Arm wrestlers, gymnasts, football quarterbacks, and baseball pitchers along with cheerleaders, runners, swimmers, and hockey players were the subjects of this study. They all had one thing in common: a medial epicondyle fractures (fracture along the inside of the elbow).
Many factors go into treatment decisions for these patients. How did the fracture occur (referred to as the injury mechanism)? Did the fracture separate (called displacement)? Is the elbow stable or unstable? What are the athlete’s goals, wishes, and desires? For young athletes, discussion and involvement of the patient and family may be important.
These are all the variables discussed by the authors who are surgeons at The Children’s Hospital of Philadelphia. They bring to this article their experience, expertise, and results of treating 20 young athletes (ages nine to 15) with this diagnosis. They were particularly interested in rates of return to sports performance comparing conservative (nonoperative) care versus surgical treatment.
Criteria for surgery included elbow fracture displacement and/or dislocation and an unstable joint. Trauma was enough to cause more than a simple fracture or avulsion (piece of bone breaks off with soft tissue still attached). The surgeon reattached the bone fragment using hardware such as a single screw (sometimes with a washer).
Patients with a nondisplaced (or minimally displaced) but stable fracture (no joint laxity or looseness) were cared for following a nonoperative management approach. This included placing the arm in a cast for three or four weeks. The elbow was kept flexed or bent approximately 70 to 90 degrees in the cast.
When the cast was removed, a splint was worn for another two to four weeks during which time the athletes were to have someone move the arm for them three to five times each day. Active motion was allowed when the medial epicondyle (fracture site — the bony bump along the inside of the elbow) was no longer tender to touch/pressure. Physical therapy was needed when full elbow motion was still not present six weeks after conservative care was started.
The results were very positive for both groups confirming what the surgeons thought at the time of evaluation: careful patient selection for each type of treatment is important. The two main considerations were 1) injury mechanism (traumatic/high-energy versus nontraumatic/low-energy) and 2) elbow laxity or instability.
Children who had a nondisplaced fracture of the medial epicondyle without apparent joint laxity did well with conservative (nonoperative) care. Other young athletes with a high energy trauma elbow fracture with instability or laxity had good outcomes with operative care. All athletes in this study returned to full participation in their sport and were very satisfied with the results.
There were no cases of growth disturbance of the still growing children. That is always a concern with bony injuries in young athletes. Temporary, transient (comes and goes) numbness was reported by half of the patients treated with surgery. This symptom occurred most often when the elbow was fully flexed (bent) with compression and did not affect their sports participation. No one had any motor weakness at the final outcome (follow-up was a minimum of two years).
The surgeons pointed out that standard X-rays may not provide enough information when making the decision regarding surgery versus no-surgery. Specialized stress radiographic views and 3D-CT scans may be needed to obtain a full understanding of the type of injury/fracture present. In this way, significant trauma to the soft tissues around the elbow can be identified and treated as well. This approach helps avoid long-term complications from undiagnosed nerve damage, capsular involvement, or fragments of bone or cartilage in the joint.