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 1-214
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.