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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
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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
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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%
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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
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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?
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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
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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
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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
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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
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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
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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
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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
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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°)
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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
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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
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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
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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
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TREATMENT
• MAINTAIN LENGTH OF ULNA
PEDIATRIC ELBOW FRACTURES
• Understand – Anatomy
– Injury types
– Treatment options
• Increased vigilance for complications
THANK YOU