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Bare medial epicondyle physeal fracture of the humerus: A case report
G Model JCOT 352 No. of Pages 3
Journal of Clinical Orthopaedics and Trauma xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Orthopaedics and Trauma journal homepage: www.elsevier.com/locate/jcot
Case report
Bare medial epicondyle physeal fracture of the humerus: A case report Takashi Oda* , Kenji Watanabe Department of Orthopedic Surgery, Kameda Daiichi Hospital, Nishimach 2-5-22, Konan-ku Niigata, 950-0165, Japan
A R T I C L E I N F O
Article history: Received 11 December 2016 Received in revised form 19 January 2017 Accepted 19 January 2017 Available online xxx Keywords: Elbow instability Medial elbow injury Medial epicondyle fracture Osteonecrosis Physeal fracture
A B S T R A C T
We identified an unusual case of the medial epiondyle physeal fracture, which has been caused by a direct blow, accompanied with complete stripping of soft tissue. Surgery was performed for open reduction and internal fixation of the medial epicondyle and reattachment of the anterior oblique bundle of medial collateral ligament and flexor muscle origin. Six months after the surgery, strength of wrist flexion and forearm pronation, range of motion and valgus stability of the left elbow had recovered. One year after the injury, radiographs showed atrophy and sclerosis of the medial epicondylar apophysis. In this type of injury, revascularization of medial epicondyle fracture is not essential for recovery of elbow function when reattachment of the medial collateral ligament and flexor-pronator muscle origin to the distal medial humerus successfully restores stability of the elbow joint. © 2017
1. Introduction In the pediatric population, fractures involving the medial epicondyle of the humerus constitute 11%–20% of all elbow fractures.1 Medial epicondyle fractures mainly occur in children between 9 and 14 years of age. This type of fracture is commonly caused by avulsion of the medial epicondyle by the flexor and pronator muscles of the forearm or the medial collateral ligament associated with elbow dislocation. A direct blow to the medial elbow can lead to medial epicondyle fracture; however, few authors have reported direct injuries.2 We identified a case of the medial epiondyle physeal fracture, which has been caused by a direct blow on the medial aspect of the elbow, accompanied with complete stripping of soft tissue including the flexor and pronator muscles origin, medial collateral ligament and periosteum. The purpose of this report is to demonstrate our unusual case and discuss surgical management for this type of injury. 2. Case report An 11-year-old right-handed healthy boy tried to vault over a horse during a physical education class at an elementary school. The student lost his balance in the air and fell to the floor on his left elbow. He was referred to our hospital for evaluation of left elbow pain. Radiographs showed a Salter-Harris type II physeal fracture of
* Corresponding author at: Department of Orthopedic Surgery, Hokkaido Saiseikai Otaru Hospital, Otaru, 047-0008, Japan. E-mail address: [email protected] (T. Oda).
the medial epicondyle of the left humerus (Fig. 1). The fragment was greatly displaced proximally and posteriorly. Computed tomography and sonography did not show any other fractures of the distal humerus, proximal ulna and radius or triceps tendon rupture. Dysfunction of the ulnar nerve was not detected. Surgery was performed for open reduction and internal fixation of the medial epicondyle and for exploration and repair of the associated soft tissue injury. Under general anesthesia, valgus instability of the left elbow compared with the contralateral elbow was found. At surgery, a fragment was found in subcutaneous space proximal and posterior to the anatomical position of the medial epicondyle. The medial epicondyle fragment was completely stripped of muscles, ligaments and even the periosteum (Fig. 2). An osseous segment on the growth plate of the fragment served as a mark to reduce the fragment accurately on the distal medial humerus. The fragment was secured to the base of the epicondylar defect with 1.2 mm Kirschner wires and 0.7 mm suture wire following the conventional tension band wiring procedure (Fig. 3). The anterior oblique bundle of medial collateral ligament and flexor muscle origin were reattached to the medial epicondyle with non-absorbable sutures stitched to wires. The ulnar nerve was exposed with release of the articular ligament, protected during the surgery and returned without anterior transposition before wound closure. After immobilization in a long arm splint for 3 weeks, active range of motion exercises of the elbow were initiated. A cock-up splint was applied to the left wrist for two weeks to protect reattachment of flexors muscle origin. Three months later, all wires were removed under general anesthesia. Intraoperative findings showed that the flexor muscle
http://dx.doi.org/10.1016/j.jcot.2017.01.008 0976-5662/© 2017
Please cite this article in press as: T. Oda, K. Watanabe, Bare medial epicondyle physeal fracture of the humerus: A case report, J Clin Orthop Trauma (2017), http://dx.doi.org/10.1016/j.jcot.2017.01.008
G Model JCOT 352 No. of Pages 3
2
T. Oda, K. Watanabe / Journal of Clinical Orthopaedics and Trauma xxx (2016) xxx–xxx
Fig. 2. Surgical view of the left elbow. The elbow joint is in flexion. The medial epicondyle, which is picked up, is stripped of soft tissue. Flexor muscle origin was torn (arrow). Left side of the wound in the photograph corresponds to proximal part of the elbow.
the medial epicondyle (Fig. 4). The patient and his parents were informed that data concerning the case would be submitted for publication and agreed to this. 3. Discussion Medial epicondyle fracture is commonly caused by avulsion of the medial epicondyle by the flexor and pronator muscles of the
Fig. 1. Preoperative radiographs of the left elbow (A, posteroanterior view; B, lateral view). The medial epicondylar fragment is displaced proximally and posteriorly.
origin was united to the medial epicondyle. Six months after internal fixation of the medial epicondyle, range of motion of the left elbow and strength of wrist flexion and forearm pronation had recovered to those of the contralateral side. Gravity stress radiographs of the bilateral elbow joints showed no evidence of functional insufficiency of the left medial collateral ligament. One year after the injury, radiographs showed atrophy and sclerosis of the medial epicondylar apophysis, suggesting avascular necrosis of Fig. 3. Postoperative radiograph of the left elbow.
Please cite this article in press as: T. Oda, K. Watanabe, Bare medial epicondyle physeal fracture of the humerus: A case report, J Clin Orthop Trauma (2017), http://dx.doi.org/10.1016/j.jcot.2017.01.008
G Model JCOT 352 No. of Pages 3
T. Oda, K. Watanabe / Journal of Clinical Orthopaedics and Trauma xxx (2016) xxx–xxx
3
and ulnar nerve impairment.6 They concluded that a fractured epicondyle should not be excised even in cases with a comminuted fracture or an old fracture. It is desirable to perform osteosynthesis in order to avoid underdevelopment of the medial aspect of the elbow if the epicondyle is normal and not crushed, especially in children less than ten years of the age.5 We tried osteosynthesis of sripped fragment and reattachment of both the anterior oblique bundle of the medial collateral ligament and flexor-pronator muscle origin. As shown by radiographs at final follow-up, this procedure will finally fail to revascularize the medial epicondyle and will lead to necrosis of the osteochondral fragment. On the other hand, the surgery resulted in recovery of elbow range of motion, valgus stability and wrist flexor strength. The result suggested that firmly placing the ligament and muscles on the medial distal humerus are sufficient for functional recovery of the elbow and wrist regardless of revascularization and union of the medial epicondyle after this type of injury. Glichrist and McKee reported one adolescence and four adults that who underwent excision of the medial epicondyle and fixation of the medial collateral ligament to the distal humerus with a suture anchor for valgus instability of the elbow due to medial epicondyle nonunion.7 All patients were satisfied with the increased stability provided by the procedure after an average of 21.6 months. Even in our 11-year-old patient, excision of the medial epicondyle combined with reattachment of the medial collateral ligament and flexor muscle origin to the epicondylar defect with a suture anchor could lead to recovery of elbow and wrist function. In such a case, simple excision would be better than osteosynthesis not only to avoid the necessity of hardware removal but also to enable early return to daily school life and sports activity. Fig. 4. Radiograph of the left elbow one year after osteosynthesis. Sclerosis and fragmentation of the medial epicondyle had occurred.
forearm or the medial collateral ligament associated with elbow dislocation. Few cases of medial epicondyle fracture due to direct trauma have been reported since Watson-Jones described 36 cases of direct injuries in 1930.2,3 The medial epicondyle fragment produced by a direct blow to the medial aspect of the elbow joint is often fragmented. We experienced unusual case of physeal fracture of the medial humeral epicondyle, which was caused by a direct force to the anterior medial aspect of the left elbow and accompanied by displacement of the fragment completely stripped of soft tissue. Surgical management for medial epicondyle fractures remains controversial with regard to degree of fracture displacement. A need for medial stability for valgus instability of the elbow has been accepted as an indication for surgical intervention.1,2 In the present case, surgical intervention was necessary to reestablish medial stability of the elbow joint because rupture of the medial collateral ligament and flexor muscles from the medial epicondyle led to gross valgus instability. The available surgical procedure was reattachment of the medial ligament as well as flexor muscle origin combined with either osteosynthesis or excision of the medial epicondyle fragment. Physeal fracture and detachment of soft tissue would interrupt blood supply to the medial epicondyle fragment and could cause osteonecrosis. Some authors recommended excision of the medial epicondyle for patients with comminution of the fragment, old fractures and risk of osteonecrosis.2,4,5 However, the result of excising the medial epicondyle for an acute fracture remains unclear. Farsetti et al. studied long-term results of treatment of fractures of the medial epicondyle in children. The authors reported that all six cases in which medial epicondyle excision and suturing of the medial collateral ligament and flexor origin to the adjacent periosteum were performed had poor or fair results because of elbow pain, limited range of motion
Conflict of interest The authors have none to declare. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Acknowledgements The authors are grateful to Dr. Mikio Muraoka, Vice President, Kameda Daiichi Hospital, Dr. Kunihiko Tokunaga, Director in Niigata Hip Surgery Center, and Dr. Koshiro Imai, Chief in the Department of Orthopedic Surgery, Kameda Daiichi Hospital for their help treating this unusual case and preparing this article. References 1. Gilchrist AD, McKee MD. Valgus instability of the elbow due to medial epicondyle nonunion: treatment by fragment excision and ligament repair a report of 5 cases. J Shoulder Elbow Surg. 2002;11:493–497. 2. Beaty JH, Kasser JR. The elbow: physeal fractures, apophyseal injuries of the distal humerus. Osteonecrosis of the trochlea, and T-condylar fractures. In: Beaty JH, Kasser JR, eds. Fractures in Children. 6th ed. Lippincott Williams & Wilkins; 2006:60–591. 3. Watson-Jones R, Orth MC. Primary nerve lesions in injuries of the elbow and wrist. J Bone Joint Surg Am. 1930;12:121–140. 4. Aiten AP, Childress HM. Intra-articular displacement of the internal epicondyle following dislocation. J Bone Joint Surg Am. 1938;20:161–166. 5. Tachidjian MO. Pediatric Orthopaedics. WB Saunders; 1972:1597–1604. 6. Fasteri P, Potenza V, Caterini R, Ippolito E. Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am. 2001;83:1299–1305. 7. Gottschalk HP, Einsner E, Hosalkar HS. Medial epicondyle fractures in the pediatric population. J Am Acad Orthop Surg. 2012;20:223–232.
Please cite this article in press as: T. Oda, K. Watanabe, Bare medial epicondyle physeal fracture of the humerus: A case report, J Clin Orthop Trauma (2017), http://dx.doi.org/10.1016/j.jcot.2017.01.008
Journal of Clinical Orthopaedics and Trauma xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Orthopaedics and Trauma journal homepage: www.elsevier.com/locate/jcot
Case report
Bare medial epicondyle physeal fracture of the humerus: A case report Takashi Oda* , Kenji Watanabe Department of Orthopedic Surgery, Kameda Daiichi Hospital, Nishimach 2-5-22, Konan-ku Niigata, 950-0165, Japan
A R T I C L E I N F O
Article history: Received 11 December 2016 Received in revised form 19 January 2017 Accepted 19 January 2017 Available online xxx Keywords: Elbow instability Medial elbow injury Medial epicondyle fracture Osteonecrosis Physeal fracture
A B S T R A C T
We identified an unusual case of the medial epiondyle physeal fracture, which has been caused by a direct blow, accompanied with complete stripping of soft tissue. Surgery was performed for open reduction and internal fixation of the medial epicondyle and reattachment of the anterior oblique bundle of medial collateral ligament and flexor muscle origin. Six months after the surgery, strength of wrist flexion and forearm pronation, range of motion and valgus stability of the left elbow had recovered. One year after the injury, radiographs showed atrophy and sclerosis of the medial epicondylar apophysis. In this type of injury, revascularization of medial epicondyle fracture is not essential for recovery of elbow function when reattachment of the medial collateral ligament and flexor-pronator muscle origin to the distal medial humerus successfully restores stability of the elbow joint. © 2017
1. Introduction In the pediatric population, fractures involving the medial epicondyle of the humerus constitute 11%–20% of all elbow fractures.1 Medial epicondyle fractures mainly occur in children between 9 and 14 years of age. This type of fracture is commonly caused by avulsion of the medial epicondyle by the flexor and pronator muscles of the forearm or the medial collateral ligament associated with elbow dislocation. A direct blow to the medial elbow can lead to medial epicondyle fracture; however, few authors have reported direct injuries.2 We identified a case of the medial epiondyle physeal fracture, which has been caused by a direct blow on the medial aspect of the elbow, accompanied with complete stripping of soft tissue including the flexor and pronator muscles origin, medial collateral ligament and periosteum. The purpose of this report is to demonstrate our unusual case and discuss surgical management for this type of injury. 2. Case report An 11-year-old right-handed healthy boy tried to vault over a horse during a physical education class at an elementary school. The student lost his balance in the air and fell to the floor on his left elbow. He was referred to our hospital for evaluation of left elbow pain. Radiographs showed a Salter-Harris type II physeal fracture of
* Corresponding author at: Department of Orthopedic Surgery, Hokkaido Saiseikai Otaru Hospital, Otaru, 047-0008, Japan. E-mail address: [email protected] (T. Oda).
the medial epicondyle of the left humerus (Fig. 1). The fragment was greatly displaced proximally and posteriorly. Computed tomography and sonography did not show any other fractures of the distal humerus, proximal ulna and radius or triceps tendon rupture. Dysfunction of the ulnar nerve was not detected. Surgery was performed for open reduction and internal fixation of the medial epicondyle and for exploration and repair of the associated soft tissue injury. Under general anesthesia, valgus instability of the left elbow compared with the contralateral elbow was found. At surgery, a fragment was found in subcutaneous space proximal and posterior to the anatomical position of the medial epicondyle. The medial epicondyle fragment was completely stripped of muscles, ligaments and even the periosteum (Fig. 2). An osseous segment on the growth plate of the fragment served as a mark to reduce the fragment accurately on the distal medial humerus. The fragment was secured to the base of the epicondylar defect with 1.2 mm Kirschner wires and 0.7 mm suture wire following the conventional tension band wiring procedure (Fig. 3). The anterior oblique bundle of medial collateral ligament and flexor muscle origin were reattached to the medial epicondyle with non-absorbable sutures stitched to wires. The ulnar nerve was exposed with release of the articular ligament, protected during the surgery and returned without anterior transposition before wound closure. After immobilization in a long arm splint for 3 weeks, active range of motion exercises of the elbow were initiated. A cock-up splint was applied to the left wrist for two weeks to protect reattachment of flexors muscle origin. Three months later, all wires were removed under general anesthesia. Intraoperative findings showed that the flexor muscle
http://dx.doi.org/10.1016/j.jcot.2017.01.008 0976-5662/© 2017
Please cite this article in press as: T. Oda, K. Watanabe, Bare medial epicondyle physeal fracture of the humerus: A case report, J Clin Orthop Trauma (2017), http://dx.doi.org/10.1016/j.jcot.2017.01.008
G Model JCOT 352 No. of Pages 3
2
T. Oda, K. Watanabe / Journal of Clinical Orthopaedics and Trauma xxx (2016) xxx–xxx
Fig. 2. Surgical view of the left elbow. The elbow joint is in flexion. The medial epicondyle, which is picked up, is stripped of soft tissue. Flexor muscle origin was torn (arrow). Left side of the wound in the photograph corresponds to proximal part of the elbow.
the medial epicondyle (Fig. 4). The patient and his parents were informed that data concerning the case would be submitted for publication and agreed to this. 3. Discussion Medial epicondyle fracture is commonly caused by avulsion of the medial epicondyle by the flexor and pronator muscles of the
Fig. 1. Preoperative radiographs of the left elbow (A, posteroanterior view; B, lateral view). The medial epicondylar fragment is displaced proximally and posteriorly.
origin was united to the medial epicondyle. Six months after internal fixation of the medial epicondyle, range of motion of the left elbow and strength of wrist flexion and forearm pronation had recovered to those of the contralateral side. Gravity stress radiographs of the bilateral elbow joints showed no evidence of functional insufficiency of the left medial collateral ligament. One year after the injury, radiographs showed atrophy and sclerosis of the medial epicondylar apophysis, suggesting avascular necrosis of Fig. 3. Postoperative radiograph of the left elbow.
Please cite this article in press as: T. Oda, K. Watanabe, Bare medial epicondyle physeal fracture of the humerus: A case report, J Clin Orthop Trauma (2017), http://dx.doi.org/10.1016/j.jcot.2017.01.008
G Model JCOT 352 No. of Pages 3
T. Oda, K. Watanabe / Journal of Clinical Orthopaedics and Trauma xxx (2016) xxx–xxx
3
and ulnar nerve impairment.6 They concluded that a fractured epicondyle should not be excised even in cases with a comminuted fracture or an old fracture. It is desirable to perform osteosynthesis in order to avoid underdevelopment of the medial aspect of the elbow if the epicondyle is normal and not crushed, especially in children less than ten years of the age.5 We tried osteosynthesis of sripped fragment and reattachment of both the anterior oblique bundle of the medial collateral ligament and flexor-pronator muscle origin. As shown by radiographs at final follow-up, this procedure will finally fail to revascularize the medial epicondyle and will lead to necrosis of the osteochondral fragment. On the other hand, the surgery resulted in recovery of elbow range of motion, valgus stability and wrist flexor strength. The result suggested that firmly placing the ligament and muscles on the medial distal humerus are sufficient for functional recovery of the elbow and wrist regardless of revascularization and union of the medial epicondyle after this type of injury. Glichrist and McKee reported one adolescence and four adults that who underwent excision of the medial epicondyle and fixation of the medial collateral ligament to the distal humerus with a suture anchor for valgus instability of the elbow due to medial epicondyle nonunion.7 All patients were satisfied with the increased stability provided by the procedure after an average of 21.6 months. Even in our 11-year-old patient, excision of the medial epicondyle combined with reattachment of the medial collateral ligament and flexor muscle origin to the epicondylar defect with a suture anchor could lead to recovery of elbow and wrist function. In such a case, simple excision would be better than osteosynthesis not only to avoid the necessity of hardware removal but also to enable early return to daily school life and sports activity. Fig. 4. Radiograph of the left elbow one year after osteosynthesis. Sclerosis and fragmentation of the medial epicondyle had occurred.
forearm or the medial collateral ligament associated with elbow dislocation. Few cases of medial epicondyle fracture due to direct trauma have been reported since Watson-Jones described 36 cases of direct injuries in 1930.2,3 The medial epicondyle fragment produced by a direct blow to the medial aspect of the elbow joint is often fragmented. We experienced unusual case of physeal fracture of the medial humeral epicondyle, which was caused by a direct force to the anterior medial aspect of the left elbow and accompanied by displacement of the fragment completely stripped of soft tissue. Surgical management for medial epicondyle fractures remains controversial with regard to degree of fracture displacement. A need for medial stability for valgus instability of the elbow has been accepted as an indication for surgical intervention.1,2 In the present case, surgical intervention was necessary to reestablish medial stability of the elbow joint because rupture of the medial collateral ligament and flexor muscles from the medial epicondyle led to gross valgus instability. The available surgical procedure was reattachment of the medial ligament as well as flexor muscle origin combined with either osteosynthesis or excision of the medial epicondyle fragment. Physeal fracture and detachment of soft tissue would interrupt blood supply to the medial epicondyle fragment and could cause osteonecrosis. Some authors recommended excision of the medial epicondyle for patients with comminution of the fragment, old fractures and risk of osteonecrosis.2,4,5 However, the result of excising the medial epicondyle for an acute fracture remains unclear. Farsetti et al. studied long-term results of treatment of fractures of the medial epicondyle in children. The authors reported that all six cases in which medial epicondyle excision and suturing of the medial collateral ligament and flexor origin to the adjacent periosteum were performed had poor or fair results because of elbow pain, limited range of motion
Conflict of interest The authors have none to declare. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Acknowledgements The authors are grateful to Dr. Mikio Muraoka, Vice President, Kameda Daiichi Hospital, Dr. Kunihiko Tokunaga, Director in Niigata Hip Surgery Center, and Dr. Koshiro Imai, Chief in the Department of Orthopedic Surgery, Kameda Daiichi Hospital for their help treating this unusual case and preparing this article. References 1. Gilchrist AD, McKee MD. Valgus instability of the elbow due to medial epicondyle nonunion: treatment by fragment excision and ligament repair a report of 5 cases. J Shoulder Elbow Surg. 2002;11:493–497. 2. Beaty JH, Kasser JR. The elbow: physeal fractures, apophyseal injuries of the distal humerus. Osteonecrosis of the trochlea, and T-condylar fractures. In: Beaty JH, Kasser JR, eds. Fractures in Children. 6th ed. Lippincott Williams & Wilkins; 2006:60–591. 3. Watson-Jones R, Orth MC. Primary nerve lesions in injuries of the elbow and wrist. J Bone Joint Surg Am. 1930;12:121–140. 4. Aiten AP, Childress HM. Intra-articular displacement of the internal epicondyle following dislocation. J Bone Joint Surg Am. 1938;20:161–166. 5. Tachidjian MO. Pediatric Orthopaedics. WB Saunders; 1972:1597–1604. 6. Fasteri P, Potenza V, Caterini R, Ippolito E. Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am. 2001;83:1299–1305. 7. Gottschalk HP, Einsner E, Hosalkar HS. Medial epicondyle fractures in the pediatric population. J Am Acad Orthop Surg. 2012;20:223–232.
Please cite this article in press as: T. Oda, K. Watanabe, Bare medial epicondyle physeal fracture of the humerus: A case report, J Clin Orthop Trauma (2017), http://dx.doi.org/10.1016/j.jcot.2017.01.008