Elbow instability secondary to lateral epicondylar nounion in an adult
© The Author(s) 2012
Received: 18 October 2011
Accepted: 26 November 2012
Published: 11 December 2012
Symptomatic nonunion of the lateral epicondyle of the elbow is a rare injury. We present the case of a 36-year-old woman who complained of elbow pain and instability several months after a conservatively treated lateral epicondyle fracture that evolved into nonunion. In order to reestablish elbow stability, the patient underwent removal of the nonunited epicondylar fragment and ligament repair, with excellent clinical outcome.
Fractures of the lateral epicondyle are commonly seen in the pediatric population but are rare injuries in adults . They occur more frequently as avulsion fractures during an episode of acute posterolateral or varus instability in which the lateral collateral ligament complex avulses a bone fragment with its attachment . Nonunion after a conservatively treated lateral epicondylar fracture has been previously described in adults, but typically, these patients are asymptomatic without any complaint of elbow instability. We present the case of a 36-year-old woman with a symptomatic lateral epicondyle nonunion who underwent removal of and epicondylar fragment and ligament repair with an excellent clinical outcome.
Avulsion fractures of the lateral humeral epicondyle in adults are rare. Although they can be caused by a direct blow to the elbow, they more frequently represent a bony avulsion of the lateral collateral ligament complex after a varus stress [3, 4]. The preferable treatment for these fractures remains controversial. Kobayashi et al. presented a series of 12 fractures of the lateral and medial epicondyles in adults ; they suggested that although surgical treatment provides good clinical results, conservative management could be selected for patients in whom the maximum diameter of the bone fragment is 13 mm or when displacement is <9 mm. Nonunion occurred in the majority of their patients treated conservatively, but none of them had any complaints or functional limitation. However, Gilchrist and McKee presented five adult patients with valgus instability of the elbow secondary to medial epicondyle nonunion . To our knowledge, posterolateral elbow instability has not been previously described after an epicondylar nonunion. The reasons for an epicondylar nonunion becoming symptomatic are not known. It might be more frequent in throwing athletes and heavy laborers in whom the elbow is subjected to high-strain stresses at the fracture site . However, it is probably more related to fragment size and extent of intra-articular involvement that may lead to communication of the fracture site with intra-articular fluid, which impairs bone healing. In this regard, we believe that examination under fluoroscopy may be helpful in identifying fractures with joint involvement and acute instability. The combination of intra-articular extent of the fracture and instability are probably the most determinant factors in nonunion development.
As this is a rare clinical scenario, the optimal treatment for established epicondylar nonunion with symptomatic instability remains unknown. Surgical treatment would be preferred if there is radiographic evidence of nonunion and the patient has significant functional impairment. Fracture fixation with or without bone grafting was been successfully used in children . However, bone healing may be difficult to achieve in an adult due to small fragment size, limited contact area available with sclerotic avascular surfaces, and presence of a very high degree of strain. Excision of the epicondyle fragment and ligament advancement has been previously described for acute fractures and symptomatic medial epicondyle nonunion . Excellent clinical results have been reported, obviating the need of bone grafting or a secondary procedure for hardware removal. Once the bone fragment is removed, the ligament is usually shortened to some degree, and it may be difficult to reattach it to its original position. Meticulous preservation of the entire available length and reattaching the ligament under the appropriate tension are essential. In our case, we combined a transosseous standard technique with a running suture to reinforce the repair.
In conclusion, lateral epicondyle fractures are rare injuries that merit careful evaluation in the acute setting. Large fragment size, evidence of instability, and fracture extension into the joint are probably the most predisposing factors for nonunion. If there is a symptomatic nonunion, fragment excision and ligament reattachment may lead to an excellent functional outcome.
Conflict of interest
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