Treatment of Elbow Fractures Affecting the Medial Epicondyle in Children
Falls and throwing injuries are the two most common causes of medial epicondyle (elbow) fractures in children and teens between the ages of seven and 15. In this article, current evidence is presented for the evaluation and treatment of these fractures.
The medial epicondyle is located on the inside of the elbow. It is the place where several muscles and ligaments of the forearm attach (flexor muscles, pronator teres, medial collateral ligament). The mechanism of injury is usually a valgus force on the elbow strong enough to pull these muscles and ligament off the bone taking with it a piece of bone.
A valgus force goes from the lateral or outside edge of the elbow to the medial or inside of the elbow. This type of injury with a bone fragment attached to soft tissue is referred to as an avulsion fracture. The child may feel or hear a popping sensation at the time of the injury. This will be followed by pain. Elbow dislocation is common and nerve damage is seen in up to 15 per cent of all patients with this type of fracture.
The goal of treatment is to heal the fracture, of course, but also to help the child regain normal motion, strength, and function. In the case of an athlete, return-to-sport and play at a preinjury level is ideal. The surgeon will use X-rays to guide the initial treatment decision.
Some children will be able to be treated with a conservative course of care (no surgery required). The selection of nonoperative versus operative care hinges on whether or not the fracture is displaced (separated) and by how much.
Surgery is required for open fractures (through the skin), fracture-dislocations, and unstable fractures (often those that go through the joint surface). Any sign of nerve or blood vessel damage must also be addressed surgically and quickly. One other reason why surgery might be needed is if the bones have separated apart (called displacement). But there's no cut off point between when surgery is needed and when it's not. What one surgeon may consider a "significant" amount of displacement may be not the same for another.
Age and size of the bone fracture fragment help guide the surgeon choose the best surgical treatment approach. Younger children are treated with bone fixation using wires. Older children and teens are more likely to be able to handle having a screw put in place to hold the fracture until healing takes place. Pins (rather than screws or wires) are used when there are small bone fragments.
Many studies report the good success of treatment when following these guidelines for both conservative care and operative treatment. Loss of elbow extension (ability to straighten the elbow) is the number one limitation after this surgery. Starting elbow and arm movement right away after the cast comes off is the best way to deal with this problem.
There are some areas where further studies would help clear up a few questions. For example, just how much displacement is an indicator that surgery is needed? Do children get back to their beloved sports activity faster when treated with surgery instead of the immobilization used during nonoperative care. Does the high level of play and intensity of activity suggest fixation should be considered more often than not?
It's easy to see that a severe fracture and unstable elbow requires surgery. The cases that fall in between are the ones that require individual consideration of all factors. The surgeon's own experience and expertise certainly fall into that category. Patient age, activity level, X-ray findings, and patient goals are additional factors.
Neeraj M. Patel, MBS, and Theodore J. Ganley, MD. Medial Epicondyle Fractures of the Humerus: How to Evaluate and When to Operate. In Journal of Pediatric Orthopaedics. June 2012. Supplement. Vol. 32. No. 1. Pp. S10-S13.