A 15-year-old patient with right elbow pain

Issue: June 2016

ByMark S. Cohen, MD

ByRachel M. Frank, MD

ByNicholas M. Brown, MD

The patient is a 15-year-old right-hand dominant high school sophomore who plays catcher for his varsity baseball team. He presented to our clinic with a history of right posterior elbow soreness associated with overhead throwing. Three months prior to presentation, he reported hearing a “pop” in the right elbow while throwing from the outfield. He felt subsequent pain in the posterior aspect of his elbow and had increased pain with the next throw.

He voluntarily removed himself from the game and at the time of presentation to our office, had not thrown since the injury. He denied a sensation of instability to the elbow and had no prior injuries or similar “popping episodes.” On physical examination, he had full elbow and forearm range of motion. He had tenderness to palpation about the medial and lateral aspects of the olecranon process. However, there was no significant tenderness to palpation directly posterior on the olecranon. He had negative provocative tests for medial collateral ligament pathology. His grip strength measured 80 pounds on the right compared to 60 pounds on the left. Radiographs of the right elbow (Figure 1) and contralateral elbow were obtained.

Anterior-posterior (a) and lateral (b) elbow radiographs of a 15-year-old right-hand dominant male patient with a proximal type persistent olecranon physis are shown.

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Persistent symptomatic olecranon physis

The right elbow radiographs revealed an open olecranon physis while contralateral elbow radiographs demonstrated near-complete closure of the olecranon physis. The elbow is a common source of pain in the young athletic patient population, particularly in the overhead athlete. Stress from repetitive motion can lead to overuse injuries such as medial collateral ligament tears, capitellar osteochondritis dissecan lesions and medial epicondyle avulsion fractures. An important but poorly understood cause of elbow pain in these patients involves the olecranon physis.

Two main categories of olecranon physeal injuries have been described, including stress fractures of the olecranon physis and the persistent symptomatic olecranon physis. Unfortunately, it can be difficult to differentiate between these two diagnoses based on clinical examination and imaging studies. In addition, significant controversy exists with respect to nomenclature, etiology and appropriate treatment of olecranon physeal abnormalities.

Intraoperative fluoroscopic radiographs are shown demonstrating open reduction and internal fixation with tension-band fixation of a proximal persistent olecranon physis nonunion, showing AP view of placement of two 0.062-mm K-wires and an 18-gauge wire (a), lateral view of placement of two 0.062-mm K-wires and an 18-gauge wire (b), lateral view of bone graft packing into the nonunion site (c), and final repair construct before 18-gauge wire was cut (d).

Discussion

The olecranon physis appears at approximately age 10 years in male patients (age 8 years in female patients) and fuses at age 16 years (age 14 in female patients). The epiphysis of the olecranon typically ossifies from two or more ossification centers, most commonly a nucleus (posterior) that forms most of the articular surface and a second center (anterior) that forms the apex of the olecranon. The anterior nucleus is smaller in size and located more proximally, at the site of the tip of the olecranon, while the posterior nucleus is larger and forms most of the articular surface. These centers usually fuse with each other before fusing with the main metaphyseal segment. This fusion typically occurs anteriorly (along the joint line) first and proceeds posteriorly. Radiographically, the physis will have a prominent sclerotic margin just prior to complete closure.

radiographs following open reduction and internal fixation with distal radius autograft — Postoperative (a) anterior-posterior and lateral (b) elbow radiographs are shown following open reduction and internal fixation with distal radius autograft of a persistent proximal olecranon physis, which demonstrates complete bony union.

Stress fractures typically occur in mature bone due to repetitive microtrauma exceeding the ability of bone to remodel, ultimately leading to fracture. In contrast, the presence of a persistent physis is thought to occur via a traction-type mechanism from the repetitive pull of the triceps. In theory, this injury mechanism is similar to apophysitis, but it should be noted neither the distal nor proximal olecranon physes represent true apophyses. Several authors have variably described the presence of distal olecranon physeal nonunions; however, to our knowledge, only two documented cases of a persistent proximal olecranon physis exist. Both cases demonstrate a more proximally located physis with widening and sclerosis. As described above, distal physeal injuries may be related to traction-overpull from the triceps while more proximal injuries may be secondary to forceful hyperextension of the elbow in the presence of an abnormal physis with abutment of the olecranon tip into the olecranon fossa at terminal extension.

Treatment

The patient failed a trial of nonoperative management, including immobilization and avoidance of elbow loading. The patient subsequently underwent open reduction and internal fixation of the right olecranon growth plate with distal radius autograft. A figure-of-eight tension band wire construct was used for fixation. Upon surgical dissection of the proximal olecranon physis, a fibrous nonunion was encountered.

Under fluoroscopic guidance, the fibrous nonunion was meticulously debrided utilizing curettes, rongeurs and a low-speed bur. Small cavities were made proximally and distally to ensure removal of all fibrous and cartilage tissue, while care was taken to avoid violation of the articular surface. The distal radius bone graft was then packed into the nonunion site and the tension band construct was completed using two 0.062-mm K-wires and 18-gauge wire. A two-wire technique was used with two knots tightened sequentially (Figure 2).

Postoperatively, the patient was placed in a long arm splint with elbow range of motion exercises beginning at 1 week. The patient was weaned from the splint at 4 weeks following surgery and at 8 weeks postoperatively, weight-bearing of the elbow was initiated. At that time, radiographs showed evidence of bony union (Figure 3). The patient successfully returned to throwing with his affected arm at 3 months to 4 months following surgery. At 4-year follow-up, he remains asymptomatic and reports no problems or issues with the hardware.

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For more information:
Rachel M. Frank, MD; Nicholas Brown, MD; and Mark S. Cohen, MD, can be reached at Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St., Suite 300, Chicago, IL 60654; Frank’s email: rmfrank3@gmail.com; Brown’s email: nmb2116@gmail.com; Cohen’s email: mcohen3@rush.edu.

Disclosures: Frank, Brown and Cohen report no relevant financial disclosures.