Downloaded from http://journals.lww.com/shoulderelbowsurgery by BhDMf5ePHKbH4TTImqenVPWx2hcEpdL/fjfohfPZbZjxYbvUlhf05uZSFCrBb/eqfQpye/aCuyg= on 08/24/2020 Symptomatic Nonunion of the Medial Humeral Epicondyle Fracture: A Case Report and Review of the Literature Rachid Maanouk, MD, Mohamed Bensaka, MD, Abdelkrim Baroudi, MD, Said Senhaji, MD, Hatim Abid, MD, Mohamed Elidrissi, MD, Abdelhalim El Ibrahimi, MD, and Abdelmajid Elmrini, MD Abstract: Symptomatic nonunion of medial epicondyle fractures of the humerus is a rare entity. The surgical technique can be difficult due to anatomic and biomechanical factors, such as the high tension and the torsional forces applied from the flexor-pronator tendon origin. The most common complications of nonunion of the medial humeral epi- condyle fracture are chronic pain, instability in valgus of the elbow, and neuropathy of the ulnar nerve. We described the case of 1 patient with symptomatic medial humeral epicondyle nonunion, who underwent open reduction and internal fixation with excellent clinical evolution after 1 year of follow-up from time of surgery. The purpose of this study was to evaluate the outcome of open reduction and internal fixation of a medial epicondyle nonunion fragment in 1 case and present a review of the literature. Key Words: humerus, epicondyle, nonunion, symptomatic, ORIF (Tech Should Elb Surg 2020;21: 84–87) F ractures of the medial humeral epicondyle are relatively common in childhood. 1 Nondisplaced medial epicondyle fractures of the humerus are best treated by conservative methods. Intra-articular displaced fractures, fractures with ulnar nerve entrapment, and unstable fractures should be treated with open reduction and internal fixation (ORIF). 1–3 There are some controversies about the treatment methods of displaced extra- articular fractures of the humeral medial epicondyle. Nonunion rates of displaced extra-articular medial humeral epicondyle fractures are reported to be as high as 90%. However, most of them remain asymptomatic without any functional deficit. 1,4 Although not common, symptomatic medial humeral epi- condyle nonunion could be disabling for patients with a painful elbow and unstable medial collateral ligament (MCL). Moreover, missed incarceration of the medial epicondyle with ulnar nerve entrapment in the joint can lead to a chronic pain and a stiff elbow with ulnar nerve neuropathy. 5 Another controversy is about the treatment of symptomatic medial epi- condyle nonunion. Excision of the fragment is recommended in several reports; however, excision is not a solution for instability. 1,6 Satisfying results were reported with ligament repair with the excision of the fragment. 1,6 Although achieving osseous union with ORIF is difficult due to small fragment size and hardware prominence, it is the optimal way to restore distal humerus anatomy and therefore obtain normal biomechanics of the elbow joint. The purpose of this study was to evaluate the outcome of ORIF of a medial epicondyle nonunion fragment about one case and present a review of the literature. CASE PRESENTATION We report the case of a patient admitted to the orthopedic department of the Hassan II University Hospital Center of Fez. She was a 27-year-old patient, a student, had a body mass index of 20 kg/m 2 , with no pathologic history, presented with an old trauma of the right elbow, due to a fall from a height with direct reception; the patient did not initially consult. Three years later, the patient consulted for right elbow pain with VAS at 5/10, and paresthesia on the territory of the ulnar nerve. The clinical examination objectified a limitation of the mobility of the right elbow to 10 to 110 degrees, with pain on palpation of the medial epicondyle of the humerus, instability in valgus, and without sensory-motor deficit, in particular, of the ulnar nerve. Mayo Elbow Performance Score (MEPS) at 40 and Quick Disability of Arm, Shoulder, and Hand (Q-DASH) score at 72.7. Frontal and lateral elbow x-ray showed nonunion of the medial epicondyle with a small fragment displaced anteroinferiorly (Fig. 1). At the operating room, the patient was placed in the lateral decubitus position and under general anesthesia with a tourniquet on the root of the limb (Fig. 2). Via the posterointernal approach of the right elbow, she initially benefited from an anterior transmuscular release and transposition of the ulnar nerve, which was incarcerated in an interfragmentary fibrosis (Fig. 3). Thereafter, in a second phase, a reduction of a fragment of the medial epicondyle after re-awakening (Fig. 4) and fixing was carried out, because of the small size of the fragment, by one cancellous screw 3.5 without washer (due to lack), associated with a graft of cancellous bone taken from the olecranon (Fig. 5). Immobilization by bandaging the elbow to the body for 3 weeks was performed. The immediate postoperative follow-ups were simple, and func- tional rehabilitation was started after 3 weeks. The evolution was marked by the disappearance of the pain with a marked reduction in paresthesia of the ulnar nerve. Radiographs objectified a consolidation of the fragment of the medial epicondyle after 3 months of follow-up, with a slight ascent of the fragment compared with its anatomic situation (Fig. 6). After 15 months of follow-up, the patient was satisfied with the surgical treatment with disappearance of pain (EVA score at zero), an MEPS of 85, and Q-DASH score of 9.1. DISCUSSION Conservative management often serves well in case of acute injuries, nondisplaced or minimally displaced fractures (according to Wilkins classification), 7 or Papavasiliou 8 type 1 fracture, that is, a small degree of avulsion of the epicondyle fragment. Although the frequency of nonunion or fibrous union in these conservatively treated patients is fairly high, 1,4,9,10 most patients remain asymptomatic. Although rare, only a small From the Orthopedic Department II, University Hospital Center HASSAN II of Fez, Fez, Morocco. The authors declare no conflict of interest. Reprints: Rachid Maanouk, MD, Orthopedic surgery resident, Orthopedic Department II, University Hospital Center HASSAN II of Fez, Fez 30000, Morocco (e-mail: rachidmaanouk@gmail.com). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. CLINICAL OUTCOMES 84 | www.shoulderelbowsurgery.com Techniques in Shoulder & Elbow Surgery  Volume 21, Number 3, September 2020 Copyright r 2020 Wolters Kluwer Health, Inc. All rights reserved.