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   Table of Contents      
CASE REPORT
Year : 2021  |  Volume : 7  |  Issue : 1  |  Page : 90-94

An innovative fixation technique for pediatric bi-epicondylar avulsion fracture of humerus


Department of Orthopaedic Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India

Date of Submission13-Nov-2020
Date of Decision05-Feb-2021
Date of Acceptance05-Feb-2021
Date of Web Publication28-Apr-2021

Correspondence Address:
Dr. Sumit Arora
Department of Orthopaedic Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_117_20

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  Abstract 


Bi-epicondylar avulsion fracture of the distal humerus is a rare injury and poses challenges for treating orthopaedic surgeons. We present a case of 11-year-old boy who presented with bi-epicondylar avulsion fractures of the distal humerus that was managed with innovative ‘synergistic tension band analogue technique’ and resulted in good clinical outcome.

Keywords: Biepicondylar fracture, distal humerus, fracture fixation, pediatric elbow


How to cite this article:
Kumar M, Kumar A, Goyal L, Arora S, Gautam VK. An innovative fixation technique for pediatric bi-epicondylar avulsion fracture of humerus. MAMC J Med Sci 2021;7:90-4

How to cite this URL:
Kumar M, Kumar A, Goyal L, Arora S, Gautam VK. An innovative fixation technique for pediatric bi-epicondylar avulsion fracture of humerus. MAMC J Med Sci [serial online] 2021 [cited 2021 Oct 24];7:90-4. Available from: https://www.mamcjms.in/text.asp?2021/7/1/90/314875




  Introduction Top


Bi-epicondylar avulsion fracture of the humerus in a child is a rare injury. Till date, very limited number of cases have been reported and most of them were associated with elbow dislocation.[1],[2],[3],[4],[5] Lateral ulnar collateral (LUCL) and anterior band of medial collateral (MCL) ligaments are the two most important soft tissue static stabilizers of the elbow joint.[6],[7],[8] Bi-epicondylar avulsion injury thus poses a significant risk to elbow stability and researchers have opined in favor of open reduction and internal fixation for this injury pattern.[1-5] Cannulated screws, Herbert screws, k-wires, and fragment excision and sutures were used for fixation of the epicondyles separately via simultaneous medial and lateral approaches. Adequate fixation of both the fractures is likely to give a satisfactory outcome in terms of fracture union, and elbow stability. Comminution of epicondylar fragments or their small sizes may pose difficulty in providing adequate fixation strength with these methods of internal fixation such as wire or screw. Thus, we used fiber-wire-based fixation method that relied on the anchorage of bone as well as attached soft tissues.

We describe an innovative technique for the fixation in this rare clinical situation that has not been used previously, to the best of authors’ knowledge, and term this as “synergistic tension band analogue technique.” The phrase “to fill two needs with one deed” aptly describe what this technique is all about.


  Case report Top


An 11-year-old boy came to us with a history of fall on an outstretched hand while playing in the field in countryside. He sustained an injury to his right elbow. His parents consulted their family physician who immobilized the limb in the arm pouch and referred him to our institution for further treatment. He presented to us a day later with pain, swelling, and inability to use the extremity. There was bruising of skin predominantly over medial aspect of elbow. Distal neurovascular status was intact. Radiographs of the elbow revealed avulsion fractures of both medial epicondyle (ME) and lateral epicondyle (LE) of the distal humerus ([Figure 1]). ME fragment was large, grossly displaced and appeared at the level of elbow joint. It did not appear to be incarcerated into the elbow joint as also evidenced by smooth extension at humero-ulnar joint [9]. Magnetic resonance imaging (MRI) of the elbow corroborated the findings of radiographs [Figure 2].
Figure 1 Antero-posterior radiograph of the right elbow showing bi-epicondylar fracture of distal humerus in skeletally immature patient

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Figure 2 Coronal sections of T2-weighted MRI of the elbow showing fractures of both the epicondyles with associated marrow and subcutaneous edema

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He was planned for open reduction and internal fixation of both the epicondyles under general anesthesia and tourniquet control. He was placed supine with the arm abducted on a radiolucent side table. The whole of the upper limb distal to the tourniquet was cleaned and draped taking all aseptic measures. Combined medical and lateral approaches were used.

Surgical technique

It is based on the principle that traction force on an epicondyle generated with each movement of the wrist and finger flexion (for ME)/extension (for LE) will be converted into compression force at the other epicondyle. It can be described in the following four steps:
  1. Medial and lateral approaches were used to expose respective avulsed epicondyles and common flexor/ extensor origins. Ulnar nerve was identified and protected with tape. A braided polyblend suture with a tapered needle (FiberWire number 2, Arthrex Inc., Florida, USA) was used to weave common flexor tendon in running stitch fashion and the two ends were delivered into the fracture bed through two holes made in the epicondylar fragment using k-wire [Figure 3].
    Figure 3 Intra-operative photograph of the case showing medial surgical wound. The common flexor tendons are seen weaved in FiberWire and the two ends of the suture are seen coming out through the fracture bed

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  2. Perpendicular to the fracture surface, two tunnels were created using 2-mm k-wires right through the base of the fracture. These tunnels are depicted in a sketch diagram using two different colors [Figure 4] (red color for the tunnel starting from medial side and green for lateral). Both the tunnels should pass proximal to the coronoid/ olecranon fossa.
    Figure 4 Line diagram showing two intraosseous tunnels, passing proximal to the coronoid/olecranon fossa, which are made perpendicular to the fracture surface for passage of sutures. The red one is depicting the tunnel starting from medial side and green for lateral one

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  3. Two suture ends were then navigated through the red tunnel into the lateral wound and again brought back into medial wound subperiosteally, under direct vision, anterior to humerus taking care not to damage neurovascular structures. From there the suture ends were passed through a green tunnel to deliver it into the lateral epicondylar avulsion fracture base. Suture lasso was used to shuttle the sutures through the tunnels easily.
  4. Similar to step 1 lateral common extensor tendon was weaved-in using a suture passing instrument (Elite Pass Premium Arthroscopic Suture Shuttle, Smith + Nephew plc, Hertfordshire, UK) that is commonly used for rotator cuff surgery and the knot was placed just over lateral epicondyle [Figure 5].
    Figure 5 Intraoperative photograph of the case showing lateral surgical wound. Good reduction of LE fracture and well-placed knot over it is seen

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Satisfactory reduction and stability were achieved with this technique and it was verified by intraoperative elbow movements. The wound was closed in layers and the limb was immobilized above the elbow plaster-of-Paris slab for a week to provide postoperative pain relief and allow the soft tissue envelope to heal satisfactorily. Range of motion exercises was started after that within the limits of comfort. Postoperative radiographs obtained after plaster removal revealed satisfactory reduction [Figure 6]. He regained full elbow movements after 12 weeks and the functional and radiological result was excellent when last followed by at 12 months [Figure 7].
Figure 6 Postoperative radiographs obtained after plaster removal (on seventh post-operative day) revealed the satisfactory reduction of both the fractures

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Figure 7 Postoperative radiographs obtained after 12 months

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Written, informed consent was obtained from the parents authorizing treatment, radiological, and photographic documentation. They were also informed that the data concerning the case might be submitted for publication and they consented.


  Discussion Top


Elbow is a common site of injury in the pediatric age group. Supracondylar fracture is the commonest to be followed by lateral condyle and ME.[10] Bi-epicondylar injuries are exceedingly rare and different mechanisms of injuries have been proposed by various researchers. This fracture pattern may be a result of excessive valgus force along with anterior displacement and internal rotation of distal humerus on planted hand that puts both the epicondyles under traction. Gani et al.[1] suggested that the fall of a heavy object on an extended elbow can lead to a direct blow on LE and valgus stress on the elbow may result in ME fracture. They also pointed out another likely mechanism in which excessive valgus stress on the elbow due to the fall of heavy object on the lateral aspect of the elbow could avulse ME and radial head shears off LE.

Complex anatomy of distal humeral epiphyses and different age of appearance of ossification center (10–12 years for LE, and 4–6 years for ME) in pediatric elbow poses a significant problem in diagnosing these fractures. A careful clinical and radiological examination may be necessary as the irregular and linear ossification center of LE may, at times, simulate a fracture. On the other hand, there may be a possibility to miss these injuries on plain radiographs. Thus, radiographs of the contralateral elbow, intraoperative stress radiographs and ultrasonography, and MRI have been considered as adjuncts to plain radiographs for the diagnosis of this rare injury pattern.[11] The importance of accurately diagnosing this injury lies in the fact that this creates a highly unstable elbow and operative fixation of epicondyles restores elbow stability.

Various fixation techniques have been recommended such as cannulated screws, k-wires, Herbert screws, fragment excision, and suture.[1],[2],[3],[4],[5] We utilized “synergistic tension band analog technique” in which a single suture configuration addresses both the epicondyles. Although the construct is entirely different from tension band wiring, an analogy with the tension band principle may be drawn. We hypothesized that flexion of wrist and fingers produces tension in the common flexor tendon that will put distraction force at ME. This force will be transmitted via sutures and will pull LE in compression. Perpendicular orientation of tunnels with respect to both the fracture surfaces ensures that the forces applied are purely compressive without any shearing component. Two holes in the epicondyles were put strategically into symmetrical position to achieve uniform compression. Our assumption that a fiber wire passing through two snuggly fitting bony tunnels and bent acutely at two exit holes of the tunnels and then traversing subperiosteally anteriorly will allow the wires to glide through its convoluted path to convert traction caused by contraction of muscles at one end into compression at another end may be rather too speculative and it is quite likely that epicondyles were held in place by initial static compression achieved intraoperatively.

K-wires were used to create holes in the epicondyles and tunnels in the bone and drill bits were purposefully avoided to inflict minimum damage to growing cartilage. The fracture base was not at all debrided off any cartilage to house epicondylar fragment as usually done in screw fixation methods. Transverse growth (width) of distal humerus is only as important as longitudinal growth in long term elbow stability.[12] The weaving of tendon in suture was done with the intent of minimizing suture cut out through small thin epicondylar fragments.

This technique has several benefits over others such as (1) it involves low cost as metallic implants are not being used and just requires few reusable instruments from the arthroscopy set, (2) it takes away the need for a second surgery for implant removal in a child, (3) additionally second surgery may put ulnar nerve at risk while attempting implant removal, (4) low risk of infection as only sutures are required for fixation and no metallic implants are needed, (5) it does not put triceps tendon at risk of attrition with screw heads, (6) screw heads can cause skin impingement which can be avoided by using the proposed method of fixation; (7) K-wires can cause skin tethering and resultant loss of motion which can be avoided by using the proposed method of fixation, (8) it involves lesser risk of growth disturbance, (9) it enables one to fix small fracture fragment of ME/LE with the respective attachment of common flexor/extensor origin that otherwise is likely to cut through with other modalities of fixation as the elbow is mobilized. Nevertheless, we admit few shortcomings of this too, like: (1) longer than usual incision is needed in this technique, (2) one must be careful while passing the sutures from one tunnel to another over the anterior aspect of the humerus to avoid injury to neural and vascular structures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gani N, Rather AQ, Mir BA, Halwai MA, Wani MM. Humeral biepicondylar fracture dislocation in a child: a case report and review of the literature. Cases J 2008;1:163.  Back to cited text no. 1
    
2.
Meta M, Miller D. Paediatric biepicondylar elbow fracture dislocation-a case report. J Orthop Surg Res 2010;5:75.  Back to cited text no. 2
    
3.
Guner S, Guner SI, Ceylan MF, Gormeli G, Gormeli CA, Onder H. Biepicondylar fracture presenting with elbow dislocation: a case report. J Med Case Rep 2012;6:265.  Back to cited text no. 3
    
4.
Konya MN, Aslan A, Sofu H, Yıldırım T. Biepicondylar fracture dislocation of the elbow joint concomitant with ulnar nerve injury. World J Orthop 2013;4:94-97.  Back to cited text no. 4
    
5.
Agrawal P, Das S, Gupta V, Arora S. Unusual association of elbow dislocation with humeral biepicondylar fracture in a child: a case-report and review of literature. J Clin Orthop Trauma 2017; 8(suppl 1):s41-s44.  Back to cited text no. 5
    
6.
Bucknor MD, Stevens KJ, Steinbach LS. Elbow imaging in sport: sports imaging series. Radiology 2016;279:12-28.  Back to cited text no. 6
    
7.
Schaeffeler C, Waldt S, Woertler K. Traumatic instability of the elbow- anatomy, pathomechanisms and presentation on imaging. Eur Radiol 2013;23:2582-93.  Back to cited text no. 7
    
8.
Chung CB. Elbow ligaments and instability. In: Chung CB, Steinbach LS (eds). MRI of the upper extremity. Philadelphia, PA: Wolters Kluwer Health/ Lippincott Williams & Wilkins 2010 pp. 402-28.  Back to cited text no. 8
    
9.
Dodds SD, Flanagin BA, Bohl DD, DeLuca PA, Smith BG. Incarcerated medial epicondyle fracture following pediatric elbow dislocation: 11 cases. J Hand Surg Am 2014;39:1739-45.  Back to cited text no. 9
    
10.
Rockwood CA, Green DP, Bucholtz RW, Heckman JD (eds). Fractures in children. 7th edn. Philadelphia, PA: Lippincott Williams & Wilkins 2009 pp. 475-7, 566-70 577–8.  Back to cited text no. 10
    
11.
Morimoto T, Izumi M, Ueba H, Ikeuchi M. Humeral avulsion of the lateral collateral ligament of the elbow concomitant with the epicondyle fracture of a child with general joint laxity. Case Reports Orthop 2019;2019:1965343.  Back to cited text no. 11
    
12.
Morrissy RT, Weinstein SL (eds). Lovell and Winter’s pediatric orthopaedics. 6th edn. Philadelphia, PA: Lippincott Williams & Wilkins 2005.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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