Open reduction; K-wire fixation

The main goals for treatment (nonoperative or operative) of these ligament injuries are:

• Restoration of elbow stability
• Prevention of nonunion of the epicondyle
• Prevention of secondary displacement

The main principles of treatment for these displaced injuries are:

• To achieve reduction and stable fixation
• Restoration and maintenance of elbow stability

Note: The lateral humeral epicondyle is intracapsular.

A double-tipped K-wire of appropriate size (1.0-1.25 mm), depending on the size of the fragment.

General anesthesia is recommended and a sterile tourniquet should be available.

The patient is placed supine with the arm draped up to the shoulder.

A standard lateral approach to the elbow is used.

As the lateral epicondyle is visualized the following can be seen:

• In younger children with an isolated cartilage avulsion, the amount of bleeding is minimal
• In older children with a bony avulsion, bleeding is visible from the site of avulsion

Note: In these illustrations, the extensor muscle group is represented by only one muscle.

The avulsed ligament and bony fragment are orientated to provide a direct view of the fracture surface.

One or two retrograde double ended K-wires are passed through the fragment, from inside out, as illustrated.

The fragment is then reduced under direct vision and the wire(s) advanced, avoiding the olecranon fossa and the physis.

The wire is bent over, cut, and embedded using a punch.

Note: A cast with the forearm in either neutral or supinated position is required to prevent secondary displacement.

Note: In any case of elbow immobilization by plaster cast, careful observation of the neurovascular situation is essential both in the hospital and at home.

See also the additional material on postoperative infection.

It is important to provide parents/carers with the following additional information:

• The warning signs of compartment syndrome, circulatory problems and neurological deterioration
• Hospital telephone number
• Information brochure

If the child remains for some hours/days in bed, the elbow should be elevated on pillows to reduce swelling and pain.

The postoperative protocol is as follows:

• Discharge from hospital according to local practice (1-3 days)
• First clinical and radiological follow-up, depending on the age of the child, 2-3 weeks postoperatively out of the cast
• During the first clinical follow-up parents/carers should be informed about the timing of implant removal
• Physiotherapy is normally not indicated