In this section
See also: - Medial epicondyle fracture of the humerus - Fracture clinics
It is important to distinguish a medial epicondyle fracture (common) from a medial condyle fracture (very rare). Medial condyle fractures are intraarticular, extending into the elbow joint and require urgent open reduction internal fixation (ORIF).
Medial epicondyle<5 mm displacement
Above-elbow backslab at 90 degrees elbow flexion for 3 weeks. The backslab and sling should be worn under clothing (e.g. loose fitting shirt) and not through the sleeve
Fracture clinic at 3 weeks with x-ray out of backslab. Child is then placed in collar and cuff for three weeks
Medial epicondyle5 mm to 15 mm displacement
Refer to nearest orthopaedic on call service.
Management (closed treatment vs. operative treatment) is dependent on a number of factors, including child's age and sporting activities. See indications for reduction
Discuss with orthopaedic service
Medial epicondyle>15 mm displacement (with elbow dislocation)
Refer to the nearest orthopaedic on call service. Requires reduction +/- ORIF
If closed reduction for an elbow dislocation is performed, always order repeat x-rays to check that the medial epicondyle fracture is not trapped in the joint. If there is any doubt, urgent ORIF should be performed
To be arranged by orthopaedic service
The medial epicondyle is a secondary growth centre at the elbow, which first appears around age 6 and fuses to the shaft of the humerus at about age 14-17 years. A medial epicondyle fracture is an avulsion injury of the attachment of the common flexors of the forearm. The injury is usually extra-articular but can be sometimes associated with an elbow dislocation. These fractures can be classified based amount of displacement and whether the medial epicondyle is incarcerated within the joint.
Medial epicondyle fractures are common and account for 10% of all elbow fractures in children. They occur between the ages of 7-15 years.
They are usually a result from an avulsion (pull off) injury caused by a valgus stress at the elbow and contraction of the flexor muscles.
Fifty percent of medial epicondyle fractures are associated with an elbow dislocation.
A child presenting with a medial epicondyle or condyle fracture of humerus presents with tenderness and swelling at the medial aspect of the elbow. There may be a dislocation of the elbow.
Anteroposterior (AP) and lateral x-rays of the elbow should be ordered. If there is clinical suspicion of injury in the forearm or wrist then separate films of these areas should be ordered.
It is very important to identify any injuries in the forearm as this has major implications with regards to swelling.
Although rare, it is important to distinguish a medial epicondyle fracture from a medial condyle fracture. Medial condyle fractures are intra-articular (extends into the joint) fractures. All medial condyle fractures require a review with the nearest orthopaedic on call service
Undisplaced or minimally displaced fractures (<5 mm)
Figure 1: AP and lateral x-ray of a minimally displaced (< 5mm) medial epicondyle fracture in seven year old girl. Undisplaced or minimally displaced fractures may be difficult to see on x-ray. Soft tissue swelling may be the only finding. Later an injury can be identified by the formation of fracture callus, periosteal reaction along the medial border of the humerus.
Figure 2: A) Thirteen year old gymnast with medial epicondyle fracture. The medial epicondyle is separated >5 mm (red arrow). This is evident on the AP view. It is more difficult to see on the lateral view due to the splint. B) Due to the child's age and type of sporting activity, management was open reduction and internal fixation.
Figure 3: Nine year old with elbow dislocation and fracture of the medial epicondyle (white arrow). Fifty percent of medial epicondyle fractures are associated with an elbow dislocation, which is easily identified on x-ray.
Medial epicondyle trapped in elbow joint
An elbow dislocation requires urgent closed reduction. Always do repeat x-rays to check that the medial epicondyle is not incarcerated in the joint. If there is any doubt that the medial epicondyle is trapped in the joint, an urgent open reduction and internal fixation is needed.
Figure 4: With an elbow dislocation, the medial epicondyle can be incarcerated in the joint (white arrow) following reduction. This can be difficult to identify on x-ray. It is important to check that the medial epicondyle is present in its anatomical position. On the AP view, the medial epicondyle is missing (red arrow). On the lateral view, the fragment appears as an additional bony opacity interposed between trochlea and olecranon. Note also that the opposing joint surfaces of the olecranon and trochlea are not congruent.
There is little consensus in the literature as to the amount of fracture displacement that warrants surgical intervention.
For medial epicondyle fractures that are displaced 5 mm to 15 mm, operative management is dependent on a number of factors such as the child's age and involvement in sporting activities (Table 1).
Table 1: Relative indications for closed treatment versus operative treatment in medial epicondyle fractures displaced 5 mm to 15 mm.
≥ 8 years
Athlete - throwing activities or gymnastics
Absolute indication for urgent open reduction and internal fixation:
Relative indications for open reduction and internal fixation:
Following reduction, <15 mm of displacement is considered acceptable.
See above. Indications for prompt consultation include:
Management is based on the amount of displacement.
Type of reduction
Immobilisation method & duration
No reduction required
Above-elbow backslab at 90 degrees elbow flexion for 3 weeks with sling. The backslab and sling should be worn under clothing (e.g. loose fitting shirt) and not through the sleeve.
Backslab is removed at 3 weeks and child is then placed in collar and cuff for three weeks
Refer to nearest orthopaedic on call service for advice
Management (closed treatment versus operative treatment) is dependent on number of factors such as child's age and sporting activities. See indications for reduction
Medial epicondyle>15 mm displacement
Refer to the nearest orthopaedic on call service
For medial epicondyle fractures that underwent closed treatment, follow-up should be arranged at three weeks in fracture clinic.
For fractures that go to theatre, follow-up should be arranged by the consulting orthopaedic team.
The backslab and sling should be worn under clothing (e.g. loose fitting shirt) and not through the sleeve.
Generally, medial epicondyle fractures are a benign injury with very good long-term functional results.
Physiotherapy is not recommended to regain range of motion (ROM).
See fracture clinics for other potential complications.
Beaty JH, Kasser JR. The elbow: Physeal fractures, apophyseal injuries of the distal humerus, avascular necrosis of the trochlea, and T-condylar fractures. In Rockwood and Wilkins' Fractures in Children, 7th Ed. Beaty JH, Kasser JR (Eds). Lippincott Williams & Wilkins, Philadelphia 2010. p.533-93.
Gottschalk HP, Eisner E, Hosalkar HS. Medial epicondyle fractures in the pediatric population. J Am Acad Ortho Surg 2012; 20(4): 223-32.
Herring JA. Upper extremity injuries. In Tachdjian's Pediatric Orthopedics, 4th Ed. Saunders, Philadelphia 2008. p.2451-536.