Managing displaced fractures of the medial humeral epicondyle in children

Listen to Andrew Duckworth, David Ferguson and Daniel C. Perry discuss the paper 'Managing displaced fractures of the medial humeral epicondyle in children' published in the March 2024 issue of The Bone & Joint Journal.

Click here to read the paper.

Find out as soon as the next episode is live by following us on Twitter, Instagram, LinkedIn, Tik Tok or Facebook!

Transcript

[00:00:00] Welcome everyone to our BJJ podcast for the month of March. I'm Andrew Duckworth and a warm welcome back to you all from your team here at The Bone & Joint Journal. As always, we'd like to thank you all for your continued comments and support, as well as a big gratitude to our many authors and colleagues who take part in the series that highlights just some of the great work published by our authors each month.

So today for our monthly podcast, I have the pleasure of being joined by two authors from an editorial published in this month's edition of the BJJ entitled, 'Managing displaced fractures of the medial humeral epicondyle in children: unveiling the enigma'. 

So firstly, I'm very pleased to be joined by Mr. David Ferguson, who is a consultant paediatric orthopaedic surgeon at James Cook University Hospital in Middlesbrough. Thank you for joining us, David. It's great to have you with us. Yeah, it's a pleasure. Thank you for inviting us. And secondly, we are delighted to welcome back David's co-author, our specialty editor for paediatrics at the BJJ and an all-round cool guy, Professor Dan Perry.

Dan, it's great to have you back with us. I'm not sure I've ever been described like that before, but thank you very much. Definitely cool. Definitely cool. So Dan, if I can maybe start with you, I just thought just as a sort of scene setter, how were you taught to manage these injuries when you were training?

So [00:01:00] displaced medial epicondyle fractures, if I'm honest, it was always a little bit dependent who was on call and what the boss was and what was discussed in the trauma meeting in the morning. I think more and more as I went on through my training, we were fixing them. And so, so I certainly fixed plenty during training, but it was always a little bit of a wild feast and it was one of those ones that you could never quite predict what was going to happen.

And you have to kind of look at the rota and kind of read what boss was on call and what they think they'd do. Yeah. No, I do. It's, I think it's a really good description, Dan, because there are certain injuries and pathologies, particularly injuries, maybe, as you go through your training and you think, actually, I just don't, I can't predict this.

I don't know what we're going to be going to be doing. And I think that shows you the equipoise really. It shows you that we just don't know the answer really, I suppose as well. So David, exactly, David, how about yourself?

Yep. So I was trained in Yorkshire area and we were told similar things really, one of the things that came across a lot of the time in our trauma meetings were if the fracture fragments displaced a centimetre, you need to [00:02:00] get it fixed.

And if it's small, just use some wires. If it's bigger, use some screws. If it's less than a centimetre, just put it in a cast, leave it for four weeks. But when you went around the rotations, everyone would have a different piece of advice for you and they would just be managed. Very difficult to, as a trainee, to understand which logic to follow.

Yeah, no, I totally agree, David. So that comes on to sort of my next question, which I think probably explains a bit of what we've, we've all described. How has the management of these injuries changed over time? And how has the, I suppose, the controversy and arguments developed and evolved regarding the management?

Yeah. So I think first of all, I don't think the management has really changed for these fractures, but the opinion has. But the opinion has changed without evidence. And that's where we have like the biggest problems, really. So over the years, I think there's been a bigger lean towards operative fixation.

And it's centred on people's beliefs and family [00:03:00] expectations. Expectations being higher, a lot more sporty kids nowadays and the demands for those sporty kids and from coaches has gone up and that's fed in the US and in this country as well now. And so that puts a bit more pressure on and people wanting and having a belief that sometimes surgery is always better.

And with all the marvels and wonders of robotic surgery and everything else that's come into the front, then, families expect a lot more. And so want, want, the surgery and so that's, that's driven a lot of change, really. 

Absolutely. I thought it was interesting reading the editorial is how some of that literature and well, some of it is coming from the US and it's obviously there's a lot of baseball there and this has implications for that. I thought that was quite interesting. Is it? Do you think that sort of skewed the view at all or not?

I think it has. And, you know when you've got lots of publications coming out about opinion without really hard evidence then there's, you know, a bigger voice being heard in one corner than the [00:04:00] other.

And so we've got to step back sometimes and really appraise the evidence properly and think, well, why are we, you know, doing this and what are the real indications for surgery and going by that to start with. 

Absolutely David. And that takes me very nice on to the next sort of point, which was what are the quoted indications for surgery? Because there are one or two sort of maybe absolute indications out there, aren't there? 

There are, yeah. So indications for surgery. First of all, if you have an open fracture, then that generally means that you do need to have some kind of surgery on that. Incarcerated fragments, where if the, the fragment of bone of the medial epicondyle has gone inside the joint, then that forms another absolute indication to extract the fragment and get the joint reduced.

And then sometimes a bit more of a relative indication is when you have failure of another kind of treatment. So a failure of non-operative treatments, then you would consider the operative treatment. Yeah, no, absolutely.

But as you sort of point out with those in your tutorial, that these are relatively rare, aren't they? They're [00:05:00] not the common occurrence with these injuries, would that be fair? 

Correct. Yeah. So they're, they're, they're smaller. The indications of surgery, absolute indications are rare. Not the majority. 

Yeah, absolutely. And in terms of just before I move on, in terms of, you mentioned about the degree of displacement, is, is there any good evidence relying on that?

Or is that just like a lot of these things, a number has been picked out of the air here and there and people have gone with it. Yeah, well, the problem we have really is how do you assess the degree of displacement? And it's a problem that's not just related to medial epicondyle fractures, it's in other forms of fractures as well.

The imaging modality that we use, plain film x-rays, can get a snapshot view. Two things about it. One is that you get parallax and you get a different shift in the position of fragments depending on the view that you've taken. But also, it's sometimes it's a dynamic thing where this is a lump of bone that stays still.

So good day, it might be in one place, a bad day, it might be another. [00:06:00] And, you know, we don't give CT scans because of the high risk of, you know, high dose of radiation to, to children. So try and use low dose imaging radiation modalities as much as we can. 

Yeah, absolutely. That totally makes sense. So if we move on, Dan, if I can maybe come to you just sort of talking about, you know, obviously we're going to talk about the trial, but you know, if you were putting forward the case for non-operative management based on the current evidence, how would you sort of frame that?

Well, I think I think it's really easy, actually, because I think it's really difficult to try and justify doing surgery based on the current evidence, and I think that's the really hard thing. So, so the, the way to put forward not doing an operation is that we've got no good evidence that doing surgery is better than not doing surgery.

We know there's potential risks of doing surgery, so risk to the ulnar nerve, albeit very small, but there's nevertheless risks. And even some of the studies from the US showed that people who have fixation have more long term pain. And probably because you end up with a [00:07:00] screw and the screw can be irritable.

And we know, you know, we know it's often not one operation. It's often two operations to take the screw out. Cause it's, you know, there's not much there between the screw head and, and, and, you know, the, the kind of the, skin. So, you know, there's loads of reasons, you know, unless you've got really clear reason to fix it. Then, then I guess you should be asking, why would we fix it? Like, why would we just not treat it? 

Absolutely, Dan. So maybe if I counter that and maybe David give you the harder question, which is, if you were going to put forward the case for operating on them, maybe, maybe put aside those absolute locations. How would you, how would you frame that yourself?

Thanks, Andrew. I've been looking forward to this all day. So I would say that, you know there's, there is evidence out there, but it's weak and it's countered by evidence for and against. 

So take, for instance, certain situations such as high performance athletes, say throwing athletes. Now we know that the ulnar collateral ligament is a structure under immense tension during [00:08:00] some of these, sporting activities. And if you have a fracture and if it involves de-tensioning or displacing the ulnar collateral ligament, you get instead of isometric points on the, the, the ligament, you, you get it uncoupled and it becomes slack in certain positions of throw.

And that can lead to a bit of instability, in theory. And this is where expert opinion comes in and says, well, there might be situations here where we have a fracture that's a bit more of a soft tissue injury with the fracture than just a small chunk of bone and the, the effect on the stability of the elbow in certain groups might be such that actually fixing it back can allow the musculature to offload some of the tension going through the ulnar collateral ligament, stop it getting stretched out and lead to better performance and better function. And so, there's certain centres in the world that have tried to prove [00:09:00] this.

And they've tried to gather the evidence they've, they've had the right idea, but they've not really got the scientific studies right to convince the whole of the orthopaedic community on it, you know. And I'll give you an example of one paper by Cruz et al from Philadelphia in 2016, and they put forward the argument about why some of these sporting injury athlete's elbows should be fixed.

Now, the other things are that, you know, the ulnar collateral ligament shifting position, what, what effects does that have in the long term? And if your medial epicondyle has, has come off and displaced it, is that going to be a problem? And so there might be certain indications, and hopefully we might find that with further evidence and further trial results, that there might be subpopulations that do benefit from fixation.

At the moment, we haven't got the evidence to say absolutely categorically which ones they are, but that's a kind of an expert opinion level [00:10:00] of theory behind it. I think you did a brilliant job there. It was excellent. Basically, he didn't convince me. I'm not so sure. I think you did a brilliant job. Like you say, it's a lot more difficult to justify that, isn't it?

I think it's good to have that balance and see where people are coming from. And like you say, there will be people who, who will be out there who will come from that side very much so like you say, and that's why there's literature out there like that. So I suppose in light of all that, that takes us very nicely, Dan to your study, SCIENCE.

So like, why don't we just, I know when most listeners will probably know about it, but can you just tell us a little bit about it and, and how is it, how it, how it's going? 

Sure. So SCIENCE is well, it's got the best acronym firstly. So SCIENCE is ‘Surgery or Cast for injuries of the EpicoNdyle in Children’s Elbows’.

So SCIENCE is a big international randomized control trial which is a superiority trial. So we're asking the question is surgery better than no surgery for displaced medial epicondyle fractures? It's run in the UK in Australia and New Zealand. So it's it really is truly [00:11:00] international and we've actually finished recruitment.

So we've recruited 334 patients, between the two interventions. So they're, they're all randomized. It's all going beautifully. Our follow up rate at the moment is fantastic. It's about 86%. I know nothing more than the result of the results of another follow up rate. And we should get the result sort of September for reporting later on in the year.

Brilliant. I just, what's the primary outcome, sorry, for SCIENCE? Sure, so the primary outcome is the promise of pro extremity. So that's so, so promise tools are the, the, the, the tools which came from the US which validated the pro extremity.

It's a computer adaptive test, which is really cool because instead of asking a whole question bank of 30 questions, if you say lift up, lift a cup up or something, because, because it's kind of clever and it knows, it knows the responses based on the previous response. 

Yeah, absolutely. Absolutely. I just, one last thing in terms of, I was reading in the editorial, your outcomes will be collected at regular intervals in the first year, then annually until the patients are 16.

Is that correct? Yeah, that's right. And then even after that, we've got [00:12:00] consent for consent for longer term follow up after that as well. So we're going to keep their NHS number beyond that. So to be able to look in HES data and stuff in the future to see whether they have any elbow surgery or anything else in the future.

And that's great, isn't it? Because that's one of the things that people will be worrying about. Well, that's one of the potentials that they worry about is there any longer term effects, but it's going to find that it can look at that as well, isn't it? 

No, it's something we're really trying to do in all the kids trials, actually, and whether it's elbows or, you know, whatever it is, we're trying to do it. It's quite actually quite difficult and it's quite difficult because kids turn into adults and therefore you have to reconsider as an adult and it causes an awful pickle. But but I think it's really important that we try and do it. No, absolutely. 

And I sort of suppose finally Dan just before we finish, you know, I think it's pretty important to highlight as well. You know, this, this editorial that David's done, which is great. And I encourage all our listeners to, to go read it. It's, you know, it's, I think it's really highlighting the awesome research in paediatric orthopaedics that's going on in the UK. You know, we've, you've got a trials on ankle fractures, wrist fractures, SUFE to name just a few.

And it really is a [00:13:00] great time and a real testament to the subspecialty of how well it's going and people like yourself. 

Yeah, thanks. I mean, the whole, the whole children's community have really embraced research over the last sort of 10 years. No, not even that, five years or so. We've really kind of pulled, and it's grown, you know, it's really grown exponentially.

There's, you know, more and more chief investigators coming on board. And I think there's about seven or eight trials which are running at the moment. As you say, Perthes' disease, Cerebral palsy, Trauma, like pretty much everything, which is, it's really cool. And we're always trying to do an editorial to spread the good news in the BJJ.

Absolutely. So, so yeah. We'll hear more about them. Absolutely. Well, I think that's a good point where we can, we can wrap up guys. So you know thank you so much to you both for taking the time to, to join me and congratulations on a really interesting editorial. And it gives a really good clear overview, I think, and the balance that's required there, why we really need robust data.

And obviously congrats to you both on, on the, on, all the hard work in the community that producing these great trials. [00:14:00] It was great to have, have you both with us and to our listeners. We do hope you've enjoyed joining us and we do encourage you all to share your thoughts and comments on the various platforms, feel free to post about anything we've discussed here today.

And thanks again for joining us. Take care of everyone.