Elbow Pain in the Splinter Series

$Medial epicondyle avulsion fracture$

A 12-year-old male pitcher for a traveling club baseball team complains of acute worsening of right elbow pain that has been bothering him for 3 months. The radiograph is shown below (Frontal elbow view. Case courtesy of Dr. Levente István Lánczi, Radiopaedia.org, rID: 46853). What is your diagnosis? What causes this injury? What patient demographic is most susceptible to this injury? How can this injury be prevented? What is the management of this injury in the Emergency Department?

$Medial epicondyle avulsion fracture$

Image 2. Lateral elbow view, Case Courtesy of Dr. Levente István Lánczi, Radiopaedia.org, rID: 46853.

What is your diagnosis?

Medial epicondyle avulsion fracture (medial displacement).

Pearl: Little League Elbow is a generic term that refers to an adolescent medial elbow injury. It can involve the ulnar collateral ligament (UCL), flexor-pronator mass strains, or the classic Little League Elbow which refers to medial epicondyle apophysitis [1].

What causes this injury?

Repetitive microtrauma from motions such as throwing which cause valgus stress on the elbow joint.

Pearl: Due to their immature skeletons, remember that pediatric patients are more likely to sustain a fracture compared to a ligament (UCL) or tendon injury.

What patient demographic is most susceptible to this injury?

Youth involved in sports with repetitive throwing mechanisms (baseball, softball, football, water polo, etc.) and have active distal humeral growth plates. These plates typically close in girls from age 14-17 and in boys between 16-18.

Pearl: Increased risk factors include participation in overhead throwing sports year-round, poor throwing mechanics, excessive conditioning routines, rapid skeletal growth, and poor physical conditioning [1].

How can this injury be prevented?

Proper mechanics, conditioning, and limitations placed on pitch/throw counts.

Players should warm-up and stretch properly prior to playing.
Young players should avoid throwing breaking pitches (curveballs, sliders, etc.) and avoid playing a single sport year-round.
Conditioning should focus on improving arm strength, flexibility, and cardiovascular fitness.

What is the management of this injury in the Emergency Department?

A posterior splint with the elbow at 90 degrees is recommended. Displacement of the medial epicondyle may require surgical fixation, especially in young, valgus-stressed athletes. The level of displacement and indication for operative management is controversial [2]. Follow-up in 1 week is recommended with sports medicine or orthopedics.

Resources and References:

Looking to bone up in general? Check out the SplintER archives. Want more information on pediatric elbow radiographs? Check out SplintER Series: Pediatric Elbow Pain.

Benjamin, Holly, Briner, William. Little League Elbow. Clin J Sport Med. 2005;15(1):37-40. PMID: 15654190
Pathy, Rubini, and Emily R. Dodwell. “Medial epicondyle fractures in children.” Curr Op Pediatr 27.1 (2015): 58-66. PMID: 25564187

Author information

Randall Beaupre, MD

Emergency Medicine Resident
Creighton University
Maricopa Medical Center

The post SplintER Series: A Pain in the Elbow appeared first on ALiEM.

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SplintER Series: A Pain in the Elbow