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A Pediatric Medial Epicondyle Fracture Cadaveric Study Comparing Standard AP Radiographic View With the Distal Humerus Axial View

Cao, Jue, MD*; Smetana, Brandon S., MD*; Carry, Patrick, MS; Peck, Kathryn M., MD*; Merrell, Gregory A., MD

Journal of Pediatric Orthopaedics: March 2019 - Volume 39 - Issue 3 - p e205–e209
doi: 10.1097/BPO.0000000000001274

Background: Controversy exists with regard to the amount of fracture displacement that warrants surgical fixation of medial epicondyle fractures. Inaccurate determination of degree of displacement on plain radiographs may account for the disputed management. Recently, a novel distal humerus axial radiograph technique has been developed to improve the accuracy of radiographs. The purposes of the study are 2-fold; to identify the anatomic orientation of the medial elbow epicondyle physis in children and to compare the accuracy of determining fracture displacement between axial radiographs and standard anterior-posterior (AP) radiographs in a cadaveric medial epicondyle fracture model.

Methods: Twelve pediatric elbow computed tomographic scans and 19 pediatric elbow magnetic resonance imaging scans were analyzed for the orientation of the medial elbow physis. After determining the correct orientation, 15 adult cadaveric medial epicondyle fracture models were created at displacements of 2, 5, 10 mm, and maximum displacement with elbow at 90 degrees of flexion. A linear mixed model regression analysis was used to compare displacement based on the axial versus the AP radiographic methods.

Results: The medial epicondyle physis was found to be a posterior structure angled distally at ~36 degrees (range, 10.7 to 49.6) and angled posteriorly at 45 degrees (range, 32.2 to 59). The AP radiograph significantly underestimated displacement relative to the axial radiograph at 5 mm [mean difference, −1.6; 95% confidence interval (CI), −2.9 to −0.3], at 10 mm (mean difference, −4.5; 95% CI, −5.8 to −3.2 mm), and at maximal displacement (mean, 15 mm; range, 13 to 20 mm) (mean difference, −7.1; 95% CI, −8.3 to −5.8).

Conclusions: The medial epicondyle physis of the distal humerus is a posterior structure angled distally and posteriorly. When displacement was >5 mm, the distal humerus axial radiograph technique was significantly more accurate than the AP radiograph technique at determining actual fracture displacement in our adult cadaveric fracture models. Therefore, we recommend clinicians to include the axial radiograph view during the evaluation of patients with medial epicondyle fractures.

Clinical Relevance: This study provides further insight into the location and orientation of the medial humeral epicondyle physis, and further supports the improved accuracy of the distal humerus axial radiograph at detecting displacement in medial epicondyle fractures.

*Indiana Hand to Shoulder Center, Indianapolis, IN

Children’s Hospital Colorado, Aurora, CO

The authors did not receive any source of funding for this study.

The authors declare no conflicts of interest.

Reprints: Jue Cao, MD, 8501 Harcourt Road, Indianapolis, IN 46260. E-mail:

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