Medial Epicondyle Avulsion Fractures/Apophysitis

The Throwing Athlete

The medial elbow is subject to significant force throughout the throwing cycle, specifically in the late cocking and early acceleration phases. The medial epicondyle is the “knob” on the inside part of our elbow and is the attachment site for many important ligaments and muscles.
Skeletal immaturity makes adolescent players prone and vulnerable to throwing injury and overuse. In fact, nearly one-third of youth baseball pitchers will experience shoulder or elbow pain during the season. This is multifactorial, but the imbalance in strength between open physis (“growth plate”) and the attached tendons and ligaments coupled with repetitive strenuous force imparted by overhead throwing put adolescent throwers at particular risk for physeal injuries.
In the growing athlete the ligamentous structures are actually 2-5x stronger than the open physes (growth plates). This means that both static (UCL) and dynamic (flexor-pronator mass) stabilizers inserting on the medial epicondyle, impart all forces to the medial epicondylar physis (growth plate)

The Throwing Athlete

The term “Little Leaguer’s Elbow” can encompass a number of pathologic conditions in the skeletally immature including medial epicondylar apophysitis, physeal widening, fractures, posteromedial impingement, capitellar osteochondritis dissecans, stress lesions of the proximal ulna, nonunion or stress fractures of the olecranon, or abnormal persistence /widening of the ulnar physis into skeletal maturity
Overuse remains the common thread throughout adolescent elbow injuries which provides an important opportunity for prevention to play a role in treatment strategy
Good pitching mechanics have been proven to generate lower shoulder and elbow torques, lower joint loads and greater efficiency
Two distinct conditions can affect the medial aspect of the skeletal immature elbow in the throwing athlete.

Medial Epicondyle Apophysitis

Medial epicondyle appophysitis refers to a chronic inflammatory state where the muscles and tendons attach to the inside of the elbow
This is an overuse injury as a result of repetitive strain across the medial elbow and associated with improper mechanics
This typically presents with progressive medial elbow pain in overhead athletes 10 years or younger
Pain in the late cocking and early acceleration phase is common as this is the highest valgus loads on the elbow
X-rays typically demonstrate widened physis and sclerosis of the apophysis. Comparison films of the contralateral extremity can be very helpful for subtle differences
Treatment is nonoperative with abstinence from throwing and a period of rest for 6-12 weeks. Throwing can begin once strength is symmetric and patient is completely symptom free

The Throwing Athlete

True fractures about the medial epicondyle typically occur between the age of 10-14 years
This is a result of an acute injury typically associated with a discrete event such as a fall or a single throw
This is not an overuse injury, but instead a result of the older athlete generating enough force to overwhelm the closing physis
Pre-existing pain or chronic overuse history is NOT usually present
Swelling is much more pronounced than with apophysitis and may have a loss of motion
Patient is typically unable to continue to throw and tingling into the pinky and ring fingers may be present
X-rays demonstrate widening or displacement of the medial epicondyle
Treatment is based on the amount of displacement and patient’s activities

The Throwing Athlete

The Throwing Athlete

If left untreated, medial epicondyle fractures can develop into a nonunion

For patients that have failed nonoperative treatment or have displaced avulsion fractures, surgery is indicated
Displacement of the medial epicondyle leads to an unloaded ligament that will atrophy and alter the mechanics of the elbow
Some studies suggest that even 2mm of displacement can lead to permanent loss of tension of the UCL in the throwing athlete
Surgical treatment typically involves open reduction and internal fixation with screw placement across the fractured bone
The patient is typically in an elbow brace for 6 weeks postop with early physical therapy to regain motion
Patient is released to play once fracture has healed and patient has successfully completed therapy and a throwing program
In general, medial epicondyle fractures are better treated surgically in the throwing athlete to allow earlier motion, less stiffness and earlier return to sporting activity with decreased chance of nonunion.

The Throwing Athlete

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