Epicondylar fractureMANAGEMENT

ARM & ELBOW · 12 SECTIONS

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462 items

☷ Legend

01Approach to the Critical Patient/attcp49

Immediate priorities

›Limb and life threats

›Hemodynamic instability

›Polytrauma triggers

›Major hemorrhage alternative source

›Open fracture concern

›Bleeding control

›Antibiotics and tetanus pathway

›Neurovascular compromise

›Weak or absent distal pulses

›Progressive motor deficit

›Compartment syndrome concern

›Pain out of proportion

›Pain with passive stretch

Limb threat priorities

›Neurovascular status

›Radial pulse

›Doppler if nonpalpable

›Comparison to contralateral side

›Capillary refill

›Delayed refill threshold

›Cool or mottled hand

›Median nerve

›Thumb opposition strength

›Palmar index finger sensation

›Ulnar nerve

›Finger abduction strength

›Small finger sensation

›Radial nerve

›Wrist and finger extension strength

›Dorsal first web space sensation

›Documentation timing

›Before splinting

›After splinting

›Ischemia escalation

›If pulseless or cool hand, immediate reduction if dislocation present

›If no rapid improvement, urgent orthopedics

›If persistent ischemia, transfer for vascular capability

›If progressive neurologic deficit, urgent orthopedics

›Entrapment concern

›Incarcerated fragment concern

Open fracture pathway

›Open injury actions

›Sterile saline moistened dressing

›Gross contamination removal only

›Splint in position of comfort

›Antibiotic timing

›As early as feasible after recognition

›Expanded coverage for heavy contamination

›Tetanus prophylaxis

›Unknown or incomplete immunization triggers immune globulin

›Booster based on wound type and vaccine timing

02History/hx34

Mechanism and timing

›Injury context

›FOOSH with valgus load

›Direct blow to elbow

›Throwing or gymnastics valgus stress

›High energy mechanism

›Timeline

›Time since injury

›Any attempted reduction

›Pain pattern

›Medial elbow pain

›Lateral elbow pain

›Functional impact

›Loss of ROM

›Inability to throw

›Dominance and baseline

›Hand dominance

›Baseline sport level

Associated injury mapping

›Dislocation indicators

›Visible deformity at time of injury

›Spontaneous relocation report

›Neuro symptoms

›Ulnar paresthesia

›Hand weakness

›Red flags

›Progressive numbness

›Increasing tightness or swelling

›Severe pain despite immobilization

›Risk modifiers

›Prior elbow instability

›Prior fracture or surgery

›Anticoagulants

›Bone health risks

›Osteoporosis

›Chronic steroids

03Physical Exam/exam39

Inspection and palpation

›Soft tissue and skin

›Swelling and ecchymosis

›Skin tenting or blanching

›Abrasions or puncture wound

›Deformity pattern

›Medial prominence tenderness

›Lateral prominence tenderness

›Local tenderness map

›Medial epicondyle

›Lateral epicondyle and lateral condyle region

›Radial head

›Olecranon

›Joint above and below

›Shoulder pain and ROM screen

›Wrist pain and ROM screen

Neurovascular and function

›Neurovascular exam

›Radial and ulnar pulses

›Median nerve motor and sensory

›Ulnar nerve motor and sensory

›Radial nerve motor and sensory

›Elbow stability and ROM

›Active ROM limitation

›Passive ROM limitation

›Mechanical block concern

›UCL and flexor pronator unit

›Valgus pain

›Medial laxity concern

›Compartment exam

›Forearm compartments firmness

›Pain with passive finger extension

PITFALLS

›Missed incarcerated fragment after dislocation reduction

›Persistent medial pain

›Mechanical block

›Confusion with medial condyle fracture in children

›Intraarticular fracture concern

›Lower threshold for urgent ortho input

›Ulnar nerve symptoms dismissed as transient

›Repeat neuro checks after splinting

›Escalation if worsening

04Differential Diagnosis/ddx27

Traumatic elbow pain differential

›Fracture patterns

›Medial epicondyle fracture

›Lateral epicondyle fracture

›Lateral condyle fracture

›Supracondylar humerus fracture

›Radial head or neck fracture

›Olecranon fracture

›Dislocation and instability

›Elbow dislocation with avulsion fragment

›Posterolateral rotatory instability

›Tendon and ligament injuries

›UCL tear

›Common flexor origin avulsion

›Common extensor origin avulsion

›Pediatric mimics

›Apophysitis from throwing

›Physeal injury

›Nonfracture mimics

›Septic arthritis if systemic symptoms

›Hemarthrosis with coagulopathy

Coding and standard terms

›ICD-10 and SNOMED CT alignment

›ICD-10 S42.44 fracture of medial epicondyle of humerus category

›ICD-10 S42.441A displaced fracture of medial epicondyle of right humerus initial encounter closed

›ICD-10 S42.442A displaced fracture of medial epicondyle of left humerus initial encounter closed

›SNOMED CT concept

›Fracture of medial epicondyle of humerus

›Fracture of lateral epicondyle of humerus

05Laboratory Tests/lt22

Minimal labs unless higher risk context

›Baseline labs triggers

›Open fracture

›CBC for infection and anemia context

›BMP for renal function before antibiotics

›Planned procedural sedation

›Point of care glucose if altered mental status risk

›Pregnancy test if relevant and uncertain status

›Anticoagulation

›INR for warfarin

›CBC for baseline hemoglobin and platelets

›Polytrauma

›Type and screen

›Lactate for shock context

›Compartment syndrome adjuncts

›CK for crush or prolonged ischemia concern

›Creatinine for rhabdomyolysis risk

Interpretation pearls and pitfalls

›Lab limitations

›Normal labs do not exclude occult fracture

›Normal CK does not exclude early compartment syndrome

›Infection context

›Elevated WBC is nonspecific for open fracture contamination

›Fever after injury suggests alternative diagnosis

06Diagnostic Tests/dt61

Scoring Systems

›Clinical decision support

›Elbow extension test

›Sensitivity 96.8% for elbow fracture detection

›Specificity 48.5% for elbow fracture detection

›Negative predictive value 98.4% adults

›Negative predictive value 95.8% children

›Pediatric medial epicondyle displacement measurement variability

›Displacement thresholds used in practice range 2 to 15 mm

›Radiographic displacement measurement reliability is limited

›Pediatric classification

›Medial epicondyle fracture association

›Elbow dislocation prevalence range 30% to 60%

›Incarceration after dislocation risk

›Lateral condyle fracture classification

›Weiss classification for displacement and stability

›Surgical threshold tied to articular displacement

Radiographs

›Imaging set

›Elbow radiographs

›AP view

›Lateral view

›Oblique view if unclear

›Joint alignment

›Radiocapitellar line

›Anterior humeral line in children

›Occult injury indicators

›Posterior fat pad sign

›Joint effusion

›Epicondylar specific pearls

›Medial epicondyle fragment

›Compare to expected ossification center position in children

›Evaluate for intraarticular fragment after dislocation

›Lateral sided fragment

›Differentiate lateral epicondyle avulsion from lateral condyle fracture

›Articular involvement concern with lateral condyle fracture

›Post procedure imaging

›After reduction if dislocation present

›After splinting if alignment concern persists

MRI

›Indications

›Persistent pain with negative radiographs

›Occult fracture concern

›Osteochondral injury concern

›Ligament and instability evaluation

›UCL tear

›Common flexor origin injury

›High level thrower with valgus pain

›Apophyseal injury versus avulsion

›Limitations

›Access and timing constraints in acute ED setting

›Motion artifact in painful injuries

›Indications

›Intraarticular fragment localization

›Suspected incarcerated medial epicondyle fragment

›Persistent block to motion

›Surgical planning

›Complex distal humerus involvement

›Suspected lateral condyle articular displacement

›Radiographs equivocal with high suspicion

›Displaced fragment unclear on plain films

›Radiation considerations

›Pediatric dose minimization

›CT only when result changes management

07Disposition/dispo25

Consultation and transfer triggers

›Emergent orthopedics

›Open fracture

›Incarcerated fragment in joint

›Irreducible dislocation

›Persistent neurovascular deficit after reduction and splinting

›Compartment syndrome concern

›Urgent orthopedics

›Elbow instability after reduction

›Significant displacement in pediatric medial epicondyle fracture with functional demand

›Lateral condyle fracture suspicion

›Transfer criteria

›No pediatric ortho coverage with suspected operative injury

›Vascular injury concern needing higher level care

Follow-up and immobilization plan

›Discharge pathway

›Pain controlled on oral meds

›Neurovascularly intact and stable

›Reliable follow-up

›Follow-up timing

›Pediatric epicondyle fracture without high risk features

›Orthopedics within 5 to 7 days

›Post reduction dislocation with avulsion fragment

›Orthopedics within 1 to 3 days

›Activity restriction

›No throwing or valgus stress activities until cleared

›No lifting with injured arm until cleared

08Treatment/t96

Immediate life-saving interventions

›Time critical actions

›If dislocation with ischemia, immediate reduction attempt

›If no pulse return, urgent escalation

›If worsening neuro deficit, urgent escalation

›If open injury, antibiotics and tetanus pathway

›Sterile dressing and splint

›Avoid closed reduction through open wound if feasible

Immobilization and Splinting

›Splint selection

›Posterior long arm splint

›Elbow at 90 degrees flexion if tolerated

›Forearm neutral rotation unless specific instability pattern

›Sling support

›Comfort and elevation

›Skin checks

›Immobilization principles

›Swelling phase avoidance of circumferential cast

›Extra padding over olecranon and epicondyles

›Two finger tightness check

›Post application reassessment

›Motor and sensory exam repeat

›Cap refill and pulses repeat

›Pain trend after splint

Reduction

›Indications

›Elbow dislocation present

›Threatened skin

›Neurovascular compromise

›Contraindications or caution triggers

›Suspected incarcerated fragment

›Gentle technique only

›Early orthopedics involvement

›Suspected medial condyle fracture

›Avoid repeated manipulation

›Urgent orthopedics

›Analgesia and anesthesia

›Non opioid options

›Acetaminophen PO

›Adult 1000 mg every 6 hours

›Pediatric 15 mg per kg every 6 hours

›Ibuprofen PO

›Adult 400 to 600 mg every 6 hours

›Pediatric 10 mg per kg every 6 to 8 hours

›Opioid options

›Fentanyl IV

›Adult 0.5 to 1 mcg per kg every 5 minutes as needed

›Pediatric 0.5 to 1 mcg per kg every 5 minutes as needed

›Morphine IV

›Adult 0.05 to 0.1 mg per kg every 10 minutes as needed

›Pediatric 0.05 to 0.1 mg per kg every 10 minutes as needed

›Procedural sedation when required

›Monitoring and staffing

›Continuous pulse oximetry

›Continuous capnography when available

›Cardiac monitor and blood pressure cycling

›Ketamine IV

›Initial 1 to 2 mg per kg over 30 to 60 seconds

›Supplemental 0.5 mg per kg every 5 to 10 minutes as needed

›Recovery positioning and airway readiness

›Propofol IV

›Initial 0.5 to 1 mg per kg

›Supplemental 0.25 to 0.5 mg per kg every 1 to 3 minutes

›Hypotension and apnea risk monitoring

›Technique principles

›Traction and countertraction

›Deformity exaggeration then reversal for dislocation patterns

›Gentle sustained force

›Avoid repeated forceful attempts

›Post reduction requirements

›Immediate neurovascular recheck

›Post reduction radiographs

›Immobilization in stable position

›Failed reduction pathway

›If persistent neurovascular deficit, immediate escalation

›If irreducible, urgent orthopedics

›If worsening pain and tight compartments, compartment syndrome escalation

Open fracture medications and timing

›Antibiotics

›Type I and II open fracture coverage

›Cefazolin IV

›Adult 2 g every 8 hours

›Pediatric 30 mg per kg every 8 hours

›Severe beta lactam allergy alternative

›Clindamycin IV

›Adult 600 to 900 mg every 8 hours

›Pediatric 10 mg per kg every 8 hours

›Gross contamination

›Add gram negative coverage per local protocol

›Farm or soil contamination expansion per local protocol

›Tetanus prophylaxis

›Vaccine status unknown or incomplete

›Tdap or Td booster

›Tetanus immune globulin for dirty wound per immunization history

DVT prophylaxis when relevant

›Upper extremity fracture context

›Routine pharmacologic prophylaxis not typical in isolated immobilized upper limb

›Individual risk assessment

›Prior VTE history

›Active cancer

›Prolonged immobility or hospitalization

09Special Populations/sp33

Pregnancy

›Maternal and fetal considerations

›Fall risk and trauma screening

›Abdominal pain or bleeding

›Rh status if indicated

›Imaging principles

›Radiographs acceptable with shielding when possible

›CT only when management changing and necessary

›Analgesia considerations

›Acetaminophen preferred

›NSAID avoidance in later pregnancy context

›Disposition modifiers

›Lower threshold for observation if significant trauma mechanism

›Obstetric consultation triggers

Geriatric

›Fragility injury context

›Low energy fall mechanism

›Osteoporosis risk

›Management considerations

›Skin fragility and pressure injury prevention in splints

›Opioid delirium risk

›Lowest effective dose

›Constipation plan

›Follow-up reliability assessment

›Higher admission threshold if unsafe home situation

Pediatrics

›Growth plate and ossification considerations

›Normal ossification centers mimic fragments

›Comparison views when uncertain

›Injury pattern data

›Medial epicondyle fractures comprise 11% to 20% of pediatric elbow fractures

›Elbow dislocation association range 30% to 60%

›Ulnar neuropathy can occur in up to 6% of cases

›Nonaccidental trauma considerations

›Mechanism inconsistent with developmental stage

›Multiple injuries or concerning history

10Background/b38

Epidemiology

›Frequency

›Pediatric elbow fractures account for about 10% of childhood fractures

›Medial epicondyle fractures comprise 11% to 20% of pediatric elbow fractures

›Demographics

›Peak age 9 to 14 years for medial epicondyle fractures

›Male predominance reported in pediatric medial epicondyle fractures

›Associated injuries

›Elbow dislocation associated in 30% to 60% of medial epicondyle fractures

Pathophysiology

›Mechanism mapping

›Valgus load avulsion at medial epicondyle

›Flexor pronator mass traction

›UCL traction

›Dislocation related avulsion

›Fragment displacement during dislocation

›Incarceration within joint after spontaneous reduction

›Anatomic risk structures

›Ulnar nerve proximity medially

›UCL attachment at medial epicondyle

›Articular surface risk with lateral condyle fractures

Therapeutic Considerations

›Nonoperative versus operative decision drivers

›Absolute operative indications commonly cited

›Incarcerated fragment in joint

›Open fracture

›Ulnar nerve entrapment or persistent deficit

›Gross valgus instability

›Relative operative considerations

›High demand throwing athlete

›Significant displacement with functional goals

›Symptomatic nonunion risk context

›Displacement measurement limitations

›Displacement thresholds used in practice range 2 to 15 mm

›Plain film displacement measurement reliability is limited

›Imaging decision support

›Elbow extension test fracture detection performance

›Sensitivity 96.8%

›Specificity 48.5%

›Adults negative test fracture risk 1.6%

›Children negative test fracture risk 4.2%

11Patient Discharge Instructions/pdi24

copy discharge instructions

›Discharge bundle

›Splint care

›Keep splint clean and dry

›Do not insert objects to scratch

›Swelling control

›Elevation above heart as much as possible for 48 to 72 hours

›Ice 15 to 20 minutes at a time with barrier

›Pain plan

›Acetaminophen scheduled option

›Ibuprofen scheduled option if allowed

›Opioid only if prescribed and as directed

›Activity limits

›Sling use for comfort

›No sports, throwing, or heavy lifting until cleared

›Return to ED now

›Increasing pain not relieved by meds

›New numbness or weakness in hand

›Fingers cold, pale, or blue

›Splint feels too tight with increasing swelling

›Worsening swelling or inability to move fingers

›Fever or wound drainage

›Follow-up

›Orthopedics appointment timing as instructed

›Return for repeat x-ray if pain persists or worsens

12References/r14

Evidence-based sources and guidance

›Core evidence and accuracy data

›Appelboam et al BMJ 2008 elbow extension test sensitivity 96.8% specificity 48.5%

›AAFP summary of elbow extension test negative predictive values adults 98.4% children 95.8%

›Pediatric medial epicondyle epidemiology and association

›Jeong et al 2022 medial epicondyle fractures 11% to 20% of pediatric elbow fractures and dislocation 30% to 60%

›POSNA study guide medial epicondyle fractures dislocation association and incarceration risk

›Practice variability and displacement thresholds

›Acta Orthopaedica Belgica 2022 displacement thresholds reported 2 to 15 mm and measurement variability concerns

›Barghi et al 2025 review management trends and operative indications for pediatric medial epicondyle fractures

›Pediatric elbow fracture general background

›AAOS OrthoInfo elbow fractures in children about 10% of childhood fractures

›Procedural sedation guidance for ED reductions

›ABEM Key Advances adult procedural sedation updated July 2025

›Miller et al 2019 clinical practice guideline for ED propofol sedation

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed March 6, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.