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Commentary and Perspective   |    
Commentary on an article by Eric W. Edmonds, MD: “How Displaced Are ‘Nondisplaced’ Fractures of the Medial Humeral Epicondyle in Children? Results of a Three-Dimensional Computed Tomography Analysis”
Desmond Brown, MD1
1 Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, Massachusetts
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The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Copyright © 2010 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Dec 01;92(17):e33 1-2. doi: 10.2106/JBJS.J.01383
The main article is available here
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In this paper, the author assesses the extent of displacement of a medial epicondylar fracture of the distal end of the humerus in eleven skeletally immature patients, using both radiographs and computed tomography (CT) scans. One fracture was identified as being a medial condylar fracture and was excluded; another fracture was nondisplaced on both the radiograph and CT scan and so did not contribute to the data about displacement. In the remaining nine fractures, the author was able to measure anterior displacement on only one of the lateral radiographs, whereas CT scans demonstrated an average of 8.8 mm of anterior displacement of these fractures. Medial displacement measured an average of 3.9 mm on anteroposterior radiographs compared with an average of 0.3 mm on CT scans. Internal oblique radiographs provided a measure of displacement similar to the anterior displacement seen on CT scans of two patients, but underestimated the displacement in three others. The author concluded that radiographs often do not provide an accurate measure of displacement for medial humeral epicondylar fractures. He suggested that the apparent medial displacement seen on anteroposterior radiographs is actually anterior displacement, visible because of slight obliquity of the anteroposterior view.
This article adds to the concern about the reliability of measuring displacement of medial epicondylar fractures of the distal end of the humerus on radiographs, which was expressed in a recent article by Pappas et al.1. Those authors showed that the intraobserver and interobserver reliability of the measurements were sufficiently poor to call into question all previous studies in which radiographic measurement of displacement was used as a criterion for surgical treatment. Edmonds shows that radiographic measurements differ markedly from those made with CT and suggests that the measurements on CT more accurately reflect the true amount of displacement.
However, there are important limitations to the data presented in this paper. The data include only nine displaced fractures. The author does not appear to have standardized the position of the elbow for either the radiographs or the CT scan, although all of the lateral radiographs shown suggest that 90° of flexion was used for both. Anterior displacement of the epicondyle seen in the flexed elbow may become distal displacement in the extended elbow2. The author does not address rotational displacement of the medial epicondylar fragment, noted by previous authors3. Measurements were not made in three dimensions; the so-called three-dimensional reconstruction is in fact a two-dimensional rendering that uses shading and perspective to suggest a third dimension. Measurements were made by stacking or overlapping multiple two-dimensional images, rather than by reformatting the images to represent the plane of displacement, and thus these measurements represent only unidirectional displacement rather than true displacement. With this technique, any single measurement necessarily represents a minimum value for displacement, ignoring displacement in other planes. Finally, the author did not measure intraobserver or interobserver variability, a known source of error with radiographs that may also be present with CT measurements.
Although clinical treatment was not the focus of this article, the assumption that the extent of displacement may affect the outcome, and the type of treatment offered, clearly is. In a recent systematic review, Kamath et al. found that operative treatment was associated with a higher rate of osseous union than was nonoperative treatment, but it was also associated with higher rates of pain (15% vs. 8.7%) and ulnar nerve symptoms (4.5% vs. 2.5%)4. Despite the lack of convincing clinical evidence in favor of operative treatment, many authors continue to recommend open reduction and internal fixation for medial humeral epicondylar fractures displaced more than some threshold, typically 5 or 10 mm. Concern for future elbow stability and the needs of the adolescent "throwing athlete" serve as additional support for operative treatment. The limited usefulness of the lateral radiograph for determining displacement of medial epicondylar fractures is well known5, but Pappas et al. proposed guidelines for improving the measurement of displacement on anteroposterior radiographs1 that could be used in a clinical trial. As far as I know, there are no published clinical series, other than the few patients presented in this article, in which displacement on a CT scan was used as a criterion for surgery. Furthermore, displacement on CT scans should not be used as a surgical criterion until a randomized trial has demonstrated that treatment based on the extent of displacement, whether measured on radiographs or on CT scans, can lead to improved outcomes. There is increased concern by physicians and the public about exposure to radiation from CT6. The infrequency of poor results with nonoperative treatment militates against an aggressive approach to diagnosis and treatment of medial epicondylar fractures on the basis of fracture displacement.
Pappas  N;  Lawrence  JT;  Donegan  D;  Ganley  T;  Flynn  JM. Intraobserver and interobserver agreement in the measurement of displaced humeral medial epicondyle fractures in children. J Bone Joint Surg Am.  2010;92:322-7.[PubMed][CrossRef]
 
Silberstein  MJ;  Brodeur  AE;  Graviss  ER;  Luisiri  A. Some vagaries of the medial epicondyle. J Bone Joint Surg Am.  1982;63:524-8.
 
Woods  GW;  Tullos  HS. Elbow instability and medial epicondyle fractures. Am J Sports Med.  1977;5:23-30.[PubMed]
 
Kamath  AF;  Baldwin  K;  Horneff  J;  Hosalkar  HS. Operative versus nonoperative management of pediatric medial epicondyle fractures: a systematic review. J Child Orthop.  2009;3:345-57.[PubMed]
 
Chessare  JW;  Rogers  LF;  White  H;  Tachdjian  MO. Injuries of the medial epicondylar ossification center of the humerus. AJR Am J Roentgenol.  1977;129:49-55.[PubMed]
 
Amis  ES  Jr;  Butler  PF;  Applegate  KE;  Birnbaum  SB;  Brateman  LF;  Hevezi  JM;  Mettler  FA;  Morin  RL;  Pentecost  MJ;  Smith  GG;  Strauss  KJ;  Zeman  RK. American College of Radiology white paper on radiation dose in medicine. J Am Coll Radiol.  2007;4:272-84.[PubMed]
 

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References

Pappas  N;  Lawrence  JT;  Donegan  D;  Ganley  T;  Flynn  JM. Intraobserver and interobserver agreement in the measurement of displaced humeral medial epicondyle fractures in children. J Bone Joint Surg Am.  2010;92:322-7.[PubMed][CrossRef]
 
Silberstein  MJ;  Brodeur  AE;  Graviss  ER;  Luisiri  A. Some vagaries of the medial epicondyle. J Bone Joint Surg Am.  1982;63:524-8.
 
Woods  GW;  Tullos  HS. Elbow instability and medial epicondyle fractures. Am J Sports Med.  1977;5:23-30.[PubMed]
 
Kamath  AF;  Baldwin  K;  Horneff  J;  Hosalkar  HS. Operative versus nonoperative management of pediatric medial epicondyle fractures: a systematic review. J Child Orthop.  2009;3:345-57.[PubMed]
 
Chessare  JW;  Rogers  LF;  White  H;  Tachdjian  MO. Injuries of the medial epicondylar ossification center of the humerus. AJR Am J Roentgenol.  1977;129:49-55.[PubMed]
 
Amis  ES  Jr;  Butler  PF;  Applegate  KE;  Birnbaum  SB;  Brateman  LF;  Hevezi  JM;  Mettler  FA;  Morin  RL;  Pentecost  MJ;  Smith  GG;  Strauss  KJ;  Zeman  RK. American College of Radiology white paper on radiation dose in medicine. J Am Coll Radiol.  2007;4:272-84.[PubMed]
 
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