Medial Epicondyle fracture

Relatively common in children, 12% of all elbow fractures in children

Treatment

Certain areas of treatment are clear:

Fractures displaced <2 mm should be treated nonsurgically. (Splint 90 degrees of flexion and then begin active movement)

Open reduction and internal fixation of the epicondylar fragment indicated when:

Unable to remove epicondylar fragment from elbow with manipulation. (Valgus stress, minimally flexed elbow and supinated forearm)
Ulna nerve entrapment.
Elbow is markedly unstable.

The grey area in treatment decision making includes:

Some authors recommend ORIF if the epicondyle is displaced >2 mm, others have reported that nonsurgical treatment yields results that are similar to or better than those of surgical treatment.

The high demand athlete, (valgus stress, gymnasts, baseball pitchers). It has been postulated that fibrous union of the medial epicondyle may result in laxity of the medial collateral ligament of the elbow. It has been suggested that in the high demand athlete these are best treated with internal fixation. This is based on a case series of only 8 patients and a biomechanical study. In the retrospective reviews of clinical outcome and function no clinical difference in long term elbow stability has been noted irrespective of treatment method. This retrospective review has been criticised that they did not perform stress radiographs to exclude instability. At the end of the day it is symptoms and function that matter. Nyska et al. reported on eight professional teenaged arm wrestlers treated with collar-and-cuff immobilization for an average of two weeks; within a few months, these patients fully recovered their ability to perform strenuous activities without any symptoms.

Although nonunion with non operative management of the epicondylar fragment can occur in up to 55% of patients, the functional results are good.
The latest long term study has limitations but has shown good function and stable movement of the elbow and suggested that nonunion of the medial epicondyle should no longer be considered a complication of nonsurgical treatment but rather should be thought of as an asymptomatic consequence.

Surgical management does reduce the non union rate but does not alter final function and leaves the scar and has been reported to induce over/ abnormal growth of the medial epicondyle.

Varus and valgus growth disturbances have been described, irrespective of treatment method. This is likely due to injury to the distal physeal growth plate at the time of injury. The medial epicondyle is an apophysis ad should not affect growth of the distal humerus

Nerve dysfunction has been reported in both operative and non operative treatment

Excision of the fractured epicondyle has been recommended for patients with comminution of the fragment as well as for fractures undergoing delayed treatment, This is probably best avoided if possible as even non unions can be asymptomatic and excision may lead to instability.

Kamath et al 2009 in there systematic review suggest operative fixation in displaced medial epicondylar fractuers to minimise the incidence of non union, yet go on to say pain and ulnar nerve symptoms are the same after non operative or operative fixation. In the review complcations following internal fixation included septic arthritis, heterotopic ossification, tender prominent keloid scar, loss of fixation (missed wires), pin tract infection.

Internal fixation reduces non union rates vs non operative treatment, despite this it has not been proven to be superior in terms of final outcome.

If the non union remains symptomatic or leads to valgus instability in the rare case it is symptomatic operative fixation remains an option.

Summary

Non operative treatment is indicated in the first instance. Unless the patient is likely to place excessive physical demands on the elbow, particularly sports that place considerable valgus force on the elbow in a repetitive manner leading to valgus overload problems (eg gymnast or baseball pitcher as an occupation not past time/ hobby).

Consider surgery

Medial epicondyle trapped in joint (Often able to reduce closed may only require MUA)
Ulnar nerve symptoms
Elbow instability
Highly competitive sports person in sport that is likely to place considerable valgus stress on elbow

References

Farsetti P, Potenza V, Caterini R, Ippolito E. Long-term results of treatment of fractures of the medial humeral epicondyle in children. JBJS Am. 2001 Sep;83-A(9):1299-305.

In our study, nonsurgical treatment of isolated fractures of the medial humeral epicondyle with between 5 and 15 mm of displacement yielded good long-term results similar to those obtained with open reduction and internal fixation. The nonunion of the epicondylar fragment that was present in most patients who had been treated only with a cast did not adversely affect the functional results. Surgical excision of the medial epicondylar fragment should be avoided because the long-term results are poor.

Injury 1988 Sep;19(5):342-4, Treatment of fractures of the medial epicondyle of the humerus. Wilson NI, Ingram R, Rymaszewski L, Miller JH.

Retrospective review, 43 medial epicondyle fracture; 20 non-operative, 23 operative. Any final disability was slight, irrespective of the treatment used. Although surgery was more likely to restore the fragment to its normal position (P = 0.0001) and achieve bony union (P = 0.04), minor symptoms were less common in the non-operatively treated group (P = 0.02). Instability of the elbow not demonstrated in any patient. Recommend that operative treatment only when an intra-articular fragment cannot be removed from the joint by manipulation.

J. M. Flynn, J. F. Sarwark, P. M. Waters, D. S. Bae, and L. Powers Lemke The Operative Management of Pediatric Fractures of the Upper Extremity
JBJS Am., November 12, 2002; 84(11): 2078 - 2089.

Atul F. Kamath,1 Keith Baldwin,1 John Horneff,1 and Harish S. Hosalkar; Operative versus non-operative management of pediatric medial epicondyle fractures: a systematic review; J Child Orthop. 2009 October; 3(5): 345–357