Lab Studies:
No lab studies were obtained.
Other Studies:
X-ray Elbow: The medial humeral epicondyle physis was not fused Case Photo #1 . There was a small well-corticated ossification adjacent to the ulna.
MRI Elbow: There was a complete tear of the distal anterior band ulnar collateral ligament. There were findings compatible with medial humeral epicondyle apophysitis Case Photo #2 . There was a chronic small avulsion fracture of the sublime tubercle. There were mild edematous changes about the ulnar nerve within the cubital tunnel.
Ultrasound Elbow: Tear of the anterior band of the left ulnar collateral ligament with abnormal laxity on valgus stress. The joint space gaps an average of 2.5 mm with valgus stress. A representative portion of the dynamic ultrasound here showed an abnormal gapping of 2.76 mm between the trochlea and coronoid process when comparing the neutral position Case Photo #3 to the valgus stress position Case Photo #4 . There was no gapping on the contralateral side.
Consultations:
Orthopedic Surgery was consulted for consideration of operative evaluation of the UCL tear. During the evaluation he had minimal pain and instability and was deemed a candidate for UCL reconstruction or nonoperative management.
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