Medial epicondyle fracture of the humerus

Last updated April 07, 2023

A medial epicondyle fracture is an avulsion injury to the medial epicondyle of the humerus; the prominence of bone on the inside of the elbow. Medial epicondyle fractures account for 10% elbow fractures in children. 25% of injuries are associated with a dislocation of the elbow.

Medial epicondyle fractures are typically seen in children and usually occur as a result of a fall onto an out-stretched hand. This often happen from falls from a scooter, roller skates, or monkey bars, as well as from injuries sustained playing sports. The peak age of occurrence is 10–12 years old.^[1]

Symptoms include pain, swelling, bruising and a decreased ability to move or use the elbow. Initial pain may be managed with NSAIDs, opioids, and splinting. The management of pain in children typically follows guidelines, such as those from the Royal College of Emergency Medicine.^[2]

The diagnosis is confirmed with X-rays and occasionally with a CT scan.

The treatment of these injuries is controversial, and there are currently ongoing international randomised studies. The SCIENCE study is an ongoing study funded by the National Institute for Health Research (UK). A similar study is being planned in the US, funded by the National Institutes for Health (US). These studies both seek to determine if surgery to restore the natural position of the elbow is better than allowing the bone to heal in a cast without restoring the natural position. Children and families internationally are being encouraged to participate in these research studies to resolve the uncertainties.

Signs and symptoms

Symptoms include pain, swelling, bruising and a decreased ability to move or use the elbow. Blood in the soft tissues and knee joint (haemarthrosis) may lead to bruising and a doughy feel of the elbow joint.^{[ citation needed ]}

Cause

An injury resulting in an outward (valgus) stress on the elbow, such as falling on an outstretched hand causes an avulsion fracture of the medial epicondyle.^{[ citation needed ]}

The medial epicondyle is often the final growth plate (ossification center) to ossify in the elbow. Growth plates are particularly vulnerable to injury compared to bone. Children can have an open medial epicondyle growth plate until age 13–17 years old, thus making the medial epicondyle more susceptible to injury.^[3]

Medial epicondyle fractures are associated with a dislocation of the elbow in about 25% of cases.^{[ citation needed ]}

Diagnosis

In all injuries to the medial epicondyle, radiographs (x-rays) are imperative. Computed tomography scans are occasionally useful in evaluating the degree of fracture displacement or the involvement of the joint surface.^{[ citation needed ]}

Displaced Fracture

Studies generally use the x-ray appearance of the arm to determine how displaced a fracture is. The definition of ‘displaced fractures' are variable, with anything from 2mm to more than 15mm;^[4] however x-rays on which this assessment is made are known to be hugely misleading with fractures showing little displacement having >10mm displacement using CT scans.^[5]^[6] The practical approach is therefore to assume that any fracture that has any degree of displacement on x-rays is ‘displaced’.^{[ citation needed ]}

Treatment

There are several treatment options.

In children with a completely non-displaced fracture (i.e. the bone fragments have not moved), children will usually be treated in a cast without surgery.^[7]

In children where the fragment of medial epicondyle is trapped in the joint, or where the elbow is dislocated and can’t be readily reduced in the emergency department, then there is universal agreement that surgery is needed to realign the bones.^[8]

In children with a displaced fracture without a dislocation of the elbow (or an elbow dislocation that has been corrected), there is debate amongst surgeons about the best approach to treatment. Half of surgeons routinely recommend surgery, and half routinely recommend against surgery. The debate is whether to realign the displaced bones back into their natural position with surgery, and hold the fragments of bone with wires or screws, or whether to allow the fragments to heal in their current position by resting the elbow in a cast. Studies that have sought to draw together all of the scientific evidence, have failed to arrive at any firm conclusion, either in support of surgery or against surgery.^[1]^[9] Some point to good to results without surgery,^[9] whilst the others conclude that surgical fixation should be strongly considered to maximise the function in these children.^[1]

However, the current published research has serious methodological limitations, particularly with regard to inconsistent follow-up, no standardisation of treatment approaches, the infrequent use of patient reported outcomes, and selection bias amongst those selected to undergo operative fixation.^[10]

Ongoing research

The uncertainty associated with this injury has prompted surgeons make the treatment of medial epicondyle fractures the most important unanswered question in children’s musculoskeletal injuries.^[11]

Surgeons want to determine if surgery to restore the natural position of the elbow is better than allowing the bone to heal in the injured position in a cast. The SCIENCE study is currently underway across the UK, Australia and New Zealand with more than 70 hospitals participating. It is funded by the UK National Institute for Health Research. A similar study has also recently got underway in North America, called the COMET study, which is funded by the National Institute of Health.^[12] These studies fairly allocate children to either surgery or cast, through a process called randomisation. Surgeons around the globe are calling on parents and children with this injury to help them resolve their uncertainty, by allowing their children to be part of these studies. Whilst being part of research is difficult, families may wish to consider that patients involved in research typically have better outcomes than those not involved in research (called the trial-effect).^[13]

Related Research Articles

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$Bone fracture Physical damage to the continuity of a bone$

A bone fracture is a medical condition in which there is a partial or complete break in the continuity of any bone in the body. In more severe cases, the bone may be broken into several fragments, known as a comminuted fracture. A bone fracture may be the result of high force impact or stress, or a minimal trauma injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, osteopenia, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture.

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<span class="mw-page-title-main">Joint dislocation</span> Medical injury

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$Distal radius fracture Fracture of the radius bone near the wrist$

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$Clavicle fracture Medical condition$

A clavicle fracture, also known as a broken collarbone, is a bone fracture of the clavicle. Symptoms typically include pain at the site of the break and a decreased ability to move the affected arm. Complications can include a collection of air in the pleural space surrounding the lung (pneumothorax), injury to the nerves or blood vessels in the area, and an unpleasant appearance.

$Lisfranc injury Type of fracture/dislocation injury of the foot$

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Osteochondritis dissecans is a joint disorder primarily of the subchondral bone in which cracks form in the articular cartilage and the underlying subchondral bone. OCD usually causes pain during and after sports. In later stages of the disorder there will be swelling of the affected joint which catches and locks during movement. Physical examination in the early stages does only show pain as symptom, in later stages there could be an effusion, tenderness, and a crackling sound with joint movement.

$Calcaneal fracture Medical condition$

A calcaneal fracture is a break of the calcaneus. Symptoms may include pain, bruising, trouble walking, and deformity of the heel. It may be associated with breaks of the hip or back.

$Open fracture Medical condition$

An open fracture, also called a compound fracture, is a type of bone fracture that has an open wound in the skin near the fractured bone. The skin wound is usually caused by the bone breaking through the surface of the skin. Open fractures are emergencies and are often caused by high energy trauma such as road traffic accidents and are associated with a high degree of damage to the bone and nearby soft tissue. An open fracture can be life threatening or limb-threatening due to the risk of a deep infection and/or bleeding. Other complications including a risk of malunion of the bone or nonunion of the bone. The severity of open fractures can vary. For diagnosing and classifying open fractures, Gustilo-Anderson open fracture classification is the most commonly used method. It can also be used to guide treatment, and to predict clinical outcomes. Advanced trauma life support is the first line of action in dealing with open fractures and to rule out other life-threatening condition in cases of trauma. The person is also administered antibiotics for at least 24 hours to reduce the risk of an infection. Cephalosporins are generally the first line of antibiotics. Therapeutic irrigation, wound debridement, early wound closure and bone fixation are the main management of open fractures. All these actions aimed to reduce the risk of infections. The bone that is most commonly injured is the tibia and working-age young men are the group of people who are at highest risk of an open fracture. Older people with osteoporosis and soft-tissue problems are also at risk.

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<span class="mw-page-title-main">Patellar dislocation</span> Medical condition

A patellar dislocation is a knee injury in which the patella (kneecap) slips out of its normal position. Often the knee is partly bent, painful and swollen. The patella is also often felt and seen out of place. Complications may include a patella fracture or arthritis.

$Supracondylar humerus fracture Medical condition$

A supracondylar humerus fracture is a fracture of the distal humerus just above the elbow joint. The fracture is usually transverse or oblique and above the medial and lateral condyles and epicondyles. This fracture pattern is relatively rare in adults, but is the most common type of elbow fracture in children. In children, many of these fractures are non-displaced and can be treated with casting. Some are angulated or displaced and are best treated with surgery. In children, most of these fractures can be treated effectively with expectation for full recovery. Some of these injuries can be complicated by poor healing or by associated blood vessel or nerve injuries with serious complications.

$Ulna fracture Medical condition$

An ulna fracture is a break in the ulna bone, one of the two bones in the forearm. It is often associated with a fracture of the other forearm bone, the radius.

$Olecranon fracture Medical condition$

Olecranon fracture is a fracture of the bony portion of the elbow. The injury is fairly common and often occurs following a fall or direct trauma to the elbow. The olecranon is the proximal extremity of the ulna which is articulated with the humerus bone and constitutes a part of the elbow articulation. Its location makes it vulnerable to direct trauma.

The following outline is provided as an overview of and topical guide to trauma and orthopaedics:

Osborne's ligament, also Osborne's band, Osborne's fascia, Osborne's arcade, arcuate ligament of Osborne, or the cubital tunnel retinaculum, refers to either the connective tissue which spans the humeral and ulnar heads of the flexor carpi ulnaris (FCU) or another distinct tissue located between the olecranon process of the ulna and the medial epicondyle of the humerus. It is named after Geoffrey Vaughan Osborne, a British orthopedic surgeon, who described the eponymous tissue in 1957.

References

1 2 3 Kamath, Atul F.; Baldwin, Keith; Horneff, John; Hosalkar, Harish S. (2009). "Operative versus non-operative management of pediatric medial epicondyle fractures: a systematic review". Journal of Children's Orthopaedics. 3 (5): 345–357. doi:10.1007/s11832-009-0192-7. ISSN 1863-2521. PMC 2758175 . PMID 19685254.
↑ "Archived copy" (PDF). Archived from the original (PDF) on 2021-04-13. Retrieved 2021-03-06.{{cite web}}: CS1 maint: archived copy as title (link)
↑ "Errata". Acta Ortopédica Brasileira. 14 (5): 282. 2006. doi: 10.1590/s1413-78522006000500012 . ISSN 1413-7852.
↑ Hines, Robert F.; Herndon, William A.; Evans, J. Patrick (1987). "Operative Treatment of Medial Epicondyle Fractures in Children". Clinical Orthopaedics and Related Research. 223 (223): 170–174. doi:10.1097/00003086-198710000-00019. ISSN 0009-921X. PMID 3652571.
↑ Souder, Christopher D.; Farnsworth, Christine L.; McNeil, Natalie P.; Bomar, James D.; Edmonds, Eric W. (2015). "The Distal Humerus Axial View: Assessment of Displacement in Medial Epicondyle Fractures". Journal of Pediatric Orthopaedics. 35 (5): 449–454. doi:10.1097/BPO.0000000000000306. ISSN 0271-6798. PMID 25171678. S2CID 23104831.
↑ Edmonds, Eric W (2010). "How Displaced Are "Nondisplaced" Fractures of the Medial Humeral Epicondyle in Children? Results of a Three-Dimensional Computed Tomography Analysis". Journal of Bone and Joint Surgery. 92 (17): 2785–2791. doi:10.2106/JBJS.I.01637. ISSN 0021-9355. PMID 21123608.
↑ Axibal, Derek Paul; Carry, Patrick; Skelton, Anne; Mayer, Stephanie Watson (2018-10-01). "No Difference in Return to Sport and Other Outcomes Between Operative and Nonoperative Treatment of Medial Epicondyle Fractures in Pediatric Upper-Extremity Athletes". Clinical Journal of Sport Medicine (6): e214–e218. doi:10.1097/jsm.0000000000000666. ISSN 1050-642X. PMC 6443487 . PMID 30277893.
↑ "Clinical Practice Guidelines : Medial epicondyle fracture of the humerus - Emergency Department". www.rch.org.au. Retrieved 2020-11-29.
1 2 Knapik, Derrick M.; Fausett, Cameron L.; Gilmore, Allison; Liu, Raymond W. (2017). "Outcomes of Nonoperative Pediatric Medial Humeral Epicondyle Fractures With and Without Associated Elbow Dislocation". Journal of Pediatric Orthopaedics. 37 (4): e224–e228. doi:10.1097/BPO.0000000000000890. ISSN 0271-6798. PMID 27741036. S2CID 8719409.
↑ Howard, Andrew (2009), "How Should We Treat Elbow Fractures in Children?", Evidence-Based Orthopaedics, Elsevier, pp. 188–194, doi:10.1016/b978-141604444-4.50030-8, ISBN 978-1-4160-4444-4 , retrieved 2020-11-29
↑ Perry, D. C.; Wright, J. G.; Cooke, S.; Roposch, A.; Gaston, M. S.; Nicolaou, N.; Theologis, T. (2018-04-27). "A consensus exercise identifying priorities for research into clinical effectiveness among children's orthopaedic surgeons in the United Kingdom". The Bone & Joint Journal. 100-B (5): 680–684. doi:10.1302/0301-620X.100B5.BJJ-2018-0051. ISSN 2049-4394. PMC 6413768 . PMID 29701090.
↑ Janicki, Joseph. "IMPACCT ? Infrastructure for Musculoskeletal Pediatric Acute Care Clinical Trials".{{cite journal}}: Cite journal requires |journal= (help)
↑ Braunholtz, David A.; Edwards, Sarah J.L.; Lilford, Richard J. (2001). "Are randomized clinical trials good for us (in the short term)? Evidence for a "trial effect"". Journal of Clinical Epidemiology. 54 (3): 217–224. doi:10.1016/s0895-4356(00)00305-x. ISSN 0895-4356. PMID 11223318.

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[:0-1] 1 2 3 Kamath, Atul F.; Baldwin, Keith; Horneff, John; Hosalkar, Harish S. (2009). "Operative versus non-operative management of pediatric medial epicondyle fractures: a systematic review". Journal of Children's Orthopaedics. 3 (5): 345–357. doi:10.1007/s11832-009-0192-7. ISSN 1863-2521. PMC 2758175 . PMID 19685254.

[2] "Archived copy" (PDF). Archived from the original (PDF) on 2021-04-13. Retrieved 2021-03-06.{{cite web}}: CS1 maint: archived copy as title (link)

[3] "Errata". Acta Ortopédica Brasileira. 14 (5): 282. 2006. doi: 10.1590/s1413-78522006000500012 . ISSN 1413-7852.

[HINES_1987_170???174-4] Hines, Robert F.; Herndon, William A.; Evans, J. Patrick (1987). "Operative Treatment of Medial Epicondyle Fractures in Children". Clinical Orthopaedics and Related Research. 223 (223): 170–174. doi:10.1097/00003086-198710000-00019. ISSN 0009-921X. PMID 3652571.

[5] Souder, Christopher D.; Farnsworth, Christine L.; McNeil, Natalie P.; Bomar, James D.; Edmonds, Eric W. (2015). "The Distal Humerus Axial View: Assessment of Displacement in Medial Epicondyle Fractures". Journal of Pediatric Orthopaedics. 35 (5): 449–454. doi:10.1097/BPO.0000000000000306. ISSN 0271-6798. PMID 25171678. S2CID 23104831.

[6] Edmonds, Eric W (2010). "How Displaced Are "Nondisplaced" Fractures of the Medial Humeral Epicondyle in Children? Results of a Three-Dimensional Computed Tomography Analysis". Journal of Bone and Joint Surgery. 92 (17): 2785–2791. doi:10.2106/JBJS.I.01637. ISSN 0021-9355. PMID 21123608.

[7] Axibal, Derek Paul; Carry, Patrick; Skelton, Anne; Mayer, Stephanie Watson (2018-10-01). "No Difference in Return to Sport and Other Outcomes Between Operative and Nonoperative Treatment of Medial Epicondyle Fractures in Pediatric Upper-Extremity Athletes". Clinical Journal of Sport Medicine (6): e214–e218. doi:10.1097/jsm.0000000000000666. ISSN 1050-642X. PMC 6443487 . PMID 30277893.

[8] "Clinical Practice Guidelines : Medial epicondyle fracture of the humerus - Emergency Department". www.rch.org.au. Retrieved 2020-11-29.

[:1-9] 1 2 Knapik, Derrick M.; Fausett, Cameron L.; Gilmore, Allison; Liu, Raymond W. (2017). "Outcomes of Nonoperative Pediatric Medial Humeral Epicondyle Fractures With and Without Associated Elbow Dislocation". Journal of Pediatric Orthopaedics. 37 (4): e224–e228. doi:10.1097/BPO.0000000000000890. ISSN 0271-6798. PMID 27741036. S2CID 8719409.

[10] Howard, Andrew (2009), "How Should We Treat Elbow Fractures in Children?", Evidence-Based Orthopaedics, Elsevier, pp. 188–194, doi:10.1016/b978-141604444-4.50030-8, ISBN 978-1-4160-4444-4 , retrieved 2020-11-29

[11] Perry, D. C.; Wright, J. G.; Cooke, S.; Roposch, A.; Gaston, M. S.; Nicolaou, N.; Theologis, T. (2018-04-27). "A consensus exercise identifying priorities for research into clinical effectiveness among children's orthopaedic surgeons in the United Kingdom". The Bone & Joint Journal. 100-B (5): 680–684. doi:10.1302/0301-620X.100B5.BJJ-2018-0051. ISSN 2049-4394. PMC 6413768 . PMID 29701090.

[12] Janicki, Joseph. "IMPACCT ? Infrastructure for Musculoskeletal Pediatric Acute Care Clinical Trials".{{cite journal}}: Cite journal requires |journal= (help)

[13] Braunholtz, David A.; Edwards, Sarah J.L.; Lilford, Richard J. (2001). "Are randomized clinical trials good for us (in the short term)? Evidence for a "trial effect"". Journal of Clinical Epidemiology. 54 (3): 217–224. doi:10.1016/s0895-4356(00)00305-x. ISSN 0895-4356. PMID 11223318.

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