Open reduction and K-wires fixation of medial humeral epicondyle fractures with intra-articular elbow entrapment in children

Abstract

Background. Medial epicondyle fracture (MEF) is a common injury of all elbow fractures in the pediatric and adolescent population and is often associated with elbow dislocation. Traditional management by cast immobilization increasingly is being replaced with early open reduction and K-wires or screws fixation. A consensus about the correct treatment of MEF is currently lacking in the medical literature.

The aim of this study was to report the clinical and radiographic outcomes and the complications of patients affected from MEF with intra-articular fragment incarceration treated by open reduction and K-wire fixation.

Materials and methods. Thirteen children (aged 8–13 years) with medial epicondyle fractures (MEF) with intra-articular elbow entrapment were retrospectively reviewed. All the enrolled patients were surgically treated with open reduction and k-wire fixation without exploration of ulnar nerve. Clinical outcomes were evaluated using upper limb alignment in the frontal plane, elbow range of motion (ROM), the Mayo Elbow Performance Score (MEPS) and with the Visual Analogue Scale (VAS). Radiographic outcomes and complications were also evaluated.

Results. At a mean follow-up of 24.1 months no patients showed axial deformity of the upper limb or instability of the elbow and with preserved elbow ROM. The mean MEPS was 98.8 and the mean value of the VAS score was 1. The final X-rays showed fracture healing in 11 patients while 2 (15.3%) reported asymptomatic nonunion. Six patients of 13 presented with preoperative paresthesia in the ulnar nerve field but all of them reported a complete recovery after a mean of 4.3 months. All patients returned to their sporting activities at a mean of 5.4 months after surgery. One patient (7.7%) reported a superficial surgical wound infection treated with oral antibiotic medication without further surgery. No other complication was found.

Conclusions. The results demonstrate that open reduction and K-wires fixation without exploration of ulnar nerve for MEF with intra-articular elbow entrapment treatment is a safe and effective procedure.

Keywords

pediatric medial epicondyle fracture / pediatric elbow injury / pediatric trauma / pediatric elbow dislocation

References

[1] Gottschalk HP, Eisner E, Hosalkar HS. Medial epicondyle fractures in the pediatric population. J Am Acad Orthop Surg. 2012;20(4):223-232. https://doi.org/10.5435/JAAOS-20-04-223.

[2] Herring JA, Christine H. Upper Extremity Injuries. In: Herring JA, editor. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Philadelphia: Saunders; 2013. P. 1245-1352.

[3] Beck JJ, Bowen RE, Silva M. What’s new in pediatric medial epicondyle fractures? J Pediatr Orthop. 2018;38(4):e202-e206. https://doi.org/10.1097/BPO.0000000000000902.

[4] Fowles JV, Slimane N, Kassab MT. Elbow dislocation with avulsion of the medial humeral epicondyle. J Bone Joint Surg Br. 1990;72-B(1):102-104. https://doi.org/10.1302/0301-620x.72b1.2298765.

[5] Hines RF, Herndon WA, Evans JP. Operative treatment of medial epicondyle fractures in children. Clin Orthop Relat Res. 1987;(223):170-174.

[6] Josefsson PO, Danielsson LG. Epicondylar elbow fracture in children. 35-year follow-up of 56 unreduced cases. Acta Orthop Scand. 1986;57(4):313-315. https://doi.org/10.3109/17453678608994399.

[7] Patel NM, Ganley TJ. Medial epicondyle fractures of the humerus: how to evaluate and when to operate. J Pediatr Orthop. 2012;32 Suppl 1:S10-13. https://doi.org/10.1097/BPO.0b013e31824b2530.

[8] Lee HH, Shen HC, Chang JH, et al. Operative treatment of displaced medial epicondyle fractures in children and adolescents. J Shoulder Elbow Surg. 2005;14(2):178-185. https://doi.org/10.1016/j.jse.2004.07.007.

[9] Watson-Jones R. Fractures and Joint Injuries. 4th ed. Edinburgh: E. & S. Livingstone; 1976.

[10] Papavasiliou VA. Fracture-separation of the medial epicondylar epiphysis of the elbow joint. Clin Orthop Relat Res. 1982;(171):172-174.

[11] Morrey B. Functional evaluation of the elbow. In: The elbow and its disorders. 2nd ed. Ed. by B. Morrey. Philadelphia: Saunders; 1993. P. 86-89.

[12] Cusick MC, Bonnaig NS, Azar FM, et al. Accuracy and reliability of the Mayo Elbow Performance Score. J Hand Surg Am. 2014;39(6):1146-1150. https://doi.org/10.1016/j.jhsa.2014.01.041.

[13] Carlsson AM. Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain. 1983;16(1):87-101. https://doi.org/10.1016/0304-3959(83)90088-x.

[14] Skak SV, Grossmann E, Wagn P. Deformity after internal fixation of fracture separation of the medial epicondyle of the humerus. J Bone Joint Surg Br. 1994;76-B(2):297-302. https://doi.org/10.1302/0301-620x.76b2.8113297.

[15] Duun PS, Ravn P, Hansen LB, Buron B. Osteosynthesis of medial humeral epicondyle fractures in children. 8-year follow-up of 33 cases. Acta Orthop Scand. 1994;65(4):439-441. https://doi.org/ 10.3109/17453679408995489.

[16] Farsetti P, Potenza V, Caterini R, Ippolito E. Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am. 2001;83(9):1299-1305. https://doi.org/10.2106/ 00004623-200109000-00001.

[17] Lawrence JT, Patel NM, Macknin J, et al. Return to competitive sports after medial epicondyle fractures in adolescent athletes: results of operative and nonoperative treatment. Am J Sports Med. 2013;41(5):1152-1157. https://doi.org/10.1177/0363546513480797.

[18] Dodds SD, Flanagin BA, Bohl DD, et al. Incarcerated medial epicondyle fracture following pediatric elbow dislocation: 11 cases. J Hand Surg Am. 2014;39(9):1739-1745. https://doi.org/10.1016/j.jhsa.2014.06.012.

[19] Tarallo L, Mugnai R, Fiacchi F, et al. Pediatric medial epicondyle fractures with intra-articular elbow incarceration. J Orthop Traumatol. 2015;16(2):117-123. https://doi.org/10.1007/s10195-014-0310-2.

[20] Park KB, Kwak YH. Treatment of medial epicondyle fracture without associated elbow dislocation in older children and adolescents. Yonsei Med J. 2012;53(6):1190-1196. https://doi.org/10.3349/ymj.2012.53.6.1190.

[21] Smith JT, McFeely ED, Bae DS, et al. Operative fixation of medial humeral epicondyle fracture nonunion in children. J Pediatr Orthop. 2010;30(7):644-648. https://doi.org/10.1097/BPO.0b013e3181ed4381.

[22] Ramachandran M, Birch R, Eastwood DM. Clinical outcome of nerve injuries associated with supracondylar fractures of the humerus in children: the experience of a specialist referral centre. J Bone Joint Surg Br. 2006;88(1):90-94. https://doi.org/10.1302/0301-620X.88B1.16869.

[23] Khademolhosseini M, Abd Rashid AH, Ibrahim S. Nerve injuries in supracondylar fractures of the humerus in children: is nerve exploration indicated? J Pediatr Orthop B. 2013;22(2):123-126. https://doi.org/10.1097/BPB.0b013e32835b2e14.

[24] Pace GI, Hennrikus WL. Fixation of displaced medial epicondyle fractures in adolescents. J Pediatr Orthop. 2017;37(2):e80-e82. https://doi.org/10.1097/BPO.0000000000000743.

RIGHTS & PERMISSIONS

Massetti D., Marinelli M., Coppa V., Falcioni D., Specchia N., Giampaolini N., Gigante A.