Proximal Humeral Epiphysiolysis

• Little League Shoulder
• Little Leaguer’s Shoulder
• Proximal Humeral Epiphysiolysis
• Osteochondrosis of proximal humeral epiphysis
• Stress fracture of the proximal humeral epiphyseal plate
• Rotation stress fracture

Pathophysiology

• General
  • Defined as a shearing or stress injury of the epiphyseal cartilage of the proximal humerus
  • Represents a Salter-Harris 1 Fracture

Causes

• Occurs as a result of excessive rotational, distraction forces that occur with repetitive overhead throwing
• 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

• Proximal Humeral Epiphysis
  • Four growth centers: head, shaft, greater tubercle, lesser tubercle
  • 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
  • Poor throwing mechanics
  • High pitch count
  • “Breaking” pitch
• Playing year-round sports
• Glenohumeral Internal Rotation Deficit (GIRD)

Differential Diagnosis

• Fractures
  • Proximal Humerus Fracture
  • Humeral Shaft Fracture
  • Clavicle Fracture
  • Scapula Fracture
  • First Rib Fracture (traumatic or atraumatic)
• Dislocations & Separations
  • Acromioclavicular Joint Separation
  • Glenohumeral Dislocation (Acute)
  • Sternoclavicular Joint Dislocation
  • Glenohumeral Instability (Chronic)
• Arthropathies
  • Glenohumeral Arthritis
  • Acromioclavicular Joint Arthritis
• Muscle & Tendon Injuries
  • Pectoralis Major Injuries
  • Pectoralis Minor Injuries
  • Proximal Biceps Tendon Injuries
  • Scapular Dyskinesis
• Rotator Cuff
  • Rotator Cuff Tear
  • Rotator Cuff Tendonitis
  • Calcific Tendinitis of the Rotator Cuff
  • Subcoracoid Impingement Syndrome
• Bursopathies
  • Subacromial Bursitis
  • Scapulothoracic Bursitis
• Ligament Injuries
  • Glenoid Labral Tears
• Neuropathies
  • Suprascapular Nerve Injury
  • Parsonage-Turner Syndrome
  • Quadrilateral Space Syndrome
  • Winged Scapula
• Other
  • Adhesive Capsulitis
  • Paget-Schroetter Syndrome
• Pediatrics
  • Coracoid Avulsion Fracture
  • Humeral Head Epiphysiolysis (Little League Shoulder)

Diagnosis

• 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
  • The 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

Radiographs

• Standard Radiographs Shoulder initially
• Findings
  • May be normal
  • May show widened physis
  • Less commonly: demineralization, sclerosis, cystic changes, and 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 the diagnosis
• Findings: physical edema

Ultrasound

• Can be used to help confirm the diagnosis
• Findings
  • Increased hypoechoic swelling not seen on the contralateral side

Classification

Neer and Horwitz’s classification

• Displacement^[7]
  • 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

Treatment

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 a Shoulder Sling for comfort
• Prevention
  • Proper pitching mechanics
  • Educate athletes, parents, coaches
  • Avoid single sport, year-round activity
  • Rigidly follow pitch count guidelines
  • Avoid “breaking” pitch
  • Improve core strength, cardiovascular fitness