Medial epicondyle fractures are common in the pediatric population, accounting for about 20% of all pediatric elbow fractures with 75% occurring in males.1 The typical mechanism of injury involves extension and valgus forces across the elbow, with elbow dislocation occurring over half of the time.1 When indicated, the current standard for operative treatment remains open reduction with cannulated screw fixation, but there is no clear consensus on operative technique, specifically regarding patient positioning and method of fracture reduction.1 Patients can be positioned supine. However, reduction can be difficult in this position due to the counteracting internal rotation forces on the humerus and external rotation forces of the forearm and flexor pronator mass attached to the fracture fragment. Previously described supine techniques have largely focused on methods of bringing the fracture fragment to the donor site rather than attempting to neutralize deforming forces.2 The challenges of confronting deforming forces in the supine position have been addressed with a variety of alternative positioning techniques.3 Some surgeons have recommended operating in the prone or lateral decubitus position, essentially internally rotating the entire forearm to the humerus instead of neutralizing the internal rotational forces of the humerus to facilitate reduction. Prone and lateral positioning; however, can present inconveniences for anesthesia airway access, intraoperative fluoroscopy, and increase operative time.4 We describe a novel reduction technique using a universally available fracture clamp to facilitate direct control of humeral rotation while in the supine position. The clamp is applied to the medial column of the distal humerus and used to externally rotate the humerus, counteracting internal rotation forces from the proximal musculature. This brings the humerus to the epicondyle fragment instead of the epicondyle fragment to the humerus. This allows for a tension-free reduction performed easily by one assistant without force applied to the epicondyle fragment and without the need for prone or lateral decubitus positioning. To the authors knowledge, this is the first description of a technique focusing on rotating the humerus to the epicondyle rather than the other way around. TECHNIQUE The case used to demonstrate this technique is an 8-year-old right-hand-dominant female with a displaced medial epicondyle fracture (Fig. 1A, B). Surgery is performed under general or regional anesthesia with the patient positioned supine with the arm on a hand table. A pneumatic tourniquet is applied as proximally on the arm as possible.FIGURE 1: Initial radiographs of an 8-year-old right-handed girl who injured the right elbow during a back handspring during gymnastics. Anteroposterior radiograph demonstrating displacement of the medial epicondyle (A). Comparison anteroposterior radiograph demonstrating the normal medial epicondyle epiphysis-metaphysis relationship (B). Following superficial and deep dissection, the fracture fragment (white arrow) and donor site (black arrow) are noted. Ulnar nerve is decompressed for visualization and protection (yellow arrow) (C). There is a notable gap between the fracture fragment and the donor site on the distal humerus when internally rotated away from the epicondylar fragment (D).A longitudinal, curvilinear incision is made over the posteromedial elbow, just posterior to the medial epicondyle. Full-thickness subcutaneous flaps are elevated while taking care to protect the medial antebrachial cutaneous nerve and associated branches. Deep to fascia, the ulnar nerve is identified and protected by releasing the Osborne ligament as well as approximately one inch proximal and distal for exposure and protection of the nerve during manipulation. Directly visualizing the ulnar nerve is standard practice for the authors to ensure the ulnar nerve is protected throughout the case and not entrapped during reduction and instrumentation. Just proximal to the epicondyle, the nerve and tissue planes are also much easier to visualize as they are usually less distorted by trauma. Gentle retraction of the nerve also allows direct inspection of the posterior cortex of the medial epicondyle, which is the only cortical “read” that is directly visible in these cases. A complete ulnar nerve decompression is not vital to this reduction technique; decompression of the nerve is performed only for visualization and protection of the nerve, which is part of the authors’ standard approach to this fracture. The fracture fragment is identified, and the fracture site is gently debrided of hematoma and interposed soft tissue while taking care to minimize trauma to the physeal tissues (Fig. 1C). The distal triceps and brachialis muscles are minimally elevated off the medial supracondylar ridge, only enough to allow application of a fracture clamp which is then applied to the medial supracondylar ridge, taking care to keep the clamp anterior to the ulnar nerve but deep to the brachialis (Fig. 1D). This technique does not require a longer initial incision or larger exposure than typical for this fracture as the clamp is placed low on the supracondylar region of the humerus immediately proximal to the fracture bed. As long as the ulnar nerve is visualized, there is little risk of clamping other vital neurovascular structures around the elbow. The brachial artery and median nerve lie superficial to the brachialis and are well away from the surgical field as long as the anterior tine of the clamp is applied directly to bone deep to the brachialis. The clamp is used to externally rotate the humerus to reduce the fracture bed to the medial epicondylar fragment under direct visualization without the need for mobilization of the epicondyle fragment. The external rotation torque is easily maintained by a single assistant sitting opposite the surgeon, allowing the primary surgeon to proceed with fracture fixation (Fig. 2A-D).FIGURE 2: Reduction technique. External rotation torque (white arrow) is applied to the humerus through a small fragment lobster claw clamp, bringing the distal humerus to the fracture fragment instead of the fracture fragment to the distal humerus (A). Alternative view of surgical wound with external rotation (white arrow) applied through the fracture reduction clamp (B). Illustrations of the reduction technique in demonstrating approximation of the fracture fragment and fracture bed (*) via external rotation of the humerus (C-D).Under direct visualization, 1 or 2 parallel guidewires are advanced proximally through the epicondylar fragment taking care to enter at a start point slightly distal and anterior within the fragment to prevent screw cutout through the proximal and posterior cortex of the fragment, which is directly visible with gentle retraction of the ulnar nerve. The wire is advanced proximally within the medial column and engaged in the proximal and lateral metaphyseal cortex of the distal humerus to achieve provisional fixation. The correct wire position is confirmed with miniature C-arm fluoroscopy. If both the forearm and the fracture clamp are held by the same person, the humerus and forearm can be internally or externally rotated as a unit over the image intensifier of the miniature C-arm fluoroscope to facilitate intraoperative imaging (Fig. 3A, B). An accurate wire trajectory up the medial column can also be directly visualized by inserting the wire between the two visible “goal posts” presented by the tines of the fracture clamp, which are on either side of the medial column (Fig. 3C). The wires are sequentially measured and over-drilled. One or 2 cannulated screws (typically between 2.5 to 3.5 mm) with or without a washer, based on the surgeon’s preference, are advanced over the wire up the medial column. The provisional wires are removed and a final fluoroscopic examination is performed to confirm anatomic alignment of the fracture and appropriate positioning of the screws (Fig. 3D-F). The reduction clamp can then be removed from the distal humerusFIGURE 3: The surgical assistant maintains control of the patient’s wrist and forearm with one hand and keeps the humerus externally rotated against the forearm with a fracture clamp held in the other hand (A). This allows easy positioning across the image intensifier of a miniature C-arm fluoroscope for a lateral view of the elbow. Internally rotating the forearm and humerus together, the assistant can then easily obtain an anteroposterior view of the elbow without moving the image intensifier (B). As long as continued gentle external rotation torque is maintained through the fracture clamp, there will be no tension across the fracture site. Two parallel guide wires are then inserted, and positioning is confirmed fluoroscopically (C). The primary wire is placed slightly anteriorly within the epicondyle fragment to prevent later posterior cutout of the cannulated screw. The more posterior wire serves as a derotational wire. Note that the assistant’s right hand controls the patient’s right wrist and forearm while the assistant’s left hand maintains an external rotation torque on the humerus through the clamp. The primary surgeon has both hands free and an optimal viewing angle for instrumentation of the fracture. Once the cannulated screw has been placed, the guide wires and clamp are removed, demonstrating anatomic reduction and rigid fixation of the fracture on direct visualization (D) and fluoroscopic examination (E, F).The wound is irrigated and closed in a layered manner using a technique and suture material of the surgeon’s preference. A bulky dry sterile dressing is applied, followed by a long arm cast. Postoperatively, the patient is maintained in a long arm cast or splint for 1 to 2 weeks, after which sling immobilization and a gentle range of motion of the elbow/forearm can be started. External rotation of the shoulder and valgus forces on the elbow should be avoided until 1 month after surgery. Approximately 6 weeks after surgery, unrestricted strengthening and athletic activity can begin. The authors obtain follow-up radiographs at 1 week, 1 month, and 3 months postoperatively. Optional screw removal can be performed no earlier than 6 months after surgery. EXPECTED OUTCOMES There are numerous approaches to intraoperative reduction and fixation of pediatric medial epicondyle fractures.2,4 All supine reduction techniques focus on bringing the fracture fragment to the donor site on the medial humerus. This is often challenging, however, because the forearm and, therefore, the displaced medial epicondyle fragment are externally rotated away from the humerus when the arm is positioned on a hand table when supine. At the same time, the forces of the pectoralis major, teres major, and subscapularis internally rotate the humerus. Some authors have described using pointed reduction clamps to forcibly pull the fracture fragment to the donor site along the medial humerus while flexing the wrist and pronating the forearm to reduce flexor pronator mass tension. This technique; however, does not control the humerus directly and relies solely on traction on the epicondyle fragment, which can result in high tensile force on the medial epicondyle fragment leading to iatrogenic comminution and intraoperative screw cut-out. To avoid these risks, Kamath et al2 proposed using an Esmarch bandage to “milk” the flexor pronator muscles from distal to proximal with the patient’s wrist fully flexed, forearm pronated, and elbow flexed at 90 degrees. This technique eliminates the need for excessive tension on the epicondylar fragment; however, it still essentially forces the surgeon to first over-reduce the fracture by bringing the displaced epicondyle fragment to a fracture bed that is internally rotated away from the fragment. To neutralize the internal rotation forces on the humerus, many surgeons prefer to perform medial epicondyle reduction and fixation in either the lateral decubitus or prone position. In these techniques, the operative elbow is flexed and pronated with the hand behind the back. Though the entire humerus will be internally rotated, so will the remainder of the forearm, thus facilitating reduction of the medial epicondyle fragment to the rest of the humerus. When comparing outcomes in prone versus supine positioning, reduction quality was significantly better in the prone group, which was hypothesized to be due to better visualization and rotational forces on the reduction.4 There are drawbacks to prone and lateral positioning during surgery. When comparing fracture reduction in the supine versus prone position, Baghdadi et al4 found prone positioning was associated with a mean increase in operating room time of 28 minutes but no difference in tourniquet time, suggesting that the difference in room time was due to patient positioning, likely due to the additional steps taken during prone positioning to avoid pressure points and protect the airway. We present here a novel but simple technique for reducing pediatric medial epicondyle fractures. This technique requires no specialized equipment, facilitates a tension-free fracture reduction, simplifies guidewire placement, simplifies intraoperative imaging with miniature C-arm fluoroscopy rather than standard large C-arm fluoroscopy, saves time on patient positioning, and simplifies airway access during anesthesia. COMPLICATIONS Significant controversy still exists regarding operative versus nonoperative management of pediatric medial epicondyle fractures, necessitating further studies to define the indications for surgery.1 When surgical management of these fractures is performed, commonly cited complications include symptomatic hardware leading to removal, complaints consistent with ulnar nerve irritability, and joint stiffness with associated restricted range of motion.5 In Patel et al5 study, 46% of patients required a second surgery with the majority requiring symptomatic screw removal. Twenty three percent reported sensory or motor complaints attributable to ulnar nerve irritation.5 The risks of other typical postoperative complications such as surgical site infection and acute compartment syndrome remain quite low.4,5 In our experience, we have not encountered complications of nonunion, loss of fixation, or ulnar neuropathy when using the technique described here.
Guenthner et al. (Fri,) studied this question.