Elbow Fractures

Paediatric Elbow

X-Ray Interpretation

Supracondylar Fracture of Humerus

Peak incidence 5-8yrs; most common paediatric elbow fracture; most common fracture <8yrs; >95% FOOSH (flexion type, <5%, from fall on flexed elbow, rare, will have volar displacement)

C

Fat Pads: anterior displacement in 50% radial head / neck fractures; if posterior present, fracture in >95%Anterior humeral line: should bisect capitellum in middle 1/3 on lateral; abnormal in supracondylar fracture, lateral condyleRadio-capitellar line: line drawn through centre of radial shaft should transect radial head and capitellum; abnormal in lateral condyle, radial neck, Monteggia, elbow dislocationBaumann Angle: angle between physeal line of lateral condyle of humerus and line perpendicular to long axis of humeral shaft = 8-28°; angle varus deformity; abnormal in supracondylar fracturesAngle between line through centre of capitellum and anterior humeral line should be 30-45°

Epi-demiology

R

I

T

O

L

Capitellum

Radial head

Internal epicondyle

Trochlea

Olecranon

Lateral epicondyle

1-3yrs

3-4yrs

5-6yrs

7-9yrs

9-10yrs

11-12yrs

Appears

14yrs

16yrs

15yrs

14yrs

14yrs

16yrs

Closes

Distal fragment displaced posteriorly; significantly displaced fractures are surgical emergencies (brachial artery, median / radial / ulnar nerve at risk; nerve involvement in 6-16% Volkmann’s ischaemic contracture); risk of compartment syndrome

Pathology

Undisplaced fracture with evidence of joint effusion; antetior and posterior periosteum intact; prognosis good; wrist-to-shoulder backslab with elbow flexed 90° for 4/52; OT preferred in adults as stiffness common, but otherwise not generally recommended; ortho FU within 48hrs

Gartland Classification

Urgent ortho review: NV compromise (eg. Altered pulse)Immediate ED reduction: cool / pale handManipulation: traction at 20° flexion flexion as far as possible while still retaining radial pulseIndications for manipulation: NV compromise / <50% bony apposition / dorsal angulation >15° / lateral or medial tilt >10° / any rotational deformity / any vagus or valgus deformity / compound fracture

Manage-ment

Supracondylar Fracture of Humerus

I

II

IIb

III

Displaced (usually posteriorly), but intact posterior periosteum; fracture visible anteriorly, hinging posteriorly; prognosis good; needs closed / open reduction by ortho

As above + rotation; prognosis bad, needs OT

Displaced anterior and posterior periosteum; no continuity between shaft and distal humerus; can displace postmed, postlat, antlat; prognosis bad, need OT

Radial (postmed) / median (postlat, especially anterior interosseous nerve which is motor only) / ulnar (less common) nerve (7%); Volkmann ischaemic contracture, compartment syndrome, non / malunion, myositic ossificans; absence of radial pulse initially in children is usually due to vasospasm

Comp-lications

Intercondylar Fracture of Humerus

Most common in adults; classified as T / Y / H depending on segments; associated with severe soft tissue injury

Epicondylar Fracture of Humerus

(beware ulnar nerve)

Medial epicondyle: 3rd most common paediatric elbow fracture; most common 9- 14yrs; 50% associated with elbow dislocation; risk of medial epicondyle becoming trapped in joint, especially in spontaenously reduced elbow dislocation; needs OT if >1cm of articular surface, or ulnar nerve involvement; needs ortho review

Lateral condyle: tend to be unstable; often also involves all of capitellum and ½ of trochlea; due to varus stress on extended arm in supination Milch I = Salter Harris IVMilch II = Salter Harris II (into joint and lateral part of trochlea), most commonOT if displaced, often required; ulnar nerve involvement; needs ortho review

Elbow Dislocation

90% postero-lateral; 85% have good functional outcome; 3rd most common large joint dislocationMOI: hyperextension, abduction Incomplete anterior and posterior ligamentous components ruptured Complete anterior, posterior and medial collateral ligaments ruptured

Reduce with traction, correction of medial / lateral displacement, downward pressure on forearm and flexion with thumbs pushing on olecranon; may fail if radial head fracture; backslab in 90° flexion and sling for 1-2/52; should have FROM post-reduction – concern if locking / clicking Re: # / capsule tear etc…

Manage-ment

1/3 have fracture (eg. Coronoid process, radial head); 15% have medial epicondyle fracture (may become entrapped post-reduction, especially in children); 5-13% have NVI; 8% have brachial artery injury; 15% ulnar nerve injury (usually resolves with conservative treatment); radial and median nerve injury also occur; “terrible triad” = dislcoation + radial head and coronoid fracture

Comp-lications