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Approach to Pediatric Elbow

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Presentation on theme: "Approach to Pediatric Elbow"— Presentation transcript:

1 Approach to Pediatric Elbow
Nicole Kirkpatrick March 27, 2008 ACH

2 Objectives Anatomy of the elbow Approach to pediatric elbow XRs
Practice Approach Management/Complications of some elbow fractures


4 Anatomy Articulations
Ulnohumeral, Radiocapitellar, Proximal radioulnar Stability Ulnar and lateral collateral ligament complexes Anterior bundle - medial stability Lateral ulnar collateral - lateral stability Origins and insertions Lateral epicondyle Extensor (wrist/finger) Medial epicondyle Forearm flexors Pronators Olecranon Extensor (elbow) Ulnohumeral - trochlea and olecranon - uniaxial hinge Radiocapitellar capitellum and radius - pivot joint Proximal radioulnar Coronoid and olecranon fossae allow for full flexion and extension Ulnar collateral ligament complex Anterior oblique bundle, Posterior oblique bundle and Transverse ligament Radial collateral ligament complex Radial collateral, lateral ulnar collateral, acc collateral and annular ligament

5 Vasculature

6 Nerves

7 Ossification Centres Mnemonic CRITOE C - capitellum R - radial head
I - Internal Epicondyle T - Trochlea O - Olecranon E - External Epicondyle

8 Ossification Centres Age at appearance Age at Closure Capitellum 1-2
14 Radius 3 16 Internal Epicondyle 5 15 Trochlea 7 Olecranon 9 External epicondyle 11


10 History Elbow injuries FOOSH Direct trauma Repetitive injury

11 Physical exam Inspection Palpation ROM Vascular
Brachial, Radial, Ulnar Neurologic Median, Ulnar, Radial, Musculocutaneous Stability Stress ulnar collateral ligament in valgus in full extension and 30 degrees of flexion Flexion ≥ 135° Extension 0° Pronation 90° Supination 90° For function need 30° to 130° in flexion and extension and ≥ 50° for pronation and supination

12 Radiography Views AP and lateral are usually sufficient
Oblique External Internal AP and lateral are usually sufficient Lateral view is most useful

13 Radiography AP Supination and full extension at elbow with slight flexion of fingers Visualize Epicondyles Carrying angle (10°-12°) Articulations Baumann’s angle (75°) Carrying angle-valgus deviation of the forearm compared to to upper arm when the arm is held in extension. Norm is degrees Baumann’s angle- which can be a subtle marker of supracondylar fracture - Angle between line drawn through the midshaft of the humerus and a line drawn through the growth plate of the capitellum. Normal is 75 degrees

14 Radiography Lateral Rest on table Elbow flexed at 90° Thumb up

15 Radiography Oblique Visualize condyles
Internal - medial epicondyle and coronoid External - capitellum and radial head

16 The 8 Step Approach Figure of 8 Anterior Fat Pad Posterior Fat Pad
Anterior humeral line Radio-capitellar line Inspect radial head Distal humerus examination Ulna/Olecranon examination

17 Approach Figure of Eight To determine if true lateral
Otherwise unable to adequately assess fat pads, anterior humeral line Overlap of capitellum and trochlea should be visualized

18 Approach Anterior Fat Pad Barely visible on normal film
Trauma - fracture Children - supracondylar Adults - Occult radial head Atraumatic - inflammation Gout, effusion, arthritis Appears as radiolucency between bony rim of coronoid fossa and moderately radioopaque brachialis muscle When pathology exists anterior fat pad is pushed anteriorly and superiorly due to fluid in the intraarticular space

19 Approach Posterior Fat Pad ALWAYS ABNORMAL
Represents fluid in the intraarticular space Think fracture/inflammation Sail sign = triangular shape of anterior or posterior fat pad due to superior displacement of fat from the coronoid and olecranon fossae when fluid/blood/pus in the joint space

20 Approach Anterior humeral line
Passes through middle third of the capitellum Disruption suggests supracondylar fracture Extension supracondylar # - distal humeral fragment is displaced posteriorly Flexion supracondylar # - distal humeral fragment is displaced anteriorly

21 Approach Radio-capitellar line On any plain film view
Bisects the capitellum Disruption represents radial head/neck# or dislocation

22 Approach Inspect radial head Inspect distal humerus
Disruption in cortical surface Inspect distal humerus Inspect ulna/olecranon

23 Case 1 Figure of eight Anterior fat pad Posterior fat pad
Anterior humeral line Radiocapitellar line Radial head Distal humerus Ulna/olecranon

24 Supracondylar Fracture
Most common paeds elbow fracture (~50%) One third of paeds limb fractures Usually between 3 and 10 years old Uncommon after 15 years Mechanism FOOSH

25 Supracondylar Fracture
2 classifications Extension ~95% of supracondylar fractures FOOSH Flexion ~5% of supracondylar fractures Direct trauma to posterior aspect of flexed elbow

26 Supracondylar Fracture
Gartland Classification System Type I Non-displaced Often only clinically suspected or fat pads visualized Type II Angulated and displaced but posterior cortex intact Type III Completely displaced distal fragment with disruption of posterior cortex Gartland Classification - Used for both extension and flexion fractures Management depends on type Type III Displacement can occur in one of 3 directions and can injury different NV structures as a result Posteromedial, posterolateral, anterolateral

27 Type III

28 Flexion Supracondylar

29 Management Type I Type II Type III
Posterior splint (wrist to axilla), elbow flexion 90° forearm neutral 3 weeks Ortho f/u Type II Ortho consult Closed reduction vs. ORIF Splint at 110° of flexion Type III Closed vs. open reduction

30 Complications Neurovascular injury in ~12%
displacement increases incidence Mostly neuropraxias that resolve in months Extension - median nerve and brachial artery Flexion - ulnar nerve Extension -most common because of posterolateral displacement distal fragment

31 Case 2 Figure of eight Anterior fat pad Posterior fat pad
Anterior humeral line Radiocapitellar line Radial head Distal humerus Ulna/olecranon

32 Lateral Condylar Fracture
Second most common paeds elbow fracture (15%) Common between 4-10 years Considered intra-articular Mechanism Fall on supinated arm, condylar fragment avulsed by extensors Fall on palm with flexed elbow compresses radial head into lateral condyle Disruption of radiocapitellar line can occur Thurston-Holland fragment may be present Posteriorly displaced metaphyseal fragment

33 Lateral Condylar Fracture
Largely cartilaginous Size and location difficult to appreciate Internal oblique views Classification Previous Milch classification system Now based on displacement Type I < 2 mm displacement Can be complete or incomplete Type II 2-4 mm displacement Type III Complete displacement and rotation Type I incomplete involves fracture line that stops and leaves a cartilaginous hinge in place making the fracture stable Complete - no cartilaginous hinge therefore unstable

34 Lateral Condylar Fracture
Management Type I Conservative but may be prolonged (6-12w of immobilization) Type II ORIF vs. Closed reduction & pinning Type III ORIF Complications NV rarely injured

35 Lateral Condylar Fracture

36 Case 3 Figure of eight Anterior fat pad Posterior fat pad
Anterior humeral line Radiocapitellar line Radial head Distal humerus Ulna/olecranon

37 Medial Epicondyle Fracture
~12% of paeds elbow fractures Common between years, majority male Associated with dislocations ~50% Mechanism Avulsion of epicondyle by forearm flexors with valgus stress

38 Medial Epicondyle Fracture
Classification Degree of displacement (< or > 5 mm) +/- trapped fragment +/- dislocation of elbow

39 Medial Epicondyle Fracture
Management Minimally displaced Long arm splint 1-2 weeks with early ROM Displaced >5mm Conservative or operative Intra-articular fragment Surgical removal of fragment

40 Medial Epicondyle Fracture
Complications Ulnar nerve injury 10-16% More common if intraarticular fragment

41 Case 4 Figure of eight Anterior fat pad Posterior fat pad
Anterior humeral line Radiocapitellar line Radial head Distal humerus Ulna/olecranon

42 Radial Head and Neck Fractures
Radial neck > head fractures Often minimal physical findings Mechanism FOOSH Elbow extended and in valgus Associated with other injuries in ~ 50% of cases Pain over lateral elbow especially with pronation/supination Associated injuries Fracture of m. epicondyle, olecranon, proximal ulna, lateral epicondyle Dislocation Rupture of ulnar collateral ligament

43 Radial Head and Neck Fractures
Classification By degree of angulation Type I < 30° angulation Type II 30° -60° angulation Type III > 60° angulation

44 Radial Head and Neck Fractures
Management Angulation>15º - closed reduction Type I Sling/posterior splint X 1-2 weeks Type II and III Percutaneous pining if closed reduction not adequate (<30°) Attempt closed reduction if older than 10 because these kids have decreased remodeling ability

45 Radial Head and Neck Fractures
Complications AVN of radial head ~ % Loss of ROM rotation

46 Case 5 Figure of eight Anterior fat pad Posterior fat pad
Anterior humeral line Radiocapitellar line Radial head Distal humerus Ulna/olecranon

47 Olecranon Fracture ~ 5% of elbow fractures
More common with increasing age Associated with other injuries (50%) Mechanism Direct blow Shear Indirect due to forceful contraction of triceps while elbow flexed in fall Hyperextension In younger kids the olecranon is protected from fracture as it is largely cartilaginous

48 Olecranon Fracture Management Extra-articular Intra-articular
Displaced <3 mm 3-4 immobilization Displaced >3 mm Closed reduction Immobilize Hyperextension/Shear - cast in flexion Hyperflexion - cast in extension Intra-articular ORIF

49 Olecranon Fracture Complications Missed injuries Ulnar nerve injury
Non-union Arthritis Poor extensor strength

50 Conclusion Be vigilant Look for associated injuries
Use a thorough approach Look for associated injuries Think about mechanism Know how it is treated in your centre

51 Other fractures Humeral Radial head/neck Ulnar Supracondylar
Transcondylar Intercondylar Condylar Epicondylar Articular surface (trochlea/capitellum) Radial head/neck Ulnar Olecranon Coronoid

52 References Wheeless’ Textbook of Orthopaedics
Rosen’s Tintinalli Carson S, et al. Pediatric Upper Extremity Injuries. Pediatr Clin N Am 2006;53:41-67. Benjamin HJ, et al. Common Acute Upper Extremity Injuries in Sport. Pediatric Emergeny Medicine 2007: Gogola GR. Pediatric Humeral Condyle Fractures. Hand Clin 2006;22:77-85. Baratz M, et al. Pediatric Supracondylar Fractures. Hand Clin 2006;22:69-75. Tamai J, et al. Pediatric Elbow Fractures: Pearls and Pitfalls. UPOJ 2002;15:43-51.

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