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Elbow Fractures in children Chanika Angsanuntsukh, MD. Patarawan Woratanarat, MD. PhD.
• Children’ bones are different • To diagnose fractures in children, you need to
know the normal bones • Outlines
– Ossification centers – Normal and abnormal radiographic findings – Common fractures around elbow in children
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First of all, we have to know that kids are not little adults. Knowing the normal bones is the necessary, in order to diagnose fractures in children. Outlines of the lectures are Ossification centers Normal and abnormal radiographic findings And common fractures around elbow in children.
Elbow ossification centers
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Normal ossification centers of the elbow known as CRITOE Now we are going to see what is CRITOE.
Elbow ossification centers
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CRITOE is the sequence of ossification center of the elbow appearing on the x-rays. This sequence is reliable Variable in time Girls are up to 2 years more advanced than boys. To count the critoe, there are 2 ways to count We are going use the simpler one; 1 3 5 7 9 11
Elbow ossification centers
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The first ossification center is Capitellum. It is at lateral side of the elbow, just distal to metaphysis of humerus. The second on in radial head, which cannot be seen in this patient. We will move to the older patient.
Elbow ossification centers
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This patient is 3 year old and you now can see the ossification center of the radial head in this picture.
Elbow ossification centers
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In a 5 year old patient, we can see the ossification center of internal epicondyle on the medial aspect of distal humerus.
Elbow ossification centers
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The next ossification center is trochlea, you can see the trochleal ossification center over lapses with proximal of ulnar.
Elbow ossification centers
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Ossification center of olecranon is the next one appearing on x-ray, just proximal to ulna.
Elbow ossification centers
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The last ossification center is external epicondyle. In this x-ray, we can see all CRITOE ossification centers.
case
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This is a case example. A 3-year-old girl fell off a slide and hurt her elbow.
case
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This is her AP x-ray. Since she is 3, the ossification centers of the elbow that we should see in her radiograph are capitellum and radial head.
case
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And in this x-ray, we can identify her capitellum and radial head. If you zoom in and look carefully, you will see a small fleck of bone at location of ossification center of external epicondyle. However, in a 3-year-old girl, the external epicondyle should not be seen. Now we know that this is abnormal.
case
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On lateral x-ray, a supracondylar fracture is seen.
FAT PAD SIGN
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The next x-ray sign is fat pad sign.
Elbow joint effusion – fat pad sign
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These are x-rays of 6 different patients. Can you tell which one is normal or abnormal? Can you see the fat pad sign?
Elbow joint effusion – fat pad sign
Anterior fat pad Anterior fat pad Posterior fat pad
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At distal end of humerus, there are 2 fat pads, anterior and posterior. Anterior fat pad fills the coracoid fossa, while the posterior fat pad fills the olecranon fossa.
Elbow joint effusion – fat pad sign
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In normal elbow x-ray, we can see a thin anterior fat pad but normally not see posterior fat pad.
Elbow joint effusion – fat pad sign
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In a case of elbow fracture, there is intra-articular hematoma that causes elbow effusion. The hematoma will increase pressure in elbow joint and elevate both anterior and posterior fat pads. In the x-ray, you will see the shadow of fluid under the shadow of fat pads.
Elbow joint effusion – fat pad sign
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A CT cut confirms joint effusion that elevates the fat pads.
Elbow joint effusion – fat pad sign
Elbow joint effusion – fat pad sign
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Let go back to our 6 patients, can you tell which one is normal or abnormal? Check the fat pad signs and you will see the abnormal fat pad on patient A, B, D, and E.
SUPRACONDYLAR FRACTURE OF HUMERUS
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Now we are going to talk about the most common fracture of the elbow in children, the supracondylar fracture.
Supracondylar fracture of humerus
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Of these case examples, can you tell which patient has supracondylar fracture? Let s study more on this elbow fracture.
Supracondylar fracture of humerus
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The elbow is made from 3 bones, humerus or upper arm bone
Supracondylar fracture of humerus
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Ulna bone, which is a medial side forearm bone. The proximal part of the ulna has coracoid and olecranon that match the fossa of the distal humerus.
Supracondylar fracture of humerus
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The third bone is radius, the lateral forearm bone.
Supracondylar fracture of humerus
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Supracondylar is the thinnest part of distal humerus, just superior to the condyles. Supracondylar fracture is a fracture of the distal part of the humerus, generally transverse through coronoid and olecranon fossa. Most of the injuries cause from an extension force with olecranon acts as a fulcrum, extend the force through the fossa.
Supracondylar fracture of humerus
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The forced extension of the elbow brakes the bone through the fossa area, causing the fracture.
Supracondylar fracture of humerus
Most common age: 5-7 years
Mechanism of injury • Fall on out stretching hand
Types • Flexion type (2.3%) • Extension type (97.7%)
Clinical presentation • Pain and swelling • S-shaped deformity • Loss of passive and active motions/ pseudoparalysis • Puckering sign
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Most commonly found in 5-7 years of age group, more often occur on a non-dominant limb. The most mechanism of injury is a fall on out stretching hand, causing majority of the cases to be extension type. Fracture of the ipsilateral distal radius can be found in 5-6% of the patients. On physical examination of the limb, you will find limited range of motion, pain, swelling, bruising, deformity, or puckering of the skin. The most important part of the examination is the neurovascular assessment. Vascular compromise reported between 12-20% of the cases. Palpation of arteries, capillary refill, temperature and color of the limb must be evaluated.
Supracondylar fracture of humerus
Puckering sign
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This is an example of puckering sign, the proximal fragment button hole in to brachioradialis, catching subcutaneous tissue and skin.
Supracondylar fracture of humerus
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The investigation should be plain films of the injured elbow, AP and lateral.
Supracondylar fracture of humerus
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On lateral radiograph, you have to measure anterior humeral line, which is the line runs along anterior cortex of humerus and should transect the middle part of capitellum, as shown in the red line. Next line is the transverse radial line, running through middle of proximal part of radius and radial head, and this line should transect the capitellum too.
Baumann’s angle
Axis of the humerus
Line at lateral physis
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In the AP film, you have to measure the Baumann angle, which is the angle form by perpendicular line to the long axis of the humerus and the tangential line running through lateral physis, the red angle. Normal range is from 9-26 degrees. You can also measure the angle between humeral axis and lateral physeal line, the yellow one. The normal range of this angle is 64-82 degrees.
Classification
Gartland’s classification (Gartland 1959) • I non-displaced fracture • II displaced, intact posterior cortex • III totally displaced
• Wilkins (1984)
• IIA extended without rotational deformity or translation • IIB extended with rotational deformity or translation
• Leitch (2006) • IV unstable in flexion and extension (loss of periosteal hinge)
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The most commonly use classification for this fracture is Gartland’s classification. The first, type 1 is non-displaced or minimally displaced Type 2 is fracture that having the anterior cortical breakage with intact posterior hinge And type 3 is a completed fracture through both anterior and posterior cortices.
Gartland I
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This is the Gartland 1, a fracture with minimal displacement with intact anterior humeral line and normal Baumann angle.
Gartland II
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Gartland 2, you can see the anterior cortex is broke and the anterior humeral line does not transect the middle of the capitellum. You may see the translation or rotational deformity of the distal fragment in some cases. If the Baumann angle is more than 82 degrees, that means there is a varus angulation or medial comminution of the metaphysis.
Gartland III
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Gartland type 3, both anterior and posterior cortices are broke. Most of the cases have some degrees of translation and rotation.
Managements – Gartland I
Immobilization with elbow in 60-90 degrees for 3-4 weeks
Rx same for positive posterior fat pad sign on initial film
76% subsequent evidence of fracture (Skaggs 1999)
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Managements of the fracture depend on type of the fractures. General treatment for type 1 fracture is to immobilize the arm in flexion for 3-4 weeks, depends on age of the patient. There is a case series published in 1999, they went back to take a look at all the patients with positive posterior fat pad sign on the initial films. At the follow up, the radiographs shown a big number of subsequent diagnosis of Gartland type 1 injury, seeing some callus formation. So the recommendation is that all the patients with positive posterior fat pads should be treated initially as Gartland type 1 fractures.
Managements – Gartland II
Normally closed reduction with casting +/- pinning
JBJS review (May 2008)
Trend toward percutaneous pinning for all type II
JAAOS guidelines (Feb 2012)
II A cast immobilization
IIB closed reduction and pinning + casting
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For Gartland type 2, treatments included closed reduction and cast immobilization, with or without pinning. From JBJS 2008, the treatments trend toward percutaneous pinning for all Gartland type 2 fractures. and JAAOS 2012 recommend cast immobilization for Gartland type 2A and pinning for type 2B. However, there is not enough evidences to conclude the best treatment options for Gartland type 2.
Managements – Gartland III
Standard of care accepted to be operative reduction and pinning
Closed reduction (rarely need open reduction)
Pinning (crossed or lateral entry)
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For Gartland type 3 fractures, the standard of care accepted to be operative reduction and pinning. Most of the cases can be treated with closed reduction. There are many techniques of pinning, cross or lateral pinning.
Pinning
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These pictures show pinning techniques. Cross pinning 2 lateral pinning 3 lateral pinning
Indications for Open Reduction
Inadequate reduction with closed methods
Vascular injury
Open fractures
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Indications for open reduction are Inadequate or fail to closely reduce Associated vascular injury And open fracture
POST OP CARE
Elevation / swelling control
Pain control
Observe for compartment syndrome
Remove pins and cast at 3-4 weeks / union
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Post-operative cares include Elevation or other swelling control Pain control Observation for compartment syndrome The pins and cast are removed at 3-4 weeks or having clinical and radiographic unions.
Guidelines for associated vascular injuries
1 • Closed reduction and k-wire fixation
• Reassess vascular status • Observe over 15-20 minutes
2 • If pulse absent + limb well perfused
• Splint in 40-60 degrees flexion • Closed observation
3
• If limb not perfused • Immediate exploration of vessel
• Remove vessel from fracture site (arterial spasm?) • Primary repair / venous graft • Consider prophylactic forearm fasciotomy
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For treatments of the associated vascular injuries, the consensus would be Reducing the fracture and stabilized with k-wire fixation And then reassessing vascular status Most of the pulseless limb in supracondylar fracture cause from vascular spasm. If the limb is pulseless but well perfused, the patient should be splint in 40-60 degrees of elbow flexion and admitted for closed observation. In patient with pulseless and poor perfused limb, the immediate exploration of the vessel is necessary to evaluate the pathology Most of the cases, the vessel is entrapped in the fracture site.
Supracondylar fracture of humerus
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Let s come back to the case examples. Case A, if you look at the anterior fat pad, you will see the bulging of the anterior fat pad which is abnormal.
Supracondylar fracture of humerus
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And when you draw an anterior humeral line, you will see that the line transect anterior part of the capitellum. This causes by an extension force that push the olecranon backward, making the line transect anterior third of the capitellum and demonstrate extension deformity of distal humerus.
Supracondylar fracture of humerus
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In case B, you can also see the abnormal anterior and posterior fat pad signs. By the way, the anterior humeral line pass through the middle third of the capitellum, which is normal. This could be a Gartland type 1 injury.
Supracondylar fracture of humerus
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But when we zoom in, we will see a crack line at proximal radius. So this patient does not have a supracondylar fracture but has other elbow fracture that also can produces abnormal fat pad signs.
Supracondylar fracture of humerus
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Case C, we will again find the abnormal anterior fat pad sign and abnormal anterior humeral line. So this patient has a supracondylar Gartland type 2.
LATERAL HUMERAL CONDYLAR FRACTURE
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Lateral humeral condylar fracture or lateral condyle fracture in brief. Why we have to know about this fracture? Uhmm…Because this fracture is the second most common pediatric elbow fracture followed the supracondylar fracture. This fracture commonly occurs in children age of 6 years old. The major mechanisms of injuries are falling in out-stretched hand in varus or valgus position of the elbow.
Classification
Milch’s classification: • Milch I • Milch II
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Milch classification is based on an anatomy of the fracture. In Milch I, the fracture traverses from metaphysis to the capitellum and the articular surface at a capitellotrochlear groove pointed by a green arrow. In Milch II, the fracture reaches the articular surface at a trochleal groove pointed by a blue arrow. The bony fragment in Milch II is bigger than that of Milch I and may lead to elbow instability.
Classification
Jakob’s classification: (J Bone Joint Surg [Br], 1975) • Jakob I • Jakob II • Jakob III
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Jakob classification is based on the degree of fracture displacement. Jakob I has zero to two millimeters of displacement. Jakob II has two- to four-millimeter displacement with intra-articular involvement. Jakob III has more than four-millimeter displacement with rotation.
Milch I
• SH - IV
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An example of Milch I. You can see the fracture passes from metaphysis, capitellum into the articular surface. The fracture passes both metaphysis and epiphysis looks alike Salter-Harris type IV.
Milch II
• SH - II
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An example of Milch II, the fracture passes from metaphysis but does not pass an epiphysis. It may be classified as Salter-Harris type II.
Jakob I
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Jakob I shows the minimally displaced fracture within 2 millimeters. The metaphyseal fragment is very thin as a wafer.
Jakob II
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Jakob II, the fragment displaces within 4 millimeters and reaches the intra-articular surface. From the lateral view, the fracture extends to the posterior aspect of the distal humerus.
Jakob III
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In Jakob III, the fragment severely displaces and rotates.
Treatments
Jakob I long arm cast/locking slab closed follow-up
Jakob II closed reduction with pinning
long arm cast/locking slab
Jakob III open reduction with pinning
long arm cast/locking slab
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The treatment of lateral condylar fracture depends on a degree of displacement. For minimally displacement, long arm slab is applied with closed follow-up every 3-5 days for a week to early detect further displacement. For Jakob II, the fragment extends to articular surface. Closed reduction with pinning is recommended to secure the fracture stability. Long arm slab is applied after fixation. For Jakob III, open reduction with pin fixation is needed. An intraarticular fragment must be realigned perfectly to prevent further traumatic elbow arthritis. Long arm slab is applied after fixation.
Pinning
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Various pinning techniques are aimed to stabilize metaphyseal and capitellar fragments after reduction. Pinning is preferred in most cases while screw fixation is suitable for a large metaphyseal fragment, especially in older children.
Post op care
Elevation / swelling control
Pain control
Observe for compartment syndrome
Remove pins and cast at 6 weeks / union
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Postoperative care composes of limb elevation for swelling control as a picture above, pain control, and observation of compartment syndrome. Follow-up radiographs should be assessed every one to two weeks. Cast should be changed when it loose or dirty under general anesthesia. Usually, pins and casts is removed at six weeks or fracture union. Callus formation is pointed out by a white arrow as a picture below.
Complications
Compartment syndrome
Non-union
Mal-union
AVN of lateral condyle
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The most common complications after lateral humeral condylar fracture are compartment syndrome, nonunion as shown in a picture on the left, malunion as shown in a picture on the right, and avascular necrosis of the lateral condyle.
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Dr. Chanika and I would like to thank you for joining our e-learning session. We would like to encourage all of you guys in recognition of common elbow fractures in children. More information about pediatric fractures is also available in our website. Thank you so much for your attention.
