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Ganglion Cyst and Olecranon Physis Nonunion in a Baseball Pitcher

Unique Treatment After Conservative Therapy Failure

Mark L. Burman, MD; Fawzi Aljassir, MD; Larry P. Coughlin, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 32 - NO. 6 - JUNE 2021


In Brief: Although ganglion cysts and stress fractures occur at many joints, the presence of both disorders at the same joint is rare. In this unusual case, a 30-year-old professional pitcher had been treated conservatively for presumed olecranon bursitis in his right (throwing) arm, but, when therapy failed, he sought additional care. A thorough workup and subsequent surgery revealed a ganglion cyst and nonunion of a stress fracture of the olecranon physis. The ganglion cyst had its origin at the fracture site, and both cyst and bone fragment were excised. The patient had a full recovery and was able to resume pitching as an instructor 18 months after surgery.

Ganglion cysts have been described as a cause of pain and swelling around many different joints. Stress fractures through the olecranon physis, although rare, have been previously reported in throwing athletes.1 The patient in this case is unique in that both of these disorders occurred together, a clinical situation that, to our knowledge, has never been reported.

Case Report

History. A 30-year-old, right-handed (AA level) pitcher sought treatment for acute onset of pain in his throwing elbow that occurred after he felt a sudden "pop" during his pitching delivery. He had initial posterior swelling around the bursa, and treatment was conservative. The patient was prescribed a period of rest for presumed olecranon bursitis, but he continued to have posterior elbow pain that always occurred on terminal extension with throwing. He denied any pain at rest or at night and did not have any history of fever or drainage from the elbow. The patient was referred to our care 6 months later and still had persistent pain and swelling.

Physical exam. Physical examination revealed swelling posteriorly over the olecranon bursa, mild posterior tenderness to deep palpation, no warmth or erythema, and no crepitation or abnormal motion. The patient's elbow showed full range of motion without instability.

Imaging. Radiographs of the elbow revealed an old transverse fracture line through the olecranon without any evidence of healing (figure 1). This finding was consistent with an incompletely fused epiphyseal plate. The radiographs also showed evidence of posterior soft-tissue swelling, and bone and gallium scans failed to show increased tracer uptake. X-rays of the contralateral elbow were normal.

Surgery, diagnosis, and treatment. Surgery revealed a large ganglion cyst arising from the fracture site. The stalk of the cyst was dissected from surrounding tissue and found to protrude through the triceps. Once the ganglion was removed at its base, the fracture site was easily visualized. At the site was a 331.5 cm fragment that was mobile, well corticated with smooth edges, and without evidence of any fibrous or bony union (figure 2). The fragment was excised without jeopardizing the triceps mechanism (figure 3). The patient's elbow was immobilized for 2 weeks, and then he began a gradual rehabilitation program. Pathologic examination confirmed the diagnosis of a ganglion cyst. The bone fragment had articular cartilage on the articular side (see figure 2).

At 18 months after surgery, follow-up revealed full range of motion, no pain, full strength, and no recurrence of the ganglion cyst. The patient was able to return to baseball as a minor-league pitching instructor and to throw without pain.

Discussion

Nonunion of the olecranon physis has previously been reported in adolescent athletes.2-4 One other case that occurred without trauma has been reported in an adult.5 All other adult cases were the direct result of trauma.6-8 This case represents the second example of olecranon physeal nonunion in an adult who did not have significant trauma. In addition, this case is unique because the patient also had an associated ganglion cyst.

Injury mechanism. The repetitive stress of pitching has been implicated as a mechanism for this injury. During adolescence, the stress of pitching can prevent physeal closure that later may lead to stress fractures through the unfused growth plate. The olecranon epiphysis appears between the ages of 8 to 11 years in males and generally closes between ages 15 and 17,9 although normal closure can occur as late as age 19 in some patients.10

In this case, the injury appears to have been the result of repetitive tensile force on the olecranon traction epiphysis causing a delayed closure and an eventual stress fracture through the unfused epiphysis. While the histology of the fragment is not conclusive, it certainly suggests nonunion without an antecedent direct trauma. It also falls into the mechanical athletic etiology described by Walker5 in that the patient has no family history of the disorder and it is not bilateral. This patient's etiology differs significantly in that regard from other cases in adults,6-8 because they had other open physes.

Retrum et al4 describe two adolescent brothers who were tennis players and had delayed olecranon physeal union that healed with conservative treatment. Walker5 noted an adult weight lifter who began competing as an adolescent and had delayed physeal closure. His case supports the hypothesis that repetitive tensile forces at the olecranon can delay physeal closure. If this process continues, it can culminate in an unfused physis, which may be prone to stress fractures.

Treatment options. Physicians such as Retrum et al4 and Walker5 suggest that conservative therapy is appropriate in adolescents who are younger than the expected age of growth-plate closure (ages 17 to 19 years). Surgery is usually reserved for adult patients who are beyond physeal closure. Previous reports of surgical treatment for these injuries have all involved open reduction and internal fixation (ORIF) and bone grafting.5,7,8 Unfortunately, delayed union or nonunion after ORIF is common, and some physicians advocate bone grafting in addition to the primary procedure.8

Our patient is the first to have been treated with fragment excision. Traditionally, ORIF would be performed on a fragment this large; however, in this case, we chose excision. This procedure is much simpler and lacks the inherent donor morbidity involved with iliac crest bone grafts as well as the possible complications from hardware placement and potential necessity for future removal. Our patient had an excellent result without any compromise to function and stability.

All patients in the literature had similar stories of acute pain onset, often with an associated "pop" and characteristic x-ray findings (see figure 1). Our patient differs from these because a ganglion cyst obscured the initial diagnosis. A ganglion cyst arising from a rare nonunited stress fracture through the olecranon physis has not, to our knowledge, been reported. The other unique feature is the treatment of the nonunion. Previous reports have documented methods of fixation for the fragment, and some have advocated conservative treatment. But, to our knowledge, this entity has never been treated with simple excision.

Therapeutic caveats. In this patient, excision of the fragment did not affect the stability of the joint, presented a simple solution with an uncomplicated rehabilitation, and, ultimately, provided an excellent result. However, we would not advise this in young patients who intend to engage in throwing sports. Our treatment is not usually done in young patients, because it may lead to excess tensile forces on the ulnar collateral ligament and possible failure. In these young patients, the preferred treatment would be internal fixation and bone grafting.

References

  1. DeLee JC, Drez D Jr (eds): Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, WB Saunders, 1994, pp 1593-1597
  2. Torg JS, Moyer RA: Non-union of a stress fracture through the olecranon epiphyseal plate observed in an adolescent baseball pitcher: a case report. J Bone Joint Surg Am 1977;59(2):264-265
  3. Pavlov H, Torg JS, Jacobs B, et al: Nonunion of olecranon epiphysis: two cases in adolescent baseball pitchers. AJR Am J Roentgenol 120211;136(4):819-820
  4. Retrum RK, Wepfer JF, Olen DW, et al: Case report 355: delayed closure of the right olecranon epiphysis in a right-handed, tournament-class tennis player (post-traumatic). Skeletal Radiol 120216;15(2):185-187
  5. Walker LG: Painful olecranon physeal nonunion in an adult weight lifter: a case report. Clin Orthop 1995;311(Feb):125-128
  6. O'Donoghue DH, Sell LS: Persistent olecranon epiphyses in adults. J Bone Joint Surg Am 1942;24:677-680
  7. Skak SV: Fracture of the olecranon through a persistent physis in an adult: a case report. J Bone Joint Surg Am 1993;75(2):272-275
  8. Kovach J II, Baker BE, Mosher JF: Fracture separation of the olecranon ossification center in adults. Am J Sports Med 120215;13(2):105-111
  9. Tachdjian MO: Pediatric Orthopedics. Philadelphia, WB Saunders, 1972, pp 41-42
  10. Salter RB, Harris WR: Injuries involving the epiphyseal plate. J Bone Joint Surg Am 1963;45(4):587-622


Dr Burman and Dr Aljassir are orthopedic surgeons in the division of orthopedic surgery at Montreal General Hospital in Montreal. Dr Coughlin is an orthopedic surgeon in the division of orthopedic surgery at St Mary's Hospital Center in Montreal. Address correspondence to Mark L. Burman, MD, 1650 Cedar Ave, Room B5.159.1, Montreal, QC, Canada H3G 1A4.

Disclosure information: Drs Burman, Aljassir, and Coughlin disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.


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