|Year : 2022 | Volume
| Issue : 3 | Page : 26-33
Medial epicondyle fractures of the humerus
Division of Paediatric Orthopaedics, Department of Orthopaedics, Sunshine Hospitals, Hyderabad, Telangana, India
|Date of Submission||29-Mar-2022|
|Date of Acceptance||04-Apr-2022|
|Date of Web Publication||25-May-2022|
Sunshine Hospitals, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
Medial epicondyle fractures are common in adolescent age group and uncommon in younger age. Unossified elbow in a younger child may pose a challenge in diagnosis. Historically fracture displacement has been quoted and used frequently as criteria for management. Plain radiographs which are routinely used for management, may underestimate the displacement. Incarcerated and open medial epicondyle fractures remain absolute indications for open reduction. Elbow dislocation, Instability, Ulnar Nerve injury, Associated fracture or ligamentous injuries and physical demands of the patient must also be considered during decision making. Isolated fractures have yielded excellent results when managed conservatively. Complications of conservatively managed fractures are rarely symptomatic. The decision to operatively manage these injuries must be individualised after considering the above mentioned factors.
Keywords: Medial epicondyle fractures, Paediatric elbow, Open reduction, Displaced
|How to cite this article:|
Chandankere V. Medial epicondyle fractures of the humerus. J Orthop Assoc South Indian States 2022;19, Suppl S1:26-33
| Introduction|| |
Medial epicondyle fractures account for 12% of pediatric elbow fractures.
About 30%–50% of these fractures are associated with elbow dislocations.,,, Fracture displacement has been used very often for guiding further management without much evidence. Medial epicondyle gets entrapped into the joint in 5%–18% of cases,, leading to limitation of motion, hence requiring prompt recognition and surgical intervention. The incidence of ulnar nerve dysfunction is seen in about 10%–15% of cases and significantly increases with fracture incarceration into the joint.
| Relevant Anatomy|| |
Medial epicondyle is the second ossification to appear at distal humerus at around 5–7 years of age and last to fuse by the age of 15–20 years. It is located posteromedially in the distal humerus and serves as attachment for the flexor pronator muscle group and the medial collateral ligament which is an important ligamentous stabilizer of the elbow. It is extra-articular in adolescents, but capsule may extend up to the apophysis in younger children. It does not contribute to longitudinal growth but is important for the width and shape of the elbow. Anterior band of the medial collateral ligament is an important stabilizer against valgus stresses. Ulnar nerve can be injured in these fractures as it passes into the cubital tunnel posterior to medial epicondyle.
The blood supply is from extensive collateral plexus round the elbow. The medial arcade is formed by superior and inferior ulnar collateral artery and posterior ulnar recurrent artery. They collectively supply the medial epicondyle from anterior as well as posterior surfaces unlike the lateral condyle.
| Mechanism|| |
Adolescents from 12 to 16 years of age commonly suffer this injury. Three mechanisms have been proposed: direct trauma, avulsion, and fracture in association with dislocations., The most common injury is fall on an outstretched hand with valgus force, on an extended elbow. Valgus stress allows the static and dynamic stabilizers of the elbow to pull away the medial epicondyle. Isolated fractures are the result of avulsion or direct trauma. Elbow dislocation with a valgus moment can create a negative suction effect in the joint, leading to incarceration of medial epicondyle. Fractured fragment displaces anteriorly, distally due to flexor muscles group attachment.
| Physical Examination|| |
Pain, swelling, ecchymosis, and limited range of motion (ROM) are common chief complaints after a history of fall or overhead activities. Medial swelling and tenderness may suggest isolated injury, whereas gross elbow swelling and deformity may indicate concomitant dislocation or other associated fractures. Crepitus may be elicited in fractures. An altered three-point relationship as noted from the posterior aspect signifies dislocation. Limitation of ROM may be due to an incarcerated fragment, persistent dislocation, or pain itself. Extension block is a characteristic of incarceration. In high-energy trauma, concomitant fractures must be ruled out. A thorough vascular and neurological evaluation must be performed.
| Imaging|| |
Anteroposterior (AP), lateral (LAT), and oblique radiographs of the elbow must be taken; occasionally, a comparative normal elbow X-ray or stress radiographs may clear the confusion. Distal humerus axial view which correlates better with true displacement can be done. Stress testing must not be performed on alert children without sedation or anesthesia.
Loss of parallelism of the sclerotic margins of apophysis, alteration in the width of apophysis, and interruption of cortical contour in the AP view may suggest fracture. Elbow fat pad sign is generally absent, but its presence may suggest reduced elbow dislocation. Displaced fractures may overlap the distal humerus or mimic trochlear ossification center, leading to misinterpretation. Presence of medial epicondyle at joint level or its absence itself may suggest incarceration. Joint congruence must also be assessed.
Radiographs are known to underestimate the displacement, and proper views may be difficult to take in an acute trauma setting. CT scans are not advocated routinely, but they can accurately determine the true extent of displacement. Arthrogram, ultrasonography (USG), and magnetic resonance imaging (MRI) can be helpful in unossified elbow in younger children and doubtful medial condylar fractures.
| Classification|| |
Most classifications consider fracture displacement, incarceration, or dislocations into account; some have included duration of injury also.
Smith classified these fractures into five types based on displacement and incarceration: (1) not apparent on X-ray, (2) minimally displaced, (3) significantly displaced, (4) incarcerated, and (5) a fracture of the medial humeral epicondyle in adults.
Papavasiliou and Crawford used a classification which is more often used today: Type 1: small degree of avulsion, Type 2: avulsed fragment at the level of the joint but not entrapped, Type 3: the fragment is incarcerated in the joint, and Type 4: associated with elbow dislocation. Both these classifications there is a scope for confusion between Type 1 and Type 2.
Mercer Rang (1974) has described these fractures based on the displacement into four types: minimally displaced, rotated, incarcerated, and dislocated.
These classifications are based on appreciation of the fragment on radiographs; hence, younger children with unossified elbows may be difficult to interpret. They are all simple and commonly used, but they do not consider associated elbow fractures or the valgus instability, which may be crucial for further management. Wilkins classified them based on duration and displacement.
In a younger child with suspicion, an USG or MRI may help identify the fracture and differentiate between medial condyle and medial epicondyle fracture [Figure 1].
|Figure 1: A 7-year-old boy with medial condyle fracture, intra-articular extension. It must not be confused with medial epicondyle fracture|
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| Management|| |
Goal of the treatment is to achieve fracture union, leading to stable pain-free elbow with good ROM and grip strength in the long run.
Mechanism of injury, a thorough clinical examination, and all three radiographs (AP, LAT, and oblique) must be obtained.
Age, instability at the elbow, fragment incarceration, associated fractures, hand dominance, neurological involvement, and level of physical activity must be considered for decision-making.
When elbow dislocation is present, it must be reduced promptly under sedation. Stress examination under gravity and valgus stress also can be performed at the same time. Extent of damage to medial stabilizers is more important than fracture displacement itself. It must be noted that in acute injuries, even simple fractures may demonstrate instability when stressed. A careful examination of neurological and vascular status must be done before and after such attempted reductions.
There is a consensus in the literature for the management of these two categories of injury:
- Nondisplaced or minimally displaced, low-energy fractures without instability can be managed conservatively
- Incarcerated intra-articular fragment and open fractures need surgical reduction and internal fixation.,,,
Controversy exists in surgical management of displaced fractures. Various authors have suggested 2–15 mm displacement as their threshold for surgical intervention.,,,,
Relative indications for operative management include displacement more than 1 cm, valgus instability at elbow, associated elbow dislocations, and associated nerve dysfunction. Some authors suggested that fractures in high-performance athletes must be fixed operatively. They believe that frequent loading of joint during activities may lead to symptoms, weakness, and disability, leading to underperformance.
The following methods have been described for reduction of an incarcerated fracture in the past.
- Roberts (1934) described keeping the wrist and fingers extended and forearm supinated with elbow in extension and applying a valgus force
- Patrick believed that forceful reduction may injure ulnar nerve and successfully used electrical stimulation of flexor mass under anesthesia for reduction
- Injection of air into the joint
- Milking technique using an Esmarch's bandage.
Nonoperative management consists of long arm cast for 3–4 weeks with elbow in 90° flexion and forearm in the neutral position.
[TAG:2]Open Reduction Procedure [/TAG:2]
After appropriate anesthesia, the patient is positioned according to the surgeon's preference.
The open reduction can be done in supine, LAT, or prone with a side arm table attached on the operative side. The prone or LAT positioning aids reduction by pronating the forearm and negates the valgus moment at elbow produced in the supine position.
Posteromedial 5–10 cm longitudinal incision is taken centered over the medial aspect of epicondyle. Ulnar nerve is identified and protected [Figure 2]. Fracture hematoma is evacuated, and the raw bed of the fractured epicondyle is exposed and curetted. Joint is inspected for loose bodies or any impediment, especially when associated with dislocations. The incarcerated fragment is brought out using Roberts' maneuver. Reduction is aided by wrist and finger flexion with forearm pronation and elbow flexion. Alternatively, an Esmarch's bandage application from distal to proximal may help bring the fragment closer while fixation. Fragment is temporarily fixed with 2 K-wires or 18G needle. Definitive fixation in a younger child with unossified elbow is done with K-wires and in adolescents using a 4/4.5 mm partially threaded cannulated cancellous (CC) screw for compression. The screw path must engage the center of fragment with maximum bone purchase and pass above the olecranon fossa roof in a posteroinferior to anterosuperior direction. Care must be taken to avoid drilling the far cortex as the radial nerve is at risk. The screw need not be bicortical. Washer will provide further compression, distribute forces over a wider area, and avoids burial of the screw. If there was ulnar nerve dysfunction preoperatively, neurolysis is performed .
|Figure 2: A 14-year-old boy sustained right elbow injury after fall. Dislocation was reduced using gentle reduction maneuver and Incarcerated medial epicondyle managed by open reduction and internal fixation. Elbow mobilized at 2 weeks with long arm slab broken. (a) Radiograph showing lateral fracture dislocation at elbow, the medial epicondyle incarcerated into the joint. The lateral view is deceiving as it shows elbow well reduced and incarcerated fragment can be easily confused with distal humerus ossification center. (b) Computed tomography anterior view. (c) Computed tomography posterior view showing dislocated radial head and incarcerated medial epicondyle in the ulnohumeral joint. (d) Acute ulnar nerve palsy with clawing of last two digits. (e) Medial approach open reduction done. Star: Trochlea; Black line: Flexor pronator muscle attachment to medial epicondyle which was into the joint; Blue circle: Fracture bed for attachment of medial epicondyle at distal humerus. (f) Medial epicondyle brought out of joint. Star: medial epicondyle; Yellow line: Ulnar nerve. (g) Fracture fixed with 4 mm partially threaded screw and ulnar nerve decompressed. Yellow line: ulnar nerve. (h) Intraoperative image with temporarily K-wire fixation during screw insertion. (i) 8 weeks postoperative X-ray showing good union. (j) Flexion and (k) extension at 8 weeks|
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Transposition of ulnar nerve is advised post-fracture fixation if the nerve remains subluxable or hardware is irritating it.
| Fixation Devices|| |
K-wires, sutures, tension band, screws, endo-button, and bone suture anchors have been used for fixation of these fractures. K-wires and simple sutures may not provide adequate compression and need further immobilization in cast. Very small or comminuted fragments can be fixed with sutures or K-wires, especially in younger children. Rickert et al. did a biomechanical study comparing three types of fixation: screws, K-wires, and suture anchor. All three fixations were able to withstand forces at elbow during routine ROM. They found screws to be a stronger and stiffer construct allowing early mobilization; however, implant removal and its costs need to be considered. Screws provide compression and scope for early mobilization but become very prominent and may cause fragmentation of epicondyle. 4 or 4.5 mm partially threaded CC screws are routinely used.
| Postoperative Care and Rehabilitation|| |
The elbow is mobilized at 4 weeks for conservatively managed cases.
Operatively managed cases can be mobilized early after surgical pain subsides, especially with screw fixation. Various authors have used immobilization from 3 days to 3 weeks postoperatively., Daily-protected elbow ROM is encouraged from 1 to 8 weeks. A slab broken at elbow or a customised hinged elbow can provide desired support when surgical fixation is insecure. The elbow joint was reduced first and incarcerated medial epicondyle managed with open reduction and internal fixation.
Noncontact activities are allowed at 8 weeks, and full return to previous activities can be allowed at 12 weeks.
| Complications|| |
Nonunion, instability, pain, elbow stiffness, ulnar nerve dysfunction, cubitus valgus, implant prominence, iatrogenic radial nerve injury, and infection are all known to occur. The last three complications are seen in surgically managed cases.
| Current Concepts and Controversies in Literature Review|| |
Medial epicondyle is an important attachment for medial stabilizers of the elbow and contributes to the shape of the elbow. Nearly half of the medial epicondyle fractures are associated with elbow dislocation, and unrecognized joint incarceration may be to significant morbidity.
Historically, the management of these fractures has relied upon fracture displacement in X-rays, but this method to assess displacement is themselves not reliable or accurate. Significance of quantification of fracture displacement and its value for decision-making is yet to be determined.
Radiographs are insufficient to assess fracture displacement and not reliable in unossified elbows. Routine radiographic assessments have very low interobserver and intraobserver accuracy. A distal humerus axial view has been shown to have highest intraobserver and interobserver agreement with significantly better correlation with the true displacement when compared with routine radiographs. Fracture displacement in the AP radiographs may be underestimated by 5.5 mm and in the LAT view displacement up to 1 cm may not be detectable. Nondisplaced or minimally displaced fractures on radiographs can have about 1 cm anterior displacement. Computed tomography (CT) scan can accurately estimate the direction and displacement; however, it is not used in the routine diagnostic workup for obviously displaced fractures [Figure 3].
|Figure 3: A 13-year-old girl with history of fall on outstretched hand while doing backflip, injured both elbow. She was a professional Kathakali dancer and sustained both elbow fracture dislocation. Managed with closed reduction of dislocation and open reduction of medial epicondyle fractures. Fracture fixed using 4 mm partially threaded cannulated cancellous screws and 1.5 mm K-wire. K-wires left outside skin and removed at 2 weeks. Elbow mobilization started at day 3. (a) right elbow, (b) left elbow, (c) right elbow after reduction of dislocation, (d) Left elbow after reduction, (e) computed tomography right elbow showed 1.5 cm anterior displacement, (f) computed tomography left elbow showed 1.4 cm anterior displacement, (g) open reduction and fixation done with a single 4 mm partially threaded screw and 1.5 mm K-wire, (h) right elbow at 4 weeks, (i) left elbow at 4 weeks|
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Isolated fractures with low-energy trauma and minimal displacement are managed conservatively. Despite the risk of nonunion, conservative management has yielded satisfactory results in long term.,,, Farsetti et al. did not observe any instability in conservatively managed cases even with 14 mm displacement. Smith accepted up to 2 cm displacement and managed them conservatively.
When managed conservatively, limitation of elbow ROM and valgus laxity was noted to be higher in fracture dislocations (42%) rather than isolated dislocations (15%). The greater soft tissue trauma and secondary ossification along with osteochondral defects may contribute to stiffness postfracture dislocations.
All displaced fractures demonstrated elbow instability in valgus, irrespective of associated elbow dislocation.
Various authors have suggested 2 mm to 1.5 cm as an acceptable limit for surgical fixation.
- Fowles et al., Hines et al., and Lee et al.: 2 mm
- Ip and Tsang, Case and Hennrikus: 5 mm
- Lawrence et al.: 8 mm
- Woods and Tullos: 10 mm
- Josefsson and Danielsson: 15 mm.
Multiple authors have considered fracture displacement, valgus instability, associated elbow dislocation, or athletic individuals, as indications for surgical management, but none of them are reliable guides for decision-making.
Irreducible dislocations, incarcerated fractures, and open fractures form absolute indications for surgery. Lee et al. advocated early mobilization after surgery. Dodds et al. reported excellent ROM and outcomes in operatively managed incarcerated fractures but higher rate of ulnar nerve dysfunction.
Surgical fixation has been noted to have a high bony union rate with satisfactory outcomes.,,,,,,, Louahem et al. managed 139 displaced fractures with surgical fixation and achieved 100% union with stable painless elbow with good ROM. Fibrous union was noted in 5% of cases but without elbow instability. Presence of bony union, however, does not reliably predict a better outcome.
Complications rates of surgical fixation are similar in prone versus supine positioning. Operatively managed group started elbow ROM earlier, but overall outcomes were similar when compared with the conservatively managed group.,,,
Fowles et al. noted a slightly higher incidence of elbow stiffness was in surgically managed cases. While surgery itself can cause surgical scarring of capsule and peri-articular structures leading to stiffness, achieving compression by screws may provide opportunity for early mobilization.
Nonunion is the most common complication (0%–90%),,,, and asymptomatic in most cases.,,,, Fibrous union may lead to laxity of medial collateral ligament, and valgus instability., In a younger child with growth, remaining some soft tissue balancing may happen with time negating that laxity. In a series managed conservatively, Josefsson and Danielsson noted higher ulnar nerve symptoms in pseudoarthrotic group.
Symptomatic nonunion occurs in 2% of cases,,, which will require further surgical intervention. Farsetti et al. managed them with excision and noted poor results due to persistent pain in long term. They noted elbow instability, grip strength weakness, hypoplasia of the medial aspect of elbow, and osteoarthritis. Gilchrist and McKee managed five cases of nonunion with valgus instability with excision of fragment and repair of medial collateral ligament (MCL) and noted satisfactory outcomes. Wilson recommended not to excise the medial epicondyle as it is important for elbow contour. Kulkarni et al. noted symptoms at mean duration of 7.7 months posttrauma and fixation with repair of MCL leads to good outcomes. They also decompressed and transposed the ulnar nerve anteriorly when neuropathy was noted preoperatively. Supplementary bone grafting may be necessary if the gap is more or there is bone loss [Figure 4] and [Figure 5].
|Figure 4: A 14-year-old boy with history of fall and injury to left elbow, managed conservatively with long arm cast. (a) Displaced medial epicondyle fracture with radial neck fracture and chip avulsion at lateral condyle. (b) 4 months later developed asymptomatic nonunion|
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|Figure 5: A 17-year-old boy sustained injury to left elbow 3 years back. He complained of left elbow pain for the last 2 months after cricket practice sessions. Symptomatic nonunion noted with medial tenderness and valgus instability. Underwent open reduction and bone grafting with screw osteosynthesis. Complete resolution of pain and instability with good union noted after 3 months. (a) Intraoperative image demonstrating original fracture bed, (b) postosteosynthesis, (c) immediate postoperative X-rays, (d) 3 months later|
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Ulnar nerve can be injured in acute trauma due to traction, contusion, compression, or entrapment. Most authors agree that routine exploration or transposition of the ulnar nerve may not be necessary.,,,, Hines et al. and Louahem et al. noted 100% spontaneous resolution of ulnar nerve dysfunction after fracture fixation. A systematic review recommended considering operative management when ulnar nerve dysfunction is noted preoperatively. However, another review did not find any differences in outcome in surgical versus nonsurgical management, when preoperative ulnar nerve dysfunction was noted. Iatrogenic radial nerve injury is reported while passing guide wire and drilling the lateral cortex, hence recommending avoidance of lateral cortex purchase.
Late ulnar nerve palsy has also been reported with an incidence of 5%, due to calcification and narrowing of tunnel., They must be explored, decompressed, and transposed anteriorly.
Median nerve involvement must be considered an indication for operative exploration.
| Conclusion|| |
Most nondisplaced or minimally displaced fractures can be managed conservatively with a long arm cast for 3–4 weeks. Incarcerated medial epicondyle and open fractures remain absolute indications for operative fixation. Relative indications for operative management are displaced fractures, elbow instability, ulnar nerve dysfunction, and high-demand patients. Treatment must be individualized based on the physical demand of the child, hand dominance, and the risks of surgery. The extent of injury to medial capsuloligamentous structures is more critical than fracture displacement.
Surgical fixation may offer advantage of higher bony union rates and early mobilization when compared with conservative management. In younger children, K–wires, and in adolescents, 4 mm partially threaded CC screws remain preferred implants for surgical fixation. The exact amount of displacement for surgical intervention is debatable; hence, when choosing conservative option, a potential for symptomatic nonunion must be explained to the parents.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]