eMedicine Specialties > Sports Medicine > Lower Limb
Medial Condylar Fracture of the Elbow
Updated: Apr 28, 2006
Introduction
Fracture of the medial condyle is rare in adults and in children; prompt recognition of this sometimes elusive injury is imperative so that complications can be averted.
Background
Frequency
United States
Trauma to the elbow has a high potential for complications and residual functional disability. Luckily, fractures of the humeral condyles are uncommon in adults. Medial condylar fractures are less common than fractures of the lateral condyle. Together, these injuries account for approximately 5% of all distal humerus fractures in adults.
During adolescence, the distal humerus is the second most common site of physeal injury (second only to the distal radius). Supracondylar fractures account for approximately two thirds of distal humeral injuries in children. In children with elbow fractures, isolated medial condyle fractures are uncommon and account for approximately 1-2% of all distal humerus fractures. In children, medial condyle fractures occur at a peak age of 8-12 years.
Fracture of the medial epicondyle of the elbow is common and occurs in approximately 10% of pediatric elbow fractures. Most of these injuries occur in males aged 10-14 years.
Functional Anatomy
The elbow joint is composed of the bony articulation between the humerus, ulna, and radius. The distal end of the humerus can be divided into the medial and lateral condyles. The articular portion of the medial condyle is the trochlea, and the articular portion of the lateral condyle is the capitulum. The epicondyle is considered part of the nonarticular portion of the condyle. The dividing point for the distal humerus, separating the medial and lateral condyles, is the capitulotrochlear sulcus.
Distinguishing between the articular and nonarticular surface of the condyles is important in the diagnosis and management of condylar fractures. By definition, fractures that involve only the intra-articular surface have no muscular attachments and can only be repositioned by pressure of the opposing articular surface or by open reduction and internal fixation. Fractures that extend beyond the joint capsule have attached muscle and ligaments. The position of the fracture fragment is often influenced by its muscular attachment.
The stability of the elbow is enhanced by its surrounding ligamentous structures. The medial collateral ligament and the lateral collateral ligament (ie, ulnar collateral ligament, radial collateral ligament) provide further stability of the elbow. The radiocapitellar joint is supported by the radial collateral and annular ligaments.
Collectively, the forearm musculature originates from the bony epicondyle prominences. The wrist flexors originate from the medial epicondyle, and the wrist extensors originate from the lateral epicondyle. Because the forearm musculature traverses the elbow joint, some inherent stability to the joint is conferred by muscular contraction.
The structures of the upper arm and elbow are located in either the anterior or posterior compartments. The anterior compartment contains the biceps brachii, brachialis, and coracobrachialis muscles. The anterior compartment also contains the brachial artery, median nerve, musculocutaneous nerve, and ulnar nerve. The ulnar nerve passes behind the medial condyle as it enters the forearm. Because of its location and relatively tight tethering to the epicondyle, the ulnar nerve can be injured when the medial humeral condyle is fractured. The posterior compartment contains the triceps brachii muscle and the radial nerve.
The bony anatomy of the elbow in the pediatric population deserves special mention. Many of the challenges encountered in diagnosing elbow fractures in pediatric patients involve proper knowledge of the ossification centers of the elbow. In general, ossification of the growth centers begins at an earlier age in girls than in boys. Although variation exists, ossification of the growth centers of the elbow occurs at the following times:
- Capitellum - 11 months
- Medial epicondyle - 4-6 years
- Radial head - 5-6 years
- Olecranon - 6-8 years
- Trochlea - 9-10 years
- Lateral epicondyle - 10-12 years
Sport Specific Biomechanics
By definition, the elbow is a true hinge joint that is very stable to all motions except varus and valgus stress. The articulation of the trochlea of the humerus and the olecranon of the ulna defines the plane of flexion and extension at the elbow. The elbow also allows for pronation and supination at the radiocapitellar articulation. The radiocapitellar joint does provide some stability against valgus stress by acting as a buttress to prevent medial elbow opening. Stability is further enhanced by the strength of the ulnar collateral ligament, the principal stabilizing ligament of the elbow that resists valgus stress.
The radial-collateral ligament protects the joint from posterolateral rotary instability and is usually injured during elbow dislocation. The wrist extensor tendons that originate on the lateral intermuscular septum of the arm and the lateral epicondyle provide the elbow with stabilization against varus stress.
Clinical
History
- When evaluating a patient with an acute elbow injury, obtain a detailed event history including the injury mechanism and the quality, intensity, duration, and location of symptoms.
- Injuries to the upper extremity, specifically the elbow, are often caused by falling on an outstretched arm, with the elbow in extension and the wrist in dorsiflexion. This type of injury can cause the medial condyle of the elbow to be avulsed as a result of ligamentous and muscular forces.
- Another mechanism responsible for medial condylar fractures is falling onto the point of a flexed elbow. The direct force applied to the posterior aspect of the elbow causes the articular portion of the olecranon to push the medial condyle off the distal humerus.
- Elicit and document hand dominance, occupation, and preexisting extremity injury.
- Also obtain a history of neurovascular complaints (eg, paresthesias, weakness, numbness, coolness). Neurologic complaints associated with acute elbow trauma suggest a neurapraxia, nerve entrapment syndrome, or compartment syndrome.
Physical
- Visual inspection is often the first step in assessing a patient with a traumatically injured elbow.
- Evaluate all injured patients in a systematic fashion as described in the Advanced Trauma Life Support provider's manual. The athletic trainer or examining physician should be aware of the possibility of a proximal upper extremity injury (ie, fracture, dislocation) in patients who have fallen onto an outstretched upper extremity.
- Systematically perform the physical examination of an acutely injured extremity. In the patient with an acutely injured elbow, evaluation of the extremity can begin at the shoulder and upper arm and then proceed to the forearm, wrist, and hand. The elbow should be examined last because tenderness elicited may interfere with a proper examination of the injured extremity.
- Assess the vascular status of the extremity. Palpate brachial, radial, and ulnar pulses. Evaluate the injured extremity for signs and symptoms of a compartment syndrome, including pain out of proportion to the injury, severe forearm pain with passive extension of the fingers, pallor, paresthesia, pulselessness, and paralysis.
- Test neurologic function. Perform distal motor and sensory testing of the radial, median, and ulnar nerves.
- Radial nerve testing
- Motor function of the radial nerve can be assessed by testing finger extension, which is primarily a function of the C7 nerve root.
- Sensory testing can be performed over the dorsal web space between the first and second digits.
- Median nerve testing
- Motor function of the medial nerve can be assessed by testing finger flexion, which is primarily a function of the C8 nerve root.
- Sensory testing can be performed over the radial aspect of the second digit.
- Ulnar nerve testing
- Motor function of the ulnar nerve can be assessed by testing finger abduction, which is primarily a function of the T1 nerve root.
- Sensory testing can be performed over the ulnar aspect of the fifth digit.
- Radial nerve testing
- Range-of-motion testing prior to radiographic evaluation should be minimized in the acutely painful extremity, especially in children.
Causes
Medial condylar fractures generally occur as a result of (1) a fall onto an outstretched upper extremity or (2) a fall onto a flexed elbow. The mechanism of injury appears to be the same in both children and adults.
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References
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Further Reading
Keywords
humeral condyle fracture, condylar fracture, epicondyle fracture, elbow fracture, distal humerus fracture, broken elbow, arm fracture, broken arm, Salter-Harris fracture, Kilfoyle fracture, Milch fracture
