Medial epicondyle fractures
ED Management | Outpatient Fracture Clinic Management | Operative Management
ED Management
The following information is for use by medical practitioners and trainees in the Emergency Department
- Treatment Pathway
- How are they classified?
- How common are they and how do they occur?
- What are likely findings on clinical exam?
- What X-rays should be ordered?
- What are some specific features found on X-ray?
- When is reduction (non-operative or operative) required?
- Do I need to refer to orthopaedics now?
- What is the usual ED management for this fracture?
- What follow up is required?
- What advice should I give to parents?
- What are the potential complications with this injury?
1. Treatment Pathway
Fifty percent of medial epicondyle fractures are associated with an elbow dislocation.
It is important to distinguish a medial epicondyle fracture (common) from a medial condyle fracture (very rare). Medial condyle fractures are intraarticular, extending into the elbow joint and require urgent open reduction and internal fixation (ORIF).
|
Fracture Type |
ED management |
Follow-up |
|
Medial epicondyle
|
Immobilization in an above-elbow backslab in 90 degrees elbow flexion with sling for 3 weeks. The backslab and sling should be worn under clothing (e.g. loose fitting shirt) and not through sleeve. TIP: Avoid putting on a short, flimsy backslab. The backslab should extend as high above the elbow as possible (i.e. close to the axilla) and down to the metacarpophalangeal joints (MCP) joints.
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At 7-10 days post-injury with repeat radiographs on arrival
|
|
Medial epicondyle
|
Discuss with the nearest orthopaedic surgery service on call
Management (non-operative vs. operative treatment) is dependent on a number of factors, including child's age and sporting activities. See indications for reduction.
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Discuss with the nearest orthopaedic surgery service on call
|
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Medial epicondyle
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Discuss with the nearest orthopaedic surgery service on call. Requires closed reduction +/- ORIF
If closed reduction for an elbow dislocation is performed, always order post-reduction elbow radiographs to check that the medial epicondyle fracture is not trapped in the joint. If there is any doubt, urgent ORIF should be performed.
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Discuss with the nearest orthopaedic surgery service on call
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2. How are they classified?
The medial epicondyle is a secondary growth centre at the elbow, which first appears around age 6 and fuses to the shaft of the humerus at about age 14-17 years. A medial epicondyle fracture is an avulsion injury of the attachment of the common flexors of the forearm. The injury is usually extra-articular but can be sometimes associated with an elbow dislocation. These fractures can be classified based amount of displacement and whether the medial epicondyle is incarcerated within the joint.
3. How common are they and how do they occur?
What specific information from the patient history should be documented?
Document the date and time of injury
Document the time of the last oral intake (all patients should be kept fasting until a decision has been made regarding the need and timing of orthopaedic intervention)
4. What are likely findings on clinical exam?
A child presenting with a medial epicondyle or medial condyle fracture of humerus presents with tenderness and swelling at the medial aspect of the elbow. There may be a dislocation of the elbow. An ulnar nerve palsy may also be present.
5. What X-rays should be ordered?
Anteroposterior (AP) and lateral x-rays of the elbow should be ordered. If there is clinical suspicion of injury in the forearm or wrist then separate films of these areas should be ordered.
It is very important to identify any injuries in the forearm as this has major implications with regards to swelling.
6. What are some specific features found on X-ray?
Medial condyle fracture
Although rare, it is important to distinguish a medial epicondyle fracture from a medial condyle fracture. Medial condyle fractures are intra-articular (extends into the joint) fractures. All medial condyle fractures require a review with the nearest orthopaedic on call service.
Undisplaced or minimally displaced fractures (<5 mm)
Figure 1: AP and lateral x-ray of a minimally displaced (< 5mm) medial epicondyle fracture in a seven year old girl. Undisplaced or minimally displaced fractures may be difficult to see on x-ray. Soft tissue swelling may be the only finding. Later an injury can be identified by the formation of fracture callus, periosteal reaction along the medial border of the humerus.
Displaced fractures (>5 mm)
A
B
Figure 2: A) Thirteen year old gymnast with medial epicondyle fracture. The medial epicondyle is separated >5 mm (red arrow). This is evident on the AP view. It is more difficult to see on the lateral view due to the splint. B) Due to the child's age and type of sporting activity, management was open reduction and internal fixation.
Medial epicondyle fracture with elbow dislocation
Figure 3: Nine year old with elbow dislocation and fracture of the medial epicondyle (white arrow). Fifty percent of medial epicondyle fractures are associated with an elbow dislocation, which is easily identified on x-ray.
Medial epicondyle trapped in elbow joint
An elbow dislocation requires urgent closed reduction. Always do repeat x-rays to check that the medial epicondyle is not incarcerated in the joint. If there is any doubt that the medial epicondyle is trapped in the joint, an urgent open reduction and internal fixation is needed.
Figure 4: With an elbow dislocation, the medial epicondyle can be incarcerated in the joint (white arrow) following reduction. This can be difficult to identify on x-ray. It is important to check that the medial epicondyle is present in its anatomical position. On the AP view, the medial epicondyle is missing (red arrow). On the lateral view, the fragment appears as an additional bony opacity interposed between trochlea and olecranon. Note also that the opposing joint surfaces of the olecranon and trochlea are not congruent.
7. When is reduction (non-operative or operative) required?
There is little consensus in the literature as to the amount of fracture displacement that warrants surgical intervention.
For medial epicondyle fractures that are displaced 5 mm to 15 mm, operative management is dependent on a number of factors such as the child's age and involvement in sporting activities (Table 1).
Table 1: Relative indications for closed treatment versus operative treatment in medial epicondyle fractures displaced 5 mm to 15 mm.
|
|
Closed treatment |
Operative treatment |
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Age |
≤8 years |
≥ 8 years |
|
Dominance |
Non-dominant arm |
Dominant arm |
|
Sports |
Nil/little sports |
Athlete - throwing activities or gymnastics |
Absolute indication for urgent open reduction and internal fixation:
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- Elbow dislocation with incarceration of medial epicondyle
Relative indications for open reduction and internal fixation:
-
- Displacement >10 mm-15 mm
- Ulnar nerve palsy
- Dominant upper limb in throwing athlete or gymnast
Following reduction, <15 mm of displacement is considered acceptable.
8. Do I need to refer to orthopaedics now?
See above. Indications for prompt consultation include:
-
- Displacement >15 mm
- Medial condyle fracture (i.e. intra-articular fracture)
- Associated elbow dislocation especially with entrapment of the medial epicondyle within the joint
9. What is the usual ED management for this fracture?
Management is based on the amount of displacement.
|
Fracture type |
Type of reduction |
Immobilization method & duration |
|
Medial epicondyle |
No reduction required |
Above-elbow backslab at 90 degrees elbow flexion for 3 weeks with sling. The backslab and sling should be worn under clothing (e.g. loose fitting shirt) and not through the sleeve. |
|
Medial epicondyle |
Discuss with the nearest orthopaedic surgery service on call
|
To be determined by the nearest orthopaedic on call service |
|
Medial epicondyle |
Refer to the nearest orthopaedic on call service |
To be determined by the nearest orthopaedic on call service |
10. What follow-up is required?
For medial epicondyle fractures that are being treated non-operatively, follow-up should be arranged in the fracture clinic in 7-10 days after injury with repeat elbow radiographs on arrival.
For fractures that are managed operatively, follow-up should be arranged by the orthopaedic surgery service on call.
11. What advice should I give to parents?
The backslab and sling should be worn under clothing (e.g. loose fitting shirt) and not through the sleeve.
Generally, medial epicondyle fractures are a benign injury with very good long-term functional results.
Physiotherapy is not usually recommended to regain range of motion (ROM).
12. What are the potential complications associated with this injury?
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- Medial elbow instability
- Nonunion (usually not symptomatic or requiring any treatment)
- Ulnar nerve palsy
- Elbow joint stiffness
See Fracture Clinic/Outpatient Clinic for other potential complications.
Outpatient/Fracture Clinic Management
The following information is for use by medical practitioners and trainees in Fracture Clinics or Outpatient Clinics.
1. How often should these fractures be followed up in fracture clinics?
2. What should I review at each appointment?
3. What are the potential complications associated with this injury?
4. What are common reasons to deviate from the treatment pathway?
5. What are the indications for discharge?
1. How often should these fractures be followed up in fracture clinics?
Table 1: Recommended follow-up schedule for medial epicondyle fractures of the humerus.
|
Fracture type |
First appointment |
Subsequent review appointments |
Discharge advice to parents |
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Closed management
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Follow up with fracture clinic in 7-10 days with:
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At 3 weeks post-injury with:
At 6 weeks with:
At 3 months for clinical review |
Avoid high-risk activities for 12 weeks Physiotherapy is not usually recommended Return if any subsequent concern regarding deformity |
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Operative management
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At 2 weeks post-operative with:
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At 6 weeks with:
At 3 months for clinical review and consideration of screw removal |
As above
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2. What should I review at each appointment?
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- Peripheral neurological exam
- Review of radiographs to assess degree of displacement and acceptability of reduction.
- If displacement is >5-15 mm and has not had surgical reduction, consider whether operative intervention is required.
3. What are the potential complications associated with this injury?
- Nonunion
- Ulnar nerve palsy
- Elbow joint stiffness
4. What are common reasons to deviate from the treatment pathway?
-
- Increasing displacement and elbow instability.
- May require referral to pediatric orthopaedic surgeon or adult orthopaedic surgeon comfortable managing pediatric fractures.
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- Medial condyle fractures
- These fractures are rare and treatment and follow-up determined on a case by case basis. Long term follow-up is required due to the concern of AVN and growth disturbance.
- Medial condyle fractures
5. What are the indications for discharge?
-
- Pain free range of motion 30-130 degrees elbow flexion
- Non-tenderness at medial epicondyle
- Joint stable to medial and lateral stress
Operative Management
Until locally specific content is available, we encourage the use of the AO Foundation's Surgery Reference's 13-M/7M Avulsion Fracture of the Pediatric distal humerus clinical practice guidelines.
References
Gottschalk HP, Eisner E, Hosalkar HS. Medial epicondyle fractures in the pediatric population. J Am Acad Ortho Surg 2012; 20(4): 223-32.https://www.ncbi.nlm.nih.gov/pubmed/22474092
Beaty JH, Kasser JR. The elbow: Physeal fractures, apophyseal injuries of the distal humerus, avascular necrosis of the trochlea, and T-condylar fractures. In Rockwood and Wilkins' Fractures in Children, 7th Ed. Beaty JH, Kasser JR (Eds). Lippincott Williams & Wilkins, Philadelphia 2010. p.533-93.
Herring JA. Upper extremity injuries. In Tachdjian's Pediatric Orthopedics, 4th Ed. Saunders, Philadelphia 2008. p.2451-536.