Medial Epicondyle Apophyseal Avulsion Fractures in Youth Throwers: A Severe Variant of Little League Elbow (132)

Objectives: Medial epicondyle apophyseal avulsion fractures sustained during throwing represent an understudied, severe variant of medial epicondyle apophysitis, or ‘Little League elbow’. The current study sought to characterize presenting features, treatment options, and clinical results of a large cohort of pre-adolescent and adolescent patients who presented with these fractures. Methods: Skeletally immature athletes with medial epicondyle apophyseal avulsion fractures sustained during throwing from 2003-2017 at a tertiary-care pediatric referral center were identified. Exclusion criteria were fractures sustained during non-throwing activity or prior elbow fracture. Medical records and radiographic images were reviewed for study variables. Treatment decisions were made independently by fellowship-trained pediatric orthopaedic surgeons or sports medicine physicians on a case-by-case basis. Patients treated with open reduction and internal fixation (ORIF) were compared to those treated non-operatively, and all fracture patients were compared to a larger control group of patients diagnosed with medial epicondyle apophysitis/Little League elbow with no fracture. Results: During the study period, a total of 317 patients were diagnosed with Little League elbow due to medial epicondyle apophyseal overuse injury, 50 of whom (16%) sustained a discreet, radiographically confirmed epicondyle fracture sustained during a single throw. Median age of the fracture cohort at presentation was 13.1 years (range 8 years – 16 years). Forty-nine fracture patients (98%) were male baseball pitchers and one (2%) was a male football quarterback. Fracture patients had significantly higher median BMI (21.3 kg/m2 vs. 19.2kg/m2, p=0.004) than the apophysitis control group, but there was no significant difference in age. Of the 37 patients with documentation regarding pre-injury symptoms, 31 patients (84%) described pre-existing medical elbow pain prior to their acute injury, while 6 (16%) denied pain prior to the inciting throw. Of the 12 patients (24%) with documented shoulder exams at presentation, 5 (42%) demonstrated glenohumeral internal rotation deficit (GIRD). Twenty-three patients (46%) were treated with ORIF (22 single screw fixation; 1 suture anchor fixation), while 27 (54%) were treated non-operatively. Median fracture displacement was significantly greater in operative patients than non-operative patients (5.0mm vs. 3.0mm, p=<.001), with all ‘minimally displaced’ (<4mm) fractures undergoing non-operative treatment (Figure 1). Multivariable analysis determined that for each additional mm of displacement, the odds of surgical intervention increased by 6.4 times (OR=6.36; 95% CI=1.83-22.07; p=.004), when controlling for age and BMI. All patients returned to their throwing sport (RTS) at a median of 12.8 weeks post-diagnosis, but 13 (26%) developed recurrent elbow pain, with no significant difference in in RTS time or recurrence rate between treatment cohorts. Nine of twenty-two (41%) screw ORIF patients underwent secondary implant removal, with no significant difference in this rate between those with or without a washer. Conclusions: Medial epicondyle apophyseal avulsion fractures in youth throwers represent a severe variant of Little League elbow, constituting approximately 16% of cases within the condition’s spectrum. These fractures may be effectively treated with either non-operative measures, particularly minimally displaced fractures <4mm, or ORIF, though >40% of operative patients may require implant removal. A large majority of patients reported medial elbow pain prior to fracture, suggesting this severe presentation of Little League elbow may be preventable.

Diagnosis and Management of Little League Shoulder: A Systematic Review

Background: Little League shoulder (LLS) is an overuse injury characterized by throwing-related pain that commonly presents in adolescent male athletes. Investigations into the optimal duration of rest from throwing and protocols for graduated return to sports (RTS) are lacking. Purpose: To summarize the current literature with respect to the diagnosis, management, RTS, and return to throwing for LLS. Design: Systematic review; Level of evidence, 4. Methods: The databases EMBASE, MEDLINE, and PubMed were searched between inception and April 22, 2020. References of retrieved records were reviewed for potentially eligible studies. English-language studies that reported the diagnosis and/or management of LLS in children or adolescents were included. Studies of animals or cadavers, review articles, and non—peer reviewed records were excluded. Data were summarized narratively using descriptive statistics. Results: Overall, 23 studies (21 level 4 studies, 2 level 3 studies) met the criteria for a total of 266 participants with a weighted mean age of 12.8 years (range, 7.4-17 years). Treatment recommendations evolved from prolonged rest and complete cessation of throwing to shorter periods of rest and graduated RTS. Less than half (11/23) of studies reported specific criteria to RTS; 1 case report discussed a coaching strategy to resume throwing, and 1 case report discussed a regimented throwing program. The proportion of participants returning to any sport participation was 94.0% (n = 157/167). The proportion returning to their preinjury level of sport was 92.5% (n = 123/133). Upon RTS, 18.7% (n = 35/187) of participants experienced a recurrence of symptoms. Premature closure of the epiphysis was reported in 1 participant. Conclusion: Young athletes with LLS may return to play after a period of rest, and a high proportion return to their preinjury level of sport. Further prospective studies are warranted to develop evidence-based, graduated RTS protocols and to better capture any long-term sequelae of the condition.

CLINICAL FEATURES AND OUTCOMES OF LITTLE LEAGUE ELBOW IN YOUNG ATHLETES

Background: As participation and specialization in youth sports has increased, so too has the incidence of overuse conditions, such as medial epicondyle apophysitis, or Little League Elbow (LLE). Hypothesis/ Purpose: The study purpose was to assess the demographic features, clinical presentation, management, and outcomes of a population of skeletally immature athletes with this increasingly common, but understudied, condition. Methods: A retrospective analysis was performed of patients diagnosed with LLE between 2003 and 2017 at a tertiary-care pediatric hospital. All patients had open apophyses with a clinical history of repetitive overhead athletic activity and radiographic and/or physical exam findings consistent with LLE. Study variables were derived from the electronic medical record. Results: Three hundred seventeen subjects (mean age: 12.8 years, range 8yrs – 16yrs; 310 males, 98%) were identified. The vast majority were baseball players (n=310, 98%), though there were several tennis players (n=4, 1%) and football quarterbacks (n=3, 1%). Two-hundred sixty-eight patients (85%) presented with apophysitis, while 49 (15%) presented with acute avulsion fractures from throwing (with 84% reporting preceding medial elbow pain). The acute fracture patients are the subject of a separate study. In the apophysitis cohort, all of whom presented with medial elbow pain, other presenting findings/symptoms included decreased elbow range of motion (16%) and concomitant ipsilateral shoulder pain (13%). Amongst those with documented shoulder exams, a majority (55%) demonstrated glenohumeral internal rotation deficit (GIRD) with a significantly longer time from diagnosis to resolution of symptoms (p=0.025). All apophysitis patients were treated with rest (complete cessation 75%, relative rest/position change 25%). Mean follow up was 32 months (sd 33 months). Return to sports occurred at a median of 12 weeks from diagnosis (IQR 7wks – 18wks). Recurrence of elbow pain occurred a median of 24 months (IQR 11mo - 43mo) following initial diagnosis in 13% of patients, a sub-cohort with significantly longer duration of symptoms prior to index presentation (p=0.024). One patient also suffered a subsequent medial epicondylar avulsion fracture while throwing in the setting of non-compliance with recommended rest. Conclusion: Little League Elbow is most commonly seen in adolescent and pre-adolescent male pitchers but may rarely be seen in other overhead athletic sub-populations. Careful evaluation of the entire kinetic chain is critical to identify concomitant pathology such as GIRD, which may portend a prolonged recovery. Proper treatment is necessary to minimize recurrence and development of epicondyle avulsion fractures, which represent a potentially preventable, but severe variant of LLE.

Description of Motor Skill Development and Parent Socio-Economic Status of West Java Little League Baseball Athletes

Elite sport achievement in early childhood is inseparable from parent financial supports. In Little League Baseball sport, parents invest money to help their children grow and develop optimally. Parents put their hopes and aspirations for their children to become a great Indonesian Baseball player. This study aimed at determining the socioeconomic status characteristics of the Little League Baseball athlete parents in West Java. This study used a cross-sectional study method. Sixteen parents volunteered to fill out the Social Economic Status questionnaire via Google Form. Data were analysed using percentage techniques and Spearman correlation test. The results showed that the Socio-Economic Status (SES) of the Little League Baseball athlete parents was in the middle to upper category. The athlete motor development was at a good level. The socio-economic status condition of the Little League Baseball athlete parents, who were included in the middle to upper category, had a beneficial effect on the optimal training process because the training demand fulfilment requires a financial support.