Medial Epicondylar Fractures: Understanding the Causes, Diagnosis, and Treatment

Introduction

Medial epicondylar fractures, often called golfer's elbow fractures due to their association with the sport, involve a break in the bony prominence located on the inner side of the elbow called the medial epicondyle. While golfing is one activity that can predispose individuals to these fractures, it can also occur as a result of various other causes, such as traumatic injuries, overuse, or age-related factors.

What Are the Causes That Lead to Medial Epicondylar Fractures?

• Direct Trauma: A common cause of medial epicondylar fractures is direct trauma to the inner side of the elbow. This can occur in various situations, such as falls onto an outstretched arm, accidents, or contact sports.

• Sports-Related Overuse: Athletes, particularly golfers and baseball players, are prone to medial epicondylar fractures because of repetitive stress on the elbow during their sports. The forceful and repeated swinging or throwing motions can lead to microtrauma that eventually results in a fracture.

• Age-Related Factors: Older individuals may be more susceptible to medial epicondylar fractures due to age-related bone density and strength changes. As bones become more brittle with age, they are more prone to fracture even with less force.

• Chronic Conditions: Certain medical conditions, such as osteoporosis, can weaken bones throughout the body, making them more susceptible to fractures, including those of the medial epicondyle. Osteoporosis reduces bone density, making bones fragile and susceptible to fractures from minor trauma.

• Occupational Factors: Some occupations involve repetitive movements that stress the elbow joint, increasing the risk of fractures. Individuals whose work demands frequent use of the forearm muscles and tendons may be at a higher risk.

• Sudden Muscle Contraction: A forceful and unexpected contraction of the forearm muscles, such as when trying to break a fall or lifting a heavy object, can result in a medial epicondylar fracture. These sudden contractions can place excessive stress on the attachment point of the tendons to the medial epicondyle.

• Previous Injuries: Individuals who have previously injured their elbow or have had surgeries in the area may have weakened or compromised structures, making them more susceptible to fractures with subsequent injuries.

• Repetitive Stress Without Adequate Rest: Engaging in activities that involve repetitive gripping, lifting, or squeezing without sufficient rest periods can lead to overuse injuries and, eventually, medial epicondylar fractures.

How Are Medial Epicondylar Fractures Diagnosed?

Physical Examination: The physician will first check the patient's elbow for tenderness, pain, and swelling, particularly over the medial epicondyle. The elbow's range of motion will be evaluated, and any limitations or abnormalities will be noted.

Patient History: A detailed patient history is essential. The physician will inquire about the circumstances leading up to the injury, including any trauma, sports activities, or repetitive motions that may have contributed to the fracture.

Imaging Studies:

1. X-rays: X-ray imaging is typically the first diagnostic tool used. It can reveal the presence of a fracture, its location, and the degree of displacement. X-rays are particularly effective for identifying fractures in the bone.

2. MRI (Magnetic Resonance Imaging): In some cases, an MRI may be ordered to check soft tissue damage, ligament injuries, or any associated joint issues.

3. CT Scan (Computed Tomography): CT scans are used less frequently than X-rays and MRIs but may be necessary in complex cases or when there is suspicion of joint involvement. CT scans provide three-dimensional images that can help assess the fracture's alignment and the extent of joint involvement.

Comparison with the Uninjured Side: The physician may compare the injured elbow with the uninjured one to assess differences in bony alignment, muscle tone, or range of motion.

Palpation and Stress Testing: Palpation involves gently feeling the affected area to identify tenderness and assess for any crepitus (grating sensation) that may indicate a fracture. Stress testing, which involves applying controlled stress to the elbow joint, can help assess stability and confirm the presence of a fracture.

Clinical Assessment of Symptoms: The patient's reported symptoms, including pain levels, specific movements that worsen pain, and numbness or tingling in the hand or forearm, are important diagnostic indicators.

Specialized Tests: In some cases, specialized tests such as ultrasound or arthroscopy may be used to evaluate the soft tissues and joint structures around the fractured area, particularly when the diagnosis is challenging.

Accurate diagnosis is crucial to determining the appropriate treatment plan for medial epicondylar fractures, whether it involves conservative management or surgical intervention. Combining physical examination, patient history, and imaging studies allows healthcare professionals to make informed diagnoses and provide the most effective care.

What Are the Approaches for Treating Medial Epicondylar Fractures?

Non-Surgical Treatment:

• Immobilization: When the fracture is stable, meaning the bone fragments are well-aligned and not significantly displaced, non-surgical treatment often involves immobilization. A splint or cast is applied to the affected arm to keep the elbow joint still and allow the fracture to heal.

• RICE Protocol: Rest, Ice, and Elevation may be recommended initially to reduce pain and swelling.

Physical Therapy:

• Range of Motion Exercises: Physical therapy is typically initiated to improve elbow joint mobility once the initial healing phase begins. Range of motion exercises help prevent stiffness.

• Strengthening Exercises: Gradually, strengthening exercises are introduced to rebuild the muscles and tendons around the elbow joint, restoring strength and function.

• Functional Training: As the patient progresses, functional exercises are incorporated to simulate activities of daily living and sports-specific movements.

Surgical Treatment:

• Open Reduction and Internal Fixation (ORIF): Surgical intervention is often necessary for displaced fractures or fractures with joint instability. During ORIF, a surgeon repositions the fractured bone fragments into their proper alignment and also uses screws, wires, or plates to secure them in place.

• Arthroscopy: In some cases, minimally invasive arthroscopy techniques may be employed. This involves making small incisions and using a camera to guide the repair of damaged ligaments or other soft tissues around the elbow while addressing the fracture.

Rehabilitation:

• Post-Surgery Rehabilitation: Patients who undergo surgery typically require a tailored rehabilitation program. This involves controlled and progressive exercises to regain strength and range of motion.

• Functional Assessment: Rehabilitation often includes functional assessments to determine when it is safe for the patient to return to their regular activities or sports.

Medications:

• Pain Management: Over-the-counter or prescription pain medications manage pain and discomfort during recovery.

• Bracing or Splinting: In some cases, post-surgery or during the initial phase of non-surgical treatment, a brace or splint may be used to protect the elbow and aid in healing.

• Avoidance of Precipitating Activities: Patients are often advised to avoid activities that caused the injury until they have fully healed and rehabilitated.

Follow-Up Care: Regular follow-up appointments with a healthcare provider are most important to monitor the healing progress, address complications, and adjust the treatment plan. Patients should actively participate in their treatment and rehabilitation to optimize recovery and minimize the risk of long-term complications.

Conclusion

Medial epicondylar fractures can be painful and debilitating injuries, but with the right diagnosis and treatment, most individuals can expect a full recovery. Early medical evaluation and appropriate intervention are essential to achieving the best possible outcome. Patients should follow their healthcare provider's recommendations and actively participate in rehabilitation to regain strength and function in their elbow joints. With proper care and diligence, individuals can return to their daily activities and sports, free from the limitations imposed by this fracture.