JBJS | Long-Term Results of Treatment of Fractures of the Medial Humeral Epicondyle in Children

The Journal of Bone & Joint Surgery, Volume 83, Issue 9

Scientific Articles | September 01, 2001

Long-Term Results of Treatment of Fractures of the Medial Humeral Epicondyle in Children

P. Farsetti, MD; V. Potenza, MD; R. Caterini, MD; E. Ippolito, MD

Investigation performed at the Department of Orthopaedic Surgery, University of Rome "La Sapienza," Rome, Italy
P. Farsetti, MD
R. Caterini, MD
Department of Orthopaedic Surgery, University of Rome "Tor Vergata," Via di Tor Vergata, 135 00133 Rome, Italy. E-mail address for P. Farsetti: farsetti@uniroma2.it

V. Potenza, MD
Department of Orthopaedic Surgery, University of Rome "La Sapienza," Piazza A. Moro, 5 00185 Rome, Italy

E. Ippolito, MD
IRCCS Santa Lucia Institute, Via Ardeatina, 306 00179 Rome, Italy

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

The Journal of Bone & Joint Surgery. 2001; 83:1299-1305

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Abstract

Background: The treatment of isolated, displaced fractures of the medial humeral epicondyle in children is controversial. Both plaster cast immobilization without reduction and open reduction and internal fixation have been advocated. The purpose of this long-term retrospective study was to analyze the functional and radiographic results of both nonsurgical and surgical management of these injuries.

Methods: Forty-two patients who had had an isolated fracture of the medial humeral epicondyle with displacement of >5 mm at an average age of twelve years (range, eight to fifteen years) were evaluated at an average age of forty-five years (range, thirty to sixty-one years). The patients were divided into three groups that were comparable with regard to the amount of fracture displacement, age at the time of the fracture, age at the time of follow-up, sports activities and occupation, and duration of follow-up. In Group I (nineteen patients), the fracture had been treated with a long-arm plaster cast without reduction of the displaced medial epicondyle. In Group II (seventeen patients), open reduction and internal fixation with either Kirschner wires or a T-nail had been performed. In Group III (six patients), the epicondylar fragment had been excised with suture reattachment of the tendons and the medial collateral ligament.

Results: According to a functional grading scale, there were sixteen good and three fair results in Group I. All but two patients were seen to have nonunion of the fragment on follow-up radiographs, but all had a normal result on valgus stress-testing of the elbow. The range of motion of the elbow was either normal or minimally decreased, and the grip strength of the ipsilateral hand was normal. There were fifteen good and two fair results in Group II. All patients had union of the medial epicondyle, with various radiographic deformities of the medial epicondyle, but the functional results were similar to those of the Group-I patients. The Group-III patients had four poor and two fair results. Four had constant pain at the elbow and paresthesias in the distribution of the ulnar nerve. One patient had a restricted range of motion of the elbow, four patients had an unstable elbow, and three patients had decreased grip strength of the ipsilateral hand.

Conclusions: In our study, nonsurgical treatment of isolated fractures of the medial humeral epicondyle with between 5 and 15 mm of displacement yielded good long-term results similar to those obtained with open reduction and internal fixation. The nonunion of the epicondylar fragment that was present in most patients who had been treated only with a cast did not adversely affect the functional results. Surgical excision of the medial epicondylar fragment should be avoided because the long-term results are poor.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Fractures of the medial humeral epicondyle are relatively common in children, accounting for 12% of all elbow fractures that occur during skeletal growth¹.

There is a consensus that fractures displaced <2 mm should be treated nonsurgically^1-3. Numerous investigators have recommended open reduction and internal fixation when the epicondyle is displaced >2 mm^4-7, but other authors have reported that nonsurgical treatment yields results that are similar to or better than those of surgical treatment^8-10. Open reduction and internal fixation of the epicondylar fragment is clearly indicated when the epicondylar fragment is displaced into the elbow joint, when ulnar nerve entrapment is suspected, or when the elbow is markedly unstable^4,11-15. Excision of the fractured epicondyle has been recommended for patients with comminution of the fragment as well as for fractures undergoing delayed treatment^4,11,16,17.

A literature search for studies of the functional results in adulthood following any type of treatment of fractures of the medial humeral epicondyle in childhood yielded only a study on nonsurgical treatment, by Josefsson and Danielsson⁹. The purpose of the present study was to analyze the long-term results of both nonsurgical and surgical treatment of isolated fractures of the medial humeral epicondyle with >5 mm of displacement.

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Fig. 1-A:: Fig. 1-A Fracture of the right medial humeral epicondyle with marked displacement in a twelve-year-old boy, treated with cast immobilization only. Fig. 1-B Thirty-nine years after the injury, the patient had a full range of motion of the elbow, despite nonunion of the medial humeral epicondyle. The carrying angle of the affected elbow measured 15°. The final result was rated as good.

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Fig. 1-B:: Fig. 1-A Fracture of the right medial humeral epicondyle with marked displacement in a twelve-year-old boy, treated with cast immobilization only. Fig. 1-B Thirty-nine years after the injury, the patient had a full range of motion of the elbow, despite nonunion of the medial humeral epicondyle. The carrying angle of the affected elbow measured 15°. The final result was rated as good.

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Fig. 2-A:: Displaced fracture of the right medial humeral epicondyle in a ten-year-old girl, treated with open reduction and internal fixation.

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Fig. 2-B:: Displaced fracture of the right medial humeral epicondyle in a ten-year-old girl, treated with open reduction and internal fixation.

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Fig. 2-C:: At thirty years postoperatively, the fracture had healed. The radiograph shows an ulnar sulcus deformity on the medial aspect of the distal part of the humerus (arrow). The final result was rated as good.

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Fig. 3-A:: Fig. 3-A Anteroposterior radiograph of a fracture of the left medial humeral epicondyle in an eight-year-old boy. Fig. 3-B Two months after excision of the epicondylar fragment.

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Fig. 3-B:: Fig. 3-A Anteroposterior radiograph of a fracture of the left medial humeral epicondyle in an eight-year-old boy. Fig. 3-B Two months after excision of the epicondylar fragment.

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Fig. 3-C:: At thirty-four years postoperatively, radiographs showed hypoplasia of the medial aspect of the distal part of the humerus and osteoarthritis of the elbow, with a small osseous fragment lying near the lateral humeral epicondyle. The patient reported pain in the elbow with paresthesias along the ulnar side of the hand. The valgus stress test was moderately positive, and the grip strength was weaker than that of the contralateral hand. The final result was rated as poor.

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Fig. 3-D:: At thirty-four years postoperatively, radiographs showed hypoplasia of the medial aspect of the distal part of the humerus and osteoarthritis of the elbow, with a small osseous fragment lying near the lateral humeral epicondyle. The patient reported pain in the elbow with paresthesias along the ulnar side of the hand. The valgus stress test was moderately positive, and the grip strength was weaker than that of the contralateral hand. The final result was rated as poor.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Two hundred and twenty-four children who had had a fracture of the medial humeral epicondyle were treated between 1950 and 1980 at the Department of Orthopaedic Surgery of the University of Rome "La Sapienza." One hundred and twenty patients were excluded for one or more of the following reasons: the medial epicondyle was displaced <5 mm, the fragment was entrapped in the humeroulnar joint, the fracture was associated with an ipsilateral elbow dislocation, or the neurologic examination suggested an ulnar nerve injury or entrapment. We also excluded patients with a history of previous elbow injury, although some patients who had had an elbow dislocation that had spontaneously reduced prior to presentation may have been included in the study. An attempt was made to contact the remaining 104 patients by mail, and they were asked to return to our hospital for both clinical and radiographic evaluation. Fifty-four patients were located, and forty-two agreed to return for the radiographic and clinical examination. Institutional review board approval for this retrospective study was obtained. Twelve patients, including seven treated nonsurgically and five managed with open reduction and internal fixation, declined to participate in the study because they considered the follow-up to be useless given the absence of any symptoms that might be related to the epicondylar fracture. Of the forty-two patients included in the study, twenty-seven were male and fifteen were female. The right elbow was involved in twenty-three patients and the left, in nineteen. The age at the time of injury ranged from eight to fifteen years (average, twelve years). All injuries were due to a fall on the outstretched hand.

We divided our forty-two patients into three groups, according to the treatment that they had received. Group I included nineteen patients who had been treated nonsurgically with immobilization in a long-arm plaster cast, with the elbow flexed at 90°, for four weeks.

Group II included seventeen patients treated with open reduction and internal fixation of the fragment with either Kirschner wires or a T-nail. The T-nail is a 1.5-mm stainless-steel implant with a short arm (8 mm) that holds the epicondylar fragment and a long arm (25 to 50 mm) that anchors the fragment to the humeral epiphysis. Ulnar nerve transposition was never performed. After the surgery, a long-arm plaster cast was applied with the elbow at 90°. At three weeks after the surgery, both the Kirschner wires and the plaster cast were removed and active motion of the elbow was encouraged. The T-nail was not removed.

Group III included six patients who had been treated with excision of the osteocartilaginous fragment, with suture of the tendons and the medial collateral ligament to the adjacent periosteum. A long-arm plaster cast was applied with the elbow at 90° and was worn for four weeks, after which active elbow motion was started. In four of these six patients, the epicondyle had fragmented into small pieces during attempted open reduction and the surgeon decided to remove them. In the other two patients, the fractures were two and a half and three weeks old and the fragments were completely stripped of all soft-tissue attachments. The surgeons decided to remove the fragment because of the risk of osteonecrosis.

The displacement of the epicondylar fragment ranged from 5 to 15 mm (average, 10 mm) in Group I, from 5 to 14 mm (average, 10 mm) in Group II, and from 8 to 14 mm (average, 12 mm) in Group III.

At the time of long-term follow-up, a detailed clinical history was obtained and a complete physical examination was performed. The patients were asked about their usual jobs, sports activities, and hobbies. The range of motion of the elbow and forearm muscle atrophy were assessed. Forearm muscle girth was measured at 8 cm from the top of the lateral epicondyle. The stability of the elbow was evaluated with a manual valgus stress test at 15° of flexion¹⁸. We graded the test as negative, moderately positive, or markedly positive, and each patient was examined separately by each of the four authors. The final grade for stability was the average of the individual evaluations of the four authors. Grip strength of the ipsilateral and the contralateral hand was assessed with a Jamar dynamometer (Asimow Engineering, Los Angeles, California), set in the second position at 90° of elbow flexion. Anteroposterior and lateral radiographs of both elbows were made and were assessed for epicondylar nonunion and posttraumatic arthritis. Electromyography was performed in six patients who reported symptoms that were thought to be possibly related to ulnar nerve impairment.

The results were rated as good, fair, or poor. A result was considered good when the patient had no symptoms, either normal elbow motion or a loss of <10°, a negative valgus stress test of the elbow, either a normal circumference of the forearm muscles or atrophy of <1 cm, grip strength of the ipsilateral hand greater than or equal to that of the contralateral hand if the former was dominant and equal to or <3% weaker¹⁹ if it was not dominant, and no radiographic signs of osteoarthritis of the elbow. A result was rated as fair when one or more of the following factors was present: occasional pain and/or paresthesia under stress at the elbow or radiating along the ulnar nerve distribution, limitation of elbow motion ranging from 11° to 30°, a moderately positive valgus stress test of the elbow, atrophy of the forearm muscles of £2 cm, grip strength of the ipsilateral hand up to 10% weaker than that of the contralateral hand if the former was dominant and up to 20% weaker if it was not dominant, and mild radiographic signs of osteoarthritis of the elbow. A result was rated as poor when one or more of the following factors was present: intermittent or continuous pain at the elbow and/or ulnar paresthesia, limitation of elbow motion of >30°, a markedly positive valgus stress test of the elbow, atrophy of the forearm muscles of >2 cm, grip strength of the ipsilateral hand >10% weaker than that of the contralateral hand if the former was dominant and >20% weaker if it was not dominant, and radiographic signs of osteoarthritis of the elbow.

In the statistical analysis of our data, we used the chi-square test to correlate union of the epicondyle with the final result. A p value of <0.05 was considered significant.

Results

Introduction | Materials and Methods | Results | Discussion | References

At the follow-up evaluation, the average age of the forty-two patients was forty-five years (range, thirty to sixty-one years). The average duration of follow-up was thirty-four years (range, eighteen to forty-eight years). The groups were comparable with regard to the amount of fracture displacement, patient age at the time of the fracture and follow-up, level of sports activities, and job type (manual versus desk employment).

With the numbers available, we did not find a significant association between union of the epicondyle and the final result.

Patients Treated with Cast Immobilization Only (Group I)

According to our rating system, sixteen patients had a good result and three had a fair result. In all of the patients in this group, the valgus stress test was negative and the grip strength of the ipsilateral hand was normal. One patient had occasional mild pain under stress in the medial epicondylar area, and another patient reported numbness on the ulnar side of the hand and along the ring and little fingers. In this patient, the Tinel sign was positive and sensation was normal. Both patients also had limitation of elbow extension, of 5° and 10°. One of them had valgus deformity of the affected elbow, and the other had 1.5 cm of forearm atrophy. The third patient who had a fair result had mild osteoarthritis of both the humeroulnar and the humeroradial joint, although he was completely asymptomatic at the time of follow-up. He was fifty-two years old, and he had been working as a mason since the age of twenty.

All but two of the nineteen patients had nonunion of the medial humeral epicondyle (Figs. 1-A and 1-B). In one of the two patients with union, the epicondyle was elongated and deformed. This patient also had a valgus deformity of the elbow, with a carrying angle of 32°. Radiographs of two patients showed small calcifications located around the lateral humeral epicondyle, and radiographs of one patient showed calcification of the brachialis muscle.

Patients Treated with Open Reduction and Internal Fixation (Group II)

Of the seventeen patients treated with open reduction and internal fixation, fifteen had a good result and two had a fair result. One patient had occasional pain at the elbow under stress and one, occasional paresthesias on the medial side of the elbow and forearm. The latter had a positive Tinel sign and normal sensation, whereas the former had a 20° limitation of elbow extension. Another patient had a 5° limitation of elbow extension. No patient had elbow instability, atrophy of the forearm muscles, or decreased grip strength of the ipsilateral hand. Two patients had an unsightly surgical scar.

The fracture had united in all patients, although the epicondyle was always irregularly shaped. Five patients had a groove on the medial aspect of the distal part of the humerus (Figs. 2-A, 2-B, and 2-C). In three patients, the epicondyle was hypoplastic. No patient had radiographic signs of osteoarthritis of the elbow.

Patients Treated with Excision of the Epicondylar Fragment (Group III)

Of the six patients in this group, two had a fair result and four had a poor result. Four patients had constant pain at the elbow joint, with paresthesias along the medial border of the forearm as well as along the ulnar side of the hand. Two of these four patients had a frequent sensation that the elbow was unstable during work. Another patient had a 30° limitation of elbow extension. The valgus stress test of the elbow was markedly positive for two patients and moderately positive for two. Four patients had atrophy of the forearm muscles of 1 to 3.5 cm. In three patients, the grip strength of the ipsilateral hand was weaker than that of the contralateral hand. Electromyography showed ulnar nerve impairment in the four patients who reported pain and paresthesias along the medial side of both the forearm and the hand.

The radiographic examination (Figs. 3-A, 3-B, 3-C, and 3-D) showed severe hypoplasia of the medial aspect of the distal humeral epiphysis in all patients; two patients had osteoarthritis of the elbow and small calcifications near the lateral humeral epicondyle.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

To the best of our knowledge, only Josefsson and Danielsson⁹ have described the long-term outcome of fractures of the medial humeral epicondyle in children. Their study included fractures with displacement ranging from 1 to 15 mm that had been treated nonsurgically with immobilization in a plaster cast for three to five weeks. They concluded that although nonunion of the epicondylar fragment was present in 55% of their patients, whose ages at the time of follow-up ranged from twenty-one to forty-eight years, the functional results were good.

In our study, long-term outcomes were compared between patients treated surgically and those treated nonsurgically. Our study had several limitations. Although all fractures were apparently isolated, we do not know whether some patients had had an elbow dislocation that had spontaneously reduced. Also, the study population was small, with Group III including only six patients. In addition, we could not exclude the possibility of surgeon’s bias in the initial management of the fractures.

According to our rating system, sixteen of the nineteen Group-I patients had a good result. Our patients with a good score had either full or minimally restricted, pain-free motion of the elbow, which was stable on manual valgus stress-testing, as well as a normal ipsilateral grip strength. Nonunion of the medial epicondyle was found in all but two of our Group-I patients. In light of these results, we believe that nonunion of the medial epicondyle should no longer be considered a complication of nonsurgical treatment but rather should be thought of as an asymptomatic consequence of it, like ulnar styloid nonunion after a physeal injury of the wrist². A similar observation has been made by several other authors in their shorter-term reports^{8,10,12,20,21}.

Fifteen of the seventeen Group-II patients had good functional results, similar to those obtained in Group I, with the exception of an unsightly surgical scar in two patients who were graded as having a good result. While nonunion has previously been described in surgically treated patients^5,10,20,22, all of our Group-II patients had union of the medial epicondyle. However, all patients had deformity of the medial epicondyle, which was often hypertrophic, and many of them also had an "ulnar sulcus," as previously described by Skak et al.²¹.

Three patients in Group I and two in Group II had a fair result. One patient from each group reported occasional mild pain at the elbow, but we were not able to explain the cause of this pain. One patient in Group I and one in Group II had paresthesias in the distribution of the ulnar nerve. The Group-I patient was one of two with union of the fragment, and he also had a cubitus valgus deformity. We do not believe that the treatment itself contributed to nerve dysfunction, but we speculate that scarring consequent to the trauma and cubitus valgus in the Group-I patient and consequent to the surgery in the Group-II patient might have caused nerve irritation over a period of time.

Hines et al.⁶ and Skak et al.²¹ both reported varus and valgus deformities of the elbow following this fracture, but we agree with van Niekerk and Severijnen²³, who postulated that the medial humeral epicondyle is an apophysis and a fracture of this apophysis cannot have any direct influence on the growth mechanism of the distal part of the humerus. Therefore, we believe that in our patient with cubitus valgus the deformity might have been caused by damage to the distal physeal plate of the humerus produced by the original injury, as occurs in a Salter-Harris type-V injury. On the basis of our long-term evaluation, we concluded that the overall results in both Group I and Group II were good.

Fowles et al.¹⁶ reported good results in three patients who had had excision of the epicondyle for the treatment of an old fracture with entrapment of the fragment in the elbow joint, which was almost ankylosed at the time of surgery. After surgery, the range of motion of the elbow improved a great deal in all three patients, but the maximum duration of follow-up was only twenty months. Our Group-III patients had surgical excision of the medial humeral epicondyle, but none of them had a good long-term result. Three of them had decreased grip strength, and two had marked elbow instability. Ulnar nerve dysfunction with electromyographic abnormalities was present in four of the six patients. Hypoplasia of the medial aspect of the distal humeral epiphysis was evident radiographically in all Group-III patients. Osteoarthritis of the elbow, probably caused by marked elbow instability, was also present in two patients. Our results showed that simple periosteal suture of the tendons and the medial collateral ligament does not restore long-term elbow stability. We do not believe that the fractured epicondyle should be excised even though this procedure has been recommended for patients with comminution of the fragment as well as for old fractures^4,11,17.

Woods and Tullos¹⁵, Schwab et al.²⁴, and more recently Case and Hennrikus¹³ postulated that fibrous union of the medial epicondyle may result in laxity of the medial collateral ligament of the elbow. They recommended open reduction and stable fixation in young athletes who require stable upper extremities in order to engage in certain sports activities, such as throwing and gymnastics. We did not find elbow instability at the time of the long-term follow-up in any of our patients who had been treated nonoperatively, although it is likely that many of them could have had a positive gravity valgus stress test²⁴ immediately after the injury. We do not know how long it took for our patients with a fibrous union of the medial epicondyle to recover full stability of the elbow. Some might speculate that heavy, repeated valgus stress on a recent fibrous union could cause chronic elbow instability. However, this idea seems to be contradicted by the report by Nyska et al.²⁵ concerning eight professional teenaged arm wrestlers treated with collar-and-cuff immobilization for an average of two weeks; within a few months, these patients fully recovered their ability to perform strenuous activities without any symptoms.

In conclusion, we do not believe that open reduction and internal fixation of an isolated fracture of the medial epicondyle is mandatory even if the fracture fragment is displaced >5 mm. We observed that nonoperative treatment can offer these children good long-term functional results. Excision of the fracture fragment should be avoided whenever possible.

References

Introduction | Materials and Methods | Results | Discussion | References

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