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Letter to Editor
8 (
1
); 92-93
doi:
10.25259/JMSR_217_2023

Pediatric elbow diagonal (MELAINE) injury: A rare variant

Department of Orthpedics, Government Medical College, Haldwani, Uttarakhand, India

*Corresponding author: Ganesh S. Dharmshaktu, Department of Orthpedics, Government Medical College, Haldwani, Uttarakhand, India. drganeshortho@gmail.com

Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Dharmshaktu GS. Pediatric elbow diagonal (MELAINE) injury: A rare variant. J Musculoskelet Surg Res. 2024;8:92-3. doi: 10.25259/JMSR_217_2023

Dear Editor,

The elbow is a common site of pediatric fractures, and mostly supracondylar or unicondylar fractures are commonly diagnosed and treated.[1] Careful identification and appropriate management are important, not only for a good outcome but also to avoid complications. Various other injuries may or may not be radiologically evident and may require additional investigations for the diagnosis. The Radiographic Appearance Seemed Harmless (TRASH) lesions are described and comprise various injuries that warrant careful suspicion and diagnosis before their final management.[2] Judicious use of imaging methods such as ultrasonography can also be used to diagnose occult elbow injuries or TRASH lesions.[3] Occasionally, rare fracture patterns are also noted and may require widespread acknowledgment among young practitioners.

A 13-year-old child presented with an isolated right elbow injury after a fall from a moving vehicle, following which he could not use it properly due to pain and swelling. Clinically, there was swelling and tenderness over the medial aspect of the elbow and radial head region. There was an active and passive restriction of elbow movement but without distal neurovascular deficit. The elbow radiograph revealed a fracture of the medial condyle along with an undisplaced radial neck fracture [Figure 1a]. The medial condyle fracture was displaced, and operative fixation was indicated. As the fractures were clearly evident, no other investigation, such as a computerized tomography scan, was done. The fracture was fixed with one cannulated screw and a Kirschner wire (K-wire), while the radial neck fracture was managed conservatively [Figure 1b]. A postoperative elbow plaster slab for 3 weeks was given, following which active range of motion elbow exercises was initiated. The good union of both fractures and good functional outcome was noted in the follow-up of 8 months [Figure 1c]. Full regain of flexor-extension and pronationsupination movement was noted with no clinical feature of elbow deformity or instability. The K-wire was removed after 4 weeks, and screw removal has been planned to remove in the coming winter vacation of the child in December.

(a) The radiograph shows a displaced medial condyle fracture with concomitant radial neck fracture. (b) The medial condyle fracture was fixed with one screw and a Kirschner wire, while the radial neck fracture was managed conservatively. (c) Gradual healing of both fractures was noted in the follow-up.
Figure 1:
(a) The radiograph shows a displaced medial condyle fracture with concomitant radial neck fracture. (b) The medial condyle fracture was fixed with one screw and a Kirschner wire, while the radial neck fracture was managed conservatively. (c) Gradual healing of both fractures was noted in the follow-up.

Concomitant fractures of the medial epicondyle and radial neck are considered diagonal injuries. They are also referred to as medial to lateral diagonal injuries of the elbow (MELAINE) in the literature.[4] Many of these cases require surgery for fracture stabilization and to avoid subsequent valgus deformity. A valgus force in a hyperextended elbow is a probable mechanism of this injury. It parallels a similar injury mechanism in the knee, which is termed a “diagonal lesion” of the knee.[5] A series by Lu et al. of six male and six female children described this new injury pattern and advocated proper identification and treatment.[4]

Classically, the medial epicondyle fracture is described as one component of diagonal fractures at the elbow. Our case, however, had a medial condyle fracture along with the ipsilateral proximal radial fracture. This short case snippet, thus, highlights a rare variant of the diagonal fracture. At present, the literature is sparse on this injury pattern. Global acknowledgment and frequent reporting of large case series or studies shall improve our knowledge in the future.

Ethical approval

The Institutional Review Board approval is not required.

DECLARATION OF THE PATIENT’S CONSENT

The author certifies that he has obtained all appropriate patient consent forms. In the form, the patient’s parent has given his consent for the patient’s images and other clinical information to be reported in the journal. The parent understands that the patient’s name and initials will not be published, and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

USE OF ARTIFICIAL INTELLIGENCE (AI)-ASSISTED TECHNOLOGY FOR MANUSCRIPT PREPARATION

The author confirms that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

CONFLICTS OF INTEREST

There are no conflicting relationships or activities.

FINANCIAL SUPPORT AND SPONSORSHIP

The study received no specific grant from the public, commercial, or not-for-profit funding agencies.

References

  1. , , , , , . Epidemiology of paediatric elbow fractures: A retrospective multi-centre study of 488 fractures. J Child Orthop. 2019;13:516-21.
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  2. , . Trash lesions around the elbow: A review of approach to diagnosis and management. Indian J Orthop. 2021;55:539-48.
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  3. , , , , , . Diagnostic imaging for elbow TRASH lesions in children and usefulness of ultrasonography using standard planes. J Pediatr Orthop B. 2023;32:557-64.
    [CrossRef] [PubMed] [Google Scholar]
  4. , , , , , , et al. Diagnosis and treatment of “medial to lateral diagonal injury of the elbow” in children: Concomitant medial epicondylar and radial neck fractures. J Child Orthop. 2023;17:339-47.
    [CrossRef] [PubMed] [Google Scholar]
  5. , , , , , . The “diagonal” lesion: A new type of combined injury pattern involving the impingement fracture of anteromedial tibial plateau and the injury of posterior cruciate ligament and posterolateral corner. J Knee Surg. 2020;33:616-22.
    [CrossRef] [PubMed] [Google Scholar]

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