I felt a pop and my elbow hurts

"I felt a pop and my elbow hurts…"

Author: Sydney Cryder, DO

Peer-reviewer and Final editor: Alex Tomesch, MD

13 year-old male presents with acute onset of medial elbow pain after throwing a football, at which time he felt a 'pop' and is now unable to fully extend at the elbow. He is tender to palpation at the medial epicondyle. He has a history of Little Leaguer's Elbow. 

Image 1. Case courtesy of Dr. Henry Knipe, Radiopaedia.org, rID: 41533

Image 2. Case courtesy of Dr. Henry Knipe, Radiopaedia.org, rID: 41533

1. What is your diagnosis?

2. What is your management in the ED?

3. What is your disposition? Do you consult orthopedics emergently?

-- see below for answers --

1. What is your diagnosis?

Medial epicondyle avulsion fracture [1]. 

In patients with a history of little league elbow, the incidence of medial epicondyle pathology increases with poor throwing mechanics, excessive pitch counts, and attempting to throw harder and longer distances. With avulsion fractures, patients report a "pop", point tenderness, swelling, and decreased range of motion. Diagnosis is made by plain films or MRI. [1,2,3]

• Pearl: Injury may have ulnar nerve involvement, therefore thorough neurologic evaluation is essential. [1,3].

• Pearl: Medial epicondyle avulsion fracture is associated with medial joint instability due to the origin of the ulnar collateral ligament and flexor-pronator mass [1,2,3]. Additionally, patients may present with a flexion contracture – seen in inability to fully extend the elbow. Incarceration of the fragment may occur in 30-50% of these injuries [1]. 

2. What is your management in the ED?

Minimally displaced fractures may be treated with immobilization; while fractures with > 5 mm displacement in the setting of joint laxity indicated the need for surgical intervention. Posterior long arm splint with or without forearm sugar-tong depending on laxity at the medial elbow or joint instability. 

3. What is your disposition? Do you consult orthopedics emergently?

Discharge home with urgent follow up in Orthopedic clinic. However, if there is evidence of ulnar nerve involvement, Orthopedic Surgery should be consulted emergently.

References:

1. Klingele KE, Kocher MS. Little league elbow: Valgus overload injury in the paediatric athlete. Sport Med. 2002;32(15):1005-1015. doi:10.2165/00007256-200232150-00004Example reference 2

2. Osbahr DC, Chalmers PN, Frank JS, Williams RJ, Widmann RF, Green DW. Acute, avulsion fractures of the medial epicondyle while throwing in youth baseball players: A variant of Little League elbow. J Shoulder Elb Surg. 2010;19(7):951-957. doi:10.1016/j.jse.2010.04.038

3. Griffith TB, Kercher J, Clifton Willimon S, Perkins C, Duralde XA. Elbow Injuries in the Adolescent Thrower. Curr Rev Musculoskelet Med. 2018;11(1):35-47. doi:10.1007/s12178-018-9457-4

4. https://wikem.org/wiki/Medial_epicondyle_fracture_(peds)

Additional reading about medial epicondyle fracture can be found at WikiSM

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