Fixation of Displaced Medial Epicondylar Fractures in Adolescents.

Abstract

The patient is placed in the supine position, and an examination under anesthesia is performed. If the elbow is stable to valgus load, the patient is placed into a long arm cast and awakened from anesthesia. If the elbow is unstable, the patient is placed in the lateral decubitus position, and the arm is prepared and draped. The fingers and wrist are wrapped with a self-adhesive bandage in flexion to relax the flexor/pronator mass. Under tourniquet control, a curvilinear medial incision is made just dorsal to the medial epicondyle. The ulnar nerve is identified and transposed if necessary. A guidewire is placed through the fracture fragment and used as a joystick. The hand is then positioned on the posterior aspect of the hip to provide varus load to the elbow and assist with reduction. The medial epicondyle is reduced, and the guidewire is advanced unicortically. A 3.0-mm, partially threaded cannulated screw is then advanced over the guidewire. A long arm cast is applied after closure of the wound with buried absorbable sutures. Nonoperative treatment in a cast has been suggested. Surgical variations include supine positioning, bicortical screws, and use of washers. Lateral decubitus positioning and wrapping of the hand and wrist in flexion facilitate reduction by both applying a varus load and relaxing the flexor/pronator mass. Unicortical fixation is sufficient and does not risk injury to anterolateral structures. Washers have a higher complication rate than screws alone and may not be necessary in most cases1.