For avulsion fractures of the medial epicondyle, a direct medial longitudinal incision is used, deepened to expose the medial face of the medial condyle.
Pearl: Take care to avoid the saphenous nerve and its infrapatellar branch.
Reduce the fracture and secure the reduction with the guide wire.
Insert a screw with or without a ligament washer.
6. Final assessment
Assessment of ligament stability
Gently examine the knee under anesthesia to test for ligament instability.
Check correct implant positioning and anatomical reduction with image intensification.
Immediate postoperative care
The patient should get out of bed and begin ambulation with crutches on the first postoperative day.
In most cases the postoperative protocol will be touch-weight bearing for the first 4 weeks.
Routine pain medication is prescribed for 3–5 days postoperatively.
The patient should be examined regularly, to exclude neurovascular compromise.
With displaced high-energy fractures watch for signs of delayed vascular problems.
Compartment syndrome, although rare, should be considered in the presence of severe swelling, increasing pain, and changes to neurovascular signs.
Discharge from hospital follows local practice and is usually possible after 1–3 days.
Clinical and radiological follow-up is usually undertaken 2 weeks postoperatively.
Follow-up for growth deformity
All patients with physeal fractures of the distal femur should have clinical and radiological examination 8–12 weeks postoperatively to assess for signs of physeal growth disturbance or resumption of growth.
Examination should be repeated at intervals until resumption of normal growth is documented. This can be seen as a horizontal growth line (Harris line) that is parallel to the entire physis on both AP and lateral views.
A growth line that converges towards the growth plate may be the earliest sign of growth arrest and should prompt investigation/treatment or referral as appropriate.
Clinical assessment of leg length and alignment is recommended at one-year.
Clinical assessment of leg length uses a tape measure from the ASIS to the medial malleolus.
If there is any concern about leg length discrepancy or malalignment, long leg x-rays are recommended.
Leg length is measured from the femoral head to the ankle joint.
If symptoms develop, the screw can be removed once the fracture is completely healed, usually 6–12 months postoperatively.