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Paediatric Orthopaedic Pathways
Paediatric Orthopaedic Pathways

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 

  1. Treatment Pathway
  2. How are they classified?
  3. How common are they and how do they occur?
  4. What are likely findings on clinical exam?
  5. What X-rays should be ordered?
  6. What are some specific features found on X-ray?
  7. When is reduction (non-operative or operative) required?
  8. Do I need to refer to orthopaedics now? 
  9. What is the usual ED management for this fracture?
  10. What follow up is required?
  11. What advice should I give to parents?
  12. 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
<5 mm displacement

 

 

 

 

  • Analgesia
  • No reduction needed
  • Long-arm backslab with the elbow flexed to 90° and broad arm sling
  • Ibuprofen for post-discharge analgesia

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.

At 7-10 days post-injury with repeat radiographs on arrival

 

Medial epicondyle
5 mm to 15 mm displacement

 

Discuss with the nearest orthopaedic surgery service on call

  • Analgesia
  • Long-arm backslab to splint elbow in position of comfort
  • Keep NPO
  • Discuss management with nearest orthopaedic surgeon 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.

 

 

 

 

 

Discuss with the nearest orthopaedic surgery service on call

 

Medial epicondyle
>15 mm displacement  +/- elbow dislocation

 

 

Discuss with the nearest orthopaedic surgery service on call. Requires closed reduction +/- ORIF

  • Analgesia
  • Long-arm backslab to splint elbow in position of comfort
  • Keep NPO
  • Urgent referral to nearest orthopaedic surgeon on call for closed reduction with possible open reduction and internal fixation

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.

 

 

 

 

Discuss with the nearest orthopaedic surgery service on call

 

 

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

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:

    •  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:

    1. Displacement >15 mm
    2. Medial condyle fracture (i.e. intra-articular fracture)
    3. 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
<5 mm displacement

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
5 mm to 15 mm displacement

Discuss with the nearest orthopaedic surgery service on call  


Management (closed treatment versus operative treatment) is dependent on number of factors such as child's age and sporting activities. See indications for reduction

To be determined by the nearest orthopaedic on call service

Medial epicondyle
>15 mm displacement +/- elbow dislocation

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?

    • 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.

 

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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

Closed management
(non-operative)

 

Follow up with fracture clinic in 7-10 days with:

  1. AP and lateral elbow radiographs  
  2. Clinical exam and review of radiographs

At 3 weeks post-injury with:

  1.  Removal of backslab
  2. AP and lateral elbow radiographs
  3. Clinical review
  4. Commence gentle range of motion exercises

At 6 weeks with:

  1. AP and lateral elbow radiographs
  2. Clinical review

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

Operative management

 

At 2 weeks post-operative with:

  1. Removal of backslab
  2. AP and lateral elbow radiographs
  3. Clinical review and wound  check
  4. Commence gentle range of motion exercises

At 6 weeks with:

  1. AP and lateral elbow radiographs
  2. Clinical review

At 3 months for clinical review and consideration of screw removal

As above

 

 

2. What should I review at each appointment?

    • 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.
    • 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.


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

 

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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.

 

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Content developed by Dr. Jonathan Peck, Dr. Justin Chang and by Alexander Tchoukanov and approved by the SKPOP Committee on August 1st, 2019.