Alternative technique for open reduction and fixation of displaced pediatric medial epicondyle fractures

Abstract

Purpose: To describe an alternative positioning technique for the fixation of pediatric medial epicondyle fractures which offers some significant advantages over traditional supine positioning.

Methods: At our institution, 27 patients with a displaced medial epicondyle fracture requiring open reduction and fixation were positioned prone for the procedure. The internally rotated operative arm lies on the hand table with the elbow in a natural flexed, pronated position. The elbow can be brought into extension and flexion for appropriate intraoperative radiographs. The fracture is then reduced with the arm in flexion and pronation, without having to pull excessively on the fragment. After reduction, the fragment is held easily in place for surgical fixation. A similar group of patients from the same time period positioned supine was also examined and compared to the patients who had the surgery prone.

Results: The average age of the 27 patients was 11.2 years (range 5.1-16.9 years). Indications for operative treatment were displaced medial epicondyle fracture (14), medial epicondyle fracture with associated elbow dislocation (12), and medial epicondyle fracture with ulnar nerve symptoms (1). At a mean of 4.5 months of follow up (1-11 months), 7 patients required the removal of hardware for screw irritation. There were no infections in the 27 surgeries and there were no other intraoperative or postoperative complications. Mild loss of flexion and extension was common in the group. Patients who had surgery in the supine position were similar with regards to patient demographics and postoperative complications, including the need for screw removal.

Conclusions: While displaced medial epicondyle fractures can be treated successfully with traditional positioning, placing patients prone for the fixation of pediatric medial epicondyle fractures offers some significant advantages over supine positioning.

Keywords: Medial epicondyle; Prone positioning; Technique.

Fig. 1

The operative table is positioned with gel bolsters aligned longitudinally to give support to the torso

Fig. 2

A hand table is attached to the operative side, and the arm is allowed to sit in a flexed pronated position with the shoulder internally rotated. The patient must have adequate internal rotation of the shoulder

Fig. 3

An approximately 4-cm incision is centered over the medial epicondyle

Fig. 4

The elbow can be easily brought into extension to obtain anteroposterior radiographs of the elbow to assess pin positioning

Fig. 5

Anteroposterior radiograph of the distal humerus with the guide wire in place prior to screw placement

Fig. 6

Final radiograph with screw in place and medial epicondyle reduced into its original position