Figure 1. Anteroposterior view of elbow.
Figure 2. Lateral view of elbow.
An 8-year-old girl presents with her mother after a fall at the playground a few hours earlier. She fell off the monkey bars and landed on her extended left arm. She has pain and swelling over the medial elbow and difficulty moving the arm. Radiographs of the elbow show a subtle medial epicondyle fracture (Figures 1 and 2).
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Elbow fractures in children can be a challenge to diagnose because the ossification centers of the elbow appear and close during childhood. The mnemonic CRITOE can be used to remember the ages of ossification: capitellum (1-2 years), radial head (3-4 years), internal (medial) epicondyle (5-6 years), trochlea (7-8 years), olecranon (9-10 years), and external (lateral) epicondyle (11-12 years). Knowing the chronologic sequence of ossification can help identify fractures and displacement.1,2
In this case, radiographs confirm that the olecranon ossification center has appeared so the medial epicondyle should be present. If there is any question of fracture, a radiograph of the contralateral elbow is useful for comparison. The medial epicondyle apophysis is the last growth plate to fuse in the elbow, generally between the ages of 15 and 20. The medial epicondyle is an attachment site for the forearm flexor-pronator mass and the ulnar collateral ligament.1,2
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.
1. Gottschalk HP, Eisner E, Hosalkar HS. Medial epicondyle fractures in the pediatric population. J Am Acad Orthop Surg. 2012;20(4):223-232. doi:10.5435/JAAOS-20-04-223
2. Bolander S, Post G. Prompt recognition: 5 pediatric elbow fractures not to miss. J Bone Joint Surg/J Orthop Phys Assist. 2023;11(2):e23.00001. doi:10.2106/JBJS.JOPA.23.00001