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Elbow Epicondyle Fractures

Categories
  • Elbow
  • Joint/Tendon
Tags
  • Elbow injury
Elbow

Upper Limb Anatomy

Right shoulder and arm, posterior view
Right shoulder and arm, posterior view

Right shoulder and arm, posterior view

Normal Upper Limb Anatomy
Triceps Brachii Muscle
Upper Limb Anatomy (Arm)
Muscles of the Forearm
Muscles of the Forearm
Upper Limb Anatomy (Nerve)
Medial aspect of right forearm

Medial aspect of right forearm

Left Brachial plexus

Left Brachial plexus

Nerves Posterior to Elbow Joint

Posterior view of right elbow

Posterior view of right elbow

Blood supply around the elbow joint

Blood supply and anastomosis

Blood supply and anastomosis around the right elbow. Anterior view

Elbow Joint

Elbow joint structural stability structures

Elbow joint structural stability structures

Left Arm

Left arm
Left arm
Humerus

Radial head/neck fractures

The triangular structure of distal humerus at elbow joint provides structural strength.

Anterior view right distal humerus bone

Anterior view right distal humerus bone

Rotation around throchlear axis

The elbow joint is a hinge joint with axis of rotation around throchlear axis

Extensor muscles

Extensor muscles

Resisted finger flexion

Flexor muscles

Bone Structure
Haversion bone system

Haversion bone system

Epicondyle Elbow Fractures

Lateral Epicondyle Fracture

Lateral epicondyle fracture is an extraarticular avulsion fracture

Lateral epicondyle fracture

Exclude Terrible Triad Injury of the Elbow Joint with Elbow Ligament Complex Injury

  • The terrible triad elbow injury is a traumatic elbow injury characterized by elbow dislocation, radial head/neck fracture and a coronoid fracture.
  • Mechanism: fall on extended arm with an axial, valgus and posterolateral complex disruption producing a posterolateral elbow dislocation.
Posterolateral elbow dislocation with radial neck

Posterolateral elbow dislocation with radial neck and coronoid fractures with ligamentous disruption

AO Epicondyle Fracture Classification

Distal humerus segment

Distal humerus segment (13)

Type A-extraarticular

  • A1- avulsion fracture
  • A2- simple fracture
  • A3-multifragmentary fracture

Management

Nonoperative:

  • Indicated for nondisplaced or minimally displaced fracture
  • Immobilization in arm split for 3-4 weeks
  • Ensure that there is no concomitant elbow ligamentous instability

Disadvantage:

  • Elbow stiffness
  • Close fracture monitoring

Surgery:

  • For displaced fragment
  • Large fragment
  • Associated elbow instability requiring repair
  • Surgery fixation options include K-wires, screw/s, staples, sutures and tension bands

Manipulation and Reduction of Lateral Epicondyle Fracture

Lateral epicondyle fragment reduction:

  • Manual traction to arm with one hand while palpating the lateral epicondyle fragment and manipulating it into its anatomical position
  • Confirm reduction with X-ray imaging
  • Maintain elbow at 90° and apply splint
Manipulation and reduction of lateral epicondyle fracture

Lateral Epicondyle Fracture Screw Fixation

Lateral epicondyle fracture screw fixation

Surgery: fragment reduction & screw fixation

Post Operative Rehabilitation

  • Immobilization in arm splint 3-4 weeks: maintain hand gripping exercises
  • After fracture healing with radiologically callous formation gravity eliminated exercises are performed
  • No load bearing exercises until fracture union
Arm sling

Arm sling

Hand grip exercises with arm in splint

Hand grip exercises with arm in splint

Strength exercises only performed after union

Strength exercises only performed after union

Download ASSIC Performance Fingerprint or Strength & Conditioning apps for rehab guideline routines or create own under professional supervision

apple app store  google play store

Surgery Technique

Surgery

Surgery Principles in Lateral Epicondyle Screw Fixation

Skin incision: lateral approach to elbow

  • Fracture and bed curettage
  • Reduce fracture, temporary fixation with K-wire optional or use of cannulated screw
  • Use 2 or 2.5 mm drill bit
  • Drill through fragment. Avoid drilling into olecranon fossa
  • Screw fixation: Use washer. A second screw can be used transversely if large fragment
Skin incision

Medial Epicondyle Fracture

Medial epicondyle fracture is an extraarticular avulsion fracture

Medial epicondyle fracture

Intraarticular Fragment

Fracture complication: Medial epicondyle intraarticular fragment require reduction and fixation

Intraarticular fragment

Management

Nonoperative:

  • Indicated for nondisplaced or minimally displaced fracture (<5mm)
  • Immobilization in arm splint
  • Ensure that there is no concomitant elbow ligamentous instability

Disadvantage:

  • Elbow stiffness
  • Close fracture monitoring
  • Fibrous nonunion
  • Note: assess Ulnar nerve function

Surgery:

  • For displaced fragment
  • Large fragment
  • Intraarticular fragment entrapment in elbow joint
  • Associated elbow instability
  • Open fracture

Medial Epicondyle Fracture Screw Fixation

Medial epicondyle fracture screw fixation

Surgery: fragment reduction & screw fixation

Surgery Technique

Surgery

Surgery Fixation of Medial Epicondyle

Surgery fixation of medial epicondyle
  • Skin incision: center over over medial supracondylar ridge, the medial epicondyle and in line with flexor/pronator mass
  • Identify Ulnar nerve between the intermuscular septum and triceps, posterior medial epicondyle groove and in between the 2 heads of flexor carpi ulnaris
  • Incise capsule
  • At the proximal end elevate muscles & joint capsule from medial supracondylar ridge. Distally open the capsule and reflect anterior to the medial collateral ligament

Rehabilitation Management:

Create Own Routine or Use Template Routines Under Professional Supervision

Shoulder pendulums

Pendulum shoulder range of motion

Shoulder pendulum_(dumbbells)

Pendulum shoulder strength exercise

Banded shoulder external rotation

Shoulder strengthening with resistance band

Download ASSIC Performance Fingerprint or Strength & Conditioning apps for rehab guideline routines or create own under professional supervision

apple app store  google play store

References

  1. A comparative Biomechanical Analysis of 2 Double-Row, Distal Triceps Tendon Repairs. Matthew A Dorweiler, Rufus O Van Dyke, Robert C Siska, Michael A Boin and Mathew J DiPaola. The Orthopaedic Journal of Sports Medicine May 2017, 5(5): 23259671177080.
  2. Traumatic elbow injuries: what the orthopedic surgeon wants to know. Sheehan S.E. Radiographics 33(3(: 869-888.
  3. A follow-up of one hundred cases of fracture of the head of the radius with a review of the literature. Johnston GW. Ulster Med J 31: 51-56.
  4. Management of severely comminuted distal radius fractures. David M Brogan, Marc J Richard, David Ruch, Sanjeev Kakar. J Hand Surg Am. 2015 Sep; 40(9): 1905-14.
  5. Surgical management for olecranon fractures in adults: a systematic review and meta-analysis. Koziarz A, Woolnough T, Oitment C, Nath S, Johal H. Orthopedic. 2019 Mar 1;42(2): 75-82.
  6. Classifications in Brief: Mayo classification of olecranon fractures. Sullivan CW, Desai K. Clin Orthop Relat Res. 2019 Apr;477(4): 908-910.
  7. Elbow fractures. Midtgaard KS, Ruzbarsky JJ, Hackett TR, Viola RW. Clin Sports Med. 2020 Jul;39(3): 623-636.
  8. Comparison of outcome between nonoperative and operative treatment of medial epicondyle fractures. Petra Grahn, Tero Hämäläinen, Yrjänä Nietosvaara, Matti Ahonen. Acta Orthop. 2021 Feb;92(1): 114-119.
  9. A narrative review on avulsion fractures of the upper limb and lower limbs. Christopher Vannabouathong, Olufemi R Ayeni, Mohit Bhandari. Clin Med Insights Arthritis Musculoskelet Disord. 2018;11: 1179544118809050.
  10. Outcome after ORIF of capitellar and trochlear fractures. JH Dubberley, KJ Faber, JC Macdermid, SD Patterson, GH King. J Bone Joint Surg Am. Vol. 88 2006: 46-54.
  11. Coronal plane partial articular fractures of the distal humerus: current concept in management. DE Ruchelsman, NC Tejwani, YW Kwon, KA Egol. J Am Acad Orthop Surg. Vol 16 2008: 716-728.
  12. Complex elbow dislocations and the “terrible triad” injury. Allistair D R Jones, Robert W Jordan. Open Orthop J. 2017 Nov 30;11: 1394-1404.

Contributor:

Dr N J Kauta

Learn More

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