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Osteochondritis dissecans lesions of the elbow occur in 3.4% of adolescent baseball players, and the lesions will inevitably progress without intervention. Fifty percentage of patients who initially presented with advanced lesions had decreased range of motion and pain with activities of daily living. Patients treated early have high return to sports rates. After radiographs are obtained, patients suspected of having an osteochondritis dissecans lesion in the elbow should undergo a magnetic resonance arthrogram to determine the integrity of the cartilage cap. Central lesions with an intact cartilage cap can often be successfully treated with bracing and a course of formal therapy. Patients who fail conservative treatment with a violated cartilage cap can undergo microfracture or fragment fixation. Patients with lesions that extend to the lateral wall require an autograft transfer to restore the structural integrity of the capitellum and prevent instability.

The overhead throwing motion is a complex movement which requires soft tissue flexibility and neuromuscular control to generate force from the legs and trunk and propel the ball forward. Repetitive motions and high levels of torque on the shoulder can compromise soft tissue balance and contribute to the high rate of shoulder injuries commonly seen in throwers. A thorough physical examination including inspection of the entire kinetic chain and total arc of shoulder motion is important in making an accurate diagnosis. Nonoperative treatment with a formal progressive rehabilitation program is typically effective in treating the thrower's shoulder. Occasionally, patients may require operative intervention for posterior inferior capsular release for refractory capsular contracture, and selective treatment of superior labrum tears or rotator cuff tears when nonoperative management has been exhausted. A decrease in a thrower's total arc of motion may be more detrimental than a loss of relative internal rotation.

Injuries to the medial ulnar collateral ligament (MUCL can be devastating in overhead and throwing athletes. Prior to 1986 injury to this ligament was considered to be career ending. In that year, Dr. Frank Jobe reported on his initial experiences with reconstruction of the MUCL. His first case was pitcher Tommy John, who underwent what at that point was considered an experimental surgery to reconstruct the ligament using the palmaris longus tendon. The success of the classic “Tommy John” surgery in professional athletes has led most of these injuries to be managed by the same reconstructive technique. However, the injuries in young athletes do not appear to be the same as those sustained by professionals; one of the issues that led Dr. Jobe to utilize a reconstruction rather than a repair was the “wear and tear” of repetitive micro-trauma rather than a discrete area of injury. Fortunately in young, active athletes, the initial injury often is isolated to a single area, increasing the chance of both nonoperative and direct repair each being successful in allowing a return to sport. Unfortunately, there has been little focus on alternative treatment options in these young, nonprofessional athletes who continue to have instability despite conservative treatment and who wish to continue in sports. Many of these young athletes may have MUCL injuries isolated to one area in the proximal or distal end of the ligament that would seemingly allow a repair rather than reconstruction. Rather than extrapolate the data from professional athletes that the classic “Tommy John” operation is necessary for all of these young athletes to return to sports, we developed a protocol of repair in these players in which the ligament had a single area of injury on either the proximal end, distal end, or both in an attempt to minimize morbidity and loss of time and allow a more rapid return to sports. The indications for repair include a repairable injury (i.e., an injury to the ligament confined to the proximal or distal end of the ligament with or without a small fragment of bone) and a patient who desires to continue his throwing activity. In our initial study, 93 % (56 of 60) of these young (age range 13–23, avg. 16) athletes in the study returned to sports within 6 months (range 4–11.7 months) postoperatively at the same or higher level of competition.

The anterior bundle of the medial ulnar collateral ligament (MUCL) is the prime valgus stabilizer of the elbow. Athletes who throw overhead, such as baseball players, and javelin throwers, most commonly fall victim to this type of injury as the MUCL is subject to significant loads during the late cocking phase/early acceleration phase of the throwing motion [9,10,11]. The MUCL reconstruction procedure, or one of its variants pioneered by Jobe, has routinely been used to stabilize the medial elbow after MUCL injury. Surgery, however, may not be necessary in all MUCL injuries. This is especially true in younger patients who may present with a more acute form of the injury to the ligament in isolated anatomical areas, and have injuries more along the lines of a sprain, which is an interstitial tear without structural incongruity, or a partial tear. Rettig et al [23] provided the first large series of patients treated with nonoperative management for MUCL injuries, thus demonstrating that MUCL injuries respond to conservative management. A structured return-to-throwing protocol, external stabilization with bracing, physical therapy, and biologic adjuncts such as platelet-rich plasma are potential solutions that may permit athletes to return their preinjury level of play while simultaneously averting the morbidity and longer return-to-play associated with operative treatment.

Arthroscopic techniques continue to evolve over time. An area of increasing interest involves the management of acute fractures and ligamentous injuries of the elbow. The complicated soft tissue and complex joint arrangement of the elbow make it an intriguing joint for acute arthroscopic management. We present techniques for the management of radial head fractures, coronoid fractures, and lateral ligament injuries.

Multidirectional instability (MDI) was first described by Neer and Foster in 1980. Although there has been much confusion over the years with a blending of classifications, the inherent concept of symptomatic inferior instability with associated anterior and posterior instability remains the hallmark of the MDI shoulder. The MDI shoulder may be thought of as one of compensation, where the balance of the scapula and rotator cuff maintain the humeral head in the glenoid. Symptoms are seen when this balance is lost. The anatomical characteristic of the MDI shoulder is increased capsular volume with widening of the critical rotator interval structures (superior glenohumeral ligament and coracohumeral ligament) along with dysfunction of the entire inferior glenohumeral ligament complex. Management centers on nonoperative treatment, with pain control and scapular rebalancing exercises being the key to successful nonoperative management. Surgery is only indicated by a failure of nonoperative treatment and is focused on closing the rotator interval and decreasing capsular volume by shifting both the anterior and posterior capsule superiorly.

Posterolateral rotatory instability has become a more commonly diagnosed entity since its initial description by O’Driscoll in 1991. Examination of the elbow in the prone position and the arthroscopic drive through sign facilitates the diagnosis. Ligament plication with or without repair to the humerus or graft substitutions provides satisfactory results in a majority of cases.

Osteochondritis dissecans is a localized condition involving the articular surface, resulting in the separation of a segment of articular cartilage and subchondral bone. The most common site of osteochondritis dissecans of the elbow is the capitellum. Lesions have been reported in the trochlea, radial head, as well as the olecranon and olecranon fossa. Osteochondritis dissecans generally occurs in athletes ages 11 to 21 years who report a history of overuse. The osteonecrotic lesion involves only a segment of capitellum, located primarily at a central or anterolateral position. Appropriate treatment of this disorder remains controversial. Often treated with benign neglect, this condition is a potentially sport-ending injury for an athlete, with long-term sequelae of degenerative arthritis. The surgical option that we present and have studied is fragment excision with debridement of the necrotic lesion.

Advances in equipment and surgical techniques in the past several years have made elbow arthroscopy aneffective and safe alternative in the management of a variety of elbow disorders. The initial indication for the excision of loose bodies remains a common indication for arthroscopy of the elbow. A thorough knowledge of neurovascular anatomy in the elbow is required to safely perform this procedure. Proper portal placement minimizes the risks to the neurovascular structures of the elbow. Indications for arthroscopic surgery include loose bodies, arthritis, osteochondritis dissecans, lateral epicondylitis, instability, and fractures. This article presents the indications and techniques of the management of loose body removal via the arthroscope, including technical tips to avoid complications and to facilitate the surgical procedure with minimal risks.

Contractures of the elbow may be successfully managed by arthroscopic techniques. Complete anterior capsularrelease, olecranon fossa fenestration, triceps elevation, medial and lateral gutter debridement and removal of excess bone can restore near normal motion in a majority of patients. Fifty-three patients managed by this technique improved their range of motion from an arc of 46° to 96° to an arc of 5° to 138°. One patient sustained an injury to the posterior interosseous nerve. The inferior aspect of the anterolateral capsule should be completely avoided to prevent this complication. Arthroscopic release, although technically demanding, provides satisfactory results in a majority of patients.

The arthroscope is a useful tool in the evaluation and management of some traumatic elbow injuries and instabilities. Certain elbow fractures and articular injuries are amenable to arthroscopic diagnosis and treatment. Some radial head fractures can be accurately assessed and reduced, and fixation achieved using arthroscopically assisted techniques. Other elbow fractures occasionally can also be treated arthroscopically. The arthroscope also serves an important role not only in the diagnosis and management of elbow instability but also in the treatment of those intra-articular changes that occur as a result of chronic instability. Removal of loose bodies and osteophytes can be effectively accomplished arthroscopically.

The etiology of posterior shoulder instability is multifactorial. Similarly, the surgical treatment of posterior shoulder instability requires more than one management technique. During the past 7 years we have used an anatomic specific approach to posterior shoulder instability, relying on physical examination and diagnostic arthroscopy to determine the correct repair technique. This study reports our results with 61 consecutive patients with refractory posterior shoulder instability requiring surgical correction. In each instance, the specific pathologic entity causing instability was corrected in an anatomic specific approach to the disorder. All patients were re-evaluated 1 to 6 years postoperatively (mean, 34 months). Fifty-five of 61 patients maintained stable shoulders, indicating a 90% success rate with this approach to posterior instability. We would recommend this approach in the management of posterior shoulder instability refractory to rehabilitative treatment.