Medial epicondyle

fracture of the
humerus

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 Fracture of the Humerus

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 (https://science.octru.ox.ac.uk/) 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.

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.

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.
 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.

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’.

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 (or a dislocation that has been
reduced), 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 achieve
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 (https://sc
ience.octru.ox.ac.uk) is currently underway across the UK, with more than 60 hospitals
participating. It is funded by the National Institute for Health Research. Such is the level of
international uncertainty, surgeons in Australia and New Zealand are joining the SCIENCE
study. Furthermore, surgeons in the USA have also been awarded a National Institute of
Health grant to address this question.[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 (https://www.sciencedire
ct.com/science/article/abs/pii/S089543560000305X) ).[13]

References

1. Kamath, Atul F.; Baldwin, Keith; Horneff, John; Hosalkar, Harish S. (2009). "Operative versus non-
operative management of pediatric medial epicondyle fractures: a systematic review" (http://online.b
oneandjoint.org.uk/doi/10.1007/s11832-009-0192-7) . Journal of Children's Orthopaedics. 3 (5):
345–357. doi:10.1007/s11832-009-0192-7 (https://doi.org/10.1007%2Fs11832-009-0192-7) .
ISSN 1863-2521 (https://www.worldcat.org/issn/1863-2521) . PMC 2758175 (https://www.ncbi.nlm.
nih.gov/pmc/articles/PMC2758175) . PMID 19685254 (https://pubmed.ncbi.nlm.nih.gov/196852
54) .

2. [1] (https://www.rcem.ac.uk/docs/RCEM%20Guidance/RCEM%20Pain%20in%20Children%20-%20Bes
t%20Practice%20Guidance%20(REV%20Jul%202017).pdf)

3. "Errata" (https://doi.org/10.1590%2Fs1413-78522006000500012) . Acta Ortopédica Brasileira. 14

(5): 282. 2006. doi:10.1590/s1413-78522006000500012 (https://doi.org/10.1590%2Fs1413-7852200
6000500012) . ISSN 1413-7852 (https://www.worldcat.org/issn/1413-7852) .
 4. Hines, Robert F.; Herndon, William A.; Evans, J. Patrick (1987). "Operative Treatment of Medial
Epicondyle Fractures in Children" (https://dx.doi.org/10.1097/00003086-198710000-00019) .
Clinical Orthopaedics and Related Research. 223 (223): 170–174. doi:10.1097/00003086-
198710000-00019 (https://doi.org/10.1097%2F00003086-198710000-00019) . ISSN 0009-921X (htt
ps://www.worldcat.org/issn/0009-921X) . PMID 3652571 (https://pubmed.ncbi.nlm.nih.gov/3652
571) .

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" (https://dx.doi.org/10.1097%2FBPO.0000000000000306) . Journal of Pediatric
Orthopaedics. 35 (5): 449–454. doi:10.1097/BPO.0000000000000306 (https://doi.org/10.1097%2FB
PO.0000000000000306) . ISSN 0271-6798 (https://www.worldcat.org/issn/0271-6798) .
PMID 25171678 (https://pubmed.ncbi.nlm.nih.gov/25171678) . S2CID 23104831 (https://api.seman
ticscholar.org/CorpusID: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" (https://dx.
doi.org/10.2106%2FJBJS.I.01637) . Journal of Bone and Joint Surgery. 92 (17): 2785–2791.
doi:10.2106/JBJS.I.01637 (https://doi.org/10.2106%2FJBJS.I.01637) . ISSN 0021-9355 (https://ww
w.worldcat.org/issn/0021-9355) . PMID 21123608 (https://pubmed.ncbi.nlm.nih.gov/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. Publish Ahead of Print (6): e214–e218. doi:10.1097/jsm.0000000000000666 (https://doi.o
rg/10.1097%2Fjsm.0000000000000666) . ISSN 1050-642X (https://www.worldcat.org/issn/1050-
642X) . PMC 6443487. PMID 30277893 (https://pubmed.ncbi.nlm.nih.gov/30277893) .

8. "Clinical Practice Guidelines : Medial epicondyle fracture of the humerus - Emergency Department" (ht
tps://www.rch.org.au/clinicalguide/guideline_index/fractures/Medial_epicondyle_emerg/#Reductio
n) . www.rch.org.au. Retrieved 2020-11-29.

9. 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" (https://dx.doi.org/10.1097%2FBPO.0000000000000890) . Journal of Pediatric
Orthopaedics. 37 (4): e224–e228. doi:10.1097/BPO.0000000000000890 (https://doi.org/10.1097%2F
BPO.0000000000000890) . ISSN 0271-6798 (https://www.worldcat.org/issn/0271-6798) .
PMID 27741036 (https://pubmed.ncbi.nlm.nih.gov/27741036) . S2CID 8719409 (https://api.semanti
cscholar.org/CorpusID:8719409) .

10. Howard, Andrew (2009), "How Should We Treat Elbow Fractures in Children?" (http://www.crossref.or
g/deleted_DOI.html) , Evidence-Based Orthopaedics, Elsevier, pp. 188–194, doi:10.1016/b978-
141604444-4.50030-8 (https://doi.org/10.1016%2Fb978-141604444-4.50030-8) , 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" (https://online.boneandjoint.org.uk/doi/full/1
0.1302/0301-620X.100B5.BJJ-2018-0051) . The Bone & Joint Journal. 100-B (5): 680–684.
doi:10.1302/0301-620X.100B5.BJJ-2018-0051 (https://doi.org/10.1302%2F0301-620X.100B5.BJJ-20
18-0051) . ISSN 2049-4394 (https://www.worldcat.org/issn/2049-4394) . PMC 6413768 (https://w
ww.ncbi.nlm.nih.gov/pmc/articles/PMC6413768) . PMID 29701090 (https://pubmed.ncbi.nlm.nih.g
ov/29701090) .

12. Janicki, Joseph. "IMPACCT ? Infrastructure for Musculoskeletal Pediatric Acute Care Clinical Trials" (h
ttps://grantome.com/grant/NIH/R34-AR075303-01) .

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" " (https://dx.doi.org/10.1016/s0895-4356
(00)00305-x) . Journal of Clinical Epidemiology. 54 (3): 217–224. doi:10.1016/s0895-
4356(00)00305-x (https://doi.org/10.1016%2Fs0895-4356%2800%2900305-x) . ISSN 0895-4356 (htt
ps://www.worldcat.org/issn/0895-4356) . PMID 11223318 (https://pubmed.ncbi.nlm.nih.gov/112
23318) .

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