ic67-r: understanding pediatric elbow fractures to

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IC67-R: Understanding Pediatric Elbow

Fractures to Maximize Outcomes

Moderator(s): Joshua M. Abzug, MD

Faculty: Andrea S. Bauer, MD, Scott H. Kozin, MD, and Francisco Soldado, MD, PhD

Session Handouts

75TH VIRTUAL ANNUAL MEETING OF THE ASSH

OCTOBER 1-3, 2020

822 West Washington Blvd

Chicago, IL 60607

Phone: (312) 880-1900

Web: www.assh.org

Email: [email protected]

http://www.assh.org/

mailto:[email protected]

7/23/2020

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IC67-R: Understanding Pediatric Elbow Fractures to Maximize Outcomes

Moderator: Joshua M. Abzug, MD

Faculty: Andrea S. Bauer, MD, Scott H. Kozin, MD, Francisco Soldado, MD, PhD

Joshua M. Abzug, MD

Speaker has no relevant financial relationships with commercial interest to disclose.

Understanding Pediatric Elbow Fractures to Maximize Outcomes: Supracondylar

Fractures

Joshua M. Abzug, [email protected]

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Supracondylar Humerus Fractures

Most common pediatric elbow fracture

79% of elbow fractures

3.3% of all pediatric fxs

Epidemiology

5-7 years of age

Males = Females

Non-dominant side (left)

Physical Exam

Observation

Skin puckering, ecchymosis, open wounds, vascular status of hand

Palpation

Specific areas about the elbow

Remainder of upper extremity

Physical Exam

Neurovascular exam

Assess AIN, Median nerve, Radial nerve, Ulnar nerve

Assess Radial artery

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X-rays

Assess for posterior fat pad sign

Assess anterior humeral line

Gartland Classification

I Non‐displaced

II Hinged

A: No rotational deformity

B: Rotational deformity

III Completely displaced

(Most common posteromedial 75%)

Gartland Classification

IV Multidirectional

Unstable in both flexion and extension because of complete loss of a periosteal hinge

•May be due to initial injury or repeated attempts at closed reduction

–Leitch et al.

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Treatment

Type I Long arm cast x 3 weeks

Type IIA Long arm cast vs. CRPP

Type IIB CRPP

Type III CRPP

Type IV CRPP

Easiest to use 2 fluoro machines

Preplace pins in distal fragment

TimingIdeal start time

6:30 AM trauma room

Bump first case

How long is too long?

Mehlman

• 8 Hours

Gupta

• 12 Hours

Bales

• 19 Hours

Leet

• 21 Hours

Not All Supracondylar Fractures are Created Equal

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The Fine Print

Mehlman, JBJS, 2001

Excluded open and pulseless fractures

The Fine Print

Gupta, et al, JPO, 2004

Excludes vascular injury, ipsilateral fracture and open fracture

My Practice

Emergency room

Orthopedic surgeon/resident evaluation

• Skin

• Neurovascular exam

• Splint– Gentle flexion

• Non-sedating pain medication

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Inpatient Management

Nursing

Elevation of limb

Q3-4 hr. NV checks

Increasing pain • CALL Orthopedic

surgeon/resident

• The A’s not the P’s– Anxiety

– Agitation

– Analgesia

Emergency SurgeryIndications

Dysvascular extremity

• Pulseless perfused hand

Open fracture

Skin tenting

“Floating Elbow”

Abnormal neuro exam

• Median nerve neuropraxia

Skin puckering

Significant swelling/ecchymosis

OR Set-up

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Reduction

Obtain length before flexing

GENTLE flexion maneuver

Appreciate rotational abnormality

Flexion supracondylar pinned in extension

Milking Maneuver and Reduction

Fluoroscopic views

Jones view (AP)

Lateral view• Externally rotate shoulder

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Acceptable Reduction

< 50% translationNo varus

No extension

Pin Size

Remember big pins for big people and big pins for little people

Usually 0.062” or 2.0 mm

Pin Configuration

Lateral entry pins

Type II = 2 pins

Type III = 3 pins

• Check the stability of fixation by stressing the fracture under live fluoroscopy

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Optimum Pin Configuration

Medial pin

Lateral pins = crossed pins

Skaggs, JBJS, 2001

Kocher, JBJS, 2007

Medial pin

10% ulnar nerve injury• Extend elbow

Cutdown to epicondyle

Poor Pin Configuration

Failure to engage both fragments with at least two pins

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Failure to achieve bicortical fixation with at least two pins


Failure to achieve ≥2 mm of pin separation at the fracture site (pins cross at fracture site)

Final Check

LIVE Fluoro

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Post-Operative Care

Splint at 70-80° flexion

Tylenol for pain

Home next day

Follow-up

1 week for x-ray

3 weeks for x-ray and pins out

Special Situations

Floating elbow

Fix both

Skin pucker

“Milk” muscles before reducing

Open Reduction

Irreducible closed

Dysvascular hand after CRPP

Open fracture

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Pulseless Supracondylar Fracture

No arteriogram

Vascular injury at end of proximal fragment

Algorithm

1. CRPP

2. Reassess vascular status

• Observe “pink, pulseless” hand

3. Open exploration of brachial artery

• Dysvascular hand

• Prophylactic forearm and hand fasciotomies with prolonged ischemia

Supracondylar Fractures

4.2% complication rate

Pin Migration

1.8%

Most common complication

Can require an unanticipated return to the OR

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Infection

<1%

Majority are superficial

Semi‐sterile technique is safe

Treat early to avoid septic arthritis

Cubitus Varus

Cubitus varus

Occurs with casting or pinning

Due to inadequate fracture reduction

• Omid et al. JBJS 2008

Typically painless

Good elbow motion maintained

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Cubitus varus

Problem

Cosmesis

Repeat fractures

• Lateral condyle

– Takahara et al. JBJS BR 1998

Snapping medial triceps tendon

• Spinner et al. JHS 1999

Cubitus varus

Problem

Tardy posterolateralelbow instability

• Presents 2‐3 decades later

• Lateral elbow pain and recurrent instability

– O’Driscoll et al. JBJS 2001

Cubitus varus - PLRI

Cubitus varusmedial displacement of mechanical axis altered vector of triceps pull

Repetitive external rotation torque applied to ulna attentuation LCL PLRI

Fig. 3

Varu

torq

exte

from

the

O’Driscoll et al. JBJS 2001

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Cubitus Varus - Treatment

Osteotomy

Lateral closing wedge

• No sagittal deformity

Biplanar

• Coronal and sagittal deformity

Biplanar Osteotomy

Follow-up

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Cubitus varus - Treatment

Osteotomy

Dome

Kim HT, Lee JS, Yoo CI. JBJS 2005

Step‐cut


Preferred technique – Lateral closing wedge osteotomy

Technically straightforward

Union is reliable

Lateral prominence is asymptomatic and unrecognized

Lower complication rate


Osteotomy

Lateral approach along supracondylar ridge

Elevate brachialis and triceps

Malleable retractors across humerus

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Osteotomy

Use K‐wires to determine extent of lateral wedge

• One parallel to distal humeral joint just above olecranon fossa

• One perpendicular to humeral shaft to determine amount of wedge


Osteotomy

Leave medial cortex intact and remove bone cut

Place 2 provisional K‐wires percutaneously from lateral side

“Crack” medial cortex by applying valgus moment and advance K‐wires


Young children with open physes

Leave K‐wires as definitive fixation

Older children/adults

Medial incision to identify, protect, and transpose ulnar nerve

Can translate distal fragment medially to reduce lateral prominence

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Compartment Syndrome

Compartment Syndromes at Boston Children’s Hospital 1992-1997- 33 children

Bae et al, Journal of Pediatric Orthopedics 2001; 21:680-688

Diagnosis

23 compartment syndromes diagnosed on admission

10 diagnosed while in house

3 fractures s/p fixation

3 elective osteotomies

4 non-displaced fractures or soft tissue injuries

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Compartment syndrome

The “P’s” – unreliable in children

Bae et al, Journal of Pediatric Orthopedics 2001; 21:680-688

10 children diagnosed in house

All 10 had an increasing analgesia requirement

Patient-controlled analgesia or nurse-administered pain control

Preceded the development of other signs or uncontrolled pain by 7.3 hours

Average time from increasing complaints to uncontrolled pain or neurovascular change resulting in surgery was 17.9 hours

Conclusions

Increasing analgesia requirement may be a more sensitive indicator of a developing compartment syndrome in children

• Medication administration record is part of the clinical diagnosis• Narcotics delay the diagnosis

Fasciotomies yield satisfactory outcomes

Despite delay in diagnosis

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The “A’s”

Anxiety

Agitation

Analgesia

Give non‐narcotic/ non‐sedating low‐dose medications


Proceed to fasciotomies quickly once recognized

High suspicion

Floating elbow

Dysvascular limbs requiring vascular repair

Median nerve palsy

Missed Compartment Syndrome

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Pre-Operative

Flexor Slide

Flexor Slide

Ulna

BrachialisBiceps Tendon

RadiusAIN FDP/FDS

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Flexor Slide

UlnaIOM

PQAIN/AIA

Intra Op

Post-op

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Compartment Syndrome - Pitfalls

Increasing analgesia requirements

Failure to recognize


My protocol

Admit for 24 hours

• 48 hours if neurovascular injury

Tylenol for pain

Q3‐4 neurovascular checks

Loss of reduction

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Loss of reduction

Ideal pin configuration

Lateral pins = crossed pins

• Skaggs, JBJS, 2001

• Kocher, JBJS, 2007

Medial pin

• 10% ulnar nerve injury

• Cutdown to epicondyle

– Extend elbow

Optimum Pin Configuration


Failure to engage both fragments with at least two pins

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Failure to achieve bicortical fixation with at least two pins


Failure to achieve ≥2 mm of pin separation at the fracture site (pins cross at fracture site)

Loss of reduction - Pearls

Live fluoroscopy

Use 3 pins

Appropriate configuration

Open placement of medial pin

Avoid ulnar nerve injury

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Nerve Injury

Nerve Injury

11% overall rate

Extension type

AIN Median Radial Ulnar

Flexion type

Ulnar most common

Nerve Injury - Pearls

Obtain thorough pre and post‐operative neurological exams

Obtain exam by proxy or through repeat exams

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Nerve Injury - Pearls

Cut down to epicondyle to place medial pin

Recognize “rubbery” feeling during reduction

Pitfalls

Failure to obtain a pre‐operative exam

4 yo female

Nerve Injury -Pitfalls

ED Physician

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Nerve Injury -Pitfalls

Attending post‐op note

Thanks!!!

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Francisco Soldado, MD, PhD


F SoldadoPediatric Upper Extremity and Microsurgery

[email protected]+34 688999890Barcelona, Spain

Humeral Lateral Condyle Fractures

10–15 % pediatric elbow fractures. Second most common elbow Fx (Landin JPO B 1992)

Epidemiology

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Problems

Articular injury : Loss of motion

Fragment Instability: Nonunion

Terminal vascularization: Osteonecrosis

Milch (J Traum 1964)

Type I Transcapitelum Type II Transtrochlea

Jakob (JBJS Br 1954)

Type INon‐displaced (Hinged)

Type IIDisplaced

Type IIIRotated

Classification and Radiology

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Amount of displacement (mm)

Internal oblique x-ray view

Classification and Radiology

6%

Treatment: Minimally displaced <2mm (Flynn JBJS Am 1975)

Weekly follow-up possible: Long arm cast (supination, wrist extension)

Weekly follow-up not possible: Percutaneous pinning

‐

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Mechanical factor: Extensor-supinator mass

3-4mm 13% risk of nonunion (Flynn JBJS 75)

Instability: Risk Nonunion

Closed reduction (Song JBJS Am 2008):Elbow varus Forearm supination KW joystick

Treatment: Displaced >2mm

Residual displacement <2mm: Percutaneous pinning

Residual displacement >2mm: ORIF

Arthrogram (Arthroscopy)

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Arthrogram (Arthroscopy)

Disrupted capsule

KW configuration

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KW configuration

Compression by cannulated screws might decrease need for ORIF (Stein JPO 2015)‐

Treatment

Open Reduction: Lateral approach

Difficult articular visualization Unsightly Scar

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Abordaje quirúrgico

Open Reduction: Anterior approach

Soldado F et al. Transverse Anterior Approach to the Elbow for Pediatric Displaced Lateral Humeral Condyle Fractures . 2020: 8(2)‐142‐146


Direct articular visualization

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Direct articular visualization

Sightly Scar


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-70%-Correlation initial displacement -Does not influence final outcome

Lateral spurring

Minor 8%: Pin tract infection, granuloma, Keloid

Major 6%: Malunion 3%, osteonecrosis 0.6%, nonunion 0.6%, stiffness 0.6%

Complications (Weiss JPO 2009)

Nonunion

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Late diagnosisSafe to operate up to 2 weeks

Nonunion: Vascularized humeral periosteal flap

3s 6s 4m

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Dome osteotomyVascularized periosteal flap

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To Maximize Outcomes:

To Stay To Maximize Outcomes:

Internal Oblique Rx

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Pin minimally displaced LCF if follow‐up not possible


Arthrogram

To To Maximize Outcomes:

Divergent pins

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Avoid posterior dissection

Thanks

F SoldadoPediatric Upper Extremity and Microsurgery

[email protected]+34 688999890

Drsoldado

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Scott H. Kozin, MD


Monteggia Fracture Dislocations

Scott H. Kozin, MDShriners Hospital for ChildrenPhiladelphia, PA

Take Home Points

• Don’t miss the diagnosis• Early treatment uniformly successful• Subacute consistently successful• Chronic treatment less reliable• Ulna is the key!

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Acute

• Natalie• 5 year-old fell 2 days ago• Diagnosed greenstick fracture in ER• Referred to orthopaedic surgeon

Orthopaedic Surgeon Concerned

• Asked radiologist if radial head was “located”• YES!• WTF?

CT Scan

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Treatment?

Now What?

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Healed

Range of Motion

Subacute

• Michael G• 7 year-old male• Tripped over tree trunk 7/31/13 • ER- no fracture and sling• Ortho f/u 8/20/13

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Treatment

• Surgery 8/26/13• Closed reduction unsuccessful, open reduction• Not quite satisfied• MRI following surgery

Second Opinion

Treatment ?

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Final Fixation

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Subacute

• Gavin B • 6 year-old fell off slide 3 months ago• Treated for “fracture”• Elbow ROM 10 to 110 degrees• Full pronation and supination

Referred with X-rays & MRI

We Can Fix It!

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Technique

• Position• Approach• Technique- Pearls!• Rehabilitation

Position

• Supine• Standard prep and drape• Antibiotics• Tourniquet

Approach

• Extended Kocher approach• ECU- Anconeous interval• Expose ulna and open radiocapitellar (RC) joint

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Approach

• Remove interposed tissue• Cut ulna (step or transverse)• Reduce RC joint and place Steinman pin• Fix ulna in situ

Close-Up

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Next…

• Remove Steinman Pin• Range of motion• Stable → Go home • Unstable → Assess situation ulna• Annular ligament reconstruction

Post-Operative

• Splint or cast• Careful follow-up• X-ray every week for 3 weeks

Two week Follow-up

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ROM

• Begin at 6 weeks• Active mainly• Kids are resilient

Three Month Follow-up

Three Month Follow-up

Hang Tight!

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• ROM• supination 90°• pronation is 75°• elbow flexion 155°• elbow extension 0°

Final X-rays

That is How We Do It !!

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Chronic Monteggia- Different Problem

Michael S

• 11 year-old right forearm fracture 5 years ago• Missed Monteggia with plastic deformation ulna• Range of motion 0 to 90º• Medial laxity

X-rays

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Chronic Monteggia- Different Problem

• Need length first- distraction osteogenesis

Chronic Monteggia

• Subsequent bony angular correction & open reduction after length achieved

Chronic Monteggia

• May need annular ligament reconstruction• Currently favor detaching biceps from radius,

reattach to ulna, split half around radial neck to from ligament

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Annular Ligament Reconstruction

Annular Ligament Reconstruction

X-ray Outcome Consolidation!

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Radial Head Reduced!

Jeremiah B

• 16 year-old• Right elbow injury at 3 years of age• Pain• Progressive valgus instability

• No radial head buttress• Ulnar collateral ligament attentuation

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Can We Fix It?

Round #1

• Radial shortening osteotomy• Acute ulnar angulation osteotomy• Open reduction radial head• Reduced but subluxates in pronation

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6 Weeks Post-Operative

Round #2

• Detach biceps• Annular ligament reconstruction

One Year Follow-up

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Is There a Role for Non-operative Management?

13 Year-old Ethiopian Child

• Vague history right elbow injury• No pain

13 Year-old Ethiopian Child

• Complains of decreased forearm rotation• Supination neutral• Full pronation

• Full elbow flexion and extension

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Supination/ Pronation

Neutral 50 degrees

Flexion/ Extension

Full Hyperextends 10 degrees

Don’t Just Do Something, Stand There

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Thank You

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Andrea S. Bauer, MD


TRASH Lesions of the Elbow

Andrea S. Bauer, MD

Boston Children’s Hospital

IC67‐R: Understanding Pediatric Elbow Fractures to Maximize Outcomes

Disclosures

• No financial disclosures

• Thank you to my partners– Carley Vuillermin & Don Bae

– Peter Waters & James Kasser

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TRASH

What is a TRASH lesion?

Elbow “TRASH” Lesions

The

Radiographic

Appearance

Seemed

Harmless

A small subset of injuries that are readily missed and together

result in poor outcomes when not initially identified

“More is missed by not looking than not knowing”

McCrae 1870-1935


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• Transphyseal Distal Humerus Separation

• Medial Condyle Fractures

• Complex osteochondral elbow fracture-dislocations

• Osteochondral fractures with joint incongruity

• Entrapped medial epicondylar fractures

• Lateral condylar avulsion shear fractures

• Anterior radial head fractures with progressive radiocapitellar subluxation

• Monteggia fracture dislocations


• Transphyseal Distal Humerus Separation

• Medial Condyle Fractures

• Complex osteochondral elbow fracture-dislocations

• Osteochondral fractures with joint incongruity

• Entrapped medial epicondylar fractures

• Lateral condylar avulsion shear fractures

• Anterior radial head fractures with progressive radiocapitellar subluxation

• Monteggia fracture dislocations

• Capitellar fractures

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Radiographic Evaluation

First impressions can be deceiving• Ossification centers• Joint alignment• Signs of subtle injuries

Assess in conjunction with• The mechanism• Patient findings

Be cautious under 4Be suspicious under 10

Physeal Separation

Physeal Separation

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Physeal Separation

Medial Condyle Fracture


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Osteochondral Injuries

Small fragments can represent major injuries in children’s elbows

Proper recognition is key

• High suspicion

• Advanced imaging


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Incarcerated Medial Epicondyle Fractures

Incarcerated Medial Epicondyle Fractures

Is this good enough?What to do?

Waters & Bae, Pediatric Hand & Upper Limb Surgery: A Practical Approach, 2012

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• All should be managed operatively

• Can be missed and present late

• Suspect the injury if the medial epicondyle is ‘at the level of the joint’

• 44% had associated ulnar nerve injury

Radial Head/neck Fractures

Commonly not isolated injuries

Small fragments can represent larger injuries

The greater the intervention, the higher the likelihood of stiffness– Stepwise approach – closed/percutaneous/open reduction

Radiocapitellar alignment and stability is critical– If any doubt exists after reduction in a young child then an arthrogram can

be helpful

Radial Head/neck Fractures

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<1% Elbow Fractures

4 sub-types– Anterior shear

– Posterolateral shear

– Acute chondral shear

Not all require surgical management however maintain a high index of suspicion

Type I: Non‐displaced Type II: Posterior shear

Type III: Anterior shear Type IV: Acute osteochondral injury

Capitellar Fractures

Capitellar fractures: Type II Posterior Shear

• 19%

• Average age 12.4y (8-15)

• Associated with known dislocation

• Poorly visualized on plain radiographs

• Best seen on sagittal CT

• Better outcomes with primary surgical treatment

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• 15%

• Age 13y (9-14)

• Best diagnosed on sagittal MRI

• All required surgery

Capitellar Fractures: Type IV Acute OCD

Summary

It’s easy to be wise in retrospect

Be suspicious from the beginning!– Age

– Mechanism

– Clinical presentation

– Imaging

Sometimes the perspective we are looking from prevents us from seeing.

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ic67-r: understanding pediatric elbow fractures to

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