A detailed history is necessary after acute injury, including the mechanism of injury and timing of the event. This history and exam also include the localization of symptoms and any prior history of injuries. In athletes, detailed information regarding hand dominance, sport and workout regimens, and changes in activity. It is essential to assess the functional demands of the patient to help tailor care.  Patients may also complain of loss of motion and neurological deficits such as decreased sensation or weakness. The history of any elbow instability events such as dislocation should be elicited.[1]

A physical exam is essential, including beginning with a skin examination for laceration, swelling, ecchymosis, deformity, or effusion. The exam also includes palpating bony landmarks for tenderness and assessing the range of motion.[1] Patients present with tenderness over medial elbow along with soft tissue swelling. The patient may have pain and crepitation with elbow motion or a mechanical block to the motion of the elbow.  Also, an examination of ulnar nerve function is key to physical examination. Ulnar nerve function includes abduction and adduction fo fingers and preserved sensation of the ulnar of the fifth digit and ulnar aspect of the ring finger. The examination should also include a thorough vascular exam and looking for other upper extremity fractures, including the radius and ulna. 

Radiographic imaging is recommended to diagnose medial epicondyle fractures. The preferred initial imaging series includes anterior-posterior (AP) and lateral view plain radiographs of the elbow, including an oblique view. The oblique view helps distinguish displacement. X-ray findings suggestive of medial epicondyle fractures include cortical contour disruption on the AP view of plain radiographs. Other findings include loss of parallelism along apophysis smooth margins. Trochlear ossification seen on radiographs in children younger than eight years old may be suggestive of an incarcerated fragment of medial epicondylar fracture as children younger than eight years old have not yet developed trochlear ossification.

Additionally, there are several classification systems present for medial epicondylar fractures. The Watson Jones classification can be useful to guide further treatment and management.  Watson Jone's classification consists of Type I through IV fractures. Type I includes fractures of less than 5 mm displacement with no rotation and are typically treated non-operatively. Type II fractures have greater than 5 mm displacement with rotation. Type III fractures have incarcerated fragments without dislocation. Type IV fractures are incarcerated with dislocation. Types III and Type IV receive operative treatment, while consideration is also given to patient factors for decision making in Type II fractures. Stress reaction or stress fractures in throwing athletes generally are treated conservatively and with a shutdown period to limit the chances of worsening the injury.[3]

Nonoperative Management

Isolated nondisplaced medial epicondyle fractures are best managed nonoperative management. This approach includes a brief period of immobilization in a long arm cast in the first week with the elbow flexed to 90 degrees.[4] After removing the splint, a protected exercise program should start, which will include active range of motion exercises. Stress fractures also receive nonoperative treated nonoperative treatment.[5]

Operative Management

Indications for surgical referral and operative management of medial epicondyle fractures include open fractures, incarcerated intra-articular fragments, and valgus instability. In these cases, surgical intervention for fracture is necessary. Intra-articular fragment entrapment occurs in 5-18% of cases of medial epicondylar fractures.[6] Operative techniques include the use of open reduction and internal fixation with a screw and washer construct, Kirschner wires,  or sutures and tension band techniques. Also, K-wires are the most common option for fragmented fractures in children.[3]  A posterior-medial approach is preferred to gain better access to the distal humerus. The patient may be placed supine but also laterally with hand placed on the back for better exposure of medial epicondyle for surgical access.[7][8]

• Medial condylar fracture
• Supracondylar fracture
• Medial epicondylitis 
• Elbow dislocation
• Olecranon bursitis
• Cubital tunnel syndrome
• Ulnar collateral ligament injury 

Both nonoperative and operative treatment and management have shown to have a good prognosis and outcomes.[2][9] Systematic reviews showed a 92.5% rate of a successful bony union in operatively managed medial epicondylar fractures versus 49.2% rate of a bony union in nonoperative managed groups.[10] Case series studies after 2 to 5 year follow up of medial epicondylar fractures show that nonoperative treatment is successful in minimally displaced medial epicondyle fractures with a stable elbow.[11]

Approximately 60% of the medial epicondyle fractures in pediatric patients are associated with elbow dislocation.[10][12] Also, about 10% to 15% percent of pediatric medial epicondyle fractures may result in ulnar nerve dysfunction.  Other complications include elbow stiffness, elbow instability, deformity, nonunion, and wound infections.[3][12] Reports of septic arthritis and myositis ossificans have been other observed complications of medial epicondylar fractures.[10]

Ulnar nerve involvement was prevalent in 9.6% of acute pediatric medial epicondyle fractures based on studies from large systematic reviews. Findings of ulnar neuropraxia included loss of sensation over the right radial aspect of the ring finger and the entire small finger after trauma. Patients with ulnar nerve palsy require surgical intervention with ulnar nerve decompression.[6] Studies showed functional outcome and nerve recovery after post-operative care. Findings showed full recovery of ulnar nerve deficits with early surgical intervention and nerve decompression.[13] 

Early postoperative motion after surgical fixation of displaced medial epicondylar fractures resulted in better outcomes.[14] Rehabilitation post-surgical intervention is key to continued recovery. The arm is immobilized, and patients start a conditioning program during immobilization. Physicians and physical therapists begin patients on an active range of motion exercise of elbow and forearm pronation and supination. When fracture shows union, strength training should commence helping further facilitate complete recovery.

Care coordination between physicians at emergent and urgent care facilities, primary care physicians, orthopedic surgeons, and physical or occupational therapists is key to improved patient outcomes with medial epicondylar fractures. Supervised active range of motion programs prescribed post-intervention, whether nonoperative or operative treatment is initialed, help protect and preserve functionality. Physical therapists and physicians working together help facilitate and execute these exercise programs.

Athletes with a history of elbow injuries require participation in a structured rehabilitation exercise program. A team consists of the physician and physical therapist, along with coordination with the patient. Types and frequency of practice sessions are gradually managed as a return to sport and play is determined in conjunction with both physician and physical therapist. [15] [Level 1]