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Journal of Orthopaedic Surgery 2007;15(2):170-3

Medial humeral epicondylar fracture in


children and adolescents
D Ip, WL Tsang
Department of Orthopaedics and Traumatology, Pamela Youde Nethersole Eastern Hospital, Hong Kong

this group needed longer rehabilitation to attain a


functional range of movement than those in other
ABSTRACT groups (treated together with a tension-band wire or
screw).
Purpose. To assess treatment outcomes of young Conclusion. Surgery is recommended for children
patients with medial epicondylar fracture of the with displaced medial epicondylar fractures of more
elbow using standard operative protocols. than 5 mm. The use of a tension-band wire, instead of
Methods. 24 consecutive patients with medial a screw, together with Kirschner wires is the preferred
humeral epicondylar fracture underwent surgery by treatment for younger children.
one of the 3 methods: (1) 2 parallel Kirschner wires,
(2) 2 parallel Kirschner wires plus a tension-band Key words: elbow; fracture fixation; humeral fractures
wire, and (3) a screw plus an anti-rotation Kirschner
wire. Fractures displaced less than 5 mm were treated
conservatively (casting for 3 weeks). Outcome was INTRODUCTION
assessed clinically and radiologically. The Mayo
Clinic Elbow Performance Index was measured. Medial epicondylar fracture of the elbow in children
Results. The 3 patients with undisplaced fractures is common. The fracture fragment may be missed
had good radiological results and scores. One when dislocation is associated with fracture. The best
patient with a displaced fracture refused surgery treatment for displaced medial epicondylar fracture
and subsequently developed pseudarthrosis and remains controversial, as decisions on fixation depend
cubitus valgus. All operatively treated patients had on the anticipated extent of growth remaining in that
good scores, but 2 treated with 2 parallel Kirschner child and a growing traction-type apophysis.
wires alone developed pseudarthrosis. Patients in Good to excellent outcomes have been reported

Address correspondence and reprint requests to: Dr David Ip, Department of Orthopaedics and Traumatology, Pamela Youde
Nethersole Eastern Hospital, Hong Kong. E-mail: ipd8686@pacific.net.hk
Vol. 15 No. 2, August 2007 Medial humeral epicondylar fractures in children 171

(a) (b)

Figure 1 Displaced medial humeral epicondylar fracture


fixed with (a) one screw and an anti-rotation Kirschner wire,
and (b) a tension-band wire and 2 parallel Kirschner wires.

for both operative1 and conservative2,3 treatments Figure 2 Cubitus valgus of the left elbow developed 3 years
for displaced medial humeral epicondylar fracture. after conservative treatment.
However, the definition of displacement varies
between studies; some define the fracture as displaced
if >2 mm,1 but others, rely on >5 mm.2 The detailed
rationale for choosing conservative versus operative 1b) or 2 non-threaded parallel smooth Kirschner wires
management may be lacking, making comparison (n=6). Postoperatively, all patients were allowed free
between results difficult. We therefore set out to elbow mobilisation, but in a hinge brace for 3 weeks
develop a rationale for treatment decisions and the (to protect the elbow from varus/valgus stresses).
type of fixation in different scenarios. The Mayo Clinic performance index for the
elbow was used for functional assessment in 4 areas:
pain (maximum 45 points, from no pain to severe
MATERIALS AND METHODS pain), stability (maximum 10 points, from stable to
grossly unstable), range of movement (maximum
Records of 24 consecutive young patients (15 males, 20 points, from >100 to <50), and activities of daily
9 females) aged 9 to 17 (mean, 13) years with medial living (maximum 25 points). Radiography was used
humeral epicondylar fracture treated in our hospital to detect pseudarthrosis or ectopic calcification.
from July 1997 to July 2003 were retrospectively Fluoroscopy was used during implant removal to
reviewed. The records constituted an unselected series detect valgus instability and solid union. Clinical
with no exclusion criteria. Fractures were defined as testing was used to detect residual valgus instability
displaced if a radiographic gap of >5 mm was evident. for patients treated conservatively. Any postoperative
Two thirds of the injuries were domestic, and the rest nerve palsy, cubitus varus or valgus, and wound or
were sports related. Associated dislocation (n=4) hardware-related complications were documented.
was reduced on the day of admission. Soft tissue
injuries including transient ulnar nerve paresis (n=1),
fragment entrapment (n=2), and valgus instability RESULTS
(n=5) were documented. No patient had other
associated fractures. The mean follow-up period for patients treated
Three patients with undisplaced fractures and conservatively was 2.7 (range, 1.83.5) years, and for
one with a displaced fracture who refused surgery the operative group was 2.2 (range, 1.53.5) years. No
were treated conservatively (3 weeks of plaster patient was lost to follow-up.
immobilisation followed by physiotherapy). The Patients with undisplaced fracture treated
remaining 20 patients with displaced fractures conservatively had excellent results with early return
underwent surgery: those who were near skeletal of range of movement (within 6 weeks of plaster
maturity and had a sizable fracture fragment were removal). There were no elbow deformities, nerve
treated with a screw plus an anti-rotation Kirschner palsies, or other complications. The patient with
wire (n=8, Fig. 1a). Those who still had several years of displaced fracture who refused surgery developed
anticipated growth were treated with either 2 parallel cubitus valgus 3 years later, with numbness (but no
Kirschner wires plus a tension-band wire (n=6, Fig. weakness) in the ulnar nerve distribution (Fig. 2).
172 D Ip and WL Tsang Journal of Orthopaedic Surgery

Table
Summary of patient demographics, injuries, type of treatment, and outcome scores

Patient Sex/ Injured Displacement Associated injury Fixation Mayo


No. age side Clinic
(years) Scores
1 M/10 L No - Conservative 100
2 F/13 R No - Conservative 100
3 M/13 R No - Conservative 95
4 M/12 L Yes - Conservative (refused surgery) 90
5 F/10 L Yes Dislocation Tension-band wire + 2 Kirschner wires 85
6 M/14 R Yes - Screw + Kirschner wire 100
7 M/15 L Yes Dislocation Screw + Kirschner wire 100
8 F/12 R Yes Transient ulnar nerve paresis 2 Kirschner wires 85
9 F/12 R Yes - 2 Kirschner wires 90
10 M/17 L Yes - Screw + Kirschner wire 100
11 F/14 L Yes - Tension-band wire + 2 Kirschner wires 90
12 M/16 L Yes - Screw + Kirschner wire 100
13 M/15 R Yes - Screw + Kirschner wire 100
14 M/12 R Yes - 2 Kirschner wires 80
15 M/13 L Yes - Tension-band wire + 2 Kirschner wires 95
16 M/11 R Yes - Tension-band wire + 2 Kirschner wires 95
17 F/9 L Yes - 2 Kirschner wires 85
18 F/15 L Yes Dislocation Screw + Kirschner wire 90
19 M/10 R Yes - 2 Kirschner wires 85
20 F/15 R Yes - Screw + Kirschner wire 100
21 M/13 L Yes - 2 Kirschner wires 85
22 M/15 R Yes - Screw + Kirschner wire 100
23 F/11 L Yes Dislocation Tension-band wire + 2 Kirschner wires 95
24 M/12 R Yes - Tension-band wire + 2 Kirschner wires 95

In patients with displaced fractures treated and was 85 (range, 8090) in patients fixed with 2
operatively, all except one regained full range of Kirschner wires only. The overall mean score in the
movement. The mean time taken was 7 (range, 58) operated group was 93 (range, 80100). Patients fixed
weeks for patients with a screw plus a Kirschner with 2 Kirschner wires alone fared worse than those
wire, and 7 (range, 68) weeks for patients with a in the other 2 groups and required a longer period of
tension-band wire plus 2 parallel Kirschner wires, physiotherapy (Table). Patients who underwent a more
and 9 (range, 810) weeks for patients with 2 parallel rigid form of fixation tended to have better scores, but
Kirschner wires. the difference was not statistically significant (possibly
One patient (treated with a screw plus a owing to the limited sample size).
Kirschner wire) developed mild cubitus varus and
another (treated with a tension-band wire plus 2
parallel Kirschner wires) acquired a superficial DISCUSSION
wound infection. Three patients (treated with 2
parallel Kirschner wires) had micromotion under Medial epicondylar fractures are common in children,4
fluoroscopy during implant removal as late as 6 and are caused by a valgus force combined with
months after surgery and were later confirmed to contraction of the forearm flexors. Most classifications
have pseudarthroses. None had any postoperative are based on the amount of fracture displacement.5
nerve palsy, ectopic calcification or ossification. Controversy arises regarding treatment of displaced
Two of 3 patients with undisplaced fractures had a (>5 mm) fractures. Surgery is indicated when there
full score (100) on the Mayo Clinic performance index is peripheral nerve entrapment or an associated
for the elbow. The patient with displaced fracture who irreducible dislocation from an entrapped intra-
refused surgery had a score of 90. The mean score for articular fracture fragment.
patients fixed with a screw and a Kirschner wire was Medial elbow stability depends on the medial
99 (range, 90100); it was 93 (range, 8595) in patients collateral ligament of the elbow and the forearm
fixed with a tension-band wire plus 2 Kirschner wires, flexors.6 The medial collateral ligament consists
Vol. 15 No. 2, August 2007 Medial humeral epicondylar fractures in children 173

of 3 bands. The eccentric position of the medial accommodate a screw). In younger children who still
epicondyle ensures that one of the 3 bands remains have years of growth, fixation with a tension-band
taut throughout the range of movement. When the wire plus 2 parallel Kirschner wires should be used,
medial epicondyle is displaced, the entire collateral as this overcomes the risk of inducing cubitus varus
ligament is displaced with the fracture fragment. by a screw across the growing apophysis.
When the tautness of the medial collateral ligament Poorly treated displaced medial epicondylar
decreases, medial instability of the elbow is likely to fractures may lead to symptomatic medial elbow
occur. It can be diagnosed by examining the patient instability. Late cases of instability may require
under anaesthesia with the elbow flexed nearly 90. fragment excision and ligamentous repair (or
This may explain the seemingly benign natural advancement) that involves fixation with suture
history of some displaced medial epicondylar anchors.7 The later the reconstruction, the greater was
fractures following conservative treatment.3 the liability to attenuated ligaments. Replacing the
The growth potential of the patient should ligaments with tendon grafts is not easy, as the exact
also be considered when deciding conservative tension is difficult to judge,8 and the use of tendon
versus operative treatment for a displaced fracture, grafts alone may not replace the function of the anterior
which is essentially an avulsion injury of a traction band of the normal medial collateral ligament, which
apophysis. In this type of traction apophysis is taut in certain positions of elbow flexion.
(especially in younger patients with years of growth
remaining), chronic traction can cause increased
underlying bone formation (similar to self-induced CONCLUSION
focal chondrodiastasis). Such patients may develop
medial epicondylar enlargement and even cubitus Surgical intervention is recommended for displaced
valgus when treated conservatively. Therefore, medial epicondylar fractures in young patients. For
we recommend operative fixation for displaced younger children, fixation with a tension-band wire
medial epicondylar fractures in children with years plus 2 smooth parallel Kirschner wires is preferred,
of growth remaining and/or those who are active as the risk of damaging the traction apophysis by
in sports, particularly javelin or baseball.7 When a a screw is avoided. For individuals near skeletal
fracture occurs in a subject near skeletal maturity, maturity, fixation with a screw plus an anti-rotation
fixation with a screw plus an anti-rotation Kirschner Kirschner wire, or a tension-band wire plus 2 parallel
wire should be chosen (assuming the fragment can Kirschner wires should be used.

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