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 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
 Ossification centres
 There are 6 ossification centres around the
elbow joint.
 They appear and fuse to the adjacent bones at
different ages.
 Order of appearance C-R-I-T-O- E (Capitellum -
Radius - Internal or medial epicondyle - Trochlea -
Olecranon - External or lateral epicondyle).
 General guide: 1-3-5-7-9-11 years.
 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.

• 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 might be obtained.
 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 articular
surface of distal
humerus lie at
about 30 - 45
degrees to the
axis of the
humerus.
30-45
 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
 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

• Note the posterior

fat pad
Type 2: Angulated/displaced fracture
with intact posterior cortex
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.
 Type 3: Complete displacement,
with no contact between fragments
 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:
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 C-Arm fluoroscopy
unit can be inverted,
using the base as a table
for the elbow joint.
• Also can use radiolucent
board
• The child should be
positioned close to the
edge of the table, to
allow the elbow to be
visualized by the c-arm.
Supracondylar Elbow Fractures:
Type 2 with Varus Malalignment
• During reduction of
medially impacted
fractures, valgus
force should be
applied to address
this deformity.
Type 3 Supracondylar Fracture
Type 3 Supracondylar Fracture,
Operative Reduction
• Closed reduction with
flexion

• AP view with elbow

held in flexed position to
maintain reduction.
 Adequate Reduction?
• No varus/valgus
• anterior hum line
• minimal rotation
• translation OK

From M. Rang, Children’s Fractures

 Medial Impaction Fracture

Type II fracture with medial impaction – not

recognized and varus / extension not
reduced
Medial Impaction Fracture

Cubitus varus 2 years later

 Supracondylar Fracture:
Pin Fixation
• Different authors have recommended different pin
fixation methods.
• The medial pin can injure the ulnar nerve. Some
advocate 2 or 3 lateral pins to avoid injuring the
ulnar nerve.
• If the lateral pins are placed close together at the
fracture site, the pins may not provide much
resistance to rotation and further displacement. If
2 lateral pins are used, they should be widely
spaced at the fracture site.
• Some recommend one lateral, and one medial pin
 Lateral Pin Placement
• AP and Lateral views with 2 pins
 Supracondylar Humerus Fractures
• After the pins have been placed, and a stable
reduction obtained, the elbow can be extended to
review the AP radiograph.

• With the elbow extended, the carrying angle of the

elbow should be reviewed, and clinical
comparison as well as radiograph comparison can
be performed to assure an adequate reduction.
 Supracondylar Humerus Fractures
• If pin fixation is used, the pins are usually
bent and cut outside the skin.
• The skin is protected from the pins by
placing felt pad around the pins.
• The arm is immobilized.
• The pins are removed in the clinic 3
weeks later, after radiographs show
periosteal healing.
• In most cases, full recovery of motion can
be expected.
 Pitfalls of Pin Placement

• Pins Too Close together

• Instability
• Fracture displacement
• Get one pin in lateral and
one in medial column
 Supracondylar Humerus Fractures:
Indications for Open Reduction
• Inadequate reduction
with closed methods
• Vascular injury
• Open fractures
 Supracondylar Humerus Fractures:
Complications
• Compartment syndrome
• Vascular injury /
compromise
• Loss of reduction /
Malunion –cubitus varus
• Loss of motion
• Pin track infection
• Neurovascular injury
with pin placement
 Supracondylar Humerus Fractures-
Flexion type
• Rare, only 2%
• Distal fracture fragment
anterior,flexed
• Ulnar nerve injury -higher
incidence
• Reduce with extension
• Often requires 2 sets of
hands in Or, hold elbow at
90 degrees after reduction
to facilitate pinning
Flexion Type
Flexion Type - Pinning
 Distal Humeral Complete Physeal
Separation
• Often in very young
children
• May be sign of NAT
• Swollen elbow,“muffled
crepitance” on exam
• Restore alignment, may
need pinning
 Lateral Condyle Fractures
• Common fracture,
representing
approximately 15
percent of elbow
trauma in children
• Usually occurs from a
fall on an outstretched
arm
 Lateral Condyle Fractures:
Jakob Classification
• Type 1: Non-displaced fracture. Fracture line does
not cross through the articular surface

• Type 2: Minimally displaced. Fracture extends to the

articular surface, but the capitellum is not rotated or
significantly displaced

• Type 3: Completely displaced. Fracture extends to

the articular surface, and the capitellum is rotated and
significantly displaced
Lateral Condyle Elbow Fractures:
Treatment
• Type 1:
• Oblique radiographs
may be necessary to
confirm that this is not
displaced. Frequent
radiographs in the cast
are necessary to ensure
that the fracture does
not displace in the cast.
 Lateral Condyle Fractures:
Jakob Type 2
If displaced more than 2
mm on any radiograph
(AP / Lateral / Oblique
views)- reduction and
pinning. Closed reduction
and percutaneous pinning
can be attempted, but
articular reduction must be
anatomic.
• If displaced, and the
articular surface is not
congruous, ORIF is
necessary
 Type 3 Lateral Condyle Fractures:
Jakob Classification
• ORIF is necessary
• A lateral approach is used
for reduction, and pins or a
screw are placed to
maintain the reduction.
• Careful dissection needed
to preserve soft tissue
attachments (and thus
blood supply) to the lateral
condyle fragment.
Lateral Condyle ORIF
 Lateral Condyle Fractures:
Complications
• Non-union: This usually
occurs if the patient is not
treated, or the fracture
displaced despite casting
• Well-described in fractures
which were displaced more
than 2 mm, and not treated
with pin fixation
• Late complication of
progressive valgus and ulnar
neuropathy reported
 Lateral Condyle
Fractures - Complications
• AVN can occur after excessive surgical
dissection
• Cubitus varus can occur, may be because of
malreduction or a result of lateral column
overgrowth
 Medial Epicondyle Fracture
• Represents 5-10 percent of pediatric elbow
fractures
• Occurs with valgus stress to the elbow,
which avulses the medial epicondyle
• Frequently associated with an elbow
dislocation
 Medial Epicondyle Fracture:
Classification and Treatment
• Nondisplaced and minimally displaced (less than 5
mm of displacement)-
May be treated without fixation, and early motion to
avoid stiffness.
• Displaced more than 5 mm - Treatment is
controversial, with some recommending operative,
and others recommending non-operative treatment.
Some have suggested that surgery is indicated in the
presence of valgus instability.
• Only absolute indication is entrapped fragment after
dislocation with incongruent elbow joint
• Long term studies – favor nonoperative treatment
Medial Epicondyle Fracture:
Elbow dislocation with Medial Epicondyle Avulsion

After attempted
Medial elbow reduction,
Epicondyle medial epicondyle
Avulsion avulsion fragment
is obvious
 Medial Epicondyle Fracture:
• Elbow dislocation with medial epicondyle
avulsion, treated with ORIF.
 Olecranon Fractures
• Relatively rare fracture in children (increased
incidence in children with OI)
• May be associated with elbow subluxation/
dislocation, or radial head fracture.
• The diagnosis may be difficult in a younger child, as
the olecranon does not ossify until 8-9 years.
• In older children, the fracture may occur through the
olecranon physis.
• Anatomic reduction is necessary in displaced
fractures, restore active elbow extension.
 Olecranon Fractures
• Olecranon fracture treated with ORIF in 14
year old, with tension band fixation.
 Proximal Radial Fractures
• 1% of children’s fractures
• 90% involve physis or neck
• Normally some angulation of head to radial
shaft (0-15 degrees)
• Much of radial neck extraarticular (no
effusion with fracture)
Proximal Radial Fractures - Types
• Valgus fractures
(intraarticular fractures
rare)
• Metaphyseal fractures
• Associated with elbow
dislocations or proximal
ulna fractures
• Can be completely
displaced, rotated
 Proximal Radius Fractures-
Treatment
• Greater than 30 degrees
angulation- manipulate
• Usually can obtain
acceptable reduction in
fractures with less than 60
degrees initial angulation
• Traction, varus force in
supination & extension,
flex and pronate
 Proximal Radius Fractures-
Treatment
• Unable to reduce
closed
• Percutaneous pin
reduction
• Intramedullary pin
reduction
• Open reduction via
lateral approach
 Proximal Radial Fractures -
Complications
• Loss of forearm rotation
• Radial head overgrowth
• Premature physeal closure – valgus
• Nonunion of radial neck rare
• AVN
• Proximal synostosis
Failed Closed Reduction
Pin Fixation
Thank you