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Fractures and Dislocationsabout the Elbow
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• C R I T O E
• 2,4,6,8,10,12
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Elbow Fractures in Children
• Very common injuries (approximately 65% of pediatric trauma)
• Radiographic assessment - difficult for non-orthopaedists, because of the complexity and variability of the physeal anatomy and development
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• Mechanism of injury• h/o trouma
• Fall from height [ jamun]
• RTA
• Fall on outstretch hand
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CLINICAL SYMPTOM
• Pain
• Swelling
• Deformity
• Loss of function
• Children will usually not move the elbow
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Elbow FracturesPhysical Examination
1]TENDER 2] Swelling 3] DEFORMITY 4] Complete vascular exam
– Doppler may be helpful to document vascular status
5]Neurologic exam is essential, as nerve injuries are common.
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Elbow FracturesPhysical Examination
• Always palpate the arm and forearm for signs of compartment syndrome
• Thorough documentation of all findings is important – A simple record of “neurovascular status is intact” is
unacceptable (and doesn’t hold up in court…)
– Individual assessment and recording of motor, sensory, and vascular function is essential
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Elbow FracturesRadiographs
• AP and Lateral views are important initial views– In trauma these views may be less than ideal, because
it can be difficult to position the injured extremity
• Oblique views may be necessary– Especially for the evaluation of suspected lateral
condyle fractures
• Comparison views frequently obtained by primary care or ER physicians– Although these are rarely used by orthopaedists
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Elbow FracturesRadiograph Anatomy/Landmarks
• Baumann’s angle is formed by a line perpendicular to the axis of the humerus, and a line that goes through the physis of the capitellum
• There is a wide range of normal for this value– Can vary with rotation of the radiograph
• In this case, the medial impaction and varus position reduces Bauman’s angle
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• The capitellum is angulated anteriorly about 30 degrees.
• The appearance of the distal humerus is similar to a hockey stick. 30
Elbow FracturesRadiograph Anatomy/Landmarks
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Supracondylar Humerus Fractures
• Most common fracture around the elbow in children– 60 percent of elbow fractures
• 95 percent are extension type injuries– Produces posterior angulation/displacement of the distal
fragment
• Occurs from a fall on an outstretched hand– Ligamentous laxity and hyperextension of the elbow are
important mechanical factors
• May be associated with a distal radius or forearm fractures
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Supracondylar Humerus FracturesClassification[Gartland]
• Type 1– Non-displaced
• Type 2– Angulated/displaced
fracture with intact posterior cortex
• Type 3– Complete displacement,
with no contact between fragments
Gartland. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959;109:145-54.
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Type 1Non-displaced
• Note the non- displaced fracture (Red Arrow)
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Type 2Angulated/displaced fracture with intact
posterior cortex
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Type 3Complete displacement, with no contact
between fragments
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Supracondylar Humerus Fractures Associated Injuries
• Nerve injury incidence is high, between 7 and 16 % – Median, radial, and/or ulnar nerve
• Anterior interosseous nerve injury is most commonly injured nerve
• Carefully document pre-manipulation exam, – Post-manipulation neurologic deficits can alter decision making
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Supracondylar Humerus Fractures Associated Injuries
• 5% have associated distal radius fracture
• Physical exam of distal forearm
• Radiographs if needed• If displaced pin radius
also– Difficult to hold
appropriately in splint
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Supracondylar Humerus Fractures Associated Injuries
• Vascular injuries are rare, but pulses should always be assessed before and after reduction
• In the absence of a radial and/or ulnar pulse, the fingers may still be well-perfused, because of the excellent collateral circulation about the elbow
• Doppler device can be used for assessment
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Supracondylar Humerus Fractures Associated Injuries
• Type 3 supracondylar fracture– Absent ulnar and
radial pulses– Fingers had capillary
refill less than 2 seconds.
• The pink, pulseless extremity
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• Type 1 Fractures– In most cases, these can be treated with
immobilization [OBOVE ELBOW POP SLAB] 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
REDUCTION + POP[A/E]
K-WIRE FIXATION IF UNSTALE
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Supracondylar Humerus Fractures Treatment
• Type 3 Fractures– These fractures have a high risk of neurologic and/or
vascular compromise– Can be associated with a significant amount of swelling– Current treatment protocols use percutaneous pin
fixation in almost all cases– In rare cases, open reduction may be necessary
• Especially in cases of vascular disruption
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Type 3Supracondylar Fracture
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Supracondylar Humerus FracturesOR Setup
• The monitor should be positioned across from the OR table, to allow easy visualization of the monitor during the reduction and pinning
-Thometz. Techniques for direct radiographic visualization during closed pinning of supracondylar humerus fractures in children. J Pediatr Orthop. 1990;10:555.-Tremains. Radiation exposure with use of the inverted-c-arm technique in upper-extremity surgery. J Bone Joint Surg Am. 2001;83-A:674.
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Adequate Reduction?
• No varus/valgus malalignment
• Anterior humeral line should be intact
• Minimal rotation• Mild translation is
acceptable
From: Rang’s children’s fractures. Edited by Dennis R. Wenger, MD, and Maya E. Pring, MD. Philadelphia: Lippincott Williams & Wilkins, 2004.
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Lateral Pin Placement
AP and Lateral views with 2 pins
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Pin Configuration
Lee. Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop. 2002;22:440.
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C-arm Views
Oblique views with the C-arm can be useful to help verify the reduction.
Note slight rotation and extension on medial column (right image).
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Supracondylar Humerus Fractures
• If pin fixation is used, the pins are usually bent and cut outside the skin
• The skin is protected from the pins by placing Xeroform and a felt pad around the pins
• The arm is immobilized• The pins are removed in the
clinic 3 to 4 weeks later– After radiographs show periosteal
healing• In most cases, full recovery of
motion can be expected
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Supracondylar Humerus Fractures: Indications for Open Reduction
• Inadequate reduction with closed methods
• Vascular injury• Open fractures
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Supracondylar Humerus Fractures:Complications
• Compartment syndrome
• Vascular injury/compromise
• Loss of reduction/malunion– Cubitus varus [GUNSTOCK
DEFORMITY]
• Loss of motion
• Pin track infection
• Neurovascular injury with pin placement
Bashyal. Complications after pinning of supracondylar distal humerus fractures. J Pediatr Orthop. 2009;29:704.
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Medial Impaction Fracture
Cubitus varus 2 years later
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Frence osteotomy for cubitus varus
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COMPARTMENT SYNDROMT/ Fasciotomy
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Supracondylar Humerus Fractures Flexion type
• Rare, only 2%
• Distal fracture fragment anterior and flexed
• Ulnar nerve injury more common
• Reduce with extension
• Often requires 2 sets of hands in OF– Hold elbow at 90 degrees after
reduction to facilitate pinning
.
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Flexion Type
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Flexion TypePinning
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Elbow dislocation
• Common in adults , rare in paediatric age
• Three bony point relationship disturbed [triangle]
• Shorting ; arm in supracondylar fracture
• Forearm ; in elbow dislocation
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Elbow dislocation
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Lateral Condyle Fractures
• Common fracture, representing approximately 15% of elbow trauma in children
• Usually occurs from a fall on an outstretched arm
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Lateral Condyle Fractures
• Oblique radiographs may be necessary to confirm that this is not displaced. Frequent radiographs in the cast are necessary to ensure that the fracture does not displace in the cast.
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Lateral Condyle Fractures
• Displaced more than 2 mm– On any radiograph
(AP/Lateral/Oblique views)– Reduction and pinning– Closed reduction can be attempted,
but articular reduction must be anatomic
• If residual displacement and the articular surface is not congruous– Open reduction is necessary Fracture line exiting posterior metaphysis
(arrow) typical for lateral condyle fractures
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Lateral Condyle Fractures
• ORIF is almost always necessary
• A lateral Kocher approach is used for reduction, and pins or a screw are placed to maintain the reduction
• Careful dissection needed to preserve soft tissue attachments (and thus blood supply) to the lateral condylar fragment, especially avoiding posterior dissection
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Lateral Condyle ORIF
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Lateral Condyle FracturesComplications
• Non-union– This usually occurs if the
patient is not treated, or the fracture displaces despite casting
– Well-described in fractures which were displaced more than 2 mm and not treated with pin fixation
– Late complication of progressive valgus and ulnar neuropathy reported
Skak. Deformity after fracture of the lateral humeral condyle in children. J Pediatr Orthop B. 2001;10:142.
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Lateral Condyle FracturesComplications
• AVN can occur after excessive surgical dissection
Foster. Lateral humeral condylar fractures in children. J Pediatr Orthop. 1985;5:16.
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Medial Epicondyle Fractures
• Represent 5% to 10% of pediatric elbow fractures
• Occurs with valgus stress to the elbow, which avulses the medial epicondyle
• Frequently associated with an elbow dislocation
Landin. Elbow fractures in children. An epidemiological analysis of 589 cases. Acta Orthop Scand. 1986;57:309.
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Medial Epicondyle FracturesTreatment
• Nondisplaced and minimally displaced– Less than 5 mm of
displacement– May be treated without
fixation– Early motion to avoid
stiffness (3 to 4 weeks)
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Medial Epicondyle FracturesTreatment
• Displaced more than 5 mm– Treatment is controversial– Some recommending operative,
others non-operative treatment– Some have suggested that surgery
is indicated in the presence of valgus instability, or in patients who are throwing athletes.
• Only absolute indication is entrapped fragment after dislocation with incongruent elbow joint
– First attempt closed reduction• Long term studies favor
nonoperative treatment
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Medial Epicondyle FractureElbow dislocation with Medial Epicondyle Avulsion
Treated with ORIF
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Olecranon Fractures
• Relatively rare fracture in children– May be associated with elbow subluxation/
dislocation, or radial head fracture
• The diagnosis may be difficult in a younger child– Olecranon does not ossify until 8-9 years
• Anatomic reduction is necessary in displaced fractures to restore normal elbow extension.
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Olecranon Fractures
• Olecranon fracture treated with ORIF in 14 year old, with tension band fixation.
Parent. Displaced olecranon fractures in children: a biomechanical analysis of fixation methods. J Pediatr Orthop. 2008;28:147.
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Proximal Radius Fractures
• 1% of children’s fractures
• 90% involve physis or neck
• Normally some angulation of head to radial shaft (0-15 degrees)
• No ligaments attach to head or neck
• Much of radial neck extraarticular (no effusion with fracture)
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Proximal Radius Fractures
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Proximal Radius Fractures Treatment
• Greater than 30° angulation– Attempt manipulation– Usually can obtain
acceptable reduction in fractures with less than 60° angulation
– Traction, varus force in supination & extension, flex and pronate
– Ace wrap or Esmarch reduction
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100% Displaced Failed Closed Reduction
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Pin fixation augmented by cast for 3 weeks
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Fracture shaft humerus
• Shaft fractures traditionally treated nonsurgically
• high rate of complications?– Infection
– Nonunion
– Radial nerve palsy
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Fracture shaft humerus
• Cardinal signs: – pain
– swelling
– deformity
• Look for associated injuries
• Document neurovascular exam!
• Radial Nerve Function
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Fracture shaft humerus
• Standard X-rays– AP
– lateral view
– Joints above and below
• CT/MRI if pathologic fx suspected, x-rays not clear
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Complication of shaft humerus
• Radial nerve injury
• Incidence varies from 1.8% to 24% of shaft fractures
• Primary - occurs @ injury
• Secondary - occurs later during closed or open management
• Management controversial
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Complication of shaft humerus
• Spontaneous recovery: ~90%• If no recovery, tendon transfers very
reliable
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Complication of shaft humerus
Vascular injury• Brachial artery
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Treatment of shaft humerus
• Most humeral fractures are amenable to closed, nonsurgical treatment– rigid immobilization is not
necessary for healing
– perfect alignment is not essential for an acceptable result
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Treatment of shaft humerus
• Great tolerances of alignment
• We don’t walk on arms• Shoulder/elbow have large
ROM – 20 degrees of anterior or
posterior angulation– 30 degrees of varus (less
in thin patients)– 3 cm of shortening
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Treatment of shaft humerus
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Treatment of shaft humerus
• Indications for surgery:– Open fractures– Secondary palsies developing after a closed
reduction
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nonunion
• Nonunion
• Bone graft pluse nail / plate
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SummaryHumeral Shaft Fractures
• Results very good for functional bracing
• Need to carefully document radial nerve exam
• Most radial nerves injuries recover
• Most prefer plates over nails