Right shoulder and arm, posterior view
Elbow Epicondyle Fractures
Upper Limb Anatomy
Medial aspect of right forearm
Left Brachial plexus
Nerves Posterior to Elbow Joint
Posterior view of right elbow
Blood supply around the elbow joint
Blood supply and anastomosis around the right elbow. Anterior view
Elbow joint structural stability structures
Left Arm
Radial head/neck fractures
The triangular structure of distal humerus at elbow joint provides structural strength.
Anterior view right distal humerus bone
The elbow joint is a hinge joint with axis of rotation around throchlear axis
Extensor muscles
Flexor muscles
Haversion bone system
Epicondyle Elbow Fractures
Lateral Epicondyle Fracture
Lateral epicondyle fracture is an extraarticular avulsion 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 and coronoid fractures with ligamentous disruption
AO Epicondyle Fracture Classification
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
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
Hand grip exercises with arm in splint
Strength exercises only performed after union
Download ASSIC Performance Fingerprint or Strength & Conditioning apps for rehab guideline routines or create own under professional supervision
Surgery Technique
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
Medial Epicondyle Fracture
Medial epicondyle fracture is an extraarticular avulsion fracture
Intraarticular Fragment
Fracture complication: Medial epicondyle intraarticular fragment require reduction and fixation
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
Surgery: fragment reduction & screw fixation
Surgery Technique
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
Pendulum shoulder range of motion
Pendulum shoulder strength exercise
Shoulder strengthening with resistance band
Download ASSIC Performance Fingerprint or Strength & Conditioning apps for rehab guideline routines or create own under professional supervision
References
- 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.
- Traumatic elbow injuries: what the orthopedic surgeon wants to know. Sheehan S.E. Radiographics 33(3(: 869-888.
- 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.
- 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.
- 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.
- Classifications in Brief: Mayo classification of olecranon fractures. Sullivan CW, Desai K. Clin Orthop Relat Res. 2019 Apr;477(4): 908-910.
- Elbow fractures. Midtgaard KS, Ruzbarsky JJ, Hackett TR, Viola RW. Clin Sports Med. 2020 Jul;39(3): 623-636.
- 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.
- 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.
- 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.
- 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.
- Complex elbow dislocations and the “terrible triad” injury. Allistair D R Jones, Robert W Jordan. Open Orthop J. 2017 Nov 30;11: 1394-1404.
