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

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Presentation on theme: "Approach to Pediatric Elbow Nicole Kirkpatrick March 27, 2008 ACH."— 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

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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)

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 appearanceAge at Closure Capitellum1-214 Radius316 Internal Epicondyle 515 Trochlea714 Olecranon914 External epicondyle 1116

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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

12 Radiography  Views  AP  Lateral  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°)

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 1. Figure of 8 2. Anterior Fat Pad 3. Posterior Fat Pad 4. Anterior humeral line 5. Radio-capitellar line 6. Inspect radial head 7. Distal humerus examination 8. Ulna/Olecranon examination

17 Approach  Figure of Eight  To determine if true lateral  Otherwise unable to adequately assess fat pads, anterior humeral line

18 Approach Anterior Fat Pad  Barely visible on normal film  Trauma - fracture  Children - supracondylar  Adults - Occult radial head  Atraumatic - inflammation  Gout, effusion, arthritis

19 Approach  Posterior Fat Pad  ALWAYS ABNORMAL

20 Approach Anterior humeral line  Passes through middle third of the capitellum  Disruption suggests supracondylar fracture

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  Disruption in cortical surface  Inspect distal humerus  Disruption in cortical surface  Inspect ulna/olecranon  Disruption in cortical surface

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

27 Type III

28 Flexion Supracondylar

29 Management  Type I  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  Ortho consult  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

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

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 ( 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

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°)

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

48 Olecranon Fracture  Management  Extra-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  Use a thorough approach  Look for associated injuries  Think about mechanism  Know how it is treated in your centre

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

52 References Wheeless’ Textbook of Orthopaedics Rosen’sTintinalli Carson S, et al. Pediatric Upper Extremity Injuries. Pediatr Clin N Am 2006;53: 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: Baratz M, et al. Pediatric Supracondylar Fractures. Hand Clin 2006;22: Tamai J, et al. Pediatric Elbow Fractures: Pearls and Pitfalls. UPOJ 2002;15:43-51.


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