Hi, I'm Todd Lawrence from the Children's Hospital of Philadelphia, and in this talk, I'll share some tips and tricks on surgical approach to medial epicondyle fractures. I have no relevant disclosures related to this presentation. So as you're probably aware, there's currently some debate as to the best treatment for medial epicondyle fractures. However, because this is a surgical technique talk, I'll try to focus my comments here on the surgical treatment of these fractures. The medial epicondyle is a posterior structure on the medial elbow that contains a number of structures important for maintaining stability of the elbow with various overhead activities. Because the biomechanics of the elbow can be significantly altered if fractures heal in an anterior position, reduction and fixation of significantly displaced fractures would seem to be the most reliable way to restore normal elbow biomechanics. When assessing fracture displacement, despite early reports noting that plain film assessment of displacement was not reliable, our recent multicenter study group found that using a corresponding point analysis was quite reproducible and reliable. This technique basically involves measuring the greatest distance between two points that you feel should go together if the fracture were perfectly reduced. We also found that the axial view had substantial reliability as well in real world use. CT-based measurements are also very reliable, but not necessary in all cases. I find CT scans most useful in cases where the treatment decision can't be made based on other criteria. It's also sometimes helpful in cases where there was a traumatic dislocation to help identify additional intra-articular pathology, or even just the true nature of the pathology. This is a classic example presented by Eric Edmonds' paper noting that the AP view is essentially looks non-displaced, but then a CT scan showed a significant anterior displacement. Here's another case example of a traumatic dislocation, a 13-year-old gymnast. In this case, the post-reduction CT scan showed some intra-articular loose bodies in the joint that then allowed us to, at the time of surgery, find those and get them out. This patient ultimately did well. My treatment algorithm still looks like this. Minimally displaced fractures are always treated non-operatively, and significantly displaced fractures are always offered operative treatment. Those fractures that still have a bit of the avulsed fragment overlapping the fracture bed can go either way, but I leaned more towards operative management for those that might benefit from a more stable elbow, i.e. overhead athletes, and more towards non-operative management for those that don't. When it comes to actually fixing these fractures, the first decision to make is how you're going to position the patient. At our institution, most of the surgeons prefer the prone position. In fact, in a recent study we just completed, basically every surgeon who tried the prone position kept using it as their preferred position. While this position does take longer to set up, most of our surgeons and trainees feel that the procedure is less of a struggle since it allows for better visualization of the fracture and you're not finding an unstable elbow and tight flexor-prone intermass. We usually use two large gel bolsters, one under the upper chest to elevate the shoulder basically above the level of the bed. A hand table is placed on the bed so that the shoulder and hand can both be positioned on the hand table. The sloppy lateral approach is an alternative for patients with decreased internal rotation because it elevates the shoulder a bit further off of the bed. Once prepped and draped, a large bump under the humerus helps stabilize the elbow in the proper position. And then if you get a smaller bump under the hand, that helps hold the wrist in flexion. I usually make a straight incision trying to stay just anterior to the medial epicondyle. If I can't exactly feel where I think it should be, I usually try to stay just anterior to the mid-humeral line, which you normally can feel. Basically you just don't want the screw head to be right under the incision when everything is all put back together. I usually perform a blunt dissection more distally in the incision first. The fascia of the flexor peroneator is very distinct, and once I find it, I follow things at that level approximately back up to the medial epicondyle fragment and raise small anterior and posterior flaps. The next step is to find the ulnar nerve and release it enough to protect it during the reduction. Currently, I only release the nerve enough to allow a retractor to be in the space between the nerve and the fracture bed. The floor of the cubital tunnel is essentially the fracture line for the average medial epicondyle, so making sure that it doesn't get pinched or tethered somehow in the reduction process is pretty critical to your success. In this picture, the ulnar nerve is back there, just off the rim of the fracture bed. Once the fragments are identified and cleared up, the fracture can be reduced. I usually add a suture to the proximal tendon to help with control of the fragment as well as reinforcement of the repair later. I use the sutures to get the piece kind of hovered over the fracture bed, and then usually use a small-toothed pickup or adsen to adjust rotation and fine-tune the fit of the medial epicondyle piece back in the fracture bed. In older throwers, scraping off the residual fysis cartilage can promote faster bone union. With the fracture reduced, I then place a guide wire for an appropriately-sized cannulated screw. Given the posterior location of the medial epicondyle, the wire trajectory is usually slightly posterior to anterior. I try to shoot for the center of the piece, but if I have to err, I tend to err more anteriorly to prevent posterior breakout. I shoot for a screw size that's no more than one-third of the size of the ossified fracture fragment, but there's no real scientific basis for that recommendation as I know it. A couple comments about the use of a washer. Washers do spread out the compression force of the screw, and this may minimize the risk of splitting the fragment. However, washers may also increase the prominence of the hardware. Some have suggested that this may increase the risk of hardware removal, although our recent review didn't confirm this finding. For me, the addition of a washer is on a case-by-case basis, but I usually lean toward using a washer if I'm a little off-center, and I pretty much always add one if we have made multiple K-wear passages through the fragment. Before the screw is finally tightened, I wrap the control sutures around the base of the screw and try to tie the knots proximally or anteriorly away from the ulnar nerve. Finally, a periosteal repair is performed with an absorbable suture, again, trying not to put any knots in the cubital tunnel. Combinuted fractures can sometimes be stabilized with suture anchors. Into the fracture bed, you have to be kind of creative, a lot of your sports tricks to do this. And then younger patients can be stabilized with smooth K-wires, but you need a good soft tissue repair to back this up. I usually immobilize these patients for one to two weeks post-op, and then switch them to some form of immobilization that allows early range of motion exercises, but still protects the elbow in uncontrolled situations. Overhead athletes can spend their early rehab working on other factors that may have contributed to their injury in the first place, such as solar motion. There are multiple pitfalls to watch out for when treating these patients. As many of these injuries are associated with elbow dislocations, you may want to make sure you carefully assess these patients for additional injuries. Careful attention must be paid to the ulnar nerve to ensure that it is not entrapped or injured during the procedure. Care should also be taken to assess for ulnar nerve subluxation following procedure. Fragment breakage can be a problem, especially if the screw is too posterior, such that a bone bridge back there is not big enough to resist the anterior pole of the fluxopronator. Fragment breakage can also be a problem if you put multiple holes in the fragment with a K-wire prior to finding your ideal position. With compression, fracture lines can propagate through these holes. Finally, there are a number of things to watch out for. With screw placement, you want to make sure the screw is perfectly up the medial column and doesn't engage the lateral cortex. A screw tip through the lateral cortex creates a stress riser that can increase the risk for a distal humerus fracture. Also, screws that are too low can get into the lacron fossa and block motion. Screws that ride up the anterior cortex finally can sometimes unwind and fall apart in you, which just looks bad on x-rays. So in conclusion, when fixing medial picondal fractures, I would encourage you to try the prone position. I bet you'll like it. Back up your screw fixation with a soft tissue repair. Use a washer if you think you need it, but you don't have to use a washer. Watch out for the ulnar nerve and make sure it's not subluxating over the screw or caught in your repair when you finish the case. Thank you for your attention, and thanks to my partners and colleagues who shared cases and images for this talk.

Todd Lawrence

Children's Hospital of Philadelphia

surgical approach

medial epicondyle fractures

reduction and fixation