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Orthopaedic Nursing • January/February 2011 • Volume 30 • Number 1 11Copyright © 2011 National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.

condyle fractures. Because 80% of the longitudinalgrowth in the arm occurs proximally (proximalhumerus), only appositional growth occurs at the elbow.This limits the ability for elbow fractures to completelyremodel and therefore makes anatomic reductions nec-essary even in young skeletally immature individuals (Do& Herrera-Soto, 2003).

Supracondylar Humerus FractureSupracondylar humerus fractures are the most commonelbow injury in children (Kasser & Beatty, 2006). Theyaccount for approximately 50% to 70% of all elbow frac-tures in children (Farnsworth, Silva, & Mubarak, 1998).This injury occurs most often in boys between the ages of4 and 7 and most frequently occurs after a fall on an out-stretched upper extremity. Supracondylar humerus frac-tures are usually divided into extension and flexion typeswith extension types being far more common(~97%–99%). Clinical findings include pain, elbowswelling or effusion, deformity, and bruising/ecchymosis(see Figure 2). It is usual to have a fairly rapid onset ofsignificant swelling with this type of elbow fracture.Providers should note the presence of skin puckering thatusually results from the fracture fragment piercing thebrachialis muscle and is a sign of considerable soft tissuedamage. Any bleeding or break in the skin associatedwith the SCH fracture should be considered an open frac-ture and treated accordingly. It is important to assessneurovascular status (both sensory and motor function)thoroughly in every patient with a suspected or knownelbow fracture. It is also important to evaluate the entireextremity, as forearm fractures can occur in associationwith SCH fractures and can significantly increase the risk

Fractures of the elbow are a very common injury in children.The most common mechanism of injury is a fall on an out-stretched upper extremity during play. Ranging in complex-ity from low-energy nondisplaced occult fractures to high-energy fractures with associated severe soft-tissue andneurovascular injuries, elbow fractures are a challengingproblem for all pediatric healthcare providers. Because ofthe wide spectrum of fracture severity and associated bonyand ligamentous injury, a very diverse spectrum of treatmentmodalities is necessary for optimal results. Management isbased on fracture pattern, patient age and bone quality,extent of soft tissue damage, functional needs of the patient,and the presence of associated injuries. This article will givea brief overview of 4 common pediatric fractures, currenttreatment algorithms, and frequent complications associ-ated with these injuries.

Elbow fractures account for approximately 5% to10% of all fractures in children. It is often help-ful to address elbow fractures from an anatomicperspective, as each specific fracture has its own

unique challenges in diagnosis and treatment. The elbowjoint is a complex articulation of three bones (humerus,radius, and ulna) that allows motion in all three planes(see Figure 1). The radial-humeral articulation allowspronation and supination of the forearm, and the ulnar-humeral articulation allows flexion and extension of theelbow (Herring, 2002). It is often very difficult to distin-guish fractures from the six normal secondary ossifica-tion centers in the elbow. The six ossification centers ac-tually develop in a systematic, fairly predictable fashionin children. The mnemonic CRMTOL is helpful in re-membering the progression of the radiographic appear-ance of the ossification centers about the elbow (seeTable 1). This stands for Capitellum, Radial head, Medialepicondyle, Trochlea, Olecranon, and Lateral epicondyle(Waters, 2006). In general, the capitellum appears radi-ographically at around 2 years of age and the remainingossification centers appear sequentially every 2 years.The appearance of the various ossification centers mightvary slightly with girls often maturing earlier than boys.However, the overall sequence generally stays the same.If it is difficult to distinguish a normal secondary centerof ossification from a fracture, it may be useful to obtaincomparison radiographs (x-rays) from the contralateralelbow. The most common elbow fractures in children in-clude supracondylar humerus (SCH) fractures, lateralcondyle fractures, radial neck fractures, and medial epi-

Erin S. Hart, MS, RN, CPNP, Massachusetts General Hospital forChildren, Department of Orthopaedic Surgery, Yawkey Center forOutpatient Care, Boston, MA.

Alison Turner, MS, RN, CPNP, Massachusetts General Hospital forChildren, Department of Orthopaedic Surgery, Yawkey Center forOutpatient Care, Boston, MA.

Maurice Albright, MD, Massachusetts General Hospital for Children,Department of Orthopaedic Surgery, Yawkey Center for OutpatientCare, Boston, MA.

Brian E. Grottkau, MD, Massachusetts General Hospital for Children,Department of Orthopaedic Surgery, Yawkey Center for OutpatientCare, Boston, MA.

The authors have disclosed that they have no financial interests to anycommercial company related to this educational activity

DOI:10.1097/NOR.0b013e31820574c6

Common Pediatric Elbow FracturesErin S. Hart ▼ Allison Turner ▼ Maurice Albright ▼ Brian E. Grottkau

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of compartment syndrome (Blakemore, Cooperman,Thompson, Wathey, & Ballock, 2000). Most nerve in-juries occur secondary to contusion and traction is-chemia at the displaced fracture (Waters, 2006).

Unless the patient presents with an ischemic hand,an open fracture or significant skin tenting, the upperextremity should be immobilized “as it lies” with a sim-ple splint (posterior long arm or sugar tong splint),while awaiting definitive treatment (Herring, 2002). Ifthe distal extremity is ischemic, a gentle attempt to bet-ter align the fracture fragments is done to restore circu-lation to the hand. All patients should be kept from hav-ing food or drink by mouth until a definitive treatmentplan has been outlined.

CLASSIFICATION

The Gartland classification system of SCH fractures isgenerally the most commonly accepted and used system(see Table 2). Type I fractures are nondisplaced and aregenerally treated with a course of short-term immobi-lization (~3- to 6-week long-arm cast). Type II fracturesare displaced but often have an intact hinged posterior

cortex. Type III SCH fractures are completely displaced(no cortical contact between fragments) and have thehighest rate of neurovascular compromise (see Figures3A and B; Waters, 2006). SCH Type II and III are gener-ally treated with closed or open reduction and percuta-neous pinning. Simanovsky, Lamdon, Mosheiff, andSimanovsky, (2007) demonstrated the importance ofreduction when treating displaced SCH fractures. Theirstudy found that patients who healed with some degreeof extension developed limited elbow flexion. Reductionsare usually done in the operating room with the patientunder general anesthesia. Malunions generally occurwhen the reduction is attempted in the emergency de-partment or clinic, when the initial angulation is notrecognized, and when the cast is applied without any re-duction attempt (Simanovsky et al., 2007).

Radiographs of nondisplaced (Type I) SCH fracturesoften show normal results or may have subtle signs such

12 Orthopaedic Nursing • January/February 2011 • Volume 30 • Number 1

Copyright © 2011 National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.

FIGURE 1. Elbow joint anatomy showing humerus, radius, andulna bone.

FIGURE 2. Large elbow joint effusion/swelling status postsupracondylar humerus fracture.

TABLE 1. OSSIFICATION CENTERS IN THE PEDIATRIC ELBOW

CRMTOLC: CapitellumR: Radial headM: Medial epicondyleT: TrochleaO: OlecranonL: Lateral epicondyle

TABLE 2. GARTLAND CLASSIFICATION SYSTEM FOR

SUPRACONDYLAR HUMERUS FRACTURES

Type I—nondisplaced, treated with immobilization in long arm cast

Type II—displaced with posterior hinge, usually treated with closed reduction and percutaneous pinning

Type III—completely displaced (no cortical contact between fracture fragments), treated with closed/open reductionand percutaneous pinning

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as a small joint effusion or elevation of the anterior orposterior fat pad. Positive anterior and posterior fat padsign generally indicates a joint effusion/hematoma andis generally treated as a nondisplaced or occult fracture.Approximately 70% of the time, posterior fat pads sug-gest an occult fracture of the supracondylar region, ra-dial neck, or olecranon (Skaggs & Mirzayan, 1999).Type I SCH fractures are generally treated with immo-bilization in a long-arm cast with the elbow in approxi-mately 70�–100� of flexion. Flexing the elbow more than100� has been shown to increase the risk of ischemiaand compartment syndrome (Battaglia, Armstrong, &Schwend, 2002). These fractures are very stable becausethe periosteum is intact circumferentially. The differen-tiation between Type I and Type II SCH fractures isoften made by evaluating the position of the capitellum(distal end of the humerus) relative to the anteriorhumeral line. In Type II fractures, the capitellum fallsposterior to the anterior humeral line. Occasionally, ob-taining a contralateral elbow x-ray film can be useful todetect subtle injuries.

TREATMENT OF TYPE II AND III SCH FRACTURES

The treatment of Type II SCH fractures is more con-troversial, although most pediatric orthopaedic sur-

geons currently recommend reduction and pinningfor any displaced SCH fracture. The treatment willvary by fracture type and pattern, but the goal remainsthe same—which is to maintain alignment of the frac-ture to allow full functional recovery (Omid, Choi, &Skaggs, 2008). Although much debate exists over theplacement of percutaneous pins, two lateral pins aregenerally used for most Type II and Type III SCH frac-tures. Kocher, Kasser, and Waters (2007) studied theefficacy of lateral entry pin fixation with that ofcrossed (medial and lateral) pins for completely dis-placed (Type III) SCH fractures. A prospective ran-domized trial was performed with 52 patients. Therewas no major loss of reduction in either group and nodifference in the rate of minor loss of reduction. Therewas also no statistical difference between groups radi-ographically or clinically (range of motion, carryingangle, return to function, complication rate). Manyother studies, however, have shown an increased riskof ulnar nerve injury associated with medial pin place-ment (Brauer, Lee, Bae, Waters, & Kocher, 2007;Skaggs et al., 2001). In their systemic review, Braueret al. (2007) found that patients requiring medial pin-ning for SCH fractures were 5.04 times more likely tohave ulnar nerve injury. Similarly, Skaggs, Cluck,Mostofi, Flynn, and Kay (2001) found a 7% incidenceof iatrogenic ulnar nerve injury when crossedKirschner wires were used and there was no differ-ence in the stability of the fracture when comparedwith lateral pins alone.

Following closed or open reduction, the fracture isusually held with two or three Kirscher wires with theelbow in approximately 40�–70� of flexion (see Figure 4;


FIGURE 4. Anteroposterior x-ray of left elbow status post closedreduction and percutaneous pinning with two Kirscher wires.

FIGURE 3. Anteroposterior/Lateral x-rays of Type III displacedsupracondylar humerus fracture.

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Abzug & Kozin, 2008). The cast and/or splint is usuallyremoved after 3–4 weeks, and the pins are removed in aclinic setting. Activities are usually restricted until fullrange of motion and strength are achieved (generally6–8 weeks after fracture).

ComplicationsComplications of SCH fractures include loss of reduc-tion, neurovascular injury, pin track infection, malu-nion, nonunion, compartment syndrome, Volkmann’sischemia, and decreased range of motion (Abzug &Kozin, 2008). Vascular injury occurs in approximately2.5% of Type III SCH fractures and neural impairmentcan occur in 17% (Gosens & Bongers, 2003). The mostcommonly injured nerve following SCH fractures is theanterior interosseous branch of the median nerve(Lyons, Quinn, & Stanitski, 2000). Anterior interosseousnerve palsy is probably underreported because it is notassociated with a sensory loss. Nearly all nerve injuriesassociated with SCH fractures recover spontaneouslyand require no treatment other than close monitoring. Ifnormal function has not returned within 8 to 12 weeks,it may be useful to obtain nerve conduction and elec-tromyographic studies for further evaluation (Herring,2002). Battle and Carmichael (2007) evaluated the infec-tion rate with the use of smooth Kirschnew wires in 202patients presenting with a SCH fracture. They found anoverall infection rate of 2% and that the infection ratedid not correlate to the type of fracture or the length oftreatment (Simanovsky et al., 2007). Malunion resultingin cubitus varus or cubitus valgus are also known com-plications of SCH fractures. Although functional deficitsare rare with these deformities, there may be slightlylimited range of motion and unacceptable cosmesis.Because there is limited potential for remodeling in thedistal humerus, the best treatment of malunion deformi-ties is early avoidance.

Lateral Condyle FracturesLateral condyle fractures of the distal humerus involvethe both physis and the articular surface. The diagnosisof condylar fractures can be very difficult in children be-cause much of the elbow remains cartilaginous and isoften not visualized well on plain radiographs (Horn,Herman, Crisci, Pizzutillo, & MacEwen, 2002). They arethe second most common elbow fracture in children(~10%–20% of all elbow fractures) and can be difficultto diagnose and treat. This type of fracture commonlyoccurs in children between the ages of 4 and 10 with apeak incidence around 5 to 6 years of age (Abzug &Kozin, 2008). The diagnosis of lateral condyle fracturesin children may be quite obvious or frustratingly subtle.Most lateral condyle fractures require surgical reduc-tion and stabilization. Similar to SCH fractures, lateralcondyle fractures are classified by the degree of dis-placement. Unlike SCH fractures, however, lateralcondyle fractures often require open rather than closedreduction and percutaneous pinning.

The most commonly used classification system for lat-eral condyle fractures is that of Milch (1964), which dif-ferentiates between Type 1, in which the fracture line tra-

verses the capitellum and falls lateral to the trochlea, andType 2, in which the fracture line extends further medi-ally to the trochlear groove. A newer and slightly simplerclassification system for lateral condyle fractures is basedsolely on the degree of displacement. Type 1 fractures arenondisplaced, Type 2 fractures are displaced less than 2mm, and Type 3 fractures are displaced and malrotated(Rutherford, 1985). The difficulty in treating lateralcondyle fractures is in differentiating “stable nondis-placed” fractures from potentially “unstable, minimallydisplaced” fractures (Mirsky, Karas, & Weiner, 1997).

The treatment of lateral condyle fractures dependson the degree of fracture displacement. There is a slightcontroversy regarding the treatment of nondisplacedand minimally displaced lateral condyle fractures. Mostpediatric orthopaedic surgeons will choose operativetreatment of lateral condyle fractures displaced morethan 2 mm (see Figure 5). Displaced lateral condylefractures are generally treated with an open reductionand pinning (see Figure 6). Open reduction is usuallyperformed through an anterior lateral approach in chil-dren. The blood supply of the lateral humeral condylearises from the posterior soft tissues of the distal frag-ment, so it is important that there be minimal dissectionof the posterior soft tissues (Herring, 2002). SmoothKirshner percutaneous pins are generally used for frac-ture fixation and the elbow is immobilized for 4–6 weekspostoperatively.

The most common complications from lateral condylefractures include delayed union, nonunion, malunion,cubitus varus, stiffness, and avascular necrosis of thelateral condyle (Launay, Leet, Jacopin, Luc-Jouvre,Bollini, & Sponseller, 2004). The most frequent problem-atic complication of lateral condyle fractures is delayedunion or nonunion (Herring, 2002). The difficulty inachieving union of lateral condyle fractures can be ex-plained by the fact that it is an intra-articular fracture(constant exposure to synovial fluid), and this area of



FIGURE 5. Anteroposterior x-ray of left elbow status post percu-taneous pinning for Type II lateral condyle fracture.

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bone has a relatively poor blood supply. The stiffness as-sociated with lateral condyle fractures is likely due to thearticular nature of the fracture and the fact that a longerperiod of immobilization is often required (Do &Herrera-Soto, 2003). The incidence of stiffness, however,has been decreasing significantly recently because of im-proved stability associated with newer methods of fixa-tion that allows for shorter periods of immobilization.

Radial Neck FracturesRadial neck fractures comprise approximately 6% of pe-diatric elbow fractures. Similar to all pediatric elbow

fractures, the treatment of radial neck fractures is basedon the degree of displacement. In children, the cartilagi-nous radial head is resistant to fracture, and thereforeradial neck fractures are much more common than ra-dial head fractures (Waters, 2006; see Figure 7). Radialneck fractures often have subtle clinical and radi-ographic findings. There may be mild local swelling,tenderness, and ecchymosis over the radial neck.Although flexion and extension of the elbow will oftenbe limited, pain with supination and pronation is actu-ally much more common in radial neck fractures. Themechanism of injury is typically a fall on an out-stretched hand with the elbow in extension and valgus.Radial neck fractures can also be seen in young patientswith an associated elbow dislocation.

There is controversy regarding the acceptable align-ment of a radial neck fracture; however, most pediatricorthopaedic surgeons agree that up to 30� of malalign-ment and one-third displacement may be acceptable inradial neck fractures (Waters, 2006). Closed reduction is


FIGURE 6. Status-post open reduction and percutaneous pin-ning for displaced lateral condyle fracture.

FIGURE 7. Anteroposterior x-ray of displaced radial neck fracture.

FIGURE 8. Anteroposterior/Lateral x-ray of displaced medialepicondyle fracture.

FIGURE 9. Anteroposterior/Lateral x-ray of elbow s/p open re-duction and internal fixation of displaced medial epicondylefracture.

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attempted first and is usually successful for most dis-placed radial neck fractures. If closed reduction is inad-equate, an open reduction through a posterolateral approach with as little dissection as possible is done.Fixation is generally achieved with smooth K-wiresplaced percutaneously from distal to proximal acrossthe fracture site.

Complications associated with radial neck fracturesincluded malunion, stiffness, nonunion, radial headovergrowth, avascular necrosis, and early joint degener-ation. Loss of motion is the most common and problem-atic complication following radial neck fractures.Rotation of the forearm is affected with loss of prona-tion greater than supination. Severely displaced andlate presenting fractures requiring open reduction andinternal fixation or pinning are more likely to developstiffness and avascular necrosis (Milbrandt & Copley,2004).

Medial Epicondyle FracturesMedial epicondyle fractures account for approximately10% of all pediatric elbow fractures and occur mostcommonly between the ages of 7 and 15 years (Herring,2002). Approximately 50% to 60% of all medial epi-condyle fractures are associated with a concurrentelbow dislocation. The mechanism of injury is usuallyexcessive valgus stress which is why this fracture isoften seen in baseball pitchers (significant valgus stresson their elbow with pitching).

The operative treatment of medial epicondyle frac-tures is somewhat controversial. Nondisplaced andminimally displaced (�5 mm) fractures are usuallytreated conservatively with immobilization/casting for aperiod of 4–6 weeks. Because this fracture is also fre-quently associated with stiffness, the period of immobi-lization in a cast should be minimized as much as possi-ble (3–4 weeks). Fractures displaced more than 5 mmwill usually require open reduction and internal fixation(see Figure 8; Do & Herrera-Soto, 2003). Serious over-head athletes require special consideration with thistype of fracture. Even minimally displaced medial epi-condyle fractures can lead to valgus instability and de-creased throwing velocity. Anatomic reduction via openreduction and internal fixation is generally recom-mended in these patients (see Figure 9). Most surgeonsprefer open reduction and fixation (often with cannu-lated screw fixation) over closed reduction and percuta-neous pinning to ensure that the ulnar nerve is not dam-aged (Herring, 2002).

Complications from medial epicondyle fractures in-clude stiffness, ulnar nerve injury, nonunion, and malu-nion (Hines, Herndon, & Evans, 1987). Stiffness is themost common complication associated with medial epi-condyle fractures. It is best avoided by decreased immobi-lization time and early gentle range-of-motion exercises.

ConclusionElbow fractures are a common injury in children and re-quire a thorough understanding of the various fracturetypes and potential treatments available. It is usually bestto address elbow fractures from an anatomic perspective

as each specific fracture has its own unique challenges indiagnosis, management, and potential complications.Most children who sustain an elbow fracture can be ex-pected to have a full functional recovery with appropriatetreatment. Because of the numerous potential pitfallsand complications associated with pediatric elbow frac-tures, it is important to respond in a timely manner withappropriate vigilance and technical skill.

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tremity trauma. Pediatric upper extremity trauma.Current Orthopaedic Practice, 19(5), 485–490.

Battaglia, T. C., Armstrong, D. G., & Schwend, R. M.(2002). Factors affecting forearm compartment pres-sures in children with supracondylar fractures of thehumerus. Journal of Pediatric Orthopaedics, 22, 431–439.

Battle, J., & Carmichael, K. D. (2007). Incidence of pin trackinfections in children’s fractures treated with Kirschnerwire fixation. Journal of Pediatric Orthopaedics, 27, 154–158.

Blakemore, L. C., Cooperman, D. R., Thompson, G. H.,Wathey, C., & Ballock, T. R. (2000). Compartment syn-drome in ipsilateral humerus and forearm fractures inchildren. Clinical Orthopaedics and Related Research,376, 32–38.

Brauer, C., Lee, B., Bae, D., Waters, P. M., & Kocher, M. S.(2007). A systemic review of medial and lateral entrypinning vs. lateral entry pinning for supracondylar frac-tures of the humerus. Journal of Pediatric Orthopaedics,27, 181–186.

Do, T, & Herrera-Soto, J. (2003). Elbow injuries in chil-dren. Current Opinion in Orthopaedics, 15, 68–73.

Farnsworth, C. L., Silva, P. D., & Mubarak, S. J. (1998).Etiology of supracondylar humerus fractures. Journal ofPediatric Orthopaedics, 18, 38–42.

Gosens, T., & Bongers, K. J. (2003). Neurovascular compli-cations and functional outcome in displaced supra-condylar fractures of the humerus in children. Injury,34(4), 267–73.

Herring, J. A. (2002). Upper extremity injuries. InTachdjian’s pediatric orthopaedics (3rd ed.). Philadelphia:WB Saunders Company: pp 2139–2197.

Hines, R. F., Herndon, W., & Evans, P. J. (1987). Operativetreatment of medial epicondyle fractures in children.Clinical Orthopaedic & Related Research, 223, 170–174.

Horn, D. B., Herman, M. J., Crisci, D., Pizzutillo, P., &MacEwen, D. G. (2002). Fractures of the lateral humeralcondyle: Role of the cartilage hinge in fracture stability.Journal of Pediatric Orthopaedics, 22(1), 8–11.

Kasser, J. R., & Beaty, J. H. (2006). Supracondylar frac-tures of the distal humerus. In Beaty JH, Kasser JR,Wilkins KE, & Rockwood CE (Eds.), Rockwood andWilkins’ fractures in children (6th ed., pp. 543–589).Philadelphia: Lippincott Williams & Wilkins.

Kocher, M., Kasser, J., & Waters, P. (2007). Lateral entrycompared with medial and lateral entry pin fixation forcompletely displaced supracondylar humeral fracturesin children. A randomized clinical trial. Journal of Boneand Joint Surgery, 89, 706–712.

Launay, F., Leet, A., Jacopin, S., Luc-Jouvre, J., Bollini, G.,& Sponseller, P. (2004). Lateral humeral condyle frac-tures in children. A comparison of two approaches totreatment. Journal of Pediatric Orthopaedics, 24(4),385–391.

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Milbrandt, T. A., & Copley, L. A. (2004). Common elbow in-juries in children: Evaluation, treatment and clinical out-comes. Current Opinion in Orthopaedics, 15, 286–294.

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Simanovsky, N., Lamdon, R., Mosheiff, R., & Simanovsky,N. (2007). Underreduced supracondylar fracture of thehumerus in children. Journal of Pediatric Orthopaedics,27, 733–738.

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Skaggs, D. L., Cluck, M. W., Mostofi, A., Flynn, J. M., &Kay, R. M. (2001). Lateral-entry pin fixation in the man-agement of supracondylar fractures in children. Journalof Bone Joint Surgery American, 86, 702–707.

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