Authors of section

Authors

Andrew Howard, Theddy Slongo

Executive Editor

Fergal Monsell

General Editor

Chris Colton

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Closed elbow reduction; splint immobilization

1. Introduction

The medial epicondyle fracture is an avulsion fracture of the apophysis and often accompanies elbow dislocation. Closed reduction of the medial epicondyle is most successful if done at the time of reduction of the elbow dislocation itself.

If the medial epicondylar fragment is trapped in the joint, open reduction is often necessary, although the following closed reduction maneuver can be attempted.

The main soft tissue attachments of the medial epicondyle are the flexor-pronator muscles of the forearm. These remain attached to the fragment and can be used to aid closed reduction.

Percutaneous fixation is not recommended due to vulnerability of the ulnar nerve.

closed elbow reduction splint immobilization

2. Patient preparation

This procedure is normally performed with the patient in a supine position.

See also the additional material on preoperative preparation.

arthrotomy and excision

3. Closed extraction of the medial epicondyle from the elbow

With the elbow near full extension, a gentle valgus force is applied to open the medial side of the joint.

closed elbow reduction splint immobilization

The fingers and wrist are fully extended, while the forearm is fully supinated.

This causes the flexor-pronator mass to pull the medial epicondyle away from the elbow joint.

The elbow joint itself is then reduced by longitudinal traction followed by flexion.

A complete and congruent reduction of the radiocapitellar and humeroulnar articulations, as well as the position of the medial epicondyle, are assessed using image intensification.

closed elbow reduction splint immobilization

4. Immobilization

If reduction of the fracture is acceptable, the arm is immobilized in a splint at 90° flexion for no more than 10-14 days.

13 m 7m

5. Postoperative care

Supracondylar humeral fractures heal rapidly and often within 3-5 weeks.

Immobilization with the elbow in 90° flexion is recommended for fractures treated without pinning.

Immobilization with the elbow in 45°-90° flexion is recommended for fractures treated with intraosseous K-wires.

Analgesia, including ibuprofen and paracetamol, should be administered regularly, with additional oral narcotic medication for breakthrough pain.

splint immobilization

Compartment syndrome

Compartment syndrome is a possible early postoperative complication that may be difficult to diagnose in younger children.

The child should be examined regularly, to ensure finger range of motion is comfortable and adequate.

Neurological and vascular examination should also be performed.

Increasing pain, decreasing range of finger motion, or deteriorating neurovascular signs should prompt consideration of compartment syndrome.

See also the additional material on postoperative infections.

splint immobilization

Discharge care

When the child is discharged from the hospital, the parent/caregiver should be taught how to assess the limb.

They should also be advised to return if there is increased pain or decreased range of finger motion.

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

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

For the first few days, the elbow and forearm can be elevated on a pillow, until swelling decreases and comfort returns.

When the limb is comfortable, the child may optionally use a sling to support any splint if desired. Many children are more comfortable without a sling.

splint immobilization

Follow-up x-rays

Control x-rays may be taken at one week following injury to assess fracture position and then at three weeks, out of any splintage, to assess fracture healing.

Removal of cast or splint

Fractures treated by closed reduction with splints, or casts, and fractures treated with closed reduction and percutaneous pinning should have the splintage removed 3 weeks after the injury date.

K-wire removal

Protruding K-wires can be removed in the clinic, without anesthesia.

A simple sling can be provided for comfort.

Recovery of motion

As symptoms recover, the child should be encouraged to remove the sling and begin active movements of the elbow.

The majority of elbow motion is recovered rapidly within the two months after the splint is removed. The older child may take a little longer.

Once the child is comfortable, with a nearly complete range of motion, he/she may resume noncontact sports incrementally. Resumption of unrestricted physical activity is a matter for judgment by the treating surgeon.