Eric Edmonds, MD, FAAOS | Andrew Pennock, MD, FAAOS | James Bomar

With the child in a supine position, an approach is made to the medial elbow at the location of the fracture bed (and not the fragment) after a tourniquet is inflated. A blunt finger dissection is made to expose the hematoma and fracture. After confirming that the fracture fragment is mobile, via one of many possible techniques that does not risk disruption to the fracture fragment, a guide pin from a cannulated screw set is then placed in the center of the medial epicondyle fragment. The tip is watched as it is advanced, being careful to protect the ulnar nerve posteriorly. The tip of the guide pin is then set at the corresponding position of the fracture bed. The angle of the pin is then adjusted to travel up the medial column of the distal humerus metaphysis (with a slight anterior aim to avoid breaching the posterior cortex proximally), and subsequently advanced without necessarily performing a reduction of the fragment. Fluoroscopy is then obtained (two views) to confirm that the guide pin insertion at the fragment matches the insertion at the fracture bed, and that the position of the pin is a suitable position for a screw. A partially-threaded screw with a washer (to help prevent splitting of the fragment) is then inserted over the guide pin following drilling of the outer cortex of the fragment. Compression of the screw is performed, reducing the fragment, while protecting the nerve posteriorly. After confirming the reduction and screw placement via imaging, the guide pin is removed and the incision irrigated and closed in a standard fashion.