Paediatric Medial Epicondyle Fracture of the Humerus
Medial epicondyle fractures are common and account for 10% of all elbow fractures in children.
50% of medial epicondyle fractures are associated with an elbow dislocation.
The medial epicondyle is a secondary growth center at the elbow, which first appears around age 6 and fuses to the shaft of the humerus at about age 14-17 years.
They occur between the ages of 7-15 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.
Medial epicondyle fracture with < 5 mm of displacement
Medial epicondyle fracture with 5 to 15 mm of displacement
Medial epicondyle fracture with > 15 mm of displacement
Medial epicondyle fractures are usually a result of an avulsion (pull off) injury caused by valgus stress at the elbow and contraction of the flexor muscles.
A child presenting with a medial epicondyle or condyle fracture of humerus presents with tenderness and swelling at the medial aspect of the elbow. There may be a dislocation of the elbow.
On examination, the elbow joint is swollen and tender on the medial aspect; the range of movement is painfully restricted.
All fractures should be assessed using the Advanced Trauma Life Support (ATLS) principles to ensure associated and potentially significant injuries are identified.
Anteroposterior (AP) and lateral x-rays of the elbow should be obtained.
If a medial condyle fracture is suspected or minimally displaced on x-rays, then oblique views are often useful.
If there is any clinical suspicion of injury in the forearm or wrist then separate films of these areas should be ordered.
In the x-ray, look for the displacement of the fracture ( <5 mm of displacement and > 5 to 15 mm of displacement, and > 15 mm displacement) and elbow dislocation (Incarcerated medial epicondyle fragment)
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 from 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.
Absolute indication for urgent open reduction and internal fixation:
Elbow dislocation with the incarceration of medial epicondyle
Relative indications for open reduction and internal fixation:
Age > 8 years
Displacement >10 mm-15 mm
Ulnar nerve palsy
Dominant upper limb in throwing athlete or gymnast
Minimally displaced (<5 mm gap) fractures are treated with above elbow back slab with the elbow flexed to 90 degrees.
All displaced fractures (>5 mm gap and/or incarcerated fragment) will need to go to the theatre either for closed reduction or open reduction or +/- fixation.
Emphasis should be placed on the elevation of the limb (elbow above the heart) for the first 48 hours and active finger mobilization.
Back slab and sling should be worn under clothing and not through the sleeve.
Generally, medial epicondyle fractures are a benign injury with very good long-term functional results.
Physiotherapy is not recommended to regain range of motion (ROM).
Medial elbow instability
Non-union (usually not symptomatic or requiring any treatment)
Ulnar nerve palsy
Elbow joint stiffness: usually more a feature of post-open reduction surgery.