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Humeral Head Epiphysiolysis
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Contents
Other Names
- Little League Shoulder
- Little Leaguer's Shoulder
- Proximal Humeral Epiphysiolysis
- Osteochondrosis of proximal humeral epiphysis
- Stress fracture of proximal humeral epiphyseal plate
- Rotation stress fracture
Background
- This page refers Humeral Head Epiphysiolysis (HHE) or Little League Shoulder
- Defined as an overuse injury to the epiphyseal cartilage of the humeral head seen in skeletally immature athletes
History
Epidemiology
- Very common in little league baseball players, especially pitchers
- In one cohort of little leaguers with shoulder pain, 36.6% of players who agreed to an xray had radiographic findings of HHE[3]
- Seen in youth throwing athletes between 11 and 16, peak age 13[4]
Introduction
General
- Defined as a shearing or stress injury of the epiphyseal cartilage of the proximal humerus
- Characterized by throwing related pain over proximal shoulder
- Represents a Salter Harris 1 Fracture
Etiology
- Occurs as a result of excessive rotational, distractional forces that occur with repetitive overhead throwing[5]
- Specifically, significant external rotational torque
- Repetitive microtrauma leads to cartilage damage of the proximal humeral epiphysis
- Epiphyseal plate injury is the weakest point in the kinetic chain
- Believed to occur during the late cocking phase of throwing
- At this point there is significant rotational torque immediately prior to acceleration
Osteology of the Proximal Humeral Epiphysis
- Four growth center: head, shaft, greater tubercle, lesser tubercle[6]
- Typically fuses between ages 14-20
- Contributes about 80% of longitudinal growth of humeral shaft
Risk Factors
- Male > Female
- Age (11-16, average 14)
- Overhead/ Throwing Sports
- Baseball, especially pitching
- Tennis
- Volleyball
- Swimming
- Pitching specific[7]
- Poor throwing mechanics
- High pitch count
- "Breaking" pitch
- Playing year round sports
- Glenohumeral Internal Rotation Deficit (GIRD)
Differential Diagnosis
Differential Diagnosis Shoulder Pain
- Fractures
- Proximal Humerus Fracture
- Humeral Shaft Fracture
- Clavicle Fracture
- Scapula Fracture
- First Rib Fracture (traumatic or atraumatic)
- Dislocations & Separations
- Arthropathies
- Muscle & Tendon Injuries
- Rotator Cuff
- Bursopathies
- Ligament Injuries
- Neuropathies
- Other
- Pediatrics
- Coracoid Avulsion Fracture
- Humeral Head Epiphysiolysis (Little League Shoulder)
Clinical Features
History
- Typical age 10 to 16
- Onset is by definition insidious although an acute trauma or event could occur
- Pain initially only with significant exertion (i.e. hard throwing)
- Eventually progresses to pain at rest or with light exertion (i.e. soft, short throws)
- May endorse decreased throwing accuracy, velocity
Physical: Physical Exam Shoulder
- Patient will be tender along the humeral epiphysis, especially laterally
- Can have pain, weakness in external rotation
- May have Glenohumeral Internal Rotation Deficit
- Painful range of motion
Evaluation
Radiographs
- Standard Radiographs Shoulder initially
- Best view of physis: anteroposterior view of the shoulder with the arm in external rotation
- Findings
- May be normal
- May show widened physis
- Less commonly
- Demineralization
- Sclerosis
- Cystic changes
- Lateral fragmentation of the prox humeral metaphysis
- Compare to unaffected shoulder if needed
MRI
- Rarely required
- If highly suspicious with uncertain radiographs or clinical exam, can clarify diagnosis
- Findings: physeal edema
Ultrasound
- Can be used to help confirm the diagnosis
- Findings
- Increased hypo-echoic swelling not see on the contralateral side
Classification
Neer and Horwitz Classification
- Displacement[8]
- Grade I: Less than 5 mm
- Grade II: Less than one third of shaft width
- Grade III: Two thirds of shaft width
- Grade IV: More than two thirds of shaft width
Management
Nonoperative
- Remove from play/ activity modification
- No throwing or overhead activities for at least 6 weeks, often 8-12 weeks
- Ok to do general conditioning, lower extremity training
- Ice
- Analgesia including NSAIDS, Acetaminophen
- Consider Shoulder Sling for comfort
Prevention
- Proper pitching mechanics
- Educate athlete, parents, coaches
- Avoid single sport, year round activity
- Rigidly follow pitch count guidelines
- Avoid "breaking" pitch
- Improve core strength, cardiovascular fitness
Rehab & Return to Play
Rehabilitation
- Initiate after at least 6 weeks of rest from overhead or throwing
- Initial: strengthening of rotator cuff, periscapular muscles
- Initiate Throwing Program when patient is pain free at rest without tenderness to epiphysis
- Correct throwing mechanics if necessary
Return to Play
- Upon completion of physical therapy and throwing program without symptoms and normal throwing mechanics
Complications & Prognosis
Prognosis
- Most athletes return to pre-injury level activity (need citation)
- Resolves with skeletal maturity
- Most athletes return to play in about 3 months
Complications
- Premature physeal Arrest
- Limb length discrepancy
- Osteonecrosis of epiphysis
See Also
Internal
- Shoulder Pain (Main)
- Shoulder Anatomy (Main)
- Physical Exam Shoulder
- Pediatric Fractures (Main)
- Apophyseal And Epiphyseal Injuries (Main)
External
References
- ↑ Dotter, W. E. Little leaguer's shoulder-Fracture of the proximal humeral epiphyseal cartilage due to baseball pitching, Guthrie Clin. Bull. 1953 July; 23:68-72.
- ↑ Adams, JE. Little league shoulder: osteochondrosis of the proximal humeral epiphysis in boy baseball pitchers. California Medicine. 1966 Jul; 105(1):22-5.
- ↑ Kanematsu Y, Matsuura T, Kashiwaguchi S, et al. Epidemiology of shoulder injuries in young baseball players and grading of radiologic findings of Little Leaguer's shoulder. J. Med. Invest. 2015;62(3-4):123-5
- ↑ Sabick MB, Kim YK, Torry MR, Keirns MA, Hawkins RJ. Biomechanics of the shoulder in youth baseball pitchers: implications for the development of proximal humeral epiphysiolysis and humeral retrotorsion. Am J Sports Med. 2005 Nov;33(11):1716-22.
- ↑ Sabick MB, Kim YK, Torry MR, Keirns MA, Hawkins RJ. Biomechanics of the shoulder in youth baseball pitchers: implications for the development of proximal humeral epiphysiolysis and humeral retrotorsion. Am J Sports Med. 2005 Nov;33(11):1716-22.
- ↑ www.wheelessonline.com/ortho/anatomy_of_proximal_humeral_physis. Accessed March 7, 2010.
- ↑ Lyman S, Fleisig GS, Andrews JR, Osinski ED. Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers. Am J Sports Med 2002;30:463-8.
- ↑ Neer CS 2nd, Horwitz BS. Fractures of the proximal humeral epiphyseal plate. Clin Orthop 41:24-31, 1965
Created by:
John Kiel on 30 June 2019 20:22:46
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Last edited:
5 June 2023 14:56:43
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