A patient, aged six years, presented to the ED with complaints of severe left elbow pain after a fall.
The patient’s mother reported the patient fell onto his left arm from the playground monkey bars and hadn’t been able to move it since the injury a few hours earlier.
On exam, the boy had swelling and tenderness over the medial elbow. Motor and sensation was intact throughout.
This case has been brought to you in partnership with the Journal of Orthopedics for Physician Assistants.
Submit your diagnosis to see full explanation.
The pictured x-rays show a displaced medial epicondyle avulsion fracture. Soft tissue swelling medial to the fracture is also noted.
Medial epicondyle fractures can occur as a result of a direct blow, avulsion type mechanism, or with an elbow dislocation. Avulsion of the medial apophysis generally occurs with a valgus loading with the arm in extension. Avulsion fractures generally involve the apophysis only.
Attachments to the medial epicondyle include the ulnar collateral ligament and common wrist flexors. These soft tissue attachments exert a pulling force distally, which typically causes fracture displacement in this direction. Isolated avulsions can occur in adolescent athletes who throw as a result of a sudden contracture of the forearm flexors.
Treatment of these fractures is controversial and typically depends on neurovascular function and degree of displacement. Incarceration of the fracture fragment into the joint space or complete ulnar nerve dysfunction generally requires open reduction and internal fixation.
Otherwise, non-operative management of medial epicondyle fractures is generally preferred as results have shown a high rate of union and good results seen with a fibrous union. Non operative treatment involves 3 to 4 weeks of immobilization with a sling or long arm cast.
Dagan Cloutier, MPAS, PA-C, practices in a multispeciality orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Kamath AF et al. J Child Orthop. 2014; doi: 10.1007/s11832-009-0185-6
- Wheeless CR. “Frx of the medial condyle in children.” Wheeless’ Textbook of Orthopaedics. 24 May 2014. Last accessed 10/14/14: http://www.wheelessonline.com/ortho/frx_of_the_medial_condyle_in_children