Initial anterior-posterior and lateral elbow radiographs were normal with the medial epicondyle physis still open. A stress radiograph was initially deemed normal. Initial MRI revealed marrow edema concerning for a non-displaced fracture of the distal metaphysis from lateral to medial in the supracondylar region. Case Photo #1, Case Photo #2An electromyography (EMG) and nerve conduction study (NCS) was performed due to neurological complaints. Results revealed decreased conduction velocity in the median motor nerve at the elbow and wrist with decreased conduction amplitudes, mild acute-on-chronic neurogenic changes in the pronator teres, as well as chronic neurogenic changes in the abductor pollicis brevis and flexor pollicis longus muscles. (SEE IMAGE 3)
Given these results, the patient was made non-weight bearing for four weeks. When the patient returned he admitted he continued to have pain and occasional tingling in his forearm but did not adhere to medical recommendations. Thus he was put into a long-arm cast with elbow at 90 degrees in neutral position for a period of three weeks. After casting patient had significant improvement as his pain resolved as did his neurological symptoms. A repeat MRI to assess for bony edema and healing, however, revealed increased marrow edema along the capitellum and extending into the trochlea without a discrete fracture line. Case Photo #4, Case Photo #5 Due to this result, the patient was referred to our upper extremity surgeon for a second opinion. On examination the patient was asymptomatic with full active and passive range of motion without pain and complete motor and sensory examination was intact and symmetric to the contralateral side. Given these findings, the patient was instructed to begin physical therapy and to progress to a light throwing program as long as asymptomatic.
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