Extraction of incarcerated medial epicondyle from the elbow joint using conventional nerve stimulator: a case report
© Dorman et al.; licensee BioMed Central Ltd. 2014
Received: 17 March 2014
Accepted: 22 July 2014
Published: 7 October 2014
Incarceration of the medial epicondyle is a well-recognised sequelae following closed reduction of the elbow. Manipulation for extraction is not usually successful and hence an incarcerated medial epicondyle is usually an indication for open reduction and fixation.
We describe a simple technique of closed reduction using a conventional nerve stimulator to extract an incarcerated medial epicondyle in a 13-year-old Caucasian boy. This technique uses contraction of the attached common flexor muscles to indirectly extract the trapped medial epicondyle.
This is a simple technique using a commonly available nerve stimulator and may obviate the need for extensile open reduction for extraction of the incarcerated medial epicondyle. We would recommend this technique where closed reduction methods have failed.
Incarceration of the medial epicondyle (ME) is a well-recognised sequelae following closed reduction of the elbow [1, 2]. Early diagnosis and prompt extraction of incarcerated ME is essential in preventing growth disturbance and disability [2, 3]. Manipulation for extraction is not usually successful and hence an incarcerated ME is usually an indication for open reduction and fixation .
We describe a simple technique of closed reduction of an incarcerated ME using a conventional nerve stimulator. This technique uses contraction of the attached common flexor muscles to indirectly extract the trapped ME.
On follow up he had no ulnar nerve symptoms, a good range of motion and the fracture had healed in an excellent position.
Humeral ME fractures account for up to 20% of all paediatric elbow fractures and 60% of these humeral ME fractures are associated with elbow dislocation ; ME incarceration is a well-recognised sequelae of elbow reduction .
Early diagnosis, anatomical reduction, and internal fixation are key to reducing the risk of growth disturbance, articular incongruence, and disability . Traditionally, an incarcerated fragment is an absolute indication for open reduction. Relative indications include ulnar nerve dysfunction, high demand athletes and displacement >2mm .
Closed reduction of an incarcerated ME fragment using a conventional nerve stimulator uses contraction of the attached common flexor muscles to indirectly reduce the ME.
Due to the proximity of the ulnar nerve and potential fracture displacement it is probable that open reduction internal fixation may still be required. The general recommendation is that if after closed reduction of elbow or after extraction of the ME fragment through this approach more than 5mm displacement still persists, then it requires an internal fixation for optimal results.
This novel technique however facilitates a minimally invasive approach, reducing the amount of force applied, preventing complications such as soft tissue injury, fragment splitting and periosteal stripping caused by surgical instruments . Furthermore this is the first known report of its kind and as such may have valid application for a wide range of avulsion fractures.
This simple technique using a commonly available nerve stimulator may obviate the need for extensile open reduction  for extraction of an incarcerated ME. We would recommend this technique where other closed reduction methods have failed.
Written informed consent was obtained from the patient’s legal guardian(s) for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
We would like to thank Medical Illustrations in Perth Royal Infirmary for their help with the photographs and to Mr Ian Christie for his help with the editing and illustrations.
- Purser DW: Dislocation of the elbow and inclusion of the medial epicondyle in adults. J Bone Joint Surg Br. 1954, 36 (2): 247-249.PubMedGoogle Scholar
- Gottschalk HP, Eisner E, Hosalker HS: Medial epicondyle fractures in the pediatric population. J Am Acad Orthop Surg. 2012, 20 (4): 223-232. 10.5435/JAAOS-20-04-223.View ArticlePubMedGoogle Scholar
- Fowles JV, Kassab MT: Displaced fractures of the medial humeral condyle in children. J Bone Joint Surg Am. 1980, 62 (7): 1159-1163.PubMedGoogle Scholar
- Hines RF, Herndon WA, Evans JP: Operative treatment of medial epicondyle fractures in children. Clin Orthop Relat Res. 1987, 223: 170-174.PubMedGoogle Scholar
- Kamath AF, Cody SR: Open reduction of medial epicondyle fractures: operative tips for technical ease. J child Orthop. 2009, 3: 331-336. 10.1007/s11832-009-0185-6.View ArticlePubMedPubMed CentralGoogle Scholar
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