elbow fractures in pediatrics

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    Introduction

    Elbow fractures are common childhood injuries,accounting for about 10% of all childhoodfractures.

    In many cases, a simple fracture will heal wellwith conservative cast treatment.

    Some types of elbow fractures, however,including those in which the pieces of bone aresignificantly out of place, may require surgery.

    Other structures in the elbowsuch as nerves,blood vessels, and ligamentsmay also beinjured when a fracture occurs and requiretreatment, as well.

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    Anatomy

    Articulations

    Ulnohumeral, Radiocapitellar, Proximal radioulnar

    Stability

    Ulnar and lateral collateral ligament complexes

    Anterior bundle - medial stability

    Lateral ulnar collateral - lateral stability

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    Vasculature

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    Nerves

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    Ossification Centres

    Age at appearance Age at Closure

    Capitellum 1-2 14

    Radius 3 16

    Internal

    Epicondyle

    5 15

    Trochlea 7 14

    Olecranon 9 14

    External

    epicondyle

    11 16

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    Ossification Centres

    Mnemonic CRITOE

    C - capitellum

    R - radial head I - Internal Epicondyle

    T - Trochlea

    O - Olecranon E - External Epicondyle

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    Elbow Fractures

    Physical Examination Children will usually not move the elbow if a fracture

    is present

    Swelling about the elbow is a constant feature,

    except for non-displaced fracture Complete vascular exam is necessary, especially in

    supracondylar fractures

    Doppler may be helpful to document vascular status

    Neurologic exam is essential, as nerve injuries arecommon

    In most cases, full recovery can be expected

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    Elbow Fractures

    Physical Examination Neurological exam may be limited by the

    childs ability to cooperate because of age,pain, or fear.

    Thumb extensionEPL RadialPIN branch

    Thumb flexionFPL

    MedianAIN branch

    Cross fingers/scissors - Ad/Abductors

    Ulnar

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    Elbow Fractures

    Physical Examination Always palpate the arm and forearm for signs of

    compartment syndrome

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    Radiography

    Views

    AP

    Lateral

    Oblique External

    Internal

    AP and lateral are usually sufficient

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    Radiography

    AP

    Supination and full extension at elbow with slight flexion

    of fingers

    Visualize

    Epicondyles

    Carrying angle (10-12)

    Articulations

    Baumanns angle (75)

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    Radiography

    Lateral

    Rest on table

    Elbow flexed at 90

    Thumb up

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    The 8 Step Approach

    1. Figure of 8

    2. Anterior Fat Pad

    3. Posterior Fat Pad

    4. Anterior humeral line

    5. Radio-capitellar line

    6. Inspect radial head

    7. Distal humerus examination

    8. Ulna/Olecranon examination

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    Approach

    Figure of Eight

    To determine if true

    lateral

    Otherwise unable to

    adequately assess fat

    pads, anterior humeral

    line

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    Approach

    Anterior Fat Pad Barely visible on normal film

    Trauma - fracture

    Children - supracondylar

    Adults - Occult radial head Atraumatic - inflammation

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    Approach

    Posterior Fat Pad

    ALWAYS ABNORMAL

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    Approach

    Anterior humeral line

    Passes through middle

    third of the capitellum

    Disruption suggests

    supracondylar fracture

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    Approach

    Inspect radial head

    Disruption in cortical surface

    Inspect distal humerus

    Disruption in cortical surface

    Inspect ulna/olecranon

    Disruption in cortical surface

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    Elbow Fractures

    Radiograph Anatomy/Landmarks

    Baumanns angle is formed by a lineperpendicular to the axis of thehumerus, and a line that goes

    through the physis of the capitellum

    There is a wide range of normal forthis value

    Can vary with rotation of the radiograph

    In this case, the medial impactionand varus position reduces Baumansangle

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    TYPES OF

    FRACTURES

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    Supracondylar Humerus Fractures

    Most common fracture around the elbow inchildren

    60 percent of elbow fractures

    Occurs from a fall on an outstretched hand

    Ligamentous laxity and hyperextension ofthe elbow are important mechanical factors

    May be associated with a distal radius orforearm fractures

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    Supracondylar Humerus Fractures

    Classification

    Type 1

    Non-displaced

    Type 2

    Angulated/displaced fracture

    with intact posterior cortex

    Type 3

    Complete displacement, with

    no contact between

    fragments

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    T 2

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    Type 2Angulated/displaced fracture with intact

    posterior cortex

    T 2

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    In many cases, the type 2fractures will be impacted

    medially Leads to varus angulation

    The varus malposition

    must be considered whenreducing these fractures Apply a valgus force for

    realignment

    Type 2Angulated/displaced fracture with intact

    posterior cortex

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    Type 3Complete displacement, with no contact

    between fragments

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    Complications

    Neurovascular injury in ~12%

    displacement increases incidence

    Mostly neuropraxias that resolve in months

    Extension - median nerve and brachial artery

    Flexion - ulnar nerve

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    Type 1 Fractures

    In most cases, these can be treated with

    immobilization 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 If minimally displaced (anterior humeral line hits

    part of capitellum) Immobilization for 3 weeks.

    Close follow-up is necessary to monitor for loss ofreduction

    Displaced (anterior humeral line misses capitellum) Reduction may be necessary

    The degree of posterior angulation that requiresreduction is controversial

    Check opposite extremity for hyperextension

    If varus/valgus malalignment exists, most authorsrecommend reduction.

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    Type 2 FracturesTreatment

    Reduction of these fractures is usually not difficult

    Maintaining reduction usually requires flexion beyond 90

    Excessive flexion may not be tolerated because ofswelling

    May require percutaneous pinning to maintain reduction

    Most authors suggest that percutaneous pinning is

    the safest form of treatment for many of thesefractures

    Pins maintain the reduction and allow the elbow to beimmobilized in a more extended position

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    Supracondylar Humerus Fractures

    Treatment

    Type 3 Fractures

    These fractures have a high risk of neurologic and/orvascular compromise

    Can be associated with a significant amount of swelling

    Current treatment protocols use percutaneous pin fixationin almost all cases

    In rare cases, open reduction may be necessary

    Especially in cases of vascular disruption

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    Lateral Condyle Fractures

    Common fracture,

    representing

    approximately 15% of

    elbow trauma in

    children

    Usually occurs from a

    fall on an outstretchedarm

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    Lateral Condyle Fractures

    Jakob Classification Type 1

    Non-displaced fracture

    Fracture line does not crossthrough the articular surface

    Type 2 Minimally displaced

    Fracture extends to thearticular surface, but thecapitellum is not rotated orsignificantly displaced

    Type 3

    Completely displaced

    Fracture extends to thearticular surface, and thecapitellum is rotated andsignificantly displaced

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    Lateral Condyle Fractures

    Jakob Type 1

    Oblique radiographs

    may be necessary to

    confirm that this is not

    displaced. Frequent

    radiographs in the cast

    are necessary to

    ensure that thefracture does not

    displace in the cast.

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    Lateral Condyle Fractures

    Jakob Type 3

    ORIF is almost alwaysnecessary

    A lateral Kocherapproach is used forreduction, and pins or

    a screw are placed tomaintain the reduction

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    Lateral Condyle Fractures

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    Lateral Condyle FracturesComplications

    AVN can occur after

    excessive surgical

    dissection

    Cubitus varus can

    occur, may be because

    of malreduction or a

    result of lateralcolumn overgrowth

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    Medial Epicondyle Fracture

    Management

    Minimally displaced

    Long arm splint

    1-2 weeks with early ROM

    Displaced >5mm

    Conservative or operative

    Intra-articular fragment Surgical removal of fragment

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    Medial Epicondyle Fracture

    Complications

    Ulnar nerve injury 10-16%

    More common if intraarticular fragment

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    Radial Head and Neck Fractures

    Classification By degree of angulation

    Type I

    < 30 angulation

    Type II

    30 -60 angulation

    Type III

    > 60 angulation

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    Radial Head and Neck Fractures

    Management

    Angulation>15 - closed reduction

    Type I

    Sling/posterior splint X 1-2 weeks

    Type II and III

    Percutaneous pining if closed reduction not

    adequate (

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    Radial Head and Neck Fractures

    Complications

    AVN of radial head ~ 10 -20%

    Loss of ROM

    rotation

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    Olecranon Fracture

    ~ 5% of elbow fractures

    More common with increasing age

    Associated with other injuries (50%)

    Mechanism

    Direct blow

    Shear

    Indirect due to forceful contraction of tricepswhile elbow flexed in fall

    Hyperextension

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    Conclusion

    Be vigilant

    Use a thorough approach

    Look for associated injuries

    Think about mechanism

    Know how it is treated in your centre

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    Thank You

    very much