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Fractures and Dislocations about the Elbow in the Pediatric Patient

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1 Fractures and Dislocations about the Elbow in the Pediatric Patient
Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick, MD; August 2006 Joshua Klatt, MD; Albert Pendleton, MD ; November 2011

2 Elbow Fractures in Children
Very common injuries (approximately 65% of pediatric trauma) Radiographic assessment - difficult for non-orthopaedists, 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

3 Elbow Fractures 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 Complete vascular exam is necessary, especially in supracondylar fractures Doppler may be helpful to document vascular status Neurologic exam is essential, as nerve injuries are common In most cases, full recovery can be expected

4 Elbow Fractures Physical Examination
Neurological 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/scissors - Ad/Abductors Ulnar

5 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 doesn’t hold up in court…) Individual assessment and recording of motor, sensory, and vascular function is essential

6 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 Oblique views may be necessary Especially for the evaluation of suspected lateral condyle fractures Comparison views frequently obtained by primary care or ER physicians Although these are rarely used by orthopaedists

7 Elbow Fractures Radiograph Anatomy/Landmarks
Baumann’s 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 In this case, the medial impaction and varus position reduces Bauman’s angle -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. -Mohammad. The Baumann angle in supracondylar fractures of the distal humerus in children. J Pediatr Orthop. 1999;19:65–69.

8 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 -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. -Herman. Relationship of the anterior humeral line to the capitellar ossific nucleus: variability with age. J Bone Joint Surg. 2009;91:2188.

9 Elbow Fractures Radiograph Anatomy/Landmarks
30 The capitellum is angulated anteriorly about 30 degrees. The appearance of the distal humerus is similar to a hockey stick.

10 Elbow Fractures Radiograph Anatomy/Landmarks
The physis of the capitellum is usually wider posteriorly, compared to the anterior portion of the physis Wider

11 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

12 Supracondylar Humerus Fractures
Most common fracture around the elbow in children 60 percent of elbow fractures 95 percent are extension type injuries Produces posterior angulation/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 fractures Omid. Supracondylar Humeral Fractures in Children. J Bone Joint Surg. 2008;90:1121.

13 Supracondylar Humerus Fractures Classification
Type 1 Non-displaced 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:

14 Type 1 Non-displaced Note the non- displaced fracture (Red Arrow)
Note the posterior fat pad (Yellow Arrows) -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.

15 Type 2 Angulated/displaced fracture with intact posterior cortex

16 Type 2 Angulated/displaced fracture with intact posterior cortex
In many cases, the type 2 fractures will be impacted medially Leads to varus angulation The varus malposition must be considered when reducing these fractures Apply a valgus force for realignment

17 Type 3 Complete displacement, with no contact between fragments

18 Supracondylar Humerus Fractures Associated Injuries
Nerve injury incidence is high, between 7 and 16 % Median, radial, and/or ulnar nerve Anterior interosseous nerve injury is most commonly injured nerve In many cases, assessment of nerve integrity is limited Children can not always cooperate with the exam Carefully document pre-manipulation exam, Post-manipulation neurologic deficits can alter decision making Cramer. Incidence of anterior interosseous nerve palsy in supracondylar humerus fractures in children. J Pediatr Orthop. 1993;13:502.

19 Supracondylar Humerus Fractures Associated Injuries
5% have associated distal radius fracture Physical exam of distal forearm Radiographs if needed If displaced pin radius also Difficult to hold appropriately in splint

20 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 White. 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;30:328.

21 Supracondylar Humerus Fractures Associated Injuries
Type 3 supracondylar fracture Absent ulnar and radial pulses Fingers had capillary refill less than 2 seconds. The pink, pulseless extremity White. 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;30:328.

22 Supracondylar Humerus Fractures Anatomy
The medial and lateral columns are connected by a thin wafer of bone Approximately 2-3 mm wide in the central portion If the fracture is malreduced, it is inherently unstable The medial or lateral columns displace easily into varus or valgus

23 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

24 Supracondylar Humerus Fractures Treatment
Type 2 Fractures: Posterior Angulation If minimally displaced (anterior humeral line hits part of capitellum) Immobilization for 3 weeks. Close follow-up is necessary to monitor for loss of reduction Displaced (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. Fitzgibbons. Predictors of failure of nonoperative treatment for type-2 supracondylar humerus fractures. J Pediatr Orthop. 2011;31:372.

25 Type 2 Fractures Treatment
Reduction of these fractures is usually not difficult Maintaining reduction usually requires flexion beyond 90° Excessive flexion may not be tolerated because of swelling May require percutaneous pinning to maintain reduction Most authors suggest that percutaneous pinning is the safest form of treatment for many of these fractures Pins maintain the reduction and allow the elbow to be immobilized in a more extended position Fitzgibbons. Predictors of failure of nonoperative treatment for type-2 supracondylar humerus fractures. J Pediatr Orthop. 2011;31:372.

26 Supracondylar Humerus Fractures Treatment
Type 3 Fractures These fractures have a high risk of neurologic and/or vascular compromise 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

27 Supracondylar Humerus Fractures OR Setup
The monitor should be positioned across from the OR table, to allow easy visualization of the monitor during the reduction and pinning -Thometz. Techniques for direct radiographic visualization during closed pinning of supracondylar humerus fractures in children. J Pediatr Orthop. 1990;10:555. -Tremains. Radiation exposure with use of the inverted-c-arm technique in upper-extremity surgery. J Bone Joint Surg Am. 2001;83-A:674.

28 Supracondylar Humerus Fractures OR Setup
The C-Arm fluoroscopy unit can be inverted, using the base as a table for the elbow joint All personnel in the room should be adequately shielded, as radiation exposure is significantly increased with inverted c-arm 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 Make sure to secure patient’s head and body -Thometz. Techniques for direct radiographic visualization during closed pinning of supracondylar humerus fractures in children. J Pediatr Orthop. 1990;10:555. -Tremains. Radiation exposure with use of the inverted-c-arm technique in upper-extremity surgery. J Bone Joint Surg Am. 2001;83-A:674.

29 Supracondylar Elbow Fractures Type 2 with Varus Malalignment
During reduction of medially impacted fractures, valgus force should be applied to address this deformity.

30 Type 3 Supracondylar Fracture

31 Type 3 Operative Reduction
Closed reduction with flexion AP view with elbow held in flexed position to maintain reduction.

32 Brachialis Sign Proximal Fragment Buttonholed through Brachialis

33 Milking Maneuver Milk Soft Tissues over Proximal Spike
Archibeck. Brachialis muscle entrapment in displaced supracondylar humerus fractures: a technique of closed reduction and report of initial results. J Pediatr Orthop. 1997;17:298.

34 Adequate Reduction? No varus/valgus malalignment
Anterior humeral line should be intact Minimal rotation Mild translation is acceptable Poll panel on their method of determining what an adequate reduction is. From: Rang’s children’s fractures. Edited by Dennis R. Wenger, MD, and Maya E. Pring, MD. Philadelphia: Lippincott Williams & Wilkins, 2004.

35 Medial Impaction Fracture
Type II fracture with medial impaction – not recognized and varus / extension not reduced

36 Medial Impaction Fracture
Cubitus varus 2 years later

37 Lateral Pin Placement AP and Lateral views with 2 pins

38 Pin Configuration Peter to comment Lee. Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop. 2002;22:440.

39 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).

40 Supracondylar Humerus Fractures Pin Fixation
Different authors have recommended different pin fixation methods The medial pin can injury the ulnar nerve Some advocate 2 or 3 lateral pins to avoid injuring the median nerve Space pins as widely as possible If the lateral pins are placed close together at the fracture site, the pins may not provide much resistance to rotation and further displacement Some recommend one lateral, and one medial pin Sankar. Loss of pin fixation in displaced supracondylar humeral fractures in children: causes and prevention. J Bone Joint Surg Am. 2007;89:713.

41 Pitfalls of Pin Placement
Pins Too Close together Instability Fracture displacement Get one pin in lateral and one in medial column

42 Supracondylar Humerus Fractures Pin Fixation
Even many children have anterior subluxation of the ulnar nerve with hyperflexion of the elbow Some recommend place two lateral pins, assess fracture stability If unstable then extend elbow to take tension off ulnar nerve and place medial pin Eberl. Iatrogenic ulnar nerve injury after pin fixation and after antegrade nailing of supracondylar humeral fractures in children. Acta Orthop. 2011;82:606.

43 Supracondylar Humerus Fractures
After stable reduction and pinning Elbow can be extended to review the AP radiograph Baumann’s angle can be assessed on these radiographs Remember there can be a wide range of normal values for this measurement 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.

44 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 Xeroform and a felt pad around the pins The arm is immobilized The pins are removed in the clinic 3 to 4 weeks later After radiographs show periosteal healing In most cases, full recovery of motion can be expected

45 Supracondylar Humerus Fractures: Indications for Open Reduction
Inadequate reduction with closed methods Vascular injury Open fractures

46 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 Bashyal. Complications after pinning of supracondylar distal humerus fractures. J Pediatr Orthop. 2009;29:704.

47 Supracondylar Humerus Fractures Flexion type
Rare, only 2% Distal fracture fragment anterior and flexed Ulnar nerve injury more common Reduce with extension Often requires 2 sets of hands in OF Hold elbow at 90 degrees after reduction to facilitate pinning Mahan. Operative management of displaced flexion supracondylar humerus fractures in children. J Pediatr Orthop. 2007;27:551.

48 Flexion Type

49 Flexion Type Pinning

50 Distal Humeral Complete Physeal Separation
Often in very young children May be sign of NAT Swollen elbow,“muffled crepitance” on exam Through area of wider cross sectional area than SC humerus fx Restore alignment, may need pinning Peterson. Physeal injuries of the distal humerus. Orthopedics. 1992;15:799. Shrader. Pediatric supracondylar fractures and pediatric physeal elbow fractures. Orthop Clin North Am. 2008;39:163.

51 Lateral Condyle Fractures
Common fracture, representing approximately 15% of elbow trauma in children Usually occurs from a fall on an outstretched arm Landin. Elbow fractures in children. An epidemiological analysis of 589 cases. Acta Orthop Scand. 1986;57:309.

52 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 Jakob. Observations concerning fractures of the lateral humeral condyle in children. J Bone Joint Surg Br. 1975;57:430.

53 Lateral Condyle Fractures Jakob 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.

54 Lateral Condyle Fractures Jakob Type 2
Displaced more than 2 mm On any radiograph (AP/Lateral/Oblique views) Reduction and pinning Closed reduction can be attempted, but articular reduction must be anatomic If residual displacement and the articular surface is not congruous Open reduction is necessary Fracture line exiting posterior metaphysis (arrow) typical for lateral condyle fractures 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.

55 Lateral Condyle Fractures Jakob Type 3
ORIF is almost always necessary A lateral Kocher 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 condylar fragment, especially avoiding posterior dissection -Foster. Lateral humeral condylar fractures in children. J Pediatr Orthop. 1985;5:16. -Song. Closed reduction and internal fixation of completely displaced and rotated lateral condyle fractures of the humerus in children. J Orthop Trauma. 2010;24:434.

56 Lateral Condyle ORIF

57 Lateral Condyle Fractures Complications
Non-union This usually occurs if the patient is not treated, or the fracture displaces 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 Skak. Deformity after fracture of the lateral humeral condyle in children. J Pediatr Orthop B. 2001;10:142.

58 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 Foster. Lateral humeral condylar fractures in children. J Pediatr Orthop. 1985;5:16.

59 Medial Epicondyle Fractures
Represent 5% to 10% of pediatric elbow fractures Occurs with valgus stress to the elbow, which avulses the medial epicondyle Frequently associated with an elbow dislocation Landin. Elbow fractures in children. An epidemiological analysis of 589 cases. Acta Orthop Scand. 1986;57:309.

60 Medial Epicondyle Fractures Classification
No good systematic method of classification Studies vary on how to measure displacement Should take into consideration displacement on both the AP and lateral Amount of rotational displacement is also important Pappas. Intraobserver and interobserver agreement in the measurement of displaced humeral medial epicondyle fractures in children. J Bone Joint Surg Am. 2010;92:322.

61 Medial Epicondyle Fractures Treatment
Nondisplaced and minimally displaced Less than 5 mm of displacement May be treated without fixation Early motion to avoid stiffness (3 to 4 weeks)

62 Medial Epicondyle Fractures Treatment
Displaced more than 5 mm Treatment is controversial Some recommending operative, others non-operative treatment Some have suggested that surgery is indicated in the presence of valgus instability, or in patients who are throwing athletes. Only absolute indication is entrapped fragment after dislocation with incongruent elbow joint First attempt closed reduction Long term studies favor nonoperative treatment 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.

63 Medial Epicondyle Fracture
Elbow dislocation with Medial Epicondyle Avulsion After attempted elbow reduction, medial epicondyle avulsion fragment is obvious Medial Epicondyle Avulsion

64 Medial Epicondyle Fracture
Elbow dislocation with Medial Epicondyle Avulsion Treated with ORIF

65 Medial Epicondyle Fracture Example of Nonoperative Treatment
12 year old female UE weight bearing athlete Treated nonoperatively Full motion, no valgus instability at 6 weeks Returned to competition at 8 weeks

66 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 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 to restore normal elbow extension. Caterini. Fractures of the olecranon in children. Long-term follow-up of 39 cases. J Pediatr Orthop B. 2002;11:320.

67 Olecranon Fractures Olecranon fracture treated with ORIF in 14 year old, with tension band fixation. Parent. Displaced olecranon fractures in children: a biomechanical analysis of fixation methods. J Pediatr Orthop. 2008;28:147.

68 Rare Distal Humeral Fractures
Lateral Epicondyle Rare Usually represent a small avulsion fracture Treated with early mobilization T-Condylar fractures Occur in patients that are almost skeletally mature Treatment similar to adult intra-articular elbow fractures Medial Condyle Treated with ORIF if displaced Beaty JH. Elbow fractures in children and adolescents. Instr Course Lect. 2003;52:661–665.

69 Proximal Radius Fractures
1% of children’s fractures 90% involve physis or neck Normally some angulation of head to radial shaft (0-15 degrees) No ligaments attach to head or neck Much of radial neck extraarticular (no effusion with fracture) Vocke. Displaced fractures of the radial neck in children: long-term results and prognosis of conservative treatment. J Pediatr Orthop B. 1998;7:217.

70 Proximal Radius Fractures Types
Valgus fractures Salter I or II Intra-articular fractures rare 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.

71 Proximal Radius Fractures Treatment
Greater than 30° angulation Attempt manipulation Usually can obtain acceptable reduction in fractures with less than 60° angulation Traction, varus force in supination & extension, flex and pronate Ace wrap or Esmarch reduction Evans. Radial neck fractures in children: a management algorithm. J Pediatr Orthop B. 1999;8:93.

72 Proximal Radius Fractures Treatment
Unable to reduce closed Percutaneous pin reduction Intramedullary pin reduction Open reduction via lateral approach -Vocke. Displaced fractures of the radial neck in children: long-term results and prognosis of conservative treatment. J Pediatr Orthop B. 1998;7:217. -Metaizeau. Reduction et fixation des fractures et decollements épiphyssaires de la tête radial par broche centromedullaire. Rev Chir Ortop 1980;66:47-9. -González-Herranz. Displaced radial neck fractures in children treated by closed intramedullary pinning (Metaizeau technique). J Pediatr Orthop. 1997;17:325.

73 Completely Displaced, Malrotated Radial Neck Fracture
After closed reduction the articular surface (arrow) is facing distally, 180 degrees malrotated

74 Proximal Radial Fractures Complications
Loss of forearm rotation Radial head overgrowth Premature physeal closure – valgus Nonunion of radial neck rare AVN Proximal synostosis Vocke. Displaced fractures of the radial neck in children: long-term results and prognosis of conservative treatment. J Pediatr Orthop B. 1998;7:217.

75 100% Displaced Failed Closed Reduction

76 Open “closed” reduction Blunt pin to push radial head back onto neck

77 Pin fixation augmented by cast for 3 weeks

78 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 Orthop. 2002;22:548.

79 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

80 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 Note anterior bow of ulnar shaft, and anterior radial head dislocation

81 Monteggia Lesions Initial Treatment
Closed reduction of ulnar angulation Direct pressure over radial head Usually will reduce with palpable clunk Immobilize in reduced position Supinate forearm for anterior dislocations Frequent radiographic follow-up to document maintenance of reduction Wilkins. Changes in the management of monteggia fractures. J Pediatr Orthop. 2002;22:548.

82 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.

83 Missed Monteggia Lesion
Anterior radial head dislocation and heterotopic ossification Healed prox ulna fx with anterior bow

84 Missed Monteggia Lesions Possible Long Term Sequelae
Progressive valgus Proximal radial migration with disruption of normal forearm and distal radioulnar joint mechanics Posterior interosseous nerve traction palsy Collateral ligament instability Nakamura. Long-term clinical and radiographic outcomes after open reduction for missed Monteggia fracture-dislocations in children. J Bone Joint Surg. 2009;91:1394.

85 Missed Monteggia Lesions Treatment Options
Annular ligament reconstructions Bell-Tawse Fascia lata Peterson 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.

86 Missed Monteggia Lesions Ulnar Osteotomy and Radiocapitellar Pin

87 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 Apr.;17(3):298–302. Bado JL. The Monteggia lesion. Clin Orthop Relat Res. 1967;50:71–86. 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 Sep.;29(7):704–708. Beaty JH. Elbow fractures in children and adolescents. Instr Course Lect. 2003;52:661–665. Bohrer SP. The fat pad sign following elbow trauma. Its usefulness and reliability in suspecting “invisible” fractures. Clin Radiol Jan.;21(1):90–94. 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 Oct.;11(4):320–328. Cramer KE, Green NE, Devito DP. Incidence of anterior interosseous nerve palsy in supracondylar humerus fractures in children. J Pediatr Orthop Jun.;13(4):502–505. 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 Oct.;82(5):606–609. Evans MC, Graham HK. Radial neck fractures in children: a management algorithm. J Pediatr Orthop B Apr. 1;8(2):93–99. 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 Sep. 1;83-A(9):1299–1305. 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 Jun.;31(4):372–376.

88 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 Dec.;57(8):1087–1092. 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: González-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):325–331. 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 Sep.;91(9):2188–2193. Jakob R, Fowles JV, Rang M, Kassab MT. Observations concerning fractures of the lateral humeral condyle in children. J Bone Joint Surg Br Nov.;57(4):430–436. Kamath AF, Baldwin K, Horneff J, Hosalkar HS. Operative versus non-operative management of pediatric medial epicondyle fractures: a systematic review. J Child Orthop Oct. 1;3(5):345–357. Landin LA, Danielsson LG. Elbow fractures in children. An epidemiological analysis of 589 cases. Acta Orthop Scand Aug.;57(4):309–312. Lee SS, Mahar AT, Miesen D, Newton PO. Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop Jun.;22(4):440–443. Mahan ST, May CD, Kocher MS. Operative management of displaced flexion supracondylar humerus fractures in children. J Pediatr Orthop Jun.;27(5):551–556. Metaizeau JP, Prevot J, Schmitt M. [Reduction and fixation of fractures of the neck of the radious be centro-medullary pinning. Original technic]. Rev Chir Orthop Reparatrice Appar Mot. 1980;66(1):47–49.

89 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):65–69. 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 Jun.;91(6):1394–1404. Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. The Journal of Bone and Joint Surgery May;90(5):1121–1132. 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 Feb. 1;92(2):322–327. 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 Mar.;28(2):147–151. Rang’s children’s 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 Apr.;89(4):713–717. Skaggs DL, Mirzayan R. The posterior fat pad sign in association with occult fracture of the elbow in children. J Bone Joint Surg Am Oct.;81(10):1429–1433.

90 Bibliography Skak SV, Olsen SD, Smaabrekke A. Deformity after fracture of the lateral humeral condyle in children. J Pediatr Orthop B Apr.;10(2):142–152. Thometz JG. Techniques for direct radiographic visualization during closed pinning of supracondylar humerus fractures in children. J Pediatr Orthop Jun.;10(4):555–558. Tremains MR, Georgiadis GM, Dennis MJ. Radiation exposure with use of the inverted-c-arm technique in upper-extremity surgery. J Bone Joint Surg Am May;83-A(5):674–678. 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 Jul. 1;7(3):217–222. 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 Jun.;30(4):328–335. Wilkins KE. Changes in the management of monteggia fractures. J Pediatr Orthop. 2002;22(4):548–554. If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an to OTA Questions/Comments Return to Pediatrics Index


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