Background:

Medial epicondylar apophyseal avulsion fractures of the distal humerus represent an understudied severe variant of elbow overuse injury in youth throwers.

Purpose:

To characterize medial epicondylar apophyseal avulsion fractures in a population of youth throwers, as well as to describe outcomes after both operative and nonoperative treatment.

Study Design:

Case series; Level of evidence, 4.

Methods:

Skeletally immature athletes with a medial epicondylar apophyseal avulsion fracture sustained during throwing from 2003 to 2017 at a tertiary care pediatric referral center were identified. Exclusion criteria were injuries sustained during nonthrowing events or previous elbow fractures. Patients treated operatively were compared with those treated nonoperatively, and the overall study population was compared with a control group of patients diagnosed with medial epicondylar apophysitis only, with no fracture.

Results:

A total of 50 patients with medial epicondylar avulsion fractures (100% male; 49 baseball pitchers, 1 football quarterback) were identified. These patients had higher body mass index (BMI) than the control group with medial epicondylar apophysitis only. Of the 37 avulsion fracture patients with documentation regarding presence or absence of preoperative symptoms, 31 patients (84%) reported preexisting elbow pain before their acute injury. Of the 12 patients who underwent shoulder exams at presentation, 5 (42%) demonstrated glenohumeral internal rotation deficit (GIRD). Of the total 50 patients, 22 (44%) underwent open reduction and internal fixation (ORIF) with a single cannulated screw, 1 (2%) patient underwent suture-based fixation, and 27 (54%) patients were treated nonoperatively. For each additional millimeter of displacement, the odds of surgical intervention increased by 6.4 times (odds ratio, 6.36; 95% CI, 1.83-22.07; P = .004) when controlling for age and BMI. All patients returned to sports, with no significant difference in recurrent elbow pain between cohorts, although 41% of applicable ORIF patients (9 of 22) underwent secondary screw removal.

Conclusion:

Displaced medial epicondylar apophyseal avulsion fractures in youth throwers may be effectively treated with operative screw fixation, although >40% of patients may require secondary screw removal. Nonoperative treatment may be appropriate for minimally displaced cases. Given that a large majority of patients reported preexisting elbow pain, and a substantial cohort demonstrated GIRD, this severe presentation of Little League elbow may be preventable.

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Medial Epicondylar Apophyseal Avulsion Fractures in Youth Throwers: A Severe Variant of Little League Elbow