ELBOW INJURIES IN CHILDREN - WordPress.com...Elbow Injuries in Children (The "RARE INJURIES" that may present Major Problems) 3 f. Stiffness is a common sequelae. 1) Thus, it is important

ELBOW INJURIES IN CHILDRENThe "RARE INJURIES" that may present major problems

Medial Epicondyle

Radial Neck

Olecranon KAYEE. WilKINS, M.D.Clinical ProfessorDepartments of Orthopaedics & PediatricsThe University of Texas Health Science Ctr.

at San Antonio, Texas

Elbow Injuries in Children (The "RARE INJURIES" that may present Major Problems) 2

ELBOW INJURIES IN CHILDREN

The "RARE INJURIES" that may present Major Problems include:

The Rare Injuries

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m~~ijI.N~ I Ji.~;Qi,~$~AA9~ II. THE MEDIAL EPICONDYLE

A. Anatomical Considerations

1. Structural Aspectsa. It is an apophysis.b. It is posteromedial

c. Serves as origin of ulnar collateral ligament which is the key to elbow stability.d. In the older child it is extra-articular.Ossification

a. Preosseous - Part of the total distal epiphysis.b. Ossification begins: 4-6 yrs.c. Last to fuse: 15-16 years.

Incidence

1. A later injury occurring between 9-14 years (correlates with dislocations).2. Higher in boys.3. 50% occur with elbow dislocation.

Mechanisms of Injury1. Direct blow2. Pure avulsion3. Elbow dislocationClassification of Fractures

1 . Acute Injuriesa. Undisplacedb. Minimally displacedc. Significantly displaced

1) Elbow not dislocated2) Elbow dislocated

Entrapment of fragment in joint1) Elbow not dislocated2) Elbow still dislocated

Fractures through the epicondylar apophysis1) Without displacement2) With displacement

f. Chronic Tension Stress Injuries (Little League Elbow Syndrome)Diagnostic Dilemmas1. Differentiate from Medial Condyle.

a. Beware in young children!b. Elbow dislocation rare in first decade.

c. Suspect if any metaphyseal bone.d. Entrapment can occur even if only a portion of epicondyle is avulsed.

Treatment

1. Acute Injuries (Operative vs. Non-operative)

a. Myths regarding non-operative treatmentl1311) Growth deformity2) Painful non-union3) Weakened forearm flexors

4) Late ulnar nerve symptomsThe literature can support either operative or non-operative methods for routinefractures.

1) Operative Proponents: Hines and co-workers(21 - 96% excellent results2) Non-operative management

a) Joseffson and Danielson(31 - excellent results even with non-

union of fragment.Comparison studies by Bede1101and Fowles(lI showed betterresults in those managed non-operatively.

2.

B.

C.

D.

d.

e.

E.

F.

b.

b)


ELBOW INJURIES IN CHILDREN

The "RARE INJURIES" that may present Major Problems include:

The Rare Injuries

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I. THEMEDIALEPICONDYLEA. Anatomical Considerations

1. Structural Aspectsa. It is an apophysis.b. It is posteromedialc. Serves as origin of ulnar collateral ligament which is the key to elbow stability.d. In the older child it is extra-articular.Ossificationa. Preosseous - Part of the total distal epiphysis.b. Ossification begins: 4-6 yrs.c. Last to fuse: 15-16 years.

Incidence1. A later injury occurring between 9-14 years (correlates with dislocations).2. Higher in boys.3. 50% occur with elbow dislocation.Mechanisms of Injury1. Direct blow2. Pure avulsion3. Elbow dislocationClassification of Fractures1. Acute Injuries

a. Undisplacedb. Minimallydisplacedc. Significantly displaced

1) Elbow not dislocated2) Elbow dislocatedEntrapment of fragment in joint1) Elbow not dislocated2) Elbow still dislocatedFractures through the epicondylar apophysis1) Without displacement2) With displacement

f. Chronic Tension Stress Injuries (little League Elbow Syndrome)Diagnostic Dilemmas1. Differentiate from Medial Condyle.

a. Beware in young children!b. Elbow dislocation rare in first decade.c. Suspect if any metaphyseal bone.d. Entrapment can occur even if only a portion of epicondyle is avulsed.

Treatment1. Acute Injuries (Operative vs. Non-operative)

a. Myths regarding non-operative treatment(1311) Growth deformity2) Painful non-union3) Weakened forearm flexors4) Late ulnar nerve symptomsThe literature can support either operative or non-operative methods for routinefractures.1) Operative Proponents: Hines and co-workers(2}- 96% excellent results2) Non-operative management

a) Joseffson and Danielson(31 - excellent results even with non-union of fragment.Comparison studies by Bede(1O)and Fowles(1)showed betterresults in those managed non-operatively.

2.

B.

C.

D.

d.

e.

E.

F.

b.

b)


f.

Stiffness is a common sequelae.1) Thus, it is important to start motion early regardless of operative or

non-operative intervention.In most cases non-operative management is adequate.Indications for operative management.1) Absolute

a) Incarceration in the joint.b) Ulnar nerve dysfunction - may be relative?Relativea) Need for a stable elbow.

(1) Necessary if there will be strong valgus forces acrossthe joint in future activities such as: Baseball, Tennis,Gymnastics or Heavy Labor.Less important in non-dominant extremity.Can use gravity valgus stress test to access elbowstability

Technical Points

a) Stabilize with screw to allow early motion.Incarceration in Joint

1) Acute - extract surgically. Manipulation can injure ulnar nerve.2) Late:

a)

2)

c.

d.e.

(2)(3)

3)

b)

Patrick(14) originally felt if after 4 weeks results equal if leftalone.

Fowles(4) has shown good results can be obtained wherefragment is extracted in late cases.

2. Chronic Stressa. Rest and muscle strengthening are the key factors.b. Assess pitching techniques.

II. RADIAL NECK FRACTURES

A. Anatomical Considerations.1. Normally pre-ossification the radial neck is angulated (pseudo fracture).2. Ossification: 5-6 years (May be bipartite).3. The proximal radioulnar joint is exactly congruous.

a) Translocation can result in a CAM effect(17)[FIGURE 1]


---~ -

FIGURE 1

B.

D.

Mechanisms of Injury1. Their major categories

a. Primary displacement of the head.b. Primary displacement neck.c. Chronic stress forces across the growth centers of the proximal radius.Associated Injuriesa. Greenstick Olecranonb. Medial Epicondyle

Classification1. Related to mechanism of Injury [TABLE 1]2. Related to fracture pattern. (Valgus Injuries - Figure 2)

a) Pure metaphyseal neck fracture.b) Type II - Salter-Harrisc) Type IV - Salter-Harris

Displacement Patterns [FIGURE4, Pg. 6]1. Angulation2. Translocations3. Complete DisplacementDiagnostic Dilemmas1. In young children, radial head pain may be referred to the wrist.

2.

C.

E.

I[ TABLE I: CLASSIFICATION OF FRACTURESINVOLVING THE PROXIMAL RADIUS]1

GROUP I

GROUP II

Primary displacement of the radial head.A. Valgus Fractures [FIGURE 2. Pg. 5]

1. Type A: Salter-Harris Type I and II injuries of the proximal radialphysis.

2. Type B: Salter-Harris Type IV injuries of the proximal radial physis.3. Type C: Fractures involving only the proximal radial metaphysis.Fractures associated with elbow dislocation [FIGURE 3. Pg. 5]1. Type D: Reduction injuries2. Type E: Dislocation injuries

Primary displacement of the radial neck.A. Angular injuries (Monteggia Type III Variant)B. Torsional InjuriesStress InjuriesA. Osteochondritis dissecans of the radial head.B. Physeal injuries with neck angulation.

B.

GROUP III


2.--

Accessory ossification centersmay simulate fractures. If indoubt, get comparison films.The radiocapitellar view or anarthrogram may help betterdelineate the true location of theradial head and neck(18)

Treatment1. Initial Considerations

a. Rem e m b erAsignificantly dislocatedradial head indicatesmore severe soft tissueinjury.Warn the parentsbeforehand of the arimprognosis.This injury has a highincidence of poorresults.

i!~~----... 3.

F.

b.

c.

/

~

[FIGURE 3]

2. Non-operative Methodsa. Manipulative closed reduction as purposed by Patterson(221first line of

management. [FIGURE5, Pg. 6] If this fails the flexion pronation technique aspurposed by Kaufmann, et al.(16)may be another effective method of closedreduction.

Other methods of treatment.a. Use of the Ace wrap. In some cases wrapping the forearm tightly with an ace

wrap may reduce the fragment.Finallyifallclosed methods fail, manipulating the fragment with a percutaneousAwl or other type of sharp instrument may provide a satisfactory reduction.

Acceptable Limitsa. Less than 30° probably does not need manipulation.b. 30° to 60° probably needs manipulation.c. Greater than 60° or with severe translocation may require open reduction.

1) It is also important to examine the patient clinically, under anesthesia.

3.

b.

4.

---

r.. I , I., , ,,I

I

'I /

I.

A B CFIGURE 2


"nsulatlon Tran~location

[FIGURE41Total (fI~placl'm('nl

2)

[FIGURE51

50° of supination and pronation will result in a very functionalextremity.

Open Reductiona. Can you improve function?b. A poor x-ray may function better than an anatomical reduction.c. Internal fixation may not be necessary. Often the fracture is stable once re-

educed by methods.Transcapetellar pin is a no-no!! If fixation required, secure it to the adjacentolecranon.

5.

d.

G. Complications1. Loss of motion2. Radial head overgrowth3. Non-union4. Avascular necrosis5. Radioulnar synostosis


III. OLECRANON FRACTURES

A. Ossification Pattern [FIGURE 6]

-------Birth

8 years

12 years

[FIGURE 6)

I

B. Classification1. Two major categories

a. Physeal Fracturesb. Metaphyseal Fractures

C. Physeal Fractures1. Two Fracture Patterns [FIGURE 7, Pg. 8]

D. Metaphyseal Fractures1. Types

a. Flexion Injuries [FIGURE 8, Pg. 8]b. Extension Injuries

1) Valgus Pattern [FIGURE 9, Pg. 8]2) Varus Patterns [FIGURE 1°, Pg. 8]

c. Shear Injuries1) Elbow Extended [FIGURE 11, Pg. 9]2) Elbow Flexed [FIGURE 12, Pg. 9]

E. Treatment1. Flexion Injuries

a. Murphy(231found a screw across the fracturesite with tension band wire was shown to bethe strongest.

b. PDS (Polydioxanonee) suture can be used. instead of stainless wire for tension band.

2. In extension and some shear injuries, the intactposterior periosteum can serve as a tension bandmechanism.a. Flexing the elbow tightens this band thus

securing the fracture fragments together.F. Complications


tI@-

A~j~

.~~,[FIGURE 7)

1. Rare

2. Delayed loss of reduction3. Pseudoarthrosis - Don't confuse with congenital

pseudoarthrosis of the olecranon.4. Apophyseal Arrest - Probably of no clinical

significance.

fj

[FIGURE 8)

---

[FIGURE 9)

[FIGURE 10)


~[FIGURE 11)

_..

[FIGURE 12]

IREFERENCES

I

I II. MEDIAL EPICONDYLE

1. Elbow Dislocation with Avulsion of the MedialHumeral Epicondyle. Fowles, J.V.; Slimane, N. &Kassab, M.T., J. Bone & Joint Surg., 72B:102-104,1990.

2.

Found that in those patients in whichsurgical intervention was added to thetrauma of elbow dislocation, that thepost-operative function was poorer thanthose who did not undergo surgery.

Operative Treatment of Medial Epicondyle Fractures

3.

in Children. Hines, R.F.; Herndon, W.A. & Evans,J.p.. Clin. Orthop. 223:170-174,1987.Epicondylar Elbow Cases: 35 years Follow-up of 56Unreduced Cases. Josefsson, P.O. & Oanielsson,L.G., Acta Orthop. Scand., 57:313-315,1986.

A long term study of non-operativemanaged fractures. Good results despitethe fact that 60% demonstrated non-union.

Untreated Intra-articular Entrapment of the MedialHumeral Epicondyle. Fowles, J.V.; Kassab, M.T. &Moula, T., J. Bone & Joint Surg., 60B:562-565,1984.

4.

Demonstrated that extracti ng thefragment on up to fourteen weeks postinjury can still result in resumption of at


5.

6.

7.

8.

9.

10.

least 80% of the elbow motion beingregained.

Fractures of the Medial Epicondyle of the Humerus:Bernstein, S.M., King, J.D. and Sanderson, R.A.,Contemp. Orthop., 637-641. 1981.

The most recent large series ofepicondylar fractures. Emphasizes goodresults with conservative measures.

Biomechanics of Elbow Instability: The Role of theMedial Collateral Ligament. Schwab, G.H. et aI.,Clin. Orthop., 146:42-52, 1980.Elbow Instability and Medical Epicondyle Fracture.Woods, G.M. & Tullos, H.G., Am. J. Sports Med.,5:23-30, 1977.

Two articles which define the true

function of the various portions of themedial collateral ligament. Describes thevalgus stress test to determine elbowstability after a fracture of the medialepicondyle.

Little League Survey: The Houston Study.Sugenheim, J.J., et aI., Am. J. Sports Med., 4:201-209,1976.Little League Elbow: The Eugene Study. Larson,R.L., et aI., Am. J. Sports Med., 4:201-209,1976.

Two consecutive articles detailing thelong term effects of throwing on youngindividuals. Demonstrated that whenmoderation is practiced in games that thelong term effects were minimal.

Fractures of the Medial Humeral Epicondyle inChildren. Bede, W.B.; Lefebure, A.R. & Rasmon,M.A., Can. J. Surg., 18:137-142, 1975.

Presented a series of comparison cases inwhich patients were treated operativelyand non-operatively in the sameinstitution. Those treated non-operatively,90% had satisfactory results, versus 75%for those treated by surgical intervention.

Injury to the Throwing Arm. Adams, J.F., Calif.Med., 102:127-132, 1964.

First to warn about the detrimental clinicaleffects of excessive throwing in LittleLeague pitchers.

Little Leaguer's Elbow. Brogdon, B.J. & Crow, N.E.,Am. J. Rengenol., 83:671-675, 1960.

The original radiographic description ofchronic irritation of the medial epicondylefrom excessive throwing in Little Leaguepitchers.

Medial Epicondyle Injuries. Smith, F.M., J.A.M.A.,142:398-402, 1950.

A classic article reviewing a series of 143cases of epicondylar fracture. His resultsdiscounted many of the previously heldconcepts regarding these fractures. Heemphasizes that there are very fewsequelae and indications for operativeintervention.

Fracture of the Medial Epicondyle with Displacementinto the Elbow Joint. Patrick, J., J. Bone & JointSurg., 28:143-147,1946.

Describes the use of Fridic Stimulation ofthe flexor muscles to extract the

epicondyle from the joint.Displacement of the Internal Epicondyle into theJoint. Roberts, N.W., Lancet, 2:78-79,1934.

Describes a simple manipulative techniquefor extracting the medial epicondyle fromthe joint.

11.

12.

13.

14.

15.

Ill. RADIAL NECK

I16.

17.

18.

19.

20.

21.

22.

Closed Reduction of Fractures of the Proximal

Radius in Children. Kaufman, B.; Rinott, & Tanzman,

M., J. Bone & Joint Surg., 71 B:66-67, 1989.Describes a technique of reducing thefractures by pressure over the radial headwith the elbow flexed at 90.' and forcibly

pronating the forearm. This is a usefulalternative technique when the standardPatterson technique fails.

Displaced Fractures of the Neck of the Radius.Wedge, J.H. & Robertson, D.E., J. Bone & Joint

Surg., 648:256, 1982.Was the first to describe the CAM effect

that occurs with translocation of the radial

head and demphasizes it's importance in

correcting this type of deformity to allowresumption of full supination andpronation.

The Radial Head-Capitellum View: Useful Technique

in Elbow Trauma. Greenspan, A. & Normal, A.,

A.J.R., 138:1186-1188, 1982.Describes in detail the radial capitellarview which outlines better the radial head

and neck, and the coronoid process.A Proximal Radial Metaphyseal Fracture Presenting

as Wrist Pain. Anderson, T.E. & Breed, A.L.,

Orthopedics, 5:425-428, 1982.Points out the pitfall of referred pain ofradial head fractures to the wrist. Can be

source of an overlooked diagnosis.Displaced Radial Neck Fractures in Children.

Newman, J.H., Injury, 9:114-121, 1977.Reports on a large series of 47 injuries.

Divides them into five types. Describesradial neck fractures as occurring when anelbow dislocation is reduced. A goodreview of the complications.

Fracture of the Head of the Radius in Children.

Jeffrey, C.C., J. Bone Joint Surg., 53B:429-439,1971.

Reviews the various mechanisms of

injury. Divides mechanisms into valgusstress and those occurring with elbowdislocations. Outlines some good

principles of treatment.Treatment of Displaced Transverse Fractures of theNeck of Radius in Children. Patterson, R.F., J. Bone& Joint Surg., 16:695-698, 1934.

Outlines the displacement forces thatoccur with fracture of the radial neck.

Describes a manipulative technique.

Im. OLECRANON

I23. Displaced Olecranon Fractures in Adults. Biomedical

Analysis of Fixation Methods. Murphy, D.F.;Greene, W.B.; Gilbert, J.A. & Dameron, T.B., Clin.

Orthop., 224:210-214.

A comparison of the various fixation methods.Shows that a screw across the fracture site,combined with a tension band, provides thestrongest fixation.


24. Some Vagaries of the Olecranon. Silberstein, J.J. etaI., J. Bone & Joint Surg., 63A:722-725, 1981.

Defines in detail the normal ossification pattern ofthe olecranon. Delineates the differences betweennormal ossification and a fracture.

25. Fracture of the Olecranon in Children. Matthews,J.G.. Injury, 12:207-212,1981.

The most recent and extensive review ofolecranon fractures in children. Points outthat many of these are part of a complexinjury to the joint. Defines many of thecomplications associated with this injury.Divides the injuries into groups.

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ELBOW INJURIES IN CHILDREN - WordPress.com...Elbow Injuries in Children (The "RARE INJURIES" that may present Major Problems) 3 f. Stiffness is a common sequelae. 1) Thus, it is important