Oh Snap
Author: Jessica Hammes, MD
Peer-Reviewer: Mathew Negaard, MD, CAQ-SM
Final Editor: Alex Tomesch, MD, CAQ-SM
A 14-year-old male presents for left medial elbow pain after pitching during a baseball game the night before when he felt a snap in his left elbow during a pitch. He continued to feel a sharp pain with every subsequent pitch in the medial elbow. He has point tenderness on the medial aspect of his left elbow and pain with elbow extension but full ROM. He has tried OTC anti-inflammatory medications and icing at home with mild relief.
Image 1: Plain radiograph of left elbow. Case courtesy of Henry Knipe, Radiopaedia.org, rID: 30678
What is the diagnosis?
The X-Ray showed an acute avulsion of the left medial epicondyle with displacement.
- Pearl: Medial epicondyle fractures are the third most common elbow fracture seen in children
- Pearl: Contralateral view can often be obtained on a non-emergent basis to help determine definitive management. If the diagnosis is in question, contralateral views can be obtained in the ED for growth plate comparison.
What is the mechanism of injury?
The most common mechanism of injury is falling onto an outstretched hand in full elbow extension. The traction placed on the flexor-pronator muscles of the forearm pulls on the medial epicondyle. In this case the mechanism was likely increased valgus stress and contraction of the flexor-pronator muscles while pitching [5]
What physical exam findings are expected?
Physical exam findings will include medial elbow pain, ecchymosis and generalized swelling, and valgus instability. The ulnar nerve is at risk for these injuries so a thorough motor and sensory function exam should be conducted in all cases. Look out for numbness, tingling, weakness specifically in the 4th and 5th digit, palm of the hand, underside of the forearm, and weakness in finger abduction and adduction (ulnar nerve functions)[8].
- Pearl: Approximately 50% of medial epicondyle fractures are associated with an elbow dislocation [6]
Which imaging modalities can be used?
Plain film radiographs are the preferred imaging modality for these injuries. A CT would be the most accurate however the radiation is much higher for minimal additional yielded information so not routinely used [9].
- Pearl: It is recommended to order AP and lateral views of the elbow, an internal oblique view specifically for displacement, and a distal humeral axial view.
What is the management in the ED?
Patient will be placed in a posterior slab splint at 90 degrees with a sling for comfort. ICE, NSAIDS can be used for symptom control. Patients will need follow up with orthopedics in 1-2 weeks [8].
- Pearl: Nonoperative management consists of splint or sling immobilization for 1-2 weeks followed by early active range of motion.
- Pearl: Considerations of age, is the dominant arm affected, athletic status often go into the discussion of operative vs non-operative management [6].
When do you consult Orthopedics?
Orthopedics rarely needs to be consulted in the Emergency Department. However, outpatient orthopedic referral should be arranged within a week of the injury. If there is concomitant elbow dislocation, fragment entrapment in the joint, or neurologic deficits, orthopedics should be consulted from the ED. Absolute indications for operative management are fracture fragment entrapment in the joint, extension of the fracture into the articular surface with medial condyle involvement, and open fractures. Relative indications include ulan nerve dysfunction, a >5mm displacement, and associated elbow dislocations [2]. Most of the definitive operative interventions will occur on a non-emergent, outpatient basis.
- Pearl: Both operative and nonoperative management strategies have good reported recovery results [4].
References:
[1] Beaty JH, Kasser JR. The elbow: Physeal fractures, apophyseal injuries of the distal humerus, avascular necrosis of the trochlea, and T-condylar fractures. In Rockwood and Wilkins' Fractures in Children, 7th Ed. Beaty JH, Kasser JR (Eds). Lippincott Williams & Wilkins, Philadelphia 2010. P.533-93.
[2] Elbashir, M., Domos, P., & Latimer, M. (2015). Paediatric medial epicondyle fracture without elbow dislocation associated with intra-articular ulnar nerve entrapment. Journal of Surgical Case Reports, 2015(11). https://doi.org/10.1093/jscr/rjv133
[3] Edmonds, E. W. (2010). How displaced are “nondisplaced” fractures of the medial humeral epicondyle in children? results of a three-dimensional computed tomography analysis. Journal of Bone and Joint Surgery, 92(17), 2785–2791. https://doi.org/10.2106/jbjs.i.01637
[4] Farsetti, P., Potenza, V., Caterini, R., & Ippolito, E. (2001). Long-term results of treatment of fractures of the medial humeral epicondyle in children. The Journal of Bone and Joint Surgery-American Volume, 83(9), 1299–1305. https://doi.org/10.2106/00004623-200109000-00001
[5] Gottschalk HP, Eisner E, Hosalkar HS. Medial epicondyle fractures in the pediatric population. J Am Acad Ortho Surg 2012; 20(4): 223-32
[6] Herring JA. Upper extremity injuries. In Tachdjian's Pediatric Orthopedics, 4th Ed. Saunders, Philadelphia 2008. p.2451-536.
[7] Josefsson, P. O., & Danielsson, L. G. (1986). Epicondyle elbow fracture in children: 35-year follow-up of 56 unreduced cases. Acta Orthopaedica Scandinavica, 57(4), 313–315. https://doi.org/10.3109/17453678608994399
[8] Raby, N., Berman, L., Morley, S., & De Lacey, G. (2015). Accident & emergency radiology: A survival guide. Saunders.
[9] Souder, C. D., Farnsworth, C. L., McNeil, N. P., Bomar, J. D., & Edmonds, E. W. (2015). The distal humerus axial view. Journal of Pediatric Orthopaedics, 35(5), 449–454. https://doi.org/10.1097/bpo.0000000000000306
