Craig, thanks everyone for getting up bright and early this morning, and I'm going to be talking about the management of acute traumatic elbow injuries, and we'll have another talk with Dr. Savoie with regard to the throwing athlete's elbow. And so I have no disclosures, and those that I do have are on the Academy website. And just as far as an overview, you know, we'll go over a little bit of the epidemiology of these elbow injuries. Real brief talk about the anatomy, just to focus on when you're thinking about these injuries. And then we'll go over the injury types that are most common, as well as some of the case examples and the management of those. So with regard to the epidemiology, Matt Batava published a study, he actually published a couple of studies looking at the injury incidence in football in both lower and upper extremity injuries. But of all football injuries, elbow injuries are actually 15 to 20 percent of those, and they're most likely sustained in games and in practice. With regard to the most common injuries, elbow hyperextension was found to be the most common, 13 percent, followed by medial and lateral elbow sprains of the ligament structures, 8 percent. Then elbow instability, followed by biceps and triceps strains. And then elbow fractures are actually fairly uncommon with regard to our acute injuries, which is fortunate for us. Most of these are seen during tackling or blocking, and really they're affected by all positions, but offensive and defensive linemen are usually most affected, because they're the ones that are doing the tackling and blocking. And elbow was the most common upper extremity injury in all positions, except for wide receivers where the wrist was most common. About a decade earlier than that, HSS and Keith Kinter out of Missouri performed a very similar study, and they too found that elbow hyperextension was going to be the most common. But then most recently, the NC2A published some data that showed very similar injury rate of elbow injuries out of all injuries, also showed that competition was much more common to have these injuries than in practice. But they actually found that elbow instability was the most common, but again, very low surgery rate. So with regard to the anatomy, just remember that this is a joint that really has three articulations. You have your radial capitellar joint, you have your humeral ulnar joint, you also have your proximal radial ulnar joint as well. And then with regard to the medial and lateral structures, on the medial side you have your UCL, or what we consider our Tommy John ligament. Remember, there's anterior, posterior, as well as transverse bundles of that. On the lateral side, there's another ligament that's complex of the lateral UCL, the radial collateral ligament, accessory LUCL, as well as the anterior ligament. But then over the top of both of those are muscular structures in the tendons. So you have the common extensor tendon group on the lateral side and the common flexor group medially. Anteriorly, you have your biceps, as well as your brachialis, and then posteriorly you have your triceps. What this simplified diagram doesn't show is the anconeus and the pronator teres, which can also become strained or contused during some of these elbow injuries. So elbow hyperextension has been shown to be fairly common in the studies that I just talked about. You can see our athlete there trying to do a tackle, and immediately he has this strain within his elbow. And his MRI there is on the right-hand side. You can see that he has injury to his UCL, as well as some strain of his flexor pronator. But he's able to play. We actually didn't even know about this until after the game, and we had the MRI ordered the next morning. And so he missed no time with this. We have another example here. This is our inside linebacker. He's going to make a tackle, and this is a little bit more of an extreme injury, as you can tell on the MRI on the left. It's kind of hard to see on this view, but we have another view here. You see him coming in to make the tackle, and it's actually his teammates that will pin his elbow against the player to cause the forceful hyperextension. So he had a much more significant flexor pronator injury there, as well as the UCL. But he came off the field. We evaluated him. He was placed into a brace, and he actually was able to play the rest of the game. He said after the fact that he wish he didn't play the rest of the game, but he was able to do it. And he didn't miss any time either. With regard to the pathoanatomy, you can't have injury to the anterior capsule. As we saw, you can have injury to the flexor pronator, but also the extensor mechanism can get damaged as well, or the common extensor tendon. Ligamentous injuries are common, but also just muscular strains. Brachialis, the ancones, and the pronator teres can all get trapped in there as they're getting this forced hyperextension. When you're seeing them on the field, generally you can tell what happened because they have pain with repetitive hyperextension. You want to make sure they have no varice valgus instability, but the vast majority of these can be placed into a brace with an extension block and get back to play. And generally, with non-operative treatment, they miss minimal time. So now we'll go to elbow instability. I'm sure Dr. Price remembers this video here where his rookie landed on his outstretched arm and had immediate deformity. It was had to be taken back. These are ones that we're all very familiar with. You do want to try to reduce these as soon as you can. There's a few different reduction maneuvers. I think that a hematoma block can be also useful for this as well. And you also want to make sure there's no concomitant fractures. Fortunately, the fractures are pretty uncommon. Usually if there is a fracture, it would be a little fleck off of the coronoid, but usually they're not needed to be treated surgically. And so we classify these as simple or complex, complex being those ones that have concomitant fractures. The mechanism, as we just saw, is a fallen outstretched hand with this axial force with the arm and valgus and supination. In general, these guys can't return back to play. There's too much tissue damage. We generally will immobilize them, but then try to get them back with regard to mobilization very soon so they don't get to shoot stiff. This is in the simple dislocations, obviously. And the time loss on these is around three to four weeks. The management of these and the return to play, though, is quite good. This is 11 C's of data out of the Rothman group. They looked at 62 elbow dislocations. They only had one fracture out of these 62, and they found that it took around 25 days to return back non-operatively. And they did have four that did have surgery, but they didn't really specify why. I think this was probably some sort of ligamentous repair, and those were 45 days to return back after a surgery. Now a severe valgus load is something a little bit different than what we just saw. We all are familiar with this play that really changed a playoff game this year. And in the throwing arm of a quarterback, this can be something that is significantly different and can change your decision making with regard to your management being surgical versus non-surgical. I'm not going to really focus on the throwing elbow, obviously. So we also had another athlete of ours, this is going to be our defensive lineman, our edge rusher coming in, and he has a valgus stretch to his elbow right there as he's just trying to push number 74 out of the way. So he actually caused this injury to himself, and you can see by his MRI, he's got basically obliteration of his UCL, it appears on this MRI, but also a massive hole in his flexor pronator where the entire tendon is detached at the musculotendinous junction from the muscle. And so with regard to these, in general, you can treat these similar to a simple elbow dislocation. We're going to immobilize them and start early range of motion, and most can get back. In general, they're going to play in a brace at least for the rest of the season. But what you really want to make sure is they can protect themselves. So that previous athlete that I just showed the video of, we took him to the locker room, we evaluated him, we knew what the diagnosis was just based upon where his pain was and his instability. We tried to put him into a brace because he wanted to play, but he just could not block, he could not protect himself. And so obviously, we're not going to let him go back out. But the decision for surgery can depend upon the complexity of the injury, as well as their specific position. This particular athlete, even though I think that it could be controversial what to do with this, he elected to have surgery. You can see that on that left-hand side, there's really no dissection that was needed to be done. He had a big open hole on the inside of his elbow there. So he wound up getting a UCL repair with an internal brace, as well as a repair of the flexor pronator. We'll go into some injuries that are more clear-cut with regard to surgery. These are the biceps and triceps injuries. So this is on a field goal. On the left-hand side, you can see number 70. They're trying to block his defender, he puts his arm outstretched there. I have a better view of it right there. These mechanisms of biceps injuries, as we're all aware of, is going to be when we're trying to flex the arm, but you get this unexpected extension force, and that will cause the injury. It's going to result in 40% loss of supination, 30% loss of your flexion strength if you're not treating these. Again, in general, you can make this diagnosis on the sideline. They usually will have some sort of visible deformity. You can perform the hook test. They're going to usually have some significant tenderness approximately over the tendon. You may be able to feel the tendon as it retracts approximately. The management, in general, is they can't play because they just hurt too badly, but it can surprise you. They tell you at the end of the game, yeah, doc, my elbow hurts, and then they could be an equivocal exam at that point too, but then you get the MRI later and you see that they've damaged the biceps. But in general, you can make the diagnosis fairly easily, sling for comfort, plan surgical management, and the prognosis is good. This is our athlete's MRI here. You'll see the avulsion off the radial tuberosity with the proximal retraction. They're very straightforward. There are a variety of different ways to fix these. You could have bicortical button, unicortical button, button with screws, as well as suture anchor fixation where it's more of an onlay technique. We will all, at meetings, argue about what is the better thing. There are some that will argue that doing a button and screw is more strong from a biomechanical standpoint. But then if you want to look at the anatomy and trying to put the long and the short head back in the proper position, probably doing the suture technique or suture anchor technique is better. He elected to proceed with this type of fixation, and he was able to get back that season as well. But fortunately, his injury was in the Super Bowl, actually, and so it wasn't that season he got back, but he got back the next following season. So rehabilitation for these is generally a splint for a week. And then we will have them start protected range of motion. I generally actually will not brace these, per se. I think that this fixation is very strong. I just have them do active extension, passive flexion for that first month before we start any kind of strengthening at all. But if you're worried about them, you can place them into a brace and unlock it progressively as you get them through that first month, and then progressive strengthening at around 12 weeks. But it usually takes these guys about a year to get back. This is a study out of Rutgers. They looked at six seasons of data, 35 NFL players with distal biceps injuries, 94% return within one year, and their career length did not change. Now, this is interesting because this is out of JSCS in 2021, same exact year. There's another study that looked at a 20-year time period, and they found that there was an 84% return within one year, so not as good. And they actually had shorter career lengths if they had this biceps injury compared to their match controls, which is different than that previous study. But I think that it really is just the 20-year time period versus the six-year time period. Therefore, the fixation techniques have evolved as well as our surgical techniques. And lastly, we'll talk about triceps injuries. These are pretty rare in the general population, but much more common in football. Usually occur from forced elbow flexion during an eccentric contraction, so basically just the opposite of the biceps injury. These can be detected fairly well also because they're going to be so weak with regard to their elbow extension, but they're going to be tender over the tip of the olecranon. This video is interesting because he injured that prior to this play, but he's able to make the tackle with one arm because he's such a beast to bring him down to prevent the touchdown. So when they come out of the game, you know, they generally are going to have this flail arm. You can see him there, and they usually will not want to play, but you could theoretically try to brace them, but most of these will stay out. Sling brace, splint for comfort, and then plan a surgical repair. As far as the surgery, remember that there's three heads. The triceps basically inserts on as a flat tendon that inserts onto the olecranon. With the surgery, you're trying to recapitulate the footprint over the olecranon. And again, this can be done in a variety of different ways with regard to bone tunnels, a variety of suture constructs, but as long as you get it down anatomically in the right position, they do quite well. Rehab for these, we'll post-operatively splint them in a little bit of extension. You know, what I've found is the ones that fail, at least in the general population, they say that their doctor splinted them at 90 degrees. It doesn't make a lot of sense. So you want to put them in a little bit of extension, usually around 70 degrees, and I will brace these ones for around six weeks with protected motion and then progressive strengthening at 12 weeks. And another study out of the Rothman group, they looked at 37 players over a 10-year period, just an average of around six months. 86% of these are linemen, which makes sense, but all players were able to return to the NFL. So in summary, elbow injuries comprise around 15 to 20% of all football injuries generally occur during blocking and tackling. Hyper-extension, ligament to strains, as well as simple dislocations are going to be the most common, therefore surgery is not that common. But in the setting of surgical management for the injuries we just discussed, return to play is very common. Thank you.

acute traumatic elbow injuries

football players

epidemiology

anatomy

management