0:01

Okay, we're gonna spend the, uh, remaining time, probably,

0:04

uh, only about 10 minutes or so.

0:07

Uh, talking about cr some of the chronic things

0:10

that we may see, particularly in baseball pitchers,

0:15

but also in other athletes, especially those involved in

0:20

overhead, uh, throwing sports.

0:22

The first of these I talked about, uh, yesterday

0:29

I talked about the hypertrophy that occurs

0:34

around the elbow

0:35

and baseball pitchers due to the elbow lock

0:39

between the humerus and the trochlear notch of the oland

0:43

because of that, particularly in professional baseball

0:46

pitchers, but also as I said in other sports

0:49

as well including, but I didn't mention

0:51

bowlers can get this as well.

0:53

Look how thick the cortex is of the distal humerus.

0:58

And I want point out again, how thick the cortex

1:02

of the ulna may become.

1:04

But when you look at the cortex of the radius,

1:07

it does not participate

1:09

because it is not part of the elbow lock.

1:14

Now, when we deal with problems in baseball pitchers,

1:18

it relates to repetitive valgus stress,

1:21

uh, in these throwers.

1:22

And there are three quadrants that may be affected.

1:26

The first of these relates to the medial compartment

1:29

where tensile forces may develop.

1:32

The second of these relates to L lateral compartment where

1:36

compressive forces may develop.

1:39

And the third relates to the postal medial compartment

1:43

where impingement and sheer forces may develop.

1:48

So when you're looking at problems in the uh,

1:51

throwing athlete elbow region, you wanna look at all three

1:56

of these quadrants, which we're gonna do.

2:00

So the first relates to the tensile injuries

2:03

that may occur in the medial supporting structures.

2:06

Typically in the late cocking phase of throwing

2:10

this may involve tendons, ligaments, and bones

2:13

because those structures are absorbing this valgus force.

2:19

So here's an example of theorization

2:23

of the humerus shown in the first image.

2:26

You can see here a fracture involving a portion here of the

2:31

sublime cubicle.

2:32

And here we can appreciate chronic thickening.

2:36

And now a new tear

2:37

that has developed near the distal attachment

2:41

with a small uls piece of bone.

2:44

So this is a fracture related to repetitive stress

2:47

with a new injury that's occurred in this region.

2:51

Here's another one.

2:52

This is a complete tear involving mainly the anterior bundle

2:56

of the medial collateral ligament and a baseball pitcher.

3:00

You can appreciate here

3:02

that the ligament is thick from the chronic stress

3:05

and there's a new fracture.

3:07

You can see it right here with some adjacent fluid.

3:11

So this is a com, I guess complete

3:14

or near complete tear of that ligament.

3:18

And then you can get these massive and deso fights.

3:23

And this probably relates at

3:24

to one time an avulsion fracture,

3:27

but now there's been bone proliferation.

3:30

You can see it's extending vertically upward.

3:32

There's other bone fragments along the course of the

3:37

anor bundle of the medial collateral ligament.

3:42

Now I mentioned before that I would come back to this topic

3:45

of partial tearing of the

3:50

anterior bundle of the medial collateral ligament at its

3:53

attachment to the sublime tubercle.

3:56

And what we're looking for is a cleft that is too long.

4:01

I showed you the physiologic cleft

4:04

that generally stops at the level of the cartilage

4:06

or the subc chondral bone plate.

4:09

But if the separation extends further down, it is abnormal

4:14

except in older people, alright, where

4:17

that cleft may become a little larger.

4:20

So here's what it looks like. This is a gradient echo image.

4:23

It's an old image, it's not very pretty,

4:26

but you can see the abnormal signal here as

4:28

that bundle has been stripped away from the sublime cubicle.

4:33

Now it still is attached to the ridge, right?

4:36

So it's not hanging loose.

4:38

It's been stripped away right from the cubicle

4:41

and a little bit of the ridge.

4:43

And here's what it would look like. Uh, on an arthrogram.

4:47

You can appreciate that appearance

4:50

as extending past the cartilage,

4:53

past the subc chondral bone plate that is abnormal.

4:56

Here's another one. There's a young baseball pitcher.

4:59

I don't remember if he was professional pitcher or not,

5:03

but we did an arthrogram

5:04

and we do arthrograms, not that often, but of the elbow.

5:07

We do it more for postoperative cases

5:10

following ligament repair.

5:12

But here's an example of the contrast extending too far down

5:17

along the medial aspect of the ulna, far

5:20

below the tubercle along the ridge.

5:22

And you can see that probably the ligament's still attached

5:25

to the lower part of the ridge.

5:27

You can see that better in the bottom image.

5:31

And one further example here may be a little bit more subtle

5:35

young person, baseball pitcher.

5:38

There may be a little bit

5:39

of ligament damage here, I'm not sure.

5:41

But you can see here this is a little bit

5:44

below the subcon bone plate.

5:47

And this has produced what has been called the T sign.

5:50

It looks like the letter T lying on its side with these,

5:55

the limbs, the upper part

5:56

Of T, and here it is on a non-fat suppressed image.

6:00

So be aware of this particular finding.

6:03

These can be very subtle.

6:05

Now again, in an older person, uh,

6:08

you may get at least a little bit of stripping of that

6:12

ligament.