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CURRENT
OPINION Medial epicondyle fractures in children
Rubini Pathy and Emily R. Dodwell
Purpose of review
The present review discusses the relevant anatomy, clinical presentation, and management of medial
epicondyle fractures, including diagnostic controversies, the indications for operative and nonoperative
management, and outcomes.
Recent findings
Recent studies have highlighted the underestimation of fracture displacement seen on typical radiographic
views and have attempted to define the location of the medial epicondyle on radiographs to improve the
accuracy of measuring displacement. They have demonstrated variable outcomes following open reduction
and internal fixation of medial epicondyle fractures that are associated with intra-articular incarceration.
Newer evidence supports the fixation of medial epicondyle fractures in adolescent athletes, to allow return
to competitive sports.
Summary
Medial epicondyle fractures of the distal humerus account for 12% of pediatric elbow fractures and are
frequently associated with intra-articular incarceration of the fracture fragment, elbow dislocation, ulnar
nerve injury, and other upper extremity fractures. Recent literature calls into question the accuracy of
measuring fracture displacement, and controversy exists regarding optimal management of these fractures.
Good outcomes have been achieved with nonoperative treatment for minimally displaced fractures, despite
a high rate of nonunion. In patients with displaced fractures, fixation yields stability, functional range of
motion, and the ability to return to previous activity levels, including sports. Complications include stiffness,
instability, deformity, superficial wound infections, and symptomatic nonunion. Further study is required to
standardize the measurement of displacement and to clarify indications for operative treatment in both
sedentary and active children.
Keywords
displacement, elbow dislocation, incarceration, management, medial epicondyle fracture
INTRODUCTION
Fractures of the medial epicondyle of the distal
humerus account for approximately 12% of all
pediatric elbow fractures [1]. These fractures occur
most frequently between the ages of 9 and 14 and
are four times more common in boys [1]. They are
associated with elbow dislocation in 50% of chil-
dren, and incarceration of the medial epicondyle
fragment within the elbow joint occurs in 15–18%
of children [1]. Ulnar nerve dysfunction has been
reported in 10–16% of children with these fractures
[1,2].
Controversy exists regarding the management
of medial epicondyle fractures, including the
reliability of measuring fracture displacement on
radiographs, the indications for operative treat-
ment, and the outcomes of operative and nonoper-
ative treatment. These are important considerations
given the increased participation of children and
adolescents in competitive sports and the desire to
return to a high level of function after such an
injury.
The present review will discuss the relevant
anatomy, clinical presentation, and management
of medial epicondyle fractures, including diagnostic
controversies, the indications for operative and
nonoperative management, and outcomes.
RELEVANT ANATOMY
The medial epicondyle ossification center at the
distal humerus appears at 4–9 years of age [1,3]
Hospital for Special Surgery, New York, New York, USA
Correspondence to Dr Emily R. Dodwell, MD, MPH, FRCSC, Pediatric
Orthopedic Surgeon, Hospital for Special Surgery, 535 E 70th St,
New York, NY 10021, USA. Tel: +1 212 606 1451; e-mail: dodwelle
@hss.edu
Curr Opin Pediatr 2015, 27:58–66
DOI:10.1097/MOP.0000000000000181
www.co-pediatrics.com Volume 27 Number 1 February 2015
REVIEW
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and is the last distal humerus ossification center to
fuse at 15–20 years old [1,4]. The medial epicondyle
is an apophysis, on the posterior-medial aspect of
the distal humerus, which is subject to traction
forces, that can lead to avulsion [1]. As an apophysis,
it does not contribute to longitudinal growth [1,4].
It serves as the origin of the flexor pronator mass
[1,4] and the ulnar collateral ligament (UCL), of
which the anterior band is the most important
stabilizer to valgus stress [4,5]. In younger children,
part of the capsule can extend up to the apophyseal
line [1]. In older children, however, as the epicon-
dyle migrates more proximally, the fracture is
typically extra-articular [1]. The ulnar nerve enters
the cubital tunnel posterior to medial epicondyle.
Its close proximity to the medial epicondyle puts it
at risk of injury with medial epicondyle fractures.
The medial epicondyle is supplied by the inferior
ulnar collateral artery and a medial vascular arcade,
which is an anastomosis between superior and
inferior ulnar collateral arteries and the posterior
ulnar recurrent branch of ulnar artery [4].
CLINICAL PRESENTATION
Common mechanisms of injury, classification of
medial epicondyle fractures, common physical
examination findings, and imaging findings will
be discussed below.
Mechanism of injury
The most common mechanisms of injury that result
in a medial epicondyle fracture include a direct blow
to the elbow or, more commonly, an avulsion injury
[1–4]. With direct trauma, the medial epicondyle
can be fragmented [1]. Avulsion fractures can occur
in several ways. Those caused by the flexor pronator
mass can occur with a valgus force on the elbow
during a fall on an outstretched hand with the elbow
extended [1,4]. Isolated avulsion fractures due to the
pull of the flexor pronator mass occur during pitch-
ing or wrestling [1,4]. Avulsion fractures can also be
caused by pull of the UCL, which can occur with
posterior elbow dislocations [1,4].
Classification
Multiple classification systems exist for medial epi-
condyle fractures; however, none have been vali-
dated. Wilkins classified fractures as acute or
chronic, with acute fractures subdivided into four
categories: undisplaced, minimally displaced, sig-
nificantly displaced, or incarcerated in the joint
[1,4]. Similarly, both the Rang and Watson Jones
classifications characterize fractures as those with
minimal displacement, displacement and rotation,
and intra-articular entrapment with or without an
elbow dislocation (see Fig. 1) [3,6]. Clinically, the
Watson Jones classification is useful as type I frac-
tures (5 mm displaced) are treated nonoperatively,
and type III and IV fractures (incarcerated with and
without dislocation) are treated operatively [6].
Controversy exists regarding the treatment of
type II fractures (5 mm displaced).
Physical examination
Patients with medial epicondyle fractures typically
have soft tissue swelling, and tenderness to palpa-
tion along the medial elbow. Crepitus and deformity
may also be identified. The range of motion of the
elbow may be decreased from an incarcerated frag-
ment, frank dislocation, or secondary to pain [4].
Careful examination of the remainder of the upper
extremity is mandatory, as this fracture has also
been reported in conjunction with other injuries,
including fractures of the distal radius, radial head
and neck, coronoid, and olecranon [1]. A detailed
neurovascular exam, with particular attention to
ulnar nerve function (abduction and adduction of
the fingers and sensation over the ulnar border of
the fifth digit), should be undertaken (Fig. 2) [7].
Imaging
Anteroposterior (AP), lateral, and internal oblique
plain radiographs of the elbow are recommended in
diagnosing medial epicondyle fractures. Typically,
there is disruption of the cortical contour on the AP
KEY POINTS
Medial epicondyle fractures often occur as a result of
an avulsion force, a direct blow, or a fall on an
outstretched hand, with 50% being associated with an
elbow dislocation.
Internal oblique and axial radiographs can be helpful
in visualizing a medial epicondyle fracture that is not
apparent on the anteroposterior (AP) and lateral views.
A medial epicondyle fracture fragment that appears
below the level of the joint or that is absent from its
normal position must be considered incarcerated in the
joint unless proven otherwise.
Incarcerated and open fractures are absolute
indications for surgery.
Satisfactory outcomes have been demonstrated with
both operative and nonoperative treatment of displaced
fractures.
Medial epicondyle fractures in children Pathy and Dodwell
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view, with loss of parallelism of the smooth sclerotic
margins of the apophysis, and increased width of
the radiolucency in the area of the apophyseal line
(Fig. 3) [1,2]. The oblique view can be particularly
useful as the direction of displacement is often out
of plane from the standard AP and lateral views;
thus, maximal displacement (typically anterior) can
be seen on the internal oblique view [1,4]. Elbow fat
pad signs or an effusion are usually absent as the
injury is extra-articular [1]. If a significant effusion
exists, one must have a high index of suspicion for
elbow dislocation or additional fractures around the
elbow [1].
The medial epicondyle fragment is not easily
incarcerated in the joint unless significant joint
displacement occurred, as in elbow dislocation.
Elbow dislocations frequently reduce spontaneously,
prior to presentation for medical attention. If the
medial epicondyle appears at the level of the joint
or is absent at its normal position, it should be
considered incarcerated, even without an associated
dislocation [1,4,8

]. The incarcerated fragment
usually lies between the trochlea and the semilunar
notch of the olecranon [1]. Failure to recognize intra-
articular entrapment of the epicondyle can cause
significant restriction of mobility and has been
reported to cause ulnar nerve symptoms in up to
50% of patients [1,9

]. The fragment can heal to
the coronoid, causing stiffness and pain, and a thick
fascial band has been reported in chronic fractures
Type I Type II Type III Type IV
(a) (b) (c) (d)
FIGURE 1. Watson Jones classification of medial epicondyle fractures. (a) Type I: 5 mm, displaced, no rotation. (b) Type II:
5 mm displaced, with rotation. (c) Type III: incarcerated, without dislocation. (d) Type IV: incarcerated with dislocation.
Reproduced from [6].
FIGURE 2. Cutaneous innervation of the hand. Cutaneous distribution of the radial (clear section), median (stippled section),
and ulnar (diagonal lines) nerves. Reproduced from [7].
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that are incarcerated, which binds the ulnar nerve to
the underlying muscle [1]. The pediatric elbow can be
difficult to assess because of the multiple ossification
centers that show up at various time points. The
appearance of ossification centers begins with the
capitellum first, followed by the radial head, medial
epicondyle, trochlea, olecranon, and finally the lat-
eral epicondyle. In a child who is too young to have
trochlear ossification (younger than age 8), ossifica-
tion in this area may be indicative of an incarcerated
fragment (Fig. 4c and d).
Controversy exists regarding the accuracy and
reliability of measuring displacement of the medial
epicondyle fracture on radiographs. When assessing
reliability, clinicians demonstrate moderate to high
agreement with themselves on the AP view, as
measured by the intraclass coefficient (ICC 0.76
for intraobserver agreement), and with other clini-
cians (ICC 0.80 for interobserver agreement) [10].
When using a criterion of a difference of at least
2 mm among reviewers as clinical disagreement,
however, evaluators disagree with their own
measurements 26% of the time and colleagues’
measurements 54% of the time [10]. It is unknown
as to whether detecting a 2 mm difference in dis-
placement is clinically significant [10].
Medial epicondyle fracture displacement has
also been assessed on computed tomography (CT)
scans and compared with plain radiographs [11].
On the sagittal CT view, an average of 8.8 mm of
anterior displacement was seen, compared with
0.9 mm on a lateral radiograph, implying that close
to 1 cm of anterior displacement is missed on a
lateral radiograph [11]. Only 1 out of 11 children
was found to have an undisplaced fracture (less than
5 mm) on the CT scan, but all 11 were reported as
undisplaced on radiographs [11]. While acknow-
ledging the radiation risk of CT scans, Edmonds
[11] states that prior studies using AP views and
valgus stress views on plain radiographs may not
be valid in measuring displacement as most frag-
ments are displaced anteriorly rather than medially.
Using a 458 internal oblique radiograph on a
cadaver model, Gottschalk et al. [12

] demonstrated
excellent interrater and intrarater reliability,
with 60% accuracy (defined as within 2 mm of true
displacement) in quantifying the displacement of
medial epicondyle fractures. Recently, Souder et al.
[13] proposed an axial radiographic view of the
elbow to improve the accuracy and reliability of
measuring the displacement of medial epicondyle
fractures. Using a cadaver model, Souder et al. [13]
found that at 10 mm displacement, AP views under-
estimated displacement by 5.5 mm and internal
oblique views underestimated displacement by
3.8 mm. Surgeons were unable to detect less than
10 mm displacement on the lateral view [13]. Axial
images more closely estimated the true amount of
displacement, with a mean 1.5 mm error for frac-
tures displaced less than 10 mm and a mean of
0.8 mm error for displacements of at least 10 mm
[13]. Furthermore, axial images had greater
reliability (ICC 0.974) than AP or internal oblique
views (ICC 0.257) [13].
In an attempt to standardize the manner in
which displacement of the medial epicondyle is
measured, Klatt and Aoki [14] analyzed radiographs
of 171 patients to identify the usual position of the
medial epicondyle. A consistent position of the
center of medial epicondyle was 0.5 mm inferior
to inferior olecranon line on the AP view and
1.2 mm anterior to the posterior humeral line on
FIGURE 3. Radiographic views of displaced medial epicondyle fractures. AP (a) and lateral (b) elbow views demonstrating
disruption of the cortical contour on the AP view, with loss of parallelism of the smooth sclerotic margins of the apophysis, and
increased width of the radiolucency in the area of the apophyseal line. In (c) and (d), the rotation of the fracture is clearly
seen on both the AP and lateral views. AP, anteroposterior.
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lateral view [14]. The average position of the medial
epicondyle as seen on the AP view remains constant
through aging, whereas on the lateral view, it shifts
1 mm anteriorly on average with age [14]. Utilizing
these parameters may improve the accuracy of
measuring medial epicondyle fracture fragment dis-
placement.
Given the attachment of the UCL on the medial
epicondyle, some authors [1,3,5,15–19] recom-
mend gravity-assisted testing (valgus stress test) of
the medial stability of the elbow with or without
fluoroscopy, often requiring sedation. The patient
lays supine, with the shoulder abducted and exter-
nally rotated to 908, with 158 of elbow flexion.
Gravity alone or an applied valgus stress can dem-
onstrate medial opening [1]. A positive valgus stress
test, however, may not necessarily be a surgical
indication, as almost all patients with any signifi-
cant displacement have a positive valgus stress test
acutely [1]
MANAGEMENT
Optimal management of medial epicondyle frac-
tures is controversial, with evidence demonstrating
good outcomes with both operative and nonoper-
ative treatment [1,3,4,8

,15–32,33

,34]. However,
there is a trend toward more aggressive surgical
fixation and early range of motion for children with
this injury. Most historic treatment algorithms are
based on the degree of displacement. Unfortunately,
as detailed above, recent studies have demonstrated
FIGURE 4. Incarcerated medial epicondyle fracture associated with an elbow dislocation. Elbow dislocation with a displaced
medial epicondyle fragment (a and b). After reduction, radiographs demonstrating an incarcerated intra-articular medial
epicondyle fragment, which can be mistaken for a trochlear ossification center on the AP (c) and lateral (d) radiographs. Note
the absence of the medial epicondyle from its customary location. AP (e) and lateral (f) radiographs demonstrating open
reduction and internal fixation, with two cannulated screws, of the medial epicondyle fracture. AP, anteroposterior.
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that traditional methods of measuring displacement
may underestimate displacement, making it diffi-
cult to assess whether patients in historic series were
appropriately categorized in their degree of displace-
ment. Therefore, results of prior studies linking dis-
placement to surgical indications and outcomes
may not be valid [10,11].
The amount of displacement that necessitates
operative management is also controversial [1,3,4,
13,15,18,25]. Historically, fractures more than 1 cm
displaced were treated surgically, and those less than
1 cm displaced were treated with a cast. Current
recommendations for fixation range from as little
as 2 mm displacement to more than 5 mm displace-
ment with signs of valgus instability [3,15,18,28].
There is general consensus that absolute indications
for operative management are open fractures or
fractures with an incarcerated medial epicondyle
[1–4,21,22]. Relative indications include ulnar nerve
dysfunction, gross elbow instability, displacement,
and the desire to return rapidly to high-level athletics
or high-demand employment [1–4,21,22].
Few prospective clinical studies comparing man-
agement techniques exist, with fewer including
standardized methods of displacement measure-
ment and validated outcome scales.
Nonoperative management
Nonoperative management usually consists of
immobilization in a long arm cast with the elbow
flexed to 908 for approximately 3–4 weeks. Good
results have been demonstrated with nonoperative
treatment of medial epicondyle fractures [20,21,
23–27]. Josefsson and Danielsson [23] followed
medial epicondyle fractures that were initially dis-
placed 4–8 mm and treated nonoperatively. At an
average of 35-year follow-up, all patients demon-
strated ‘good’ function, despite a 63% nonunion
rate, with no difference in symptoms in the healed
versus nonunion group [23]. Similarly, Farsetti et al.
[24] followed children with medial epicondyle
fractures displaced 5–15 mm, during an average of
45 years. The authors [24] reported ‘fair’ to ‘good’
outcomes in both the nonoperative and operative
groups, despite an 89% rate of nonunion in the non-
operative group. They also reported long-term pain
with acute fragment excision [24]. Given the recently
recognized errors in measuring displacement, it is
possible that these studies underestimated the degree
of displacement. Furthermore, the terms ‘good’ and
‘fair’ are not standardized across studies. Recently,
Ip and Tsang [25] reported that nonoperative treat-
ment of medial epicondyle fractures that were dis-
placed less than 5 mm yielded good to excellent
functional outcomes, as measured by the Mayo
Elbow Performance Scores. Teenage arm wrestlers
who underwent nonoperative treatment of medial
epicondyle fractures have been reported to be able
to return to arm wrestling despite the majority of
athletes experiencing a nonunion [26,27]. Thus,
although nonunion occurs in the majority of frac-
tures treated nonoperatively, patients achieve good
functional outcomes.
Operative management
Options for fixation include sutures, Kirschner
wires (K-wires), cannulated screws, and excision of
the fragment with advancement of the medial
soft tissues [1–4,8

,9

,15,16,18,19,27–32,33

,34–37].
Many authors [1–4,8

,9

,15,16,18,19,27–32,33

,
34–37] suggest the use of K-wires in younger children
and cannulated screws in older children. Sutures are
typically used only for very small or comminuted
fragments. K-wires are used if the fragment is too
small to accept a screw, typically in younger children.
When using cannulated screws, the use of a washer
can help increase surface area for compression (and
thus better distribute the compressive force of the
screw), avoidscrewheadpenetration of the fragment,
and prevent screw migration. Various techniques for
reduction have been described, including prone or
supine positioning [29], using an Esmarch to milk the
soft tissues toward the fracture site to assist in the
reduction [30], and utilizing the Roberts maneuver
[1,4]. The Roberts maneuver consists of applying a
valgus stress on the elbow, with forearm supination
and extension of the wrist and fingers, in order to
extract the intra-articular fragment [1]. As the medial
epicondyle is a posterior structure, the screw is typi-
cally oblique, directly from medial to lateral, and
from posterior to anterior. One must avoid implants
entering the olecranon fossa, as this will lead to a loss
of extension [2–4]. Typically, a 3.5 or 4.0mm parti-
ally threaded cannulated screw is used. Because of
the compression gained from the partial threads, the
screw does not need to be bicortical.
Most authors [4,29–31,33

,34] agree that the
ulnar nerve does not require routine exploration or
transposition. The ulnar nerve may be more suscept-
ible to partial devascularization after transposition
following recent trauma versus transposition in an
elective nontraumatic situation [31]. To avoid stiff-
ness following rigid fixation of the fragment with a
screw, most authors prefer a short period of
immobilization (7–10 days), and then early mobiliz-
ation, either with or without a brace to prevent
excess valgus stress on the fixation[1–4,8

,9

,15,
16,18,19,27–32,33

,34–37].
Operative fixation of fractures displaced more
than 5 mm with valgus instability yields union rates
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ranging from 90 to 100%, with negative valgus stress
tests and excellent functional scores [15,16,24]. A
functional postoperative range of motion is typical
following surgical fixation, with an average of 1108
arc [15]. The majority of patients achieve full exten-
sion, with only 4% reporting an extension deficit of
up to 208 [16]. The elbow is typically stable following
surgical fixation, ranging from no valgus instability
[16] to as much as 108 valgus opening in 4% of
patients [15].
In competitive athletes, successful and timely
return to the prior level of athletic activity has been
demonstrated following surgical fixation of medial
epicondyle fractures that were displaced more than
5 mm or in whom preoperative valgus instability
was noted [15,18]. Several authors [8

,19,35] report
excellent Mayo Elbow Performance Scores, no
deformity or valgus instability, and an average loss
of 4–6.4 degrees of extension following open
reduction and internal fixation of medial epicon-
dyle fractures associated with incarceration, dis-
location, or both. Furthermore, these patients can
be expected to return to sports, an average 4 months
postoperatively, at their preinjury level [35].
Superficial infection rates following the fixation
of medial epicondyle fractures range from 0 to 6%
[15,16,24,28]. Management of superficial infections
usually includes oral antibiotics and local wound
care. Long-term radiographic findings following
medial epicondyle fracture include hyperplasia or,
less commonly, hypoplasia of the medial epicon-
dyle, periarticular calcification, a medial condyle
groove, and fragmentation of the medial epicondyle
[15,16].
The incidence of ulnar nerve dysfunction varies
from 10 to 16% and, if incarcerated in the joint, can
be as high as 50% [1,2]. A spontaneous resolution
rate of 100% of preoperative ulnar nerve dysfunc-
tion was reported postoperatively by both
Hines et al. [28] and Louahem et al. [16]. Anakwe
et al. [31] reported delayed ulnar neuropathy after
screw fixation in two patients, both of whom
required a secondary procedure to decompress the
ulnar nerve palsy, with complete recovery between
18 months and 2 years. Marcu et al. [32] reported
two cases of radial neuropathy, likely caused by the
end of a threaded guide pin inadvertently advanced
into anterolateral soft tissues.
Comparative studies
Although prospective clinical trials are lacking, a
systematic review of medial epicondyle fractures
[21] showed no difference in pain or ulnar nerve
symptoms between operative and nonoperative
groups, despite a 9.33 greater odds of union with
operative treatment. This systematic review, how-
ever, included studies that were quite varied in their
analysis of range of motion, outcome measures, and
description of fracture displacement and compli-
cations.
Other studies [33

,34] report successful return to
sports following both operative and nonoperative
treatment. In two retrospective reviews comparing
nonoperative treatment of minimally displaced
fractures with no instability with operative fixation
of displaced fractures with instability in competitive
athletes [33

,34], all athletes were able to return to
sport, including overhead athletes and competitive
baseball pitchers.
In patients with medial epicondyle fractures
that are associated with incarceration, disloca-
tion, or both, several authors [8

,19,35] report excel-
lent Mayo Elbow Performance Scores, no deformity
or valgus instability, and an average loss of
4–6.4 degrees of extension following open reduc-
tion and internal fixation. Furthermore, these
patients can be expected to return to sports,
an average 4 months postoperatively, at their pre-
injury level [35]. Risk of ulnar neuropathy in these
injuries can be as high as 55% preoperatively and up
to 36% postoperatively [8

]. Other complications
include screw irritation and median nerve entrap-
ment in the joint by the fragment and by the UCL
[35]. In contrast, Fowles et al. [36] reported good
results with nonoperative treatment and increased
stiffness following operative fixation, in children
who sustained a medial epicondyle fracture and
an elbow dislocation. A total of 61% of those treated
nonoperatively had a pain-free, stable elbow, with
42% losing an average of 158 flexion. In fractures
that were open, or had significant displacement or
incarceration, 60% lost an average of 378 flexion
[36].
Two recent studies [20,37] have demonstrated
equivalent elbow range of motion following oper-
ative and nonoperative management of medial
epicondyle fractures. However, one of the studies
[37] reported a 53% complication rate in the non-
operativegroup, with 47% of those patients requiring
surgery within 3 years, although the complications
were not specified. Thus, outcomes are variable
when directly comparing nonoperative and opera-
tive treatment of medial epicondyle fractures.
Trends in treatment over time
Because of prolonged casting, stiffness, and the
potential for instability following nonoperative
treatment, and increasing athletic activities in
children and adolescents, the surgical indications
for medial epicondyle fractures have been shifting,
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although not necessarily based on strong evidence
[2–4,15,18,22,28]. Many surgeons believe that sur-
gical fixation of medial epicondyle fractures allows
earlier return to sports and more rapid return to a
preinjury level of function [15,18]. We, however, do
not yet have definitive clinical studies supporting
this belief, as a number of studies report full return
to sports at the previous level of play for fractures
treated nonoperatively [26,27,33

,34].
Nonunion following nonoperative treatment of
medial epicondyle fractures is common, but is often
asymptomatic [21,24–26]. At an average of 11 years
after injury, Smith et al. [38] reported a 21% rate of
symptomatic nonunion of medial epicondyle frac-
tures that were initially displaced an average of
4.3 mm. At an average of 4.7 years following fixation
of the nonunion, patients demonstrated improved
pain scores and range of motion, and returned
to athletic activity an average of 5 months after
fixation, at the same or higher level than prior to
the fracture, except for one patient [38]. Gilchrist
and McKee [17] performed excision of the medial
epicondyle and UCL advancement on patients with
symptomatic nonunion with valgus instability,
with an average of 11-year follow-up. The authors
[17] demonstrated improved Mayo Elbow Perform-
ance Scores and no valgus instability. Therefore,
chronic symptomatic nonunion, although less com-
mon than asymptomatic nonunion, can be treated
successfully with operative fixation or excision.
CASE EXAMPLE
An 8-year-old girl presented with a closed fracture
dislocation of the right elbow sustained in a fall onto
her outstretched arm. Initial radiographs demon-
strate a posterolateral dislocation and displaced
medial epicondyle fracture (Fig. 4a and b). After
closed reduction (Fig. 4c and d), radiographs dem-
onstrated intra-articular incarceration of the medial
epicondyle fragment. This patient underwent suc-
cessful open reduction and internal fixation of the
medial epicondyle fracture with two cannulated
screws (Fig. 4e and f).
CONCLUSION
Medial epicondyle fractures of the distal humerus
account for 12% of pediatric elbow fractures and are
frequently associated with intra-articular incarcera-
tion of the fracture fragment, elbow dislocation,
ulnar nerve injury, and other upper extremity frac-
tures. Recent literature calls into question the
accuracy of measuring fracture displacement, and
controversy exists regarding optimal management
of these fractures. Good outcomes have been
achieved with nonoperative treatment for mini-
mally displaced fractures, despite a high rate of
nonunion. In patients with displaced fractures,
fixation yields stability, functional range of motion,
and the ability to return to previous activity levels,
including sports. Complications include stiffness,
instability, deformity, superficial wound infections,
and symptomatic nonunion. Further study is
required to standardize the measurement of dis-
placement and to clarify indications for operative
treatment in both sedentary and active children.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
None.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
of special interest
of outstanding interest
1. Beaty JH, Kasser JH. The elbow-physeal fractures, apophyseal injuries of the
distal humerus, osteonecrosis of the trochlea, and T-condylar fractures. In:
Beaty JH, Kasser JR, editors. Rockwood Wilkins’ fractures in children.
Philadelphia, PA: Lippincott Williams Wilkins; 2005. pp. 628–642.
2. Patel NM, Ganley TJ. Medial epicondyle fractures of the humerus: how to
evaluate and when to operate. J Pediatr Orthop 2012; 32:S10–S13.
3. Pring M, Rang M, Wenger D. Elbow-distal humerus: medial epicondyle
fractures. In: Rang M, Pring ME, Wenger DR, editors. Rang’s children’s
fractures, 3rd ed. Philadelphia, PA: Lippincott Williams Wilkins; 2005. pp.
115–118.
4. Gottschalk HP, Eisner MD, Hosalkar HS. Medial epicondyle fractures in
children. J Am Acad Orthop Surg 2012; 20:223–232.
5. Schwab GH, Bennett JB, William GW, Tullos HS. Biomechanics of elbow
instability: the role of the medial collateral ligament. Clin Orthop Relat Res
1980; 146:42–52.
6. Vrettos BC, Hoffman EB. Condylar fractures in children: fractures of the
medial epicondyle. In: Stanley D, Trail IA, editors. Operative elbow surgery,
1st ed. Edinburgh, UK: Elsevier Health Sciences UK; 2012. pp. 65–66.
7. Gordon J, Fisher MA. Peripheral neuropathy. In: Weiner WJ, Goetz CG, Shin
RK, Lewis SL, editors. Neurology for the non-neurologist, 6th ed. Philadelphia,
PA: Lippincott Williams Wilkins; 2010. p. 278.
8.

Dodds SD, Flanigan BA, Bohl DD, et al. Incarcerated medial epicondyle
fracture following pediatric elbow dislocation: 11 cases. J Hand Surg Am
2014; 39:1739–1745.
This article describes outcomes following open reduction and internal fixation of
medial epicondyle fractures associated with elbow dislocation.
9.

Lima S, Correia JF, Ribeiro RP, et al. A rare case of elbow dislocation
associated with unrecognized fracture of medial epicondyle and delayed
ulnar neuropathy in pediatric age. J Shoulder Elbow Surg 2013; 22:e9–e11.
This article describes a case of an ulnar nerve palsy that uncovered a delayed
diagnosis of a medial epicondyle fracture associated with an elbow dislocation.
10. Pappas N, Lawrence JT, Donegan D, et al. Intraobserver and interobserver
agreement in the measurement of distal humeral medial epicondyle fractures
in children. J Bone Joint Surg Am 2010; 92:322–327.
11. Edmonds EW. How displaced are ‘nondisplaced’ fractures of the medial
humeral epicondyle in children? Results of a three-dimensional computed
tomography analysis. J Bone Joint Surg Am 2010; 92:2785–2791.
12.

Gottschalk HP, Bastrom TP, Edmonds EW. Reliability of internal oblique
elbow radiographs for measuring displacement of medial epicondyle humerus
fractures: a cadaveric study. J Pediatr Orthop 2013; 33:26–31.
This article describes the accuracy and reliability of utilizing 45 and 608 internal
oblique radiographs to assess fracture displacement.
Downloaded
from
by
on
11/04/2024

13. Souder CD, Farnsworth CL, McNeil NP. The distal humerus axial view:
assessment of displacement in medial epicondyle fractures. J Pediatr Orthop
2014; doi: 10.1097/BPO.0000000000000306. [Epub ahead of print]
14. Klatt JB, Aoki SK. The location of the medial humeral epicondyle in children:
position based on common radiographic landmarks. J Pediatr Orthop 2012;
32:477–482.
15. Lee HH, Chen HC, Chang JH, et al. Operative treatment of displaced medial
epicondyle fractures in children and adolescents. J Shoulder Elbow Surg
2005; 14:178–185.
16. Louahem DM, Bourelle S, Buscayret F, et al. Displaced medial epicondyle
fractures of the humerus: surgical treatment and results. A report of 139
cases. Arch Orthop Trauma Surg 2010; 130:649–655.
17. Gilchrist AD, McKee MD. Valgus instability of the elbow due to medial
epicondyle nonunion: treatment by fragment excision and ligament repair:
a report of 5 cases. J Shoulder Elbow Surg 2002; 11:493–497.
18. Case SL, Hennrikus WL. Surgical treatment of displaced medial epicondyle
fractures in adolescent athletes. Am J Sports Med 1997; 25:682–686.
19. Pimpalnerkar AL, Balasubramaniam G, Young SK, Read L. Type four fracture
of the medial epicondyle. A true indication for surgical intervention. Injury
1998; 29:751–756.
20. Kwak JL, Silva M. The outcome of nonoperative treatment of medial epicon-
dyle fractures in the pediatric population. In: Podium presentation: POSNA.
2013.
21. Atul KF, Baldwin K, Hornef H, Hosalkar HS. Operative versus nonoperative
management pediatric medial epicondyle fractures: a systematic review.
J Child Orthop 2009; 3:345–357.
22. Mehlman CT, Howard AH. Medial epicondyle fractures in children: clinical
decision making in the face of uncertainty. J Pediatr Orthop 2012; 32:S135–
S142.
23. Josefsson PO, Danielsson LG. Epicondylar elbow fracture in children: 35-year
follow-up of 56 unreduced cases. Acta Orthop Scand 1986; 57:313–315.
24. Farsetti P, Potenza V, Caterini R, Ippolito E. Long-term results of treatment of
fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am
2001; 83A:1299–1305.
25. Ip D, Tsang WL. Medial humeral epicondylar fracture in children and ado-
lescents. J Orthop Surg (Hong Kong) 2007; 15:170–173.
26. Lokiec F, Velkes S, Enjel J. Avulsion fracture of the medial epicondyle of the
humerus in arm wrestlers: a report of five cases and a review of the literature.
Injury 1991; 22:69–70.
27. Nyska M, Peiser J, Lukiec F, et al. Avulsion fracture of the medial epicondyle
caused by arm wrestling. Am J Sports Med 1992; 20:347–350.
28. Hines RF, Herdon WA, Evans JP. Operative treatment of medial epicondyle
fractures in children. Clin Orthop Relat Res 1987; 223:170–174.
29. Glotzbecker MP, Shore B, Matheney T, et al. Alternative technique for open
reduction and fixation of displaced pediatric medial epicondyle fractures.
J Child Orthop 2012; 6:105–109.
30. Kamath AF, Cody SR, Hosalkar HS. Open reduction of medial epicondyle
fractures: operative tips for technical ease. J Child Orthop 2009; 3:331–336.
31. Anakwe RE, Watts AC, McEachan JE. Delayed ulnar nerve palsy after open
reduction internal fixation of medial epicondylar fractures. J Pediatr Orthop B
2010; 19:239–241.
32. Marcu DM, Balts J, McCarthy JJ, et al. Iatrogenic radial nerve injury with
cannulated fixation of medial epicondyle fractures in the pediatric humerus: a
report of 2 cases. J Pediatr Orthop 2011; 31:e13–e16.
33.

Lawrence JT, Patel NM, Macknin J, et al. Return to competitive sports after
medial epicondyle fractures in adolescent athletes: results of operative and
non operative treatment. Am J Sports Med 2013; 41:1152–1157.
This article compares nonoperative and operative treatment outcomes of athletes
with medial epicondyle fractures.
34. Osbahr DC, Chalmers PN, Frank JS, et al. Acute, avulsion fractures
of the medial epicondyle while throwing in youth baseball players: a
variant of Little League elbow. J Shoulder Elbow Surg 2010; 19:951–
957.
35. Tarallo L, Mugnai R, Fiacchi F. Pediatric medial epicondyle fractures with
intra-articular elbow incarceration. J Orthop Traumatol 2014. [Epub ahead of
print]
36. Fowles JV, Slimane N, Kassab MT. Elbow dislocation with avulsion of the
medial humeral epicondyle. J Bone Joint Surg Br 1990; 72:102–104.
37. Mayer EE, Eisman EA, Mehlman CT. Displaced medial epicondyle fractures in
children: comparative effectiveness of operative vs. nonoperative treatment.
E-poster. POSNA. 2014.
38. Smith JT, McFeely ED, Bae DS. Operative fixation of medial humeral epi-
condyle fracture nonunion in children. J Pediatr Orthop 2010; 30:644–648.
Orthopedics
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