Treatment of symptomatic medial epicondyle nonunion: Case report and review of the literature

INTRODUCTIONSymptomatic nonunion of humeral medial epicondyle can be problematic and difficult to treat due to high complication rates related to open reduction and internal fixation methods.PRESENTATION OF CASEWe described four patients with symptomatic medial humeral epicondyle nonunion who underwent open reduction and internal fixation.DISCUSSIONSymptomatic nonunion of humeral medial epicondyle is a rare entity. Surgical technique can be difficult because of anatomical and biomechanical factors. In the literature, there are a few cases of humeral medial epicondyle treated by open reduction and internal fixation.CONCLUSIONOpen reduction and internally fixation of the medial epicondyle nonunion with one cannulated screw results with improved elbow function.     

Rotational radioulnar dissociation: a case report and review of the literature

We report a rare case of radioulnar dissociation in an 11-year-old boy associated with fracture of the medial humeral epicondyle. Open reduction and Kirschner wire fixation was performed for the epicondylar fracture. The radial head was reduced closed, and the distal radioulnar joint reduced spontaneously. The mechanism of this unusual injury appears to be hyperpronation of the forearm and valgus stress to the elbow.     

Pediatric medial epicondyle fractures with intra-articular elbow incarceration

BackgroundIntra-articular incarceration of the epicondylar fragment occurs in 5–18 % of all cases of medial epicondyle fracture. It requires stable fixation to allow early motion, since elbow stiffness is the most common complication following medial epicondyle fracture. In this retrospective study, we report the clinical and functional outcomes and the complications that occurred following open reduction and screw fixation of medial epicondyle fractures with intra-articular fragment incarceration.MethodsThirteen children who had a fracture of the medial epicondyle with incarceration of the fragment in the elbow joint (type III) were surgically treated in our university hospital between 1998 and 2012. There were eight male and five female patients. The mean age at the time of injury was 13 years (range 9–16). Operative treatment consisted of open reduction and internal fixation with one or two 4.0-mm cannulated screws under fluoroscopic control.ResultsAll of the patients were clinically reviewed at an average follow-up of 29 months. The overall range of motion limitation was about 5° for flexion–extension and 2° for pronation–supination. The score was excellent in all patients (mean 96.3). Complications occurred in four (31 %) children: two cases of symptomatic screw head prominence, irritation with partial lesion of the distal triceps myotendinous junction in one patient, and median nerve entrapment syndrome in one patient.ConclusionsIn conclusion, open reduction and screw fixation yielded excellent clinical and functional outcomes for the treatment of medial epicondyle fractures with intra-articular fragment incarceration. However, particular attention is should be paid when treating these potentially serious injuries in order to minimize the risk of possible complications.

Level of evidence

Therapeutic IV.     

Die Behandlung der Apophysenabrissverletzung des Epicondylus ulnaris im Kindesalter

OBJECTIVE: Surgical reduction and retention of apophyseal avulsion injuries at the medial epicondyle to prevent joint instability, lasting malalignment, or pseudarthrosis. INDICATIONS: Absolute: intraarticular apophyseal dislocation of the medial epicondyle, complete lesion of the ulnar nerve. Relative: dislocation of the apophysis (> 4 mm) in children > 5 years of age; the need for intervention increases in children as the degree of dislocation, age, and athletic activity increase. CONTRAINDICATIONS: Dislocation of the medial epicondyle (< or = 4 mm) in children < 5 years of age, provided the fragment location is not intraarticular. SURGICAL TECHNIQUE: Open reduction of the apophysis through a medial approach. Identification of the ulnar nerve. In young children or with small fragments fixation with Kirschner wire. Screw fixation in older children or for larger fragments. POSTOPERATIVE MANAGEMENT: Long upper-arm plaster cast until wound healing is achieved. Subsequently, upper-arm plaster cast for 3 weeks. Removal of Kirschner wires after 4-6 weeks, screw removal after 8-12 weeks. Physiotherapy only if marked reduction of elbow mobility is found 6 weeks after cast removal. RESULTS: From January 1, 1994 to December 31, 2003, 25 children with an average age of 12 years suffering from medial epicondylar avulsion fractures were operated on using open reduction and Kirschner wire fixation. An average of 3 years after the injury 14 of these children underwent follow-up examination using a procedure that took subjective, clinical and radiologic parameters into account. Two children showed a slight reduction in overall strength of the injured extremity when compared with the contralateral extremity. One child had a flexion deficit of 10 degrees, all other children showed movement limitations of < or = 5 degrees compared to the contralateral extremity. In all the cases available to follow-up, there was a slight increase in valgus alignment of the elbow joint compared with the uninjured side (3 degrees on average). All fractures consolidated within 6 weeks.     

Valgus instability of the elbow due to medial epicondyle nonunion: treatment by fragment excision and ligament repair--a report of 5 cases

We identified 5 patients with valgus instability of the elbow due to nonunion of a previous fracture of the medial epicondyle. There were 4 male patients and 1 female patient with a mean age of 35 years (range, 15-54 years). The original avulsion fracture of the medial epicondyle had occurred a mean of 10.1 years previously (range, 4 months to 25 years), and all patients had had their initial fracture treated nonoperatively. After the development of medial epicondyle nonunion, 3 patients had been treated nonoperatively and 2 had undergone unsuccessful attempts at osteosynthesis. All patients were treated with excision of the medial epicondyle, advancement of the medial collateral ligament, and fixation to the distal humerus with suture anchors. The mean Mayo Elbow Performance Score improved from 66 preoperatively to 91 postoperatively (P <.05), and all patients were satisfied with the increased stability provided by the procedure. On the basis of our experience with these 5 patients, it appears that excision of the nonunion fragment and repair of the medial collateral ligament to the distal humerus can provide satisfactory outcomes in these patients.     

Elbow instability secondary to lateral epicondylar nounion in an adult

Symptomatic nonunion of the lateral epicondyle of the elbow is a rare injury. We present the case of a 36-year-old woman who complained of elbow pain and instability several months after a conservatively treated lateral epicondyle fracture that evolved into nonunion. In order to reestablish elbow stability, the patient underwent removal of the nonunited epicondylar fragment and ligament repair, with excellent clinical outcome.     

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.     

Concurrent little leaguer's elbow and shoulder in a 15-year-old baseball pitcher and football quarterback

Little leaguer's elbow and Little leaguer's shoulder are overuse pathologies seen in overhead-throwing athletes. No instance of simultaneously occurring pathologies has been published. A 15-year-old baseball pitcher and football quarterback developed pain in his throwing shoulder and elbow during spring baseball, which partially resolved with several months of rest. During fall football practice, he felt a pop and pain over his medial throwing elbow. Five days after the initial injury, medial elbow tenderness, mild swelling, and decreased range of motion were noted. Radiographs revealed a Salter I avulsion fracture of the medial humeral epicondyle (Little leaguer's elbow) and a periosteal reaction along the lateral aspect of the humeral metadiaphysis with slight widening (Little leaguer's shoulder). Surgical fixation of the medial epicondyle fracture and nonoperative treatment of the shoulder pathology were performed. Two-year follow-up radiographs showed a healed medial epicondylar fracture and resolution of the periosteal reaction of the humeral metadiaphysis. The patient returned to full activity and was starting quarterback for his football team. Biomechanical forces specific to overhead-throwing activities are associated with the development of Little leaguer's elbow and shoulder. Treatments of both pathologies remain controversial, with either initial operative vs nonoperative care. In this patient, a good outcome was achieved with surgical fixation of the elbow fracture and conservative management of the shoulder pathology. Educating coaches and parents on proper throwing technique and pitching limits should be the first step in reducing the occurrence of either pathology in this population.     

Open reduction of medial epicondyle fractures: operative tips for technical ease

In the pediatric population, medial humeral epicondylar fractures account for nearly 12% of all elbow fractures. There is ongoing debate about the surgical management of medial epicondyle fracture cases. Our technique in the operative management of medial epicondyle fractures uses the external application of an Esmarch bandage, as well as provisional fixation with needle rather than K-wire fixation. This technique decreases the need for soft-tissue release and, therefore, theoretically, maintains soft-tissue vascularity of the small fracture fragments. Moreover, it preserves the soft-tissue tension medially. It involves the use of a bandage that is universally available in orthopedic operating rooms, including those in developing nations. It is easy to apply by either the principal or assisting surgeon. With practice, it cuts down operative time and can help substitute for an assistant. This relatively simple operative technique makes for a more seamless operative process, improved reduction, and key preservation of soft-tissue vascularity.     

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.     

Custom AO small T plate for transcondylar fractures of the distal humerus in the elderly

The purpose of this study was to present a new internal fixation technique for transcondylar fractures of the humerus in elderly patients. Seventeen patients, aged older than 70 years, with displaced transcondylar fractures were treated by our new surgical method. All fractures were fixed by a customized AO small T plate and a transcondylar screw passed from the lateral epicondyle to the medial wall of the trochlea across the humeral condyle. The plate was hand-shaped, trimmed, and applied at the lateral side of the fracture site, and either a cannulated cancellous screw or an AO one-third tubular plate was applied at the medial side of the fracture site. All patients in this study had osteoporotic bone and a small distal fragment. They were followed up for a mean of 30 months (range, 24 to 60 months). Radiographically, union was achieved completely in all patients, and all except 1 had maintained the postoperative alignment. Bone graft or cement fixation was not required in any case. The assessment of the results by use of the modified Cassebaum's rating scale was excellent in 3 cases, good in 11, and fair in 3. With the custom AO small T plate and transcondylar screw fixation technique, the screw that passes through the humeral condyle provides good stability even in cases with a small osteoporotic fragment of the distal humerus. The screw does not damage the articular surface of the elbow joint, and stable fixation can be obtained even in osteoporotic bone.     

Osteosynthesis of medial humeral epicondyle fractures in children: 8-year follow-up of 33 cases

33 children with a mean age of 12 (7-15) years had open reduction and osteosynthesis for a displaced fracture of the medial humeral epicondyle. 8 (2-15) years after the operation a clinical and radiographic examination was performed. 22/33 had a prominent scar. No patients had symptoms from the ulnar nerve. Function and range of motion of the elbow were good in all cases, albeit with 20-25 degrees of extension in 3. There were 3 cases of asymptomatic nonunion. Surgery was found to reduce the frequency of nonunion, compared to previous reports of non-operative treatment.     

Treatment of the humeral shaft nonunion after surgical failure using the Selfdynamisable internal fixator

Introduction A nonunion of the humeral shaft is not a rare condition and is a complication of both nonoperative and operative treatment of the fracture. Several fixation options were used in the nonunion treatment, including various plate techniques, intramedullary nails and external fixator. We applied our Selfdynamisable internal fixator for the treatment of humeral shaft nonunion after surgical failure and evaluated its clinical outcome. Materials and methods Six patients with persistent atrophic nonunion of the humeral shaft were treated with Selfdynamisable internal fixator. The inclusion criteria were mobile, unstable resistant nonunion of the humeral diaphysis which persisted after surgical treatment for nonunion. All patients were men with a mean age of 32 (27–39) years. The initial fracture treatment was external fixator in two patients and plaster cast for four patients. All cases failed to unite after primary treatment. Plate fixation was resorted for fracture union but failed. The revision surgery consisted of removal of hardware, freshening of bone ends and bone grafting, and internal fixation with a Selfdynamisable internal fixator. Results The average follow-up was 33 months. All the nonunions healed after indexed operation. The average time for union was 5.5 months (range 4–9 months). There was no loosening or breakage of the fixation device. The functional results, according to the scale of Constant and Murlay modified by Ring, were excellent in five and good in one patient. There were no complications of nerve injuries or infections related to the operation. Conclusion Selfdynamisable internal fixator with bone graft for the treatment of recalcitrant humeral shaft nonunion provided successful clinical outcome with minimal complications.     

Changes in the management of pediatric medial humeral epicondyle fractures with and without associated elbow dislocation

Purpose The optimal management of medial humeral epicondyle fractures continues to be debated since decades. This single center study analyzes changes and optimizations of treatment over an observation period of 16 years and reports the results.Materials and Methods Retrospective analysis of all patients treated with a medial humeral epicondyle fracture between 2005 and 2020 at our institution.Results Ninety-six patients (mean 9.3 years, range 1 - 15) were included in the study. In 25 cases (26 %), the fracture was associated with an elbow dislocation. Most patients received surgical treatment (83.3 %), whereas 17.7 % were treated nonoperatively. Surgical treatment consisted of open reduction and fixation with compression screw (n = 44 steel, n = 2 absorbable), K-wire (n = 30), a combination of screw/K-wire (n = 2), or a PDS suture (n = 1). Compression screws have been used significantly more often in the latter half of the study period (p = 0.006). Patients were immobilized in a long arm cast for 29 days (range 11 – 50). Eleven surgically treated patients were early mobilized in an elbow orthosis. After a mean follow up of 7.6 months [2 – 61), Mayo elbow performance index (MEPI) outcome was excellent in all 96 patients. Loss of elbow movement (LOM) was found to be mild in 30 and moderate in 15 patients. LOM was found to be associated with surgical treatment (p = 0.001), and with concomitant elbow dislocations (p = 0.29). One pseudarthrosis occurred after conservative treatment. A persistence of ulnar nerve palsy or recurrent joint instability has not been described.Conclusion Most children with medial humeral epicondyle fractures nowadays undergo surgery. Screw osteosynthesis represents the increasingly preferred method in order to prevent joint instability or non-union, and to allow shorter immobilization duration. Overall results after medial epicondyle fractures are good.     

Deformity after fracture of the lateral humeral condyle in children

We studied 28 displaced (Jacob types II and III) fractures of the lateral humeral condyle in 28 children. There were only two Milch type I fractures. Twenty-one fractures were treated by open reduction and internal fixation with K-wires, Palmer nails, or sutures. Seven patients were treated with a plaster cast, five following closed reduction, and the primary displaced position being accepted in two. Anatomic reduction was obtained in 18 patients. All but one fracture were united at review 2 years to 16 years later. The distal humerus was wider on the injured side in all patients. Six patients had a visible varus deformity, and three patients had a visible valgus deformity. The radiologic tilt of the joint surface and the depth of the trochlear groove were measured in patients more than 10 years old at review. All patients with a final varus tilt of the joint surface on the injured side were less than 9 years of age at injury, and all but one of the patients with Milch type II fractures had a deepening of the trochlear groove. Two patients developed avascular necrosis of the trochlea. One of these had a concomitant fracture of the medial humeral epicondyle, and the other suffered a lateral condylar fracture preceded by a supracondylar fracture. We conclude that a reduced growth potential at the trochlear groove is a regular complication of the Milch type II fracture, and that the Jacobs classification is the most useful in the assessment of the method of treatment.     

Articular fractures of the distal part of the humerus

BACKGROUND: The purpose of this retrospective study was to identify the patterns of distal humeral articular fractures and to analyze the results of open reduction and internal fixation of these injuries. METHODS: The cases of twenty-one patients with an articular fracture of the distal part of the humerus were reviewed at an average of forty months after the injury. Five components of the injury were identified: (1) the capitellum and the lateral aspect of the trochlea, (2) the lateral epicondyle, (3) the posterior aspect of the lateral column, (4) the posterior aspect of the trochlea, and (5) the medial epicondyle. All fractures were reduced and were stabilized with implants buried beneath the articular surface. RESULTS: All fractures healed, and no patient had residual ulnohumeral instability or weakness. Ten patients required a second operation: six, for release of an elbow contracture; two, for treatment of ulnar neuropathy; one, for removal of hardware causing symptoms; and one, because of early loss of fixation. The average arc of ulnohumeral motion was 96 degrees (range, 55 degrees to 140 degrees ). The results according to the Mayo Elbow Performance Index were excellent in four patients, good in twelve, and fair in five. CONCLUSIONS: Apparent fractures of the capitellum are often more complex fractures of the articular surface of the distal part of the humerus. Treatment of these injuries with operative reduction and fixation with buried implants can result in satisfactory restoration of elbow function.     

肘关节脱位与肱骨远端关节内骨折

Objective To describe dislocation of the elbow with articular fracture of the distal humerus,a type of elbow fracture-dislocation about which little has been written.Methods Four patients with a dislocation of the elbow and fracture of the distal humerus were identified.Three had dislocation and complex intraarticular fracture of the capitellum,trochlea,and lateral epicondyle.Results Two patients(one treated with a second operation to address avascular necrosis of the capitellum)achieved a functional arc of elbow motion and one patient was lost after removal of the implants 3 months after fracture with documented healing.The fourth patient had a complex open fracture dislocation involving the entire articular surface.An attempt to salvage the articular surface resulted in deep infection.Extensive heterotopic bone led to arthrodesis of the elbow.Conclusions Dislocations of the elbow with articular fracture of the humerus are uncommon.Most injuries involve the capitellum,lateral trochlea,and lateral epicondyle.Open reduction and internal fixation of the distal humerus fracture can restore stability without repairing the medial collateral ligament.     

改良肘后入路Y形钢板治疗肱骨髁部骨折

目的:探讨改良肘后正中纵行入路Y形钢板内固定治疗肱骨髁部粉碎性骨折的临床疗效。方法:23例肱骨髁部骨折(按AO/ASIF分类法:A3型10例,C1型6例,C2型4例,C3型3例),采用改良肘后正中纵行入路Y形钢板内固定,术后配合肘关节功能锻炼,早期应用非甾体类药物。结果:术后平均随访15个月,按Cassebaum标准进行肘关节功能评定:优17例,良4例,可2例,优良率91.3%。无血管神经损伤、内固定失败、骨化性肌炎、骨折畸形愈合、骨不连等发生。结论:改良肘后正中纵行入路Y形钢板内固定具有暴露安全充分、内固定可靠、术后并发症少的优点,可作为治疗肱骨髁部粉碎性骨折的首选。     

Fractures of the femoral neck in childhood. Results of conservative treatment

Experience with nine patients with fracture of the femoral neck in childhood, eight of whom were treated conservatively by closed reduction and fixation with a plaster cast, and one in whom Steinmann pins and open reposition had to be employed to accomplish fixation, is presented in brief. In six children the results were evaluated as good and in three (including the one case of open reduction) as fair. No serious complications were observed. The problem of nonsurgical versus surgical approach is discussed in the light of the relevant literature. It is suggested that while there can be no set rule as to which treatment should be used, conservative management yields results which are comparable with those attained with a more aggressive approach.     

Posteromedial dislocation of the elbow with lateral condyle fracture in children

Posteromedial dislocation of the elbow in children is an extremely rare injury. The current study describes four boys with posteromedial dislocation of the elbow associated with a displaced fracture of the lateral humeral condyle. The patients ranged in age from 6 to 12 years (average age, 9 years 6 months). Closed reduction of the elbow dislocation and open reduction of the lateral humeral condyle fracture with fixation by Kirschner wires by a lateral approach was done in each patient. This was followed by 4 weeks immobilization wearing a long-arm cast. There were three excellent results and one good result. Healing and return of normal function occurred in all but one patient who had minor loss of full extension. Average duration of followup was 7 years 6 months (range, 3-13 years). Dislocation of the elbow associated with a displaced fracture of the lateral humeral condyle can be treated by closed reduction of the elbow dislocation and open anatomic reduction and fixation of the lateral condyle fracture with good results.