paediatric elbow fractures
TRANSCRIPT
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