Medial elbow ossicle

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Case
A 17 year-old U-20 representative football player presented with an injury to his right elbow five days prior to a World Cup qualification tournament. He described falling to his right arm the day previously. He had an x-ray at a local hospital, was told he had “fractured his elbow” and was placed in an above elbow cast. He reports having being surprised about this as his pain was “not too bad”.

Findings
On the symptomatic right side there is a 17 x 8 x 5 mm ossicle adjacent to the medial epicondyle. The ossicle appears largely corticated. There is no corresponding ossicle on the left side.

The MR images shows that the ossicle is non-oedematous and that there is no oedema at the medial epicondyle. There is however irregular fluid signal separating the medial epicondyle and the ossicle and there is extensive surrounding subcutaneous oedema. Some fibres of both the medial collateral ligament and common flexor tendon attach to the ossicle – while the majority of these structures are attached to the medial epicondyle and are intact. The fluid and oedema around the ossicle would be consistent with disruption of a synchondrosis or fibrous union.

Discussion
Based on the well-corticated look of the ossicle the cast was removed to allow a clinical assessment. There was modest swelling about the medial elbow and only modest tenderness over the medial epicondyle. The medial collateral ligament was clinically intact while the common flexor origin also appeared normal (with no pain or weakness on resisted pronation or wrist flexion). Based on these clinical findings (and reassuring imaging) the player was removed from the cast. He was able to play a full part in the qualifying campaign starting five days later. His elbow was strapped to limit valgus loading during games and training sessions. His symptoms slowly resolved over a six week period. 

Medial epicondyle fractures are typically seen in children, and can be challenging to identify. Failure to diagnose these injuries can lead to significant long term disability. In young patients, knowledge of the sequence of ossification of the elbow (remembered using the mnemonic CRITOE) is essential as an avulsed and displaced apophysis can mimic another centre. Overall all centres are ossified by approximately 12 years of age. A medial epicondyle fracture would be unlikely in this patient due to his age, the well corticated appearance of the ossicle and the absence of similar findings on the contralateral side.

Important notice
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Bangoura
27 août 2018 16:40

De toutes les articulations le coude semble être plus compliqué dans les cas de trauma non ou mal traité. Dans les cas de fracture du coude il faut plâtre en première intention. Mais si la RADIOGRAPHIE révèle une fracture avec présence d un osselet la chirurgie s impose.
La rééducation doit se faire correctement pour éviter des antilopes.

Dr Ian Beasley
28 août 2018 13:04

hi there,
I think the comments about the medial epicondyle could be confusing. Ossification often happens before 12 years, but fusion not until mid to later teens. I think in your article, you should make this clear, and what this means for imaging findings.
best wishes to all,
Ian Beasley