You are in: eMedicine Specialties > Orthopedic Surgery > ELBOW Medial Humeral Condyle FractureArticle Last Updated: Feb 14, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: John J Walsh IV, MD, Associate Professor, Department of Orthopedic Surgery, University of South Carolina School of Medicine John J Walsh, IV, is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, and Christian Medical & Dental Society Coauthor(s): Lee A Patterson, MD, Staff Physician, Department of Orthopedic Surgery, Atlanta Medical Center; Joseph Rectenwald, MD, Staff Physician, Department of Orthopedic Surgery, Palmetto Richland Memorial Hospital Editors: Jegan Krishnan, MBBS, FRACS, PhD, Chair, Senior Clinical Director, Department of Orthopedic Surgery, Flinders Medical Centre and Repatriation General Hospital, Flinders University of South Australia; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Michael Yaszemski, MD, PhD, Associate Professor, Departments of Orthopedic Surgery and Bioengineering, Mayo Foundation, Mayo Medical School; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine Author and Editor Disclosure Synonyms and related keywords: medial condyle, medial epicondyle, medial column, medial epicondylar apophysis, medial condyle fracture, medial epicondyle fracture, elbow fracture, broken arm, broken elbow INTRODUCTIONSection 2 of 12
  Medial condyle fractures involve a fracture line that extends through and separates the medial metaphysis and epicondyle from the rest of the humerus (see Image 1). By definition, the fracture line must involve the trochlear articular surface. Medial condyle fractures must not be confused with medial epicondyle fractures that involve the medial column but are extra-articular (see Image 2). These 2 fracture patterns are separate entities and are treated differently. Both fracture patterns may be difficult to diagnose in young children, especially before the secondary ossification centers have formed.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education articles Broken Arm and Broken Elbow. History of the ProcedureMedial condyle fracture Fracture of the medial condyle of the humerus is a rare injury. Isolated case reports appear in the literature. Although the medial condyle fracture has been described in the literature since the early 1800s, some controversy exists as to whether these were descriptions of true medial condyle fractures or whether these were really descriptions of more common medial epicondyle fractures. Studies have reported greater numbers of medial condyle fractures in the literature; however, the overall incidence of these fractures remains quite low. Of all elbow fractures in children, medial condyle fractures are reported to account for less than 1%.1, 2, 3, 4, 5, 6, 7, 8, 9, 12 In 1964, Milch proposed the first classification system for unicondylar humerus fractures.13 The Milch system is based on the location of the fracture line in the distal humeral epiphysis. Milch first described an avulsion fracture due to a transverse valgus force. He then described a classification system for 2 types of fracture caused by longitudinal forces. A Milch type I fracture splits the trochlear groove, leaving the lateral trochlear ridge intact (see Image 1). A Milch type II fracture splits the capitotrochlear sulcus such that the lateral trochlear ridge is part of the fracture fragment (see Image 1). A type II fracture is inherently unstable and is called a fracture dislocation.4 The avulsion and type I fractures can be treated open or closed; however, more complex type II fractures should be treated only with open reduction and internal fixation (ORIF).7 In 1965, Kilfoyle combined his own experience with 5 colleagues to collect a total of 11 examples of medial condyle fracture and separated them into 3 types of injury (see Image 3).14 Type I involves a greenstick fracture or crush of the medial condyle metaphysis down to but not including the physis. He also stated that these may actually be incomplete supracondyle or intracondyle fractures. Type 2 involves a fracture through the physeal plate and epiphysis without displacement or rotation. Type 3 is similar to type 2 but with moderate-to-severe displacement and rotation of the fracture fragment. Medial epicondyle fracture In 1818, Granger reported the first unequivocal description of a medial epicondyle fracture. Granger described a fracture that resolved rapidly and left little functional deficit. In the early 1900s, several authors recognized that the fracture was often associated with elbow dislocation and that the avulsed fragment could become entrapped within the joint. In 1950, Smith dispelled many of the complications previously attributed to medial epicondyle fractures. Smith refuted that medial epicondyle fractures were associated with growth disturbance, pain and disability, weak elbow flexion, or ulnar nerve dysfunction and went on to prove his theories in his classic study. He concluded that fractures involving the medial epicondyle were relatively benign and were not associated with significant functional deficit. Farsetti et al confirmed Smith's conclusions.15 Even in 42 patients with isolated fractures of the medial epicondyle with displacement of 5-15 mm, no significant difference was found between those treated with ORIF and those treated nonsurgically. No universally accepted system exists for classification of medial epicondyle fractures. ProblemInjuries to the medial aspect of the distal humerus in young children can range from an avulsion fracture of the medial epicondyle to a much more serious Salter-Harris type IV fracture of the medial condyle, which crosses the physeal plate.16 The distinction between these types of fractures is key to the selection of appropriate treatment. This diagnosis may be difficult to ascertain due to the limitations of radiographic visualization of cartilaginous fractures observed with the developing anatomy in this area. Inadequate reduction of the physeal growth plate and the joint surface cartilage in a medial condyle fracture can lead to serious complications. The age of the patient, the extent of initial injury and displacement, and delay in initial treatment play important roles in the clinical outcome. For medial epicondyle fractures, nonoperative management of fractures displaced up to 15 mm does not appear to be associated with functional deficit unless there is entrapment of the epicondyle fragment in the joint. Entrapment of the epicondyle fragment in the joint can block motion, and therefore, the fragment should be reduced. FrequencyFracture of the medial condyle is very rare, especially when compared to frequency of other elbow fractures. In one study, radiographs of 589 elbow fractures in children younger than 16 years were reviewed. The most common fractures were the supracondyle fracture (55%), radial neck fracture (14%), lateral humeral condyle fracture (12%), medial epicondyle fracture (8%), and olecranon fracture (7%). No cases of medial condyle fracture were reported.17 Fractures of the medial condyle are so rare that they receive little coverage in most popular textbooks and may not be mentioned at all in others. The incidence is described in the literature from less than 1-2% of all elbow injuries in children. Most displaced medial condyle fractures occur when the trochlea is not ossified completely. In some studies, the average age has varied (ie, age 10, 11, 9.5, and 7 years). Although a child of any age can sustain this fracture, it is most common during the developing years (ie, in children aged 7-14 years). Medial epicondyle fractures are much more common than medial condyle fractures. In a large combined series of 5228 fractures of the distal humerus, medial epicondyle fractures constituted 14.1% of all distal humeral fractures and 11.5% of all fractures occurring around the elbow. Medial epicondyle fractures are 4 times as likely to occur in males, and most cases occur in children aged 9-14 years. Peak incidence is in children aged 11-12 years. The reported incidence of association with elbow dislocation reaches 55% in some series, and the fragment may be incarcerated in the joint in approximately 15-18% of cases.18 EtiologyMedial condyle fracture The following 3 possible mechanisms for medial condyle fracture1, 2, 3, 5, 6, 7, 8, 9, 11, 12 have been described:
Medial epicondyle fracture Three mechanisms of injury for medial epicondyle fractures19, 20 have been proposed for an acute injury. All 3 mechanisms result in a partial or complete separation of the apophyseal fragment from the rest of the humerus. The 3 mechanisms are as follows:
PathophysiologyIn the developing elbow, fracture through the medial condyle involves part of the cartilaginous or partially ossified trochlea and the ossified medial epicondyle. With the insertion of the common flexor tendon of the forearm and the medial collateral ligament on the medial epicondyle, the fracture fragment tends to rotate around the axis of the epicondyle and can present at various degrees of rotation. Complete rotation puts the fracture surface facing the anterior and medial side of the elbow, with the medial epicondyle pulled distally and the articular surface facing posteriorly and laterally. In addition, the surrounding soft tissues can be torn, and there may be damage to the articular surface of the ulna. Damage to the articular capsule or medial collateral ligament of the elbow may be present. The ulnar nerve and the vasculature surrounding the elbow joint are also at risk. The blood supply to the epiphysis enters with the attachment of the medial collateral ligament and the common flexor tendon. Separation of these structures at the time of injury or at surgery may lead to avascular necrosis. The medial epicondyle fragment is usually displaced distally, although at least 2 cases of displacement of the fragment proximally have been reported (see Images 11-12). The fracture line usually involves only the apophysis; however, occasionally a fragment of metaphyseal bone is found attached to the avulsed fragment. If the fragment is incarcerated within the joint, the fragment may become adherent to the coronoid process of the ulna. When the fragment is incarcerated within the joint, the universal finding is a thick fascial band that binds the ulnar nerve to the underlying muscle. This thick fascial band is responsible for ulnar nerve dysfunction, either acutely or as a late finding. Other elbow fractures may be associated with medial epicondyle fractures, and care must be taken to recognize the full extent of the injury. Associated injuries include radial neck fractures, olecranon fractures, and coronoid process fractures. ClinicalMedial condyle fracture The patient usually presents with a recent history of a significant fall on an outstretched hand or directly on the apex of the flexed elbow. The elbow may be severely painful following this injury. Swelling, deformity, and loss of function of the elbow may be present. Palpable crepitus may be present over the medial condyle. Elbow motion may be decreased due to swelling and pain. The patient often holds the elbow fixed at approximately 90° of flexion. The patient may present with medial dislocation of the forearm, referred to as a fracture dislocation. Distal neurovascular changes may occur, especially in the ulnar nerve distribution. Other injuries may be present that are easier to detect, such as elbow dislocation or fracture of the radial head or olecranon, which may distract the physician from making the diagnosis of medial condyle fracture. A high index of suspicion for this type of injury concurrent with other elbow injuries can ensure timelydiagnosisandtreatment.1, 2, 3, 5, 6, 7, 8, 9, 11, 12 Medial epicondyle fracture The presentation of a patient with a medial epicondyle fracture does not differ significantly from that of a patient with a medial condyle fracture, as described above. A through physical examination should include a valgus stress test to assess for instability of the anterior oblique band of the ulnar collateral ligament (see Image 8-14). The test is performed with the patient supine and the arm abducted 90º. The shoulder and arm are externally rotated 90º, with the elbow flexed at least 15º to unlock the olecranon. Valgus stress is then placed through the elbow to assess for ligamentous instability.19, 20 INDICATIONSSection 3 of 12
Medial condyle fracture Salter-Harris type IV injuries with 2 mm or more of displacement usually require ORIF. A displaced medial condyle fragment or instability of the fragment with closed reduction is an indication for open reduction with rigid internal fixation. Accurate apposition of the fracture surfaces is important to reduce the risk of growth plate disturbance and to prevent loss of motion due to articular incongruence. Nondisplaced fractures can be treated without surgery. Medial epicondyle fracture For nondisplaced or minimally displaced fractures, nonoperative management is the procedure of choice (see Images 9-10). More controversy exists with displacement of 5-15 mm. Similar functional results have been reported with operative and nonoperative surgical management. Long-term functional assessment has demonstrated similar results even with radiographic nonunion being apparent on most of the fractures treated nonoperatively. Irreducible incarceration of the medial epicondyle fragment and open fracture are indications for operative management. Excision of the comminuted medial epicondyle fragment has been associated with less optimal results. Other controversial relative surgical indications include complete ulnar nerve dysfunction after an injury or reduction attempt and valgus instability in high-demand athletes19, 20.21 RELEVANT ANATOMYSection 4 of 12
The humerus is a bone in the arm. The distal humeral physis, also called the growth plate, is located between the humeral metaphysis proximally and epiphysis distally. The distal humeral epiphysis is bordered proximally by the physeal growth plate and distally by its articular surface with the ulna and radius. The humeral metaphysis is the growing portion of the humerus that lies between the epiphysis and diaphysis (the shaft or central part of a long bone).22, 23 The medial condyle of the humerus is the medial column of the distal expansion of the humerus that includes the trochlea, the coronoid fossa, the olecranon fossa, the medial epicondyle, the medial supracondyle ridge, the medial metaphysis, and the groove for the ulnar nerve. Trochlea means pulley. The trochlea is the distal medial articulating end of the humerus, which acts as a pulley for the ulnar trochlear notch to rotate around as the elbow is flexed. The coronoid fossa is the depression on the anterior surface of the medial condyle proximal to the trochlea that accommodates the coronoid process of the ulna. The olecranon fossa is the depression on the posterior surface of the medial condyle proximal to the trochlea, which accommodates the olecranon of the ulna. The medial epicondyle is a prominent palpable process that projects medially from the trochlea and is the point of origin of the pronator teres and common flexor tendon, which includes the flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and flexor digitorum superficialis.24 The medial supracondyle ridge is a bony ridge that runs proximally on the medial humerus from the medial epicondyle. The capitellum, a rounded ball of bone adjoining the trochlea laterally, is the distal lateral articulating end of the humerus that articulates with the radial head. The lateral epicondyle is a prominent palpable process that projects laterally from the capitellum and is the point of origin of the common extensor tendon. The lateral supracondyle ridge is a bony ridge that runs proximally on the lateral humerus from the lateral epicondyle. The ulnar nerve, which runs in close proximity to the medial epicondyle, often may be palpated as a rounded cord just posterior to this bony prominence. The elbow joint is a hinge-type synovial joint formed where the distal end of the humerus articulates with the proximal ends of the radius and ulna. This is a uniaxial joint with movements of flexion and extension. Normal range of motion is from 0° (full extension) to 135° (full flexion). Most functions of the elbow require motion of 30-130°. Consequently, a 30° extension lag has little functional significance. The normal physiologic carrying angle of the elbow in the anatomic position (full supination and extension) is approximately 165-170° (10-15° of valgus angulation). Flexion is produced by the brachialis (main flexor muscle) and the brachioradialis muscles. In supination, the biceps brachii muscle also flexes this joint; in pronation, the pronator teres assists in flexion. Flexion is limited by the apposition of the anterior surfaces of the forearm and arm, by tension of the posterior arm muscles, and by the collateral ligaments. Extension is produced by the triceps brachii muscle and is assisted by gravity and the anconeus muscle. Extension is limited by impingement of the olecranon of the ulna on the olecranon fossa of the humerus and by tension of the anterior muscles and collateral ligaments. At birth, a single cartilaginous cap covers the distal end of the humerus. During development, 4 separate ossification centers form at different times:
Further complicating this pattern of development, the trochlear ossification center is frequently composed of multiple irregularly sized foci that eventually coalesce into a single structure. The trochlear and capitellar ossification centers eventually fuse. The pattern of ossification at these multiple sites is highly variable. CONTRAINDICATIONSSection 5 of 12
If the patient is unable to tolerate a long surgical procedure due to polytrauma, closed reduction and cast immobilization with 90° of flexion is an option. WORKUPSection 6 of 12
Lab Studies
Imaging Studies
TREATMENTSection 7 of 12
Medical therapyClosed reduction and cast immobilization is adequate for nondisplaced stable medial condyle fractures. Medial epicondyle fractures also may be treated in a closed fashion if the medial epicondyle is nondisplaced, minimally displaced, or even displaced up to 15 mm (see Images 9-10). In many studies, including long-term follow-up reports, patients treated nonsurgically had results similar to those of patients treated surgically, even for fracture fragments displaced as much as 15 mm. A radiographic nonunion of the medial epicondyle fracture fragment associated with nonsurgical treatment was not found to have any functional impairment in at least 1 long-term study.1, 2, 3, 5, 6, 7, 8, 9, 11, 25, 28 The only absolute indications for operative management of closed medial epicondyle fractures are the incarceration of the medial epicondyle fragment within the joint and an open fracture. An incarcerated fragment within the joint must be removed. Several closed means of reduction can be used, and the success rate with these methods approaches 40%. One such maneuver (Roberts manipulative technique) is performed under sedation and involves placing a valgus stress on the elbow while supinating the forearm and simultaneously dorsiflexing the wrist and fingers to place the forearm flexor muscles on stretch. If employed, this maneuver is usually performed in the operating room with the patient under general anesthesia. Joint distention techniques also have been described to help facilitate the closed reduction of the incarcerated medial epicondyle fracture.19, 20, 21 Initially, the arm should be splinted in 90° of elbow flexion. Gentle active range-of-motion exercises may begin within 1 week after injury. Protective splinting may be continued for 3 weeks if necessary. Surgical therapyOpen reduction with rigid internal fixation is used (see Intraoperative details). Preoperative detailsThe arm is placed in a posterior splint for stabilization, elevated, and treated with ice packs to decrease swelling. Intraoperative detailsMedial condyle fracture A medial approach may be used. A longitudinal incision is made over the medial supracondyle ridge of the humerus and continued just distal to the medial condyle. Branches of the medial antebrachial cutaneous nerve should be identified and preserved. The ulnar nerve is identified and protected and may be transposed anteriorly. The fracture surfaces are identified and cleaned, and the joint space is cleaned and irrigated to remove loose particles. The condyle fragment is then reduced and secured at a minimum of 2 sites to prevent rotation (see Image 12). Kirschner wires (K-wires) or cancellous screws may be used. Plate-and-screw fixation is another option. The reduction should be confirmed radiographically. The wound is closed, and the arm is splinted in 90° of flexion with the forearm in the neutral position.1, 2, 3, 5, 6, 7, 8, 9, 11, 25, 28 Medial epicondyle fracture A longitudinal incision is made just anterior to the medial epicondyle. The fragment is usually displaced distally and anteriorly. As with any fracture reduction, periosteum and bone fragments are cleared from the fracture site to allow anatomic reduction. The ulnar nerve must be identified and protected. Ulnar nerve transposition is usually unnecessary. With the elbow flexed and pronated, the fracture fragment is reduced and pinned with 1-2 Kirschner wires (K-wires). A lag screw is then placed to maintain and compress the fracture fragment. Elbow stability and range of motion are assessed. A posterior splint is then applied for at least 7-10 days until range of motion is initiated.19, 20, 21, 25, 28 If the epicondyle is fragmented, excision of the fragment and fixation of the flexor-pronator origin and medial collateral ligament to bone with an alternative form of fixation (such as suture anchors) may be used. Excision of the fragment does not appear to yield results comparable to those of nonoperative treatment. Postoperative detailsWith all degrees of injury, immobilization must continue until solid union is demonstrated. Radiographs must be repeated until the union is ensured. This may be as early as 3 weeks for nondisplaced fractures and is usually approximately 6 weeks for displaced fractures but may be several months. This immobilization must be balanced with the need for physical therapy to prevent loss of range of motion. For fractures treated with ORIF, the arm should be put in a cast in 90° of flexion for 3 weeks and then placed in a posterior mold for 3 weeks with supervised active flexion and extension out of the mold. Internal fixation allows for this early physical therapy without compromising the reduction. Active range of motion with physical therapist supervision is critical to prevent excess loss of flexion and extension. Passive range of motion should be avoided because it can result in damage to contracted soft tissues and has been associated with myositis ossificans. Follow-upLate follow-up should be considered to screen for growth disturbance after injury to the epiphysis. COMPLICATIONSSection 8 of 12
Medial condyle fracture Nonunion with a thickening deformity at the fracture site can occur with inadequate reduction, fixation, or immobilization. Catgut suture as a means of internal fixation has proved to be inadequate, as it has often resulted in this complication. Malunion can result in loss of motion or angulation. As with nonunion, this can result from inadequate fixation or premature mobilization. Some minor loss of motion (flexion and extension) is a common sequela of many displaced medial condyle fractures. The degree of loss is usually minimal and does not decrease function. When the loss is related to another complication, such as nonunion, malunion, or heterotopic ossification, it can be significant. A progressive cubitus varus deformity may develop due to growth inhibition or avascular necrosis of the medial humeral condyle. This also can result from premature closure of the physis. Forty degrees of varus angulation was reported in 1 case that went untreated for 4 years. This was treated with a supracondyle wedge osteotomy to restore range of motion and correct the cubitus varus deformity. Avascular necrosis of the epiphysis can be the result of loss of blood supply during an overaggressive soft-tissue dissection in attempts to adequately expose the fracture. The blood supply to the epiphysis is through the soft-tissue attachments at the medial epicondyle. A valgus deformity also can result from imperfect restoration of position. This is usually related to an overgrowth of the medial condyle. Heterotopic ossification can result in severe loss of flexion and extension. This is often associated with delayed fixation and closed head injuries. Myositis ossificans can result from overaggressive physical therapy with passive range of motion. Pronation and supination are usually not affected. Concurrent injury to the radial head may result in decreased motion. Injury to the ulnar nerve may result in a partial clawhand, muscle weakness, and partial loss of sensation. If necessary, transposition of the nerve can be performed to reduce tension and prevent further injury. Partial or complete recovery may take months. Misdiagnosis or delay in diagnosis or treatment increases the risk of impairment and complications. Medial epicondyle fracture The 2 main complications associated with medial epicondyle fractures are failure to recognize incarceration into the joint with functional loss and ulnar or median nerve dysfunction. Most of the other complications associated with medial epicondyle fractures are considered minor and do not result in a loss of function. The main complication with an unrecognized medial epicondyle fracture is loss of motion secondary to impingement of the fragment. The second major complication involves ulnar nerve dysfunction that varies 10-16%. If the fragment is incarcerated in the joint, the incidence of ulnar nerve dysfunction can reach 50%. More profound ulnar nerve dysfunction has been observed to occur with manipulative reduction attempts, especially if closed manipulation of an incarcerated fragment is attempted. A median nerve injury may occur as well; however, this is more common with an associated elbow dislocation (see Image 11). Minor complications include radiographic nonunion of the medial epicondyle fragment in cases in which the fracture is treated closed. Functionally, any limitation from this radiographic finding does not appear to exist. A loss of elbow extension of 10-15% can be expected in up to 20% of cases, and this appears to be correlated more with prolonged immobilization than the fracture itself. Myositis ossificans has been described as a rare occurrence and has been correlated with repeated manipulation to reduce an incarcerated fragment. A significant alteration in the carrying angle of the elbow has not been demonstrated in long-term studies and does not appear to be a major issue with these fractures. OUTCOME AND PROGNOSISSection 9 of 12
Children younger than 5 years tend to have nondisplaced fractures and good results. Older children tend to have more severely displaced fractures that involve the partially developed trochlear ossification center. Good results are obtained in patients who are seen early after injury and who have adequate reduction and fixation of their fractures. In patients seen late, proper reduction and immobilization are necessary to achieve satisfactory results; however, this is usually more difficult to achieve. Preserving full range of motion of the elbow depends on restoring the snug relationship between the humerus and ulna throughout the arc of motion. Most children with medial epicondyle fractures treated either nonsurgically or surgically end up with good long-term functional results. Children with fracture displacement greater than 5 mm treated nonsurgically had results that were comparable to those of children who underwent surgical stabilization. ORIF is required in children with medial epicondyle fractures and incarcerated fragments that block motion. Comminuted medial epicondyle fractures appear to do worse if the epicondyle is excised as opposed to nonsurgical fracture treatment. FUTURE AND CONTROVERSIESSection 10 of 12
Some authors advocate routine ulnar nerve transposition, while others believe this to be unnecessary unless the ulnar nerve has been injured. Controversy exists regarding how to manage a fracture that has remained untreated for several weeks or longer. Formation of callus and fibrous tissue may obliterate the fracture site and cause a malunion that makes accurate dissection and reduction less accurate. Misdiagnosis or inadequate early treatment increases the risk of complications such as loss of movement and angulation. Some suggest conservative treatment for fractures older than 4 weeks, while others have demonstrated some restored function in treating these fractures at the time of delayed diagnosis, although results are imperfect. Supracondyle wedge osteotomy is advocated to restore anatomic angulation and motion loss from previous injury. Controversy exists regarding whether this should be performed during growth or after the physis has closed. The major controversy involving medial epicondyle fractures involves the management of displaced medial epicondyle fractures. Good results have been reported with both operative and nonoperative treatment of the displaced medial epicondyle fracture. The medial epicondyle is the origin of the medial collateral ligamentous complex (see Image 14). Some advocate operative treatment of high-demand athletes, since even minor amounts of valgus instability can result in significant disability. Others recommend nonsurgical management because several long-term studies do not appear to substantiate significant valgus instability, even in individuals who went on to have radiographic nonunion of the epicondyle. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Medial Humeral Condyle Fracture excerpt Article Last Updated: Feb 14, 2008 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
