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8/10/2019 Elbow Fractures in Pediatrics
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Introduction
Elbow fractures are common childhood injuries,accounting for about 10% of all childhoodfractures.
In many cases, a simple fracture will heal wellwith conservative cast treatment.
Some types of elbow fractures, however,including those in which the pieces of bone aresignificantly out of place, may require surgery.
Other structures in the elbowsuch as nerves,blood vessels, and ligamentsmay also beinjured when a fracture occurs and requiretreatment, as well.
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Anatomy
Articulations
Ulnohumeral, Radiocapitellar, Proximal radioulnar
Stability
Ulnar and lateral collateral ligament complexes
Anterior bundle - medial stability
Lateral ulnar collateral - lateral stability
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Vasculature
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Nerves
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Ossification Centres
Age at appearance Age at Closure
Capitellum 1-2 14
Radius 3 16
Internal
Epicondyle
5 15
Trochlea 7 14
Olecranon 9 14
External
epicondyle
11 16
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Ossification Centres
Mnemonic CRITOE
C - capitellum
R - radial head I - Internal Epicondyle
T - Trochlea
O - Olecranon E - External Epicondyle
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Elbow Fractures
Physical Examination Children will usually not move the elbow if a fracture
is present
Swelling about the elbow is a constant feature,
except for non-displaced fracture Complete vascular exam is necessary, especially in
supracondylar fractures
Doppler may be helpful to document vascular status
Neurologic exam is essential, as nerve injuries arecommon
In most cases, full recovery can be expected
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Elbow Fractures
Physical Examination Neurological exam may be limited by the
childs ability to cooperate because of age,pain, or fear.
Thumb extensionEPL RadialPIN branch
Thumb flexionFPL
MedianAIN branch
Cross fingers/scissors - Ad/Abductors
Ulnar
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Elbow Fractures
Physical Examination Always palpate the arm and forearm for signs of
compartment syndrome
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Radiography
Views
AP
Lateral
Oblique External
Internal
AP and lateral are usually sufficient
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Radiography
AP
Supination and full extension at elbow with slight flexion
of fingers
Visualize
Epicondyles
Carrying angle (10-12)
Articulations
Baumanns angle (75)
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Radiography
Lateral
Rest on table
Elbow flexed at 90
Thumb up
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The 8 Step Approach
1. Figure of 8
2. Anterior Fat Pad
3. Posterior Fat Pad
4. Anterior humeral line
5. Radio-capitellar line
6. Inspect radial head
7. Distal humerus examination
8. Ulna/Olecranon examination
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Approach
Figure of Eight
To determine if true
lateral
Otherwise unable to
adequately assess fat
pads, anterior humeral
line
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Approach
Anterior Fat Pad Barely visible on normal film
Trauma - fracture
Children - supracondylar
Adults - Occult radial head Atraumatic - inflammation
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Approach
Posterior Fat Pad
ALWAYS ABNORMAL
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Approach
Anterior humeral line
Passes through middle
third of the capitellum
Disruption suggests
supracondylar fracture
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Approach
Inspect radial head
Disruption in cortical surface
Inspect distal humerus
Disruption in cortical surface
Inspect ulna/olecranon
Disruption in cortical surface
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Elbow Fractures
Radiograph Anatomy/Landmarks
Baumanns angle is formed by a lineperpendicular to the axis of thehumerus, and a line that goes
through the physis of the capitellum
There is a wide range of normal forthis value
Can vary with rotation of the radiograph
In this case, the medial impactionand varus position reduces Baumansangle
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TYPES OF
FRACTURES
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Supracondylar Humerus Fractures
Most common fracture around the elbow inchildren
60 percent of elbow fractures
Occurs from a fall on an outstretched hand
Ligamentous laxity and hyperextension ofthe elbow are important mechanical factors
May be associated with a distal radius orforearm fractures
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Supracondylar Humerus Fractures
Classification
Type 1
Non-displaced
Type 2
Angulated/displaced fracture
with intact posterior cortex
Type 3
Complete displacement, with
no contact between
fragments
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T 2
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Type 2Angulated/displaced fracture with intact
posterior cortex
T 2
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In many cases, the type 2fractures will be impacted
medially Leads to varus angulation
The varus malposition
must be considered whenreducing these fractures Apply a valgus force for
realignment
Type 2Angulated/displaced fracture with intact
posterior cortex
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Type 3Complete displacement, with no contact
between fragments
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Complications
Neurovascular injury in ~12%
displacement increases incidence
Mostly neuropraxias that resolve in months
Extension - median nerve and brachial artery
Flexion - ulnar nerve
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Type 1 Fractures
In most cases, these can be treated with
immobilization for approximately 3 weeks, at 90
degrees of flexion If there is significant swelling, do not flex to 90
degrees until the swelling subsides
Supracondylar Humerus Fractures
Treatment
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Supracondylar Humerus Fractures
Treatment
Type 2 Fractures: Posterior Angulation If minimally displaced (anterior humeral line hits
part of capitellum) Immobilization for 3 weeks.
Close follow-up is necessary to monitor for loss ofreduction
Displaced (anterior humeral line misses capitellum) Reduction may be necessary
The degree of posterior angulation that requiresreduction is controversial
Check opposite extremity for hyperextension
If varus/valgus malalignment exists, most authorsrecommend reduction.
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Type 2 FracturesTreatment
Reduction of these fractures is usually not difficult
Maintaining reduction usually requires flexion beyond 90
Excessive flexion may not be tolerated because ofswelling
May require percutaneous pinning to maintain reduction
Most authors suggest that percutaneous pinning is
the safest form of treatment for many of thesefractures
Pins maintain the reduction and allow the elbow to beimmobilized in a more extended position
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Supracondylar Humerus Fractures
Treatment
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 pin fixationin almost all cases
In rare cases, open reduction may be necessary
Especially in cases of vascular disruption
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Lateral Condyle Fractures
Common fracture,
representing
approximately 15% of
elbow trauma in
children
Usually occurs from a
fall on an outstretchedarm
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Lateral Condyle Fractures
Jakob 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 displaced
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Lateral Condyle Fractures
Jakob Type 1
Oblique radiographs
may be necessary to
confirm that this is not
displaced. Frequent
radiographs in the cast
are necessary to
ensure that thefracture does not
displace in the cast.
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Lateral Condyle Fractures
Jakob Type 3
ORIF is almost alwaysnecessary
A lateral Kocherapproach is used forreduction, and pins or
a screw are placed tomaintain the reduction
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Lateral Condyle Fractures
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Lateral Condyle FracturesComplications
AVN can occur after
excessive surgical
dissection
Cubitus varus can
occur, may be because
of malreduction or a
result of lateralcolumn overgrowth
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Medial Epicondyle Fracture
Management
Minimally displaced
Long arm splint
1-2 weeks with early ROM
Displaced >5mm
Conservative or operative
Intra-articular fragment Surgical removal of fragment
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Medial Epicondyle Fracture
Complications
Ulnar nerve injury 10-16%
More common if intraarticular fragment
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Radial Head and Neck Fractures
Classification By degree of angulation
Type I
< 30 angulation
Type II
30 -60 angulation
Type III
> 60 angulation
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Radial Head and Neck Fractures
Management
Angulation>15 - closed reduction
Type I
Sling/posterior splint X 1-2 weeks
Type II and III
Percutaneous pining if closed reduction not
adequate (
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Radial Head and Neck Fractures
Complications
AVN of radial head ~ 10 -20%
Loss of ROM
rotation
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Olecranon Fracture
~ 5% of elbow fractures
More common with increasing age
Associated with other injuries (50%)
Mechanism
Direct blow
Shear
Indirect due to forceful contraction of tricepswhile elbow flexed in fall
Hyperextension
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Conclusion
Be vigilant
Use a thorough approach
Look for associated injuries
Think about mechanism
Know how it is treated in your centre
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Thank You
very much