Outcomes of Nonoperative Pediatric Medial Humeral Epicondyle Fractures With and Without Associated Elbow Dislocation

Protocol for Surgery or Cast of the EpicoNdyle in Children's Elbows (SCIENCE)

Aims

The management of fractures of the medial epicondyle is one of the greatest controversies in paediatric fracture care, with uncertainty concerning the need for surgery. The British Society of Children's Orthopaedic Surgery prioritized this as their most important research question in paediatric trauma. This is the protocol for a randomized controlled, multicentre, prospective superiority trial of operative fixation versus nonoperative treatment for displaced medial epicondyle fractures: the Surgery or Cast of the EpicoNdyle in Children's Elbows (SCIENCE) trial.

Methods

Children aged seven to 15 years old inclusive, who have sustained a displaced fracture of the medial epicondyle, are eligible to take part. Baseline function using the Patient-Reported Outcomes Measurement Information System (PROMIS) upper limb score, pain measured using the Wong Baker FACES pain scale, and quality of life (QoL) assessed with the EuroQol five-dimension questionnaire for younger patients (EQ-5D-Y) will be collected. Each patient will be randomly allocated (1:1, stratified using a minimization algorithm by centre and initial elbow dislocation status (i.e. dislocated or not-dislocated at presentation to the emergency department)) to either a regimen of the operative fixation or non-surgical treatment.

Outcomes

At six weeks, and three, six, and 12 months, data on function, pain, sports/music participation, QoL, immobilization, and analgesia will be collected. These will also be repeated annually until the child reaches the age of 16 years. Four weeks after injury, the main outcomes plus data on complications, resource use, and school absence will be collected. The primary outcome is the PROMIS upper limb score at 12 months post-randomization. All data will be obtained through electronic questionnaires completed by the participants and/or parents/guardians. The NHS number of participants will be stored to enable future data linkage to sources of routinely collected data (i.e. Hospital Episode Statistics).

Comparison of Surgical Treatment Outcomes of Pediatric Medial Epicondyle Fractures With and Without Elbow Dislocation

PURPOSE

The aim of this study was to compare surgical treatment outcomes of pediatric medial epicondyle fractures with and without elbow dislocation.

METHODS

A total of 139 patients (75 boys and 64 girls; mean ± SD age, 9.6 ± 3.3 years) who received surgical treatment for medial epicondyle fractures at the Children's Hospital of Nanjing Medical University from January 2012 to December 2018 were included in our study. There were 99 cases that had a medial epicondyle fracture alone (group A) and 40 cases had a concomitant elbow dislocation (group B). Pain, ulnar nerve palsy, and stability of the elbow joint were recorded. Robert's criteria was used to assess elbow function.

RESULTS

The prevalence of ulnar nerve palsy was lower in group A compared to group B, both before and after surgery. More patients underwent ulnar nerve transposition in group B than in group A. The incidence of elbow valgus instability was higher in group B than in group A. At the final follow-up, all patients had achieved good radiographic restoration of the elbow joint. Clinical outcomes in group A, according to Robert's criteria, were better than those in group B.

CONCLUSIONS

Elbow dislocation was associated with poorer functional outcomes following surgical treatment of medial epicondyle fractures in children.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Diagnosis and treatment of "medial to lateral diagonal injury of the elbow" in children: Concomitant medial epicondylar and radial neck fractures

Purpose

The simultaneous and ipsilateral occurrence of medial epicondylar and radial neck fractures is rare. This study evaluated the clinical and radiological outcomes of medial to lateral diagonal injury of the elbow (MELAINE).

Methods

Six males and 6 females were diagnosed with MELAINE (left: 10, 83.3%; right: 2, 16.7%). Medial epicondylar and radial neck fractures were classified according to Papavasiliou's classification (seven type II, two type III, three type IV) and Judet's classification (three type I, four type II and five type III), respectively. All patients underwent surgery. The carrying angle, range of motion, and Kim et al. Elbow Performance Score were used to evaluate clinical and functional outcomes; related complications were recorded.

Results

Mean age at injury and mean follow-up were 11.1 ± 2.5 (range, 6-14) and 40 ± 25.6 months (range, 13-90), respectively. All fractures consolidated in 6.3 ± 1.2 weeks on average (4-9). Outcomes were good (n = 1; 8.3%) to excellent (n = 11; 91.7%). The carrying angle of the injured and uninjured side was 15.5°± 2.6° and 14.7°± 2°, respectively (p = 0.218). The range of motion of elbow flexion-extension and forearm pronation-supination of the injured side was 144.2°± 10.4°, 4.6°± 5.4°, 76.7°± 9.1°, 80.4°± 9.2°, respectively, with no significant differences from the healthy side (p > 0.05). The Elbow Performance Score of the injured and uninjured side was 96.3 ± 5.3 and 98.8 ± 2.3, respectively (p = 0.139). No cases of infection, cubitus valgus, stiffness, or instability were recorded.

Conclusion

Although uncommon, MELAINE should not be neglected. Surgery aims to stabilize the elbow and avoid valgus deformity. If diagnosed and treated, clinical and radiological results are excellent in most cases.

Pediatric Elbow Dislocations and Associated Fractures

The objective was to evaluate pediatric patients with acute elbow dislocation and/or associated fracture to determine which were indicated for surgical intervention, using a single institution, Institutional Review Board (IRB) approved retrospective review of patients who presented to the Emergency Department (ED) with an acute elbow dislocation. Inclusion criteria were age ≤ 18 years, acute elbow dislocation injury, and appropriate imaging. A total of 117 patients were included 37 had a simple elbow dislocation, 80 had an associated fracture (medial epicondyle 59, lateral condyle 9, radial head/neck 7, other 5). A total of 62% (73/117) were male. The average age was 10.3 years (range 4-17). Mechanisms of injury included: falls from height/playground equipment (46), trampoline (14), and sports (57). All 37 patients with a simple elbow dislocation were successfully treated with closed reduction. Of the 80 patients with an associated fracture, 30 (38%) went on to open reduction internal fixation (ORIF). A total of 59 patients had an associated medial epicondyle fracture; 24 (41%) of whom went on to ORIF. Nine patients had an associated lateral condyle fracture, five (56%) of whom went on to ORIF. Patients with a simple elbow dislocation can be successfully treated with a closed reduction in the ED. However, 30/80 patients with an associated fracture (medial epicondyle, lateral condyle, or radial neck) required operative management.

Medial Humeral Epicondyle Fracture Incarcerated Into the Elbow Joint in an Adolescent Patient With Ulnar Nerve Palsy

Medial humeral epicondyle fractures are seen in about one-fourth of all elbow fractures in the pediatric population. Though it seems to be a common occurrence, there is still controversy existing on the treatment aspects to date. Among these fractures, about one-fourth are seen incarcerated into the elbow joint and this is managed surgically. This is a case report of an adolescent male who had a medial epicondyle fracture of the humerus with the fracture fragment incarcerated into the elbow joint, and the patient also had ulnar nerve palsy, He was surgically treated with screw fixation and had an uneventful intra-operative and post-operative period.

Sequelae of childhood elbow fracture

Elbow fracture is frequent in children, and often requires surgery. There are many potential sequelae: neurovascular, ligamentous and osseous. Some are liable to be overlooked, due to young age and the cartilaginous nature of the joint. There is little bone remodeling in the elbow and displacement fracture, and especially supracondylar or lateral condyle fracture, has to be corrected rigorously, notably in older children. In case of lateral tilt in fracture of the neck of the radial head, on the other hand, remodeling is effective. Deformity in cubitus varus and cubitus valgus leads to neurological lesions and instability. Treatment should be early, with adapted surgery in expert hands. Post-traumatic stiffness is rare. Early intensive physiotherapy is unsuited to children and could worsen the stiffness due to inflammation. Lateral condyle non-union is a classic complication of fracture. Simple percutaneous screwing is a useful option. The equivalent in the medial epicondyle is well-tolerated, and simple monitoring now suffices. Late posterolateral rotational instability is a poorly known complication. It should be considered in case of cubitus varus that becomes painful after a long asymptomatic course. Radiocapitellar subluxation is seen on X-ray. Residual radial head dislocation after primary treatment (Monteggia lesion) responds well to the Bouyala technique of ulnar flexion osteotomy associated to annular ligament repair, without requiring ligament reconstruction.

Medial Epicondyle Fracture in Children and Its Association with Increased Carrying Angle

BACKGROUND

This study aimed to evaluate the injury mechanism of medial epicondylar fractures in children and adolescents and its association with increased carrying angle (CA) as a predisposing factor.

MATERIALS AND METHODS

We evaluated 37 patients with medial epicondylar fractures who were surgically treated at our institution. Medical records and plain radiographs were reviewed to determine the mechanism of injury and the humerus-elbow-wrist angle (HEWA) and CA of the uninjured arm. To evaluate the effect of coronal alignment on specific fracture type, we compared the CA and HEWA of the 23 patients with medial epicondylar fracture who were injured by falling onto an outstretched hand (group I) with age- and sex-matched controls of 23 patients who had sustained extension-type supracondylar fractures (group II).

RESULTS

The mean age at injury was 11.7 ± 2.8 years (range, 5 to 16 years). Of the 37 patients, 23 (62.2%) recalled the injury mechanism as falling onto an outstretched hand and 10 patients (27.0%) were injured while arm wrestling, and in one patient (2.7%), the injury was associated with elbow dislocation. In the case-matched analysis, the mean HEWA of group I was 13.1 ± 2.8° (range, 7.1° to 19.8°) and the mean CA was 17.7 ± 2.7° (range, 13.0° to 22.2°). These angles were significantly increased in group I (p=0.003 and p=0.001, respectively).

CONCLUSION

Falling onto an outstretched hand is the most common injury mechanism in patients with medial epicondylar fractures, and these fractures are associated with an increased CA.

Changes in the management of pediatric medial humeral epicondyle fractures with and without associated elbow dislocation

Purpose The optimal management of medial humeral epicondyle fractures continues to be debated since decades. This single center study analyzes changes and optimizations of treatment over an observation period of 16 years and reports the results. Materials and Methods Retrospective analysis of all patients treated with a medial humeral epicondyle fracture between 2005 and 2020 at our institution. Results Ninety-six patients (mean 9.3 years, range 1 - 15) were included in the study. In 25 cases (26 %), the fracture was associated with an elbow dislocation. Most patients received surgical treatment (83.3 %), whereas 17.7 % were treated nonoperatively. Surgical treatment consisted of open reduction and fixation with compression screw (n = 44 steel, n = 2 absorbable), K-wire (n = 30), a combination of screw/K-wire (n = 2), or a PDS suture (n = 1). Compression screws have been used significantly more often in the latter half of the study period (p = 0.006). Patients were immobilized in a long arm cast for 29 days (range 11 - 50). Eleven surgically treated patients were early mobilized in an elbow orthosis. After a mean follow up of 7.6 months [2 - 61), Mayo elbow performance index (MEPI) outcome was excellent in all 96 patients. Loss of elbow movement (LOM) was found to be mild in 30 and moderate in 15 patients. LOM was found to be associated with surgical treatment (p = 0.001), and with concomitant elbow dislocations (p = 0.29). One pseudarthrosis occurred after conservative treatment. A persistence of ulnar nerve palsy or recurrent joint instability has not been described. Conclusion Most children with medial humeral epicondyle fractures nowadays undergo surgery. Screw osteosynthesis represents the increasingly preferred method in order to prevent joint instability or non-union, and to allow shorter immobilization duration. Overall results after medial epicondyle fractures are good.

A qualitative study of parents' and their child's experience of a medial epicondyle fracture

AIMS

The aim of this study was to explore parents and young people's experience of having a medial epicondyle fracture, and their thoughts about the uncertainty regarding the optimal treatment.

METHODS

Families were identified after being invited to participate in a randomized controlled trial of surgery or no surgery for displaced medial epicondyle fractures of the humerus in children. A purposeful sample of 25 parents (22 females) and five young people (three females, mean age 11 years (7 to 14)) from 15 UK hospitals were interviewed a mean of 39 days (14 to 78) from injury. Qualitative interviews were informed by phenomenology and themes identified to convey participants' experience.

RESULTS

The results identify parents' desire to do the best for their child expressed through two themes: 1) 'uncertainty' (being uncertain about the best treatment option); and 2) 'facilitating recovery' (sharing the experience). Parents and young people were shocked when confronted with uncertainty about treatment and they felt responsible for the decision. They searched for further information, drew on their own experience, and struggled to weigh up risks of the treatments. Discussion with surgeons provided crucial support for decision-making, and young people were involved to a varying degree. In facilitating recovery, parents balanced increasing activity with protecting their child, but lacked knowledge about pain management, and how to improve strength and function of the arm. They hoped for a return to normal, including competitive sports.

CONCLUSION

Surgeons are aware of the impact of injury on children and their parents; however, they may be less aware of the turmoil created by treatment uncertainty. Confident surgeons who appreciate and contextualize the importance of pre-existing experience and beliefs are best placed to help the family develop confidence to embrace uncertainty, particularly regarding participation in clinical trials. Cite this article: Bone Jt Open 2021;2(6):359-364.

Long-Term Outcomes of Operatively Treated Medial Epicondyle Fractures in Pediatric and Adolescent Patients

Purpose

Medial epicondyle fractures are among the most common pediatric elbow injuries. The management of these fractures continues to be debated. To better understand patient results with operative fixation, we reviewed the outcomes of operatively treated medial epicondyle fractures.

Methods

A retrospective review was performed to identify all patients less than 18 years of age at the time of injury who were treated surgically for medial epicondyle fractures. Outcomes were assessed based on the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity and Pain Interference domains, Visual Analog Scale for pain, subjective range of motion, ulnar nerve function, and requirement for secondary surgery.

Results

We identified a cohort of 95 patients treated for a medial epicondyle fracture with open reduction and screw fixation. Of these, 39 patients with a mean age of 12.2 years (SD, 2.2 years; range, 7.6–16.0 years) at surgery were assessed for an average follow-up of 6.3 years (SD, 3.2 years; range, 2.2–13.9 years). Outcome measures and pain scores were excellent. The mean PROMIS Upper Extremity score was 56.9, the mean Pain Interference score was 38.5, and the mean Visual Analog Scale score was 0.4.Sixteen patients (41%) required secondary surgery for symptomatic hardware removal. Seven patients (18%) developed sensory complaints and 2 (5%) developed motor complaints consistent with ulnar nerve irritability. Three patients (8%) reported dissatisfaction with elbow range of motion. Patients who required secondary surgeries had higher (worse) PROMIS Pain Interference scores.

Conclusions

At an average of 6.3 years after surgery, the clinical outcomes for medial epicondyle fracture were excellent. While operative treatment for medial epicondyle fractures in children leads to excellent clinical outcomes, patients and surgeons should be aware of high rates of hardware removal.

Type of study/level of evidence

Therapeutic IV

Open Reduction of Medial Epicondyle Fractures in the Pediatric Population: Supine Versus Prone Position

BACKGROUND

Operative treatment of medial epicondyle fractures can be performed in either a supine or prone position. In the supine position, fracture visualization is sometimes difficult due to the posterior position of the medial epicondyle. However, the prone position requires extensive patient repositioning but may improve visualization. The purpose of this study was to compare the results and complications between the supine and prone position when treating medial epicondyle fractures.

METHODS

In a retrospective chart review, patients below 18 who underwent open reduction and internal fixation of an acute medial epicondyle fracture from January 2011 to August 2019 were identified. Patients with <2 months follow-up and concomitant fractures were excluded. Surgical variables, outcomes, and complications were recorded and compared between the supine and prone positions.

RESULTS

Sixteen surgeons treated the 204 patients evaluated in this study. The mean age was 11.7 years. In all, 122 (60%) patients were treated in the supine position, and 82 (40%) in the prone position. The mean time in the room was 113 minutes in the supine group, and 141 minutes in the prone group (P<0.001). Tourniquet time was similar between groups (P=0.4). Displacement of the fracture on the first postoperative x-rays was 2.06 mm for the supine position and 1.1 mm for the prone position (P<0.001). We also found good interobserver and intraobserver reliability for the measurements. Five patients (2.5%) required reoperation due to stiffness, 2 patients due to nonunion, 1 patient due to tardy ulnar nerve palsy, and 53 (26%) had surgical hardware removal. The surgical position was not associated with complications or reoperation.

CONCLUSIONS

While the prone position requires additional time in the operating room, presumably for positioning, the length of the surgical procedure itself does not differ between the 2 positions. Although the trend of the surgeons at our center is towards the prone position, with surgeons that try it usually doing all their subsequent cases that way, both positions provide excellent clinical outcomes with minimal complications.

LEVEL OF EVIDENCE

Therapeutic level III-retrospective cohort study.

Complex paediatric fracture dislocation of the elbow - A rare case report

Traumatic elbow dislocation with concomitant fractures of the lateral condyle and the medial epicondyle in the paediatric population is an extremely rare injury. We are reporting a case of a locked fracture-dislocation of the elbow in an 11-year-old girl. The dislocation was treated by open reduction and the lateral condyle was surgically fixed. There are only seven similar cases described in the literature. This is the only reported case where the elbow dislocation was locked, requiring an open reduction.

Prospective study of pediatric medial humeral epicondyle fractures nonoperatively treated. Clinical, radiologic, and functional evaluation at long term

The objective of the study is to evaluate the natural history of the medial epicondyle avulsion in children with nonoperative treatment (NOPT) on different magnitude of displacement and long-term follow-up. A prospective study of 34 patients with medial epicondyle avulsion with (NOPT) was performed. Clinical test (stability, strength, atrophy, tenderness, Tinel test, and range of motion), subjective scores [Visual Analog Scale (VAS), Likert scale, side-to-side valgus test], and objective four scores were performed. Age at the time of injury was 8.9 ± 2.81 years. Follow-up was 7 ± 2.81 years. Four of the patients had anterior displacement. Displacement varied between 3 and 26 mm (10.49 ± 6.16 mm). Subjective: VAS and ordinal three-point Likert scale were excellent. Objective results were also excellent Mayo Elbow Score: 98.67 ± 4.31 (85-100), Oxford Elbow Score: 59.35 ± 1.68 (51-100), Elbow Assessment Score System: 96.27 ± 9.77 (57-100), Disabilities of the Arm, Shoulder, and Hand (DASH) score 0.64 ± 1.001 (0-4.16). We did not find any differences in strength or forearm diameter. There was an extension deficit in seven cases with a significant association with the magnitude of displacement (P = 0.02) and with the presence of concomitant lesions or anterior displacement of the medial epicondyle >5 mm. All except one were stable clinically on valgus stress. There is a significant association between the objective outcomes (scores) and concomitant lesions but not with regards to the DASH score P = 0.102). There is no association between the magnitude of medial epicondyle displacement or the follow-up and the objective outcomes. Instability was associated with valgus stress activities. There is no association between the magnitude of displacement of the medial epicondyle or the follow-up and the objective outcomes. NOPT produces excellent subjective and objective outcomes that worsened when there were associated lesions, anterior medial epicondyle displacement, or in patients who performed activities with repeated valgus stress. Based on our study, NOPT is suitable except for Open Reduction Internal Fixation indications: absolute indications, high energy injury with associated lesions, medial humeral epicondyle fracture in the dominant elbow in patients subject to activities with chronic valgus stress, and anterior displacement.

What's New in Pediatric Orthopaedic Trauma: The Upper Extremity

BACKGROUND

Upper extremity fractures are the most common fractures in children. Many high-quality studies have been reported regarding operative and nonoperative treatment of different upper extremity fractures in children. This review will summarize the literature on 4 major upper extremity fractures in children over the past 5 years.

METHODS

PubMed and Embase databases were queried for publications in the English language on supracondylar humerus (SCH) fractures, lateral humeral condyle fractures, medial epicondyle fractures, and clavicle fractures from January 1, 2013 until November 1, 2018. Papers believed to yield significant findings to our profession were included in this review.

RESULTS

A total of 1150 studies were related to the search terms, and after cursory assessment, the authors elected to fully review 30 papers for this publication: 12 related to SCH fractures, 10 related to lateral condyle humerus fractures, 3 related to medial epicondyle humerus fractures, and 5 involving clavicle fractures. The level of evidence for these studies was either level III or IV.

CONCLUSIONS

SCH fractures are increasingly being treated at trauma centers or pediatric hospitals in the United States. The rate of open reduction in this fracture type is decreasing overall, but the flexion type SCH fractures (especially in the setting of ulnar nerve injury) continue to be at increased risk of requiring open reduction. There has been a paradigm shift in the treatment of lateral condyle humerus fractures, wherein authors have demonstrated successful management with closed reduction and percutaneous pinning when an adjunct arthrogram is performed demonstrating articular congruity. More studies are needed to find the optimal treatment for displaced medial epicondyle and clavicle fractures in adolescents, as results to date do not necessarily mirror those seen in the adult population.

LEVEL OF EVIDENCE

Level IV.

A pediatric medial epicondyle fracture study using fresh frozen adult cadavers comparing fracture displacement and loss of terminal elbow extension

Medial epicondyle fractures are the 3rd most common pediatric elbow fractures. Regardless of treatment method, some degree of elbow motion loss has been reported. The purpose of our study was to determine the relationship between the amount of anterior fracture displacement and loss of elbow passive extension in an adult cadaveric medial epicondyle fracture model. Fifteen fresh frozen adult cadavers were procured to create fracture models at scenarios of 2, 5, 10 mm, and maximum displacement. Terminal elbow extension was recorded for each cadaveric model at each fracture scenario. A linear mixed model regression analysis was used to test the association between fracture displacement and loss of terminal elbow passive extension. At 2 mm of displacement, the average loss of terminal extension was 3.89°; at 5 mm, it was 7°; at 10 mm, it was 10.7°; at maximum displacement (~15 mm), it was 17°. A statistically significant positive linear association between fracture displacement and loss of terminal elbow extension was observed (5 mm of displacement = loss of ~4.7°). In our fracture model, when the medial epicondyle displaced anteriorly, we noticed a change in the tension of the medial collateral ligaments which lead to a decrease in terminal elbow extension. However, this only contributed partially to the loss of motion observed clinically in the literature. Even though our findings did not support the recommendation of surgical intervention to prevent loss of elbow motion in medial epicondyle fractures, we still encourage physicians to consider the consequence of displacement and its potential influence of elbow range of motion.

Washers do not affect the rate of implant removal or elbow motion in medial epicondyle fractures

The use of a washer to supplement screw fixation can prevent fragmentation and penetration during the surgical treatment of pediatric medial epicondyle fractures. However, concerns may arise regarding screw prominence and the need for subsequent implant removal. The purpose of this study is to evaluate the impact of washer utilization on the need for hardware removal and elbow range of motion (ROM). All pediatric medial epicondyle fractures treated with a single screw over a 7-year period were queried for this retrospective case-control study. Hardware removal was performed only if the patient experienced a complication or implant-related symptoms that were refractory to non-operative management. Of the 137 patients included in the study, a washer was utilized in 90 (66%). Thirty-one patients (23%) ultimately underwent hardware removal. There was not an increased need for implant removal in those with a washer (P = 0.11). When analyzing a subgroup of 102 athletes only, there was similarly no difference in the rate of implant removal if a washer was used (P = 0.64). Overall, 107 (78%) patients regained full ROM at a mean of 13.9 ± 9.7 weeks after surgery with no significant difference along the lines of washer use. Use of a washer did not affect the need for subsequent implant removal or elbow ROM after fixation of medial epicondyle fractures, even in athletes. If there is concern for fracture fragmentation or penetration, a washer can be included without concern that future unplanned surgeries may be required.

Variation Among Pediatric Orthopaedic Surgeons When Treating Medial Epicondyle Fractures

BACKGROUND

Medial epicondyle fractures are a common pediatric and adolescent injury accounting for 11% to 20% of elbow fractures in this population. This purpose of this study was to determine the variability among pediatric orthopaedic surgeons when treating pediatric medial epicondyle fractures.

METHODS

A discrete choice experiment was conducted to determine which patient and injury attributes influence the management of medial epicondyle fractures by pediatric orthopaedic surgeons. A convenience sample of 13 pediatric orthopaedic surgeons reviewed 60 case vignettes of medial epicondyle fractures that included elbow radiographs and patient/injury characteristics. Displacement was incorporated into the study model as a fixed effect. Surgeons were queried if they would treat the injury with immobilization alone or open reduction and internal fixation (ORIF). Statistical analysis was performed using a mixed effect regression model. In addition, surgeons filled out a demographic questionnaire and a risk assessment to determine if these factors affected clinical decision-making.

RESULTS

Elbow dislocation and fracture displacement were the only attributes that significantly influenced surgeons to perform surgery (P<0.05). The presence of an elbow dislocation had the largest impact on surgeons when choosing operative care (β=-0.14; P=0.02). In addition, for every 1 mm increase in displacement, surgeons tended to favor ORIF by a factor of 0.09 (P<0.01). Sex, mechanism of injury, and sport participation did not influence decision-making. In total, 54% of the surgeons demonstrated a preference for ORIF for the included scenarios. On the basis of the personality Likert scale, participants were neither high-risk takers nor extremely risk adverse with an average-risk score of 2.24. Participant demographics did not influence decision-making.

CONCLUSIONS

There is substantial variation among pediatric orthopaedic surgeons when treating medial epicondyle fractures. The decision to operate is significantly based on the degree of fracture displacement and if there is a concomitant elbow dislocation. There is no standardization regarding how to treat medial epicondyle fractures and better treatment algorithms are needed to provide better patient outcomes.

LEVEL OF EVIDENCE

Level V.

Recent trends in children's elbow dislocation with or without a concomitant fracture

BACKGROUND

The elbow is the joint that most usually dislocates in children. In contrast to the widely known recent increase in the incidence of upper-extremity fractures and their operative treatment in children, potential trends in elbow dislocation are not clear. In this study we aimed to clarify the recent epidemiology of childhood elbow dislocation, in particular the potential change in incidence and treatment.

METHODS

A population-based study was performed to evaluate the annual incidence and the characteristics of injury, patients and treatment. All children < 16 years of age with an elbow dislocation in 1996-2014 in the Oulu University Hospital District, Finland, were included. Elbow dislocations with and without an associated fracture were included. The mean number of children in the population at risk was 85,600, according Statistics Finland.

RESULTS

There were 104 patients with a mean age of 11.3 years (SD 2.6). The annual incidence was 6.4 (mean) per 100,000 children in 1996-2014 and no changing trend in incidence during the study period was found. Trampoline jumping was the most usual reason for the dislocations (N = 15, 14.4%). The majority (N = 73/104, 70.2%) were treated non-operatively by reduction and casting. There was no change in surgical treatment during the study time.

CONCLUSION

In contrast to increasing incidence of upper-extremity fractures in children, there has not been a change in the incidence of elbow dislocation in children. There was no change in surgical treatment in 1996-2014.

Elbow Injuries in the Adolescent Thrower

PURPOSE OF REVIEW

With an increasing rate of adolescent elbow injuries, especially in throwing athletes, the purpose of this review is to investigate the current literature regarding the diagnosis, treatment, and non-operative and operative outcomes of medial epicondyle fractures, ulnar collateral ligament repair, osteochondritis dissecans of the elbow, and olecranon stress fractures.

RECENT FINDINGS

Acceptable outcomes with both non-operative and operative treatments of medial epicondyle fractures have been reported, with surgical indications continuing to evolve. Unstable osteochondritis dissecans lesions, especially in patients with closed growth plates, require operative fixation, and emerging open and arthroscopic techniques including lesion debridement, marrow stimulation, autograft transfer, and allograft transplantation are described with good outcomes. Ulnar collateral repair has emerged as an exciting treatment option for an avulsion of either end of the ligament in young throwing athletes, with faster rehabilitation times than traditional ulnar collateral ligament reconstruction. Olecranon stress fractures are increasing in prevalence, and when a non-operative treatment course is unsuccessful, athletes have a high return-to-play rate after percutaneous cannulated screw placement. With proper indications, non-operative and operative treatment modalities are reported with a high return-to-play and acceptable clinical outcomes for common elbow injuries, including medial epicondyle fractures, ulnar collateral ligament repair, osteochondritis dissecans of the elbow, and olecranon stress fractures, in adolescent throwing athletes. Further research is needed to better define treatment algorithms, surgical indications, and outcomes.

What's New in Pediatric Upper Extremity Sports Injuries?

BACKGROUND

Sports injuries are common in pediatric and adolescent patients and the evaluation and treatment of these injuries continues to evolve. The purpose of this review is to provide a comprehensive appraisal of the most recent literature, highlighting updates on sports-related upper extremity injuries in pediatric patients.

METHODS

An electronic search of the PubMed, EMBASE, and Google Scholar databases was performed for keywords related to pediatric overhead athletes, osteochondritis dissecans (OCD) of the capitellum, medial epicondyle fractures, shoulder instability, and clavicle fractures. Search results were filtered by publication date to yield articles published electronically or in print on or after January 1, 2013 to May 30, 2017. Papers were selected based on expert opinion and consensus by the authors and included if deemed to have contributed important findings to the above topics.

RESULTS

A total of 51 articles were deemed to have contributed significant findings to the literature: 11 overhead athlete, 9 OCD of the capitellum, 6 medial epicondyle fractures, 17 shoulder instability, and 8 clavicle fractures. The level of evidence for most studies was either Level III or IV.

CONCLUSIONS

Overuse and traumatic conditions of the pediatric elbow including UCL tear, capitellar OCD, and medial epicondyle fractures represent a significant portion of injuries in the overhead athlete. Research in the prevention and treatment of primary and recurrent shoulder instability in young athletes continues to evolve. The operative treatment of clavicle fractures in adolescents has been increasing without a commensurate increase in the level of evidence supporting such treatment. Advances have been made in the treatment of sports-related upper extremity injuries in pediatric patients, however, high-level, comparative outcomes research in many areas is lacking and this review may help inform topics for future study.

LEVEL OF EVIDENCE

Level IV-Literature review.

Radiological, clinical and functional evaluation using the Quick Disabilities of the Arm, Shoulder and Hand questionnaire of children with medial epicondyle fractures treated surgically

PURPOSE

The main goal of this study was to retrospectively evaluate the clinical, functional and radiographic outcomes of displaced medial epicondyle fractures with or without associated elbow dislocation in children undergoing surgical treatment and to evaluate upper-extremity function with the Quick Disbilities of the Arm, Shoulder and Hand (Quick DASH) questionnaire. The hypothesis was that patients with associated elbow dislocation would have similar functional outcome to patients with displaced fractures with or without intra-articular entrapment of the medial epicondyle.

METHODS

A review of medical charts was performed to identify all children and adolescents who underwent surgical treatment for displaced medial epicondyle humeral fractures managed at a single institution. Patients with a closed fracture on plain radiographs, presence of growth cartilages and managed surgically were included in the study. Fractures were radiologically assessed on anteroposterior and lateral radiographs and rated according to Papavasiliou and Crawford classification. Functional outcome was measured with the Quick DASH questionnaire. Sixty-six patients met inclusion criteria, and 38 children presented with isolated displaced medial epicondyle fracture (Group A: type II and type III) and 28 with medial epicondyle fractures associated with elbow dislocation (Group B: type IV).

RESULTS

The Papavasiliou and Crawford system classified 36 fractures as type II (54.6%), two (3%) as type III and 28 as type IV (42.4%). All patients underwent open reduction. Fracture fixation was performed with K-wires in 26 (35%) children and a with single screw in 40 (65%). Mean follow-up was 37.5 months (range, 12-68). Overall complication rate was 18%. In particular, three adverse events (3/38, 8%) were recorded in Group -A and nine (9/28, 32%) in Group B (p = 0.003). Mean Quick DASH score at final follow-up was 4.6 ± 3.8 (range, 0-15.9) and was not significantly different between Groups A (5.4 ± 4.3; range, 0-15.9) and B (4.1 ± 3.5; range, 0-15.9) (p > 0.05).

CONCLUSIONS

Children with type II, III and IV medial epicondyle fractures undergoing surgical treatment have good radiological, clinical and functional outcome but warrant special attention to detect intra-articular entrapment of the broken epicondyle. In these cases, both patient and family should be warned of the potential risk of loss of elbow range of motion and possibly poor functional outcome, especially if treatment is delayed.