7/26/2017

1

PEDIATRIC ELBOW FRACTURES

JASON NYDICK, DO

Hand & Upper Extremity

FLORIDA ORTHOPAEDIC INSTITUTE

TAMPA, FL

Orthopaedics for the Primary Care and Rehab Therapist

July 22, 2017 Clearwater, FL

7/26/2017

2

PEDIATRIC ELBOW

• 7-9% OF FRACTURES

• MOST COMMON FRACTURE SURGERY

DEVELOPMENTAL ANATOMY

ANATOMY

• Brachial artery

• Median nerve– Anterior interosseous

nerve

• Ulnar nerve– Subluxates out of ulnar

groove in 15% of children

• Radial nerve

7/26/2017

3

DIAGNOSES

• SUPRACONDYLAR FRACTURE

• LATERAL CONDYLE FRACTURE

• MEDIAL EPICONDYLE FRACTURE– DISLOCATION

• RADIAL NECK FRACTURE

• MONTEGGIA FRACTURE-DISLOCATION

SUPRACONDYLAR FRACTURE

• 60% OF ELBOW FRACTURES

• PEAK AGE 6 Y

• 97% EXTENSION TYPE

ASSOCIATED INJURIES

• NEUROLOGICAL 7%

• VASCULAR 0.5%

• COMPARTMENT SYNDROME <1%

7/26/2017

4

GARTLAND CLASSIFICATION

• TYPE 1– NON-DISPLACED

• TYPE 2– EXTENDED, POSTERIOR CORTEX

INTACT

• TYPE 3– DISPLACED, NO BONY CONTACT

TYPE 1

• CAST

Skaggs et al, J Bone Joint Surg, 1999

TYPE 2

• CLOSED REDUCTION AND CAST

Parikh et al, J Pediatr Orthop, 2004

7/26/2017

5

VARUS DEFORMITY

NOT ALL TYPE 2 FRACTURES ARE THE SAME

• TRANSLATION/ ROTATION

• MEDIAL COLUMN COMMINUTION

TYPE 3

• CLOSED REDUCTION AND PINNING– WHEN TO PIN?

– HOW TO PIN?

7/26/2017

6

TIMING OF SURGERY

• > 8 HOURS AFTER INJURY– NORMAL

NEUROVASCULAR EXAM

– SKIN INTACT

– ISOLATED INJURY

• EMERGENT– NEUROVASCULAR

COMPROMISE

– OPEN FRACTURE

Mehlman et al, J Bone Joint Surg, 2001; Gupta et al, J Pediatr Orthop, 2004

CLOSED REDUCTION AND PERCUTANEOUS PINNING

PIN PLACEMENT

• LATERAL PINS

• .062 OR LARGER

• ACHIEVE STABILITY

Skaggs et al, J Bone Joint Surg, 2001

7/26/2017

7

PIN PLACEMENT

• MEDIAL AND LATERAL PINS– MEDIAL COLUMN

COMMINUTION

– INSTABILITY WITH LATERAL PINS

ACCEPTABLE REDUCTION

BAUMANN’S ANGLE

ANTERIOR HUMERAL LINE CARRYING ANGLE

OPEN REDUCTION

• INDICATIONS– IRREDUCIBLE

FRACTURE

– NEUROVASCULAR EXPLORATION

– OPEN FRACTURE

• ANTERIOR APPROACH

7/26/2017

8

FLEXION SUPRACONDYLAR FRACTURE

• CLOSED REDUCTION WITH EXTENSION (80%)

• OPEN REDUCTION

DYSVASCULAR LIMB

• No arteriogram– Vascular injury at end

of proximal fragment

• Algorithm– 1. CRPP

– 2. Reassess vascular status

– 3. Open exploration of brachial artery

NERVE INJURY(NEUROPRAXIA)

• 7-10% of fractures

• Anterior interosseous > median > ulnar > radial

• Distal end of proximal fragment

• Most resolve within 3 months

7/26/2017

9

COMPARTMENT SYNDROME

• BEWARE– NEUROPRAXIA

• MEDIAN NERVE

– FLOATING ELBOW

– INCREASING MORPHINE REQUIREMENT

Bae et al, J Pediatr Orthop, 2001

CUBITUS VARUS

• 5-10% OF CASES

• COSMETIC DEFORMITY

• OSTEOTOMY FOR CORRECTION

DISTAL HUMERAL PHYSEAL SEPARATION

• CHILDREN < 6Y

• CHILD ABUSE, BIRTH INJURY

• MISDIAGNOSED AS DISLOCATION

• CUBITUS VARUS

7/26/2017

10

TREATMENT

• Closed reduction and percutaneous fixation

• ARTHROGRAM/ ULTRASOUND TO DOCUMENT REDUCTION

LATERAL CONDYLE FRACTURE

• 17% OF ELBOW FRACTURES

• RARE NEUROVASCULAR INJURY

• VARUS/VALGUS MECHANISMS

CLASSIFICATIONS

MILCHJAKOB

7/26/2017

11

TREATMENT

• MINIMALLY DISPLACED FRACTURE– CAST

– PERCUTANEOUS PINNING

TREATMENT

• DISPLACED FRACTURE– OPEN REDUCTION

AND FIXATION

PIN PLACEMENT

• .062 OR LARGER– PERCUTANEOUS

• ACHIEVE STABILITY

• REMOVE AT 4-6 WEEKS

7/26/2017

12

COMPLICATIONS

LATERAL OVERGROWTH

NONUNION AVASCULAR NECROSIS (fishtail)

Thomas et al, J Pediatr Orthop, 2001; Skak et al, J Pediatr Orthop B 2001

MEDIAL EPICONDYLE FRACTURE

• 12% OF ELBOW INJURIES

• PEAK AGE 11 Y

TREATMENT

• CAST– <1 CM MEDIAL DISPLACEMENT

– < 45° ROTATED

– NOT DISTAL TO JOINT

– ALL FRACTURES??

Farsetti et al, J Bone Joint Surg, 2001

7/26/2017

13

OPEN REDUCTION AND FIXATION

• UNACCEPTABLE DISPLACEMENT

• ATHLETE (?)– OVERHAND

THROWING

– WEIGHT-BEARING ON HANDS

• DISLOCATED ELBOW

ELBOW DISLOCATION

• 6% OF ELBOW INJURIES

• PEAK AGE 13Y

• POSTERIOR

• 11% NERVE INJURY– ULNAR

CLOSED REDUCTION

• NEUROVASCULAR EXAM

• BRIEF IMMOBILIZATION (2WK)

• LOSS OF EXTENSION (10°)

7/26/2017

14

BEWARE ENTRAPMENT OF MEDIAL EPICONDYLE

RADIAL HEAD AND NECK FRACTURES

• 5% OF ELBOW INJURIES

• WIDE AGE RANGE

• ASSOCIATED FRACTURES

O’BRIEN CLASSIFICATION

• TYPE 1– <30° ANGULATED

• TYPE 2– 30-60 ° ANGULATED– TRANSLATED<4mm

• TYPE 3– 60° ANGULATED– TRANSLATED >4mm

7/26/2017

15

TREATMENT• TYPE 1

– CAST

• TYPE 2– CLOSED REDUCTION

– CAST

CLOSED REDUCTION

• ROTATE FOREARM TO IDENTIFY MAXIMAL DISPLACEMENT

REDUCTION TECHNIQUES

• ACCEPTABLE REDUCTION– < 30° OF

ANGULATION

– <25 % TRANSLATION

Vocke et al, J Pediatr Orthop B, 1998;Neher et al, J Pediatr Orthop, 2003

7/26/2017

16

TREATMENT

• TYPE 3 – OPEN REDUCTION AND WIRE FIXATION

COMPLICATIONS

• 20 % POOR RESULTS– STIFFNESS

– AVN

– POSTERIOR INTEROSSEOUS NERVE PALSY

– SYNOSTOSIS

MONTEGGIA FRACTURE-DISLOCATION

• 0.4% OF FOREARM FRACTURES

• COMMON MISDIAGNOSIS

7/26/2017

17

RADIAL HEAD POSITION

BEWARE

PROXIMAL ULNA FRACTURES

ISOLATED RADIAL HEAD DISLOCATION

TREATMENT

• CLOSED REDUCTION– CAST

• SUPINATION

• 100° ELBOW FLEXION

• OPERATIVE– FIXATION OF ULNA

– CLOSED REDUCTION OF RADIAL HEAD

– OPEN REDUCTION OF RADIAL HEAD

• LATE DIAGNOSIS (>6 WEEKS)

• ENTRAPPED ANNULAR LIGAMENT

7/26/2017

18

TREATMENT

• MAINTAIN LENGTH OF ULNA

PEDIATRIC ELBOW FRACTURES

• Understand – Anatomy

– Injury types

– Treatment options

• Increased vigilance for complications

THANK YOU