Professional Documents
Culture Documents
Elbow Fractures
Physical Examination
Children will usually not move the elbow if a fracture is
present, although this may not be the case for nondisplaced fractures
Swelling about the elbow is a constant feature, except for
non-displaced fracture
Complete vascular exam is necessary, especially in
supracondylar fractures
Doppler may be helpful to document vascular status
Elbow Fractures
Physical Examination
Neurological exam may be limited by the childs
ability to cooperate because of age, pain, or fear.
Thumb extension EPL
Radial PIN branch
Elbow Fractures
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 (and doesnt hold up in court)
Individual assessment and recording of motor, sensory,
and vascular function is essential
Elbow Fractures
Radiographs
AP and Lateral views are important initial views
In trauma these views may be less than ideal, because
it can be difficult to position the injured extremity
Elbow Fractures
Radiograph Anatomy/Landmarks
Baumanns 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
Can vary with rotation of the radiograph
Elbow Fractures
Radiograph Anatomy/Landmarks
Anterior Humeral Line
Drawn along the
anterior humeral cortex
Should pass through
the middle of the
capitellum
Variable in very young
children
Elbow Fractures
Radiograph Anatomy/Landmarks
The capitellum is
angulated
anteriorly about
30 degrees.
The appearance
of the distal
humerus is
similar to a
hockey stick.
30
Elbow Fractures
Radiograph Anatomy/Landmarks
The physis of the
capitellum is
usually wider
posteriorly,
compared to the
anterior portion of
the physis
Wider
Elbow Fractures
Radiograph Anatomy/Landmarks
Radiocapitellar
line should
intersect the
capitellum in all
views
Make it a habit to
evaluate this line
on every pediatric
elbow film
Type 2
Angulated/displaced
fracture with intact
posterior cortex
Type 3
Complete displacement,
with no contact between
fragments
Gartland. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959;109:145-
Type 1
Non-displaced
Note the nondisplaced fracture
(Red Arrow)
-Skaggs. The posterior fat pad sign in association with occult fracture of
the elbow in children. J Bone Joint Surg Am. 1999;81:1429.
-Bohrer. The fat pad sign following elbow trauma. Its usefulness and
reliability in suspecting invisible fractures. Clin Radiol. 1970;21:90.
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
Leads to varus angulation
Type 3
Complete displacement, with no contact
between fragments
Type 2 Fractures
Treatment
Reduction of these fractures is usually not difficult
Maintaining reduction usually requires flexion beyond 90
Fitzgibbons. Predictors of failure of nonoperative treatment for type2 supracondylar humerus fractures. J Pediatr Orthop. 2011;31:372.
Type 3
Supracondylar Fracture
Type 3
Operative Reduction
Closed reduction with
flexion
Brachialis Sign
Proximal Fragment Buttonholed through Brachialis
Milking Maneuver
Milk Soft Tissues over Proximal Spike
Adequate Reduction?
No varus/valgus
malalignment
Anterior humeral line
should be intact
Minimal rotation
Mild translation is
acceptable
From: Rangs childrens fractures. Edited by Dennis R. Wenger, MD,
and Maya E. Pring, MD. Philadelphia: Lippincott Williams & Wilkins,
Pin Configuration
C-arm Views
Oblique views with the C-arm can be useful to help verify the
reduction.
Note slight rotation and extension on medial column (right image).
Loss of motion
Pin track infection
Neurovascular injury with
pin placement
Flexion Type
Flexion Type
Pinning
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
Flynn. Prevention and treatment of non-union of slightly displaced fractures of the lateral
humeral condyle in children. An end-result study. J Bone Joint Surg Am. 1975;57:1087.
Kamath. Operative versus non-operative management of pediatric medial epicondyle fractures: a systematic review. J Child Orthop. 2009;3:345.
Farsetti. Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am. 2001;83-A:1299.
Medial
Epicondyle
Avulsion
After attempted
elbow reduction,
medial epicondyle
avulsion fragment
is obvious
Olecranon Fractures
Relatively rare fracture in children
Increased incidence in children with OI
Olecranon Fractures
Olecranon fracture treated with ORIF in 14
year old, with tension band fixation.
T-Condylar fractures
Occur in patients that are almost
skeletally mature
Treatment similar to adult intraarticular elbow fractures
Medial Condyle
Rare
Treated with ORIF if displaced
Beaty JH. Elbow fractures in children and adolescents. Instr Course Lect. 2003;52:661665.
Metaphyseal fractures
Associated with elbow
dislocations or proximal
ulna fractures
Can be completely
displaced, rotated
Vocke. Displaced fractures of the radial neck in children: long-term results
and prognosis of conservative treatment. J Pediatr Orthop B. 1998;7:217.
100% Displaced
Failed Closed Reduction
Monteggia Lesions
Ulnar Fracture-Radial Head Dislocation
Bado Classification
Type I anterior radial
head dislocation
Type II posterior radial
head dislocation
Type III lateral radial
head dislocation
Type IV associated
fracture of radius
Bado JL. The Monteggia lesion. Clin Orthop Relat Res. 1967;50:71
86.
Wilkins. Changes in the management of monteggia fractures. J Pediatr
Monteggia Lesions
Most important is to make
the diagnosis initially
Radiocapitellar line
critical
A commonly missed
diagnosis
Every ulna fracture should
have good elbow joint
radiographs to avoid
missing Monteggia lesion
Monteggia Lesions
Be wary of plastic
deformation of ulna or
minimally displaced
ulna fracture with
radial head dislocation
On lateral radiograph
the ulna should be
straight
Monteggia Lesions
Initial Treatment
Monteggia Lesions
If unable to obtain or
maintain reduction of
radial head
Operative stabilization of
ulnar fracture to correct
angulation
Oblique fractures may need
plate fixation
Assess radial head stability
Flexion may help for
anterior dislocation
Wilkins. Changes in the management of monteggia
fractures. J Pediatr Orthop. 2002;22:548.
Ulnar osteotomy
Combination
Transcapitellar pinning
Be wary of possible pin
breakage
-Nakamura. Long-term clinical and radiographic outcomes after open reduction for missed
Monteggia fracture-dislocations in children. J Bone Joint Surg. 2009;91:1394.
-Wilkins. Changes in the management of monteggia fractures. J Pediatr Orthop. 2002;22:548.
Bibliography
Archibeck MJ, Scott SM, Peters CL. Brachialis muscle entrapment in displaced supracondylar humerus fractures: a
technique of closed reduction and report of initial results. J Pediatr Orthop. 1997 Apr.;17(3):298302.
Bado JL. The Monteggia lesion. Clin Orthop Relat Res. 1967;50:7186.
Baumann E. Beitrage zur Kenntnis der Frakturen am Ellbogengelenk: Unter besonderer Berucksichtigung der
Spatfolgen. I. Allgemeines und Fractura supra condylica. Beitr Klin Chir 1929;146:1-50.
Bashyal RK, Chu JY, Schoenecker PL, Dobbs MB, Luhmann SJ, Gordon JE. Complications after pinning of
supracondylar distal humerus fractures. J Pediatr Orthop. 2009 Sep.;29(7):704708.
Beaty JH. Elbow fractures in children and adolescents. Instr Course Lect. 2003;52:661665.
Bohrer SP. The fat pad sign following elbow trauma. Its usefulness and reliability in suspecting invisible
fractures. Clin Radiol. 1970 Jan.;21(1):9094.
Caterini R, Farsetti P, D'Arrigo C, Ippolito E. Fractures of the olecranon in children. Long-term follow-up of 39
cases. J Pediatr Orthop B. 2002 Oct.;11(4):320328.
Cramer KE, Green NE, Devito DP. Incidence of anterior interosseous nerve palsy in supracondylar humerus
fractures in children. J Pediatr Orthop. 1993 Jun.;13(4):502505.
Eberl R, Eder C, Smolle E, Weinberg AM, Hoellwarth ME, Singer G. Iatrogenic ulnar nerve injury after pin fixation
and after antegrade nailing of supracondylar humeral fractures in children. Acta Orthop. 2011 Oct.;82(5):606609.
Evans MC, Graham HK. Radial neck fractures in children: a management algorithm. J Pediatr Orthop B. 1999 Apr.
1;8(2):9399.
Farsetti P, Potenza V, Caterini R, Ippolito E. Long-term results of treatment of fractures of the medial humeral
epicondyle in children. J Bone Joint Surg Am. 2001 Sep. 1;83-A(9):12991305.
Fitzgibbons PG, Bruce B, Got C, Reinert S, Solga P, Katarincic J, et al. Predictors of failure of nonoperative
treatment for type-2 supracondylar humerus fractures. J Pediatr Orthop. 2011 Jun.;31(4):372376.
Bibliography
Flynn JC, Richards JF, Saltzman RI. Prevention and treatment of non-union of slightly displaced fractures of the
lateral humeral condyle in children. An end-result study. J Bone Joint Surg Am. 1975 Dec.;57(8):10871092.
Foster DE, Sullivan JA, Gross RH. Lateral humeral condylar fractures in children. J Pediatr Orthop. 1985;5(1):16
22.
Gartland. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959;109:14554.
Gonzlez-Herranz P, Alvarez-Romera A, Burgos J, Rapariz JM, Hevia E. Displaced radial neck fractures in children
treated by closed intramedullary pinning (Metaizeau technique). J Pediatr Orthop. 1997;17(3):325331.
Herman MJ, Boardman MJ, Hoover JR, Chafetz RS. Relationship of the anterior humeral line to the capitellar
ossific nucleus: variability with age. J Bone and Joint Surg. 2009 Sep.;91(9):21882193.
Jakob R, Fowles JV, Rang M, Kassab MT. Observations concerning fractures of the lateral humeral condyle in
children. J Bone Joint Surg Br. 1975 Nov.;57(4):430436.
Kamath AF, Baldwin K, Horneff J, Hosalkar HS. Operative versus non-operative management of pediatric medial
epicondyle fractures: a systematic review. J Child Orthop. 2009 Oct. 1;3(5):345357.
Landin LA, Danielsson LG. Elbow fractures in children. An epidemiological analysis of 589 cases. Acta Orthop
Scand. 1986 Aug.;57(4):309312.
Lee SS, Mahar AT, Miesen D, Newton PO. Displaced pediatric supracondylar humerus fractures: biomechanical
analysis of percutaneous pinning techniques. J Pediatr Orthop. 2002 Jun.;22(4):440443.
Mahan ST, May CD, Kocher MS. Operative management of displaced flexion supracondylar humerus fractures in
children. J Pediatr Orthop. 2007 Jun.;27(5):551556.
Metaizeau JP, Prevot J, Schmitt M. [Reduction and fixation of fractures of the neck of the radious be centromedullary pinning. Original technic]. Rev Chir Orthop Reparatrice Appar Mot. 1980;66(1):4749.
Bibliography
Mohammad S, Rymaszewski LA, Runciman J. The Baumann angle in supracondylar fractures of the distal humerus
in children. J Pediatr Orthop. 1999;19(1):6569.
Nakamura K, Hirachi K, Uchiyama S, Takahara M, Minami A, Imaeda T, et al. Long-term clinical and radiographic
outcomes after open reduction for missed Monteggia fracture-dislocations in children. J Bone and Joint Surg. 2009
Jun.;91(6):13941404.
Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. The Journal of Bone and Joint Surgery.
2008 May;90(5):11211132.
Pappas N, Lawrence JT, Donegan D, Ganley T, Flynn JM. Intraobserver and interobserver agreement in the
measurement of displaced humeral medial epicondyle fractures in children. J Bone Joint Surg Am. 2010 Feb.
1;92(2):322327.
Parent S, Wedemeyer M, Mahar AT, Anderson M, Faro F, Steinman S, et al. Displaced olecranon fractures in
children: a biomechanical analysis of fixation methods. J Pediatr Orthop. 2008 Mar.;28(2):147151.
Rangs childrens fractures. Edited by Dennis R. Wenger, MD, and Maya E. Pring, MD. Philadelphia: Lippincott
Williams & Wilkins, 2004.
Rogers. Plastic bowing, torus and greenstick supracondylar fractures of the humerus: radiographic clues to obscure
fractures of the elbow in children. Radiology. 1978;128:145.
Sankar WN, Hebela NM, Skaggs DL, Flynn JM. Loss of pin fixation in displaced supracondylar humeral fractures
in children: causes and prevention. J Bone Joint Surg Am. 2007 Apr.;89(4):713717.
Skaggs DL, Mirzayan R. The posterior fat pad sign in association with occult fracture of the elbow in children. J
Bone Joint Surg Am. 1999 Oct.;81(10):14291433.
Bibliography
Skak SV, Olsen SD, Smaabrekke A. Deformity after fracture of the lateral humeral condyle in children. J Pediatr
Orthop B. 2001 Apr.;10(2):142152.
Thometz JG. Techniques for direct radiographic visualization during closed pinning of supracondylar humerus
fractures in children. J Pediatr Orthop. 1990 Jun.;10(4):555558.
Tremains MR, Georgiadis GM, Dennis MJ. Radiation exposure with use of the inverted-c-arm technique in upperextremity surgery. J Bone Joint Surg Am. 2001 May;83-A(5):674678.
Vocke AK, Laer von L. Displaced fractures of the radial neck in children: long-term results and prognosis of
conservative treatment. J Pediatr Orthop B. 1998 Jul. 1;7(3):217222.
White L, Mehlman CT, Crawford AH. Perfused, pulseless, and puzzling: a systematic review of vascular injuries in
pediatric supracondylar humerus fractures and results of a POSNA questionnaire. J Pediatr Orthop. 2010
Jun.;30(4):328335.
Wilkins KE. Changes in the management of monteggia fractures. J Pediatr Orthop. 2002;22(4):548554.
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