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.
4. Screw fixation
A hole of appropriate size is made in the center of the epicondylar bed using a 2.0 mm K-wire.
The avulsed ligament and bony fragment is orientated to provide a direct view of the fracture surface.
A retrograde drill hole is made in the center (as illustrated).
Pearl: It is useful to make this hole one size larger than the cannulated screw guide wire as this prevents the fragment from splitting during screw insertion.
A guide wire for a cannulated screw is inserted by hand through the epicondylar fragment. It is then advanced into the predrilled hole in the metaphysis. The wire is used to guide the fragment into its reduced position.
Once the fragment is reduced, a screw is placed over the guide wire and inserted.
Note: Care should be taken not to split the fragment and use of a washer should be considered. A plastic washer with teeth is preferable. The use of a washer increases the likelihood of subsequent screw removal.
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.