Clin Orthop Surg.  2017 Dec;9(4):542-546. 10.4055/cios.2017.9.4.542.

A Neglected Markedly Displaced Medial Epicondyle Fracture with Simultaneous Ulnar Nerve Palsy in an Adolescent

• EL-Sobky T
• Haleem JF
• Sakr HM
• Aly AS

• KMID: 2412258
• DOI: http://doi.org/10.4055/cios.2017.9.4.542

Abstract

Humeral medial epicondyle fractures constitute around 15% of pediatric elbow fractures. Up to 60% occur in association with elbow dislocations. Knowledge of potential imaging pitfalls when examining acute elbow fractures in children contributes significantly to accurate diagnosis. Nevertheless, management of missed pediatric medial epicondyle fractures has rarely been reported. We present an 11-year-old boy with a neglected and severely displaced medial epicondyle fracture with concurrent ulnar nerve palsy. We performed neural decompression, fragment excision, and muscular and capsuloligamentous reconstruction of the medial elbow. This study demonstrates that the surgical outcome of a late presenting fracture can be satisfactory in terms of function and neural recovery. It also underscores the importance of careful interpretation of elbow imaging including normal anatomic variants.

Keyword

Pediatric elbow trauma; Distal humeral epiphyseal injuries; Ulnar nerve ultrasound; Normal anatomic variants

MeSH Terms

Child
Delayed Diagnosis
Diagnostic Errors
Elbow Joint/injuries/*surgery
Epiphyses
Humans
Humeral Fractures/*complications/diagnostic imaging/*surgery
Male
Ulnar Neuropathies/*complications/*surgery

Figure

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  Fig. 1 Preoperative plain radiographs of the right elbow. Note that various degrees of forearm rotation in the anteroposterior (A, B, C) and oblique views (D) affect medial epicondylar fragment visualization (arrows). The depicted epicondylar fragment was shown to be equivalent in size to that of the normal elbow (see Fig. 4E).

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  Fig. 2 Three-dimensional volume rendering computed tomography images (A, B) are apparently impressive of intra-articular fragment location. Note widening of the humeroulnar joint space.

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  Fig. 3 Ulnar nerve status. (A) Intraoperative image. Note the contused segment (arrows) of the ulnar nerve, the retracted stump of the flexor-pronator mass after fragment excision (hollow arrow), and the medial epicondyle fracture bed (arrow head). (B) Preoperative photograph showing ulnar clawing. (C) One-year postoperative photograph demonstrating full resolution.

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  Fig. 4 One-year follow-up imaging evaluation. Note the irregular fragmented appearance of the trochlear epiphysis (arrows) in the anteroposterior radiograph (A) and axial (B), sagittal (C), and coronal (D) computed tomography images. (E) Anteroposterior radiograph of the normal left elbow at the same follow-up session. Note the ossified medial epicondylar fragment (arrow) and absent trochlear epiphysis ossification. (F) Longitudinal ultrasound images of the right (RT) and left (LT) common flexor origin showing fanning of the right (injured) one due to reattachment.

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