Elbow dislocation with avulsion of the medial humeral epicondyle

After dislocation of the elbow with avulsion of the medial epicondyle, the management of the latter is controversial. Of 28 children followed up after initial closed reduction of the elbow, 19 had a satisfactory closed reduction of the epicondyle and were treated in plaster. At follow-up, 11 children had a normal elbow and eight had lost an average of 15 degrees of flexion. Nine children had had open reduction and internal fixation of the fragment, one for an open injury, three for displacement of the epicondyle and six for intra-articular entrapment of the fragment. Five of these children had ulnar nerve contusion or compression, four requiring anterior transposition of the nerve. At review, only three had normal elbows and six had lost an average of 37 degrees of flexion. We agree with other authors that surgery is indicated only for children in whom the epicondyle is trapped in the joint or is significantly displaced after closed reduction.     

Long-term results of treatment of fractures of the medial humeral epicondyle in children

BACKGROUND: The treatment of isolated, displaced fractures of the medial humeral epicondyle in children is controversial. Both plaster cast immobilization without reduction and open reduction and internal fixation have been advocated. The purpose of this long-term retrospective study was to analyze the functional and radiographic results of both nonsurgical and surgical management of these injuries. METHODS: Forty-two patients who had had an isolated fracture of the medial humeral epicondyle with displacement of >5 mm at an average age of twelve years (range, eight to fifteen years) were evaluated at an average age of forty-five years (range, thirty to sixty-one years). The patients were divided into three groups that were comparable with regard to the amount of fracture displacement, age at the time of the fracture, age at the time of follow-up, sports activities and occupation, and duration of follow-up. In Group I (nineteen patients), the fracture had been treated with a long-arm plaster cast without reduction of the displaced medial epicondyle. In Group II (seventeen patients), open reduction and internal fixation with either Kirschner wires or a T-nail had been performed. In Group III (six patients), the epicondylar fragment had been excised with suture reattachment of the tendons and the medial collateral ligament. RESULTS: According to a functional grading scale, there were sixteen good and three fair results in Group I. All but two patients were seen to have nonunion of the fragment on follow-up radiographs, but all had a normal result on valgus stress-testing of the elbow. The range of motion of the elbow was either normal or minimally decreased, and the grip strength of the ipsilateral hand was normal. There were fifteen good and two fair results in Group II. All patients had union of the medial epicondyle, with various radiographic deformities of the medial epicondyle, but the functional results were similar to those of the Group-I patients. The Group-III patients had four poor and two fair results. Four had constant pain at the elbow and paresthesias in the distribution of the ulnar nerve. One patient had a restricted range of motion of the elbow, four patients had an unstable elbow, and three patients had decreased grip strength of the ipsilateral hand. CONCLUSIONS: In our study, nonsurgical treatment of isolated fractures of the medial humeral epicondyle with between 5 and 15 mm of displacement yielded good long-term results similar to those obtained with open reduction and internal fixation. The nonunion of the epicondylar fragment that was present in most patients who had been treated only with a cast did not adversely affect the functional results. Surgical excision of the medial epicondylar fragment should be avoided because the long-term results are poor.     

Medial epicondyle fractures in the pediatric population

Humeral medial epicondyle fractures in the pediatric population account for up to 20% of elbow fractures, 60% of which are associated with elbow dislocation. Isolated injuries can occur from either direct trauma or avulsion. Medial epicondyle fractures also occur in combination with elbow dislocations. Traditional management by cast immobilization increasingly is being replaced with early fixation and mobilization. Relative indications for surgical fixation include ulnar nerve entrapment, gross elbow instability, and fractures in athletic or other patients who require high-demand upper extremity function. Absolute indications for surgical intervention are an incarcerated fragment in the joint or open fractures. Radiographic assessment of these injuries and their true degree of displacement remain controversial.     

Results of treatment of traumatic elbow dislocation in children]

Between 1987 and 1997 the authors treated 49 children with traumatic dislocation of the elbow joint. The study presents the results of treatment of 26 children, mean age of 10.7 years (ranging from 5.5 to 14.5 years) at the time of trauma. The mean follow-up time was 4.3 years (ranging from 1 to 10.5 years). In one case an anterior dislocation was observed, while in the remaining cases posterior dislocation was diagnosed. Twenty-five children were treated with closed reduction of the dislocation, followed by immobilization in a plaster cast. One case with a chronic dislocation was treated surgically. Concurrent injuries were observed in 18 (69.2) children. The most common concurrent trauma was a fracture of the medial epicondyle (44% of cases with additional trauma). The following additional fractures were also noted: fracture of the lateral epicondyle, fractures of the forearm, of the neck of the radius, of the olecranon, epiphyseolysis of the distal epiphysis of the radius with a concomitant fracture of the medial epicondyle. In 19 cases very good result was achieved. In 7 cases sequels of the dislocation were noted. These were: in 3 cases flexion contractures (5 degrees, 10 degrees, 15 degrees) of the elbow joint, in two cases periarticular ossification (in 1 case this entity was treated surgically with very good result), in 1 case an asymptomatic non-union of the medial epicondyle with a 30 degrees flexion contracture in the elbow joint, and in 1 case (treated surgically) a 90 degrees flexion contracture with a movement range up to 105 degrees with degenerative changes visible on X-ray in the joint was noted.     

Die Behandlung der Condylus-radialis-humeri-Fraktur im Kindesalter

Objective

Surgical treatment of lateral humeral condyle fractures with reduction and retention in order to prevent lasting malalignment, pseudarthrosis, and joint instability.

Indications

Absolute: fractures with a complete dislocation or those in which plaster-free control X-ray on day 4 shows a gap of > 2 mm. Relative: complete fractures of the lateral humeral condyle which demonstrate a dislocation ≤ 2 mm on follow-up.

Contraindications

Incomplete, so-called hanging fractures of the lateral humeral condyle without notable secondary dislocation on follow-up.

Surgical Technique

Open reduction of the lateral humeral condyle via a lateral approach to the elbow joint. In smaller children (< 5 years of age) fixation with Kirschner wires. In older children (≥ 5 years of age) or in cases requiring compression radial screw fixation is recommended. In all cases, suture repair of the periosteum is advisable.

Postoperative Management

Long upper-arm plaster cast until wound healing is achieved. Subsequently, upper-arm plaster cast for 3–4 weeks postoperatively. Implants are removed following consolidation (confirmed by X-ray) after approximately 2–3 months. Routine physiotherapy is normally not required.

Results

From January 1, 1999 to December 31, 2006, 85 children with a median age of 6.1 years had lateral condyle fracture of the humerus treated. 47 patients underwent surgery. Of these, 31 were treated with a combination of screw and Kirschner wire fixation, 13 with a single screw, and in three cases, the fracture was fixed with Kirschner wires only. After a median of 8.6 weeks (range, 5.0–17.1 weeks), implants were removed. Median follow-up time was 6 months (range, 2–50 months). There were no late complications in this series (e.g., lack of consolidation, pseudarthrosis). In five cases, hyposensitivity of the skin above the proximal aspect of the radial bone was noted postoperatively. This problem was solved in all instances within the following 6 months. A telephone survey with a response rate of 87% (74 patients) was undertaken in September 2007. Three children noted a minimal deficiency in strength of the injured arm in comparison to the contralateral extremity. One of these children additionally stated a minor flexion deficit of the elbow already present at the last follow-up in the outpatient clinic, which showed no progress. None of the patients had to be referred back to the outpatient clinic because of persistent problems and/or unacceptable results.     

微创治疗儿童肱骨髁上不稳定骨折

目的 探讨以生物学固定及间接复位技术为基础,微创治疗儿童肱骨髁上不稳定骨折的临床疗效.方法 对86例儿童肱骨髁上不稳定骨折采用闭合复位,部分加内侧小切口,然后经皮克氏针交叉固定辅加石膏托外固定进行治疗.结果 术后随访时间为6个月至5年(平均2.5年),骨折全部愈合,平均愈合时间为1.2个月.参照Flum临床功能评定标准评定:优78例,良6例,可2例;优良率为98%.结论 以微创为原则闭合复位,经皮交叉克氏针内固定治疗儿童肱骨髁上不稳定骨折,该方法 符合生物学固定的观点,创伤小,并发症少,恢复快,疗效满意.     

Divergent dislocation of the elbow in an adolescent. A case report

A case of simultaneous proximal radio ulnar joint divergent dislocation combined with a bone avulsion of the coronoid apophysis of the same elbow in a 16 years-old girl is presented. After a closed reduction and two weeks of plaster immobilization, normal function of the elbow was recovered within three months. There are only ten cases reported of such a divergent elbow dislocation in modern literature.     

High-definition magnetic resonance images on medial elbow injuries in preadolescent Little Leaguers

BackgroundThe incidence of throwing-related elbow injuries is still rising. The study aimed to enhance the pathology of acute medial elbow injuries among young Little Leaguers by examining the medial elbows of symptomatic 9–10 years old Little Leaguers using High-Definition Magnetic Resonance Images (HDMRI), which uses a small-diameter surface coil on the target area, leading to greater image resolution.MethodWe identified Little Leaguers aged 9–10 years old. To minimize the detection of the chronic adaptative changes, players who experienced the medial elbow pain previously and whose HDMRI had not been taken within 4 weeks from the onset of medial elbow pain were excluded. This study considered 21 players, and the mean age was 9.4 ± 0.5 years.ResultThe fragmentation of the medial epicondyle apophysis via HDMRI was found in 15 elbows (71.4%), while the avulsion was seen in three cases. The signal hyperintensity at the medial epicondyle apophysis was observed in 2 cases. Our data showed abnormal changes to the medial epicondyle apophysis and surrounding structures, such as the ulnar collateral ligament (UCL), flexor-pronator tendons or the coronoid process of the ulna. We detected 11 abnormalities on X-ray imaging, while 20 subjects showed some abnormal findings via HDMRI.DiscussionThe current study showed that initial medial elbow injury in Little Leaguers without a history of previous elbow injury could be attributed to multi-structure injury. Over 90% of subjects were injured in the perichondrium, while 71.4% demonstrated a fragmentation of the secondary ossification center, and 14.3% experienced an avulsion of the medial epicondyle apophysis. Because the injuries were not limited to bony structures, HDMRI may be beneficial for the appropriate evaluation of medial elbow pain. The pathology of initial medial elbow injuries in young baseball players may be due to acute trauma instead of repetitive microtrauma.     

经皮撬拨复位双克氏针内固定联合石膏托治疗儿童GartlandⅢ型肱骨髁上骨折

目的：观察经皮撬拨复位双克氏针内固定联合石膏托治疗儿童GartlandⅢ型肱骨髁上骨折的临床疗效。方法：自2007年6月至2008年12月,采用经皮撬拨复位双克氏针内固定联合石膏托治疗儿童GartlandⅢ型肱骨髁上骨折27例。男18例,女9例;年龄6～12岁,平均8.1岁。伸直型15例,屈曲型12例;尺偏型14例,桡偏型13例。伤后就诊时间0.5～8d,平均3.6d。结果：27例均获随访,时间6～24个月,平均13.5个月。所有骨折均于术后4～6周愈合,平均愈合时间4.5周。未出现内固定物松动和骨折再移位,无Volkmarm挛缩、针眼或深部感染、尺神经损伤、骨化性肌炎等并发症。术后发生肘内翻畸形2例,但内翻角均不超过15°,可能为过早拆除外固定和不适当功能锻炼所致。按Flynn标准评定,结果优19例,良5例,可2例,差1例。结论：C形臂X线机透视下闭合复位经皮克氏针内固定治疗儿童不稳定肱骨髁上骨折手术创伤小,固定可靠,可以获得良好的肘关节功能和外形。     

闭合复位克氏针内固定治疗GartlandⅢ型儿童肱骨髁上骨折

目的探讨闭合复位内外侧3针交叉固定治疗GartlandⅢ型儿童肱骨髁上骨折的疗效。方法对195例GartlandⅢ型儿童肱骨髁上骨折患者行闭合复位后,C臂机监视下先在肱骨髁外侧用2枚克氏针平行或交叉固定,再伸直肘关节到50°,保护尺神经下用1枚克氏针在内侧交叉固定,术后长臂石膏托固定于肘关节伸直70°制动3周。结果 195例均获随访,时间5~35个月。出现医源性尺神经损伤2例,肘内翻畸形需截骨矫形1例,肘部前侧局限性骨化4例。按Flynn标准评定疗效:优180例,良8例,一般6例,差1例,优良率为96.4%。结论闭合复位内外侧3针交叉固定治疗GartlandⅢ型儿童肱骨髁上骨折可有效减少医源性尺神经损伤,降低肘内翻畸形发生率,疗效满意。     

Untreated intra-articular entrapment of the medial humeral epicondyle

Six children with entrapment of the medial epicondyle in the elbow after closed reduction of a posterior dislocation were seen an average of 14 weeks after injury. The elbows were painful and the average range of flexion was 22 degrees. Two children had ulnar nerve involvement which recovered after operation. The epicondyle was removed from the joint and either reattached to the humerus or excised, and the muscles reattached. Two children had anterior transposition of the ulnar nerve, one for pre-operative hyperaesthesia, and the other to relieve tension on the nerve. At follow-up, at an average of 15 months after operation, flexion had increased fivefold, none of the children had pain and all were leading normal lives.     

Radiocarpal dislocations: classification and proposal for treatment. A review of twenty-seven cases

BACKGROUND: The radiographic characteristics and treatment of radiocarpal dislocation are not well defined. There have been only two reported series of more than eight patients. Thus, there are many questions concerning treatment and functional results. METHODS: Two groups of patients were defined. Group 1 included all patients with pure radiocarpal dislocation and patients with only a fracture of the tip of the radial styloid process. Group 2 included patients with radiocarpal dislocation and an associated fracture of the radial styloid process that involved more than one-third of the width of the scaphoid fossa. A retrospective review and a clinical evaluation were performed. RESULTS: From 1975 to 1998, we observed twenty-seven cases of radiocarpal dislocation. Four were displaced volarly, and twenty-three were displaced dorsally. Fourteen patients presented with associated lesions. Four patients were treated with closed reduction and immobilization in a plaster cast; five, with percutaneous Kirschner wire fixation and cast immobilization; and two, with an external fixator. Eleven patients had open reduction with Kirschner wire fixation and cast immobilization. The seven patients in Group 1 had a highly unstable injury, and four of the seven patients presented with ulnar translation of the carpus. At the time of follow-up, at an average of 26.8 months, pronation averaged 76 degrees; supination, 66 degrees; wrist flexion, 54 degrees; wrist extension, 54 degrees; radial inclination, 15 degrees; and ulnar inclination, 18 degrees. The average grip strength was 27 kg. Group 2 included twenty patients. Only thirteen, with dorsal dislocation, were evaluated at the time of follow-up, which averaged fifty-one months. At that time, six reported no pain; four, slight pain; and two, moderate pain. Pronation averaged 63 degrees; supination, 76 degrees; wrist flexion, 51 degrees; wrist extension, 56 degrees; radial inclination, 21 degrees; and ulnar inclination, 39 degrees. Grip strength averaged 38 kg. Seven patients had complications. CONCLUSIONS: On the basis of our experience and a review of the literature, we believe that patients with pure radiocarpal dislocation or with radiocarpal dislocation with a fracture of the tip of the radial styloid process should be treated with reattachment of the ligaments through a volar approach. In patients with radiocarpal dislocation and a fracture of the radial styloid process that involves more than one-third of the width of the scaphoid fossa, the ligaments are still attached to the radial fragment. We believe that in this group of patients, exact articular reduction should be performed through a dorsal approach. Additional studies are needed to support these hypotheses.     

克氏针撬拨复位石膏外固定治疗儿童尺桡骨远端背靠背骨折

目的：探讨克氏针撬拔复位治疗儿童尺桡骨远端背靠背骨折的疗效及可行性。方法：2010年7月至2012年3月,采用克氏针撬拨复位石膏外固定治疗儿童尺桡骨远端背靠背骨折37例,男24例,女13例;年龄6～13岁,平均9．5岁;伤后至就诊时间4h～3d,均为摔伤,无其他合并伤。结果：37例患者获得随访,时间1-6个月。临床愈合时间21—42d,平均31．5d,所有患者骨性愈合,外观无畸形,无手术治疗。Moed等功能评价结果,优14例,良20例,中3例。结论：运用克氏针撬拔复位、石膏托外固定治疗儿童尺桡骨远端背靠背骨折,既可实现骨折复位后的理想固定,又可早期进行患肢功能锻炼,取得满意疗效。     

桡骨远端完全关节内骨折的手术治疗分析

目的探讨切开复位内固定综合手术治疗桡骨远端完全关节内骨折的疗效。方法26例桡骨远端完全关节内骨折患者,行手术切开复位,钢板内固定加必要时克氏针辅助固定,及粘胶粘合碎骨块,术后予管型石膏外固定。结果术后平均随访8．1（5～11）个月,其腕关节功能评定：优14例,良8例,差4例,优良率为84．6％（22／26）。结论综合手术治疗能有效恢复并牢固维持桡骨远端的解剖形状,有利于腕关节早期功能锻练,可使腕关节功能得到最大的恢复。     

Origin of the medial ulnar collateral ligament on the pediatric elbow

Purpose

Surgical reconstruction of the adult anterior bundle of the medial ulnar collateral elbow ligament (UCL) is a common and established treatment that yields satisfactory results. Children sustain these injuries less frequently, and surgical intervention is complicated by the juxtaposed medial epicondyle apophysis. The purpose of this study was to identify the anatomical origin of the pediatric UCL and determine if this location changes with elbow maturity.

Methods

A retrospective analysis of children with an elbow MRI between 2009 and 2012 was performed. Ninety children (68 boys, 22 girls), mean age 12.8 years (range 6–18), were grouped by age (<11, 11–13, and >13) and gender. Measurements of UCL width and UCL midpoint distance from medial epicondyle apophysis were recorded on coronal T1 images utilizing digital PACS software.

Results

Across all groups, boys had a wider UCL than girls (4.05 ± 0.16 mm vs 3.72 ± 0.20 mm, p = 0.03); however, there was no difference in the anatomical origin of the UCL relative to the medial epicondyle apophysis between gender (p = 0.52), between gender age-matched groups, or within gender age-matched groups. Yet, the anatomic origin of the UCL always remained medial to the cartilaginous interface of the apophysis with the osseous distal humerus and was centered approximately 3 mm medial to the lateral edge of the apophysis.

Conclusion

Regardless of age or gender, the humeral origin for the medial ulnar collateral ligament is medial to the interface between the medial epicondyle apophysis and distal humerus, which has surgical implications for anatomic reconstruction in children.     

Calcaneal apophyseal avulsion fracture

Isolated fracture of the calcaneal apophysis is a rare injury in children and adolescents. In this study, we report on a case of a displaced calcaneal apophyseal avulsion fracture in a child treated with open reduction and internal fixation, as well as a review of the literature. A 9-year-old female child presented to the senior surgeon complaining of acute heel pain after a gymnastic injury. She was diagnosed with a displaced, isolated fracture of the proximal calcaneal apophysis for which she underwent open reduction and internal fixation. On the magnetic resonance imaging (MRI) examination, we could diagnose that her injury was not chronic but acute because there was no change of intensity in the metaphyseal area. A combination of bioabsorbable suture tacks and pins was used to anatomically fix the fragment using the tension band wiring technique. At 2 years and 6 months follow-up, she had full range of motion, complete return of strength. We report here on the successful surgical treatment and the first case evaluated by MRI of an avulsion fracture of the calcaneal apophysis in a child.     

Peritalar dislocations: a retrospective study of 18 cases

The purpose of this study is to retrospectively evaluate 18 consecutive cases of peritalar dislocations referred to our department during a period of 25 years and to delineate the factors influencing long-term prognosis. There were 13 (73%) medial and 5 (27%) lateral dislocations. Six patients (33%) suffered an open injury, including 2 of 13 (15%) medial and 4 of 5 (80%) lateral dislocations. Associated fractures involving the hindfoot or forefoot were noted in 7 feet, including 3 of 5 lateral dislocation cases. Reduction was accomplished under general anesthesia; in no case was open reduction necessary. In 4 of 6 open injuries with associated fractures, temporary fixation with Kirschner wires was performed. Patients were immobilized in a plaster cast for 4 weeks, or for 6 weeks in the presence of fracture, followed by weightbearing as tolerated. At a mean follow-up of 10.2 years (range, 4 to 26 years), 10 patients (56%) showed excellent results; all had sustained a closed medial low-energy dislocation. There were 3 cases (17%) with fair results and 5 cases (28%) with poor results. Forty-five percent of patients showed a restriction of activity, a reduction of subtalar range of motion, and moderate or severe radiographic signs of hindfoot degenerative arthritis. There were no cases of talar avascular necrosis, and in no case was secondary surgery necessary. Lateral dislocation and open medial dislocations with concomitant fractures showed a greater potential for poor prognosis. The results were independent from period of cast immobilization, suggesting that 4 to 6 weeks of immobilization provides acceptable long-term results.     

经皮克氏针撬拨复位内固定治疗儿童跟骨关节内骨折的疗效分析

目的：介绍经皮克氏针撬拨复位内固定治疗儿童跟骨骨折,评估该方法的临床疗效。方法：2001年3月至2009年2月,采用经皮克氏针撬拨复位内固定治疗儿童跟骨关节内骨折12例（13足）,其中男8例,女4例;年龄3～14岁,平均8.7岁。骨折按Essex-Lopresti分型：舌型骨折5足,压缩型骨折8足。按Sanders分型：Ⅱ型9足,Ⅲ型4足。手术前后摄X线片,比较跟骨B觟hler角和Gissane角的恢复情况,疗效评价采用Maryland足部评分系统。结果：所有患者均获随访,时间16～71个月,平均35.9个月。骨折均获愈合,无创口愈合不良、坏死感染发生。术前B觟hler角为（19.7±5.3）°,术后为（32.6±3.7）°;术前Gissane角为（137.3±7.5）°,术后为（125.4±2.9）°,上述影像学测量结果与术前比较差异均有统计学意义（P〈0.01）。Maryland评分92～100分,平均（96.3±2.4）分。结论：经皮克氏针撬拨复位内固定术,软组织损伤小、固定可靠、疗效满意,是儿童跟骨关节内骨折有效的微创治疗方法。     

Treatment of completely displaced supracondylar fracture of the humerus in children by cross-fixation with three Kirschner wires.

The authors investigated 63 consecutive patients (average age 6 years 6 months) who underwent cross-fixation with three Kirschner wires after reduction of a completely displaced supracondylar fracture (type 3) of the humerus. All fractures were reduced and fixed by inserting two parallel Kirschner wires in the lateral side, followed by one crossed medial Kirschner wire under fluoroscopic guidance. Lateral pins were inserted in parallel or divergent fashion to ensure stability. With a medial crossed pin insertion, the elbow was carefully extended for easy palpation and protection of the ulnar nerve without displacing the reduced fracture. Skin incision for detection of the ulnar nerve before medial Kirschner wire fixation was not required. There was no iatrogenic ulnar nerve injury caused by the Kirschner wires. The clinical outcome of the surgery after an average of 17 months was investigated: 62 (98.4%) of the 63 patients studied showed a "satisfactory" result. Cross-fixation with three Kirschner wires is considered an effective and safe method for avoiding ulnar nerve injury in the treatment of a completely displaced supracondylar fracture of the humerus in children.     

Comparison of clinic-radiological outcome of cross pinning versus lateral pinning for displaced supracondylar fracture of humerus in children: A randomized controlled trial

IntroductionSupracondylar fracture of humerus (SFH) is frequently encountered in the immature skeleton, [1] predominantly in the non-dominant extremity.AimThis study compared the clinic-radiological outcome between cross pinning with lateral pinning for fixation of displaced supracondylar fracture of humerus in children.Materials and methodsAll eligible patients were randomized into two groups, group I for lateral pinning and group II for cross pinning. Before passing medial pin in group II a stab incision was given to visualise the medial epicondyle. Patients were followed up on 3 weeks, 6 weeks and 3 months. Final outcome was measured in terms of clinic-radiological union, Baumann angle, loss of reduction, stability of fracture fixation, incidence of iatrogenic nerve injury and Flynn's score. Results: There were 37 patients in group I and 40 in group II. Both groups were comparable in terms of demographic details. At the final outcome there were no difference in between the groups in terms of all radiological and clinical outcome. Two patients of group I developed delay ulnar neuritis, which resolve completely in subsequent follow-up.ConclusionBoth techniques provide stable fixation, union and good functional outcome without iatrogenic ulnar nerve injury provided that small incision sufficient enough to identify the medial epicondyle is given with passing of medial pin.