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Humeral Head Epiphysiolysis

From WikiSM

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

  • Initially described by Dotter in 1953[1]
  • Described by Adams in 1966 as Osteochondrosis[2]

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

Parasagittal T2-weighted fat saturation image of the right shoulder shows an anterior widening of the physis with adjacent periosteal edema and a high-signal marrow edema in the adjacent periphyseal region[5]
Representative images of the humeral stages. Stage 1 demonstrates an incompletely ossified lateral epiphysis leaving a triangular area of radiolucency on the lateral aspect of the epiphysis. Stage 2 demonstrates increased ossification of the lateral epiphysis leaving a crescent shaped area of radiolucency on the lateral side of the epiphysis. These shapes are highlighted below the annotations with representative images shown both unmodified and with the shapes superimposed. Note that in stages 1 and 2, the black line parallel to the lateral metaphysis does not touch the epiphysis. Stages 3 through 5 all demonstrate colinearity between the lateral margin of the epiphysis and the metaphysis. In Stage 3, the lateral half of the physis is open without obvious fusion. In stage 4, the lateral half of the physis thins and begins partial fusion. Finally, by stage 5 the lateral half of the physis demonstrates essentially complete fusion. The same annotations used on the schematic are superimposed upon the radiographic examples for ease of comparison.[6]

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[7]
    • 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[8]
  • 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[9]
    • Poor throwing mechanics
    • High pitch count
    • "Breaking" pitch
  • Playing year round sports
  • Glenohumeral Internal Rotation Deficit (GIRD)

Differential Diagnosis

Differential Diagnosis Shoulder Pain

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

Evaluation

PA shoulder radiograph of a patient with little leaguers shoulder. The red arrow shows a widened proximal humerus physis, yellow arrow shows subchondral sclerosis[10]
Sagittal T2-weighted fat-suppressed image demonstrating periphyseal edema[11]

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[12]
    • 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

External

References

  1. ↑ 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.
  2. ↑ Adams, JE. Little league shoulder: osteochondrosis of the proximal humeral epiphysis in boy baseball pitchers. California Medicine. 1966 Jul; 105(1):22-5.
  3. ↑ 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
  4. ↑ 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.
  5. ↑ Popkin, Charles A., Alejandro Posada, and Paul D. Clifford. "Little Leaguer's shoulder." Clinical imaging 30.5 (2006): 365-367.
  6. ↑ Li, Don T., et al. "Humeral head ossification predicts peak height velocity timing and percentage of growth remaining in children." Journal of Pediatric Orthopaedics 38.9 (2018): e546-e550.
  7. ↑ 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.
  8. ↑ www.wheelessonline.com/ortho/anatomy_of_proximal_humeral_physis. Accessed March 7, 2010.
  9. ↑ 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.
  10. ↑ Case courtesy of Samir Benoudina, Radiopaedia.org, rID: 79413
  11. ↑ Pennock, Andrew T., et al. "Shoulder MRI abnormalities in asymptomatic little league baseball players." Orthopaedic Journal of Sports Medicine 6.2 (2018): 2325967118756825.
  12. ↑ 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
Authors:
Last edited:
3 May 2025 17:01:49
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