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Introduction
  • Fracture of the medial epicondylar apophysis on the posterormedial aspect of the elbow
    • medial epicondyle is avulsed via tension created by structures attached to it
      • include flexor-pronator mass and MCL
    • fracture occurs secondary to excess valgus stress at elbow 
  • Mechanism
    • fall on outstretched arm
      • most common
    • elbow dislocation 
      • associated with elbow dislocations in up to 50% q 
      • most spontaneously reduce but fragment may be incarcerated in joint
    • traumatic avulsion
      • usually occurs in overhead throwing athletes
  • Epidemiology
    • usually occur in children between the ages of 9 and 14 years
Anatomy
  • Common flexor wad muscles of medial epicondyle include
    • pronator teres 
    • flexor carpi radialis 
    • palmaris longus 
    • flexor digitorum superficialis 
    • flexor carpi ulnaris 
Presentation
  • Symptoms
    • medial elbow pain
  • Physical exam
    • tenderness over medial epicondyle
    • valgus instability
Imaging
  • Radiographs
    • recommended views
      • AP and lateral of elbow
      • axial view is most accurate as medial epicondyle is located on the posteromedial aspect of the distal humerus    
        • especially because fragment displaces anteriorly
      • internal oblique views helpful
  • CT 
    • most accurate but associated with increased radiation  
Treatment
  • Nonoperative
    • brief immobilization (1 to 2 weeks) in a long arm cast or splint
      • indications
        • < 5mm displacement usually treated non-operatively, 5-15 mm remains controversial
        • often heal with fibrous union
        • fibrous union of the fragment is not associated with significant symptoms or diminished function
  • Operative
    • open reduction internal fixation
      • indications
        • absolute
          • displaced fx with entrapment of medial epicondyle fragment in joint  q q
          • if medial condyle is involved (articular surface)
        • relative
          • ulnar nerve dysfunction
          • > 5-15mm displacement
          • any displacement in valgus stress athletes (gymnast, pitchers, etc)
Techniques
  • Open Reduction Internal Fixation
    • approach
      • medial approach to elbow 
        • incision is made directly over medial epicondyle
        • brachialis / triceps interval, ulnar nerve at risk 
        • patient supine on table with arm abducted to 90 degrees and externally rotated
    • technique
      • identify ulnar nerve (easiest from proximal to distal) and protect
      • reduce fracture 
      • use cannulated screw for fixation 
      • K-wires indicated for smaller fragments or in younger children
Complications
  • Nerve injury
    • ulnar nerve can become entrapped
    • neuropathy with dislocatoin which usually resolves
  • Missed incarceration
    • missed incarceration of fragment in elbow joint
  • Elbow stiffness
    • loss of elbow extension, avoid prolonged immobilization 
  • Non-union
 

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