HUME FRACTURES IN CHILDREN: DIFFERENT TREATMENT MODALITIES-PERSONAL EXPERIENCE

Dr A. K. Pall, Dr. D. S. Roy2, Dr. D. Banerjee3, Dr. D. BaksP, Dr. A. N. Mukherjee5

Abstract : Six patients (four boys and two girls) in the age group

offour to ten years (average 6.6 years) had Hume Fractures following fall on ground or from running bicycle or tree. of which one had associated fracture of coronoid process. Two cases had posterior interosseous nerve palsy.

One case needed operative reduction and Internal fixation . Two cases needed close reduction and plaster immobilisation. In 6 to 32 months follow up, all fractures united with excellent results except one who had good result due to restriction of terminal lQ" extension. Nerve palsy in both cases recovered in six to eight weeks.

Key word: Hume fracture fn children

Anterior dislocation of the head of the radius associated with undisplaced fracture of the olecranon process in children(HUMES FRACTURES) was described in 1957 t . Variations of similar injuries were also reported by other workers: Anterior dislocation of radius following

Fig. I. A. P. & lateral radiograph of a 8 yrs old boy showing oblique metaphyseal fracture of olecranon with lateral

subluxation of radial head (Case No . I)

pronation of forearm and hyperextension of elbow2• Anterior dislocation of radial head with displacement of olecranon epiphysis following hyperextension injury of elbow &. dislocation of radial head with displaced and unstable olecranon fracture4• However, a series of cases having Hume fractures were studied and their final outcome, following different methods of treatment art? being reported.

The Materials:

The Patients: There were six patients, four boys and two girls in the age group of 4 to 10 years (average 6.6 years). Most patients sustained trauma over the elbow by falling on the ground during contact games or falling from running bicycle or from tree. Three patients (Case No.1, 2 and 4) had clear description of injury where they sustained trauma following an outstretched hand with the elbow extended and pronated (Table - II) . Two patients had posterior interosseous nerve palsy.

Fig. 2. A. P. & lateral radiography of the above patients. two year after open reduction and internal fixation showing union of the fracture (lnt. fixation devices removed).

1. & 3. Asst. Prof Dept. of Orthopaedics, Burdwan Medical College. Burdwan. 2. Associate Prof Dept. of Orthopaedics. Burdwan Medical College Burdwan 4. Registrar lPGME & R, Kolkata 5. Head, Dept. of Orthopaedics. 1. N. Roy Gen. Hospital.

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52 Dr. A. K. Pal et al : Hume Fractures in Children

Table-l

Pain Rom Muscle Functional adiology (ElF) Power (Bff) Activitie of

elbow

Excellent Nil Full Normal Full Union ofFr. ±Upto SO malalignment

Good Nil Terminal Normal Full Union + 5°_ 10° limitation mal alignment

Fair Occasional 50% Less than Amost fully Delayed/Malunion Limitation MRC4 restricted

N. B. : E-Elbow, F-Forearm, B-Biceps, T-Triceps, MRC-Medical Research Council, Fr-Fracture.

Nature of injury: All had fracture of proximal ulnar metaphysis with oblique fracture line having lateral angulation of which two (Case No. 1 & 2) had significant displacement.

Among the injuries of radial head, one had lateral dislocation (Fig-I); three had lateral subluxalion (Fig-3), two had antero-Iateral subluxation of radial hend (Fig-4).

Apart from the above injuries, one (Case No.1) had displaced fracture of coronoId process.

Methods:

In this series, one (Case No.1) needed operative

Case Age Sex Sides Associated No. (years) (MIF) (RIL) Injuries

1 8 M L Fr. Coronoid + Post Int. nv. Palsy

2 5 M L -

3 4 F L -

4 5Y2 M R Post Int. nv. Palsy

5 10 F L -

6 7 M L -

correction. Two cases (Case No.2 & 4) needed close reduction and others were treated by deltoid to Knuckle pluster casing without anaesthesia for two to three weeks followed by gradual mobilization.

The Case No. I (Fig-l & 2) was operated by open reduction of ulnar fracture using Tension band wiring. Postoperatively. the elbow was immobilized in plaster cast at about 110° flexion with forenrm fully supinated. Mobilisation of elbow started from fourth week with intermittent splintage.

Table-II

Mode of Complications Functional Gradation Treatment Activity of Result

ORIP Nil Full Excellent

CR+POP Terminal 10° Full Good

Casing Limitationof Elbow

Extension

POP Casing Nil Full Excellent

CR+POP Nil Full Excellent Casing

POP Casing Nil Full Excellent

POP Casing Nil Full Excellent

N. B. : MIF-Male I Female, R-Right, L-Lejt, Fr-Fracture, Post. Int. Nv. -Posterior Interosseous Nerve ORIF-OPen reducation & internal Fixation, CR-Close reduction, POP-Plaster of Paris.

Journal of West Bengal Orthopaedic Association

Dr. A. K. Pal et al : Hume Fractures in Children

Fig. 3. A. P. & lateral radiograph of a 5 years 6 months old boy showing oblique metaphyseal fracture of olecranon (Case No.4)

Results and Complications :

The cases were followed up for six to thirty two months. The evaluation was done clinically on the basis of pain at or around the elbow, range of elbow and forearm motions, muscle powers around the elbow, functional activity and also radiologically, on the basia of union of olecranon fracture, delayed and malunion (Table-I). The case which was operated regained painless full functional activities since four months after operation and retained full elbow as well as forearm motions at 32 months follow-up with excellent result. Posterior interosseous nerve palsy in this case was recovered at eighth postoperative week.

The cases who required close reduction (Table-2), showed good result in one due to terminal 10° limitation of extension and excellent in another. The posterior interosseous nerve palsy in Case No.4 required six weeks for it's complete recovery. The other cases showed excellent results (Table-2)

Discussion:

The injury described by A.c. Hume (1957) is different from Monteggia equivalent injuries described by Bado because there are either isolated radial head dislocation or there are fracture of the radial neck along with fracture of ulnar mLtaphysis8. This is similar to components of Monteggia Equivalent Type III injuries6.7. but all types of

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Fig. 4. A. P. and lateral radiograph of a 10 years old boy showing oblique metaphyseal fracture of olecranon with antero-Iateral

subluxation of radial head (Case No. 2).

metaphysial and diaphysial fractures of the ulna were included in that type of injurys.9.lo. in our series, all cases having oblique metaphysial fractures of ulna with dislocation or subluxation of radial head either laterally or anterolaterally, were studied.

However, the injury pattern was a varus stress at the level of elbow, when the outstretched hand with pronated forearm was planted firmly over the ground, generating a twisting as well as compressive load over ulnar metaphysis resulting in oblique ulnar metaphysial fracture with or without fracture of coronoid process. The radial head dislocation may be the result of hyperextension of elbow combined with pronation of the forearm as suggested by Hume. A,C.1• Posterior interosseous nerve palsy is common with lateral dislocation or subiuxation of radial head, recovered following their reduction.

Conservative treatment is the mainstay as it produced excellent to good result In majority. Close reduction was effective by revising the mechanism of injury exerting valgus stress in longitudinal traction of extended elbow which realigned both the ulnar fracture as well as dislocation or subluxation of Radial h~ad. Open reduction is usually not needed unless there is failure of close reduction due to interposition of soft tissue between the radial head and the ulna or capitellum.

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References:

l. Hume, A.c. :- Anterior dislocation of the head of the radius associated with undisplaced fracture of the olecranon in children : J, Bone Joint Surg .. 39B : 508 - 512,1957.

2. Co~bett, C. H. : Anterior dislocation of the Radius and it's recurrence, British Journal of Surgery, 19:155; 1931.

3. Speed K. : A Text-Book of Fractures and Dislocations. Third Edition. London: Henry Kimpton : 1935.

4. Rang M. : Children's Fractures. Second Edition . Philadelphia, J. B. LIppIncott, p 191; 1983 .

5. Bado, J.L.: The Monteggia Lesion. Clip Orthop-ReI. Res .. 50 : 71-86, 1967.

6. Wright, P.R,: Greenstick Fracture of the upper end

Dr. A. K. Pal et al : Hume Fractures in Children

of the ulna with dislocation of the Radio -Humeral Joint or displacement of the Superior Radial Epiphysis, J. Bone Joint Surg. 45B : 727,1033.

7. Rockwood. Wilkins. Beaty: Textbook of "Fractures in Children" Vol. 3 Fourth Edition 1996.

8. Olney, B., and Menelaus, M. : Monteggia and Equivalent Lesion In childhood, 1. Pedlatr. Orthop .. 9 :219, 1989.

9. Wiley, J. J, . and Galey. J . P.: Monteggia Injuries in Children. J. Bone Joint Surg. 67B : 728-731,1085 .

10. Wise. R. A. : Lateral dislocation of the Head of Radius with Fracture of the ulna, 1. Bone Joint Surg. 23: 379,194l.

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