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Medial Epicondylar Fractures - Pediatric

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Topic updated on 03/26/16 8:32pm
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
  • 3D CT  
    • most accurate but radiation dose is 200x that of plain film
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
        • relative
          • ulnar nerve dysfunction
          • > 5-15mm displacement
          • displacement in high level athletes
Techniques
  • Open Reduction Internal Fixation
    • approach
      • medial approach to elbow 
        • incision is made directly over medial epicondyle
        • patient supine on table with arm abducted to 90 degrees and externally rotated
    • technique
      • identify ulnar nerve 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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Qbank (8 Questions)

TAG
(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? Topic Review Topic
FIGURES: A          

1. Long arm cast for 1 week, followed by passive and gentle active ROM
2. Placement in a hinged elbow brace with immediate active motion
3. Closed reduction followed by K-wire fixation
4. Open reduction and internal fixation
5. Fragment excision and flexor/pronator mass re-attachment

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

PREFERRED RESPONSE ▶
TAG
(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: Topic Review Topic
FIGURES: A   B        

1. Displacement of greater than 5 mm
2. An incarcerated fragment in the ulnohumeral joint
3. 2+ valgus laxity seen with manual stressing
4. To prevent cubitus valgus deformity
5. High risk of symptomatic non-union of fragment

PREFERRED RESPONSE ▶
TAG
(OBQ08.64) Which of the following muscles is involved in the avulsion injury that creates the fracture shown in Figure A? Topic Review Topic
FIGURES: A          

1. Pronator quadratus
2. Pronator teres
3. Extensor carpi radialis longus
4. Brachioradialis
5. Brachialis

PREFERRED RESPONSE ▶
TAG
(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 Topic Review Topic
FIGURES: A          

1. Percutaneous pinning
2. Hinged elbow brace locked at 90 degrees of flexion for 10 days followed by gentle passive range of motion
3. Open reduction and internal fixation
4. Long arm cast for 4 weeks
5. Sling for comfort and return to activities as tolerated

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic

1. Interposed annular ligament
2. Interposed lateral epicondyle fragment
3. Interposed medial epicondyle fragment
4. Interposed ulnar nerve
5. Interposed brachialis muscle

PREFERRED RESPONSE ▶
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