Fractures and Dislocations of Elbow - Orthopaedic Trauma - Lecture Slides, Slides of Orthopedics

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Fractures and Dislocations

about the Elbow

in the Pediatric Patient

Elbow Fractures in Children

• Very common injuries (approximately 65% of pediatric trauma)
• Radiographic assessment - difficult for non- orthopaedists, because of the complexity and variability of the physeal anatomy and development
• A thorough physical examination is essential, because neurovascular injuries can occur before and after reduction
• Compartment syndromes are rare with elbow trauma, but can occur

Elbow Fractures in Children:

Physical Examination

• children will usually not move the elbow if a fracture is present, although this may not be the case for non-displaced fractures
• Swelling about the elbow is a constant feature, except for non-displaced fracture. Swelling may not develop in the first 12 to 24 hours.
• Complete vascular exam is necessary, especially in supracondylar fractures. The doppler device may be helpful to document vascular status
• Neurologic exam is essential, as nerve injuries are common. In most cases, full recovery can be expected

Elbow Fractures in Children:

Physical Examination

• Neuro-motor exam may be limited by the

child’s ability to cooperate because of age,

pain, or fear.

• Thumb extension– EPL (radial – PIN branch)
• Thumb flexion – FPL (median – AIN branch)
• Cross fingers - Adductors (ulnar)

Elbow Fractures in Children:

Physical Examination

• Always palpate the arm and forearm for signs of

compartment syndrome.

• Thorough documentation of all findings is important.

A simple record of “neurovascular status is intact” is unacceptable.

• Individual assessment and recording of motor,

sensory, and vascular function is essential

Elbow Fractures in Children:

Radiographs

• AP and Lateral views are important initial views. In fracture situations, these views may be less than ideal, because it can be difficult to position the injured extremity.
• Oblique views may be necessary for evaluation, especially for the evaluation of suspected lateral condyle fractures.
• Comparison views frequently obtained by primary care or ER physicians, although these are rarely used by orthopaedists.

Elbow Fractures in Children:

Radiograph Anatomy/Landmarks

• Bauman’s angle is formed by a line perpendicular to the axis of the humerus, and a line that goes through the physis of the capitellum.
• There is a wide range of normal for this value, and it can vary with rotation of the radiograph.
• In this case, the medial impaction and varus position reduces Bauman’s angle.

Elbow Fractures in Children:

Radiograph Anatomy/Landmarks

• Anterior Humeral

Line: This is drawn along the anterior humeral cortex. It should pass through the middle of the capitellum.

Elbow Fractures in Children:

Radiograph Anatomy/Landmarks

• The capitellum is

angulated

anteriorly about

30 degrees.

• The appearance

of the distal

humerus is

similar to a

hockey stick.

Elbow Fractures in Children:

Radiograph Anatomy/Landmarks

• The physis of the

capitellum is

usually wider

posteriorly,

compared to the

anterior portion

of the physis

Wider

Elbow Fractures in Children:

Radiograph Anatomy/Landmarks

• Radiocapitellar

line – should

intersect the

capitellum

• Make it a habit to

evaluate this line

on every pediatric

elbow film

Supracondylar Humerus Fractures

• Most common fracture around the elbow in children (60 percent of elbow fractures)
• 95 percent are extension type injuries, which produces posterior displacement of the distal fragment
• Occurs from a fall on an outstretched hand
• Ligamentous laxity and hyperextension of the elbow are important mechanical factors
• May be associated with a distal radius or forearm fracture

Supracondylar Humerus Fractures:

Classification

• Gartland (1959)
• Type 1 non-displaced
• Type 2 Angulated/displaced fracture with

intact posterior cortex

• Type 3 Complete displacement, with no

contact between fragments

Type 1: Non-displaced

• Note the non-

displaced fracture

(Red Arrow)

• Note the posterior

fat pad (Yellow

Arrows)

Type 2: Angulated/displaced fracture

with intact posterior cortex

• In many cases, the type 2 fractures will be impacted medially, leading to varus angulation.
• The varus malposition must be considered when reducing these fractures, applying a valgus force for realignment.

Supracondylar Humerus Fractures:

Associated Injuries

• Nerve injury incidence is high, between 7 and 16 % (radial, median, and ulnar nerve)
• Anterior interosseous nerve injury is most commonly injured nerve
• In many cases, assessment of nerve integrity is limited , because children can not always cooperate with the exam
• Carefully document pre-manipulation exam, as post- manipulation neurologic deficits can alter decision making

Supracondylar Humerus Fractures:

Associated Injuries

• 5% have associated

distal radius fracture

• Physical exam of distal

forearm

• Radiographs if needed
• If displaced pin radius

also

Supracondylar Humerus Fractures:

Associated Injuries

• Vascular injuries are rare, but pulses should always

be assessed before and after reduction

• In the absence of a radial and/or ulnar pulse, the

fingers may still be well-perfused, because of the excellent collateral circulation about the elbow

• Doppler device can be used for assessment

Supracondylar Humerus Fractures:

Associated Injuries

• Type 3

supracondylar fracture, with absent ulnar and radial pulses, but fingers had capillary refill less than 2 seconds.

• The pink, pulseless

extremity

Supracondylar Humerus Fractures -

Anatomy

• The medial and lateral columns are connected

by a thin wafer of bone, that is approximately

2-3 mm wide in the central portion.

• If the fracture is malreduced, it is inherently

unstable. The medial or lateral columns

displace easily into varus or valgus

Supracondylar Humerus Fractures:

Treatment

• Type 1 Fractures:
• In most cases, these can be treated with

immobilization for approximately 3 weeks, at

90 degrees of flexion. If there is significant

swelling, do not flex to 90 degrees until the

swelling subsides.

Supracondylar Humerus Fractures:

Treatment

• Type 2 Fractures: Posterior Angulation
• If minimal (anterior humeral line hits part of capitellum) -immobilization for 3 weeks. Close follow-up is necessary to monitor for loss of reduction
• Anterior humeral line misses capitellum - reduction may be necessary. The degree of posterior angulation that requires reduction is controversial- check opposite extremity for hyperextension
• If varus/valgus malalignment exists, most authors recommend reduction.

Type 2 SCH Fractures:

Treatment

• Reduction of these fractures is usually not difficult, although maintaining the reduction usually requires flexion beyond 90 degrees.
• Excessive flexion may not be tolerated because of swelling, and these fractures may require percutaneous pinning to maintain the reduction.
• Most authors suggest that percutaneous pinning is the safest form of treatment for many of these fractures, as the pins maintain the reduction and allow the elbow to be immobilized in a more extended position

Supracondylar Humerus Fractures:

Treatment

• Type 3 Fractures:
• These fractures have a high risk of neurologic and/or vascular compromise, and can be associated with a significant amount of swelling.
• Current treatment protocols use percutaneous pin fixation in almost all cases.
• In rare cases, open reduction may be necessary, especially in cases of vascular disruption.

Supracondylar Humerus Fractures:

OR Setup

• The monitor should

be positioned across

from the OR table, to

allow easy

visualization of the

monitor during the

reduction and pinning