Journal of Orthopaedic Surgery 2007;15(2):170-3
Medial humeral epicondylar fracture in
children and adolescents
D Ip, WL Tsang
Department of Orthopaedics and Traumatology, Pamela Youde Nethersole Eastern Hospital, Hong Kong
ABSTRACT
Purpose. To assess treatment outcomes of young
patients with medial epicondylar fracture of the
elbow using standard operative protocols.
Methods. 24 consecutive patients with medial
humeral epicondylar fracture underwent surgery by
one of the 3 methods: (1) 2 parallel Kirschner wires,
(2) 2 parallel Kirschner wires plus a tension-band
wire, and (3) a screw plus an anti-rotation Kirschner
wire. Fractures displaced less than 5 mm were treated
conservatively (casting for 3 weeks). Outcome was
assessed clinically and radiologically. The Mayo
Clinic Elbow Performance Index was measured.
Results. The 3 patients with undisplaced fractures
had good radiological results and scores. One
patient with a displaced fracture refused surgery
and subsequently developed pseudarthrosis and
cubitus valgus. All operatively treated patients had
good scores, but 2 treated with 2 parallel Kirschner
wires alone developed pseudarthrosis. Patients in
Address correspondence and reprint requests to: Dr David Ip, Department of Orthopaedics and Traumatology, Pamela Youde
Nethersole Eastern Hospital, Hong Kong. E-mail: ipd8686@pacific.net.hk
this group needed longer rehabilitation to attain a
functional range of movement than those in other
groups (treated together with a tension-band wire or
screw).
Conclusion. Surgery is recommended for children
with displaced medial epicondylar fractures of more
than 5 mm. The use of a tension-band wire, instead of
a screw, together with Kirschner wires is the preferred
treatment for younger children.
Key words: elbow; fracture fixation; humeral fractures
INTRODUCTION
Medial epicondylar fracture of the elbow in children
is common. The fracture fragment may be missed
when dislocation is associated with fracture. The best
treatment for displaced medial epicondylar fracture
remains controversial, as decisions on fixation depend
on the anticipated extent of growth remaining in that
child and a growing traction-type apophysis.
Good to excellent outcomes have been reported
Vol. 15 No. 2, August 2007 Medial humeral epicondylar fractures in children 171
(a) (b)
Figure 1 Displaced medial humeral epicondylar fracture
fixed with (a) one screw and an anti-rotation Kirschner wire,
and (b) a tension-band wire and 2 parallel Kirschner wires.
for both operative1 and conservative2,3 treatments
for displaced medial humeral epicondylar fracture.
However, the definition of displacement varies
between studies; some define the fracture as displaced
if >2 mm,1 but others, rely on >5 mm.2 The detailed
rationale for choosing conservative versus operative
management may be lacking, making comparison
between results difficult. We therefore set out to
develop a rationale for treatment decisions and the
type of fixation in different scenarios.
MATERIALS AND METHODS
Records of 24 consecutive young patients (15 males,
9 females) aged 9 to 17 (mean, 13) years with medial
humeral epicondylar fracture treated in our hospital
from July 1997 to July 2003 were retrospectively
reviewed. The records constituted an unselected series
with no exclusion criteria. Fractures were defined as
displaced if a radiographic gap of >5 mm was evident.
Two thirds of the injuries were domestic, and the rest
were sports related. Associated dislocation (n=4)
was reduced on the day of admission. Soft tissue
injuries including transient ulnar nerve paresis (n=1),
fragment entrapment (n=2), and valgus instability
(n=5) were documented. No patient had other
associated fractures.
Three patients with undisplaced fractures and
one with a displaced fracture who refused surgery
were treated conservatively (3 weeks of plaster
immobilisation followed by physiotherapy). The
remaining 20 patients with displaced fractures
underwent surgery: those who were near skeletal
maturity and had a sizable fracture fragment were
treated with a screw plus an anti-rotation Kirschner
wire (n=8, Fig. 1a). Those who still had several years of
anticipated growth were treated with either 2 parallel
Kirschner wires plus a tension-band wire (n=6, Fig.
Figure 2 Cubitus valgus of the left elbow developed 3 years
after conservative treatment.
1b) or 2 non-threaded parallel smooth Kirschner wires
(n=6). Postoperatively, all patients were allowed free
elbow mobilisation, but in a hinge brace for 3 weeks
(to protect the elbow from varus/valgus stresses).
The Mayo Clinic performance index for the
elbow was used for functional assessment in 4 areas:
pain (maximum 45 points, from no pain to severe
pain), stability (maximum 10 points, from stable to
grossly unstable), range of movement (maximum
20 points, from >100 to <50), and activities of daily
living (maximum 25 points). Radiography was used
to detect pseudarthrosis or ectopic calcification.
Fluoroscopy was used during implant removal to
detect valgus instability and solid union. Clinical
testing was used to detect residual valgus instability
for patients treated conservatively. Any postoperative
nerve palsy, cubitus varus or valgus, and wound or
hardware-related complications were documented.
RESULTS
The mean follow-up period for patients treated
conservatively was 2.7 (range, 1.83.5) years, and for
the operative group was 2.2 (range, 1.53.5) years. No
patient was lost to follow-up.
Patients with undisplaced fracture treated
conservatively had excellent results with early return
of range of movement (within 6 weeks of plaster
removal). There were no elbow deformities, nerve
palsies, or other complications. The patient with
displaced fracture who refused surgery developed
cubitus valgus 3 years later, with numbness (but no
weakness) in the ulnar nerve distribution (Fig. 2).
172 D Ip and WL Tsang Journal of Orthopaedic Surgery

Table
Summary of patient demographics, injuries, type of treatment, and outcome scores

Patient Sex/ Injured Displacement Associated injury Fixation Mayo

No. age side Clinic
(years) Scores
1 M/10 L No - Conservative 100
2 F/13 R No - Conservative 100
3 M/13 R No - Conservative 95
4 M/12 L Yes - Conservative (refused surgery) 90
5 F/10 L Yes Dislocation Tension-band wire + 2 Kirschner wires 85
6 M/14 R Yes - Screw + Kirschner wire 100
7 M/15 L Yes Dislocation Screw + Kirschner wire 100
8 F/12 R Yes Transient ulnar nerve paresis 2 Kirschner wires 85
9 F/12 R Yes - 2 Kirschner wires 90
10 M/17 L Yes - Screw + Kirschner wire 100
11 F/14 L Yes - Tension-band wire + 2 Kirschner wires 90
12 M/16 L Yes - Screw + Kirschner wire 100
13 M/15 R Yes - Screw + Kirschner wire 100
14 M/12 R Yes - 2 Kirschner wires 80
15 M/13 L Yes - Tension-band wire + 2 Kirschner wires 95
16 M/11 R Yes - Tension-band wire + 2 Kirschner wires 95
17 F/9 L Yes - 2 Kirschner wires 85
18 F/15 L Yes Dislocation Screw + Kirschner wire 90
19 M/10 R Yes - 2 Kirschner wires 85
20 F/15 R Yes - Screw + Kirschner wire 100
21 M/13 L Yes - 2 Kirschner wires 85
22 M/15 R Yes - Screw + Kirschner wire 100
23 F/11 L Yes Dislocation Tension-band wire + 2 Kirschner wires 95
24 M/12 R Yes - Tension-band wire + 2 Kirschner wires 95

In patients with displaced fractures treated
operatively, all except one regained full range of
movement. The mean time taken was 7 (range, 58)
weeks for patients with a screw plus a Kirschner
wire, and 7 (range, 68) weeks for patients with a
tension-band wire plus 2 parallel Kirschner wires,
and 9 (range, 810) weeks for patients with 2 parallel
Kirschner wires.
One patient (treated with a screw plus a
Kirschner wire) developed mild cubitus varus and
another (treated with a tension-band wire plus 2
parallel Kirschner wires) acquired a superficial
wound infection. Three patients (treated with 2
parallel Kirschner wires) had micromotion under
fluoroscopy during implant removal as late as 6
months after surgery and were later confirmed to
have pseudarthroses. None had any postoperative
nerve palsy, ectopic calcification or ossification.
Two of 3 patients with undisplaced fractures had a
full score (100) on the Mayo Clinic performance index
for the elbow. The patient with displaced fracture who
refused surgery had a score of 90. The mean score for
patients fixed with a screw and a Kirschner wire was
99 (range, 90100); it was 93 (range, 8595) in patients
fixed with a tension-band wire plus 2 Kirschner wires,
and was 85 (range, 8090) in patients fixed with 2
Kirschner wires only. The overall mean score in the
operated group was 93 (range, 80100). Patients fixed
with 2 Kirschner wires alone fared worse than those
in the other 2 groups and required a longer period of
physiotherapy (Table). Patients who underwent a more
rigid form of fixation tended to have better scores, but
the difference was not statistically significant (possibly
owing to the limited sample size).
DISCUSSION
Medial epicondylar fractures are common in children,4
and are caused by a valgus force combined with
contraction of the forearm flexors. Most classifications
are based on the amount of fracture displacement.5
Controversy arises regarding treatment of displaced
(>5 mm) fractures. Surgery is indicated when there
is peripheral nerve entrapment or an associated
irreducible dislocation from an entrapped intra-
articular fracture fragment.
Medial elbow stability depends on the medial
collateral ligament of the elbow and the forearm
flexors.6 The medial collateral ligament consists
Vol. 15 No. 2, August 2007 Medial humeral epicondylar fractures in children 173

of 3 bands. The eccentric position of the medial
epicondyle ensures that one of the 3 bands remains
taut throughout the range of movement. When the
medial epicondyle is displaced, the entire collateral
ligament is displaced with the fracture fragment.
When the tautness of the medial collateral ligament
decreases, medial instability of the elbow is likely to
occur. It can be diagnosed by examining the patient
under anaesthesia with the elbow flexed nearly 90.
This may explain the seemingly benign natural
history of some displaced medial epicondylar
fractures following conservative treatment.3
The growth potential of the patient should
also be considered when deciding conservative
versus operative treatment for a displaced fracture,
which is essentially an avulsion injury of a traction
apophysis. In this type of traction apophysis
(especially in younger patients with years of growth
remaining), chronic traction can cause increased
underlying bone formation (similar to self-induced
focal chondrodiastasis). Such patients may develop
medial epicondylar enlargement and even cubitus
valgus when treated conservatively. Therefore,
we recommend operative fixation for displaced
medial epicondylar fractures in children with years
of growth remaining and/or those who are active
in sports, particularly javelin or baseball.7 When a
fracture occurs in a subject near skeletal maturity,
fixation with a screw plus an anti-rotation Kirschner
wire should be chosen (assuming the fragment can
accommodate a screw). In younger children who still
have years of growth, fixation with a tension-band
wire plus 2 parallel Kirschner wires should be used,
as this overcomes the risk of inducing cubitus varus
by a screw across the growing apophysis.
Poorly treated displaced medial epicondylar
fractures may lead to symptomatic medial elbow
instability. Late cases of instability may require
fragment excision and ligamentous repair (or
advancement) that involves fixation with suture
anchors.7 The later the reconstruction, the greater was
the liability to attenuated ligaments. Replacing the
ligaments with tendon grafts is not easy, as the exact
tension is difficult to judge,8 and the use of tendon
grafts alone may not replace the function of the anterior
band of the normal medial collateral ligament, which
is taut in certain positions of elbow flexion.
CONCLUSION
Surgical intervention is recommended for displaced
medial epicondylar fractures in young patients. For
younger children, fixation with a tension-band wire
plus 2 smooth parallel Kirschner wires is preferred,
as the risk of damaging the traction apophysis by
a screw is avoided. For individuals near skeletal
maturity, fixation with a screw plus an anti-rotation
Kirschner wire, or a tension-band wire plus 2 parallel
Kirschner wires should be used.

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