Question
A 12 year old boy falls onto his outstretched arm. Radiographs show a displaced medial epicondyle fracture, and the fragment cannot be seen on the AP view.
- What is the significance of the missing fragment?
- What are the indications for surgery?
- How would you manage it?
Answer
Significance
- The fragment may be incarcerated in the joint after an elbow dislocation
- Medial epicondyle fractures are associated with elbow dislocation in about half
- Always identify the medial epicondyle using the CRITOE sequence of ossification
- Assess the ulnar nerve
Indications for surgery
- Absolute, an incarcerated fragment in the joint
- Relative, displacement over about 5 to 15 mm, valgus instability, ulnar nerve dysfunction and throwing athletes or gymnasts
- Many minimally displaced fractures do well without surgery, often with fibrous union
Management
- Attempt manipulation with valgus stress and supination to extract the fragment, then open reduction if needed
- Open reduction through a medial approach, protecting the ulnar nerve
- Screw fixation with or without a washer allows early motion
- Cast for 3 to 4 weeks for non-operative treatment, then early motion
- Stiffness is the most common complication
Related pages
Author Contributions
Orthofracs team
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.