Pediatric Elbow Fractures

1. Pediatric Elbow Fractures Eric Jepson September 22, 2000

2. Supracondylar Fractures of the Humerus in Children • 2/3 of all hospitalizations for elbow injuries in children • Most common in children <10 years old, usually between the ages of 5-8 years old. • Historically associated with significant morbidity secondary to malunion, neurovascular complications and compartment syndrome

3. Classification • Extension or flexion injuries • 90-98% extension type • Extension injury is caused by fall on outstretched hand with elbow hyperextended • Displacement of distal fragment in extension type injuries has been reported to be posteromedial in 90% and posterolateral in 10% • Otsuka and associates reported 49% to be posterolateral

4. Gartlands Classification • Type I – nondisplaced • Type II – displaced with variable angulation, but posterior cortex of the humerous is intact A. Posterior tilt B. Posterior translation • Type III – completely displaced with no cortical contact

5. Physical Examination • Rule out associated trauma – evaluate for midshaft humerus fractures(rare) and distal forearm fractures(common) • Nerve injuries – 11-49% associated with supracondylar injuries - posterolateral displacement associated with median and anterior interosseous nerve dysfunction

6. Physical Examination - posteromedial displacement associated with radial nerve injury - ulnar nerve injury more often associated with flexion type injuries - anterior interosseous nerve most often injured – evaluate flexor pollicus longus and flexor digitorum profundus of index finger

7. Physical Examination • Vascular injuries – permanent vascular compromise of extremity occurs in less that 1% • Brachial artery may become compromised by anterior spike of proximal fragment - Usually resolves with reduction of fracture • Entrapment of brachial artery in fracture site may compromise circulation of extremity with reduction - constant vascular evaluation necessary

8. Physical Examination • Following clinical assessment, immobilize injured elbow with splint in a position of 20 to 30 degrees of flexion - will prevent further displacement of fracture and additional neurovascular damage

9. Radiographic Evaluation • AP and lateral of elbow • fat pad sign may be helpful with minimally displaced fractures • “anterior humeral line” should transect the ossification center of the capitellum in the normal elbow - in Type II and Type III fractures will not transect the capitellum

10. Radiographic Evaluation • Baumann’s angle – intersection of a line drawn perpendicular to the humeral axis and line drawn along the growth plate of the lateral condyle of the elbow - contralateral elbow should be used for comparison - distal fracture fragment is often rotated medially or internally and into varus deviation in relation to the proximal humerus, which produces an increased Baumann’s angle - also useful in evaluating postreduction

11. Baumann’s Angle

12. Treatment • Type I – splint or circular cast with the elbow flexed to 90 degrees and the forearm in the neutral position - reray in one week to be sure displacement has not occurred; usually appears as varus angulation - 3 weeks of immobilization followed by protected active range of motion exercises

13. Treatment • Type II – reduction achieved by flexion of the elbow and pronation of the forearm with the patient under anesthesia - 120 degrees elbow flexion required to maintain reduction - hyperflexion in a circular cast carries a high risk of compartment syndrome - These fractures should be pinned percutaneously if there is significant swelling, there is inadequate circulation when the elbow is flexed, or if the fracture might become unstable

14. Treatment • Type III – closed reduction with percutaneous pinning - to close reduce: 1) traction is applied to disengage proximal fragment from brachialis muscle, 2) translation of the distal fragment to proper medial-lateral orientation, 3) internal rotation deformity corrected, 4) distal fragment is pushed forward with examiners thumb while flexing the patients elbow to 120 degrees and pronating the wrist to tighten the periosteal hinge

15. Treatment - evaluate with AP and lateral radiograph - deviation of >5 degrees relative to Baumann’s angle in non-injured elbow represents inadequate reduction

16. Treatment • Percutaneous pinning – use sterilely draped screen of the fluoroscopy unit as the operating surface - with maximally flexed and pronated arm, approach the lateral side first - insert Kirchner wire thru lateral condyle, crossing lateral to olecranon fossa and engaging medial humeral cortex - medial wire placed with arm in 80-90 degrees flexion - protect ulnar nerve and direct Kirchner wire through medial condyle in more transverse manner than lateral wire

17. Treatment • Following pinning place elbow in splint at 60-90 degrees of flexion with the forearm in neutral rotation • Remove wires in 3-4 weeks

18. Adequacy of Reduction • Baumann’s angle • Relationship of the capitellum to the anterior humeral line • Restoration of the anatomy of the olecranon fossa

19. Traction • Lost popularity with acceptance of pinning • Primary indication for traction is supracondylar comminution • Overhead traction with use of an olecranon screw is the easiest to manage

20. Indications for Open Reduction • Fracture irreducible by closed methods • Vascular compromise necessitating exploration and repair of brachial artery • Open fracture requiring irrigation and debridement

21. Flexion-type Fractures • Only 2-10% supracondylar fractures • Classified like extension type injuries • Reduction maneuver is opposite to extension injuries, with reduction done in extension • Pinning necessary for most flexion-type fractures that require reduction

22. Complications • Most nerve deficits that occur at the time of injury are neuropraxias(may take up to six months to regain sensory) • Vascular insufficiency in 5-12% - immediate closed reduction recommended - Volkmann’s contracture is complication of vascular compromise – fasciotomy may be necessary

23. Complications • Angular deformities of distal humerus common after supracondylar injuries - cubitus varus deformity most common result of malreduction

24. Conclusions • Expedient management with fracture reduction and stabilization markedly decrease neurovascular complications • Kirschner-wire fixation with attention to soft tissues are key to management of this injury in children

25. Lateral Condyle Fractures • Second most common elbow fractures in children • Type IV Salter-Harris • Caused by varus stress on an extended elbow with the forearm in supination • Reputation for complications

26. Diagnosis • Swelling and tenderness to lateral elbow • AP and lateral of elbow; obliques if high suspicion for fracture or for determining amount of displacement

27. Classification • Milch Type I – fracture line is lateral to the trochlea • Milch Type II – fracture line enters trochlea, which allows lateral translation of the ulna and radius

28. Milch Classification

29. Displacement • Type I – minimal displacement(<2mm) and no articular movement • Type II – moderate hinged displacement(2-4mm) with intact articular surface • Type III – complete displacement and frequently rotated • This system used for treatment

30. Treatment • Type I – cast immobilization successful; reray fracture in 5-7 days • Type II – percutaneous pinning and evaluate for stability thru full range of motion; long arm cast if stable • Type III – ORIF; lateral incision with direct fracture visualization and parallel or divergent pin placement; cast in 70-90 degrees of flexion

31. Complications • Nonunion, osteonecrosis, cubitus valgus, and tardy ulnar nerve • Treatment in a timely fashion key to good results

32. Medial Condyle Fractures • Most common between ages of 10-14 • As many as 50% associated with elbow dislocations • No universally accepted classification system

33. Treatment • Most literature supports nonoperative treatment for both nondisplaced and displaced fractures • Only two absolute indications for treatment are irreducible incarceration of the medial epicondyle in the joint and the rare open fracture

34. Proximal Radial Fractures • Involve the metaphyseal neck or physis • Salter-Harris I or II • Fall on outstretched hand with a valgus moment directing the force through the radius • Pronation and supination more painful than flexion and extension • Tenderness well localized in isolated fractures

35. O’Brien Classification • Based on amount of angulation • Type I – 0-30 degrees • Type II – 30-60 degrees • Type III - >60 degrees

36. Wilkin’s Classification

37. Treatment • Type I – simple immobilization • Type II – closed reduction with manipulation - apply varus stress to elbow and reduce radial head with direct thumb pressure • Type III – immediate ORIF with oblique K-wires