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History: 13-year-old right hand dominant male presenting with 1-year concerns of bilateral elbow locking, popping, and pain. Right elbow tends to be affected more frequently than left. Patient states that at random, when he is trying to extend at the elbow joint, his elbows will "lock up". He will not be able to extend past this region and has significant pain when this occurs. He has to proceed back into elbow flexion and again try to "push through" into full extension. This will result in a loud pop followed by about 5-10 minutes of pain which slowly resolves. This happens typically once a day for about 4 days out of the week. He denies any mechanism of injury and specifically denies any previous elbow contact injuries. He is in 8th grade and participates in baseball, basketball, and tennis. Physical Examination: Constitutional- Well-developed well-nourished. MSK: Bilateral Elbow. Neuro- sensation intact in the distal UE bilat Vascular- 2+ pulses in upper/lower extremity. Inspection - no swelling, bruising, erythema or skin changes. Palpation: -Non-tender: medial/lateral epicondyle, radial head, olecranon, triceps. - Tender: Radio-capitellar Joint, Flexor-Pronator Complex, Extension-Supination Complex. Range of motion of the elbow -Normal: flexion, extension, pronation, supination. Strength- normal elbow flexion, elbow extension, wrist flexion, wrist extension, pronation/supination. Special Testing Test: Valgus- no pain, Varus- No pain, Moving Valgus- no pain, Tinel's test negative Differential Diagnosis: 1. Capitellar OCD 2. Panner disease 3. Loose bony fragment in the joint space 4. Repetitive elbow subluxation 5. Arteriovenous malformation Tests & Results: After obtaining history and completing the physical exam bilateral elbow x-rays were ordered. X-ray read from radiology showed No fracture or dislocation involving the bilateral elbows with clinical overread and physical exam correlation showing concerns for possible trochlear OCD lesions bilaterally. MRI was obtained showing mild so called fishtail deformities of the bilateral humeri. Final/Working Diagnosis: Hegemann's Disease (post-traumatic disturbance of the epiphysis of the humeral trochlea). Discussion: Hegemann's Disease is a rare diagnosis. It presents with elbow pain, locking sensation, decreased range of motion, and sometimes swelling. A discussion has begun on whether this diagnosis would more properly exists on the same playing field as the rare but more well-known, fishtail deformity. The etiology of both have been postulated to be secondary to disruption of the vulnerable vascular supply of the trochlea. It has been proposed that these two diagnoses be lumped together and more accurately termed post-traumatic disturbance of the epiphysis of the trochlea. Our patient providers another example of such a deformity without a clear inciting injury. It is unique in its bilateral nature. Outcome: This patient was instructed on activity modification (held from sport and instructed to avoid throwing and arm weight-bearing activities) and began formal PT. The rarity of this disease lends to the lack of a consensus treatment though some form of activity modification seems to be common. Return to Activity and Follow-Up: Patient has yet to return to full activity and is continuing physical therapy. In our patient it is possible that if vascular supply recovers before closure of the physeal plate, the injury will remodel into a normal trochlea but could also still ultimately develop a fishtail deformity.
Orthopedics | Pediatrics
Munro, Thomas and Harvey, Brian, "A rare cause of elbow pain with a controversial name" (2022). Posters. 261.
Presented at the American Medical Society for Sports Medicine (AMSSM) National Conference 2022; Austin, TX; April 10, 2022.