Incarcerated Medial Epicondyle Fractures With Elbow Dislocation: Risk Factors Associated With Morbidity

Incarcerated medial epicondyle fractures in association with elbow trauma are rare and an absolute indication for intervention. Because of the infrequent nature, outcomes following this injury are not well documented. We studied a large cohort of these injuries to determine factors associated with functional outcomes. It was hypothesized that a greater duration between initial presentation and time of surgery would lead to poorer outcomes.

A total of 32 patients aged 18 and under who underwent surgical treatment for an incarcerated medical epicondyle fracture at a level-1 pediatric trauma center from 2003 to 2015 were identified. All patients had a confirmed diagnosis of an incarcerated medial epicondyle at surgery. Medical records and radiographs were reviewed to determine the patient demographics, mechanism of injury, preoperative neurological symptoms, time of primary presentation, time of elbow reduction, and time to surgical intervention. Postoperative outcomes, including pain, range of motion, and ulnar nerve symptoms, were also collected. The Roberts outcome score was determined for each subject.

A radiographically confirmed elbow dislocation was identified in 25 subjects. The mean age at injury was 13.2 years (range, 7.3 to 17.8 y). Initial presentation was at a referring institution in 30 patients (94%). First closed reduction attempt of the ulnohumeral joint occurred in the emergency room in 24 subjects (75%); of these 7 subjects (22%) had a first reduction attempted in the emergency room at our institution, 2 patients experienced first elbow reduction during surgical intervention. The median time from first presentation to surgery was 21.9 hours (interquartile range, 15 to 40). Fourteen subjects displayed preoperative ulnar nerve symptoms. Of these, 9 subsequently reported postoperative ulnar nerve symptoms. There was no effect of time to surgical intervention on the Roberts outcome scores at follow-up, nerve symptoms, symptomatic hardware, or need for second surgery to remove hardware. There were 16 subjects with excellent outcomes, 13 with good outcomes, 3 with fair outcomes, and 0 with poor outcomes (based on the Roberts criteria).

Incarcerated medial epicondyle fractures are commonly associated with ulnar nerve symptoms; however, they are not associated with a significant rate of other complications. There was no increased risk of complications in subjects who had a longer duration between initial presentation and surgery. This suggests that, while the presence of an incarcerated medial epicondyle fracture is certainly an indication for timely operative intervention; the injury in isolation does not need to be considered emergent. Other factors including neurovascular status and ability to achieve joint reduction may still necessitate emergency operative care.

Level IV-therapeutic study, case series.