What are the next steps for a 12-year-old patient with a history of hyperextension injury requiring surgery, now experiencing pain inside the elbow?

Post-Operative Hyperextension Injury with Medial Elbow Pain in a 12-Year-Old

This 12-year-old requires urgent orthopedic re-evaluation to assess for post-surgical complications including ulnar collateral ligament injury, medial epicondyle fracture, ulnar nerve injury, or inadequate fracture fixation—all of which can cause medial elbow pain after hyperextension injury surgery. 1

Immediate Diagnostic Approach

Clinical Assessment Priority

• Examine for ulnar nerve symptoms (numbness in ring/small fingers, weakness in grip) as traction neuropathies are common complications after elbow surgery 2
• Assess medial collateral ligament stability through valgus stress testing, as medial elbow pain suggests potential UCL injury from the hyperextension mechanism 1
• Evaluate for medial epicondyle involvement, which is frequently injured in pediatric hyperextension trauma 1

Imaging Algorithm

If initial post-operative radiographs are normal or indeterminate:

• MRI without contrast is the appropriate next study for evaluating suspected tendon, ligament, or muscle injury causing medial elbow pain 1
• MRI demonstrates high sensitivity (96%) and specificity (81%) for UCL tears and can identify associated soft tissue injuries 1
• Ultrasound is an alternative if MRI is unavailable, showing 95.2% sensitivity for medial epicondylalgia and 96% sensitivity for UCL injury with dynamic stress testing 1

Critical Time Period for Recovery

The first 6 months post-surgery represent the critical rehabilitation window:

• 70% of functional range of motion recovery occurs between months 3-6 after complex elbow surgery 3
• Early rehabilitation (starting 2 days post-op) is essential to prevent stiffness 3
• Flexion recovery is slower than extension in pediatric patients 3

Common Post-Surgical Complications to Rule Out

Traction Neuropathy

• Most common complication after elbow surgery, particularly affecting the ulnar nerve 2
• Presents as medial elbow pain with paresthesias

Inadequate Fracture Fixation

• Hyperextension injuries in 12-year-olds typically involve supracondylar fractures 4
• Malunion can cause persistent pain and limited motion 4

Ligamentous Injury

• Medial collateral ligament (UCL) injury commonly accompanies hyperextension trauma 1
• Dynamic fluoroscopy can distinguish stages of collateral ligament injury if surgical re-exploration is considered 1

Management Algorithm

If imaging confirms soft tissue injury without fracture displacement:

• Continue conservative management with activity modification, ice application, and NSAIDs 5
• Maintain aggressive physical therapy through the 6-month critical period 3

If imaging shows ligamentous disruption or fracture malunion:

• Surgical re-intervention is indicated for unstable injuries or significant malunion affecting function 2, 4
• Corrective osteotomy may be necessary if hyperextension deformity limits flexion (flexion <100°) 4

If conservative management fails after 6-12 months:

• Surgical consultation for possible capsular release or ligament reconstruction 2

Key Pitfalls to Avoid

• Do not delay MRI if clinical examination suggests ligamentous or nerve injury—early identification changes management 1
• Do not assume pain is normal post-operative course—medial elbow pain specifically suggests UCL or ulnar nerve pathology requiring investigation 1
• Do not stop rehabilitation before 6 months—the critical recovery window extends through this period 3
• Avoid corticosteroid injections in this acute post-surgical setting due to risk of tendon weakening and infection 5