MEDIAL EPICONDYLE FRACTURE
(KIDS BROKEN ELBOW)
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related topics: broken arm, broken wrist, broken radial head, broken elbow, broken lateral condyle, broken forearm
What is a Medial Epicondyle Fracture (Pediatric Broken Elbow)?
A Medial Epicondyle Fracture is a type of broken elbow seen in kids.
To better understand this injury, lets quickly review the anatomy of our elbow.
Our elbow is a joint where the arm bone (humerus) meets up with your two forearm bones (the radius and the ulna). The radius bone is on the lateral side (outside) of the elbow, while the ulna bone is on the medial side (inside). The medial epicondyle is part of the humerus bone, and its the bump you can feel on the inner aspect of your elbow. It is an important little bump because a lot of the muscles that bend and rotate your wrist and forearm attach here. Additionally, the medial collateral ligament of the elbow, which is an important stabilizer of the elbow attaches here too.
The injury usually occurs with a fall onto an outstretched arm, which causes the elbow to bend excessively. A bending stress to the elbow causes this bump to be pulled off (or “avulsed”) from the main portion of the arm bone. This is a type of fracture, but its classified as an avulsion injury, and it occurs because the bone is actually weaker than the strong ligament and tendon attachment.
Diagnosing a Medial Epicondyle Fracture (Pediatric Broken Elbow):
Kids with this injury report pain on the inside of their elbow and maybe some elbow laxity (increased bending of the elbow) because those important ligaments are now loose. In fact 50% of these injuries are accompanied by an elbow dislocation because that ligament (the MCL) is so important for elbow stability. Therefore its critical for doctors to evaluate elbow stability when seeing someone with this injury (and if the elbow is dislocated, to put it back in place!).
Doctors that are suspicious for this injury will order X-rays of the elbow, which gives the diagnosis and helps to guide treatment.
Treating a Medial Epicondyle Fracture (Pediatric Broken Elbow):
These injuries typically heal well without surgery, although surgery occasionally required in more severe injuries.
Non-surgical treatment involves placing the arm into a cast for about 2-4 weeks and then begin early range of motion activities to prevent stiffness. The break will heal and the elbow will typically regain its stability.
The only time surgery is absolutely indicated is when a piece of broken bone gets stuck within the elbow joint preventing motion. In these cases, surgery will retrieve this piece of bone and reattach it.
Surgery is also considered in competitive athletes (especially in gymnastics) because they put high stress on their elbows and this can magnify any subtle persistent elbow instability (which would never be noticed by a regular kid) and may cause the elbow to re-break or dislocate.
Surgery is also considered in any kid if the broken fragment of bone appears to be squishing the ulnar nerve, causing numbness and/or weakness in the hand, or if the elbow is notably unstable (high risk for dislocating).
Lastly, surgery is also considered if the bone fragment is pulled very far away (between 5 - 15 mm) because there is a higher chance the break will not heal completely (although most cases still heals). In these circumstances, surgery may be beneficial but remains controversial (nonsurgical treatment is also acceptable).
If surgery is required, a single screw is placed through the bone fragment to reattach it to the arm bone (humerus). After surgery the arm is placed into a protected brace and passive elbow motion is allowed for 4 weeks, at which time the arm comes out of the brace and active motion is started.
What is the long term outcome?
Kids typically have excellent outcomes when this injury is treated and should expect no significant residual deficits.
If the bone fragment is significantly separated from the arm bone it will sometimes heal with scar tissue instead of normal bone (this is called a fibrous nonunion), however this rarely causes symptoms or long-term deficits (but on x-ray the crack will never fill in with bone, so it may appear unhealed).
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References
1) Gottschalk, HP. Medial epicondyle fractures in the pediatric population. JAAOS 2012; 20: 223-32. full article.
2) Louahem DM et al. Displaced medial epicondyle fractures of the humerus: Surgical treatment and results. A report of 139 cases. Arch Orthop Trauma Surg 2010; 130:649-655. full article.
4) Case SL, Hennrikus WL. Surgical treatment of displaced medial epicondyle fractures in adolescent athletes. Am J Sports Med. 1997; 25:682-6. full article.