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Average 4.3 of 38 Ratings
A 15-year-old Little League pitcher sustains an injury to his dominant elbow shown in Figure A. Radiographs demonstrate 7 mm of displacement. Which of the following treatments will result in the highest rate of bony union?
Long arm cast for 1 week, followed by passive and gentle active ROM
Placement in a hinged elbow brace with immediate active motion
Closed reduction followed by K-wire fixation
Open reduction and internal fixation
Fragment excision and flexor/pronator mass re-attachment
Select Answer to see Preferred Response
The clinical scenario and image depict a displaced medial epicondyle fracture. Surgical treatment indications based on displacement vary across the literature from 2 to 10 mm. Fracture fragment incarceration and open fractures are absolute indications while relative indications include valgus instability and ulnar nerve dysfunction. Non-operative treatment can lead to fibrous unions which may be symptomatic in some cases.
Case et al reviewed 8 cases of adolescent displaced medial epicondyle fractures, all fixed a screw and washer with the initiation of motion in a hinged elbow brace on day 4 for 4 weeks. Half the patients had concomitant elbow dislocations. All patients went on to union, were pain-free and were stable to valgus and varus stressing. All patients returned to full sports activity. One patient lost 5 degrees of hyperextension compared to the contralateral elbow.
Illustration A demonstrates a gravity valgus stress examination with marked instability of the medial elbow.
Case SL, Hennrikus WL.
Am J Sports Med. 1997 Sep-Oct;25(5):682-6. PMID: 9302476 (Link to Abstract)
Case, AJSM 1997
Please rate question.
Average 3.0 of 26 Ratings
Which of the following fracture patterns (Figures A-E) is most commonly associated with a combined ulnohumeral and radiocapitellar elbow dislocation in children?
Medial epicondyle fractures are the most common fractures patterns associated with elbow dislocations in a child.
Rasool reports in a Level 4 study that 33% of the children sustaining elbow dislocations had concomitant medial epicondyle fractures.
Fowles et al peformed a Level 4 investigation of 28 pediatric elbow fractures with associated medial humeral epicondyle fractures and found 25% had the medial epicondyle entrapped in the joint. They concluded that surgery is indicated only for children where the epicondyle is entrapped in the joint or is significantly displaced after closed reduction attempt.
Illustration A is a radiograph of a dislocated elbow which shows a medial epicondyle fracture fragment that is in the joint.
Answer 1: Lateral condyle fractures are not the most common fracture associated with elbow dislocations.
Answer 3 & 4: Supracondylar fractures are not the most common fracture associated with elbow dislocations.
Answer 5: Radial neck fractures are not the most common fracture associated with elbow dislocations.
J Bone Joint Surg Br. 2004 Sep;86(7):1050-8. PMID: 15446537 (Link to Abstract)
Rasool, BJJ 2004
Fowles JV, Slimane N, Kassab MT.
J Bone Joint Surg Br. 1990 Jan;72(1):102-4. PMID: 2298765 (Link to Abstract)
Fowles, BJJ 1990
Average 3.0 of 28 Ratings
A 9-year-old boy fell off of a swing set and injured his left elbow. Radiographs are shown in Figures A and B. Open reduction and internal fixation of this fracture is indicated secondary to which of the following:
Displacement of greater than 5 mm
An incarcerated fragment in the ulnohumeral joint
2+ valgus laxity seen with manual stressing
To prevent cubitus valgus deformity
High risk of symptomatic non-union of fragment
Medial epicondyle avulsion fractures can be treated with open reduction and internal fixation when the fractured fragment is incarcerated in the ulnohumeral joint or if there is significant ulnar nerve dysfunction. Figures A and B show a displaced medial epicondyle fracture that is incarcerated in the ulnohumeral joint, thus requiring ORIF.
Lee et al studied 25 pediatric patients who had undergone ORIF of a medial epicondyle fracture and found no correlation between surgical outcome and injury mechanism, displacement, interval from injury to surgery, dislocation, fixation method, or duration of immobilization. All patients in this study had good to excellent outcomes.
Farsetti et al compared pediatric patients with medial epicondyle fractures with displacement > 5mm who received a long arm cast without reduction, ORIF, and excision. They found no difference in long term results between patients treated with ORIF and those who received non-op treatment, while those treated with excision had poor long term results.
Lee HH, Shen HC, Chang JH, Lee CH, Wu SS
J Shoulder Elbow Surg. 2005 Mar-Apr;14(2):178-85. PMID: 15789012 (Link to Abstract)
Lee, JSES 2005
Farsetti P, Potenza V, Caterini R, Ippolito E
J Bone Joint Surg Am. 2001 Sep;83-A(9):1299-305. PMID: 11568189 (Link to Abstract)
Farsetti, JBJS 2001
Average 4.0 of 27 Ratings
Which of the following muscles is involved in the avulsion injury that creates the fracture shown in Figure A?
Extensor carpi radialis longus
The radiographs show a displaced medial epicondyle fracture, which results from extreme valgus loads or violent muscle contractions in overhead athletes during the throwing motion and commonly occur in adolescents as the medial epicondyle begins to fuse. The medial epicondyle is avulsed by forceful contraction of the common flexor wad, which includes the pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, and flexor carpi ulnaris.
Gilchrist et al treated these injuries successfully surgically in cases that had gone on to nonunion or instability with initial conservative treatment.
Farsetti et al had good results with non-operative treatment of these injuries, even in the face of nonunion.
Gilchrist AD, McKee MD.
J Shoulder Elbow Surg. 2002 Sep-Oct;11(5):493-7. PMID: 12378170 (Link to Abstract)
Gilchrist, JSES 2002
Average 4.0 of 20 Ratings
An 11-year-old boy presents to the emergency room with a left elbow injury after falling off of the monkey bars. His neurovascular examination in the extremity is normal and his pain is controlled. Post-reduction radiographs are shown in Figure A. What is the next most appropriate step in management
Hinged elbow brace locked at 90 degrees of flexion for 10 days followed by gentle passive range of motion
Long arm cast for 4 weeks
Sling for comfort and return to activities as tolerated
Figure A shows a displaced medial epicondyle fracture that is incarcerated in the ulnohumeral joint following an attempt at closed reduction. Closed reduction manuever to extricate the incarcerated fragment can be performed with the Roberts' technique, which includes placing valgus stress on the elbow, supinating the forearm, and extending the wrist and fingers. Medial epicondyle fractures with incarcerated fragments that fail manipulative closed reduction require open reduction. In contrast, displaced medial epicondyle fractures can be treated with closed management if the fragment is not incarcerated in the joint.
Farsetti et al. compared the long-term results of pediatric patients with non-incarcerated medial epicondyle fractures with displacement >5 mm who received a long arm cast without reduction, ORIF, and excision. There was no difference in clinical results between patients treated with ORIF and those who received non-operative treatment, while those treated with excision had poor long term results. In practice, the magnitude of acceptable displacement of these fractures is highly variable among surgeons.
Illustration A demonstrates the incarcerated medial epicondyle with red arrows.
Average 4.0 of 37 Ratings
An 11-year-old child sustains an elbow dislocation. The elbow is reduced, but post-reduction radiographs demostrate that the ulnohumeral joint remains slightly incongruent. What is the most likely etiology for this continued incongruency?
Interposed annular ligament
Interposed lateral epicondyle fragment
Interposed medial epicondyle fragment
Interposed ulnar nerve
Interposed brachialis muscle
The review article by Skaggs notes that as many as 50% of medial epicondyle fractures are associated with elbow dislocations. Illustration A and B display a medial epicondyle incarcerated within the ulnohumeral joint following an elbow dislocation. Fractures of the medial epicondyle tend to occur in older children between the ages of 10 and 14. Simple fractures of the medial epicondyle are extra-articular injuries with limited soft-tissue involvement.
Minimally displaced fractures may be treated conservatively with initial splinting in 90 degrees and then initiation of AROM within one week with protective splinting for another few weeks. Absolute indications for operative treatment are irreducible incarceration of the medial epicondyle in the joint and the rare open fracture. Functional demands of the patient (thrower, gymnast) and magnitude of displacement may be considered as well, but are not absolute indications. Closed reduction of an incarcerated fragment may be attempted by supinating the forearm, placing a valgus stress on the elbow, and extending the wrist and fingers. If unsuccessful, ORIF while protecting the ulnar nerve is necessary.
The Level 4 article by Fowles et al found that 6 of the 28 medial epicondyle fractures had the epicondyle fragment incarcerated within the joint. They also found satisfactory results with plaster casting of medial epicondyle fracture if closed reduction was successful.
J Am Acad Orthop Surg. 1997 Nov;5(6):303-312. PMID: 10797226 (Link to Abstract)
Skaggs, JAAOS 1997
Average 3.0 of 18 Ratings
HPI - valgus hyperextension injury while wrestling. tender at medial epicondyle. good rom. pain with valgus of elbow.
what is the diagnosis on the right elbow
HPI - 22 yrs male with 1 months old fracture, right hand dominance
How would you treat this injury?
HPI - pain and swelling of elbow , restricted movement , paresthesia in little finger