Medial epicondyle fracture
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Medial epicondyle fractures represent almost all epicondyle fractures and occur when there is avulsion of the medial epicondyle. They are typically seen in children and can be challenging to identify. Failure to diagnose these injuries can lead to significant long term disability.
Medial epicondylar avulsion fractures are the most common avulsion injury of the elbow and are typically seen in children and adolescents 4. Medial epicondyle fractures are often associated with elbow dislocation and make up approximately 12-20% of all pediatric elbow fractures 5,6.
A number of mechanisms have been implicated in medial epicondylar avulsion fractures 2,4:
- posterior elbow dislocation transmitting force to the medial epicondyle via the ulnar collateral ligament (most common; accounts for two-thirds of cases of medial epicondylar fractures 3)
- fall on an outstretched hand with the elbow in full extension, resulting in sudden traction on the flexor-pronator muscle group of the forearm
- direct blow (rare)
- chronic injury can also occur both in children (little league elbow) and adults (golfer's elbow) - discussed separately
In young patients, knowledge of the sequence of ossification of the elbow (remembered using the mnemonic (CRITOE) is essential as an avulsed and displaced apophysis can mimic another center.
Overall all centers are ossified by approximately 12 years of age, appearing in a predictable order: capitellum, radial head, medial (internal) epicondyle, trochlear, olecranon, and lastly lateral (external) epicondyle). Any missing ossification center or centers appearing in the wrong sequence should be viewed with a high suspicion of injury.
A particularly devastating miss is that of an avulsed fragment displaced into the joint, mimicking the center of ossification of the trochlear 4.
Plain films are usually sufficient for the assessment of medial epicondylar avulsion fractures. If in doubt, comparison with the contralateral side can be helpful to diagnose a slight injury. In the setting of more complex injury, cross-sectional imaging may be needed.
Features of a medial epicondylar avulsion injury include 1-3:
- soft tissue swelling
- this may be the only sign of an undisplaced injury
- this may be the only sign in children younger than ~7 years, in whom the medial apophysis is not ossified
- widening of the growth plate (comparison to the contralateral side may be useful)
- obvious displacement of the apophysis
- fracture through the adjacent humeral metaphysis
In addition to stating that a medial epicondylar fracture is present, a number of features should be sought and commented upon:
- degree of displacement
- location of the displaced fragment
- presence of a fracture of the adjacent humeral metaphysis
- presence of comminution of the apophysis
Treatment and prognosis
Treatment depends on both the particulars of the fracture and the patient.
An undisplaced fracture, particularly in the non-dominant arm of a non-athlete can be treated conservatively (three weeks in an upper arm splint) with good results 2,3.
Minimally displaced fractures can be treated with either cast immobilization or an upper arm splint, with a 50% of resulting in a pseudoarthrosis 3.
Displaced fractures or those occurring in the dominant arm, especially in athletes, ulnar nerve dysfunction or elbow instability are relative indications for surgery 5. These typically require operative management, usually with open reduction and internal fixation with a cannulated screw, which results in rigid fixation permitting early motion 2. Bony union is achieved in 90% of cases 3. Union rates are nine times higher with operative management compared to non-operative management 6.
Absolute indication for operative fixation includes irreducible incarcerated fracture fragments and open fractures 5.
Comminuted fractures can also be treated by suture fixation 2.
Fortunately, as these injuries involve an apophysis rather than an epiphysis, no growth arrest of the arm occurs, however elbow instability and even recurrent dislocations can result from suboptimal healing 2,3.
- 1. El-khoury GY, Daniel WW, Kathol MH. Acute and chronic avulsive injuries. Radiol. Clin. North Am. 1997;35 (3): 747-66. - Pubmed citation
- 2. Flynn JM, Wiesel SW. Operative Techniques in Pediatric Orthopaedics. (2010) ISBN:1451102631. Read it at Google Books - Find it at Amazon
- 3. Laer LV. Pediatric Fractures and Dislocations. TIS. (2004) ISBN:1588906809. Read it at Google Books - Find it at Amazon
- 4. Stevens MA, El-khoury GY, Kathol MH et-al. Imaging features of avulsion injuries. Radiographics. 19 (3): 655-72. Radiographics (citation) - Pubmed citation
- 5. Stepanovich Matthew, Bastrom Tracey P., Munch John III, Roocroft Joanna H., Edmonds Eric W., Pennock Andrew T.. Does operative fixation affect outcomes of displaced medial epicondyle fractures?. (2016) Journal of Children's Orthopaedics. doi:10.1007/s11832-016-0757-1 Epub 2016 Jul 8. PMID: 27393557; PMCID: PMC5033776.
- 6. Kamath Atul F., Baldwin Keith, Horneff John, Hosalkar Harish S.. Operative versus non-operative management of pediatric medial epicondyle fractures: a systematic review. (2009) Journal of Children's Orthopaedics. doi:10.1007/s11832-009-0192-7 Epub 2009 Aug 15. PMID: 19685254; PMCID: PMC2758175.