Upper extremity injuries in youth sports

Abstract

This article provides an overview of common upper extremity injuries in youth sports, including injuries to the shoulder, elbow, and wrist. Pain in the shoulder and elbow is common among youngsters who participate in throwing sports, raquet sports, and swimming, while wrist pain is common among young gymnasts. Acute trauma to the shoulder and elbow can occur in almost any sporting activity. This article provides descriptions of common injuries and guidelines for treatment.

Full text

Upper extremity injuries in youth sports
Jorge E. Go
´mez, MS, MD
Department of Pediatrics, The University of Texas Health Science Center at San Antonio,
7703 Floyd Curl Drive,. San Antonio, TX 78229-3900, USA
Acute injuries of the shoulder
Clavicle fractures
Presentation
Clavicle fractures are among the most common fractures in childhood. The
typical mechanism of the clavicle fracture is a fall on the point of the shoulder.
Falls on the outstretched hand or direct blows may also fracture the clavicle. More
than 80% of clavicle fractures occur in the middle third of the bone. Patients
usually present with severe pain, guarding, and difficulty carrying the arm.
Evaluation
On examination, there is often a visible and palpable deformity. Complications
from a clavicle injury are rare. Nevertheless, as with all fractures, it is prudent to
document a normal neurovascular examination of the involved extremity. In the
case of a deformity clearly in the middle of the clavicle, it is marginally helpful to
obtain a radiograph. Even fractures with comminuted, angulated, separated, and
overlapping fragments usually heal without difficulty, although significantly
angulated fractures often heal with a residual deformity. When there is any doubt
about the location of the fracture along the bone, a radiograph should be obtained.
Unlike fractures in the middle third of the clavicle, fractures at the distal and
medial thirds are more difficult to manage and have a less favorable prognosis if
not anatomically reduced [1].
Management
Traditionally, clavicle fractures were treated with a clavicle strap or ‘‘figure 8’’
strap. It was believed that the strap, which retracted and depresses the shoulders,
would provide some reduction of the fracture as well as some comfort. Recent
0031-3955/02/$ – see front matter D2002, Elsevier Science (USA). All rights reserved.
PII: S 0031-3955(02)00013-5
E-mail address: gomezje@uthscsa.edu (J.E. Go
´mez).
Pediatr Clin N Am 49 (2002) 593 – 626

textbooks on orthopedic fractures no longer recommend their routine use in
children younger than 12 years of age because they are not needed for adequate
healing and may cause discomfort rather than alleviate it. For children younger
than 12, the arm should be place in a sling. The sling should be used during
waking hours for at least the first 2 weeks or until the patient can carry the arm
without discomfort. Initially, the patient may sleep more comfortably in the sitting
position. Clavicle fractures are quite painful and may require use of hydrocodone/
acetaminophen elixir or tablets for pain relief in the first 2 to 3 days. Afterward,
acetaminophen alone or ibuprofen may be used for analgesia.
Adolescents (older than 12 years) have less of a capacity for healing markedly
displaced clavicle fractures. For these patients, using of the figure 8 strap in ad-
dition to a sling may help reduce the fracture. It should be used for about 4 weeks.
When the arm sling is discontinued, the patient should be instructed in range
of motion exercises and encouraged to begin using the arm for activities of daily
living. The patient should be restricted from any activities in which contact,
collision, or a fall is likely, including bicycling, skating, and skate boarding, for a
minimum of 4 weeks. Follow-up evaluation should take place at 2 and 4 weeks.
At those visits, it should be determined whether there is any pain and the extent to
which the patient is using the arm. Parents should be told to expect the callus to
be visible for up to 1 year and that there may be a permanent deformity, which is
usually of little consequence.
Significantly angulated fractures in which there is severe tenting of skin or the
presence of neurovascular compromise warrant consultation with an orthopedist.
Pain persisting beyond 2 weeks or failure to form a palpable callus indicate
nonunion and are also reasons to refer to an orthopedist.
Fractures in the medial and distal thirds of the clavicle should probably be
evaluated by an orthopedic surgeon. Fractures at the ends of the clavicle that
involve the growth plates must be reduced anatomically for adequate healing.
These fractures may be difficult to distinguish from fractures of the diaphysis,
which do not require anatomic reduction.
Acromioclavicular sprain
Presentation
Sprain of the acromioclavicular (AC) joint usually occurs as a result of a blow
to the top of the shoulder. It has also been known to occur with a fall on the lateral
or posterior aspects of the shoulder. The patient reports pain on top of the shoulder.
The severity of the pain varies with the severity of the injury.
Classification
Rockwood has developed a classification of AC injuries that is widely used
[2]. The classification is primarily based on the radiographic appearance of the
injury. With a normal anteroposterior (AP) radiograph of the shoulder, the distal
clavicle and AC joint may be obscured by the body of the scapula. An
unobstructed view of the AC joint is obtained with an AP radiograph made with
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the beam angled cephalad about 15°(ie, 15°cephalad AP of the shoulder). In the
grade I sprain there is complete congruity, or overlap, of the distal clavicle and
acromion. In the grade II sprain, there is incomplete overlap of the clavicle and
acromion. In the grade III sprain, the clavicle and acromion are completely
separated, a result of complete rupture of the AC and coracoclavicular ligaments.
Grades IV, V, and VI are variations of the completely disrupted AC joint, with the
clavicle being displaced posteriorly, superiorly, or inferiorly respectively. The
severely displaced clavicle in grades IV, V, and VI may pierce the brachial plexus,
subclavian vessels, or deltopectoral fascia.
Evaluation
Inspection of the shoulder may reveal swelling over the involved AC joint.
There may be a visible or palpable step-off. Palpation reveals tenderness over the
AC joint. Palpation in the interval between the coracoid and the clavicle reveals
tenderness because the coracoclavicular ligament will also be injured to some
degree. If the injury was caused by a direct blow to the shoulder and it is difficult
to distinguish a contusion of the shoulder from a grade I or II AC sprain, the scarf
test (Fig. 1) should be done. This test often elicits pain that the patient can
localize to the AC joint. Range of motion of the shoulder is limited depending on
the severity of the injury. Other tests of stability of the shoulder are normal.
Radiographic evaluation is indicated whenever there appears to be a deformity
and should include the 15°cephalad view.
Management
Grade I and II AC sprains may be treated in the same fashion. The arm is put in
a sling until the patient can tolerated carrying the arm freely. This will be about 2 to
3 days with the grade I sprain and up to 1 to 2 weeks with the grade II sprain.
Fig. 1. Scarf test.
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During the acute phase, ice should be applied to the painful area for 10 to15
minutes (remembering that the AC joint is a superficial structure and analgesia
from cooling can be accomplished in a short time). Analgesics may be used during
the acute phase. As soon as possible, the patient begins pendulum exercises (Fig. 2)
and advances to exercises to strengthen the trapezius and deltoid muscles. Athletes
with grade I sprains usually can return to contact/collision activity in 7 to 10 days,
whereas grade II sprains usually require 2 to 4 weeks to heal properly.
Readiness to return to contact/collision sports is evidenced by having full
range of motion of the shoulder, full strength (especially abduction), and the
absence of pain or weakness when performing the scarf test.
Because of the potential for vascular and visceral damage with grades IV, V,
and VI AC injuries and the difficulty that may be encountered in distinguishing
grade III injuries from higher grade injuries, grade III and higher injuries should
be referred to an orthopedic surgeon.
Glenohumeral dislocation
Presentation
Approximately 90% of all acute glenohumeral dislocations involve anterior
displacement of the humeral head with respect to the glenoid [3]. Posterior
glenohumeral dislocation is relatively rare. The following discussion pertains
primarily to the anterior dislocation. This injury typically occurs as a result of the
shoulder being abducted and forcefully externally rotated and extended. Other
mechanisms that may produce this injury include a fall on the outstretched arm or
a blow to the posterior shoulder. This injury can occur in the patient who has
Fig. 2. Pendulum exercises—the patient swings the arm back and forth, side-to-side, and around.
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congenital anterior or mulitdirectional instability of the shoulder (discussed under
Recurrent Glenohumeral Subluxation or Dislocation) as well as in the patient
with no preexisting shoulder instability.
After the injury, the patient is in severe discomfort not only from pain but
because of the sensation of derangement of the shoulder. The patient may
complain of generalized weakness of the entire extremity.
Evaluation
Inspection of the patient with an acute glenohumeral dislocation reveals gross
deformity of the shoulder. In the case of the football, hockey, or lacrosse player
the deformity may not be fully appreciated until the pads are removed. The
shoulder appears as if the deltoid muscle has disappeared, with a significant step-
off lateral to the acromion. There is a protrusion inferior to the acromion and
lateral to the coracoid, which is the head of the humerus displaced anteriorly and
inferiorly. Palpation of the proximal arm and clavicle is performed to elicit any
crepitus and to reveal any other deformity that may represent a fracture. A careful
neurologic examination must be done of the entire extremity. The most common
neurologic finding is decreased sensation in the distribution of the axillary nerve
(deltoid region).
Under circumstances in which radiographs of the injured shoulder can be
obtained in less than 30 minutes, the health care provider may wish to obtain these
to rule out fracture before an attempt at reduction; however, waiting to obtain
radiographs should not delay treatment unnecessarily, particularly if the neuro-
vascular examination is normal and there is no palpatory evidence of a fracture.
Radiographic evaluation before reduction may be limited by the patient’s inability
to abduct the shoulder. In this case, a plain AP film will suffice to rule out any
gross fracture.
Management
There are several methods for reducing the acutely dislocated shoulder [4]. All
the techniques presented here probably work equally well when attempted before
significant muscle spasm has developed. Reduction of the acute glenohumeral
dislocation should be attempted as soon as possible, particularly if the neuro-
vascular examination is intact. If a glenohumeral dislocation occurs in the field
1 hour or more from a medical facility and there is evidence of neurovascular
compromise, reduction should probably be attempted, as reduction is more likely
to alleviate neurovascular compression than it is to worsen it.
Fig. 3A shows what is known as the Hippocratic method of reduction. The
important points to remember with this technique are that counter traction usually
aids in the reduction and that traction on the arm should be slow and steady. It
may take up to 5 minutes for steady traction to overcome the muscle spasm
around the shoulder. When there is more than one person available to render aid,
the second person should wrap a towel or sheet around the torso as shown in
Fig. 3A to apply counter traction. If there is a single person rendering aid, the foot
may be placed against the chest wall to apply the counter traction.
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Fig. 3B shows another method for reducing the acutely dislocated shoulder
described by Westin and colleagues [5]. This technique reportedly is highly
Fig. 3. Methods of reducing glenohumeral dislocations. (A) Hippocratic method. (B) Sitting method.
(C) Prone method.
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successful and carries a low complication rate. The method shown in Fig. 3C is a
useful technique to learn for patients who have recurrent episodes of instability
and who may find themselves alone when an episode occurs.
When initial attempts at reduction fail, the patient must be sent to a facility
equipped to administer sedation and analgesia. In these cases, an emergency
medicine trained physician or orthopedic surgeon should attempt reduction after
intravenous sedation
After reduction, the neurovascular examination should be repeated and
documented. Radiographic evaluation should include a true AP of the shoulder
and an axillary view. The oblique orientation of the glenohumeral joint with
respect to the sagittal plain causes the glenoid and proximal humerus to appear
overlapped on a plain AP radiograph. A ‘‘true AP’’ of the shoulder is obtained
with the x-ray beam angle slightly away from the center of the shoulder,
providing a view of the glenoid unobstructed by the humerus. Acute anterior
glenohumeral dislocation may result in osteochondral fractures of the anterior
glenoid rim (Bankart lesion), which are best seen on true AP and axillary views.
Another bony lesion may occur as the posterior humerus impacts on the glenoid
during traumatic autoreduction of the dislocation, producing an indentation on
the posterior humerus (Hill-Sacks lesion). This lesion is best seen on the
axillary view.
After reduction, the arm is placed in a sling. Ice is applied for 15 to 20 minutes
every 3 to 4 hours during the first 2 days after injury to minimize swelling and
pain. Analgesics are in order during this time also. As soon as the patient is able
to tolerate carrying the arm, the sling should be discontinued. Pendulum exercises
are begun, followed by isometric strengthening exercises as tolerated. When the
patient is pain-free, a rotator cuff strengthening routine is begun. It may require 4
to 6 weeks after the shoulder dislocation for the patient to return to sports.
Fig. 3 (continued).
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Readiness to return is evidenced by the patient having full range of motion and
full strength of the deltoid and rotator cuff muscles. Although the shoulder may
be functionally normal, residual anterior laxity may cause the patient to have a
persistently positive apprehension test (Fig. 4).
The presence of a concurrent fracture of the clavicle or humerus, radio-
graphic demonstration of a Bankart lesion, or pain and disability persisting
beyond 4 weeks are reasons to refer a patient with a shoulder dislocation to
an orthopedist.
Brachial plexus injury
Presentation
Acute brachial plexus injury, commonly termed a burner, is most often seen
in collision sports, and usually occurs by one of two mechanisms. The most
common mechanism is a blow that depresses the shoulder and applies traction
to the brachial plexus. The less common mechanism occurs exclusively in
athletes wearing shoulder pads: the shoulder is elevated while the head is bent
toward the shoulder, with the shoulder pad impinging or compressing the
brachial plexus. The athlete experiences immediate burning pain down the
arm with dysesthesia, numbness, and weakness. The upper trunks of the brachial
plexus (C5 and C6) are most commonly involved. Consequently, the symptoms
of pain and numbness are usually worse in these dermatomes, and the weakness
is most prominent in the deltoid and biceps, which receive most of their
innervation from C5.
Fig. 4. Apprehension test.
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Evaluation
Initial evaluation focuses on ruling out associated osseous injury, particularly
cervical spine injury, but also including such injuries as a clavicle fracture, AC
sprain, glenohumeral dislocation, or fracture of the proximal humerus. A detailed
neurologic examination is done to identify decreased sensation in a dermatomal
pattern as well as specific muscle weakness.
Brachial plexus injuries have been classified as mild, moderate, or severe [6].
Most brachial plexus injuries are mild (grade I injuries) with symptoms and
signs resolving within minutes to hours. This injury is thought to represent a
brachial neuropraxia and complete recovery is the rule. Moderate or grade II
injuries are thought to result from axonotmesis of nerve fibers. The presentation
is identical to the milder plexopathy, but recovery is longer. Although normal
sensation may be restored quickly, weakness, particularly of the deltoid and
biceps, may persist for 4 to 6 weeks. Some athletes have required up to 6 months
to regain full strength. The most severe injury probably involves neurotmesis of
nerve fibers. An athlete with a severe or grade III injury has weakness that
persists beyond 6 months.
Some advocate obtaining plain films of the cervical spine in any athlete who
has experienced a first brachial plexus injury [1]. Certainly, the athlete with a
more severe injury, as evidenced by sensory and motor changes persisting beyond
a few days, should have a thorough evaluation of the cervical spine, particularly
for congenital cervical spinal stenosis. Plain films, including oblique, flexion, and
extension views, are necessary to rule out cervical spine fracture; however, for the
purpose of evaluating possible spinal stenosis, magnetic resonance imaging
(MRI) is the modality of choice because plain radiographs have been found to
be insufficient to assess the size of the spinal canal accurately with respect to the
cervical cord itself [7]. Nerve conduction studies may be obtained to evaluate the
specific location and type of nerve injury, although EMG result may not ac-
curately predict prognosis.
Management
Management of the grade I brachial plexus injury involves merely rest and
observation until symptoms subside and full strength has been regained.
Unfortunately, physical therapy, either in the form of resistance exercises or
modalities such as heat, ultrasound, or electrical stimulation, has not been shown
to speed recovery from moderate and severe brachial plexus injuries. Neverthe-
less, during recovery, patients should be encouraged to continue an upper
extremity strengthening routine to avoid losing further strength due to inactivity.
Heavy lifts, particularly those involving lifting a barbell off the floor, should be
avoided to prevent further traction injury to the plexus. Athletes with grade II
brachial plexus injuries may return to collision sports when neurologic function is
normal and there is no evidence of cervical spinal stenosis. Most experts agree
that the athlete with a grade III brachial plexus injury should henceforth be
disqualified from all collision sports, because it is not known what effect repeat
injuries may have on the function of the plexus.
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Considerations for allowing the athlete with a grade I or II injury to return to
play include performing exercises to maximize the strength of the shoulder and
neck muscles and wearing protective equipment. In football, neck rolls or collars
may prevent further injuries by limiting bending of the neck away from the
shoulder, thus minimizing traction on the plexus.
Proximal humerus fracture
Presentation
Fracture of the proximal humerus usually occurs from a blow to or collision
with the arm or a fall backward with the arm behind the body. Most of these
fractures occur to patients between 10 and 14 years of age [8]. Two thirds of these
fractures involve the metaphysis and the other third involve the physis. Nearly all
fractures through the proximal humeral growth plate are either Salter-Harris type
I or II injuries [9]. The patient appears in moderate to severe distress but may not
have any obvious deformity.
Evaluation
Examination of the patient with a painful shoulder after a trauma includes
inspection for deformity and swelling, palpation for deformity and crepitus, and
neurovascular evaluation. Neurovascular complications from these injuries are
not common. At least two radiographic views of the arm should be obtained: an
AP view and a lateral view. The patient with a fracture of the humerus has
considerable difficulty abducting the arm because the fracture is usually in the
vicinity of the deltoid insertion. Therefore, the best technique for obtaining a
lateral view of the humerus in this circumstance is the scapular-Y view. Radio-
graphs usually reveal a fracture that is minimally displaced and angulated.
Management
Fortunately, the proximal humerus, like the clavicle, has a tremendous capacity
for remodeling, particularly in younger children, such that mildly displaced and
angulated fractures tend to heal without the need for anatomic reduction. Proximal
humerus fractures in patients younger than 11 years old, with less than 20°
angulation and less than 2 cm of overlap, and that involve the metaphysis may be
treated in a sling combined with a swath to hold the arm close to the body [1].
Hydrocodone with acetaminophen is appropriate for pain relief in the first 3 to
5 days after injury. Beyond this period, nonsteroidal anti-inflammatory medica-
tions or acetaminophen alone are sufficient for pain relief. The sling and swath are
continued for 2 weeks. During this time, patients are instructed to take the arm out
of the sling three to four times a day for pendulum exercises. Earlier discontinua-
tion of the sling may be desirable to ensure full range of motion of the shoulder
after healing.
Fractures occurring in individuals older than 11 years of age are more likely to
heal with a deformity if not anatomically reduced and should therefore be
managed by an orthopedic surgeon. Fractures angulated more than 20°, overrid-
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ing by more than 2 cm, or comminuted should be referred to the orthopedic
specialist as well. Fractures through the growth plate are particularly difficult to
manage, especially since these fractures can involve rotation of the epiphysis, and
should therefore be managed by the orthopedist.
Overuse injuries of the shoulder
Recurrent glenohumeral subluxation/dislocation
Presentation
Most patients with repeated episodes of glenohumeral subluxation/dislocation
have congenital laxity of the glenohumeral ligaments, creating multidirectional
instability of the shoulder. Other patients with recurrent episodes of shoulder
instability had a normal shoulder before a traumatic a glenohumeral dislocation,
which caused significant stretching and residual laxity of the anterior glenohu-
meral ligaments. Patients usually describe the shoulder ‘‘popping’’ or ‘‘popping
out’’ with activities that place the shoulder in a position of abduction and external
rotation. Most of these patients have recurrent episodes of instability in the
anterior direction.
Evaluation
Examination of the patient with recurrent glenohumeral subluxation/disloca-
tion may reveal atrophy of the deltoid and trapezius muscles on the involved side.
The rotator cuff muscles (supraspinatus, infraspinatus, teres minor, and subscap-
ularis) are usually weak from overuse. Testing the strength of the various com-
ponents of the rotator cuff is illustrated in Fig. 5A–C. Direct proof of
glenohumeral instability is obtained using the load and shift test as shown in
Fig. 6. In the patient with congenital multidirectional instability, the laxity on the
more symptomatic side, usually the dominant side, may be the same as on the
asymptomatic side. In general, instability is most prominent in the anterior
direction. In the patient with instability as a result of trauma, there is an obvious
difference in the degree of laxity between the involved and uninvolved sides. The
examiner should also perform the apprehension test (see Fig. 4). Patients with
severe glenohumeral instability may dislocate if the apprehension test is done
in the upright position. For this reason, the apprehension test should be done with
the patient supine and the examiners hand closest to the patient placed lightly over
the anterior deltoid. With the hand over the deltoid, the examiner is able to feel the
humeral head displacing forward as the arm is taken into external rotation.
Apprehension on the part of the patient yields a positive test and the examiner
can then apply pressure with the hand over the deltoid to prevent further
subluxation or dislocation.
Patients with recurrent shoulder instability should have true AP and axillary
view radiographs obtained specifically to detect an osteochondral fragment off
the glenoid (Bankart lesion).
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Management
Recurrent glenohumeral instability is treated primarily by strengthening the
rotator cuff muscles. Referral to a physical therapist familiar with the demands of
sport is appropriate for this purpose. Unnecessary offending activities, that is,
those that place the shoulder in abduction and external rotation, should be
avoided. Strapping devices have been developed that primarily limit abduction of
the arm. These devices appear to be effective in preventing recurrent episodes
Fig. 5. Manual muscle testing of the rotator cuff muscles: (A) supraspinatus, (B) infraspinatus and
teres minor, and (C) subscapularis.
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of subluxation/dislocation, particularly for the athlete involved in a contact or
collision sport; however, these devices are not a substitute for full strength of the
rotator cuff muscles.
Operative stabilization of the glenohumeral joint is another treatment option,
although evidence suggests that outcome after shoulder stabilization surgery is
not as good for highly active patients with recurrent glenohumeral instability
episodes as it is for patients after only a single episode of dislocation [10].
Rotator cuff tendonitis
Presentation
Overuse of the rotator cuff muscles, which are the primary dynamic stabilizers
of the glenohumeral joint, is common in young athletes involved in throwing,
swimming, and racquet sports. Athletes with rotator cuff tendonitis present with
dull, aching pain of the shoulder made worse with overhead activity. They may
complain of weakness of otherwise powerful shoulder movements. They may or
may not have a history of glenohumeral instability. Patients with rotator cuff
tendonitis who also have glenohumeral instability may have a condition known
as impingement syndrome (see later discussion).
Evaluation
The diagnosis of rotator cuff tendonitis is made fairly easily by obtaining a
history of heavy use of the shoulder and demonstrating weakness of the rotator cuff
muscles (see Fig. 5). Of course, other chronically painful conditions of the shoulder
must be ruled out, specifically osteolysis of the proximal humerus (see later dis-
cussion), benign and malignant tumors of the proximal humerus, and entrapment
Fig. 5 (continued).
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of the suprascapular nerve [11]. These conditions can be evaluated by performing
a neurologic examination of the shoulder region and by obtaining radiographs
(AP and axillary views). Instability of the shoulder should be evaluated as
described in the section on recurrent glenohumeral subluxation/dislocation.
Management
Treatment consists primarily of decreasing the offending activity for 2 to
6 weeks, depending on the severity of the condition, and increasing the strength of
the rotator cuff muscles. Ice applications may be useful. Nonsteroidal anti-
inflammatory medications may help with pain relief and may allow the patient
to tolerate strengthening exercises sooner. Throwers should follow a progressive
throwing program (Table 1) that gradually reintroduces the demands of throwing.
A similar gradual return should be required of racquet sport athletes and
swimmers. Return to full activity may be allowed when there is full, pain-free
range of motion of the shoulder and full (5/5) strength of the rotator cuff muscles.
Fig. 6. Load and shift test.
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Rehabilitation of rotator cuff tendonitis should also include proprioceptive train-
ing for the shoulder. Careful attention should be paid to the athlete’s throwing or
racquet technique and any technical problems should be corrected before the
patient returns to play.
Impingement syndrome
Presentation
In the shoulder with multidirectional instability, abduction may result in im-
pingement of the supraspinatus tendon between the humerus and acromion. With
abduction, the pull of the deltoid will cause the humeral head to translate
superiorly, pinching the supraspinatus tendon between the humeral head and the
acromion. This impingement may lead to inflammatory or degenerative changes in
the supraspinatus tendon, which may produce a clinical picture similar to rotator
cuff tendonitis.
Evaluation
The keys to diagnosing impingement syndrome are the demonstration of
multidirectional instability by the load and shift tests and reproduction of the
patient’s pain by various impingement tests. The Kennedy-Hawkins impingement
test is shown in Fig. 7, and the Neer impingement test is shown in Fig. 8. In the
‘‘drop-arm’’ test, the patient is asked to slowly abduct the shoulder. Near 90°of
abduction, the contraction of the deltoid causes the humeral head to ride up,
Table 1
Sample progressive throwing program
Phase 1
.Warm up with shoulder stretching and tubing exercises.
.Short, easy throws, overhand, with smooth motion and follow-through, to teammate 10 yd away, for
20 minutes on 2 consecutive days. Rest 1 day.
Phase 2
.Warm up with shoulder stretching and tubing exercises.
.Long, easy throws, with good form, outfield to home (about 30–40 yd) for 20 minutes, on 2
consecutive days. Rest 1 day.
Phase 3
.Warm up with shoulder stretching and tubing exercises.
.Stronger throws, with good form, outfield to home (about 30 – 40 yd) for 20 minutes, on 2
consecutive days. Rest 1 day.
Phase 4
.Warm up with shoulder stretching and tubing exercises.
.Strong, crisp throws with a relatively straight trajectory, from second base to home (about 30 yd) for
20 minutes, on 2 consecutive days.
The throwing program may be started when the athlete has full pain-free range of motion and full
strength. If pain develops during any phase of the throwing program, the athlete should stop
immediately, apply ice, and wait 2 days before trying the program again. The athlete should plan on
taking about 2 weeks to complete the program. The athlete may return to full activity only after he or
she is able to complete phase 4 of the program.
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causing the supraspinatus tendon to be pinched between the humeral head and the
acromion, resulting in sudden pain and dropping the arm.
Management
Treatment of impingement syndrome is similar to that for rotator cuff
tendonitis. Patients with significant impingement who do not respond to
2 months of treatment, including relative rest, anti-inflammatory measures,
and strengthening, may need magnetic resonance evaluation to rule out a tear
Fig. 7. Kennedy-Hawkins impingement maneuver.
Fig. 8. Neer impingement maneuver.
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of the supraspinatus tendon or other component of the rotator cuff. Rotator
cuff tears are difficult to detect clinically [12]. Fortunately, rotator cuff tears
are not nearly as common among adolescent athletes as they are among
adult athletes.
Physiolysis of the proximal humerus (Little League shoulder)
Presentation
Little League shoulder constitutes a stress fracture through the proximal
humeral physis. It has been reported to occur exclusively in throwers, with most
patients being between 11 and 16 years of age [13]. Repetitive throwing causes
degeneration of the proximal humeral growth plate, resulting in pain of insidious
onset, which is made worse by throwing.
Evaluation
Physical examination of the patient with Little League shoulder reveals
tenderness to deep palpation of the proximal upper arm. There may be slight
limitation of motion as well as mild weakness of the rotator cuff muscles, which
is primarily related to the heavy use of the shoulder rather than being related to
the pathology at the proximal humerus. The lack of striking or specific physical
findings should alert the practitioner to consider other diagnoses, including
cervical radiculopathy, local tumor, or arthritis.
AP and axillary views of the involved shoulder should be obtained along with
comparison views of the uninvolved shoulder. Characteristically, there is widen-
ing of the proximal humeral physis, sclerosis along the margins of the physis, and
areas of rarefaction indicating degeneration of the adjacent bone (Fig. 9)
Management
The proximal humeral physis contributes more to the length of its bone than
any other physis [14]. The significance of proximal humeral physiolysis is that
there is potential for permanent damage to this growth plate, which may result in
either deformity of the humerus or growth arrest, leading to limb-length
discrepancy. Because of this potential for growth disturbance, management is
generally quite conservative. Currently, recommended treatment consists of total
cessation from throwing for 6 weeks to 6 months [15], during which time
radiographs are obtained at 2-month intervals to demonstrate a return to the
normal radiographic appearance of the physis. During the period of rest, rotator
cuff and general shoulder strengthening exercises may be done to correct any
coexisting strength deficits. Heavy lifting with the arms should be avoided.
Criteria for return to throwing are (1) at least 6 weeks of no throwing, (2) no
symptoms of pain and a normal shoulder examination, and (3) normal radio-
graphic appearance of the proximal humeral physis. Fortunately, in a review of 23
cases of Little League shoulder, Carson and Gasser found no patients with
significant growth disturbances on long-term follow-up [16].
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Osteolysis of the distal clavicle
Presentation
Although this condition is still considered to be relatively rare, osteolysis of
the distal end of the clavicle has been reported in adolescent and young adult
weight lifters [17]. Heavy use of the bench press, push-ups, and dip exercises
have been implicated as the offending activities in most cases [18]. Biomechan-
ical studies have also shown that gripping the weight lifting bar with hands
spaced more than the width of the shoulders apart causes increased shear stress at
the AC joint and distal clavicle [17]. Typically, the patient presents with insidious
onset of pain in one or both shoulders.
Evaluation
Examination of the patient may reveal swelling at the distal end of the clavicle,
which is also tender to palpation. Manual muscle testing of the deltoid and
pectoralis may be normal. Osteolysis may be evident on plain films. As in the
evaluation of the AC joint, visualization of the distal clavicle is best obtained
Fig. 9. Physiolysis proximal humeral physis (Little League shoulder): (A) normal side, (B) abnormal
side. Note the widening and fragmentation of the physis.
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with a 15°cephalad view of the shoulder. Views of both shoulders should be
obtained for comparison. The radiograph classically reveals markedly decreased
mineralization of the bone, with evidence of bone lysis and vacuolization. In the
absence of typical findings on plain film, diagnosis can be made by bone scan or
MRI. Differential diagnosis of bony lysis of the clavicle includes leukemia,
trauma, and metastatic disease.
Management
Initial treatment of osteolysis is conservative. It is best for the athlete to refrain
from bench, incline, or overhead press exercises, push-ups, and dips until the
condition has resolved. Several weeks of such relative rest may be needed. Local
ice applications help with pain. Nonsteroidal anti-inflammatory drugs may help
with analgesia but are unlikely to aid in healing. Follow-up evaluation should
occur at monthly intervals with serial radiographs obtained to demonstrate return
of normal bony architecture. In cases in which 2 to 3 months of conservative
management do not result in either symptomatic relief or normalization of the
radiographic appearance of the clavicle, referral to an orthopedist for surgical
Fig. 9 (continued).
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excision may be necessary. Surgical excision has been shown to be effective in
allowing return to full activity in recalcitrant cases [19].
Thoracic outlet syndrome
Presentation
The thoracic outlet syndrome usually consists of traction or impingement of
the brachial plexus, particularly the lower roots, associated with the presence of a
cervical rib. Patients are often tall and thin with down sloping shoulders [20].
They complain of numbness and parasthesias in the ulnar distribution and may
complain of similar symptoms in the radial and ulnar distributions. These athletes
are often involved in sports that involve overhead motions. Symptoms occur
within 5–10 minutes after beginning the overhead activity and may persist for a
short time after cessation of the activity. Lifting and carrying cause pain.
Evaluation
Patients may have the typical build described previously. A careful neurologic
and vascular examination is needed to identify distributions of decreased light
touch or parathesias. It is unusual to find wasting of the intrinsic muscles of the
hand. Several maneuvers have been described to reproduce the symptoms of
thoracic outlet compression. Having the patient abduct the shoulders to 90°, flex
the elbows to 90°, and open and close the hands repeatedly for up to 2 minutes
often reproduces symptoms [21]. Provocation of symptoms using this maneuver
is thought to be highly indicative of thoracic outlet compression in the absence of
any evidence of a vascular phenomenon (see later discussion). An AP view of the
upper chest should be obtained to demonstrate a cervical rib. Tests of nerve
conduction can be helpful in excluding local entrapment neuropathies; however,
the diagnosis is usually made on clinical evidence.
Management
Initial management is conservative. Exercises to strengthen the shoulder
elevators (trapezius, levator scapulae, and scalenes) should be initiated along
with restriction of the offending activity for 2 to 4 weeks [22]. Posture training
should be performed under the guidance of a physical therapist. After the period
of relative rest, activity may be resumed with attention to improving throwing or
racquet technique. Patients who fail to respond to conservative treatment may
require excision of the cervical rib if present.
Effort thrombosis
Presentation
Effort thrombosis, also known as Paget-Schroetter syndrome, is the formation
of a thrombus, usually in the axillary vein, associated with heavy use of the arm.
Effort thrombosis has been reported in adolescents [23,24]. Nearly all cases of
effort thrombosis in the upper extremity related to sporting activity have occurred
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in throwers. Typically, patients present with symptoms of vascular occlusion/
insufficiency, that is, deep, dull, aching pain in the upper arm and shoulder,
numbness or parasthesias in the distal arm, and swelling associated with throwing.
Symptoms of dyspnea or chest pain indicate embolization of the thrombus. The
exact cause of effort thrombosis is not known. Effort thrombosis has been reported
in a young swimmer on oral contraceptives [25]. Usually, no underlying clotting
disorder is found. More often, patients have a cervical rib, which may impinge on
the subclavian vein, particulary with overhead motions. These patients often have
premorbid symptoms suggestive of the thoracic outlet syndrome.
Evaluation
Patients with effort thrombosis appear to be in some distress. Examination of
the involved extremity reveals distal swelling and impaired capillary refill due to
venous congestion and distention. The arterial pulses at the wrist are usually well
preserved. There may also be generalized decreased sensation to light touch in the
forearm and hand. These signs and symptoms are most likely to be present when
there is total occlusion of the brachial vein. There may be a firm, tender, cordlike
mass along the inside of the upper arm, which represents the thrombus, although
the absence of such a finding does not rule out a thrombus. In cases in which
occlusion of the brachial vein is incomplete, the symptoms may be less severe or
less consistent. In these cases, symptoms may be reproduced by the same
maneuvers used to evaluate the thoracic outlet syndrome (see earlier discussion).
Definitive diagnosis of effort thrombosis is made by performing either
Doppler flow ultrasonography or venography. Laboratory studies should be
performed including assays for antithrombin III, protein C, and protein S [26].
Other congenital disorders associated with the tendency to form thrombi include
homocysteinuria and elevated lipoprotein (a). Acquired hypercoagulable states
include lupus, leukemia, other malignancies, pregnancy, and nephrotic syndrome.
Differentiation of effort thrombosis from a compartment syndrome in the upper
arm may be difficult; definitive diagnosis can be made by obtaining compartment
pressures. Early in the course of the condition, before overt signs of vascular
occlusion have developed, effort thrombosis may be confused with thoracic outlet
syndrome associated with traction on the brachial plexus, cervical radiculopathy,
and cervical spinal stenosis. Electromyography may be needed to assess nerve
function, and MRI of the cervical spine may be needed to rule out radiculopathy
or cervical stenosis.
Management
Initial management of effort thrombosis should include immediate cessation of
all athletic activities. Anticoagulation with warfarin (Coumadin) has most often
been used as the initial medical treatment. There is no consensus in the literature
about the duration of treatment or criteria for return to play after effort thrombosis
[23]. Anticoagulation therapy should probably be continued for at least 6 months
in the otherwise normal healthy adolescent or young adult. It would seem wise to
withhold the athlete from any activities involving the arm until no symptoms are
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present with normal activities and either (1) the thrombus has resolved or (2) the
thrombus has been demonstrated to be stable using Doppler ultrasonography or
venography, and (3) there is adequate collateral circulation. Obviously, athletes
should not return to contact or collision sports while on anticoagulant therapy.
In patients with a cervical rib, some authors advocate surgical excision of the
rib in every case [27]. Certainly, patients with a cervical rib who experience a
recurrence of arm symptoms suggestive of vascular occlusion after a trial of
conservative management should consider excision of the rib.
Acute elbow injuries
Elbow fracture
Presentation
Fractures about the elbow are common in children. They may occur in the
supracondylar region or through the capitellar growth plate, the olecranon, or
radial head. Fractures of the supracondylar region carry a high rate of compli-
cations, including neurovascular compromise, nonunion, and difficult reduction
[28]. In general, fractures about the elbow in children and teens should be
managed by the orthopedic surgeon; however, some elbow fractures are not
easily detected on plain radiographs, and the pediatrician is therefore faced with
the task of recognizing the occult elbow fracture based on subtle clinical and
radiographic findings.
Evaluation
Examination of the child with an elbow fracture often reveals diffuse swelling
and limited range of motion. The presence of a joint effusion in an acutely injured
pediatric elbow should be considered evidence of fracture until proven otherwise.
Identifying a joint effusion when it coexists with soft tissue swelling about the
elbow may be difficult. On inspection, the examiner should identify the triangle
formed by the lateral epicondyle of the humerus, the radial head, and the tip of
the olecranon (Fig. 10). When light fingertip palpation in this triangle reveals a
mushy feeling compared to the uninjured side, an effusion is likely to be present.
As in all situations in which a fracture may be present, a thorough neurovascular
examination should be performed and documented.
AP, lateral, and oblique films of the elbow should be obtained to evaluate a
possible fracture. Brodeur and colleagues [29] have described four principles of
evaluating elbow radiographs for possible fracture in the child.
First, the six secondary centers of ossification about the elbow differ in time of
appearance (age 1 –10) and closure (11– 16) years. The first ossification center to
appear is the capitellum (6 months to 2 years). The last center to appear is the
lateral epicondyle (10 –12 years).
Second, unusual characteristics of the normal physis are unique to this joint.
On the lateral view, the physis separating the capitellum from the humerus is
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wider posteriorly, often mistaken for a fracture– separation. On the AP view,
before ossification of the radial head, a line drawn through the center of the radial
neck does not intersect the capitellum. The same line drawn on the lateral view,
however, does intersect the capitellum. Early during ossification, the radial head
normally appears wedge shaped, suggesting a fracture. The olecranon ossification
center first appears widely separated from the ulna and may have two centers, one
larger and one smaller, suggesting a fracture. The physis of the medial epicondyle
is the last to ossify and may remain lucent after all the other physes have closed,
again suggesting a fracture line.
Third, displacement of the coronoid fat pad is the most sensitive indicator of
traumatic joint effusion. This fat pad overlies the joint capsule on the anterior
distal aspect of the humerus. In the absence of an effusion, the fat pad lies flat
against the humerus and is either not visible on a lateral radiograph or is seen as a
narrow lucent shadow. Fractures about the elbow produce either sympathetic
effusions or frank hemarthrosis, which will displace the anterior fat pad
superiorly. This is seen on the lateral radiograph as a delta-shaped lucent
shadow—the fat-pad sign (Fig. 11) Similar displacement of the fat pad along
the posterior distal aspect of the humerus along with displacement of the anterior
fat pad results in the sail sign.
Fourth, normal alignments of the humerus, radius, and ulna may resolve
uncertainty about the presence of a fracture, especially in the young child. On the
lateral view, a line drawn past the inferior margin of the coronoid just touches the
anteriormost part of the capitellum or passes just anterior to it. A line drawn
through the center of the radial shaft on the lateral view also intersects the
capitellum. A line drawn along the anterior margin of the humerus passes through
the capitellar ossification center.
Fig. 10. The best place to detect small effusions in the elbow is the triangle formed by the lateral
epicondyle, radial head, and olecranon.
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Management
The patient with a suspected elbow fracture should have the elbow splinted in
with a posterior splint and the arm placed in a sling. Immediate consultation with
an orthopedic surgeon should be sought when there is evidence of neurovascular
compromise, when there is significant deformity of the elbow, or when a
supracondylar fracture is seen on radiographs or is suspected on the basis of
findings of exquisite tenderness to palpation between or just above the medial and
lateral epicondyles.
Elbow dislocation
Presentation
Dislocation of the elbow, specifically the ulnar– humeral articulation, most
often occurs with a fall on the outstretched hand. Often, the hand is turned
outward (supinated), forcing the elbow into valgus. Forward momentum of the
body over the hand results in hyperextension of the elbow [30]. Most elbow
Fig. 11. Deflection of the coronoid fat pad with a joint effusion (fat pad sign) showing evidence of
a fracture.
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dislocations involve posterior displacement of the ulna with respect to the
coronoid. This injury usually results in rupture of the ulnar collateral ligament
and stretching or tearing of the anterior capsule. A variety of fractures may
accompany elbow dislocation, including fractures of the medial epicondyle,
coronoid process, and radial head [31].
Evaluation
Inspection of the dislocated elbow reveals gross deformity, consisting pri-
marily of prominence of the ulna both medially and posteriorly. Careful neuro-
logic and vascular examinations should be performed before any attempt at
reduction. Function of the finger and wrist flexor and extensor tendons should be
evaluated as well as sensation in the radial, ulnar, and median nerve distributions.
Vascular examination includes inspection for distal swelling and pallor, palpation
of the radial and ulnar artery pulses, and assessment of capillary refill. The
neurovascular examination should be repeated after reduction. If there is any
question about vascular integrity, an arteriogram should be performed immedi-
ately. Prolonged ischemia of the arm may result in Volkmann’s contracture.
Management
The issue of whether closed posterior elbow dislocations should be reduced in
the field is complicated [32]. Peripheral nerve injuries are more common with
elbow dislocation than vascular injuries, the most common nerve injury being
that to the ulnar nerve. Often, compromise of ulnar nerve function is relieved by
reduction. Median nerve injuries, although less common, are usually more severe
and are more likely to occur after reduction of closed dislocations than after the
dislocation itself. Significant arterial injury may be present even with normal
peripheral pulses. The longer the elbow remains unreduced in the presence of
vascular compromise, the greater the likelihood for ischemic injury. Repeated or
forceful reduction attempts may potentially worsen the injury. Ideally, reduction
should be done under controlled conditions in which adequate anesthesia and
sedation are provided; however, the easiest reduction may be the one done on the
playing field before muscle spasm has set in. A gentle reduction attempt with
minimal force is less likely to cause further nerve or vessel damage than a more
forceful attempt later.
Before reduction, the patient’s parents should be told that reduction may
worsen the injury, and that loss of range of motion is common after reduction. A
thorough neurovascular examination should be done. Several techniques for
reducing posterior elbow dislocations have been described for younger and older
children [32]. The technique described by Parvin [33] is illustrated in Fig.12.
First, the forearm is fully supinated. Then, a posteriorly directed force is applied
to the volar surface of the proximal forearm while longitudinal traction is applied
with a hand at the wrist. If a second person is available to assist with the
reduction, that person applies posteriorly directed traction to the upper arm. The
person in control of the forearm then gently flexes the elbow while continuing to
apply longitudinal traction and pressure on the volar aspect of the forearm.
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Immediately after reduction, the neurovascular examination should be
repeated. Radiographs should be obtained to identify any fractures. The elbow
should be placed in a posterior splint in 90°of flexion. Compression bandages or
excessive padding should not be applied, because the elbow swelling, which
invariably ensues, may compromise circulation. The arm is held in a sling. Wilkins
[32] advocates hospitalization of the patient overnight, primarily to monitor the
vascular status, which may deteriorate because of unrecognized arterial damage.
In the acute phase of treatment, ice should be applied for 15 minutes three to
four times a day to minimize swelling. The splint and sling should be discontinued
after just 3 to 5 days. Loss of elbow motion, especially extension, is common after
dislocation [34]. Loss of motion can be minimized with early mobilization. Arm
and forearm strengthening exercises may be started as early as 2 to 3 weeks. In the
absence of vascular injury, fracture, or repeat dislocation, the patient may return to
full activity in 4 to 6 weeks. Valgus instability due to incompetence of the ulnar
collateral ligament is common after dislocation.
Fig. 12. Method of reducing the posterior elbow dislocation.
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Overuse injuries of the elbow
Medial epicondylitis (Little League elbow)
Presentation
Youngsters involved in pitching commonly develop medial elbow pain.
During the acceleration phase of the throwing motion, the elbow is subjected
to valgus stress, which applies a tensile stress to the medial elbow. Repetitive
tensile stress on the medial elbow causes the growth plate that attaches the medial
epicondyle to the body of the humerus to break down. This apophysitis is termed
medial epicondylitis or Little League elbow. Unlike medial epicondylitis in
adults, which is actually flexor-pronator tendonitis, medial epicondylitis in the
skeletally immature athlete represent a true apophysitis. Youngsters with this
condition are typically 8 to 12 years of age and present with a history of heavy
throwing, medial elbow pain of insidious onset, no loss of motion, and no
symptoms of locking or catching.
Evaluation
The diagnosis of medial epicondylitis is usually clinical, although radio-
graphic findings may support the diagnosis. Inspection may reveal mild soft
tissue swelling over the medial epicondyle. There is also tenderness to palpation
at this site. Elbow flexion and extension are normal. A valgus stress applied to the
elbow (Fig. 13) may reproduce the pain. Performing the Tinnel test (lightly
tapping the ulnar groove below the medial epicondyle) may cause parasthesias in
the ulnar distribution, a result of irritation of the ulnar nerve due to the adjacent
soft tissue swelling. Three radiographic views of the elbow should be obtained,
along with comparison views of the other side. During late childhood, the various
Fig. 13. Application of a valgus stress to the elbow.
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growth plates and their associated epiphyses and apophyses may be difficult to
distinguish from fracture fragments. The medial epicondyle and its associated
physis may appear normal in mild cases or there may be widening of the lucent
line, which represents the physis, along with sclerosis and fragmentation of the
lateral epicondyle apophysis. In some cases, there may be fragmentation of the
olecranon and capitellum as well, evidence of severe overuse of the elbow [35].
Management
Treatment of medial epicondylitis consists primarily of rest. One study from
Japan, where Little League baseball is very popular, found that the single
strongest determinant of elbow pain in pitchers was the number of pitches
thrown [36]; therefore, the amount of throwing allowed the patient during
treatment should be commensurate with the degree of pain and disability. Patients
with moderate to severe symptoms should refrain from all throwing until
symptoms subside. Ice should be applied daily for just 10 to 15 minutes,
remembering that the ulnar nerve lies superficially just posterior to the medial
epicondyle and is therefore vulnerable to thermal injury. Analgesics also may be
used. As pain subsides, the patient is started on exercises to strengthen the wrist
flexors and may begin a progressive throwing program as tolerated (Table 1). The
patient may resume regular practice and games after completing a progressive
throwing program without recurrence of pain.
Little League elbow is most effectively prevented by limiting the amount of
throwing done by young pitchers. Most Little League associations follow rules
that limit throwers to no more than 6 innings of pitching per week [37].
Panner’s disease
Presentation
Panner’s disease is a developmental osteochondrosis of the humeral capitel-
lum. It tends to occur in children aged 6 to12 and almost exclusively in baseball
pitchers [38]. During the cocking and acceleration phases of throwing, the lateral
elbow (radial-capitellar joint) is subjected to compressive stresses. The repetitive
compression of the capitellum at a time in the development of the humerus in
which the blood supply to this part of the bone is limited causes what appears to
be avascular necrosis of the capitellum. Collapse of the capitellum causes pain
and joint symptoms including swelling and loss of motion.
Evaluation
The elbow of the patient with Panner’s disease has mild diffuse swelling,
especially on the lateral side, and the presence of an effusion. There is tenderness
to palpation on the lateral side, specifically in the radial-capitellar joint. The
radial-capitellar joint is best palpated with the elbow near full extension (Fig. 14).
Extension of the elbow will be limited to 5 to 20°compared with the uninvolved
side. The finding of limitation of joint motion is an ominous finding and suggests
serious joint pathology.
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Three views of the elbow should be obtained in the presence of these findings
with comparison views of the normal side. The appearance of the humeral
capitellum is characteristic (Fig. 15). There is sclerosis alternating with areas of
rarefaction throughout the capitellum. The capitellum appears somewhat flat-
tened, and the margin of the capitellum on the articular side, which is normally
smooth, appears rough and fragmented.
Management
Conservative treatment of Panner’s disease begins with rest, meaning com-
plete cessation of throwing. In general the prognosis for normal elbow function in
a patient with Panner’s disease is very good; with adequate rest, the capitellum
revascularizes and remodels nicely, resulting in a smooth radial-capitellar
articulation. During recovery, patients should be followed with serial radiographs
to demonstrate arrest of the process and gradual return to a more normal
architecture. Arthroscopy has been suggested for recalcitrant cases [39].
Osteochondritis dissecans
Presentation
Osteochondritis dissecans represents an island of abnormal subchondral bone
in the body of the capitellum and its overlying articular cartilage, which begins to
separate from the rest of the bone. Separation of this osteochondral fragment
interferes with normal joint function. The etiology of ostechondritis dissecans is
not clear [40]. The common denominator, however, appears to be overuse.
Osteochondritis of the elbow is not seen in youngsters who are not using their
elbow heavily.
Fig. 14. Radial-capitellar joint.
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The presentation of osteochondritis dissecans of the elbow can be similar to
that of Panner’s disease, but there are some important distinctions (Table 2).
Patients with osteochondritis dissecans of the elbow are usually between the ages
of 12 and 15 and are almost always throwers [41]. They complain of pain on the
lateral elbow and may have joint symptoms including locking and catching.
Evaluation
On physical examination, there may or may not be tenderness at the radial-
capitellar joint. There often is an effusion. Range of motion of the elbow is
limited in extension. Radiographs usually reveal either a lucency in the humeral
capitellum or a radiolucent line demarcating the osteochondral fragment with
irregularity of the articular contour of the capitellum.
Fig. 15. Panner’s disease. Note fragmentation of the humeral capitellum and flattening of the articular
surface (arrow). (Courtesy of Ralph J. Curtis, MD.)
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Management
The patient with osteochonritis dissecans should be referred to an orthopedic
surgeon familiar with this condition. Treatment depends on whether the articular
surface overlying the defect is intact. Violation of the articular surface is
evidenced by mechanical symptoms such as locking or catching. In some cases,
MRI is necessary to evaluate the articular surface. If clinical examination and
imaging studies indicate the fragment is not loose and the articular surface is
intact, treatment consists of total rest until there is radiographic resolution of the
lesion. When there is evidence that the fragment is loose, the best option for
treatment may be surgical.
Injuries about the wrist
Fractures of the distal radius and ulna
Fractures of the radius and ulna are common in active children. Recognition
and management of various types of forearm fractures is treated in detail in
orthopedic texts and is beyond the scope of this article. Most fractures of the
radius and ulna should be referred to an orthopedic surgeon.
One type of fracture that is common and may be treated by the primary care
physician is buckle fracture or torus fracture of the distal radius. This injury
usually occurs as a result of a fall on the outstretched hand. The patient presents
with pain and swelling localized to the distal radius. Radiographic examination of
the youngster with a possible radius or ulna fracture should include visualization
of the elbow and wrist. In the case of the buckle fracture, plain radiographs reveal
an abrupt widening of the bone with minimal disruption of the cortex and usually
intact periosteum at the level of the metaphysis. At least three views of the wrist
should be obtained. The buckle fracture must be distinguished from the green-
stick fracture, in which the cortex remains intact on one side, because the
greenstick fracture requires different treatment. The buckle fracture that is
minimally angulated (less than 15°) may be treated in a short arm cast for
3 weeks [42]. As with all radius and ulna fractures, the youngster should be
Table 2
Differentiation of Panner’s Disease and osteochondritis dissecans of the elbow
Characteristic Panner’s disease Osteochondritis dissecans
Lateral elbow pain Yes Yes
Throwing activity Nearly always Usually
Age (y) 7 – 12 13 – 16
Locking, catching No Yes
Loss of extension Yes Yes
X-ray appearance Entire capitellum fragment,
lytic, irregular
Island of bone demarcated
from capitellum
Treatment Nonoperative May require surgery
Prognosis Good Guarded — may have
loss of function
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followed periodically for up to 12 months to ensure that any growth disturbance
of the fractured bone is detected early.
Carpal bone fractures
Carpal bone fractures usually occur with a fall on the outstretched hand.
Fortunately, the most commonly fractured carpal bones, the scaphoid and the
lunate, are also easily palpated. The patient with the scaphoid fracture has
swelling of the wrist on the radial side, tenderness in the anatomic snuffbox
and on the tubercle of the scaphoid, which is palpable on the volar side of the
wrist just proximal to the base of the thumb metacarpal. Three views of the wrist
should be obtained. Nondisplaced scaphoid fractures are treated with a thumb
spica cast to the elbow for 6 weeks. Patients with swelling and tenderness over
the scaphoid but in whom initial radiographs are normal may have a fracture that
will not be visible for weeks. These patients should be treated in a thumb spica
splint for 2 to 3 weeks followed by re-examination and repeat films.
Physiolysis of the distal radius
Pathomechanics
Wrist pain in gymnasts is common and may signify degenerative changes of
the distal radial physis, which if untreated may lead to premature closure of the
physis and a discrepancy between the length of the radius and ulna [43,44].
Relative shortening of the radius with respect to the ulna results in deviation of
the hand toward the radial side, a condition termed positive ulnar variance,
because the ulna becomes relatively longer than the radius [45]. This abnormal
variance may lead to problems with other wrist structures with repetitive weight
bearing.
Presentation and evaluation
The gymnast with physiolysis of the distal radius presents with insidious onset
of pain. Physical examination reveals mild swelling and tenderness on the radial
side of the wrist and decreased range of motion. Passive deviation of the hand
toward the radial side produces pain. Plain radiographs may reveal either a
narrowing of the distal radial physis when compared with the normal side or
widening. There is sclerosis adjacent to the physis, and changes in the metaphysis
such as widening or beaking also may be seen.
Treatment
Initial treatment of the gymnast with history, physical examination, and
radiographic evidence of damage to the distal radial physis is cessation of weight
bearing activities on the wrist for 6 to 8 weeks. During this time, ice may be
applied for relief of pain and swelling, and exercises to stretch and strengthen the
wrist flexors and extensors may be initiated as tolerated. Continued symptoms
may require complete immobilization of the wrist for 6 weeks. The persistence of
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symptoms despite these measures is an indication for MRI to further evaluate the
damage to the physis and to rule out other possible causes of wrist pain.
References
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