Working Diagnosis:
Tear of the left distal anterior band of the ulnar collateral ligament with laxity and associated medial epicondyle apophysitis.

Treatment:
Ultimately this patient had mild symptoms and was given options to continue nonoperative management vs operative management of the UCL injury. He opted for nonoperative management with a plan for a total of 4 weeks of rest for his left upper extremity. He was allowed to maintain cardio fitness through other activities, with a progression back to wrestling activity if he continued to have minimal symptoms.

Outcome:
He had significant improvement with 4 weeks of rest and minimal instability with valgus testing on exam. He progressed back to full wrestling participation quickly and competed in his entire season. He had no limitations secondary to elbow pain or instability during his season.

Author's Comments:
Growth hormone acts to stimulate linear growth in children by acting on the epiphyseal plates of long bones and through synthesis of Insulin-like growth factor 1. Growth hormone deficiency may lead to delayed growth to full stature, reduced peak bone mass, and increased rate of fractures. 1 Mechanisms of injury that typically cause muscular strains in adults, may cause serious injuries to growth centers in skeletally immature patients because the apophysis is weaker than the attached muscle-tendon unit.2 In a skeletally immature elbow, the most common site of avulsion injury is the medial epicondyle.2 Valgus overload can put significant strain on the medial epicondyle apophysis leading to possible widening or fragmentation.2 The ulnar collateral ligament is the primary stabilizer of the elbow that resists valgus stress. Chronic stress on the ulnar collateral ligament without adequate recovery time has been associated with an increased risk of injury to the ligament. When considering potential pathologies for an injured adult patient with growth hormone deficiency, it is important to remember that they may have delayed bone age and lower bone density compared to other age-matched adults leading to an expanded differential.1 During this patient's initial visit, an x-ray was obtained which demonstrated that his physis was not fused Case Photo #1 prompting consideration of apophyseal injuries. Subsequently, an MRI was ordered that revealed apophysitis without widening Case Photo #2 . Although his MRI showed a UCL tear and is a study of choice for identifying UCL tears, it cannot assess dynamic ligament laxity. Therefore, an ultrasound was ordered to evaluate for signs of instability to help guide surgical vs non-operative management, which showed abnormal laxity with valgus stress and average gapping of 2.5 mm Case Photo #3 , Case Photo #4 . For operative and nonoperative management, factors including severity of injury, patient's symptoms, and specific biomechanical factors of sport must all be considered. Current trends show increasing rates of UCL reconstruction, with most from baseball.3 This athlete does not participate in overhead throwing sports and was able to return to full play without surgical intervention.

Editor's Comments:
It is important to remember that the medial epicondyle is the last ossification center to fuse in the distal humerus. Fusion of the medial epicondyle is typically seen between the ages of 16-18. In this case, in addition to an ulnar collateral ligament injury that would be expected in a 20 year old patient, further evaluation of the apophysis via MRI is imperative given the patient's bone age.

References:
Wydra A, Czajka-Oraniec I, Wydra J, Zgliczyński W. The influence of growth hormone deficiency on bone health and metabolisms. Reumatologia. 2023;61(4):239-247. doi: 10.5114/reum/170244. PMID: 37745147
Choi C, Lee SJ, Choo HJ, Lee IS, Kim SK. Avulsion injuries: an update on radiologic findings. Yeungnam Univ J Med. 2021 Oct;38(4):289-307. doi: 10.12701/yujm.2021.01102. PMID: 34411477
Zaremski JL, McClelland J, Vincent HK, Horodyski M. Trends in Sports-Related Elbow Ulnar Collateral Ligament Injuries. Orthop J Sports Med. 2017 Oct 16;5(10). doi: 10.1177/2325967117731296. PMID: 29085844

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