Medial epicondyle fracture of the humerus

Symptoms include pain, swelling, bruising and a decreased ability to move or use the elbow. Blood in the soft tissues and knee joint (haemarthrosis) may lead to bruising and a doughy feel of the elbow joint.

An injury resulting in an outward (valgus) stress on the elbow, such as falling on an outstretched hand causes an avulsion fracture of the medial epicondyle.

The medial epicondyle is often the final growth plate (ossification center) to ossify in the elbow. Growth plates are particularly vulnerable to injury compared to bone. Children can have an open medial epicondyle growth plate until age 13–17 years old, thus making the medial epicondyle more susceptible to injury.[3]

Medial epicondyle fractures are associated with a dislocation of the elbow in about 25% of cases.

In all injuries to the medial epicondyle, radiographs (x-rays) are imperative. Computed tomography scans are occasionally useful in evaluating the degree of fracture displacement or the involvement of the joint surface.

There are several treatment options.

In children with a completely non-displaced fracture (i.e. the bone fragments have not moved), children will usually be treated in a cast without surgery.[7]

In children where the fragment of medial epicondyle is trapped in the joint, or where the elbow is dislocated and can’t be readily reduced in the emergency department, then there is universal agreement that surgery is needed to realign the bones.[8]

In children with a displaced fracture without a dislocation of the elbow (or an elbow dislocation that has been corrected), there is debate amongst surgeons about the best approach to treatment. Half of surgeons routinely recommend surgery, and half routinely recommend against surgery. The debate is whether to realign the displaced bones back into their natural position with surgery, and hold the fragments of bone with wires or screws, or whether to allow the fragments to heal in their current position by resting the elbow in a cast. Studies that have sought to draw together all of the scientific evidence, have failed to arrive at any firm conclusion, either in support of surgery or against surgery.[1][9] Some point to good to results without surgery,[9] whilst the others conclude that surgical fixation should be strongly considered to maximise the function in these children.[1]

However, the current published research has serious methodological limitations, particularly with regard to inconsistent follow-up, no standardisation of treatment approaches, the infrequent use of patient reported outcomes, and selection bias amongst those selected to undergo operative fixation.[10]

The uncertainty associated with this injury has prompted surgeons make the treatment of medial epicondyle fractures the most important unanswered question in children’s musculoskeletal injuries.[11]

Surgeons want to determine if surgery to restore the natural position of the elbow is better than allowing the bone to heal in the injured position in a cast. The SCIENCE study is currently underway across the UK, with more than 70 hospitals participating. It is funded by the UK National Institute for Health Research. Such is the level of international uncertainty, surgeons in Australia and New Zealand are joining the SCIENCE study. Furthermore, surgeons in the USA have also been awarded a National Institute of Health grant to address this question.[12] These studies fairly allocate children to either surgery or cast, through a process called randomisation. Surgeons around the globe are calling on parents and children with this injury to help them resolve their uncertainty, by allowing their children to be part of these studies. Whilst being part of research is difficult, families may wish to consider that patients involved in research typically have better outcomes than those not involved in research (called the trial-effect).[13]