Courtesy: Ashok Shyam, IORG, OrthoTV
Medial Epicondyle Fracture (Pediatric Elbow)
Epidemiology
- Accounts for ~10% of pediatric elbow fractures
- Common age group:
- 8–15 years (adolescents)
Less Common Than
- Supracondylar fractures
- Lateral condyle fractures
Mechanism of Injury
1. Avulsion Injury (Most Common)
- Mechanism:
- Fall on outstretched hand (FOOSH)
2. Associated with Elbow Dislocation
- Common association
3. Direct Trauma
- Rare
Important Diagnostic Pitfalls
1. Missed Incarcerated Fragment
Scenario
- Occurs with elbow dislocation
- After reduction:
- Fragment may become trapped inside the joint
Consequences
- Elbow stiffness
- Ulnar nerve palsy
2. Misdiagnosis in Younger Children (<6–8 years)
Possible Confusion
- Apparent medial epicondyle fracture may actually be:
- Medial condyle fracture
Key Difference
- Medial condyle fracture:
- Intra-articular – MUST FIX
- Medial epicondyle fracture:
- Extra-articular
Assessment of Displacement
Problem
- Fragment displaces anteriorly
- Standard views:
- AP & lateral – underestimate displacement
Better Imaging
- Internal oblique view
- Distal humeral axial (axial oblique) view:
- Elbow partially flexed
- Beam angled ~25°
CT Scan
- Most accurate method
- Not routinely required
Conservative vs Operative Treatment
Evidence (Systematic Review)
- Union rates:
- Conservative – ~28%
- Operative – ~96%
Important Insight
- Functional outcomes:
- Often similar
Clinical Implication
- Creates treatment controversy
Indications for Surgery
Absolute Indication
- Fragment incarcerated in the joint
Relative Indications
- Elbow instability or dislocation
- Displacement >5 mm
- High-demand patients:
- Throwing athletes
- Weight-bearing upper limb
Management Options
1. Conservative Management
Method
- Above-elbow cast
Indications
- Minimal displacement
- Stable elbow
2. Operative Management (ORIF)
Patient Position
- Supine (most common)
- Prone (alternative):
- Easier reduction
- Less valgus stress
Surgical Technique (Key Steps)
- Medial approach
- Identify and protect ulnar nerve
- Reduction techniques:
- Forearm pronation + wrist flexion – relax flexor origin
- Esmarch bandage – reduces muscle pull
- Dental pick – manipulate fragment
- Fascia release if required
Fixation Methods
Most Common
- Cannulated cancellous screw
- ± washer
- Usually unicortical sufficient
Other Options
- K-wires (younger children)
- Suture anchors (less common)
Special Scenario: Incarcerated Fragment
Attempt Closed Reduction
- Supination
- Wrist and finger extension
- Gentle elbow flexion with varus–valgus movement
If Unsuccessful
- Proceed to open reduction
Complications
Common
- Non-union (especially with conservative treatment)
- Often asymptomatic
Other Complications
- Pain
- Valgus instability
- Reduced range of motion (stiffness)
- Ulnar neuropathy
Key Exam Pearls
- Most important indication for surgery:
- Fragment incarceration
- Displacement:
- Poorly assessed on AP/lateral views
- Non-union:
- Does not always mean poor function
Critical Differential Diagnosis
- Always differentiate from:
- Medial condyle fracture (intra-articular)
Final Message
- Management requires:
- Careful diagnosis
- Proper imaging
- Understanding of functional outcomes
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