Fracture Of Medial Epicondyle Of Humerus

A fracture of the medial epicondyle of the humerus, a bony prominence on the inner side of the elbow, is a common injury, especially in children and adolescents. This type of fracture often results from a fall onto an outstretched arm or a direct blow to the elbow. Understanding the anatomy, causes, symptoms, diagnosis, and treatment options for this fracture is crucial for effective management and optimal patient outcomes.

Anatomy of the Medial Epicondyle

The humerus, or upper arm bone, extends from the shoulder to the elbow. At the elbow, the humerus broadens into two bony prominences known as epicondyles: the medial epicondyle on the inner side and the lateral epicondyle on the outer side.

• Medial Epicondyle: This serves as the attachment site for several forearm muscles responsible for wrist flexion (bending the wrist downward) and pronation (turning the palm downward). The ulnar nerve, one of the major nerves in the arm, runs behind the medial epicondyle in a groove.
• Lateral Epicondyle: This is the attachment point for muscles that extend the wrist (bending the wrist upward) and supinate the forearm (turning the palm upward).

Because the medial epicondyle is the attachment site for important muscles and is closely related to the ulnar nerve, fractures in this area can lead to various complications affecting the elbow joint and forearm function.

Causes and Mechanisms of Injury

Fractures of the medial epicondyle are more common in children and adolescents because the growth plate (also called the epiphyseal plate), a weaker area of cartilage near the end of the bone, is more susceptible to injury than mature bone. The most common causes include:

• Fall onto an Outstretched Arm: This is the most frequent mechanism. When a child falls onto an outstretched arm, the force travels up the forearm to the elbow, potentially pulling the medial epicondyle away from the humerus. This is particularly likely if the elbow is dislocated at the time of injury.
• Direct Blow to the Elbow: A direct impact on the inner side of the elbow can also fracture the medial epicondyle. This can occur during sports activities, accidents, or falls.
• Avulsion Fracture: In children and adolescents, the medial epicondyle can be pulled off by the strong tendons and ligaments that attach to it. This is known as an avulsion fracture. This typically happens when the elbow is forcefully pulled or twisted.

Symptoms and Clinical Presentation

The symptoms of a medial epicondyle fracture can vary depending on the severity and displacement of the fracture. Common symptoms include:

• Pain: Immediate and intense pain on the inner side of the elbow.
• Swelling: Swelling and bruising around the elbow joint.
• Tenderness: Tenderness to the touch over the medial epicondyle.
• Limited Range of Motion: Difficulty bending, straightening, or rotating the elbow.
• Numbness or Tingling: Numbness, tingling, or weakness in the fingers, particularly the little finger and ring finger, may indicate injury to the ulnar nerve.
• Deformity: In severe cases, a visible deformity of the elbow may be present.
• Snapping Sensation: The patient may describe a snapping or popping sensation at the time of injury.

Diagnosis

A prompt and accurate diagnosis is essential for appropriate management. The diagnostic process typically involves:

1. Medical History and Physical Examination: The healthcare provider will ask about the mechanism of injury, the patient's symptoms, and any relevant medical history. A thorough physical examination will be performed to assess the elbow's range of motion, stability, and neurological function.

2. Imaging Studies:

   • X-rays: X-rays are the primary imaging modality used to diagnose medial epicondyle fractures. Anteroposterior (AP), lateral, and oblique views of the elbow are typically obtained. In children, it is important to compare the injured elbow with the uninjured elbow to assess the growth plates accurately.
   • CT Scan: In complex fractures or when X-rays are inconclusive, a computed tomography (CT) scan may be necessary. CT scans provide detailed images of the bone and can help determine the extent of the fracture and any associated injuries.
   • MRI: Magnetic resonance imaging (MRI) may be used to evaluate soft tissue injuries, such as ligament damage or nerve compression, particularly if there are concerns about ulnar nerve involvement.

3. Neurological Assessment: A careful neurological examination is performed to assess the function of the ulnar nerve. This includes testing sensation in the fingers and hand, as well as evaluating motor function of the forearm and hand muscles.

Classification of Medial Epicondyle Fractures

Medial epicondyle fractures can be classified based on the degree of displacement and the presence of associated injuries. Common classifications include:

• Minimally Displaced Fractures: The fractured bone fragments are close together and have not shifted significantly.
• Displaced Fractures: The fractured bone fragments have moved out of their normal alignment.
• Avulsion Fractures: The medial epicondyle is pulled away from the humerus by the attached tendons and ligaments.
• Fractures with Elbow Dislocation: The medial epicondyle fracture occurs in conjunction with an elbow dislocation.
• Fractures with Ulnar Nerve Injury: The ulnar nerve is injured as a result of the fracture.

Treatment Options

The treatment for a medial epicondyle fracture depends on several factors, including the patient's age, activity level, the degree of displacement, and the presence of associated injuries. Treatment options include non-operative and operative methods.

Non-Operative Treatment

Non-operative treatment is typically recommended for minimally displaced fractures with no associated injuries. This approach involves:

1. Immobilization: The elbow is immobilized in a cast or splint to protect the fracture and allow it to heal. The duration of immobilization is typically 3 to 6 weeks.
2. Pain Management: Pain is managed with over-the-counter pain relievers, such as acetaminophen or ibuprofen. In some cases, stronger pain medications may be prescribed.
3. Physical Therapy: After the cast or splint is removed, physical therapy is initiated to restore range of motion, strength, and function to the elbow.

Operative Treatment

Operative treatment, or surgery, is typically recommended for displaced fractures, avulsion fractures, fractures associated with elbow dislocation, and fractures with ulnar nerve injury. The goals of surgery are to restore the normal anatomy of the elbow, stabilize the fracture, and protect the ulnar nerve. Surgical techniques include:

1. Open Reduction and Internal Fixation (ORIF): This involves making an incision over the medial epicondyle to visualize the fracture. The fractured bone fragments are then realigned (reduced) and held in place with hardware, such as screws, pins, or plates.
2. Percutaneous Fixation: In some cases, the fracture can be stabilized with percutaneous fixation, which involves inserting pins or screws through small incisions in the skin. This technique may be used for minimally displaced fractures or in situations where a large incision is not necessary.
3. Ulnar Nerve Decompression: If the ulnar nerve is compressed or injured as a result of the fracture, a surgical procedure to release the nerve (ulnar nerve decompression) may be performed. This involves making an incision to access the nerve and releasing any surrounding tissue that is compressing it.
4. Repair of Associated Injuries: If there are associated injuries, such as ligament tears, these may be repaired during the surgical procedure.

Surgical Procedure: Step-by-Step

Here is a step-by-step overview of a typical open reduction and internal fixation (ORIF) procedure for a displaced medial epicondyle fracture:

1. Anesthesia: The patient is placed under general anesthesia.
2. Positioning: The patient is positioned on the operating table with the arm supported and prepped for surgery.
3. Incision: An incision is made over the medial epicondyle, taking care to identify and protect the ulnar nerve.
4. Fracture Visualization: The fracture site is exposed, and any blood clots or debris are removed.
5. Reduction: The fractured bone fragments are carefully realigned to their normal position.
6. Fixation: The reduced fracture fragments are held in place with hardware, such as screws or pins. The choice of hardware depends on the fracture pattern and the surgeon's preference.
7. Ulnar Nerve Assessment: The ulnar nerve is carefully inspected to ensure that it is not compressed or injured. If necessary, an ulnar nerve decompression is performed.
8. Wound Closure: The incision is closed in layers with sutures.
9. Immobilization: A cast or splint is applied to protect the elbow during the healing process.

Potential Complications

While the majority of medial epicondyle fractures heal without complications, there are potential risks associated with both non-operative and operative treatment. These include:

• Nonunion: The fracture fails to heal properly.
• Malunion: The fracture heals in a non-anatomical position, leading to pain, stiffness, or limited range of motion.
• Stiffness: Stiffness of the elbow joint, which may require physical therapy or additional procedures to improve range of motion.
• Ulnar Nerve Injury: Damage to the ulnar nerve, resulting in numbness, tingling, weakness, or pain in the fingers and hand.
• Infection: Infection at the surgical site.
• Hardware Failure: Breakage or loosening of the hardware used to fix the fracture.
• Compartment Syndrome: A condition in which increased pressure within the muscles of the forearm can compromise blood flow and nerve function.
• Growth Disturbance: In children, fractures involving the growth plate can potentially lead to growth disturbances of the elbow.

Rehabilitation and Recovery

Rehabilitation is a crucial part of the recovery process following a medial epicondyle fracture. The rehabilitation program is tailored to the individual patient and the specific type of treatment they received. The goals of rehabilitation include:

• Pain Management: Controlling pain and swelling.
• Restoring Range of Motion: Regaining full range of motion in the elbow.
• Strengthening Exercises: Strengthening the muscles around the elbow.
• Improving Function: Returning to normal activities and sports.

The rehabilitation program typically includes:

1. Early Phase (Immobilization):

   • Edema Control: Elevating the arm and using ice packs to reduce swelling.
   • Gentle Range of Motion Exercises: Moving the fingers, wrist, and shoulder to prevent stiffness.

2. Intermediate Phase (After Cast Removal):

   • Range of Motion Exercises: Performing gentle exercises to gradually increase the range of motion in the elbow. These may include flexion, extension, pronation, and supination exercises.
   • Scar Management: Massaging the incision site to prevent scar tissue from forming.

3. Late Phase (Strengthening):

   • Strengthening Exercises: Performing exercises to strengthen the muscles around the elbow, such as wrist curls, bicep curls, and triceps extensions.
   • Proprioceptive Exercises: Exercises to improve balance and coordination.
   • Sport-Specific Training: If the patient is an athlete, sport-specific training is initiated to prepare them for returning to their sport.

Return to Activity

The timeline for returning to activity after a medial epicondyle fracture varies depending on the individual and the type of treatment they received. In general, it takes several months to fully recover from this type of fracture.

• Non-Operative Treatment: Patients treated non-operatively may be able to return to light activities within a few weeks after the cast is removed. Full return to sports or strenuous activities may take 2 to 3 months.
• Operative Treatment: Patients treated with surgery may require a longer recovery period. Light activities may be resumed within a few weeks after surgery, but full return to sports or strenuous activities may take 3 to 6 months.

It is important to follow the healthcare provider's instructions and gradually increase activity levels to avoid re-injury.

Prevention

While it is not always possible to prevent a medial epicondyle fracture, there are some steps that can be taken to reduce the risk of injury:

• Proper Technique: Using proper technique when participating in sports or other activities.
• Protective Gear: Wearing appropriate protective gear, such as elbow pads, during sports or activities that involve a risk of falls or direct blows to the elbow.
• Strength and Conditioning: Maintaining good strength and conditioning of the muscles around the elbow.
• Fall Prevention: Taking steps to prevent falls, such as removing hazards from the home and using assistive devices if needed.

Frequently Asked Questions (FAQ)

• How long does it take for a medial epicondyle fracture to heal?
  • The healing time for a medial epicondyle fracture varies depending on the severity of the fracture and the type of treatment received. In general, it takes 6 to 12 weeks for the fracture to heal.
• Will I need surgery for a medial epicondyle fracture?
  • Whether or not you need surgery depends on the degree of displacement of the fracture and the presence of associated injuries. Minimally displaced fractures can often be treated with non-operative methods, while displaced fractures may require surgery.
• What are the potential complications of a medial epicondyle fracture?
  • Potential complications include nonunion, malunion, stiffness, ulnar nerve injury, infection, and hardware failure.
• How long will I be in a cast or splint?
  • The duration of immobilization in a cast or splint is typically 3 to 6 weeks.
• When can I return to sports after a medial epicondyle fracture?
  • The timeline for returning to sports varies depending on the individual and the type of treatment they received. In general, it takes several months to fully recover and return to sports.

Conclusion

A fracture of the medial epicondyle of the humerus is a common injury, particularly in children and adolescents. Prompt diagnosis and appropriate management are essential for optimal outcomes. Treatment options range from non-operative methods, such as immobilization in a cast or splint, to operative methods, such as open reduction and internal fixation. Rehabilitation plays a crucial role in restoring range of motion, strength, and function to the elbow. By understanding the causes, symptoms, diagnosis, treatment options, and potential complications of this type of fracture, healthcare providers can provide effective care and help patients return to their normal activities as quickly and safely as possible.