Type-V Median Nerve Entrapment in a Pediatric Medial Condyle Fracture: A Case Report

Outcomes in children with delayed surgical treatment of medial humeral condyle fractures

PURPOSE

Medial humeral condyle (MHC) fractures are easily overlooked in young patients. This can lead to delayed or incorrect diagnosis, resulting in delayed treatment, which is often associated with complications such as nonunion, osteonecrosis, fishtail deformity, and cubitus varus. The purpose of this study is to evaluate the clinical and radiographic outcomes in a cohort of paediatric patients who underwent delayed surgery for an untreated MHC fracture.

METHODS

From January 2017 to December 2022, we conducted a retrospective study of paediatric patients who underwent delayed treatment for a MHC fracture. In all cases, the initial diagnosis was incorrect and surgery was performed at least one week after injury. Patients were divided into two groups based on the time between trauma and surgery: Group 1 consisted of individuals who underwent early delayed treatment within seven to 30 days of injury, while Group 2 consisted of those who underwent late delayed treatment more than one month after injury. Elbow function was assessed using the Mayo Elbow Performance Score (MEPS) and range of motion (ROM). The related literature was also reviewed (1970-2023).

RESULTS

We enrolled 12 patients (7 boys, 5 girls); the average age at the time of surgery was 7.7 years (range, 2-14 years). Six patients underwent early delayed treatment (Group 1) while another six underwent late delayed treatment (Group 2). The mean time from injury to surgery was 17.7 days (range, 7-30 days) and 33.3 months (range, 70 days-9 years) in Groups 1 and 2, respectively. Open reduction and internal fixation were performed via a medial approach in 11 patients, while one patient underwent closing wedge osteotomy and internal fixation to correct cubitus varus deformity. The mean duration of follow-up was 39.4 months (range, 8-60 months). The average MEPS score was 98.3 in Group 1 (range, 95-100) and 94.2 in Group 2 (range, 85-100; P = 0.21). The following postoperative complications were recorded: heterotopic ossification (n = 2), fishtail deformity (n = 1), MHC necrosis (n = 1), and reduction of elbow ROM (n = 1); one complication occurred in Group 1 and five occurred in Group 2 (P = 0.18). We reviewed nine related studies (n = 14 patients).

CONCLUSIONS

Diagnosis of MHC fractures can be challenging in paediatric patients, especially in younger individuals with incompletely ossified trochlea. Patients requiring surgery for delayed MHC fractures with an unossified trochlea should undergo ORIF to prevent progressive varus deformity. On the other hand, in patients with cubitus varus and an already ossified trochlea, distal humeral osteotomy should be considered instead of ORIF. This will minimize the potential negative impact on joint mobility.

Current concepts in diagnosis and management of common upper limb nerve injuries in children

Peripheral nerve injuries (PNI) of the upper limb are a common event in the paediatric population, following both fractures and soft tissues injuries. Open injuries should in theory be easier to identify and the repair of injured structures performed as soon as possible in order to obtain a satisfying outcome. Conversely, due to the reduced compliance of younger children during clinical assessment, the diagnosis of a closed nerve injury may sometimes be delayed. As the compliance of patients is influenced by pain, anxiety and stress, the execution of the clinical manoeuvres intended to identify a loss of motor function or sensibility, can be impaired. Although the majority of PNI are neuroapraxias resulting in spontaneous recovery, there are open questions regarding certain aspects of closed PNI, e.g. when to ask for electrophysiological exams, when and how long to wait for a spontaneous recovery and when a surgical approach becomes mandatory. The aim of the article is therefore to analyse the main aspects of the different closed PNI of the upper limb in order to provide recommendations for timely and correct management, and to determine differences in the PNI treatment between children and adults.

Medial Condyle Fractures of the Humerus in the Pediatric Population: Diagnostic Challenges: A Report of 3 Cases

CASE

We describe 3 cases of children, ages ranging from 3 years 11 months to 6 years 3 months, who presented with medial condyle fractures (MCF) over a 3-year period with 3 distinct treatment outcomes.

CONCLUSION

Pediatric MCFs are rare and difficult to diagnose, but evidence of severe edema in the presence of an apparent avulsion fracture on the medial side of the elbow in patients younger than 6 years old could suggest the possibility of a displaced fracture of the medial humeral condyle and additional assessment involving evaluation under anesthesia, arthrography, or advanced imaging may be warranted. Open reduction with internal fixation should be considered for displaced fractures.