Elbow Fractures In Children

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Fractures and Dislocationsabout the Elbowin the Pediatric PatientAmy L. McIntosh, MD

Elbow Fractures in Children Very common injuries (approximately 65% ofpediatric trauma) Radiographic assessment– difficult for non-orthopaedists– Complex physeal anatomy and developmentTachdjian's Pediatric Orthopaedics:From the Texas Scottish Rite Hospitalfor Children, 5th Edition Elsevier,2013 Figure 33-29

Elbow FracturesPhysical Examination Children will usually not move the elbow ifa fracture is present, although this may notbe the case for non-displaced fractures Neurologic exam is essential, as nerveinjuries are common– neurovascular injuries can occur beforeand after reduction– In most cases, full recovery can beexpected

Elbow FracturesPhysical Examination Neurological exam may be limited by thechild’s ability to cooperate because of age,pain, or fear. Thumb extension – EPL– Radial – PIN branch Thumb flexion – FPL– Median – AIN branch Cross fingers/scissors - Ad/Abductors– Ulnar

Elbow FracturesRadiographs AP and Lateral views are important initial views– In trauma these views may be less than ideal, becauseit can be difficult to position the injured extremity Oblique views may be necessary– Especially for the evaluation of suspected lateralcondyle fractures Comparison views frequently obtained by primarycare or ER physicians– Although these are rarely used by orthopaedists

Elbow FracturesRadiograph Anatomy/Landmarks Anterior Humeral Line– Drawn along theanterior humeral cortex– Should pass throughthe middle of thecapitellum– Variable in very youngchildren-Herman. Relationship of the anterior humeral line to the capitellarossific nucleus: variability with age. J Bone Joint Surg. 2009;91:2188.Tachdjian's Pediatric Orthopaedics: From the Texas Scottish RiteHospital for Children, 5th Edition Elsevier, 2013 Figure 33-46

Elbow FracturesRadiograph Anatomy/Landmarks The capitellum isangulatedanteriorly about30 degrees. The appearanceof the distalhumerus issimilar to ahockey stick.Tachdjian's Pediatric Orthopaedics: From the Texas Scottish RiteHospital for Children, 5th Edition Elsevier, 2013 Figure 33-46

Elbow FracturesRadiograph Anatomy/Landmarks The physis of thecapitellum isusually widerposteriorly,compared to theanterior portion ofthe physisWider

Elbow FracturesRadiograph Anatomy/Landmarks Radiocapitellarline shouldintersect thecapitellum in allviews Make it a habit toevaluate this lineon every pediatricelbow film

Supracondylar Fractures Most common elbow fx inchildren & adolescents 50 – 70% of all elbow fx. Frequently seen btw 3-10yrs. 2 Types– Extension Type– Flexion TypeCourtesy of AL McIntosh

Appropriate Use Criteria 2014: AAOS adopted appropriate use criteria(AUC) for the management of pediatricsupracondylar humerus fractures. 2015 : AUC for pediatric supracondylar humerusfractures with vascular injury These AAOS references should be reviewed priorto engaging in the treatment of a pediatricsupracondylar humerus fracture.Appropriate Use Criteria: Management of Pediatric Supracondylar HumerusFractures. Journal of the American Academy of Orthopaedic Surgeons, 2015.23(10): p. e52-e55.

Extension Type 95-98% of all SCH fx Mechanism FOOSH Forces the elbowinto hyperextension. Olecranon acts as afulcrum. Force propagatesacross medial &lateral columnsTachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Distal fragment :Hospital for Children, 5th Edition Elsevier, 2013figure 33-30posterior

Flexion Type 2- 5% of SCHfx. Mechanism Direct blow to aflexed elbow. Distal Fragment: AnteriorTachdjian's Pediatric Orthopaedics: From the Texas ScottishRite Hospital for Children, 5th Edition Elsevier, 2013Figure 33-31

Ulnar n. tented over posteriorMargin of prox. Fx.

Flexion Type Mahan et al: JPO 27(5)2007 n 58 (1994- 2004) 3%: SCH II & III flexion Older (7.5 yrs vs. 5.8 yrs) Increased need for openreduction (31% vs.10%) Ulnar nerve injury (19%vs. 3%) Need for ulnar nervedecompression (19% vs.0.5%)Courtesy AL McIntosh

Gartland Classification (1959) Type I- no displacement Type II- moderate displacement Posterior cortex intact Plastic Deformation Possible Type III- severe displacement Ant & post cortex disruption Type IV: multi-directionally unstable Skaggs: JBJS 88A, 2006Surg Gyn Obstet 1959 109(2) 145-154.

Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospitalfor Children, 5th Edition Elsevier, 2013 Figure 33-34

extensionType IVCourtesy of AL McIntoshflexion

Supracondylar Humerus FracturesTreatment Type 1 Fractures– In most cases, these can be treated withimmobilization for approximately 3 weeks, at90 degrees of flexion– If there is significant swelling, do not flex to 90degrees until the swelling subsides

Type 1Non-displaced Note the nondisplaced fracture(Red Arrow) Note the posteriorfat pad (Yellow Arrows)

Type I Subdivision (1994) Mubarak &Davids: Master TechElbow. Type IA:nondisplaced cast Type IB: medialcomminution CRPP– More unstable– Varus/hyperextension malunionTachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital forChildren, 5th Edition Elsevier, 2013 Figure 33-38

Type 2 FracturesTreatment Reduction of these fractures is usually not difficult– Maintaining reduction usually requires flexion beyond90 Excessive flexion may not be tolerated because ofswelling– May require percutaneous pinning to maintain reduction Most authors suggest that percutaneous pinning isthe safest form of treatment for many of thesefractures– Pins maintain the reduction and allow the elbow to beimmobilized in a more extended positionFitzgibbons. Predictors of failure of nonoperative treatment for type-2supracondylar humerus fractures. J Pediatr Orthop. 2011;31:372.

Supracondylar Humerus FracturesTreatment Type 3 Fractures– These fractures have a high risk of neurologic and/orvascular compromise– Can be associated with a significant amount of swelling– Current treatment protocols use percutaneous pinfixation in almost all cases– In rare cases, open reduction may be necessary Especially in cases of vascular disruption

Type III CRPPCourtesy of AL McIntosh

Ipsilateral Fx of distalradius (5%)Courtesy of TSRH/CMC

Supracondylar Humerus FracturesAssociated Injuries 5% have associateddistal radius fracture Physical exam ofdistal forearm Radiographs if needed If displaced pin radiusalso– Difficult to holdappropriately in splintCourtesy of TSRH/CMC

How to perform a CRPP

Brachialis SignProximal Fragment Buttonholed through BrachialisCourtesty of TSRH/ CMC

1. Correct coronal plane alignment & reestablish LengthTachdjian's PediatricOrthopaedics: From theTexas Scottish RiteHospital for Children,5th Edition Elsevier,2013 Figure 33-49With the elbow in extension, align the distal fragmentto the proximal fragment in the coronal plane.

3.Correct AngulationandPosterior DisplacementTachdjian's PediatricOrthopaedics: Fromthe Texas Scottish RiteHospital for Children,5th Edition Elsevier,2013 Figure 33-49Apply longitudinal traction Then, slowly flex the elbow to bringwith the elbow semithe distal fragment into alignment.flexed,while applying posteriorpressure on the proximal fragment.

cethe fragmentsTachdjian'sPediatricOrthopaedics:From the TexasScottish RiteHospital forChildren, 5thEdition Elsevier,2013 Figure 33-49hyper-flex the elbowwithhyper-pronationThen,confirmthe reductionto lockthe distalin full externalfragmentto the rotationon themonitor.proximalfragment.

Rule of Thumb Thumb should point in thedirection of initial displacement. Posterolateral (25%): Supinate tightens the intact lateral softtissue sleeve. Posteromedial (75%) : Pronate tightens the intact medial softtissue sleeve.

Posteromedial displacement pronateforearm to tension the intact medial tissuesTachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital forChildren, 5th Edition Elsevier, 2013 Figure 33-37

Type 3Operative Reduction Closed reduction withflexion AP view with elbowheld in flexedposition to maintainreduction.Courtesy of AL McIntosh

Which pin pattern is better?Courtesy of AL McIntosh

Brauer et al: JBJS 89A,2007Systematic ReviewN 205435 studiesStandard crossed pins: 5.04Xhigher probability of iatrogeniculnar n. injury Crossed pins: more stabile (0.58x)less likely to lose reduction

C-arm ViewsOblique views with the C-arm can be useful to help verify thereduction.Note slight rotation and extension on medial column (right image).

Supracondylar Humerus FracturesPin Fixation many children have anterior subluxation ofthe ulnar nerve with hyperflexion of theelbow Some recommend place two lateral pins,assess fracture stability If unstable then extend elbow to taketension off ulnar nerve and place medial pinEberl. Iatrogenic ulnar nerve injury after pin fixation and after antegrade nailingof supracondylar humeral fractures in children. Acta Orthop. 2011;82:606.

Placement of medial pin w/ulnarnerve protectedTachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children,5th Edition Elsevier, 2013 Figure 33-52

Supracondylar Humerus Fractures After stable reduction and pinning– Elbow can be extended to review the AP radiograph– Baumann’s angle can be assessed on these radiographs Remember there can be a wide range of normal values for thismeasurement With the elbow extended, the carrying angle of theelbow should be reviewed, and clinicalcomparison as well as radiograph comparison canbe performed to assure an adequate reduction.

Supracondylar Humerus Fractures If pin fixation is used, the pinsare usually bent and cut outsidethe skin The skin is protected from thepins by placing a felt padaround the pins The arm is immobilized The pins are removed in theclinic 3 to 4 weeks later– After radiographs show periostealhealing In most cases, full recovery ofmotion can be expected

Supracondylar Humerus Fractures:Indications for Open Reduction Inadequate reductionwith closed methods Vascular injury Open fracturesCouretsy of TSRH/CMC

Supracondylar Humerus Fractures:Complications Compartment syndrome Vascular injury/compromise Loss of reduction/malunion– Cubitus varus Loss of motion Pin track infection Neurovascular injury withpin placementTachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital forChildren, 5th Edition Elsevier, 2013 Figure 33-56

Distal Humeral Complete PhysealSeparation Often in very young children May be sign of NAT Swollen elbow,“muffledcrepitance” on exam Through area of wider crosssectional area than SChumerus fx Restore alignment, may needpinning.Courtesy of TSRH/CMC

Lateral Condyle Fractures Common fracture,representingapproximately 15% ofelbow trauma in children Usually occurs from afall on an outstretchedarmTachdjian's Pediatric Orthopaedics: From the Texas Scottish RiteHospital for Children, 5th Edition Elsevier, 2013 Figure 33-71.

Lateral Condyle FracturesJakob Classification Type 1– Non-displaced fracture– Fracture line does not crossthrough the articular surface Type 2– Minimally displaced– Fracture extends to thearticular surface, but thecapitellum is not rotated orsignificantly displaced Type 3– Completely displaced– Fracture extends to thearticular surface, and thecapitellum is rotated andsignificantly displacedTachdjian's Pediatric Orthopaedics: From the Texas ScottishRite Hospital for Children, 5th Edition Elsevier, 2013Figure 33-72Jakob. Observations concerning fractures of the lateral humeralcondyle in children. J Bone Joint Surg Br. 1975;57:430.

Lateral Condyle Fractures Oblique radiographsmay be necessary toconfirm that this is notdisplaced. Frequentradiographs in the castare necessary to ensurethat the fracture doesnot displace in thecast.

Lateral Condyle FracturesJakob Type 2 Displaced more than 2 mm– On any radiograph(AP/Lateral/Oblique views)– Reduction and pinning– Closed reduction can beattempted, but articular reductionmust be anatomic If residual displacement and thearticular surface is notcongruousTachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite– Open reduction is necessaryHospital for Children, 5th Edition Elsevier, 2013 Figure 33-76A new classification system predictive of complications in surgically treatedpediatric humeral lateral condyle fractures. J Pediatr Orthop. 2009 Sep;29(6):602-5

Lateral Condyle FracturesJakob Type 3 ORIF is almost alwaysnecessary A lateral Kocher approach isused for reduction, and pins ora screw are placed to maintainthe reduction Careful dissection needed topreserve soft tissue attachments(and thus blood supply) to thelateral condylar fragment,especially avoiding posteriordissectionTachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital forChildren, 5th Edition Elsevier, 2013 Figure 33-75

Lateral Condyle FracturesComplications Non-union– This usually occurs if thepatient is not treated, or thefracture displaces despitecasting– Well-described in fractureswhich were displaced morethan 2 mm and not treatedwith pin fixation– Late complication ofprogressive valgus and ulnarneuropathy reportedTachdjian's Pediatric Orthopaedics: From the Texas ScottishRite Hospital for Children, 5th Edition Elsevier, 2013Figure 33-80

Lateral Condyle FracturesComplications AVN can occur afterexcessive surgicaldissection Cubitus varus canoccur, may be becauseof malreduction or aresult of lateralcolumn overgrowthTachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital forChildren, 5th Edition Elsevier, 2013 Figure 33-82

Medial Epicondyle Fractures Represent 5% to 10% of pediatric elbowfractures Occurs with valgus stress to the elbow,which avulses the medial epicondyle Frequently associated with an elbowdislocationLandin. Elbow fractures in children. An epidemiologicalanalysis of 589 cases. Acta Orthop Scand. 1986;57:309.

Medial Epicondyle FracturesClassification No good systematicmethod of classification Studies vary on how tomeasure displacement The best x-ray is obatinedby positioning the centralray above the shoulder at15 to 20 degrees from thelong axis of the humerus,centered on the distalhumerus.J Pediatr Orthop. 2015 Jul-Aug;35(5):449-54.Tachdjian's Pediatric Orthopaedics: From the Texas Scottish RiteHospital for Children, 5th Edition Elsevier, 2013 Figure 33- 42

Medial Epicondyle FracturesTreatment Nondisplaced andminimally displaced– Less than 5 mm ofdisplacement– May be treated withoutfixation– Early motion to avoidstiffness (3 to 4 weeks)Tachdjian's Pediatric Orthopaedics: From the TexasScottish Rite Hospital for Children, 5th Edition Elsevier, 2013 Figure 33-84

Medial Epicondyle FracturesTreatment Displaced more than 5 mm– Treatment is controversial– Some recommending operative,others non-operative treatment– Some have suggested that surgeryis indicated in the presence ofvalgus instability, or in patientswho are throwing athletes. Only absolute indication isentrapped fragment afterdislocation with incongruent elbowjoint– First attempt closed reduction Long term studies favornonoperative treatmentTachdjian's Pediatric Orthopaedics: From the Texas ScottishRite Hospital for Children, 5th Edition Elsevier, 2013Figure 33-83

Medial Epicondyle FractureElbow dislocation with Medial Epicondyle AvulsionMedialEpicondyleAvulsionAfter attemptedelbow reduction,medial epicondyleavulsion fragmentis obvious

Olecranon Fractures Relatively rare fracture in children– Increased incidence in children with OI– May be associated with elbow subluxation/dislocation, or radial head fracture The diagnosis may be difficult in a younger child– Olecranon does not ossify until 8-9 years In older children, the fracture may occur throughthe olecranon physis Anatomic reduction is necessary in displacedfractures to restore normal elbow extension.Caterini. Fractures of the olecranon in children. Long-term follow-up of 39 cases. J Pediatr Orthop B. 2002;11:320.

Olecranon Fractures Olecranon fracture treated with ORIF in 14year old, with tension band fixation.Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition Elsevier,2013 Figure 33-101

Rare Distal Humeral FracturesMedial Condyle Fracture Lateral Epicondyle– Rare– Usually represent a smallavulsion fracture– Treated with early mobilization T-Condylar fractures– Occur in patients that are almostskeletally mature– Treatment similar to adult intraarticular elbow fractures Medial Condyle– Rare– Treated with ORIF if displacedTachdjian's Pediatric Orthopaedics: From the Texas Scottish RiteHospital for Children, 5th Edition Elsevier, 2013 Figure 33- 104.

Proximal Radius Fractures 1% of children’s fractures 90% involve physis or neck Normally some angulation of head to radialshaft (0-15 degrees) No ligaments attach to head or neck Much of radial neck extraarticular (noeffusion with fracture)Vocke. Displaced fractures of the radial neck in children: long-term resultsand prognosis of conservative treatment. J Pediatr Orthop B. 1998;7:217.

Proximal Radius FracturesTypes Valgus fractures– Salter I or II– Intra-articular fracturesrare Metaphyseal fractures Associated with elbowdislocations or proximalulna fractures Can be completelydisplaced, rotatedTachdjian's Pediatric Orthopaedics: From the Texas Scottish RiteHospital for Children, 5th Edition Elsevier, 2013 Figure 33-96

Proximal Radius FracturesTreatment Greater than 30 angulation– Attempt manipulation– Usually can obtainacceptable reduction infractures with less than60 angulation– Traction, varus force insupination & extension,flex and pronate– Ace wrap or EsmarchreductionTachdjian's Pediatric Orthopaedics: From the Texas Scottish RiteHospital for Children, 5th Edition Elsevier, 2013 Figure 33-94

Proximal Radius FracturesTreatment Unable to reduceclosedIM nail reduction– Percutaneous pinreduction– Intramedullary nailreduction– Open reduction vialateral approachTachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital forChildren, 5th Edition Elsevier, 2013 Figure 33-97

Proximal Radial FracturesComplications Loss of forearm rotationRadial head overgrowthPremature physeal closure – valgusNonunion of radial neck rareAVNProximal synostosisVocke. Displaced fractures of the radial neck in children: long-term resultsand prognosis of conservative treatment. J Pediatr Orthop B. 1998;7:217.

100% DisplacedFailed Closed ReductionTachdjian's Pediatric Orthopaedics: From the Texas Scottish RiteHospital for Children, 5th Edition Elsevier, 2013 Figure 33-96

Open “closed” reductionBlunt pin to push radial head back onto neckCourtesy of TSRH/CMC

Pin fixation augmented by cast for 3 weeksTachdjian's Pediatric Orthopaedics: From the Texas Scottish RiteHospital for Children, 5th Edition Elsevier, 2013 Figure 33-96

Monteggia LesionsUlnar Fracture-Radial Head DislocationBado Classification Type I – anterior radialhead dislocation Type II – posterior radialhead dislocation Type III – lateral radialhead dislocation Type IV – associatedfracture of radius

Monteggia Lesions Most important is to makethe diagnosis initially Radiocapitellar linecritical A commonly misseddiagnosis Every ulna fracture shouldhave good elbow jointradiographs to avoidmissing Monteggia lesionTachdjian's Pediatric Orthopaedics: From the Texas Scottish RiteHospital for Children, 5th Edition Elsevier, 2013 Figure 33-109

Monteggia LesionsInitial Treatment Closed reduction of ulnar angulationDirect pressure over radial headUsually will reduce with palpable clunkImmobilize in reduced positionSupinate forearm for anterior dislocationsFrequent

(AUC) for the management of pediatric supracondylar humerus fractures. 2015 : AUC for pediatric supracondylar humerus fractures with vascular injury These AAOS references should be reviewed prior to engaging in the treatment of a pediatric supracondylar humerus fracture. Appropriate Use Criteria: Management of Pediatric Supracondylar .

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