A 15-Year-Old Boy with a Painful Elbow After a Baseball Game

Differential Diagnosis

• Displaced avulsion fracture, medial epicondyle
• Medial epicondylitis (golfer’s elbow)
• Apophysitis of the medial epicondyle (little league elbow)
• Supracondylar fracture
• Normal apophysis

Diagnosis

The correct diagnosis is a significantly displaced avulsion fracture of the medial epicondyle. Note on the lateral x-ray, there is a joint effusion. On the AP x-ray, there is a large fragment avulsed from the medial epicondyle with associated soft tissue swelling.

Learnings/What to Look for

• Medial epicondyle avulsion is typically seen in adolescent throwers
• In contradistinction to the repetitive trauma resulting in apophysitis (little league elbow), this fracture usually results from a single high-force valgus trauma and athletes often hear a “pop”
• It is important to distinguish an avulsion fracture from a widened (apophysitis) or normal growth plate

Pearls for Urgent Care Management

• Medial epicondyle fractures are best immobilized with a posterior long arm splint and arm sling
• Surgical fixation is required for injuries with complete neurologic deficit, incarcerated fragments, open wounds, or significant displacement
• Orthopedic follow-up is always necessary within 7 days. Possible surgical cases should be referred for same- or next-day evaluations
• Surgical reduction is often preferred for mild-moderate displacement in overhead adolescent athletes (swimmers, pitchers) or weightbearing athletes (gymnasts) who will continue to have valgus instability if the fragments is not stabilized

Acknowledgment: X-rays and case presented by Experity Teleradiology (www.experityhealth.com/teleradiology).