This document provides information on apophyseal injuries of the distal humerus, including fractures of the medial and lateral epicondyles and intercondylar fractures. For medial epicondyle fractures, the fragment is often displaced distally and may become incarcerated in the joint. They are typically treated nonoperatively with immobilization, while operative treatment is required for irreducible fragments. Lateral epicondyle fractures involve avulsion of the extensor tendon origin and are also usually treated nonoperatively. Intercondylar fractures involve displacement of articular fragments and rotation of the condyles. Treatment depends on the degree of displacement and comminution, ranging from nonoperative immobilization to open reduction

1. INTRODUCTION,MECHANISM OF
INJURY,DIAGNOSIS AND MANAGEMENT OF
APOPHYSEAL INJURIES OF DISTAL
HUMERUS INCLUDING T & Y CONDYLAR
FRACTURES
Dr.y.saipramod

2. • These comprise 11%–20% of distal humerus fractures.
• Of these fractures, 60% are associated with elbow
dislocations.
• The male-to-female ratio is 4:1.
• The medial epicondyle is a traction apophysis for the
medial collateral ligament and wrist flexors.
MEDIAL EPICONDYLAR APOPHYSEAL INJURIES

3. • The fragment is usually displaced distally and may
be incarcerated in the joint (15% to 18%) .
• It is often associated with fractures of the proximal
radius, olecranon, and coronoid.
• More common than lateral epicondylar fractures
owing to the relative prominence of the epicondyle
on the medial side of the elbow

4. Mechanism of injury:
• Direct:
Trauma to the posterior or posteromedial aspect of the
medial epicondyle.
•Indirect:
 Secondary to elbow dislocation: The ulnar
collateral ligament provides avulsion force.

5. Avulsion injury by flexor muscles results from valgus and
extension force during a fall onto an outstretched hand or
secondary to an isolated muscle avulsion from throwing a
ball or arm wrestling

6. Clinical evaluation:
• Pain, tenderness, and swelling medially.
• Symptoms may be exacerbated by resisted wrist
flexion.
• Decreased range of motion - mechanical block to range
of motion may result from incarceration of the
epicondylar fragment within the elbow joint.
• Valgus instability can be appreciated on stress testing
with the elbow flexed to 15 degrees to eliminate the
stabilizing effect of the olecranon

7. • AP, lateral, and oblique radiographs of the elbow should be
obtained.
• Better visualization may be obtained by a slight oblique
view, which demonstrates the posteromedial location of the
apophysis.
• A gravity stress test may be performed, demonstrating
medial opening on stress radiographs
Radiographic evaluation:

8. • Most medial epicondylar fractures may be managed
nonoperatively with immobilization.
• Nonoperative treatment is indicated for nondisplaced or
minimally displaced fractures and for significantly
displaced fractures in older or low-demand patients.
• The patient is initially placed in a posterior splint with
the elbow flexed to 90 degrees with the forearm in
neutral or pronation.

9. • The splint is discontinued 3 to 4 days after injury and
early active range of motion is instituted. A sling is
worn for comfort.

10. Operative
• An absolute indication for operative intervention is an
irreducible, incarcerated fragment within
the elbow joint.
• Closed manipulation may be used to attempt to extract
the incarcerated fragment from the joint - Roberts.
The forearm is supinated, and valgus stress is
applied to the elbow, followed by dorsiflexion of the wrist
and fingers to put the flexors on stretch.

11. • This maneuver is successful approximately 40% of the
time.
• Relative indications for surgery include ulnar nerve
dysfunction owing to scar or callus formation, valgus
instability in an athlete, or significantly displaced
fractures in younger or high-demand patients.

12. • After reduction and provisional fixation with Kirschner
wires, fixation may be achieved with a lag-screw
technique.
• Postoperatively, the patient is placed in a posterior splint
or long arm cast with the elbow flexed to 90 degrees and
the forearm pronated. This may be converted to a
removable posterior splint or sling at 7 to 10 days
postoperatively, at which time active range-of-motion
exercises are instituted.

13. Complications:
• Unrecognized intra-articular incarceration: An
incarcerated fragment tends to adhere and form a
fibrous union to the coronoid process, resulting in
significant loss of elbow range of motion.
excision of the fragment.
• Ulnar nerve dysfunction: 10% to 16%
• Nonunion: May occur in up to 60% of cases with
significant displacement treated nonoperatively

14. • Loss of extension: A 5% to 10% loss of extension is
seen in up to 20% of cases
• Myositis ossificans

15. • very rare
• The lateral epicondyle represents the origin of many of
the wrist and forearm extensors; therefore,avulsion
injuries account for a proportion of these fractures.
.
Lateral Epicondylar Apophyseal Fractures

16. Mechanism of Injury:
• Direct trauma to the lateral epicondyle
• Indirect trauma may occur with forced volar flexion of
an extended wrist, causing avulsion of the extensor
origin

17. Clinical Evaluation:
• Lateral swelling and painful range of motion of the
elbow and wrist, with tenderness to palpation of the
lateral epicondyle.
• Loss of extensor strength

18. Treatment:
Nonoperative
With the exception of an incarcerated fragment within the
joint, almost all lateral epicondylar apophyseal fractures
may be treated with immobilization with the elbow in the
flexed, supinated position until comfortable, usually by 2
to 3 weeks.

19. Operative:
• Incarcerated fragments within the elbow joint may be
simply excised.
• Large fragments with associated tendinous origins may
be reattached with screws or Kirschner wire fixation
and postoperative immobilization for 2 to 3 weeks until
comfortable.

20. Complications
• Nonunion: Commonly occurs with established fibrous
union of the lateral epicondylar fragment
• Incarcerated fragments: May result in limited range of
motion, most commonly in the radiocapitellar
articulation, although free fragments may migrate to the
olecranon fossa and limit terminal extension.

21. • It is the second most common distal humeral fracture
(next to extra-articular).
• Fracture fragments are often displaced by unopposed
muscle pull at the medial (flexor mass) and lateral
(extensor mass) epicondyles, which rotate the articular
surfaces.
Intercondylar Fractures

22. Mechanism of Injury:
Force is directed against the posterior aspect of an elbow
flexed >90 degrees, thus driving the ulna into the trochlea.

23. Riseborough and Radin
classification
Type I: Nondisplaced
Type II: Slight
displacement with no
rotation between the
condylar fragments
Type III: Displacement
with rotation
Type IV: Severe
comminution of the
articular surface

24. Treatment:
Treatment must be individualized according to patient
age, bone quality, and degree of comminution.
Nonoperative: indications
1. nondisplaced fractures
2. elderly patients with displaced fractures and
severe osteopenia and comminution,
3. patients with significant comorbid conditions
precluding operative management.

25. Nonoperative options for displaced fractures include:
• Cast immobilization
• “Bag of bones”: The arm is placed in a collar and cuff
with as much flexion as possible after initial reduction
is attempted; gravity traction helps effect reduction.
The idea is to obtain a painless “pseudarthrosis,” which
allows for motion.

26. Operative
• Open reduction and internal fixation
• This is indicated for displaced reconstructible
fractures.
• Goals of fixation are to restore articular congruity and
to secure the supracondylar component.

27. Methods of fixation include:
• Interfragmentary screws
• Dual plate fixation: one plate medially and another plate
placed posterolaterally, 90 degrees from the medial plate
or two plates on either column, 180 degrees from one
another
• Total elbow arthroplasty (cemented, semiconstrained):
This may be considered in markedly comminuted
fractures and with fractures in osteoporotic bone

28. Postoperative care: Early range of motion of the elbow is
essential unless fixation is tenuous.
Complications:
• Posttraumatic arthritis
• Failure of fixation: Postoperative collapse of fixation is
related to the degree of comminution, the stability of
fixation, and protection of the construct during the
postoperative course.

29. • Loss of motion (extension): This is increased with
prolonged periods of immobilization. Rangeof- motion
exercises should be instituted as soon as the patient is
able to tolerate therapy, unless fixation is tenuous.
• Heterotopic bone formation
• Neurologic injury (up to 15%): The ulnar nerve is
most commonly injured during surgical exposure.

30. Thank you