summary Medial Epicondylar Fractures are the third most common fracture seen in children and are usually seen in boys between the age of 9 and 14. Diagnosis is made with plain radiographs. Treatment is nonoperative for the majority of fractures. Operative management is indicated for entrapment of medial epicondyle fragment in the joint, extension to the articular surface with medial condyle involvement (articular surface), and open fractures. Epidemiology Incidence account for up to 20% of all pediatric and adolescent elbow fractures Demographics 75% occur in boys between the ages of 9 and 14 years increasing in frequency due to the increased athletic demands in the pediatric population. Etiology Pathoanatomy avulsion mechanism fracture occurs secondary to excess valgus stress with contraction of flexor-pronator mass direct trauma Associated injuries elbow dislocation associated with elbow dislocations in approximately 50-60% of cases most spontaneously reduce but fragment remains incarcerated in joint in ~ 15% of cases Anatomy Osteology medial epicondyle last ossification center to fuse in distal humerus does not contribute to longitudinal growth (apophysis) origin of flexor-pronator mass and UCL Ossification center of the Elbow Years at ossification (appear on xray) Years at fusion (appear on xray) Capitellum 1 12-14 Radial head 3 14-16 Internal (medial) epicondyle 5 16-18 Trochlea 7 12-14 Olecranon 9 15-17 External (lateral) epicondyle 11 12-14 Muscles/ligaments common flexor-pronator wad muscles of medial epicondyle include pronator teres flexor carpi radialis palmaris longus flexor digitorum superficialis flexor carpi ulnaris Blood supply anterior branches of inferior ulnar collateral artery posterior branches of the superior and inferior ulnar collateral artery Classification No routinely used classification system Can be more simply classified as acute vs. chronic acute subtypes Nondisplaced Minimally displaced Displaced Fragment entrapped in joint Fracture through epicondyle apophysis chronic related to tension stress injuries Presentation Symptoms medial elbow pain Physical exam valgus instability ecchymosis (especially with direct trauma) ulnar nerve dysfunction- motor and sensory function should be documented in all cases generalize swelling suggests elbow may have dislocated Imaging Radiographs displacement is difficult to measure accurately as medial epicondyle is located on the posteromedial aspect of the distal humerus and fragment displaces anteriorly recommended views AP and lateral of elbow internal oblique view to evaluate displacement distal humeral axial view may also improve accuracy of measuring displacement obtained by angling beam 25 degrees anterior to long axis of humerus CT most accurate but associated with increased radiation Differential Medial condyle fracture Simple elbow dislocation Treatment Nonoperative immobilization (1-3 weeks) in a long arm cast with elbow flexed to 90 degrees indications controversial < 5mm displacement amount of true displacement difficult to determine on plain radiographs outcomes lower rate of osseous union rate compared to surgically treated patients radiographic nonunion (or fibrous union) often asymptomatic Operative open reduction internal fixation indications absolute displaced fx with entrapment of medial epicondyle fragment in joint extension to the articular surface with medial condyle involvement (articular surface) open fracture relative ulnar nerve dysfunction > 2-15mm displacement, also controversial >2-5 mm in valgus stress athletes such as throwers or gymnasts associated elbow dislocation Techniques Open Reduction Internal Fixation approach medial approach to elbow typically with patient supine and arm abducted to 90 degrees, a prone position also described incision is made directly over medial epicondyle brachialis/triceps interval ulnar nerve at risk technique identify and protect ulnar nerve (easiest from proximal to distal) reduce fracture screw fixation (often cannulated) a washer may improve fixation, but more prominant avoid iatrogenic comminution during screw insertion K-wires indicated for smaller fragments or in younger children Complications Non-union majority are asymptomatic odds of radiographic union are 9 times greater with surgery Nerve injury ulnar nerve (reported between 10% - 16%) neuropraxia after dislocation will usually resolve with observation radial nerve at risk with bicortical screw fixation Missed incarceration in elbow joint Elbow stiffness the most common complication is the loss of few degrees of elbow extension associated with prolonged immobilization, occurs after nonoperative and operative treatment Prognosis Good to excellent results have been reported for both surgical and non-surgical management
QUESTIONS 1 of 16 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ18.234) A 12-year-old female present with the injury shown in Figure A and B. The patient undergoes open reduction internal fixation. In the immediate postoperative period, the physical exam demonstrates weakness in palmar flexion at the wrist and numbness of the ring and small fingers. Which of the following statements is true of the affected nerve? QID: 213130 FIGURES: A B Type & Select Correct Answer 1 Originates from the posterior cord and splits the two heads of the FCU in the proximal forearm 10% (180/1870) 2 Originates from the lateral cord and runs in Guyon's canal 15% (280/1870) 3 Originates from the medial cord and runs deep to the transverse carpal ligament as it enters the hand 4% (67/1870) 4 Originates from the lateral cord and runs medial to the associated artery at the level of the wrist 3% (49/1870) 5 Originates from the medial cord and runs between the FDP and FCU in the forearm 68% (1280/1870) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ11.136) A 15-year-old Little League pitcher sustains an injury to his dominant elbow shown in Figure A. Radiographs demonstrate 7 mm of displacement. Which of the following treatments will result in the highest rate of bony union? QID: 3559 FIGURES: A Type & Select Correct Answer 1 Long arm cast for 1 week, followed by passive and gentle active ROM 4% (115/2967) 2 Placement in a hinged elbow brace with immediate active motion 1% (39/2967) 3 Closed reduction followed by K-wire fixation 12% (370/2967) 4 Open reduction and internal fixation 82% (2420/2967) 5 Fragment excision and flexor/pronator mass re-attachment 0% (14/2967) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ10.126) Which of the following fracture patterns (Figures A-E) is most commonly associated with a combined ulnohumeral and radiocapitellar elbow dislocation in children? QID: 3220 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 9% (408/4318) 2 Figure B 58% (2483/4318) 3 Figure C 3% (122/4318) 4 Figure D 5% (195/4318) 5 Figure E 25% (1095/4318) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ09.178) A 9-year-old boy fell off of a swing set and injured his left elbow. Radiographs are shown in Figures A and B. Open reduction and internal fixation of this fracture is indicated secondary to which of the following: QID: 2991 FIGURES: A B Type & Select Correct Answer 1 Displacement of greater than 5 mm 5% (184/3709) 2 An incarcerated fragment in the ulnohumeral joint 88% (3256/3709) 3 2+ valgus laxity seen with manual stressing 1% (28/3709) 4 To prevent cubitus valgus deformity 3% (99/3709) 5 High risk of symptomatic non-union of fragment 3% (125/3709) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.64) Which of the following muscles is involved in the avulsion injury that creates the fracture shown in Figure A? QID: 450 FIGURES: A Type & Select Correct Answer 1 Pronator quadratus 1% (24/1885) 2 Pronator teres 88% (1665/1885) 3 Extensor carpi radialis longus 4% (73/1885) 4 Brachioradialis 5% (88/1885) 5 Brachialis 1% (27/1885) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ07.85) An 11-year-old boy presents to the emergency room with a left elbow injury after falling off of the monkey bars. His neurovascular examination in the extremity is normal and his pain is controlled. Post-reduction radiographs are shown in Figure A. What is the next most appropriate step in management QID: 746 FIGURES: A Type & Select Correct Answer 1 Percutaneous pinning 8% (164/1995) 2 Hinged elbow brace locked at 90 degrees of flexion for 10 days followed by gentle passive range of motion 8% (156/1995) 3 Open reduction and internal fixation 56% (1117/1995) 4 Long arm cast for 4 weeks 23% (459/1995) 5 Sling for comfort and return to activities as tolerated 4% (85/1995) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ05.4) An 11-year-old child sustains an elbow dislocation. The elbow is reduced, but post-reduction radiographs demostrate that the ulnohumeral joint remains slightly incongruent. What is the most likely etiology for this continued incongruency? QID: 41 Type & Select Correct Answer 1 Interposed annular ligament 15% (174/1159) 2 Interposed lateral epicondyle fragment 6% (66/1159) 3 Interposed medial epicondyle fragment 71% (828/1159) 4 Interposed ulnar nerve 2% (28/1159) 5 Interposed brachialis muscle 5% (54/1159) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
All Videos (0) Podcasts (1) Pediatrics | Medial Epicondylar Fractures Pediatrics - Medial Epicondylar Fractures - Pediatric Listen Now 18:50 min 10/15/2019 720 plays 5.0 (4)
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