Pediatric Elbow Fractures

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Pediatric Elbow Fractures

• Eric Jepson
• September 22, 2000

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Supracondylar Fractures of the Humerus in Children

• 2/3 of all hospitalizations for elbow injuries in
  children
• Most common in children lt10 years old, usually
  between the ages of 5-8 years old.
• Historically associated with significant
  morbidity secondary to malunion, neurovascular
  complications and compartment syndrome

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Classification

• Extension or flexion injuries
• 90-98 extension type
• Extension injury is caused by fall on
  outstretched hand with elbow hyperextended
• Displacement of distal fragment in extension type
  injuries has been reported to be posteromedial in
  90 and posterolateral in 10
• Otsuka and associates reported 49 to be
  posterolateral

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Gartlands Classification

• Type I nondisplaced
• Type II displaced with variable angulation, but
  posterior cortex of the humerous is intact
• A. Posterior tilt
• B. Posterior translation
• Type III completely displaced with no cortical
  contact

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Physical Examination

• Rule out associated trauma evaluate for
  midshaft humerus fractures(rare) and distal
  forearm fractures(common)
• Nerve injuries 11-49 associated with
  supracondylar injuries
• - posterolateral displacement associated with
  median and anterior interosseous nerve
  dysfunction

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Physical Examination

• - posteromedial displacement associated with
  radial nerve injury
• - ulnar nerve injury more often associated with
  flexion type injuries
• - anterior interosseous nerve most often
  injured evaluate flexor pollicus longus and
  flexor digitorum profundus of index finger

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Physical Examination

• Vascular injuries permanent vascular compromise
  of extremity occurs in less that 1
• Brachial artery may become compromised by
  anterior spike of proximal fragment
• - Usually resolves with reduction of fracture
• Entrapment of brachial artery in fracture site
  may compromise circulation of extremity with
  reduction
• - constant vascular evaluation necessary

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Physical Examination

• Following clinical assessment, immobilize injured
  elbow with splint in a position of 20 to 30
  degrees of flexion
• - will prevent further displacement of fracture
  and additional neurovascular damage

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Radiographic Evaluation

• AP and lateral of elbow
• fat pad sign may be helpful with minimally
  displaced fractures
• anterior humeral line should transect the
  ossification center of the capitellum in the
  normal elbow
• - in Type II and Type III fractures will not
  transect the capitellum

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Radiographic Evaluation

• Baumanns angle intersection of a line drawn
  perpendicular to the humeral axis and line drawn
  along the growth plate of the lateral condyle of
  the elbow
• - contralateral elbow should be used for
  comparison
• - distal fracture fragment is often rotated
  medially or internally and into varus deviation
  in relation to the proximal humerus, which
  produces an increased Baumanns angle
• - also useful in evaluating postreduction

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Baumanns Angle
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Treatment

• Type I splint or circular cast with the elbow
  flexed to 90 degrees and the forearm in the
  neutral position
• - reray in one week to be sure displacement has
  not occurred usually appears as varus
  angulation
• - 3 weeks of immobilization followed by
  protected active range of motion exercises

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Treatment

• Type II reduction achieved by flexion of the
  elbow and pronation of the forearm with the
  patient under anesthesia
• - 120 degrees elbow flexion required to
  maintain reduction
• - hyperflexion in a circular cast carries a
  high risk of compartment syndrome
• - These fractures should be pinned
  percutaneously if there is significant swelling,
  there is inadequate circulation when the elbow
  is flexed, or if the fracture might become
  unstable

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Treatment

• Type III closed reduction with percutaneous
  pinning
• - to close reduce 1) traction is applied to
  disengage proximal fragment from brachialis
  muscle, 2) translation of the distal fragment to
  proper medial-lateral orientation, 3) internal
  rotation deformity corrected, 4) distal fragment
  is pushed forward with examiners thumb while
  flexing the patients elbow to 120 degrees and
  pronating the wrist to tighten the periosteal
  hinge

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Treatment

• - evaluate with AP and lateral radiograph
• - deviation of gt5 degrees relative to Baumanns
  angle in non-injured elbow represents
  inadequate reduction

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Treatment

• Percutaneous pinning use sterilely draped
  screen of the fluoroscopy unit as the operating
  surface
• - with maximally flexed and pronated arm,
  approach the lateral side first
• - insert Kirchner wire thru lateral condyle,
  crossing lateral to olecranon fossa and engaging
  medial humeral cortex
• - medial wire placed with arm in 80-90 degrees
  flexion
• - protect ulnar nerve and direct Kirchner wire
  through medial condyle in more transverse manner
  than lateral wire

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Treatment

• Following pinning place elbow in splint at 60-90
  degrees of flexion with the forearm in neutral
  rotation
• Remove wires in 3-4 weeks

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Adequacy of Reduction

• Baumanns angle
• Relationship of the capitellum to the anterior
  humeral line
• Restoration of the anatomy of the olecranon fossa

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Traction

• Lost popularity with acceptance of pinning
• Primary indication for traction is supracondylar
  comminution
• Overhead traction with use of an olecranon screw
  is the easiest to manage

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Indications for Open Reduction

• Fracture irreducible by closed methods
• Vascular compromise necessitating exploration and
  repair of brachial artery
• Open fracture requiring irrigation and debridement

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Flexion-type Fractures

• Only 2-10 supracondylar fractures
• Classified like extension type injuries
• Reduction maneuver is opposite to extension
  injuries, with reduction done in extension
• Pinning necessary for most flexion-type fractures
  that require reduction

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Complications

• Most nerve deficits that occur at the time of
  injury are neuropraxias(may take up to six months
  to regain sensory)
• Vascular insufficiency in 5-12
• - immediate closed reduction recommended
• - Volkmanns contracture is complication of
  vascular compromise fasciotomy may be
  necessary

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Complications

• Angular deformities of distal humerus common
  after supracondylar injuries
• - cubitus varus deformity most common result
  of malreduction

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Conclusions

• Expedient management with fracture reduction and
  stabilization markedly decrease neurovascular
  complications
• Kirschner-wire fixation with attention to soft
  tissues are key to management of this injury in
  children

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Lateral Condyle Fractures

• Second most common elbow fractures in children
• Type IV Salter-Harris
• Caused by varus stress on an extended elbow with
  the forearm in supination
• Reputation for complications

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Diagnosis

• Swelling and tenderness to lateral elbow
• AP and lateral of elbow obliques if high
  suspicion for fracture or for determining amount
  of displacement

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Classification

• Milch Type I fracture line is lateral to the
  trochlea
• Milch Type II fracture line enters trochlea,
  which allows lateral translation of the ulna and
  radius

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Milch Classification
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Displacement

• Type I minimal displacement(lt2mm) and no
  articular movement
• Type II moderate hinged displacement(2-4mm)
  with intact articular surface
• Type III complete displacement and frequently
  rotated
• This system used for treatment

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Treatment

• Type I cast immobilization successful reray
  fracture in 5-7 days
• Type II percutaneous pinning and evaluate for
  stability thru full range of motion long arm
  cast if stable
• Type III ORIF lateral incision with direct
  fracture visualization and parallel or divergent
  pin placement cast in 70-90 degrees of flexion

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Complications

• Nonunion, osteonecrosis, cubitus valgus, and
  tardy ulnar nerve
• Treatment in a timely fashion key to good results

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Medial Condyle Fractures

• Most common between ages of 10-14
• As many as 50 associated with elbow dislocations
• No universally accepted classification system

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Treatment

• Most literature supports nonoperative treatment
  for both nondisplaced and displaced fractures
• Only two absolute indications for treatment are
  irreducible incarceration of the medial
  epicondyle in the joint and the rare open fracture

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Proximal Radial Fractures

• Involve the metaphyseal neck or physis
• Salter-Harris I or II
• Fall on outstretched hand with a valgus moment
  directing the force through the radius
• Pronation and supination more painful than
  flexion and extension
• Tenderness well localized in isolated fractures

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OBrien Classification

• Based on amount of angulation
• Type I 0-30 degrees
• Type II 30-60 degrees
• Type III - gt60 degrees

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Wilkins Classification
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Treatment

• Type I simple immobilization
• Type II closed reduction with manipulation
• - apply varus stress to elbow and reduce radial
  head with direct thumb pressure
• Type III immediate ORIF with oblique K-wires