Open Reduction of Medial Epicondyle Fractures in the Pediatric Population: Supine Versus Prone Position

Abstract

Background: Operative treatment of medial epicondyle fractures can be performed in either a supine or prone position. In the supine position, fracture visualization is sometimes difficult due to the posterior position of the medial epicondyle. However, the prone position requires extensive patient repositioning but may improve visualization. The purpose of this study was to compare the results and complications between the supine and prone position when treating medial epicondyle fractures. Methods: In a retrospective chart review, patients below 18 who underwent open reduction and internal fixation of an acute medial epicondyle fracture from January 2011 to August 2019 were identified. Patients with < 2 months follow-up and concomitant fractures were excluded. Surgical variables, outcomes, and complications were recorded and compared between the supine and prone positions. Results: Sixteen surgeons treated the 204 patients evaluated in this study. The mean age was 11.7 years. In all, 122 (60%) patients were treated in the supine position, and 82 (40%) in the prone position. The mean time in the room was 113 minutes in the supine group, and 141 minutes in the prone group (P < 0.001). Tourniquet time was similar between groups (P = 0.4). Displacement of the fracture on the first postoperative x-rays was 2.06 mm for the supine position and 1.1 mm for the prone position (P < 0.001). We also found good interobserver and intraobserver reliability for the measurements. Five patients (2.5%) required reoperation due to stiffness, 2 patients due to nonunion, 1 patient due to tardy ulnar nerve palsy, and 53 (26%) had surgical hardware removal. The surgical position was not associated with complications or reoperation. Conclusions: While the prone position requires additional time in the operating room, presumably for positioning, the length of the surgical procedure itself does not differ between the 2 positions. Although the trend of the surgeons at our center is towards the prone position, with surgeons that try it usually doing all their subsequent cases that way, both positions provide excellent clinical outcomes with minimal complications. Level of Evidence: Therapeutic level III-retrospective cohort study.

Methods to Facilitate Reduction of Medial Epicondyle Fractures in the Supine Position

“…In recent years, prone position for ORIF of pediatric medial epicondylar fractures has gained considerable attention. [9][10][11] Proponents of this method report that the positioning avoids the inherent supination force and valgus load experienced at the elbow with supine positioning. 9 However, there has been no statistically significant differences identified between supine and prone position in patient outcomes for the treatment of pediatric medial epicondylar fractures, 11 indicting that both methods are viable options based upon the treating surgeon's experience and comfort.…”

He likes it! Mikey likes it!

“…We thank Drs Rehm, Ong, and Ashby for their letter commenting on our study, "Open reduction of medial epicondyle fractures in the pediatric population: supine versus prone position." 1 As we write this response, we are reminded of an old Life cereal commercial which ran for more than a decade in the 1970s. In this commercial, 2 boys who are reluctant to try a new and supposedly healthy cereal get their little brother Mickey who "hates everything," to do so.…”

“…Without there being any difference in objective outcomes between prone and supine positioning or a proven measured technical advantage for either position but increased costs for prone positioning, 1 we would like to ask Baghdadi et al 1…”

“Open Reduction of Medial Epicondyle Fractures in the Pediatric Population: Supine Versus Prone Position”

“…We read with interest the recent publication by Baghdadi et al1 Edmonds2 measured displacement of medial epicondyle fractures using computed tomography scans (CT), anteroposterior radiograph (APR), lateral radiograph (LR) and internal oblique radiograph (IOR). CT measurements were the most accurate and IORs approximated the amount of displacement but APRs and LRs were not sufficient to measure displacement, with a mean medial displacement measured on APRs of 3.5 mm compared with 0.3 mm on CT.…”

“…Considering the above,2,3 we would like to ask Baghdadi et al1 why only APRs were reviewed and if they agree that it is therefore likely that their reported significantly increased postoperative mean fracture displacement of 0.9 mm for supine positioning does not represent true overall displacement, with the possibility that there could have even been less postoperative displacement in the supine than the prone group?…”