Paediatric Medial Epicondyle Fracture ORIF

Surgical Indications

Absolute Indications

• Incarcerated (intra-articular) fragment that does not reduce after closed reduction of the elbow - the fragment blocks motion and will not unite in a functional position
• Ulnar nerve dysfunction - especially a nerve incarcerated within the joint or a persistent symptomatic neuropathy
• Open fracture
• Vascular injury requiring exploration (rare)
• An irreducible elbow dislocation in which the fragment is interposed and prevents reduction

Relative Indications (the contested ground)

• Significant displacement - the traditional thresholds of greater than 5 mm, greater than 10 mm, and greater than 15 mm are widely debated and are not supported as standalone indications by modern evidence
• High-demand overhead-throwing athletes in whom valgus stability is critical to function
• Objective valgus instability on stress testing, indicating incompetence of the ulnar collateral ligament origin
• A fragment that lies within the cubital tunnel and irritates the ulnar nerve

Contraindications

Absolute:

• A fracture without incarceration, nerve compromise, open injury, or demonstrated instability - these do well nonoperatively

Relative:

• Gross swelling or fracture blisters that delay safe surgery
• A near-skeletal-maturity child with a chronic, asymptomatic fibrous nonunion

The Displacement Controversy

Traditional teaching (Smith; Hines) recommended ORIF for displacement greater than 5 mm, with some authors proposing thresholds of greater than 10 mm or greater than 15 mm, citing theoretical risks of nonunion, valgus instability, and ulnar nerve problems.

Modern evidence challenges this position:

• The Kamath systematic review (2009) found no conclusive evidence that operative treatment of displaced medial epicondyle fractures improves outcome over nonoperative care, and highlighted the lack of high-quality prospective studies.
• Farsetti and colleagues (2001) reported excellent long-term elbow function in patients treated nonoperatively despite residual displacement and frequent fibrous union.
• Josefsson and Danielsson (1986) found that adults reviewed long after childhood nonoperative treatment were largely asymptomatic, even when the fragment had gone on to fibrous union.
• Louahem and colleagues (2010) showed in a multicentre series that long-term outcome was driven by associated elbow injuries and ulnar nerve involvement rather than by the degree of fragment displacement.

The defensible modern position is to operate for absolute indications (incarceration, ulnar nerve dysfunction, open injury, instability), to treat the remainder nonoperatively, and to individualise for the high-demand throwing athlete in whom the ulnar collateral ligament origin must be restored.

Non-Operative Treatment

• A long-arm splint or cast at 90 degrees of flexion for 1 to 3 weeks, followed by early active motion.
• Acceptable for minimally displaced fractures and for displaced fractures that carry no absolute indication.
• Fibrous union is common and is usually asymptomatic; it is not by itself an indication for surgery.
• Counsel the family to expect a minor loss of terminal extension and a small residual cosmetic bump at the medial epicondyle.

Evidence at a Glance - Operative versus Non-Operative

The Medial Epicondyle - an Apophysis

• The medial epicondyle is a traction APOPHYSIS on the posteromedial distal humerus, not a true epiphysis. It contributes little to longitudinal growth, so growth disturbance is uncommon after injury or fixation.
• It ossifies around 5 to 7 years of age (girls earlier than boys) and fuses to the distal humeral metaphysis around 13 to 15 years.
• Remember the CRITOE order of ossification of the elbow: Capitellum, Radial head, Internal (medial) epicondyle, Trochlea, Olecranon, External (lateral) epicondyle. The medial epicondyle ossifies BEFORE the trochlea - the anatomical basis of the incarceration imaging trap.

Musculoligamentous Attachments

• Flexor-pronator mass origin: pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and flexor digitorum superficialis arise from the medial epicondyle.
• Ulnar collateral ligament origin (the anterior bundle is the prime static restraint to valgus): restoring its origin is the priority in a throwing athlete.
• The avulsion occurs because acute valgus stress tensions the flexor-pronator mass and the UCL, levering the apophysis off the distal humerus.

The Ulnar Nerve

• The ulnar nerve courses posterior to the medial epicondyle through the cubital tunnel, immediately deep to the operative field.
• It may be displaced distally with the fragment or, rarely, incarcerated within the joint alongside it.
• Pre-injury ulnar nerve symptoms occur in a substantial minority of these fractures, so the nerve must always be identified and protected.

Classification (Wilkins)

Stages 3 and 4 (incarceration) are absolute operative indications. Stage 4 requires urgent reduction of the dislocation and fixation of the fragment.

Associated Injuries to Exclude

• Elbow dislocation (common) - assess and reduce first.
• Lateral condyle fracture - do not miss, as it requires its own management.
• Radial neck fracture, olecranon fracture, and an extension-type supracondylar fracture.
• Document the ulnar nerve and the vascular (brachial artery) status before and after any reduction.

Positioning and Preparation

Patient position: Supine with the arm on a hand table, the shoulder externally rotated so the medial elbow faces the surgeon. A well-padded bump helps deliver the elbow. Alternatively, supine with the arm across the chest over a bolster.

Tourniquet and imaging: A pneumatic upper-arm tourniquet; an image intensifier is essential throughout.

Anaesthesia and consent: General anaesthesia in children, with pre-operative antibiotics. Counsel specifically regarding ulnar nerve injury, stiffness and loss of terminal extension, hardware prominence, infection, and the possibility of asymptomatic fibrous union if treated nonoperatively.

The Medial (Hotchkiss) Approach - Step-by-Step

Step 1: Skin Incision

Make a longitudinal or gently curved incision over the medial epicondyle, centred between the medial epicondyle and the olecranon, long enough to expose both the fragment and the ulnar nerve.

Step 2: Identify and Protect the Ulnar Nerve (FIRST)

Before mobilising the fragment, identify the ulnar nerve proximal to the cubital tunnel and trace it gently distally; protect it with a vessel loop. Decompress the roof of the cubital tunnel. If there is pre-operative ulnar neuropathy, if the nerve is compressed, or if the fragment was incarcerated near the nerve, perform an anterior subcutaneous transposition.

Step 3: Expose the Fragment and the Fracture Bed

Follow the flexor-pronator mass distally to the displaced fragment, which remains attached to the mass. Deliver the fragment gently. If the fragment is incarcerated within the joint, extract it carefully after protecting the ulnar nerve and the articular cartilage. Clear haematoma and early callus from both the fragment and its bed on the distal humerus to allow an anatomic reduction.

Step 4: Anatomic Reduction

Reduce the fragment onto its bed using a small pointed reduction clamp or a towel clip, seating the cortical margins flush. Confirm the reduction on AP and lateral fluoroscopy.

Step 5: Fixation - Single Cannulated Screw with Washer

Place a guide wire from the fragment across the distal humerus toward the lateral column, aiming for the capitellar or lateral cortex while avoiding the olecranon fossa (a screw here blocks extension) and the joint surface. Confirm the wire position, trajectory, and length on fluoroscopy and measure. Drill and place a partially threaded cannulated cancellous screw (commonly 4.0 mm or 4.5 mm) with a washer. The washer spreads load and prevents the screw head sinking into the soft cancellous fragment. Engage the far (lateral) cortex for purchase without over-penetrating it. Avoid over-compression that could comminute the fragment, and avoid multiple drill passes.

Step 6: Verify

Through a full arc of flexion-extension and pronation-supination, confirm the fragment is stable, the elbow extends fully with no bony block, and the ulnar nerve is neither compressed nor subluxing over the hardware. Take final fluoroscopic images to confirm reduction and hardware position.

Step 7: Closure and Immobilisation

Irrigate, achieve haemostasis, and close in layers over the ulnar nerve. Apply a long-arm splint or cast at 90 degrees of flexion with the forearm in neutral for 3 to 4 weeks. If the ulnar nerve was transposed, close the cubital tunnel fascia appropriately so the nerve sits in a stable anterior position.

Fixation Alternatives

• For very small or comminuted fragments, use K-wires with a tension band, or suture fixation of the flexor-pronator origin to the distal humerus.
• Avoid smooth K-wires across the medial epicondyle as definitive fixation in older children unless protected, because of pin-site problems and loss of fixation. The cannulated screw is preferred whenever the fragment will accept it.

Post-operative Protocol

Early Phase (0 to 4 weeks)

• Long-arm splint or cast at 90 degrees of flexion, forearm in neutral, for 3 to 4 weeks.
• Elevation and simple analgesia.
• Radiographs at 1 to 2 weeks to confirm maintenance of reduction and hardware position.

Motion and Strengthening (4 to 8 weeks)

• Begin active then active-assisted range of motion.
• Avoid valgus stress for the first 6 weeks to protect the UCL origin.
• Progress to strengthening once radiographic union is advancing.

Return to Sport

• Non-contact activities from around 8 to 12 weeks, once motion and strength are full and pain-free.
• Overhead throwing is delayed: a progressive throwing programme typically begins no earlier than 3 months, with full competitive pitching often at 4 to 6 months.

Special Case: The Incarcerated Fragment

• After reducing any elbow dislocation, recognise the fragment trapped within the joint using the CRITOE order and a true lateral film.
• Extract it carefully while protecting the ulnar nerve and the articular cartilage.
• Fix it anatomically and explore the ulnar nerve, which may be symptomatic or incarcerated alongside the fragment.

Special Case: Ulnar Nerve Management

• Document nerve status pre-operatively.
• Intra-operatively, decompress the cubital tunnel and translocate the nerve anteriorly (subcutaneous) when there is pre-operative neuropathy, severe compression, or incarceration.
• Confirm after fixation that the nerve does not sublux over the screw or washer.

Special Case: The Overhead-Throwing Athlete

• Chronic apophysitis (little league elbow) is managed with rest from throwing and a structured throwing programme; an acute displaced fracture in a thrower deserves a lower threshold for anatomic fixation to restore the UCL origin.
• Counsel on a delayed return to throwing and on age-appropriate pitching-load limits (rest days and pitch counts).

Special Case: Elbow Dislocation

• Reduce the dislocation first, then reassess the fragment and the neurovascular status.
• Fix the fragment if it is incarcerated or unstable.
• Use a brief period of protected motion to limit the stiffness that follows a paediatric elbow dislocation.