Bilateral anteroposterior elbow radiographs are performed for comparison on an 11-year-old girl who presents with right elbow pain after a cheerleading injury 2 days earlier.
A right elbow radiograph of the patient shows some displacement of the medial apophysis.
An 11-year-old girl presents with right elbow pain after a cheerleading injury 2 days earlier. She fell from 4 feet in the air and landed directly on her outstretched arm. She is now experiencing pain and difficulty moving the elbow. She has a cheerleading competition in 2 days and is hoping for clearance to get back to practice. On examination, she has tenderness to palpation of the posterior and medial elbow with mild generalized elbow swelling. Bilateral anteroposterior elbow radiographs are performed for comparison. The injured right elbow appears to have some displacement of the medial apophysis.
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The medial epicondyle apophysis is on the posterior medial elbow and is an attachment site for the wrist flexors. A fall on an outstretched arm causes the flexor-pronator mass and medial collateral ligament to pull on the apophysis, which can result in fracture. With enough force, avulsion of the medial apophysis off the distal humerus may occur.
Fracture displacement may be quite subtle, and therefore, bilateral elbow radiographs are commonly performed to compare the contralateral apophysis. The peak age incidence of medial apophyseal fractures is 11 to 12 years, which is a period of increased skeletal growth. The medial apophysis fuses at age 15 years on average.1,2
Bilateral comparison anteroposterior radiographs of this patient’s elbow show minimal medial apophyseal displacement of 2 mm to 3 mm. Displacement of <5 mm should be treated nonoperatively.
A brief period (generally 2-3 weeks) of immobilization is recommended for these injuries. A long arm cast is a good option for potentially noncompliant children, as in this case of a young girl who is anxious to begin cheerleading again. Elbow stiffness is a common complication associated with elbow fractures, so gentle range of motion should be initiated when the cast comes off in 2 to 3 weeks. A sling can be used at that time to facilitate daily range of motion exercises. Patients should be warned that these fractures can cause some loss of elbow extension and valgus instability, although most will never notice these complications functionally.1
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Beaty JH, Kasser JR. The elbow: physeal fractures, apophyseal injuries of the distal humerus, osteonecrosis of the trochlea, and T-condylar fractures. In: Beaty JH, Kasser JR, eds. Rockwood and Wilkins’ Fractures in Children. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:614-620.
- Jones T. Medial Epicondylar Fractures—Pediatric. http://www.orthobullets.com/pediatrics/4008/medial-epicondylar-fractures–pediatric. Accessed March 20, 2017.