Sinha Rishi, Wyatt Charles W, Althoff Claire, Jones Jacob C, Johnson Ben, Ellis Henry B, Wilson Philip L
Scottish Rite for Children, Dallas, Texas, USA.
University of Texas Southwestern Medical Center, Dallas, Texas, USA.
Am J Sports Med. 2024 Jul;52(8):2101-2109. doi: 10.1177/03635465241252156. Epub 2024 May 27.
Although pediatric medial epicondylar fractures and apophysitis are well studied, patterns of subapophyseal avulsion and ligamentous injuries of the medial elbow in this population merit investigation to inform optimal treatment strategies.
To describe the occurrence and demographic correlates of ulnar collateral ligament (UCL) avulsion and soft tissue injuries of the pediatric and adolescent elbow.
Cross-sectional study; Level of evidence, 3.
An institutional review board-approved review was conducted to identify consecutive patients with medial elbow injuries treated in a tertiary pediatric sports medicine practice between 2016 and 2021. Radiographs were obtained during injury evaluation, and patients with nondisplaced medial epicondylar apophysitis and complete epicondylar fracture were excluded, resulting in 150 patients with soft tissue injuries occurring distal to the medial epicondyle apophysis (subapophyseal) for study. Radiographs were evaluated for bony avulsion of the UCL from either the medial epicondyle proximally or the ulnar sublime tubercle distally. Injuries without radiographic evidence of bony avulsion, but with clinical examination findings consistent with ligamentous injury, were classified as radiographically negative UCL injuries, and magnetic resonance imaging (MRI) was performed to further evaluate these injuries if moderate to severe medial swelling of the elbow or significant concern for medial structural injury was present on examination. These MRI scans were evaluated to classify the UCL injury and assess for periosteal or cartilaginous avulsions.
A total of 150 patients (mean age, 12.5 ± 3.4 years; 70 female), 55% (150/274) of the entire medial elbow injury population, had a subapophyseal injury. Of these patients, 62 had a bony avulsion detected on radiograph, and 88 had a radiographically negative injury. In addition to the 62 radiographic avulsions, the 61 MRI scans obtained on those radiographically negative injuries revealed 33 complete UCL disruptions, resulting in 63.3% (95/150) of patients sustaining a complete ligamentous disruption. With the MRI scans, 37 (61%) cases of cartilaginous or periosteal avulsion of the UCL were diagnosed. Overall, 66% of all 150 subapophyseal injuries had a bony, cartilaginous, or periosteal UCL avulsion. Patients with cartilaginous (mean age, 10.3 years) and bony (mean age, 10.6 years) avulsions were younger than those with central ligament injury (mean age, 14.2 years) or periosteal (mean age, 14.2 years) avulsions ( = .005). There was a significant association between the mechanism of injury and the location of UCL tear identified on MRI scans: traumatic falls were associated with distal tears, and throwing injuries were associated with proximal tears ( < .001).
UCL central ligament and avulsion lesions may be frequently diagnosed after injury to the pediatric medial elbow, the majority of which are complete injuries, and may require MRI for diagnosis. The mechanism of injury may predict the location of ligamentous injury, and osteocartilaginous avulsions are more likely to present at younger ages than injuries to the soft tissue of the UCL or periosteum. The prevalence of these injuries merits further investigation into best protocols of nonoperative treatment or surgical repair techniques and outcomes.
尽管小儿内上髁骨折和骨突炎已得到充分研究，但该人群中内侧肘部骨骺下撕脱和韧带损伤的模式仍值得研究，以指导最佳治疗策略。
描述小儿和青少年肘部尺侧副韧带（UCL）撕脱和软组织损伤的发生率及人口统计学相关性。
横断面研究；证据等级，3级。
进行了一项经机构审查委员会批准的回顾性研究，以确定2016年至2021年期间在一家三级小儿运动医学诊所接受治疗的连续内侧肘部损伤患者。在损伤评估期间获取X线片，排除无移位的内侧上髁骨骺炎和完全上髁骨折患者，最终纳入150例在内侧上髁骨骺远端（骨骺下）发生软组织损伤的患者进行研究。评估X线片上UCL从近端内侧上髁或远端尺骨小结节的骨质撕脱情况。无骨质撕脱X线证据但临床检查结果与韧带损伤一致的损伤被分类为X线阴性UCL损伤，若肘部中度至重度内侧肿胀或检查时高度怀疑内侧结构损伤，则进行磁共振成像（MRI）以进一步评估这些损伤。对这些MRI扫描进行评估，以分类UCL损伤并评估骨膜或软骨撕脱情况。
共有150例患者（平均年龄12.5±3.4岁；70例女性），占整个内侧肘部损伤人群的55%（150/274），发生了骨骺下损伤。在这些患者中，62例在X线片上检测到骨质撕脱，88例为X线阴性损伤。除了62例X线撕脱外，对那些X线阴性损伤进行的61次MRI扫描显示33例UCL完全断裂，导致63.3%（95/150）的患者发生完全韧带断裂。通过MRI扫描，诊断出37例（61%）UCL软骨或骨膜撕脱。总体而言，150例骨骺下损伤中有66%发生了骨质、软骨或骨膜UCL撕脱。软骨撕脱（平均年龄10.3岁）和骨质撕脱（平均年龄10.6岁）的患者比中央韧带损伤（平均年龄14.2岁）或骨膜撕脱（平均年龄14.2岁）的患者年龄更小（P = 0.005）。损伤机制与MRI扫描确定的UCL撕裂位置之间存在显著关联：创伤性跌倒与远端撕裂相关，投掷损伤与近端撕裂相关（P < 0.001）。
小儿内侧肘部损伤后，UCL中央韧带和撕脱性病变可能经常被诊断出来，其中大多数是完全损伤，可能需要MRI进行诊断。损伤机制可能预测韧带损伤的位置，与UCL软组织或骨膜损伤相比，骨软骨撕脱更可能在较年轻的年龄出现。这些损伤的发生率值得进一步研究非手术治疗或手术修复技术及结果的最佳方案。
