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= Medial Epicondyle Fracture of the Humerus = A medial epicondyle fracture of the humerus is a break in the medial epicondyle of the humerus, the bumpy portion of bone on the inside of the elbow. It is an important part of the arm, as it is the point of attachment for the muscles that flex the wrist and rotate the arm.

Medial epicondyle fractures are typically seen in children and adolescents, most often as a result of a fall onto an out-stretched hand. This can happen from falls from a scooter, roller skates, or monkey bars, as well as from injuries sustained playing sports. These fractures typically occur in children around 10-12 years old, with or without dislocation of the elbow joint. They occur in 10% of elbow injuries.

Symptoms include pain, swelling, bruising and a decreased ability to move or use the elbow. Initial pain may be managed with NSAIDs, opioids, and splinting. The management of pain in children may follow guidelines, such as those from the Royal College of Emergency Medicine.

The diagnosis is typically made based on symptoms and confirmed with X-rays and occasionally with a CT scan.

The treatment of these injuries is controversial, and there are currently ongoing international randomised studies. The SCIENCE study is an ongoing study funded by the National Institute for Health Research (UK) and National Institutes for Health (US), and aims to engage children and their families to help determine the optimal way to treat these injuries for others in the future.

Signs and symptoms
Symptoms include pain, swelling, bruising and a decreased ability to move or use the elbow. Blood in the soft tissues and knee joint (haemarthrosis) may lead to bruising and a doughy feel of the elbow joint.

Cause
An injury resulting in an outward (valgus) stress on the elbow, such as falling on an outstretched hand, or through throwing or wrestling, causes an avulsion fracture of the medial epicondyle.

The medial epicondyle is often the final growth plate (ossification center) to ossify in the elbow. Growth plates are particularly vulnerable to injury compared to bone. Children can have an open medial epicondyle growth plate until age 13-17 years old, thus making the medial epicondyle more susceptible to injury.

Medial epicondyle fractures are associated with a dislocation of the elbow in about 10% of cases.

Diagnosis
In all injuries to the medial epicondyle, radiographs (x-rays) are imperative. Computed tomography scans are occasionally useful in evaluating the degree of fracture and determining a treatment plan that would not be possible with plain radiographs.

Displaced Fracture
Studies generally use the x-ray appearance of the arm to determine how displaced a fracture is. Studies vary, though generally consider ‘displaced’ to mean anything from more than 2mm, to more than 15mm ; however x-rays on which this assessment is made are known to be hugely misleading with fractures showing very little displacement frequently having >10mm displacement apparent when comparing them to CT scans. The practical approach is therefore to assume that any fracture that has any degree of displacement on x-rays is ‘displaced’.

Treatment
There are several treatment options.

In children with a completely non-displaced fracture (in other words, the bone fragments did not move or separate), they will usually be treated in a cast without surgery.

If a child has a displaced or separated fracture, there is debate amongst surgeons about the best way to treat these. The debate amongst doctors is whether to realign the displaced bones with surgery and hold the fragments of bone with wires or screws, or whether to allow the fragments to heal in their current position without surgery by resting the elbow in a cast. The studies that have sought to draw together all of the scientific evidence, have failed to arrive at any firm conclusion, either in support of surgery or against surgery. One of these studies concluded that nonsurgical treatment offers excellent functional results equivalent to surgical treatment, whilst the other concludes that surgical fixation should be strongly considered to achieve union of the bone fragments thereby maximise the function in these children.

However, the current published research has serious methodological limitations, particularly with regard to inconsistent follow-up, no standardisation to the treatment approaches, the infrequent use of patient reported outcomes, and selection bias amongst those selected to undergo operative fixation.

Is surgery ever definitely necessary?
There is widespread agreement that in those instances where the fragment of medial epicondyle is trapped in the joint, or where the elbow is dislocated and can’t be readily reduced in the emergency department, then operative intervention is needed to realign the bones.

Ongoing research
The uncertainties of this injury has prompted surgeons to recognise the treatment of medial epicondyle fractures to be the most important unanswered question in children’s injuries.

Surgeons are currently performing a randomised study to find out the best way to treat displaced medial epicondyle fractures, comparing surgical fixation to no surgery in a study called ‘the SCIENCE Study’. The SCIENCE study is currently underway across the UK, with more than 60 of UK hospitals participating. It is funded by the National Institute for Health Research. Such is the level of international uncertainty, surgeons in Australia and New Zealand are hoping to join the SCIENCE study. Furthermore, surgeons in the USA have been awarded a NIH grant to being to address this question. .

Surgeons around the globe are calling on parents and children with this injury to help them resolve their uncertainty, by allowing their children to be part of these studies. Families involved in research typically have a more positive outcome (called the trial-effect). Through randomised studies doctors hope to resolve the uncertainty for children and their families in the future.