial epicondylar apophysitis Medial epicondyle avulsion fracture Ulnar collateral ligament injury Olecranon injury Lateral epicondylar apophysitis Panner's disease Osteochondritis dissecans

RELEVANT ANATOMY

The growth and development of the human skeleton can be divided into three general stages. The first, childhood, ends with the appearance of the secondary centers of ossification. Adolescence ends with the fusion of the secondary ossification centers to their respective long bones. Finally, young adulthood terminates with the completion of all bone growth and the achievement of the final adult musculoskeletal form.1 Characteristic patterns of elbow injury occur during each stage of elbow growth and development. The injury patterns are influenced greatly by the sport played and the resulting forces applied to the athlete's upper extremity. In each stage of development, the elbow has a characteristic weak link that is susceptible to injury.

Skeletal growth and development of the male and female elbow occur at characteristic times.1-4 At birth, the distal humerus is a single epiphysis comprised of both condyles and epicondyles with one physis. Over the course of the first decade, the epiphysis differentiates into two epiphyses (the capitellum and trochlea) and two apophyses (the medial and lateral epicondyles). The radial head and olecranon epiphyses also develop secondary growth centers during this period. The appearance of the secondary centers of ossification follows a characteristic pattern. The capitellum appears at age 1 to 2. At roughly 2-year intervals, the other centers appear. The appearance of the radial head at age 3 is followed by the medial epicondyle at age 5, the trochlea at age 7, the olecranon at age 9, and the lateral epicondyle at age 10 in females and age 11 in males. Fusion of these secondary ossification centers occurs in a sequential, age-dependent order in the early teens in girls and mid-teens in boys. The capitellum, trochlea, and olecranon close at approximately age 14, while the medial epicondyle closes at 15, and the radial head and lateral epicondyle fuse at 16 years of age.

LITTLE LEAGUER'S ELBOW

The term little leaguer's elbow refers to a group of elbow problems in the young throwing athlete.4-7 The injuries include medial epicondyle fragmentation and avulsion, delayed or accelerated apophyseal growth of the medial epicondyle, delayed closure of the medial epicondylar apophysis, osteochondrosis and osteochondritis of the capitellum, osteochon-drosis and osteochondritis of the radial head, hypertrophy of the ulna, olecranon apophysitis, and delayed closure of the olecranon apophysis.

Repetitive overuse injuries in the adolescent elbow can be categorized based on the pattern of applied forces. These categories include medial tension, lateral compression, and posterior shear or traction injuries. Medial epicondyle apophysitis, medial epicondyle avulsion fractures, and ulnar collateral ligament injuries comprise medial tension overload injuries. Lateral compression injuries include Panner's disease and osteochondritis dissecans (OCD) of the capitellum. Olecranon apophyseal injury and avulsion of the olecranon fall within the realm of posterior shear or traction injuries.

CLINICAL FEATURES AND EVALUATION

A thorough clinical history and physical examination along with routine radiography are critical for the diagnosis of adolescent elbow pathology.2,4 Necessary historical information includes the

INTRODUCTION

• The widespread participation in organized sports among skeletally immature athletes has led to an increase in elbow injuries among this population in recent years. Children and adolescents are competing at earlier ages, and single-sport specialization often requires these athletes to participate throughout the year.

• As the frequency and intensity of these athletes' participation have increased, the cause of elbow injuries has shifted from macrotrauma, including fractures and dislocations, to repetitive microtrauma.

• Athletic elbow injuries are seen in both overhead sports, such as baseball and tennis, and sports requiring the elbow to serve as a weight-bearing joint, as in gymnastics.

• Treatment of elbow injuries in these athletes requires a thorough knowledge of the anatomy and bony development of the adolescent elbow, an understanding of the natural history of its disorders, and a grasp of the expected outcomes with conservative and operative management.

age, handedness, sport, and position of the athlete as well as the level of competition and the amount of practice and playing time per week. The onset, duration, quality, and anatomic location of elbow symptoms must be elicited. Whether sports participation affects the symptoms is critical to address. The specific motions and positions that precipitate the elbow complaints, such as medial pain in the late cocking and acceleration phases of throwing, should be sought. Previous treatments should be noted. The duration of symptoms and the acute or chronic nature of the injury are important for making the diagnosis. A single traumatic episode suggests an acute traumatic condition such as an avulsion fracture of the medial epicondyle, while an insidious onset of chronic pain implies an overuse syndrome such as medial epi-condylar apophysitis.

The physical examination includes inspection and palpation of the elbow, motion assessment, stability testing, and neurologic and vascular evaluation. Bony hypertrophy, flexion contracture, and carrying angle are important to note. The presence of tenderness at the epicondyles, olecranon, radial head, and collateral ligaments should be recorded. Any ulnar nerve subluxation should be recorded. The ulnar collateral ligament is tested with valgus stress and external rotation of the arm, while the lateral ligaments are stressed with varus and internal rotation.

Basic imaging includes at least anteroposterior and lateral radiographs. Often oblique views and stress films are helpful. Common lateral elbow radiographic findings include lucent areas in the capitellum or loose bodies in the anterior or lateral compartments that suggest OCD of the capitellum or radial head. Enlargement, beaking, and fragmentation of the medial epi-condyle or an avulsion of the epicondyle are common observations on the medial side of immature elbows. Posterior findings, including osteophytes or loose bodies, are often seen with repetitive impingement of the olecranon. It is critical to evaluate comparison views of the opposite elbow when assessing equivocal radiographic findings of the symptomatic elbow.

Magnetic resonance imaging is becoming more popular for evaluation of pediatric elbow injuries. Young patients often have difficulty cooperating sufficiently to obtain a magnetic resonance imaging, but in older adolescents, it can be helpful for defining developing apophyses and epiphyses, joint capsules, ligaments, and soft tissues that are not well seen on plain radiographs.

MEDIAL EPICONDYLAR APOPHYSITIS

Repetitive tensile stress from the flexor-pronator mass and the ulnar collateral ligament on the medial epicondyle can lead to medial epicondylar apophysitis and ultimately a stress fracture of the medial epicondylar apophysis.1,3,8 Throwing athletes with this disorder will often complain of progressively worsening medial elbow pain with activity. The characteristic triad includes medial epicondyle pain, a decrease in throwing distance or velocity, and a decrease in throwing effectiveness.1,4 The valgus stress placed on the elbow in the late cocking or early acceleration phases causes an exacerbation of the pain with repetitive throwing.

Physical examination reveals tenderness at the medial epi-condyle. Valgus stress often reveals pain, but obvious instability is not present. Radiographs often appear normal. A comparison with the opposite elbow will sometimes demonstrate widening of the apophysis. Occasionally fragmentation or hypertrophy of the medial epicondyle is present.

Conservative management of medial epicondylar apophysitis usually results in complete resolution of symptoms with no lasting functional deficit. Eliminating repetitive valgus stress on the elbow by stopping all throwing activities, often for at least 6 weeks, as well as ice and nonsteroidal anti-inflammatory medications will usually provide symptomatic relief. Physical therapy focusing on range of motion, muscle stretching, and strengthening can be helpful. Evidence of radiographic healing is not necessary to allow a return to activity, as long as the athlete gradually increases his throwing in a supervised program that emphasizes proper mechanics.

MEDIAL EPICONDYLE AVULSION FRACTURES

Medial epicondyle avulsions are acute injuries that usually result from a single tensile force applied to the medial elbow of adolescent athletes.1-4,6,9,10 Failure of the medial epicondylar apoph-ysis results from an acute valgus stress coupled with a violent contraction of the flexor-pronator muscle mass. The player will present with acute onset of medial pain after a throw. The pain is severe enough to prevent him or her from returning to play. It usually occurs in the late cocking or early acceleration phases of throwing, and the athlete will often feel or hear a pop. Ulnar nerve paresthesias may occur after the injury. Chronic medial elbow symptoms occasionally precede the event.

Physical examination reveals discrete tenderness to palpation at the medial epicondyle, edema, and occasionally ecchymosis. The last 15 degrees of elbow extension are limited due to pain, which can make stability testing difficult. Ulnar collateral ligament injury is possible in this setting, although it is less likely given the fact that the physis of the medial epicondyle is the weak link in the developing elbow. Coexisting ulnar collateral ligament rupture and medial epicondyle avulsion is unusual. The occurrence of a spontaneously reduced elbow fracture-dislocation should be kept in mind.

Radiographs will usually show a minimally displaced avulsion fracture (Fig. 37-1). Findings are often subtle, requiring comparison elbow views or stress radiographs. While rare, the avulsed fragment can be displaced by the flexor-pronator mass, sometimes into the elbow joint, as often seen in elbow dislocations.

The appropriate treatment for these fractures is a matter of some debate. Stress fractures and nondisplaced fractures are usually treated nonoperatively, while fractures in which the fragment is displaced or incarcerated in the joint are treated operatively if the fragment cannot be reduced by closed manipulation. Ulnar nerve dysfunction often mandates exploration along with open reduction and internal fixation of the fracture.

Nonoperative management of minimally displaced medial epicondyle fractures is based on the observation that fractures displaced less than 3 to 5 mm will develop an asymptomatic fibrous union. Ulnar nerve symptoms and valgus instability must be absent. Whether this approach is adequate for the young throwing athlete is not fully understood. If a nonoperative approach is chosen, the elbow should be immobilized in 90 degrees of flexion and moderate pronation in a long-arm splint for as long as 2 to 3 weeks.2,3,8,11 A hinged elbow brace can then be used to regain range of motion. When the fracture site is nontender and there is radiographic evidence of healing, flexor-pronator strengthening is started, and a gradual return to

Figure 37-1 A 15-year-old male pitcher with long history of pain at the medial epicondyle who showed no improvement with conservative management. A, Magnetic resonance arthrography demonstrates edema in the medial epicondyle, consistent with a nondisplaced avulsion injury. B and C, Anteroposterior and lateral postoperative radiographs showing two cancellous screws across the fracture.

Figure 37-1 A 15-year-old male pitcher with long history of pain at the medial epicondyle who showed no improvement with conservative management. A, Magnetic resonance arthrography demonstrates edema in the medial epicondyle, consistent with a nondisplaced avulsion injury. B and C, Anteroposterior and lateral postoperative radiographs showing two cancellous screws across the fracture.

throwing is initiated in a supervised program when the athlete is asymptomatic.2,3

Many authors advocate an operative treatment of these fractures, especially with more than 2 mm of displacement, rotation or incarceration of the fragment, valgus instability, or ulnar nerve symptoms.3,10,12,13 Young overhead throwing athletes may be prone to developing radiocapitellar degenerative changes if displaced fractures are treated nonoperatively,12 so accepting less displacement may be indicated in these patients.

Surgical management consists of open reduction and internal fixation using one or two cancellous screws (see Fig. 37-1B and C). Valgus stability is determined intraoperatively after fixation is achieved, with exploration and possible repair of the ulnar collateral ligament necessary if instability still exists. If the fragment is too small for adequate fixation, it should be excised, and the ulnar collateral ligament and possibly the flexor-pronator muscles primarily repaired.2,3,10 Postoperatively, the elbow is placed in a hinged-elbow orthosis for 6 weeks, with early range-of-motion and strengthening exercises started immediately if the fixation is adequate. When radiographs show fracture union and the athlete is asymptomatic, a gradual return to activity is allowed.

ULNAR COLLATERAL LIGAMENT INJURIES

Ulnar collateral ligament injuries, especially the chronic attri-tional tears seen in the skeletally mature, are uncommon in the juvenile and adolescent thrower.12 If a rupture is present, it most likely is the result of an acute event.9,14 The thrower will complain of the acute onset of pain and inability to continue throwing. The physical examination will reveal tenderness to palpation distal to the medial epicondyle. Jobe's valgus stress test may demonstrate pain and instability. Radiographs are needed to rule out the presence of a medial epicondyle fracture. Stress films are often helpful to demonstrate instability. Greater than 2 mm of medial opening compared to the uninjured side is strongly suggestive of a tear. Magnetic resonance arthrography with gadolinium contrast can also help demonstrate the presence of an ulnar collateral ligament tear.15

The treatment for an ulnar collateral ligament tear in the juvenile or adolescent thrower begins with conservative measures before proceeding to operative intervention, if necessary. A brief period of immobilization, nonsteroidal anti-inflammatory medications, and ice are used to control the initial pain. Physical therapy to regain motion and maintain strength and a hinged elbow brace to prevent valgus stress on the elbow are used for approximately 6 weeks. At this point, stability of the elbow is reassessed. If a complete tear and instability are present in a young thrower who wants to continue throwing sports, surgical treatment is advised. Athletes who do not demonstrate a complete tear or instability but continue to have medial elbow pain with activity for at least 3 months are also offered surgery. If an avulsion of the ligament is observed, direct repair may be possible. Reconstruction using autograft tendon such as the palmaris longus, as is commonly performed in adults, is more commonly the procedure of choice. Premature closure of the medial epi-condylar apophysis is possible, but this is not significant clinically, as the longitudinal growth of the distal humerus is not affected.

AVULSION OF THE OLECRANON

An avulsion fracture of the tip of the olecranon results from an acute overload failure of the olecranon apophysis. It occurs more commonly in older adolescents than in juvenile or young adolescent throwers. The injury occurs in the acceleration or follow-through phases of throwing. The athlete will note an acute onset of severe pain at the olecranon. Physical examination will reveal tenderness to palpation at the tip of the olecranon and pain with active extension. Full active extension of the elbow is often not present. Radiographs will demonstrate avulsion of the tip of the olecranon. This diagnosis may be difficult in younger throwers in whom the secondary ossification center of the olecranon is not visible. If more than 2 mm of displacement of the fracture exists, open reduction and internal fixation using a tension band or cannulated screw technique is recommended.

OLECRANON APOPHYSEAL INJURY

Repetitive throwing places stress on the olecranon apophysis due to powerful contraction of the triceps during the acceleration phase of throwing. The resulting tensile stress can lead to ole-cranon apophyseal injury.2,8,11,12 A traction apophysitis, similar to that which occurs at the medial epicondyle, occurs as a result of the traction force applied by the triceps. Throwers often complain of acute or chronic pain at the posterior tip of the elbow, swelling, and decreased range of motion. Tenderness to palpation at the olecranon tip and pain with resisted extension are seen on physical examination. Radiographs will show widening, fragmentation, or sclerosis of the olecranon physis compared to the uninvolved elbow. Normal radiographs, however, do not rule out the presence of this disorder, so a high index of suspicion must be maintained when appropriate signs and symptoms exist. Comparison views of the opposite elbow are important to differentiate this entity from a stress fracture of the olecranon, which can be seen in the older adolescent athlete whose olecranon apophysis has already closed.

Treatment of olecranon apophyseal injury depends on the duration and severity of symptoms, as well as the degree of separation of the apophysis. The initial management consists of conservative measures to decrease the athlete's symptoms, such as ice, nonsteroidal anti-inflammatory drugs, activity modification, and physical therapy. Good results are usually seen in 4 to 6 weeks. The persistence of symptoms or failure of the olecranon apophysis to close as seen on radiographs within 3 to 6 months of conservative treatment implies the need to consider operative management. Fixation can be achieved with a single cancellous screw (Fig. 37-2A and B). A short period of immobilization followed by physical therapy to resume active flexion and passive extension begins postoperatively. Active extension should be restricted for 6 weeks.

LATERAL EPICONDYLAR APOPHYSITIS

Lateral epicondylitis in the adolescent is similar to the analogous disorder in adults. It is more commonly seen in the athlete who participates in racquet sports due to repetitive wrist extension. While medial epicondylitis is more common in the throwing athlete, lateral symptoms can occur due to the eccentric activity of the wrist extensors and traction forces applied to the lateral apophysis during the follow-through phase of throwing.2 Improper technique or equipment can exacerbate the microtrauma to the apophysis.9 The athlete will give a history of pain at the lateral epicondyle or the extensor muscle origin that is aggravated by activity. On examination, pain may be reproduced with resisted wrist and finger extension. If the symptoms are attributable to an apophysitis, point tenderness will be present at the lateral epicondyle rather than the muscle origin, as in a tendonitis. Radiographs are usually normal but can show widening or fragmentation of the lateral epicondylar apophysis.

In the vast majority of cases, successful treatment can be achieved with nonsurgical measures. Ice, nonsteroidal anti-inflammatory drugs, and activity modification should decrease symptoms. When the athlete is more comfortable, physical therapy for stretching and strengthening are instituted. Correcting improper techniques and poorly fitting equipment is essential. A counterforce brace can be used to try to alter the pull of the extensor muscles on the apophysis. Surgical treatment is rarely indicated.

PANNER'S DISEASE

Panner's disease is a focal lesion or osteochondrosis of the subchondral bone and overlying articular cartilage of the capitellum that begins as degeneration or necrosis followed by regeneration or recalcification of the capitellar ossification center.2,3,8,14,16,17 It is the most common cause of lateral elbow pain in young children, characteristically occurring in children younger than 10 years old. In the vast majority of cases, it is a benign, self-limiting process. The appearance, size, and contour of the capitellum and the overlying cartilage are usually restored. Collapse of the subchondral bone is rare.17-19 The distinction between Panner's disease and osteochondritis dissecans is important because they

have markedly different natural histories and therefore, different treatment options.

Children with Panner's disease complain of dull, aching pain of the lateral elbow that is increased with activity and relieved with rest. They may complain of joint stiffness or loss of motion. Physical examination may reveal tenderness at the radiocapitel-lar joint, a flexion contracture of 20 degrees or less, and crepitus. Radiographs often show an irregular capitellum that appears smaller than that on the opposite side. Areas of fissuring or fragmentation can be seen. Involvement can be found in the anterior capitellum or in the entire ossific center.3,20

Conservative management of Panner's disease, including activity modification, avoidance of valgus stress to the elbow, ice, nonsteroidal anti-inflammatory drugs, and exercises to maintain range of motion, is usually sufficient. Arthroscopic treatment for this disorder has been described,16 but surgical treatment is rarely necessary. Symptoms may persist for many months, but the long-term prognosis is excellent.3,20

OSTEOCHONDRITIS DISSECANS

OCD of the capitellum is a condition in which a focal injury to the subchondral bone causes a loss in structural support for the overlying articular cartilage. The articular cartilage and subchondral bone then undergo degeneration and fragmentation, often resulting in alteration of the capitellar articular surface congruency and even the development of loose bodies. Although the term OCD implies an inflammation of the osteochondral articular surface, a true inflammatory process has not been proven to exist.3,20 The exact cause of OCD is unknown, but it is commonly thought to be related to a combination of repetitive microtrauma in the face of a tenuous blood supply to the capitellum.2,3,21,22

Unlike Panner's disease, which affects children younger than 10 years old, OCD usually causes lateral elbow pain in adolescents between ages 11 and 16. It is seen in the elbows of throwing athletes, which sustain repetitive valgus stress and lateral compression and in those of gymnasts whose elbows function as weight-bearing joints and thus are subjected to repetitive com-pressive loads and shear forces.23 The athlete will present complaining of poorly localized, progressive lateral elbow pain. Pain is often exacerbated with activity and relieved with rest. Mechanical symptoms such as locking, clicking, and catching can occur if a fragment has become unstable or a loose body is present. Physical examination often reveals tenderness to palpation in the anterolateral elbow, swelling, and crepitus. Loss of extension and forearm rotation can be seen. The active radio-capitellar compression test, consisting of pronation and supination with the elbow in full extension, often provokes symptoms.3 Radiographs classically demonstrate radiolucency or rarefaction of the capitellum with flattening and irregularity of the articular surface (Fig. 37-3A). The lesion will often be seen as a

Figure 37-3 A 13-year-old female gymnast with lateral elbow pain but no mechanical symptoms. A, Anteroposterior radiograph demonstrates the osteochondritis dissecans (OCD) lesion in the capitellum. B and C, T1- and T2-weighted magnetic resonance images showing marrow edema and disruption of the subchondral plate. The fluid deep to the base of the lesion suggests that this is an unstable lesion.

Figure 37-3 A 13-year-old female gymnast with lateral elbow pain but no mechanical symptoms. A, Anteroposterior radiograph demonstrates the osteochondritis dissecans (OCD) lesion in the capitellum. B and C, T1- and T2-weighted magnetic resonance images showing marrow edema and disruption of the subchondral plate. The fluid deep to the base of the lesion suggests that this is an unstable lesion.

Osteochondral Injury Talar Dome

Figure 37-3—Cont'd D, Arthroscopy demonstrates the nondisplaced, unstable OCD lesion in the capitellum. E, A probe placed in the fissure on the medial side of the lesion proves this to be unstable. F, The crater of the lesion is seen after the unstable flap of cartilage has been detached. G, The cartilaginous piece is manually removed with an arthroscopic grasper. H, A microfracture awl is directed into the base of the lesion. I, Bleeding is demonstrated from the multiple microfracture sites after the tourniquet has been deflated.

focal sclerotic rim surrounding a radiolucent crater. Anteroposterior radiographs with the elbow in 45 degrees of flexion can be helpful.24 In advanced OCD, collapse of the articular surface, loose bodies, enlargement of the radial head, subchondral cysts, and osteophyte formation can be seen. However, plain radiographs are often nondiagnostic in this condition, especially in the early stages of the disease.

Magnetic resonance imaging can be useful in diagnosing OCD in its earlier stages and assessing the status of the articular car-tilage.25,26 Low signal changes on T1-weighted images in the capitellum can suggest early OCD lesions.24 Fluid between a fragment and the capitellum seen on T2-weighted images indicates a detached fragment (Fig. 37-3B and C).

The natural history of a capitellar osteochondritis dissecans lesion is hard to predict. There are no reliable criteria to predict which lesions will heal and which will collapse and cause later joint incongruity. If healing is to occur, it will occur by the time that the physes close. If the lesion is left untreated and the elbow continues to experience repetitive microtrauma, the sub-chondral bone may eventually collapse. The joint incongruity can cause articular cartilage damage, loose body formation, and degenerative joint changes.1-3,27 Therefore, appropriate treatment of OCD lesions in the young athlete is not only critical for return to competition but also for long-term acceptable elbow function with normal everyday activities.

A useful classification of capitellar OCD is based on the stability of the subchondral bone and its overlying articular cartilage. The combination of clinical, radiographic, and arthroscopic findings can be used to classify lesions into three types.17 Type Ia lesions have intact articular cartilage and no loss of subchon-dral bone stability. Type Ib lesions are intact but unstable, having intact articular cartilage but unstable subchondral bone potentially at risk of collapse. The treatment of these type I lesions is initially nonsurgical, emphasizing rest, ice, nonsteroidal anti-inflammatory drugs, and early range-of-motion exercises. Activity should be modified until radiographs demonstrate evidence of revascularization and healing.1 Radiographic changes in OCD often persist for several years, so the decision to return an athlete to sports is based on resolution of symptoms. Conservative treatment of OCD of the capitellum is not always successful.14,26,28 Surgical indications for type I lesions include radiographic evidence of lesion progression, such as capitellar collapse, or failure of nonsurgical management to relieve symptoms after a 6-month period. The preferred surgical treatment involves arthroscopic evaluation; debridement, if necessary; and drilling or microfracture of the lesion.

Type II lesions are open and unstable, with cartilage fracture and collapse or partial displacement of the subchondral bone. These are often flap lesions that should be treated surgically, usually with debridement and drilling the bed of the lesion.18,27,29 If the fragment is large and has adequate subchondral bone backing, open reduction and internal fixation can be attempted.30

Type III lesions are completely detached loose bodies within the elbow joint. The most accepted surgical treatment involves arthroscopy or arthrotomy with excision of the loose bodies, debridement, and drilling the bed of the lesion.1,18,31,32 Type IV lesions have accompanying radial head involvement. These

"bipolar" lesions often lead to severe degenerative changes with likely poor long-term outcomes.

Few long-term studies of OCD lesions have been published. Ruch et al32 presented the results of 12 adolescents who had undergone arthroscopic debridement. They noted that at an average follow-up of 3.2 years 92% of the patients were highly satisfied with minimal symptoms.32 McManama et al18 reviewed the results of 14 athletes who underwent arthrotomy, excision of loose bodies, and curettage of the lesion beds. Of those 14 athletes, 12 returned to competitive activity without restrictions. Many authors believe that the beneficial short-term results will deteriorate over time if repetitive loads are continually placed on incongruous joints. Jackson et al31 observed that in gymnasts with OCD lesions that required surgery, return to competition was unlikely. Bauer et al25 showed that at an average follow-up of 23 years, radiographic evidence of degenerative changes and reduced range of motion were present in more than half of the elbows studied. While pain and limited motion were the most common complaints, little functional impairment resulted.

SURGERY

For arthroscopic treatment of OCD lesions, we prefer to place the patient in the prone position with the elbow draped over a padded arm board. Portals are carefully made in standard fashion to avoid neurovascular injury. We base our decision regarding portal placement on the pathology observed and the angle at which the appropriate instruments can approach the lesion. We use anteromedial and anterolateral portals to visualize the anterior compartment, followed by proximal posterolateral, direct posterior, and direct lateral or anconeus portals for work in the posterior compartment.

The OCD lesion is visualized and probed in order to plan treatment. Loose bodies observed in the assessment of each elbow compartment are removed. The articular cartilage is probed for fissures and flaps, and the stability of the underlying subchondral bone is assessed. If a ballotable area without an unstable flap is noted, drilling with a Kirschner wire is performed. Areas of cartilage surface fraying can be debrided with a shaver if necessary. If an unstable flap of cartilage is lifted with the probe, inspection for attached subchondral bone is necessary. If sufficient subchondral bone is seen on the base of the lesion, internal fixation using cannulated screws can be attempted. In our experience, subchondral bone is rarely found on the flap of cartilage. If no subchondral bone is seen attached to the lesion, fixation efforts are unlikely to be successful. The articular surface is debrided back to a stable rim of cartilage. Microfracture of the subchondral bone in the lesion bed is performed. The tourniquet is deflated to ensure adequate bleeding from the microfracture sites (Fig. 37-3D through I).

The portal incisions are closed with a nylon suture. A sterile soft dressing is applied, and the patient's upper extremity is placed in a standard sling for comfort. Early range-of-motion exercises are begun in the immediate postoperative period. Strengthening is delayed until approximately 12 weeks postop-eratively. Return to sports such as baseball or gymnastics is not permitted for at least 6 to 12 months.

REFERENCES

1. Pappas AM: Elbow problems associated with baseball during childhood and adolescence. Clin Orthop 1982;164:30-41.

2. DeFelice GS, Meunier MJ, Paletta GA: Elbow injuries in children and adolescents. In Altchek DW Andrews JR (eds): The Athlete's Elbow. New York, Lippincott Williams & Wilkins, 2001, pp 231-248.

3. Rudzki JR, Paletta GA: Juvenile and adolescent elbow injuries in sports. Clin Sports Med 2004;23:581-608.

4. Bradley JP, Petrie RS: Elbow injuries in children and adolescents. In DeLee JC, Drez D, Miller MD (eds): DeLee & Drez's Orthopaedic Sports Medicine: Principles and Practice, 2nd ed. Philadelphia, Saunders, 2003, pp 1249-1264.

5. Augustine SJ, McCluskey GM, Miranda-Torres L: Little league elbow. In Baker CL, Plancher KD (eds): Operative Treatment of Elbow Injuries. New York, Springer, 2002, pp 69-77.

6. Gugenheim JJ, Stanley RF, Woods GW et al: Little league survey: The Houston study. Am J Sports Med 1976;4:189-200.

7. Larson RL, Singer KM, Bergstrom R, et al: Little league survey: The Eugene study. Am J Sports Med 1976;4:201-209.

8. DaSilva MF, Williams JS, Fadale PD, et al: Pediatric throwing injuries about the elbow. Am J Orthop 1998;27:90-96.

9. Jobe FW, Nuber G: Throwing injuries of the elbow. Clin Sports Med 1986;5:621-636.

10. Woods GW Tullos HS: Elbow instability and medial epicondyle fractures. Am J Sports Med 1977;5:23-30.

11. Gill TJ, Micheli LJ: The immature athlete. Common injuries and overuse syndromes of the elbow and wrist. Clin Sports Med 1996;15:401-423.

12. Ireland ML, Andrews JR: Shoulder and elbow injuries in the young athlete. Clin Sports Med 1988;7:473-494.

13. Case SL, Hennrikus WL: Surgical treatment of displaced medial epicondyle fractures in adolescent athletes. Am J Sports Med 1997;25:682-686.

14. Norwood LA, Shook JA, Andrews JR: Acute medial elbow rupture. Am J Sports Med 1981;9:16-19.

15. Chen AL, Youm T, Ong BC, et al: Imaging of the elbow in the overhead throwing athlete. Am J Sports Med 2003;31:466-473.

16. Ruch DS, Poehling GG: Arthroscopic treatment of Panner's disease. Clin Sports Med 1991;10:629-636.

17. Petrie RS, Bradley JP: Osteochondritis dissecans of the humeral capitellum. In DeLee JC, Drez D, Miller MD (eds): DeLee & Drez's Orthopaedic Sports Medicine: Principles and Practice, 2nd ed. Philadelphia, WB Saunders, 2003, pp 1284-1293.

18. McManama GB, Micheli LJ, Berry MV et al: The surgical treatment of osteochondritis of the capitellum. Am J Sports Med 1985;13:11-21.

19. Baumgarten TE, Andrews JR, Satterwhite YE: The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum. Am J Sports Med 1998;26:520-523.

20. Kobayashi K, Burton KJ, Rodner C, et al: Lateral compression injuries in the pediatric elbow: Panner's disease and osteochondritis dissecans of the capitellum. J Am Acad Orthop Surg 2004;12:246-254.

21. Cain EL, Dugas JR, Wolf RS, et al: Elbow injuries in throwing athletes: A current concepts review. Am J Sports Med 2003;31:621-635.

22. Schenck RC, Athanasiou KA, Constantinides G, et al: A biomechanical analysis of articular cartilage of the human elbow and a potential relationship to osteochondritis dissecans. Clin Orthop 1994;299:305-312.

23. Peterson RK, Savoie FH, Field LD: Osteochondritis dissecans of the elbow. Instr Course Lect 1999;48:393-398.

24. Takahara M, Shundo M, Kondo M, et al: Early detection of osteochon-dritis dissecans of the capitellum in young baseball players. Report of three cases. J Bone Joint Surg Am 1998;80:892-897.

25. Bauer M, Jonsson K, Josefsson PO, et al: Osteochondritis dissecans of the elbow. A long-term follow-up study. Clin Orthop 1992;284: 152-160.

26. Takahara M, Ogino T, Sasaki I, et al: Long term outcome of osteochon-dritis dissecans of the humeral capitellum. Clin Orthop 1999;363: 108-115.

27. Schenck RC, Goodnight JM: Osteochondritis dissecans. J Bone Joint Surg Am 1996;78:439-456.

28. Takahara M, Ogino T, Fukushima S, et al: Nonoperative treatment of osteochondritis dissecans of the humeral capitellum. Am J Sports Med 1999;27:728-732.

29. Byrd JW, Jones KS: Arthroscopic surgery for isolated capitellar osteo-chondritis dissecans in adolescent baseball players: Minimum three-year follow-up. Am J Sports Med 2002;30:474-478.

30. Harada M, Ogino T, Takahara M, et al: Fragment fixation with a bone graft and dynamic staples for osteochondritis dissecans of the humeral capitellum. J Shoulder Elbow Surg 2002;11:368-372.

31. Jackson DW, Silvino N, Reiman P: Osteochondritis in the female gymnast's elbow. Arthroscopy 1989;5:129-136.

32. Ruch DS, Cory JW, Poehling GG: The arthroscopic management of osteochondritis dissecans of the adolescent elbow. Arthroscopy 1998;14:797-803.

In This Chapter

History Wrist pain Radial Dorsal Ulnar Palmar

Wrist instability and impaction Wrist tendonitis Hand injuries Imaging

Injuries to the wrist and hand are common in all sports. About 10% of all athletic injuries involve the wrist and hand.1 The incidence of wrist problems is much higher in contact sports and is seen in as many as 85% of participants in gymnastics.2 The function of the wrist in athletic endeavors is twofold. The primary motion is from a position of radial deviation/extension to ulnar deviation/flexion. This motion assists in the power of throwing activities where the wrist is cocked into radial deviation/extension, accelerates through a neutral position into ulnar deviation/flexion, and then recovers back to a neutral position. For example, basketball free-throw shooting involves an extension-flexion arc of about 120 degrees in the shooting hand.1 In baseball, the arc of motion is approximately 94 degrees.3 The second function of the wrist is to position the hand in space, along with positioning the forearm in various degrees of pronation and supination. The function of the hand in sports is to grasp objects such as rackets, balls, or clubs.

Wrist anatomy is complex, but functionally the extensor carpi radialis longus and extensor carpi radialis brevis are the cocking muscles of the wrist, with flexor carpi ulnaris the primary accelerator. The flexor carpi radialis and extensor carpi ulnaris are primarily dynamic stabilizers of the wrist. These four primary motors of the wrist (extensor carpi radialis longus and extensor carpi radialis brevis act together) sit at four corners of a quadrilateral pulling the wrist into the distal radius like a hot air balloon is held against the ground by guide ropes. The true collateral ligaments of the wrist assist in holding the carpus against the radius. These include the radioscaphocapitate ligament on the volar side and the dorsal radiocarpal ligament on the dorsal side, the former coming from a relatively radial volar position and the latter coming from a dorsal ulnar direction. The hand and carpus are slung up to the distal radius. At the distal radioulnar joint, the ulnar head holds up the distal radius during pronation and supination of the wrist. The distal radius is held against the distal ulna by the ligaments within the triangular fibrocartilage. The ligaments from the ulna to the carpus are relatively loose.

Joint anatomy within the hand is relatively uniform. Each interphalangeal and metacarpophalangeal joint contains a volar plate to prevent translation of the joint, two collateral ligaments, and a flimsy dorsal capsule.

Injuries to the wrist and hand can be summarized as being either traumatic in nature or from overuse. Overuse injuries occur due to either compression or stretch tension when the wrist is moved outside its primary range of motion. An example is ulnar-side wrist pain in tennis players who use a western grip, which places the wrist into extreme ulnar deviation. These athletes are prone to tendonitis of the first and second dorsal compartments due to stress and compression problems of the triangular fibrocartilage. Traumatic injuries include fractures, dislocations, and ligament tears, all of which are common in collision or contact sports.

CLINICAL FEATURES AND EVALUATION

Evaluation of the hand and wrist in athletes requires a careful history followed by a specific examination. Many radiographic techniques have been described to assist in the visualization of the wrist and hand, and these should be obtained when looking for specific problems. Table 38-1 shows the radiographic views that are available and summarizes when they should be used.

The history should begin with an evaluation of the specific sport and level at which the patient participates. This often directly affects the management of the wrist or hand problem.

INTRODUCTION

• The history is important in directing the examination of the wrist and hand.

• When inspecting or examining the wrist, it is best to divide the wrist into four basic areas for assessment: radial, dorsal, ulnar, and palmar.

• Special examination tests are available to test for wrist instability and impaction syndromes.

• Plain radiographs are the mainstay of diagnostic imaging of the wrist and hand.

• Specific radiographic views are available for many wrist problems.

• Computed tomography and magnetic resonance imaging scans are often used when further studies are necessary.

Table 38-1 Summary of Radiologic Views

Radiograph

When to Use

Reasons for Use

Posteroanterior

Routine view

Standard radiograph looking at contours of distal radius and ulna for fractures; alignment of proximal and distal rows

Oblique wrist

Routine view

Helpful in looking at distal radius fractures with displacement in ulnar columns

Lateral

Routine view

Important for proper carpal alignment looking for dorsal and volar intercollating instability deformities

Radial deviation

Instability series

Scaphoid should flex and thus the ring sign should be present; look for scapholunate widening

Ulnar deviation

Instability series

Also for scapholunate widening, ulnar impaction, and instability; increases relative ulnar variance, important in ulnar impaction syndromes

Clenched fist

Impaction and stability series

Can increase the scapholunate and lunotriquetral gap when there is ligament injury

Posteroanterior in pronation

Impaction series

Increased ulnar plus impaction

Scaphoid view

Special view

Look for scaphoid fractures

Carpal tunnel view

Special view

Look for hamate and scaphoid tubercle fractures

Pisotriquetral view

Special view

Shows pisotriquetral osteoarthritis and hamate fractures

For example, a lineman in football can often play wearing a cast, but a quarterback needs a nearly complete range of wrist motion. The history important in decision making is how the problem started, how the problem is affecting the patient's sporting endeavor currently, wh

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Cure Tennis Elbow Without Surgery

Cure Tennis Elbow Without Surgery

Everything you wanted to know about. How To Cure Tennis Elbow. Are you an athlete who suffers from tennis elbow? Contrary to popular opinion, most people who suffer from tennis elbow do not even play tennis. They get this condition, which is a torn tendon in the elbow, from the strain of using the same motions with the arm, repeatedly. If you have tennis elbow, you understand how the pain can disrupt your day.

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