Review Question - QID 212963

Entrapment of a medial epicondyle fragment within the joint is an absolute indication for open reduction and internal fixation.

Medial epicondyle fractures occur in 50-60% of pediatric elbow dislocations. Minimally displaced fractures may be treated conservatively with initial splinting in 90 degrees and then initiation of AROM within one week with protective splinting for another few weeks. Absolute indications for operative treatment are irreducible incarceration of the medial epicondyle in the joint and the rare open fracture. Closed reduction of an elbow dislocation with a medial epicondyle fracture may be attempted by supinating the forearm, placing a valgus stress on the elbow, and extending the wrist and fingers in an attempt to place traction on the fracture fragment to prevent incarceration.

Edmonds retrospectively reviewed 11 patients with medial epicondlye fractures. They compared radiographs of the humerus to CT scans to compare measured displacement. They concluded that standard AP and lateral imaging in these fracture often underestimate the true degree of displacement and advocate for an internally rotated axial view or a CT scan for true displacement measurement.

Pathy et al. authored a review on pediatric medial epicondyle fractures. They note that recent studies have highlighted the underestimation of fracture displacement seen on typical radiographic views and have attempted to define the location of the medial epicondyle on radiographs to improve the accuracy of measuring displacement. They report that newer evidence supports the fixation of medial epicondyle fractures in adolescent athletes, to allow return to competitive sports.

Gottschalk et al. also authored a review on medial epicondlye fractures in the pediatric population. They suggest 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.

Figure A is a displaced both bone forearm fracture (BBFF). Figure B is a Salter Harris IV distal tibia fracture with an associated fibula fracture. Figure C is a lateral condyle fracture on an internal rotation view demonstrating approximately 2mm of displacement. Figure D is a medial epicondyle fracture with the fragment entrapped in the ulnotrochlear joint. Figure E is a displaced proximal humeral shaft fracture in a patient with significant growth remaining.
Illustration A is the same patient in figure A status post reduction. Illustration B is that same patient in figure B status post reduction. Illustration C is an example of a medial epicondyle fracture fixed with a screw and washer.

Incorrect Answers:
Answer 1: Displaced BBFFs can often be treated with closed reduction and immobilization. The acceptable degree of angulation depends on the age of the patient and location of the fracture but is generally 10-15 degrees.
Answer 2: Displaced distal tibia fractures can be treated with closed reduction and casting as long as reduction results in a displacement of 2mm or less at the articular surface. The tolerances for physeal displacement are not well defined.
Answer 3: Lateral condyle fractures with less than 2mm of displacement (indicating an intact hinge) can be treated with casting alone and close serial follow up. An interally rotated view of the elbow should be used to determine the true degree of displacement.
Answer 5: Humeral shaft and proximal humerus fractures in the pediatric population have a tremendous ability to heal with nonoperative treatment and can often be treated with a hanging arm cast or bracing. An angular deformity up to 70 degrees with shortening can be accepted and expected to remodel in children under 12 years of age.