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Avulsion of the Medial Epicondyle After Ulnar Collateral Ligament Reconstruction: Imaging of a Rare Throwing Injury

Martin L. Schwartz1, D. Dean Thornton1, Matthew C. Larrison1,2, E. Lyle Cain3, Don G. Aaron3,4, Kevin E. Wilk5 and James R. Andrews3

1 Radiology Associates of Birmingham, 2090 Columbiana Rd., Ste. 4400, Birmingham, AL 35216.
2 Present address: Department of Radiology, University of Alabama at Birmingham, Birmingham, AL.
3 Andrews Sports Medicine and Orthopaedic Center, Birmingham, AL.
4 Present address: Southeastern Orthopedic Center, Statesboro, GA.
5 Champion Sports Medicine, American Sports Medicine Institute, Birmingham, AL.


Figure 1
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  		Fig. 1A —21-year-old male right-handed college baseball pitcher with medial elbow pain (patient 7 in Table 1). Anteroposterior (AP) radiograph of right elbow shows expected immediate postoperative appearance of ulnar collateral ligament (UCL) reconstruction. Note vertically oriented humeral tunnel (arrow) at base of medial epicondyle.

 

Figure 2
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  		Fig. 1B —21-year-old male right-handed college baseball pitcher with medial elbow pain (patient 7 in Table 1). Twelve months after UCL reconstruction, patient again presented with severe medial elbow pain after throwing. AP radiograph shows avulsion fracture of medial epicondyle (arrow) up to humeral tunnel.

 

Figure 3
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  		Fig. 1C —21-year-old male right-handed college baseball pitcher with medial elbow pain (patient 7 in Table 1). Coronal T2-weighted fat-suppressed MR image shows moderately displaced medial epicondyle avulsion fracture (curved arrow) involving humeral tunnel. UCL graft (straight arrow) contains increased signal but remains intact and attached to avulsed fragment.

 

Figure 4
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  		Fig. 1D —21-year-old male right-handed college baseball pitcher with medial elbow pain (patient 7 in Table 1). Axial T2-weighted fat-suppressed MR image again shows fracture that extends to humeral tunnel (arrow).

 

Figure 5
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  		Fig. 1E —21-year-old male right-handed college baseball pitcher with medial elbow pain (patient 7 in Table 1). Intraoperative radiograph shows internal fixation of fracture (arrow) with cannulated screw and washer.

 

Figure 6
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  		Fig. 2A —22-year-old male baseball player with medial elbow pain 2.5 months after ulnar collateral ligament reconstruction (patient 1 in Table 1). Stress radiographs without (A) and with (B) 15 kPa of force depict avulsion fracture of medial epicondyle (arrow, A). Medial instability is shown by marked widening of medial joint space (double arrow, B) with valgus stress. Stress view also shows additional displacement of medial epicondyle fragment (curved arrow, B).

 

Figure 7
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  		Fig. 2B —22-year-old male baseball player with medial elbow pain 2.5 months after ulnar collateral ligament reconstruction (patient 1 in Table 1). Stress radiographs without (A) and with (B) 15 kPa of force depict avulsion fracture of medial epicondyle (arrow, A). Medial instability is shown by marked widening of medial joint space (double arrow, B) with valgus stress. Stress view also shows additional displacement of medial epicondyle fragment (curved arrow, B).

 

Figure 8
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  		Fig. 3A —29-year-old male baseball player with avulsion of medial epicondyle after ulnar collateral ligament (UCL) reconstruction (patient 2 in Table 1). Axial T1-weighted MR image shows avulsed fragment (circle) and its relationship to humeral tunnel (arrow). Fragment is displaced anteromedially.

 

Figure 9
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  		Fig. 3B —29-year-old male baseball player with avulsion of medial epicondyle after ulnar collateral ligament (UCL) reconstruction (patient 2 in Table 1). Coronal T1-weighted MR image. Despite its irregular, heterogeneous appearance, UCL graft (arrows) and its attachment to avulsed fragment (circle) were intact at surgery.

 

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