Medial epicondyle fractures are common in children, accounting for 10% to 20% of pediatric elbow fractures, with a peak age between 11 and 12 years. The mechanism of injury is usually a valgus elbow force produced by a fall on the outstretched hand or by overhead throwing.3,4 The medial epicondyle is typically avulsed distally by the flexor pronator mass and medial collateral ligament. Concomitant elbow dislocation is common (50% to 60% of cases), and approximately 20% of these involve incarceration of the fractured fragment within the elbow joint.5,6 This requires meticulous assessment of the injury radiographs to look for any subtle joint gapping that could indicate an incarcerated fragment.7,8
Treatment of medial epicondyle fracture in children remains controversial. For fragments displaced less than 1 cm on the radiograph, management has traditionally been nonsurgical, consisting of immobilization followed by gradual resumption of activity. However, recent work by Edmonds9 indicates that standard radiographs are neither sufficient nor accurate enough to measure true displacement of medial epicondyle fractures. The absolute indication for surgical treatment is an entrapped intra-articular apophyseal fragment. Otherwise, current literature does not offer a consensus as to the exact indications that warrant surgical intervention versus nonsurgical management, because excellent outcomes have been demonstrated in both, even when the fragment heals with a fibrous union.3,10,11 However, surgery has been recommended in patients who place a high demand on the elbow during athletic activities or those who present with ulnar nerve symptoms.6,8,12 A systematic review by Kamath et al showed a 92.5% rate of bony union in surgical versus 49.2% in nonsurgical treatments at the final follow-up. The odds of bony union were 9.33 times increased with surgical fixation versus nonsurgical treatment, and no notable difference was observed in pain or ulnar nerve symptoms at the final follow-ups ranging from 6 to 216 months.
Up to 90% of medial epicondyle fractures treated with conservative measures result in nonunion.1,11 However, only 21% become symptomatic, presenting with pain, weakness, decreased range of motion, joint instability, or ulnar nerve paresthesia.10 Few reported cases of symptomatic nonunion exist, but they are more common in high-demand individuals such as athletes who are at higher risk of reinjury after initial conservative treatment.13
For symptomatic nonunions, both fragment excision and fixation have been advocated. Gilchrist and McKee14 performed excision of the medial epicondyle with advancement and fixation of the ulnar collateral ligament. All five patients reported increased stability and satisfaction at an average of 10 years after injury. However, a long-term retrospective study by Farsetti et al found fragment excision to be inferior to open reduction and internal fixation.12 Others have assessed open reduction and internal fixation, with all patients returning to sport and reporting notable improvements in pain and stability.10 In this case, late repair after failed conservative measures was likely a contributing factor to the extensive perineural scar tissue encountered during dissection. In most cases, adequate exposure will likely require circumferential mobilization of the ulnar nerve to facilitate exposure. Careful assessment of the nerve stability after fracture fixation should be performed to determine whether a transposition should be performed. In the above case, the authors thought that because of the extensive ulnar nerve dissection required to facilitate exposure, in conjunction with the patients' preoperative history, she would benefit from an ulnar nerve transposition. Nonabsorbable suture or Kirschner wires may be used to augment a cannulated screw, or in place of it if the fragment is very small or comminuted. Supplemental bone grafting is usually unnecessary but may be considered when there is inadequate cortical contact or bone loss. Ulnar nerve decompression is recommended when patients present preoperatively with ulnar nerve compression symptoms, and subcutaneous transposition should be considered when there is clear ulnar nerve instability after fragment fixation or to avoid impingement by the screw.6,12,15-17 When a screw is used, a washer helps avoid fragment comminution or screw migration.16
In one similar case, a 14-year-old male patient had a history of medial epicondyle fracture that was initially treated conservatively. A radiograph-proven nonunion remained asymptomatic until a second trauma 2 years later. Open reduction and screw fixation was performed along with ulnar nerve transposition, and the patient returned to sport without any report three months later.13 A retrospective analysis of 14 cases of symptomatic medial epicondylar nonunion treated with open reduction and internal fixation found excellent results. The mean age at presentation was 14.9 years, although it ranged from 6 to 50 years. At a mean of 3 years after surgery, patients reported statistically notable reduction in pain and improved mobility. Radiographic union was achieved in all but one patient.18
To conclude, medial epicondyle fracture nonunions are common but rarely become symptomatic. Highly active athletes such as the case presented here are more likely to endure a secondary injury, which precipitates symptoms. In this case, open reduction and internal fixation with one fully-threaded screw accompanied by ulnar nerve transposition achieved an excellent outcome and high patient satisfaction.
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