What is the appropriate management for a patient with a physical injury to the medial epicondyle of the elbow?

Management of Medial Epicondyle Physical Injury

Begin with plain radiographs immediately to assess for fracture, displacement, and associated elbow dislocation, then proceed with either conservative management for minimally displaced fractures or surgical intervention for displaced fractures >5mm or incarcerated fragments. 1

Initial Diagnostic Approach

Obtain anteroposterior and lateral radiographs as the mandatory first-line imaging to identify fracture presence, degree of displacement, and exclude associated injuries including elbow dislocation, intra-articular loose bodies, or heterotopic ossification. 1, 2

Key Clinical Presentations to Recognize:

• Acute avulsion fractures in throwing athletes: Sudden onset of medial elbow pain during throwing motion with immediate inability to continue throwing, most commonly in skeletally immature baseball players aged 11-15 years who often do not adhere to pitch count recommendations. 3

• Incarcerated medial epicondyle with elbow dislocation: Approximately 78% of incarcerated medial epicondyle fractures present with confirmed elbow dislocation, with 44% demonstrating preoperative ulnar nerve symptoms. 4

• Adult avulsion fractures: Extremely rare presentation following acute trauma (such as falls) with extensive internal joint derangements often present on advanced imaging. 5

Advanced Imaging Indications

If radiographs are normal or indeterminate and soft tissue injury is suspected, proceed with ultrasound or MRI without IV contrast as equivalent alternatives. 1, 6

• Ultrasound demonstrates 81% sensitivity and 91% specificity for detecting full-thickness ulnar collateral ligament tears, with dynamic stress ultrasound improving sensitivity to 96%. 1

• MRI provides high inter- and intraobserver reliability for identifying common flexor tendon pathology, paratendinous edema, and associated ligamentous injuries. 6

• MRI is particularly valuable in adult cases where extensive internal joint derangements frequently accompany the fracture. 5

Treatment Algorithm Based on Fracture Characteristics

Non-Operative Management (Displacement ≤5mm):

Immobilize with hinged brace and initiate early protected range of motion. 5, 3

• Five of eight youth baseball players with ≤5mm displacement treated non-operatively returned to play at average 7.6 months (range 4-10 months) without complications. 3

• Progressive strengthening exercises and activity modification are essential components of rehabilitation. 2

• Serial radiographs at 10-14 days can assess healing progression if initial films are indeterminate. 1

Operative Management (Displacement >5mm or Incarcerated Fragment):

Perform open reduction and internal fixation for fractures with >5mm displacement or any incarcerated medial epicondyle fragment. 4, 3

• Incarcerated medial epicondyle fractures are an absolute indication for surgical intervention, though timing does not need to be emergent unless neurovascular compromise or irreducible elbow dislocation exists. 4

• Median time from presentation to surgery of 21.9 hours showed no correlation with worse outcomes, nerve symptoms, or need for hardware removal. 4

• Surgical outcomes demonstrate 50% excellent, 41% good, and 9% fair results using Roberts criteria, with zero poor outcomes reported. 4

Critical Management Pitfalls

Avoid blind corticosteroid injections into the medial epicondyle as the posterior division of the medial antebrachial cutaneous nerve may lie directly over the medial epicondyle, risking direct nerve injury with immediate dysesthesia and chronic pain. 7

Always assess for ulnar nerve symptoms preoperatively and postoperatively, as 44% of incarcerated fractures present with preoperative ulnar nerve involvement, with 64% of these experiencing persistent postoperative symptoms. 4

Distinguish medial epicondyle fractures from medial epicondylitis (tendinopathy), as the latter responds to conservative management with NSAIDs, activity modification, and structured rehabilitation programs in the majority of cases. 8

Special Considerations for Throwing Athletes

Evaluate adherence to USA Baseball youth pitching recommendations, as all five age-appropriate players in one series who sustained acute avulsion fractures while throwing had violated pitch count guidelines. 3

Return to throwing protocols should be gradual, with average return to play of 7.6 months following both operative and non-operative treatment in youth baseball players. 3