Medial epicondyle fracture of the humerus
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A medial epicondyle fracture is an avulsion injury to the medial epicondyle of the humerus; the prominence of bone on the inside of the elbow. Medial epicondyle fractures account for 10% elbow fractures in children. 25% of injuries are associated with a dislocation of the elbow. Medial epicondyle fractures are typically seen in children and usually occur as a result of a fall onto an out-stretched hand. This often happen from falls from a scooter,
roller skates Roller skates, are shoes or bindings that fit onto shoes that are worn to enable the wearer to roll along on wheels. The first roller skate was an inline skate design, effectively an ice skate with wheels replacing the blade. Later the "quad ska ...
, or
monkey bars A jungle gym (called a climbing frame in British English) is a piece of playground equipment made of many pieces of material, such as metal pipes or ropes, on which participants can climb, hang, sit, and—in some configurations—slide. Monkey ...
, as well as from injuries sustained playing sports. The peak age of occurrence is 10–12 years old. Symptoms include pain, swelling, bruising and a decreased ability to move or use the elbow. Initial pain may be managed with NSAIDs,
opioid Opioids are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief, including anesthesia. Other medical uses include suppression of diarrhea, replacement therapy for opioid us ...
s, and splinting. The management of pain in children typically follows guidelines, such as those from the Royal College of Emergency Medicine. The diagnosis is confirmed with
X-rays An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 Picometre, picometers to 10 Nanometre, nanometers, corresponding to frequency, ...
and occasionally with a
CT scan A computed tomography scan (CT scan; formerly called computed axial tomography scan or CAT scan) is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers ...
. The treatment of these injuries is controversial, and there are currently ongoing international randomised studies
The SCIENCE study
is an ongoing study funded by the
National Institute for Health Research The National Institute for Health and Care Research (NIHR) is the British government’s major funder of clinical, public health, social care and translational research. With a budget of over £1.2 billion in 2020–21, its mission is to "impr ...
(UK). A similar study is being planned in the US, funded by the National Institutes for Health (US). These studies both seek to determine if surgery to restore the natural position of the elbow is better than allowing the bone to heal in a cast without restoring the natural position. Children and families internationally are being encouraged to participate in these research studies to resolve the uncertainties.


Signs and symptoms

Symptoms include pain, swelling, bruising and a decreased ability to move or use the elbow. Blood in the soft tissues and knee joint (
haemarthrosis Hemarthrosis is a bleeding into joint spaces. It is a common feature of hemophilia. Causes It usually follows injury but occurs mainly in patients with a predisposition to hemorrhage such as those being treated with warfarin (or other anticoagulan ...
) may lead to bruising and a doughy feel of the elbow joint.


Cause

An injury resulting in an outward (valgus) stress on the elbow, such as falling on an outstretched hand causes an
avulsion fracture An avulsion fracture is a bone fracture which occurs when a fragment of bone tears away from the main mass of bone as a result of physical trauma. This can occur at the ligament by the application of forces external to the body (such as a fall ...
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. Medial epicondyle fractures are associated with a dislocation of the elbow in about 25% of cases.


Diagnosis

In all injuries to the medial epicondyle,
radiograph Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical radiography ("diagnostic" and "therapeut ...
s (x-rays) are imperative.
Computed tomography A computed tomography scan (CT scan; formerly called computed axial tomography scan or CAT scan) is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers ...
scans are occasionally useful in evaluating the degree of fracture displacement or the involvement of the joint surface.


Displaced Fracture

Studies generally use the
x-ray An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10  picometers to 10  nanometers, corresponding to frequencies in the range 30&nb ...
appearance of the arm to determine how displaced a fracture is. The definition of ‘displaced fractures' are variable, with anything from 2mm to more than 15mm; however x-rays on which this assessment is made are known to be hugely misleading with fractures showing little displacement having >10mm displacement using CT scans. The practical approach is therefore to assume that any fracture that has any degree of displacement on x-rays is ‘displaced’.


Treatment

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. 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. 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. Some point to good to results without surgery, whilst the others conclude that surgical fixation should be strongly considered to maximise the function in these children. 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.


Ongoing research

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. 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. Th
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 The National Institute for Health and Care Research (NIHR) is the British government’s major funder of clinical, public health, social care and translational research. With a budget of over £1.2 billion in 2020–21, its mission is to "impr ...
. 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 The National Institutes of Health, commonly referred to as NIH (with each letter pronounced individually), is the primary agency of the United States government responsible for biomedical and public health research. It was founded in the late 1 ...
grant to address this question. 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 th
trial-effect
.


References

{{Fractures Bone fractures