paediatric elbow fractures

Paediatric elbow fractures

By Nick Harper

• Anatomy

• Ossification

• General Prinicples

• Supracondylar Fractures

• Lateral Condyle Fractures

• Medial Epicondyle Avulsion

• Proximal Radius Fractures

• Radial head dislocations

• Nursemaid’s elbow

Paediatric elbow fractures

Anatomy – Adult Elbow

Anatomy – Adult Elbow

Ossification centers

1 C Capitulum3 R Radial Head5 I Internal Epicondyle7 T Trochlea9 O Olecranon

11 L Lateral Epicondyle

Ossification centers

Ossification centers•The Trochlea has several ossification centers•Can mimic loose bodies within the joint

General principles

Fat Pad sign Lateral view, 90° flexion

NEGATIVE

Anterior Fat Pad

Fat Pad sign Lateral view, 90° flexion

Anterior Fat Pad

POSITIVE

Posterior Fat PadIn presence of trauma, predicts fracture in 76% of cases

•Distension of the joint capsule•Joint effusion•Haemarthrosis

General principles

Fat Pad Sign

Fat Pad Sign

Fat Pad Sign

Salter – Harris Classification

SALTR

S - Slipped

A - Above

L - Lower

T - Through

R - Ruined

Fractures involving the Physis (growth plate)

General Principles

Radiocapitellar line.• “A line drawn from the centre of the radial

neck should pass through the center of the capitulum in all views”

Anterior humeral line.• “A line drawn along the anterior cortex of the

humerus in lateral view should pass through the middle third of the capitulum.”

Radiocapitellar line

Anterior humeral line

Supracondylar fractures

Supracondylar fractures

Supracondylar fractures

• >60% of all elbow fractures in children• 95% are hyperextension injuries• The elbow becomes locked in hyperextension

Supracondylar fractures

• >60% of all elbow fractures in children• 95% are hyperextension injuries• The elbow becomes locked in hyperextension

Supracondylar fractures

• >60% of all elbow fractures in children• 95% are hyperextension injuries• The elbow becomes locked in hyperextension

Supracondylar fractures

• >60% of all elbow fractures in children• 95% are hyperextension injuries• The elbow becomes locked in hyperextension

Supracondylar fractures

• Flexion – type fractures are uncommon (5%)• Direct impact to the flexed elbow• Ulnar nerve injury common• More likely to be unstable than extension injuries

Supracondylar fractures

Gartland Classification Management1 Minimally displaced fracture Conservative

2 Displaced with intact posterior cortex Closed reduction and percutaneous fixation

3 Complete displacement (Posteromedial 75%, Posterolateral, 25%)

Closed/open reduction and fixation

IIII II

Supracondylar fractures

Complications• Neurovascular compromise• Malunion may cause cubitus varus “gunstock deformity”

Lateral Condyle fractures

Lateral condyle fractures

Lateral condyle fractures

• 2nd most common elbow fracture in children (17%)

• Varus force to an extended elbow

• Localised swelling over the lateral

• Intrarticular

• Salter-Harris IV

• Instability due to forearm extensors• Can be challenging to see

on radiograph

Lateral condyle fractures

Milch Classification

1. - Fracture line traverses lateral to capitello-trochlear groove- Elbow is stable

2. - Fracture passes through the capitello-trochlear groove- Elbow is unstable

Hard to classify on radiograph as fracture fragments are primarily cartilagenous

Lateral condyle fractures

• Displacement classification

Lateral condyle fracturesDisplacement Classification Management

1 <2mm conservative

2 >2mm Surgical - Pins

3 Wide displacement and rotation

Surgical - Open reduction, Internal fixation

I II III

Lateral condyle fractures

Lateral condyle fractures

Complications• Non union

• Malunion

• Excessive bone formation

• Avascular necrosis of lateral condyle (iatrogenic)

• Ulnar nerve neuropathy (22 years post fracture, Cubitus Valgus)

Lateral condyle fractures

Cubitus Varus Cubitus Valgus

Medial Epicondyle Avulsion

Medial Epicondyle Avulsion

Medial Epicondyle Avulsion

• 3rd most common elbow fracture in children

• adolescent boys

• Acute valgus stress (sometimes during armwrestling)

• Severe pain over medial aspect, “pop” sound, Ulnar nerve irritation

• Elbow dislocations occur in 50% of cases

Medial Epicondyle Avulsion

• Avulsed medial epicondyle becoming entrapped in the dislocated joint

Medial Epicondyle Avulsion

Management

Non displaced – Conservative

Displacement 5-15mm – Conservative/Surgical

Displacement>15mm - Surgical

Medial Epicondyle Avulsion• Avulsed medial epicondyle becoming entrapped in the dislocated joint• Don’t confuse with Trochlea ossification centers

Proximal Radiusfractures

Proximal Radius fractures

• Adults – articular surface of radial head

• Children – Radial neck (metaphyseal bone weaker due to constant remodeling)

• Fall on extended and supinated outstretched hand

• 90% are Salter Harris II

Proximal Radius fractures

ManagementChildren under 4 have a normal valgus angulation

to the radial neck (Up to 15°)

<30° Conservative

>30° Closed reduction

K-wires used if closed reduction unsuccessful or unable to pronate and supinate upto 60°

Proximal Radius fractures

Radial Head Dislocations

• Radiocapitellar line useful!• Can be obvious or quite subtle• Always look for associated injury

•Monteggia Fracture•Dislocation of the radial head with fracture

of the proximal third of the ulnar •Fall on outstretched hand with forearm in

excessive pronation

Monteggia Fracture

Nursemaid’s elbow

• Annular ligament poorly attached in children <5

• If the forearm is pulled, radial head moves distally. The annular ligament slips over the radial head and becomes trapped in the joint

Nursemaid’s elbow

• Sudden longitudinal force applied to the forearm• Audible snap• Limb held in extension• Pain on moving the forearm• Radiograph is often normal

• Treatment – manipulation- Supination & Flexion- Pronation

Summary• Supracondylar

Fractures

• Lateral Condyle Fractures

• Medial Epicondyle Avulsion

• Proximal Radius Fractures & Dislocations

References• Agur, A.M.R. & Dalley, A.F. Grant’s Atlas of Anatomy (12th

ed). Lippincott, Williams & Wilkins

• John Harris et al The Radiology of Emergency Medicine, 3rd Ed, Williams and Wilkins, 1993, p 352

• http://www.radiologyassistant.nl/en/4214416a75d87• http://emedicine.medscape.com/article/415822-overview• http://www.wheelessonline.com/ortho/

frx_of_the_lateral_condyle_in_children• http://orthoinfo.aaos.org/topic.cfm?topic=A00037• http://www.joint-pain-expert.net/index.html