After a significant time off, sports are on their way back; and for some that is sooner rather than later. Injuries are a huge concern as athletes attempt to return back to their pre-quarantine level of activity as quickly as possible. For overhead athletes, the medial epicondyle fracture is an injury to keep in mind.
The medial (inner side) of the elbow tends to be the greatest area of concern when it comes to elbow pain in overhead athletes. A variety of elbow conditions can occur at the medial elbow such as little leaguer’s elbow, ulnar collateral ligament injury (Tommy John Ligament) or ulnar nerve irritation (ulnar neuritis). However, rather than focusing on injuries that typically develop over time, I want to describe one that happens all at once, a medial epicondyle fracture.
Anatomy of an Injury
First, a look at the anatomy. There are several growth plates that develop in the elbow during a child's life. It is quite variable when they appear, but generally speaking, the medial epicondyle appears around age 6 and closes around age 15 with differences between male and female patients. In addition, the muscles that flex your fingers, as well as the stabilizing ligament called the UCL (ulnar collateral ligament), attach to the bone at this structure. Lastly, the ulnar nerve or "funny bone" runs just below the medial epicondyle.
Identifying the Injury
I have seen this most commonly in baseball players as well as in tumbling athletes. Typically the baseball athlete will be pitching or making a throw from the outfield and feel a pop over the inner elbow associated with pain and swelling. Similarly, a gymnast might encounter the same injury while doing a back handspring. As mentioned above, the ulnar nerve runs just underneath this area of the bone and many times athletes will report numbness or tingling in the pinky and ring finger.
Initial Work-Up and Evaluation
With this type of injury, we are typically going to start with an x-ray looking for the suspected fracture. I am only showing one view below for teaching purposes, however, you always will want multiple views to identify the exact location of the medial epicondyle. There are a few key points to note in the x-ray below. Note there is a small crescent of bone at the tip of the arrow which indicates the sliver of bone that was pulled away with the epicondyle. In this x-ray the medial epicondyle is minimally displaced with no rotation. Lastly, note the position of the ulnar nerve in comparison to the area of injury, which explains why an athlete may have associated nerve irritation.
Treatment of Medial Epicondyle Fracture
The typical approach for a non-displaced or minimally displaced medial epicondyle is cast or splint immobilization for approximately three to four weeks followed by physical therapy and a return to throwing program. There is debate over what extent of displacement of the medial epicondyle requires surgery. I typically will allow between 0.5 cm to 1 cm displacement however, there are complicating factors such as arm dominance and type of sport being played. For example, I may treat the dominant arm of a baseball athlete differently than the non-dominant arm of a soccer player.
Surgical Indications
Surgical indications include significant displacement, however, the position of the displaced fragment plays a factor as well. For example, with an elbow dislocation, the epicondyle can be pulled into the joint, which requires removal and surgical fixation. Additionally, (as seen below) if the fragment is displaced but also turned and rotated, surgical intervention is needed. Surgical fixation typically includes a single canulated screw fixation which can be viewed through the link below.
Example of a single cannulated surgical screw fixation as posted on the Hospital for Special Surgery Radiology Website
Of note, elbow dislocations are also associated with medial epicondyle fracture and aren't thoroughly discussed in this post.