FRACTURES IN FRACTURES IN CHILDRENCHILDREN

ELBOWELBOWHUMERUSHUMERUS

PRESENTERPRESENTER

DR.AHSAN-UL-HAQDR.AHSAN-UL-HAQ

POST-GRADUATE RESIDENT POST-GRADUATE RESIDENT

Lahore General HospitalLahore General Hospital

Ossification CentresOssification Centres

There are 6 ossification There are 6 ossification centres around the elbow centres around the elbow joint.joint.

The ossification centers The ossification centers always appear in a strict always appear in a strict order. order. Come-Read-My-Tale-Of-Come-Read-My-Tale-Of-LoveLove (Capitellum - Radius - (Capitellum - Radius - medial epicondyle - medial epicondyle - Trochlea - Olecranon - Trochlea - Olecranon - lateral epicondyle).lateral epicondyle).

As a general guide As a general guide remember 1-3-5-7-9-11 remember 1-3-5-7-9-11 years.years.

ELBOW JOINT FRACTURES AND ELBOW JOINT FRACTURES AND DISLOCATIONSDISLOCATIONS

Radial Head and Radial Head and Neck FracturesNeck Fractures 4 to 14 years 4 to 14 years Ossification of the Ossification of the

radial head usually radial head usually does not begin does not begin before 5 years of agebefore 5 years of age

Most fractures in Most fractures in children are of the children are of the radial neck and not radial neck and not the radial headthe radial head

Usually Salter-Harris Usually Salter-Harris type IV fractures.type IV fractures.

Classification Radial Head Classification Radial Head and Neck Fracturesand Neck Fractures

Wilkins Wilkins Type AType A

Salter-Harris type I Salter-Harris type I and II injuries of the and II injuries of the proximal radial proximal radial epiphysesepiphyses

Type BType BSalter-Harris type IV Salter-Harris type IV

injuries of the injuries of the proximal radial proximal radial epiphysesepiphyses

Type CType CFractures involving Fractures involving

only the proximal only the proximal radial metaphysisradial metaphysis

Radial Head and Neck Radial Head and Neck FracturesFractures

• Type DType D• Fractures Fractures

occurring when a occurring when a dislocated elbow dislocated elbow is being reducedis being reduced

Type EType E Fractures occurring Fractures occurring

in conjunction with in conjunction with the elbow the elbow dislocationdislocation

Acceptable CriteriaAcceptable Criteria

30 to 45 degrees of 30 to 45 degrees of residual angulation residual angulation usually is accepted usually is accepted in closed treatment in closed treatment with satisfactory with satisfactory resultsresults

Patterson TechniquePatterson Technique

Close ManipulationClose Manipulation Neher and Torch Neher and Torch

modified the original modified the original closed reduction closed reduction technique of Patterson. technique of Patterson. General anesthesia if General anesthesia if

needed and fluoroscopyneeded and fluoroscopy An assistant stabilizes An assistant stabilizes

the radius distal to the the radius distal to the fractured radial neck fractured radial neck

With the elbow in With the elbow in extension, the surgeon extension, the surgeon applies a varus stress applies a varus stress with one hand on the with one hand on the elbow and lateral elbow and lateral pressure directly over pressure directly over the radial head with the the radial head with the thumb of the other handthumb of the other hand

Closed ReductionClosed Reduction

Pesudo et al.Pesudo et al. Using a Using a

percutaneous pin percutaneous pin with the aid of an with the aid of an image intensifier to image intensifier to manipulate and manipulate and reduce the reduce the angulation of the angulation of the fracture fragmentsfracture fragments

Closed ReductionClosed Reduction Metaizeau technique.Metaizeau technique.

Inserting a curved steel Inserting a curved steel Kirschner wire that is Kirschner wire that is sharply bent at the last 1.5 sharply bent at the last 1.5 cm through the distal cm through the distal radial metaphysis into the radial metaphysis into the medullary canal medullary canal

The wire or nail is The wire or nail is advanced until the point advanced until the point fixes in the epiphysis and fixes in the epiphysis and elevates and replaces it elevates and replaces it under the lateral condyle. under the lateral condyle. The pin is turned around The pin is turned around its long axis through 180 its long axis through 180 degrees, producing a degrees, producing a medial shift of the radial medial shift of the radial head and reducing it.head and reducing it.

AFTERTREATMENT AFTERTREATMENT

The arm is immobilized in a long-arm The arm is immobilized in a long-arm cast for 2 to 3 weeks. cast for 2 to 3 weeks.

The Kirschner wire is not removed The Kirschner wire is not removed until approximately 2 months later until approximately 2 months later when the fracture has consolidated.when the fracture has consolidated.

ORIFORIF If a satisfactory closed reduction cannot be If a satisfactory closed reduction cannot be

obtained, open reduction should be done obtained, open reduction should be done

Surgery should be performed within 5 to 7 days of Surgery should be performed within 5 to 7 days of injury to prevent myositis ossificans of the elbow,injury to prevent myositis ossificans of the elbow,

Before skeletal maturity is reached, radial head Before skeletal maturity is reached, radial head resection may result in proximal radioulnar resection may result in proximal radioulnar synostosis, cubitus valgus, and radial deviation of synostosis, cubitus valgus, and radial deviation of the handthe hand

Complications After Open Complications After Open ReductionReduction

IncludeInclude Loss of motionLoss of motion Premature physeal closurePremature physeal closure Nonunion of the radial neckNonunion of the radial neck Osteonecrosis of the radial headOsteonecrosis of the radial head Radioulnar synostosis Radioulnar synostosis Myositis ossificans Myositis ossificans Injury to the posterior interosseous Injury to the posterior interosseous

nervenerve

Radial Head DislocationRadial Head Dislocation(Pulled Elbow) (Pulled Elbow)

Age: usually 1 to 4 Age: usually 1 to 4 years oldyears old

History of “pull” on History of “pull” on the elbow the elbow

In 50%: no history In 50%: no history of a "pull" on the of a "pull" on the arm arm

Examination Examination

Not using the Not using the affected limb affected limb

Elbow in extension Elbow in extension and the forearm in and the forearm in pronation pronation

Marked resistance Marked resistance and pain with and pain with supination of the supination of the forearm forearm

Reduction TechniqueReduction Technique

Olecranon Fractures Olecranon Fractures

Pure physeal Pure physeal fractures of the fractures of the olecranon are olecranon are extremely rareextremely rare

Has secondary Has secondary ossification centreossification centre

The epiphysis fuses The epiphysis fuses to the metaphysis to the metaphysis at about age 14.at about age 14.

Grantham and Kiernan and Grantham and Kiernan and WilkinsWilkins

The first type is The first type is purely physeal purely physeal

The second type The second type occurs in older occurs in older children and has a children and has a large metaphyseal large metaphyseal fragment attached fragment attached to the epiphysisto the epiphysis

Papavasiliou et al.Papavasiliou et al.

Intraarticular (Group A)Intraarticular (Group A)Simple crack fracturesSimple crack fracturesFractures with minimal displacement Fractures with minimal displacement Complete fractures of the olecranon Complete fractures of the olecranon

involving the articular cartilage and with involving the articular cartilage and with slight dorsal displacement of the slight dorsal displacement of the proximal fragmentproximal fragment

Grossly displaced fracturesGrossly displaced fractures Extraarticular (Group B)Extraarticular (Group B)

Greenstick fractureGreenstick fracture

Evans and Graham Evans and Graham

If displacement, especially If displacement, especially intraarticular, is more than 3 to 4 intraarticular, is more than 3 to 4 mm, open reduction and internal mm, open reduction and internal fixation are indicated fixation are indicated

Regardless of the Regardless of the type of fracture, if type of fracture, if significant significant displacement displacement persists after persists after attempts at closed attempts at closed reduction, open reduction, open reduction and reduction and internal fixation internal fixation should be should be performedperformed

Methods of ORIFMethods of ORIF

Tension band Tension band wiringwiring

Axial pinsAxial pins Oblique screwsOblique screws

Fractures of the Coronoid Fractures of the Coronoid ProcessProcess

Regan and Morrey Regan and Morrey classificationclassification Type IType I

a small chip fracture;a small chip fracture; Type IIType II

a fracture involving a fracture involving less than 50% of the less than 50% of the process; process;

Type IIIType III a fracture involving a fracture involving

more than 50% of the more than 50% of the processprocess

Treatment OptionsTreatment Options

Closed treatment Closed treatment Type I and II fracturesType I and II fractures

Open reduction and internal fixationOpen reduction and internal fixationType III fractures Type III fractures

Elbow Dislocations Elbow Dislocations

Acute DislocationsAcute Dislocations

Most pure Most pure dislocations are dislocations are posteriorposterior

But they can occur But they can occur anteriorly, medially, anteriorly, medially, or laterallyor laterally

Regardless of the Regardless of the type, most elbow type, most elbow dislocations can be dislocations can be reduced closedreduced closed

Under GA, longitudinal Under GA, longitudinal tractiontraction

Immobilization for Immobilization for approximately 6 approximately 6 weeksweeks

Indications for open Indications for open reductionreduction

Inability to obtain a closed reductionInability to obtain a closed reduction Open dislocationOpen dislocation Medial epicondyle fractureMedial epicondyle fracture Radial neck fractureRadial neck fracture Arterial injuriesArterial injuries

Chronic Recurrent Elbow Chronic Recurrent Elbow DislocationsDislocations

Four primary underlying causes Four primary underlying causes 1.1. Shallow trochlear notch that allows easy Shallow trochlear notch that allows easy

dislocation of the olecranon from the trochlea dislocation of the olecranon from the trochlea

2.2. Medial, lateral, or combined capsular laxity of Medial, lateral, or combined capsular laxity of the elbowthe elbow

3.3. Intraarticular fractures that cause medial or Intraarticular fractures that cause medial or lateral instability of the olecranon in the lateral instability of the olecranon in the trochlea trochlea

4.4. Congenital laxity of the medial and lateral Congenital laxity of the medial and lateral ligaments around the elbow.ligaments around the elbow.

EvaluationEvaluation Anteroposterior and lateral radiographs of Anteroposterior and lateral radiographs of

both elbows both elbows Any osseous loose bodies or articular Any osseous loose bodies or articular

fractures also can be notedfractures also can be noted Varus and valgus stress radiographs of both Varus and valgus stress radiographs of both

elbows to determine any medial or lateral elbows to determine any medial or lateral ligamentous instability ligamentous instability

Arthrogram or MRIArthrogram or MRI suspected intraarticular condylar fracturesuspected intraarticular condylar fracture

Fluoroscopic examinationFluoroscopic examination

Treatment Treatment

Surgical procedure should be selected to Surgical procedure should be selected to correct the specific conditioncorrect the specific condition If plain radiographs reveal a shallow If plain radiographs reveal a shallow

trochlear notchtrochlear notchTransfer of the biceps or triceps tendon or both Transfer of the biceps or triceps tendon or both ReichenheimReichenheim

Biceps tendon onto the coronoid process of the ulna, Biceps tendon onto the coronoid process of the ulna, suturing it to the periosteum on the anterior aspect of suturing it to the periosteum on the anterior aspect of the coronoid process with two smooth wiresthe coronoid process with two smooth wires

KingKing Passing the tendon through a drill hole in the coronoid Passing the tendon through a drill hole in the coronoid

to the subcutaneous border of the ulna, where it was to the subcutaneous border of the ulna, where it was suturedsutured

TreatmentTreatment

KapelKapelThreading a strip of biceps tendon through a drill Threading a strip of biceps tendon through a drill

hole in the small partition of bone separating the hole in the small partition of bone separating the coronoid and olecranon fossae and suturing it to coronoid and olecranon fossae and suturing it to the tip of the olecranon; a central slip of triceps the tip of the olecranon; a central slip of triceps tendon was pulled through the same hole and tendon was pulled through the same hole and sutured to the coronoid process.sutured to the coronoid process.

If stress radiographs reveal significant If stress radiographs reveal significant ligamentous laxityligamentous laxityCapsular repair and imbricationCapsular repair and imbrication

Old Unreduced Elbow Old Unreduced Elbow DislocationsDislocations

Satisfactory functional result can be Satisfactory functional result can be obtained by an open reduction upto 03 obtained by an open reduction upto 03 monthsmonths

Campbell posterolateral approach Campbell posterolateral approach Free subperiosteally all muscle Free subperiosteally all muscle

attachmentsattachmentsRelease the attachments of the joint Release the attachments of the joint

capsule around the humeral condyles. capsule around the humeral condyles. Detach the collateral ligaments from their Detach the collateral ligaments from their

proximal insertionsproximal insertions

Old Unreduced Elbow Old Unreduced Elbow DislocationsDislocations

If the triceps is tight, preventing reduction If the triceps is tight, preventing reduction or limiting flexion to about 30 degrees after or limiting flexion to about 30 degrees after reduction, lengthen the muscle using reduction, lengthen the muscle using Speed's V-Y muscle-plasty Speed's V-Y muscle-plasty

Do not reattach the ligaments to bone to Do not reattach the ligaments to bone to avoid making the repair too tight.avoid making the repair too tight.

If the ulnar nerve is tight or was If the ulnar nerve is tight or was compressed preoperatively, transpose it compressed preoperatively, transpose it anteriorlyanteriorly

Check the stability of the reduction Check the stability of the reduction manually at 90 degrees of flexionmanually at 90 degrees of flexion

AFTERTREATMENTAFTERTREATMENT

The cast and any Kirschner wires are The cast and any Kirschner wires are removed at 2 to 3 weeks. removed at 2 to 3 weeks.

Active mobilization of the elbow is Active mobilization of the elbow is started slowly and is encouraged.started slowly and is encouraged.

Distal Humeral FracturesDistal Humeral Fractures

Capitellar FracturesCapitellar Fractures

Classification of fractures of Classification of fractures of the Capitellumthe Capitellum

Depends on the size of the Depends on the size of the articular fragment and its articular fragment and its comminution.comminution.

A good quality Lateral view A good quality Lateral view Type 1 fractureType 1 fracture

a large fragment of a large fragment of bone and articular bone and articular cartilage cartilage

Type 2 fractureType 2 fracture a small shell of bone a small shell of bone

and articular cartilageand articular cartilage Type 3 fractureType 3 fracture

comminuted fracturecomminuted fracture

Treatment optionsTreatment options

Closed reductionClosed reduction usually not successfulusually not successful

Open reduction with Open reduction with and without internal and without internal fixationfixation Type I & II (large Type I & II (large

fragment)fragment) Kirschner wireKirschner wire Herbert screwsHerbert screws cannulated screwscannulated screws

Excision of the Excision of the fragmentsfragments Most of type III fractures.Most of type III fractures.

Lateral Condylar FracturesLateral Condylar Fractures

Fracture of necessityFracture of necessity

Occur at Occur at approximately age 6 approximately age 6 yearsyears

Mechanism of injuryMechanism of injury

When a varus force is applied to the When a varus force is applied to the extended elbow. extended elbow.

They tend to be unstable and They tend to be unstable and become displaced because of the become displaced because of the pull of the forearm extensors.pull of the forearm extensors.

Since these fractures are intra-Since these fractures are intra-articular they are prone to nonunion articular they are prone to nonunion because the fracture is bathed in because the fracture is bathed in synovial fluid. synovial fluid.

Milch ClassificationMilch Classification

Type I fracture,Type I fracture, The fracture line courses The fracture line courses

medially to the trochlea medially to the trochlea through and into the through and into the capitellar-trochlear capitellar-trochlear groovegroove

Type II fracture,Type II fracture, The fracture line extends The fracture line extends

into the area of the into the area of the trochlea and produces trochlea and produces inherent instability of the inherent instability of the elbowelbow

Lateral condylar fractures also have Lateral condylar fractures also have been classified according to the been classified according to the amount of displacement:amount of displacement:

(1) Undisplaced,(1) Undisplaced,

(2) Moderately displaced, (2) Moderately displaced,

(3) Completely displaced and rotated(3) Completely displaced and rotated

Finnbogason et al. Finnbogason et al.

Type AType A Fracture through Fracture through

the lateral humeral the lateral humeral condyle with condyle with minimal lateral gap minimal lateral gap

A stable fractureA stable fracture

Type BType B Fracture through Fracture through

the lateral humeral the lateral humeral condyle to the condyle to the epiphyseal cartilage epiphyseal cartilage with a lateral gap with a lateral gap

A fracture with A fracture with undefinable riskundefinable risk

Type CType C Fracture through Fracture through

the lateral humeral the lateral humeral condyle with the condyle with the fracture gap as fracture gap as wide laterally as wide laterally as mediallymedially

A fracture with high A fracture with high risk of later risk of later displacementdisplacement

MRIMRI

MRI distinguishes MRI distinguishes the potentially the potentially unstable fracture unstable fracture (Type II) from the (Type II) from the stable, minimally stable, minimally displaced fracture displaced fracture (Type I). (Type I).

Treatment OptionsTreatment Options Mostly closed Mostly closed

manipulation and POP manipulation and POP castingcasting

Percutanious K wire Percutanious K wire fixationfixation

Open reduction and Open reduction and internal fixationinternal fixation1) suture fixation, which is 1) suture fixation, which is

inadequate;inadequate;2) smooth pin fixation, 2) smooth pin fixation,

preferably with two pins, preferably with two pins, through the epiphysis or through the epiphysis or through the metaphyseal through the metaphyseal spikespike

3) screw fixation, preferably 3) screw fixation, preferably through the metaphyseal through the metaphyseal area.area.

AftertreatmentAftertreatment

Immobilization for approximately 6 Immobilization for approximately 6 weeks.weeks.

Gentle active motion of the elbow Gentle active motion of the elbow usually is resumed intermittently out usually is resumed intermittently out of the splint. of the splint.

The splint is not removed The splint is not removed permanently until the radiographs permanently until the radiographs show solid union.show solid union.

ComplicationsComplications

Physeal arrestPhyseal arrest Physeal stimulationPhyseal stimulation Osteonecrosis Osteonecrosis Nonunion with Nonunion with

resultant cubitus resultant cubitus valgusvalgus

Bone Grafting for Nonunion or Bone Grafting for Nonunion or Delayed UnionDelayed Union

Open Reduction and Open Reduction and Internal Fixation with Internal Fixation with Bone Grafting for Bone Grafting for Nonunion or Delayed Nonunion or Delayed Union of Minimally Union of Minimally Displaced FracturesDisplaced Fractures

AftertreatmentAftertreatment

The limb is immobilized in plaster with The limb is immobilized in plaster with the elbow at 90 degrees of flexion and the elbow at 90 degrees of flexion and the forearm in neutral rotation for 12 the forearm in neutral rotation for 12 weeks. The pin or screw is removed, weeks. The pin or screw is removed, and active exercises are begunand active exercises are begun

Established Nonunion with Established Nonunion with Cubitus ValgusCubitus Valgus

Occur, not from premature closure of Occur, not from premature closure of the capitellar physis, but from the capitellar physis, but from nonunion with proximal migration of nonunion with proximal migration of the lateral condyle the lateral condyle

Masada et alMasada et al. . concluded that osteosynthesis is concluded that osteosynthesis is

indicated for the treatment of nonunion indicated for the treatment of nonunion of the lateral humeral condyle only if of the lateral humeral condyle only if The patient has severe pain in the elbow or The patient has severe pain in the elbow or

is apprehensive about using the elbow is apprehensive about using the elbow because of lateral instabilitybecause of lateral instability

TreatmentTreatment

Milch devised two osteotomies for Milch devised two osteotomies for nonunion of the lateral condyle; with nonunion of the lateral condyle; with each, internal fixation and bone each, internal fixation and bone grafting are recommended.grafting are recommended.

OsteotomyOsteotomy

In Milch type I In Milch type I fractures fractures

Opening wedge lateral Opening wedge lateral osteotomy as described osteotomy as described by by MilchMilch

A closing wedge medial A closing wedge medial osteotomy as described osteotomy as described by by Speed Speed

OsteotomyOsteotomy

In Milch Type II In Milch Type II fractures, there is fractures, there is significant lateral significant lateral displacement of displacement of the fragment and the fragment and some rotationsome rotation Milch recommended Milch recommended

an opening wedge an opening wedge displacement displacement osteotomy osteotomy

Technique Technique Patient prone Patient prone Posterior muscle-splitting Posterior muscle-splitting

incisionincision Identify the ulnar nerveIdentify the ulnar nerve Perform transverse Perform transverse

osteotomy at the level of osteotomy at the level of the intersection of the the intersection of the forearm axis with the forearm axis with the lateral cortex of the lateral cortex of the humerus humerus

Notch the inferior surface Notch the inferior surface of the proximal fragment of the proximal fragment to receive the apex of the to receive the apex of the superior surface of the superior surface of the distal fragment, which is distal fragment, which is moved laterally moved laterally

TechniqueTechnique

When correction is When correction is satisfactory, fix the satisfactory, fix the fragments by fragments by inserting two inserting two smooth crossed smooth crossed Kirschner wiresKirschner wires

Carefully flex the Carefully flex the elbow, and elbow, and immobilize it in immobilize it in plaster at 90 plaster at 90 degreesdegrees

AftertreatmentAftertreatment

The cast is left on for 6 to 12 weeks, The cast is left on for 6 to 12 weeks, depending on the age of the child depending on the age of the child and evidence of bony union. The and evidence of bony union. The wires are removed, and motion is wires are removed, and motion is encouraged at that time.encouraged at that time.

Kim OsteotomyKim Osteotomy

Step-Cut Translation Osteotomy with a Y-Shaped Step-Cut Translation Osteotomy with a Y-Shaped Humeral Plate Humeral Plate

Perform the initial osteotomy 0.5 cm superior to Perform the initial osteotomy 0.5 cm superior to the olecranon fossa, perpendicular to the axis of the olecranon fossa, perpendicular to the axis of the humeral shaft, with an electrical saw. Place the humeral shaft, with an electrical saw. Place the triangular template over the proximal portion the triangular template over the proximal portion of the humerus, and mark the area of the humerus, and mark the area

Osteotomize the proximal part of the humerus Osteotomize the proximal part of the humerus according to the drawn lineaccording to the drawn line

Step-cut Translation Step-cut Translation Osteotomy.Osteotomy.

A,A, After humerus-elbow-wrist angle is After humerus-elbow-wrist angle is determined on anteroposterior determined on anteroposterior radiograph, initial transverse radiograph, initial transverse osteotomy line is made about 0.5 to 1 osteotomy line is made about 0.5 to 1 cm superior to olecranon fossa and cm superior to olecranon fossa and perpendicular to axis of humerus. perpendicular to axis of humerus. Triangular area indicates area to be Triangular area indicates area to be resected.resected.

BB and and C,C, Cubitus varus is corrected by Cubitus varus is corrected by rotating distal fragment and rotating distal fragment and translating it medially after completing translating it medially after completing initial transverse osteotomy. initial transverse osteotomy. Triangular overlapping of proximal and Triangular overlapping of proximal and distal humeral portions means that distal humeral portions means that resection is indicated. For cubitus resection is indicated. For cubitus varus, degree of correction increases varus, degree of correction increases as location of apex moves medially. as location of apex moves medially.

DD and and E,E, Cubitus valgus is corrected Cubitus valgus is corrected by rotating distal part of humerus by rotating distal part of humerus medially and translating it laterally medially and translating it laterally according to anatomical shape of according to anatomical shape of normal elbow.normal elbow.

F,F, Fixation of osteotomy site. Fixation of osteotomy site.

Medial Epicondylar FracturesMedial Epicondylar Fractures

Most fractures of the Most fractures of the medial epicondylar medial epicondylar epiphysis are acute epiphysis are acute avulsion injuries caused avulsion injuries caused by overpull of the by overpull of the forearm flexor tendonforearm flexor tendon

Can occur in dislocation Can occur in dislocation of the elbow, and the of the elbow, and the fragment may or may fragment may or may not become caught in not become caught in the jointthe joint

Treatment Treatment Most nondisplaced or Most nondisplaced or

minimally displaced minimally displaced fractures can be treated by fractures can be treated by closed methodsclosed methods

Indications for open Indications for open reduction include reduction include (1) rotation and (1) rotation and

displacement of more than displacement of more than 1 cm because of the 1 cm because of the resulting weakness of the resulting weakness of the forearm flexors or cosmetic forearm flexors or cosmetic deformity deformity

(2) persistent entrapment of (2) persistent entrapment of a fracture fragment in the a fracture fragment in the joint after reduction of an joint after reduction of an elbow dislocation, elbow dislocation,

(3) ulnar nerve dysfunction(3) ulnar nerve dysfunction (4) valgus instability(4) valgus instability

TreatmentTreatment The medial epicondyle should be identified and The medial epicondyle should be identified and

its location noted after every elbow dislocationits location noted after every elbow dislocation

If the fragment remains caught within the joint, If the fragment remains caught within the joint, a closed reduction should be attempted with a closed reduction should be attempted with the forearm supinated and stressed in valgus the forearm supinated and stressed in valgus with the patient under general anesthesiawith the patient under general anesthesia

Passive dorsiflexion of the fingers may help put Passive dorsiflexion of the fingers may help put traction on the epiphysis. traction on the epiphysis.

TreatmentTreatment

If closed methods fail, open reduction is If closed methods fail, open reduction is required with removal of the fragment from the required with removal of the fragment from the joint and excision or reduction and internal joint and excision or reduction and internal fixation of the fragment through k wire or screwfixation of the fragment through k wire or screw

Small fragment can be excised and muscles to Small fragment can be excised and muscles to be sutured to humerus metaphysisbe sutured to humerus metaphysis

AftertreatmentAftertreatment

The splint is worn for 4 weeks. Next, The splint is worn for 4 weeks. Next, the arm is supported by a sling the arm is supported by a sling permitting active motion of the elbow permitting active motion of the elbow but preventing forced dorsiflexion of but preventing forced dorsiflexion of the wrist or supination of the the wrist or supination of the forearm. forearm.

At 6 weeks, the wire or screw is At 6 weeks, the wire or screw is removed, and normal activities are removed, and normal activities are resumed gradually.resumed gradually.

Medial Condylar FracturesMedial Condylar Fractures Least common injuries Least common injuries

of the elbowof the elbow Kilfoyle described three Kilfoyle described three

typestypes Type IType I

Greenstick or impacted Greenstick or impacted fracturefracture

Type IIType II Fracture through the Fracture through the

humeral condyle into the humeral condyle into the joint with little or no joint with little or no displacement displacement

Type IIIType III An epiphyseal fracture An epiphyseal fracture

that is intraarticular and that is intraarticular and involves the medial involves the medial condyle with the condyle with the fragment displaced and fragment displaced and rotatedrotated

TreatmentTreatment Type I and undisplaced type II fractures Type I and undisplaced type II fractures

Observation and posterior splintingObservation and posterior splinting Type II fractures Type II fractures

Open reduction and internal fixation are Open reduction and internal fixation are appropriate to avoid growth disturbance and appropriate to avoid growth disturbance and nonunion. nonunion.

Type III fracturesType III fractures Open reduction and internal fixation. Open reduction and internal fixation.

Early diagnosis, accurate reduction, and Early diagnosis, accurate reduction, and internal fixation are essential to avoid internal fixation are essential to avoid growth disturbance, articular roughening, growth disturbance, articular roughening, functional disability, nonunion, and functional disability, nonunion, and osteonecrosisosteonecrosis

Open Reduction and Internal Open Reduction and Internal Fixation Fixation

Medial incision just distal to the fractured Medial incision just distal to the fractured condylecondyle

Extend it proximally 7.5 cm parallel to the Extend it proximally 7.5 cm parallel to the long axis of the humeruslong axis of the humerus

Isolating the ulnar nerve and retracting it Isolating the ulnar nerve and retracting it posteriorlyposteriorly

Gently reduce the fracture, and hold it with a Gently reduce the fracture, and hold it with a towel clip towel clip

Insert two smooth Kirschner wires through Insert two smooth Kirschner wires through the condylar fragment and into the humerus the condylar fragment and into the humerus in a proximal and lateral direction. in a proximal and lateral direction.

Close the wound and apply a plaster splint Close the wound and apply a plaster splint with the elbow flexed 90 degreeswith the elbow flexed 90 degrees

Supracondylar FracturesSupracondylar Fractures ObservationsObservations (1) (1)

97.7% extension type97.7% extension type only 2.2% were of the only 2.2% were of the

flexion typeflexion type (2) (2)

Most occurred in boys, Most occurred in boys, especially between ages 5 especially between ages 5 and 8 years and 8 years

(3) (3) Volkmann ischemic Volkmann ischemic

contracture occurred in contracture occurred in 0.5% of the fractures; 0.5% of the fractures;

(4)(4) The radial, median, and The radial, median, and

ulnar nerves were involved ulnar nerves were involved in that order of frequency. in that order of frequency.

Mechanism of injuryMechanism of injury

Fall on Fall on outstretched handoutstretched hand

Know basic landmarks on lateral view to give clues to Know basic landmarks on lateral view to give clues to distinguish fracture from normaldistinguish fracture from normal

Anterior humeral lineAnterior humeral line—middle 1/3 —middle 1/3 capitellumcapitellum

Know basic landmarks on lateral view to give clues to Know basic landmarks on lateral view to give clues to distinguish fracture from normaldistinguish fracture from normal

Radiocapitellar lineRadiocapitellar line—points directly to —points directly to capitellumcapitellum

Gartland Classification Gartland Classification

Type IType I undisplaced; undisplaced;

Type IIType II displaced with displaced with

intact posterior intact posterior cortex cortex

Type III Type III displaced with no displaced with no

cortical contact. cortical contact.

The three most common reasons for The three most common reasons for residual cubitus varus or valgus residual cubitus varus or valgus deformity are deformity are (1) The inability to interpret poor (1) The inability to interpret poor

radiographs radiographs and acceptance of less and acceptance of less than adequate than adequate reduction, reduction,

(2) The inability to interpret good (2) The inability to interpret good radiographs radiographs because of a lack of because of a lack of knowledge of the knowledge of the pathophysiology of the fracture, pathophysiology of the fracture,

(3) The loss of reduction (3) The loss of reduction

Jones view Jones view

Anteroposterior plane should be Anteroposterior plane should be taken properly with the elbow flexed taken properly with the elbow flexed maximally, the cassette underneath maximally, the cassette underneath the elbow, and the tube at a 90-the elbow, and the tube at a 90-degree angle to the cassette degree angle to the cassette

An anterior spike on the lateral view An anterior spike on the lateral view usually implies rotation rather than usually implies rotation rather than posterior displacement. posterior displacement.

crescent sign crescent sign

Crescent sign. A, Normal lateral view of elbow. B, In varus deformity, part of ulna overlies distal humeral epiphyses, producing crescent sign

Baumann angle.Baumann angle. a, Midline diaphysis of a, Midline diaphysis of

humeral shaft.humeral shaft. b, Line perpendicular to b, Line perpendicular to

midline. midline. c, Line through physis of c, Line through physis of

lateral condyle.lateral condyle. Angle A is original Angle A is original

Baumann angle. Angle B is Baumann angle. Angle B is more commonly used more commonly used currently. currently.

A change of 5 degrees in A change of 5 degrees in the Baumann angle the Baumann angle corresponds to a 2-degree corresponds to a 2-degree change in the clinical change in the clinical carrying angle.carrying angle.

O'Brien et al O'Brien et al

Metaphyseal-Metaphyseal-diaphyseal angle diaphyseal angle was more accurate was more accurate than the Baumann than the Baumann angle in angle in determining the determining the adequacy of adequacy of reduction reduction

Varus tilting is Varus tilting is reduced by reduced by pronation of the pronation of the forearm that closes forearm that closes the fracture the fracture laterally laterally

Criteria for closed reductionCriteria for closed reduction

Easy reduction Easy reduction Stable fractureStable fractureMinimal swelling Minimal swelling No vascular compromise No vascular compromise

Conservative treatmentConservative treatment

Skeletal traction Skeletal traction using an olecranon using an olecranon pin or screw pin or screw advantages are advantages are

increased mobility, increased mobility, decreased pain and decreased pain and swelling, and swelling, and improved improved alignment. alignment.

. .

Percutanious pin fixationPercutanious pin fixation

Most displaced Most displaced Gartland type II Gartland type II and reducible type and reducible type III fractures are III fractures are treated by treated by percutaneous percutaneous pinningpinning

Closed Reduction and Closed Reduction and Percutaneous Pinning Percutaneous Pinning

Different options of Different options of wire fixationswire fixations 2 parallel pins2 parallel pins Divergent pinsDivergent pins Crossed pinsCrossed pins Medial and lateral Medial and lateral

pinspins

Skaggs et al. noted an incidence of Skaggs et al. noted an incidence of 4% ulnar nerve palsy with use of a 4% ulnar nerve palsy with use of a medial pin and 15% ulnar nerve medial pin and 15% ulnar nerve palsy when the elbow was acutely palsy when the elbow was acutely flexed with insertion of a medial pin flexed with insertion of a medial pin

Resolve spontaneously Resolve spontaneously

Royce et al. Royce et al.

For comminuted or unstable fractures, For comminuted or unstable fractures, medial and lateral pins are used. medial and lateral pins are used.

To prevent nerve injury when a medial pin To prevent nerve injury when a medial pin is used, small incision over the medial is used, small incision over the medial epicondyle is given and placing a drill epicondyle is given and placing a drill guide on the bone, through which the wire guide on the bone, through which the wire is inserted. is inserted.

The pins should be angulated superiorly The pins should be angulated superiorly approximately 40 degrees and posteriorly approximately 40 degrees and posteriorly 10 degrees.10 degrees.

AFTERTREATMENTAFTERTREATMENT

A long arm posterior plaster splint is A long arm posterior plaster splint is worn for 3 weeks worn for 3 weeks

The pins are removed at 3 weeks, The pins are removed at 3 weeks, and another posterior splint is and another posterior splint is applied.applied.

At 4 weeks, the splint is removed, At 4 weeks, the splint is removed, intermittent active range-of-motion intermittent active range-of-motion exercises are started exercises are started

Open Reduction and Internal Open Reduction and Internal Fixation Fixation

IndicationsIndicationsClosed reduction is unsatisfactory Closed reduction is unsatisfactory Type III displaced fracture with no Type III displaced fracture with no

cortical contact cortical contact After one or two attempts at closed After one or two attempts at closed

reductionreductionNeurovascular deficit Neurovascular deficit Open fractures that require irrigation Open fractures that require irrigation

ApproachesApproaches

AnteriorAnteriorMedialMedialAnteromedialAnteromedialPosteriorPosteriorLateralLateral

Depending upon complications/fracture Depending upon complications/fracture configurationconfiguration

Early Complications Early Complications

Neurological compromise 3% to 22% Neurological compromise 3% to 22% Injury to the brachial artery 10% Injury to the brachial artery 10% Compartment syndrome Compartment syndrome

Late Complications Late Complications

Cubitus varus Cubitus varus (gunstock (gunstock deformity)deformity)

Cubitus valgus rareCubitus valgus rare Myositis ossificansMyositis ossificans

Causes of cubitus varusCauses of cubitus varus

Medial displacement and rotation of Medial displacement and rotation of the distal fragmentthe distal fragment

Varus tilting of the distal fragmentVarus tilting of the distal fragmentOvergrowth of the lateral condyleOvergrowth of the lateral condyleMalunited supracondylar fracturesMalunited supracondylar fractures

OsteotomiesOsteotomies

Medial opening wedge osteotomy Medial opening wedge osteotomy with a bone graftwith a bone graft

Oblique osteotomy with derotationOblique osteotomy with derotationLateral closing wedge osteotomyLateral closing wedge osteotomy

Three-dimensional Three-dimensional osteotomyosteotomy

Lateral closing wedge osteotomy is Lateral closing wedge osteotomy is the easiest, safest, and inherently the easiest, safest, and inherently the most stable osteotomy.the most stable osteotomy.ProceduresProcedures

Two screws and a wire attached between Two screws and a wire attached between themthem

Plate fixationPlate fixationCompression fixationCompression fixationCrossed Kirschner wiresCrossed Kirschner wiresStaplesStaples

Voss et al techniqueVoss et al technique

French techniqueFrench technique

Derosa and GrazianoDerosa and Graziano

Separation Of Entire Distal Separation Of Entire Distal Humeral EpiphysisHumeral Epiphysis

In younger children the entire distal humeral In younger children the entire distal humeral epiphysis may separate from the humerusepiphysis may separate from the humerus

It is weaker because it is epiphyseal It is weaker because it is epiphyseal cartilagecartilage

Group A fractureGroup A fracture Salter-Harris type I physeal injuriesSalter-Harris type I physeal injuries can be mistaken for elbow dislocationscan be mistaken for elbow dislocations can occur as a birth injury or in newbornscan occur as a birth injury or in newborns usually can be reduced satisfactorily and usually can be reduced satisfactorily and

immobilized in a posterior plaster splintimmobilized in a posterior plaster splint

Group B fracturesGroup B fractures Between the ages of 1 and 3 yearsBetween the ages of 1 and 3 years May be Salter-Harris type I or II fractureMay be Salter-Harris type I or II fracture

Group C fracturesGroup C fractures Older children and produce a large Older children and produce a large

metaphyseal fragment,metaphyseal fragment, Closed reduction with the patient under Closed reduction with the patient under

general anesthesia and cast immobilizationgeneral anesthesia and cast immobilization If reduction was unsatisfactory, open reductionIf reduction was unsatisfactory, open reduction

and internal fixation with smooth pins were and internal fixation with smooth pins were carried out.carried out.

Fractures of Shaft and Fractures of Shaft and Proximal End of HumerusProximal End of Humerus

Fractures of shaft are rareFractures of shaft are rareUnite in castUnite in castRarely need open reduction.Rarely need open reduction.

Fractures of Shaft and Fractures of Shaft and Proximal End of HumerusProximal End of Humerus

Fractures of the Fractures of the proximal humerus are proximal humerus are usually physealusually physeal

Most commonly Most commonly Salter-Harris type II Salter-Harris type II injuriesinjuries

Classified according to Classified according to displacementdisplacement

A grade I fracture is A grade I fracture is displaced less than 5 displaced less than 5 mm, whereas a grade mm, whereas a grade IV fracture involves IV fracture involves total displacement.total displacement.

Salter-Harris Salter-Harris classification of classification of proximal humeral proximal humeral physeal injuriephyseal injurie

Fractures of Shaft and Fractures of Shaft and Proximal End of HumerusProximal End of Humerus

Open reduction is Open reduction is indicated if the distal indicated if the distal fragment is buttonholed fragment is buttonholed completely through the completely through the deltoid muscle and is deltoid muscle and is impinging against the impinging against the skinskin

Cannot be repositioned Cannot be repositioned by closed methodby closed method

Displaced Salter-Harris Displaced Salter-Harris types III and IV types III and IV fracturesfractures

Interposition of the Interposition of the biceps tendonbiceps tendon

Fracture DislocationsFracture Dislocations

Fracture-Fracture-dislocations dislocations

Needs ORIFNeeds ORIF