My son has a medial epicondyle fracture. What is that?

A medial epicondyle fracture is a little different from other fractures that we see in kids.  This type of fracture mostly occurs in boys and is highly correlated with participation in sports.  It also can occur well into adolescence.  Read on to learn more about medial epicondyle fractures.  We will start with anatomy!

The elbow

The elbow joint is where the humerus, ulna, and radius come together.  The humerus is the upper arm bone and forms individual joints with the ulna and radius, which are the forearm bones.  Movements of the elbow include flexion and extension.  Flexion is when the forearm and upper come closer together (bending the elbow) and extension is when they are moved farther apart (straightening the elbow).  The upper parts of the radius and ulna will also form a joint which allows for the movements of pronation and supination.  Pronation is rotating the forearm, so the palm faces downward, and supination is forearm rotation where the palm faces upward.

The medial epicondyle

At the elbow, there are two big bony bumps on either side of the joint.  These are the epicondyles at the end of the humerus.  Epicondyles are large bony bumps where ligaments and the tendons of muscles attach.  There is a lateral epicondyle and a medial epicondyle.  The medial epicondyle is the one closest to the body when the arms are beside the body with the palms up.  The lateral epicondyle will be farther from the body in this position.

The muscles that are used to extend the wrist are attached to the lateral epicondyle while the muscles that are used to flex the wrist and pronate the forearm are attached to the medial epicondyle.  The ulnar collateral ligament, also, attaches to the medial epicondyle.  Ligaments are strong, connective tissue that attach bone to bone.  They are important in stabilizing joints.  The ulnar collateral ligament plays a vital role in stabilizing the medial area of the elbow.

The medial epicondyle apophysis

There is a growth plate at the medial epicondyle called an apophysis.   An apophysis is an area of growth for a protuberance of bone on a larger bone.  This protuberance of bone is not associated with a joint but is usually the site of a tendon or ligament attachment.  The common tendon from the wrist flexor and pronator muscles attaches to the medial epicondyle at the area of the apophysis.  The apophysis is the weakest area of this bone, tendon, muscle group.  As the wrist flexors and the pronator teres pull on the medial epicondyle over and over, it causes microvascular tears, swelling, inflammation, and pain at the apophysis.  This apophysis does not close (ossify) until the age of 14 to 15 which makes it more susceptible to injury.

What is a medial epicondyle fracture?

A medial epicondyle fracture is a bone break at the medial epicondyle.  It usually occurs during early adolescence, between the ages of 9 to 14.  About 75% of all medial epicondyle fractures occur in boys.  This is primarily due to sports.  The prevalence of this injury is increasing because of the athletic demands on children.

The main mechanism of injury is an avulsion fracture.  An avulsion fracture occurs when a piece of bone is pulled away from the larger bone.  In this case, part of the medial epicondyle is pulled away from the humerus at the apophysis.  It is the pull from the ulnar collateral ligament, pronators, and wrist flexors that causes the fracture.  This typically occurs with certain sports like baseball which require a lot of force from the pronators and wrist flexors.  A fall on an outstretched hand or direct trauma could also cause a medial epicondyle fracture.

A disruption to the ulnar collateral ligament can cause instability in the elbow joint.  Remember that the ulnar collateral ligament also attaches to the medial epicondyle.  Up to 50% of medial epicondyle fractures are associated with an elbow dislocation.

What are the symptoms of a medial epicondyle fracture?

There are several symptoms of a medial epicondyle fracture.  They include:

• Tenderness over the medial area of the elbow
• Swelling at the elbow and forearm
• Possible weakness in the hand
• Abnormal sensations in the hand
• Decreased ability to move the elbow
• Feelings of instability in the elbow

Are there any potential complications with a medial epicondyle fracture?

There are several complications that could occur with this injury.  These include:

• Medial elbow instability – As mentioned above, this injury is associated with elbow dislocation in about 50% of cases.
• Nonunion – This means that the fracture is not healing and there is little chance of it healing without surgical intervention.
• Nerve injury – The ulnar nerve runs behind the medial epicondyle and is one of the major nerves of the arm. It could be injured during an elbow fracture or dislocation.  This could cause loss of sensation or numbness and tingling at the ring and pinky finger.
• Elbow stiffness – This typically occurs after being in a sling or cast for several weeks. The elbow can become incredibly stiff and is notorious for not returning to full extension.  This means that your child will not be able to completely straighten the elbow.
• Cubital valgus – This is a misalignment of the elbow joint. It causes the forearm to be deviated away from the body when the elbow is straight.

Will my child need surgery?

The answer is possibly.  If the fracture is not displaced or is displaced less than 5mm, then a cast is applied for 1-4 weeks.  If the fracture is displaced more than 5mm, there is entrapment of a bone fragment in the joint, or the elbow is unstable, then surgery will be needed.

Who should I see?

• Physician – If you suspect that your child has sustained a medial epicondyle fracture (or some other type of fracture), it is best to go to the emergency room.  Because of the potential complications, this fracture should be treated quickly.  However, if your fracture has already been treated and you suspect additional injury or complication, then it would be best to see your orthopedist, pediatrician, or primary care physician.  Additional imaging and inspection might be needed to rule out other conditions.
• Physical therapist – Physical therapy might be needed if your child is having difficulty regaining strength and/or motion around the elbow.  Kids usually do not need therapy because they tend to perform their own therapy by playing.  However, this fracture is notorious for elbow stiffness.  Your PT can evaluate your child to determine the extent of their deficits and use manual therapy, as well as, stretching, and strengthening to help address all problems in and around the elbow.  If your child is an athlete, a physical therapist can be vital in helping your child safely return to sport.

What can I do?

• Relative rest – Resting the area to decrease further pain and damage from occurring is one of the best ways to allow the bones to heal.  If you are not able to participate in your activity or sport, then you can supplement with non-irritating activities such as walking or jogging while your elbow is healing.
• Ice – Ice can help decrease pain and symptoms at the elbow.  Ice the painful area for 15 to 20 minutes at a time.  I would recommend using an ice pack several times per day if the pain is constant or is preventing you from participating in an activity.  Ice immediately after activity.
• The following are activities that your child can do after the cast is removed or they are cleared by their surgeon.
  • Soft tissue mobilization – Soft tissue mobilization helps release the muscles around the elbow and decreases the tension on the tendon.  Use a massage ball, lacrosse ball, tennis ball, or your own fingers to massage painful areas all around the elbow.  Spend a good 3 to 5 minutes rolling.  Do not roll so hard that you bruise the area, but it should be a pretty painful sensation.  Roll out the area no more than a few times a week.  See the video below.

• • Elbow stretches – The elbow might have limited motion in certain directions.  Typically, extension or straightening the elbow is the hardest to fully regain.  However, depending on the person, then flexion, pronation, or supination might also be tight.  See the video below in how to stretch the muscles around the elbow.

• • Wrist flexion and extension stretching – You will also need to stretch out the wrist flexors and extensors.  These muscles attach at or near the elbow and could be tight.  See the video below.

• • Strengthening the muscles around the elbow and wrist – Strengthening the muscles around the wrist and elbow are also important in being able to return to your activity.  Decrease your resistance or number of repetitions if the pain is moderate to severe during the exercise or returns after the exercise. Using dumbbells or resistance bands can increase strength and difficulty.  See the video below.

In review

• The elbow joint is where the humerus, ulna, and radius come together.
• Movements of the elbow include flexion and extension.
  • The upper parts of the radius and ulna will also form a joint which allow for the movements of pronation and supination.
• Epicondyles are large bony bumps where the tendons of muscles and ligaments attach.
  • There is a lateral epicondyle and a medial epicondyle.
• The muscles that are used to extend the wrist are attached to the lateral epicondyle while the muscles that are used to flex the wrist and pronate the forearm are attached to the medial epicondyle.
  • The ulnar collateral ligament, also, attaches to the medial epicondyle.
• There is a growth plate at the medial epicondyle called an apophysis.
• A medial epicondyle fracture is a break at the medial epicondyle at the apophysis.
• It usually occurs during early adolescence, between the ages of 9 to 14.
  • About 75% of all medial epicondyle fractures occur in boys.
• Swelling, pain, and difficulty moving the elbow are symptoms of a medial epicondyle fracture.
• The main mechanism of injury is a strong contraction of the wrist flexors and pronators that pulls the medial epicondyle from the humerus.
• There can be serious complications including dislocations, so it is important to seek medical help when a fracture is suspected.
• Physical therapy will play a role in regaining strength and mobility in the elbow.
• There are things your child can do once the cast is off or your child is cleared by the surgeon.
  • Ice
  • Soft tissue mobilization
  • Elbow stretches
  • Wrist stretches
  • Strengthening of the muscles around the elbow and wrist

As always, If you have questions about the content of this post or any other musculoskeletal questions, please e-mail me.

Additional resources

https://www.ncbi.nlm.nih.gov/books/NBK558947/

https://posna.org/physician-education/study-guide/humerus-medial-epicondyle-fractures