Medial Humeral Condyle Fracture Treatment & Management

Treatment indications

Salter-Harris type IV medial condyle fractures with 2 mm or more of displacement usually must be treated by means of open reduction with internal fixation (ORIF). A displaced medial condyle fragment or instability of the fragment with closed reduction is an indication for open reduction with rigid internal fixation. Accurate apposition of the fracture surfaces is important to reduce the risk of growth-plate disturbance and to prevent loss of motion due to articular incongruence. Nondisplaced medial condyle fractures can be treated without surgery.

For nondisplaced or minimally displaced medial epicondyle fractures, nonoperative management is the procedure of choice. More controversy exists with displacement of 5-15 mm. Similar functional results have been reported with operative and nonoperative surgical management. Long-term functional assessment has demonstrated similar results even with radiographic nonunion being apparent on most of the fractures treated nonoperatively.

Irreducible incarceration of the medial epicondyle fragment ^{[37, 38]} and open fracture are indications for operative management. Excision of the comminuted medial epicondyle fragment has been associated with less beneficial results. ^[39] Other controversial relative surgical indications include complete ulnar nerve dysfunction after an injury or reduction attempt and valgus instability in high-demand athletes. ^{[20, 21, 40]}

If the patient is unable to tolerate a long surgical procedure because of polytrauma, closed reduction and cast immobilization with 90° of flexion is an option.

Areas of controversy

Some authors have advocated routine ulnar nerve transposition, whereas others have maintained that this is unnecessary unless the ulnar nerve has been injured.

There has been disagreement regarding how to manage a fracture that has remained untreated for several weeks or longer. Formation of callus and fibrous tissue may obliterate the fracture site and cause a malunion that makes accurate dissection and reduction less accurate. Misdiagnosis or inadequate early treatment increases the risk of complications such as loss of movement and angulation.

Some have suggested conservative treatment for fractures older than 4 weeks, whereas others have demonstrated some restored function in treating these fractures at the time of delayed diagnosis, though the results are imperfect. Supracondyle wedge osteotomy has been advocated to restore anatomic angulation and motion loss from previous injury. Whether this is best performed during growth or after the physis has closed has not yet been determined.

The major controversy involving medial epicondyle fractures has involved the management of displaced fractures. ^[41] Good results have been reported with both operative and nonoperative treatment of the displaced medial epicondyle fracture. Some have advocated operative treatment of high-demand athletes, on the grounds that even minor amounts of valgus instability can result in significant disability. Others have recommended nonsurgical management, on the grounds that several long-term studies appeared not to substantiate significant valgus instability, even in individuals who went on to have radiographic nonunion of the epicondyle.

Closed reduction with cast immobilization is adequate for nondisplaced stable medial condyle fractures. Medial epicondyle fractures also may be treated in a closed fashion if the medial epicondyle is nondisplaced, minimally displaced, or even displaced up to 15 mm (see the image below).

In many studies, including long-term follow-up reports, patients treated nonsurgically had results similar to those of patients treated surgically, even for fracture fragments displaced as much as 15 mm. A radiographic nonunion of the medial epicondyle fracture fragment associated with nonsurgical treatment was not found to have any functional impairment in at least one long-term study. ^{[2, 3, 4, 6, 7, 8, 9, 10, 12, 31]}

The only absolute indications for operative management of closed medial epicondyle fractures are the following:

• Incarceration of the medial epicondyle fragment within the joint
• Open fracture

An incarcerated fragment within the joint must be removed. Several closed means of reduction can be used, and the success rate with these methods approaches 40%. One such maneuver (the Roberts manipulative technique) is performed under sedation and involves placing a valgus stress on the elbow while supinating the forearm and simultaneously dorsiflexing the wrist and fingers to place the forearm flexor muscles on stretch. If employed, this maneuver is usually performed in the operating room with the patient under general anesthesia. Joint distention techniques also have been described to help facilitate closed reduction of the incarcerated medial epicondyle fracture. ^{[20, 21, 40]}

Initially, the arm should be splinted in 90° of elbow flexion. Gentle active range-of-motion (ROM) exercises may begin within 1 week after injury. Protective splinting may be continued for 3 weeks if necessary.

In preparation for ORIF, the arm is placed in a posterior splint for stabilization, elevated, and treated with ice packs to decrease swelling.

Medial condyle fracture

A medial approach may be used. A longitudinal incision is made over the medial supracondyle ridge of the humerus and continued just distal to the medial condyle. Branches of the medial antebrachial cutaneous nerve should be identified and preserved. The ulnar nerve is identified and protected and may be transposed anteriorly. The fracture surfaces are identified and cleaned, and the joint space is cleaned and irrigated to remove loose particles.

The condyle fragment is then reduced and secured at a minimum of two sites to prevent rotation. Kirschner wires (K-wires) or cancellous screws may be used. Plate-and-screw fixation is another option. The reduction should be confirmed radiographically. The wound is closed, and the arm is splinted in 90° of flexion with the forearm in the neutral position. ^{[2, 3, 4, 6, 7, 8, 9, 10, 12, 31, 42]}

Medial epicondyle fracture

A longitudinal incision is made just anterior to the medial epicondyle. The fragment is usually displaced distally and anteriorly. As with any fracture reduction, periosteum and bone fragments are cleared from the fracture site to allow anatomic reduction. The ulnar nerve must be identified and protected; ulnar nerve transposition is usually unnecessary. With the elbow flexed and pronated, the fracture fragment is reduced and pinned with one or two K-wires. A lag screw is then placed to maintain and compress the fracture fragment. Elbow stability and ROM are assessed. A posterior splint is then applied for at least 7-10 days until ROM is initiated. ^{[20, 21, 40, 31, 42]}

If the epicondyle is fragmented, excision of the fragment and fixation of the flexor-pronator origin and medial collateral ligament (MCL) to bone with an alternative form of fixation (eg, suture anchors) may be used. Excision of the fragment does not appear to yield results comparable to those of nonoperative treatment.

Ergin et al, in a long-term (median, 10 years; range, 5-15) comparative study of 42 children with displaced medial epicondyle fractures of the humerus, assessed internal fixation with K-wires (group A; n = 22) vs cannulated screws (group B; n = 20). ^[43]  The Mayo Elbow Performance Score (MEPS) was used to assess clinical outcomes, in addition to elbow ROM at the last follow-up. Median MEPS scores were 95 in group A and 94 in group B. No significant differences in ROM were observed. The authors concluded that favorable clinical and radiologic outcomes at long-term follow-up may be achievable by using two smooth K-wires for younger children and screw fixation for children near skeletal maturity.

With all degrees of injury, immobilization must continue until solid union is demonstrated. Radiography must be repeated until the union is ensured. This may be as early as 3 weeks for nondisplaced fractures and is usually about 6 weeks (occasionally as long as several months) for displaced fractures. This immobilization must be balanced against the need for physical therapy to prevent loss of ROM.

For fractures treated with ORIF, the arm should be put in a cast in 90° of flexion for 3 weeks and then placed in a posterior mold for 3 weeks with supervised active flexion and extension out of the mold. Internal fixation allows this early physical therapy to be instituted without compromising the reduction. Active ROM with physical therapist supervision is critical to prevent excess loss of flexion and extension. Passive ROM should be avoided because it can result in damage to contracted soft tissues and has been associated with myositis ossificans.

Late follow-up should be considered to screen for growth disturbance after injury to the epiphysis.

Medial condyle fracture

Nonunion ^[44] with a thickening deformity at the fracture site can occur with inadequate reduction, fixation, or immobilization. Catgut suture as a means of internal fixation has proved to be inadequate, in that it has often resulted in this complication. Malunion can result in loss of motion or angulation. As with nonunion, this can result from inadequate fixation or premature mobilization.

Some minor loss of motion (flexion and extension) is a common sequela of many displaced medial condyle fractures. The degree of loss is usually minimal and does not decrease function. When the loss is related to another complication, such as nonunion, malunion, or heterotopic ossification, it can be significant.

A progressive cubitus varus deformity may develop as a consequence of growth inhibition or avascular necrosis (AVN) of the medial humeral condyle. This also can result from premature closure of the physis. In one case, 40º of varus angulation was reported that went untreated for 4 years. This was treated with a supracondylar wedge osteotomy to restore ROM and correct the cubitus varus deformity.

AVN of the epiphysis can be the result of loss of blood supply during an overaggressive soft-tissue dissection in attempts to achieve adequate exposure of the fracture. The blood supply to the epiphysis is through the soft-tissue attachments at the medial epicondyle. A valgus deformity also can result from imperfect restoration of position. This is usually related to an overgrowth of the medial condyle.

Heterotopic ossification can result in severe loss of flexion and extension. This is often associated with delayed fixation and closed head injuries. Myositis ossificans can result from overaggressive physical therapy with passive ROM.

Pronation and supination are usually not affected. Concurrent injury to the radial head may result in decreased motion. Injury to the ulnar nerve may result in a partial clawhand, muscle weakness, and partial loss of sensation. If necessary, transposition of the nerve can be performed to reduce tension and prevent further injury. Partial or complete recovery may take months.

Misdiagnosis or delay in diagnosis or treatment increases the risk of impairment and complications.

Medial epicondyle fracture

The two main complications associated with medial epicondyle fractures are as follows:

• Failure to recognize incarceration into the joint with functional loss
• Ulnar or median nerve dysfunction

The first major complication with an unrecognized medial epicondyle fracture involves loss of motion secondary to impingement of the fragment. The second involves ulnar nerve dysfunction, which may occur in 10-16% of cases. If the fragment is incarcerated in the joint, the incidence of ulnar nerve dysfunction can reach 50%. More profound ulnar nerve dysfunction has been observed to occur with manipulative reduction attempts, especially if closed manipulation of an incarcerated fragment is attempted. A median nerve injury may occur as well; however, this is more common with an associated elbow dislocation.

Most of the other complications associated with medial epicondyle fractures are considered minor and do not result in a loss of function. These minor complications include radiographic nonunion of the medial epicondyle fragment in cases in which the fracture is treated closed. Functionally, no limitation from this radiographic finding appears to exist. A loss of elbow extension of 10-15% can be expected in up to 20% of cases, and this appears to be correlated more with prolonged immobilization than the fracture itself.

Myositis ossificans has been described as a rare occurrence and has been correlated with repeated manipulation to reduce an incarcerated fragment. A significant alteration in the carrying angle of the elbow has not been demonstrated in long-term studies and does not appear to be a major issue with these fractures.