aa Elbow Fractures in Children and Adolescents James H. Beaty, MD Abstract Fructus ofthe upper extremity are common injeres in tle ative cde ad adolescents, These injuries usually occur during falls ona outstretched arm, Upper extremity fates acount for 65% to 75% of fractures inthis group, and fractures abot the low for approximately 10% ‘Although most elbow features heal unevenly with immobilization only, determining which Fractures will do wel with cat treatment alone anc wih require surgical eduction ad stabiliza- sion i fie dicate An accurate diagnosis is imperative in avoiding risks associated with the treat- ment of elbow fractures in children. The normal ossification centers ofthe elbow ‘must be distinguished from abnormal processes. Knowledge aboot the sequence and timing of ossification of these cen ters is essential (Table 1) (Fig 1). Other anatomic landmarks that can aid in diag nosis are the olecranon (posterior), coro- noid (anterior), and supinator fat pads that overlie the major structures of the elbow: Displacement of any of the fat pads is indicative of the presence of an occult fracture, but displacement of the posterior fat pad is considered the most reliable sign. Skaggs and Mireayan® te- ported that 34 of 45 children (76%) with a history of elbow trauma and an elevated posterior fat pad had radiographic evi- dence of elbow fractures at an average of 661-665. Inst Course Lect 2003; 3 weeks after injury even though AP lat- cra, and oblique radiographs taken at the time of injury showed no other evidence ‘of fracture. Donnelly and associates,’ however, found evidence of fracture in only 9 of 54 children (17%) who had a history of trauma and elbow joint eff sion but no identifiable fracture on initial radiographs. Aline drawn along the anterior bor- der of the distal humeral shaft should ‘pass through the mide third ofthe ossi- fication center of the capitellum (Fig. 2); if this anterior humeral line passes through the anterior portion ofthe lter= al condlar ossification center or antetior to it, posterior angulation of the distal Fhurmerusis present." Routine radiographic examination should include AP, lateral, and oblique views. An arthrogram may be helpful to AOS Instructional Course Lectures, Volume $2, 2003 Table 1 Timing of Normal Ossification’ Gk Boys ears Wes Osifcation Center ofA) oF Ag) Capel io 10 acl ead 5060 Medalepicondle 50.75 ‘Olecanon ay 105 Toches 30107 Latealepiconive 100120 determine the extent of displacement with lateral or medial condylar fractures, and in selected patients MRI or ultra sonography also may aid in evaluation of injury to an unosstied epiphysis. Supracondylar Fractures Supracondylar humeral fractures are the most common elbow fractures, account- ing for 70% ofall elbow fractures in chil~ dren, and they also are the source of much physician distress Treatment ‘ommendations generally are based on the classification ofthe fracture: type I, non- displaced; type Il, displaced but with cor- tical contact; and type I, completely dis- placed ' Type I fractures generally can be 661Pediatrics Fig. 1 The appearance an fusion ofthe four secondary ossification centers ofthe elbow are shown, The ages at which fusion of the secondary ossification centers accu is also noted. (Reproduced! with permission from Beaty JH, Chambers HG, Toniolo RM: Fractures and dsl Cations ofthe elbow region, in Rockwood CA I, Wilkins KE, Beaty JH ec): Fractures ia Chileon, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, p 661.) Fig. 2 A line dawn along the anterior border ofthe distal humeral shaft should pass through the middle thd of the ‘ossification center ofthe capite Tum. (Reproduced with permis: sion from Smith FM: Children’s elbow injuries: Fractures acl l= locations. Clin Orthop 1967;50: 7:30) treated with 3 weeks of immobilization in a posterior splint or long arm cast, eype IL fractures may require reduction and per- cutaneous pinning for severe varus or valgus impaction, and type IIT fractures, generally ae best treated by closed reduc 662 tion and percutaneous pinning to avoid vascular and neurologic complications and angular deformities (cubitus varus). ‘Type Il fiaceures with medial impaction are especially prone to the development of cubitus varus; reduction and pint are imperative to prevent this complica tion, Open reduction occasionally is quired for irreducible fractures, open fractures, or fractures accompanied by vas- cular injury. The current trend is toward anterolateral open reduction of postero- medially displaced fractures. About 6 of patients wieh type IIT supracondylar fractures. present with a palseless but pink and viable hands!” amteriogram is not indicated as pat of the preoperative evaluation, and few of these patients require surgical treatment for brachial artery injury” After immediate closed reduction and stabilization with Kirschner wires and avoidance of extreme flexion of the elbow, pulse generally returns within days. Obliteration of the radial pulse afier closed reduction and pinning isa strong indication for brachial artery exploration, as is persistent vascular insufficiency after reduction and pinning. Nerve injuries occur with approxic mately 7% of supracondylar fracture Reports differ as to whether the radial or medial nerve is the most frequently i Jjured; in most modern series, the ante 6r interosseous nerve appears to be the most commonly injured, with loss of mo- torpower to the flexor pollicis longus and the deep flexor to the index finger’! Observation generally is all that is neces sary; rarely, exploration might be consid ered for nerve dysfunction that persists more than 6 to 12 months, Flexion-type supracondylar fractures account for approximately 2% of hun al factures Type II flexion fractures be difficult to reduce closed and, because reduction is obtained with the elbows in cestension, pinning of the distal fragment can be quite difficult. Pinning usually is done with the elbow in about 30° oF flex- ion, Open reduction frequently is required and is best accomplished through a pos- terior approach. Lateral Condylar Fractures Lateral condylar fractures are classified according to the amount of displacement AOS Instructional Course Lectures, Volume 52, 2003,Elbow Fractures in Children and Adolescents type 1, 2mm or les; type Il, 2 to 4 mms and type Ill, completely displaced and rorated.!” Type 1 and most stable type TL fractures can be splinted but should be checked weekly until union is achieved ‘The risk of late displacement is 5% to 10% and often depends more om the degree of associated softtissuc injury and whether the articular cartilage of the troche is intact than on the amount of | initial displacement. Percutaneous pin= ning can ensure maintenance of reduc- tion in questionable type 1 and I frac tures with 2.¢0 4mm of displacement. Unstable type Il and IH factures gener- ally require reduction and internal fist- tion (about 60% of fractures involving, the ltral condylar phys). Ifthereisany {question as to the stability of the reduc tion, oper reduction and internal fixation with smooth Kirschner wires should be done. Extreme care must be taken avoid dissection near the posterior por- tion of the fragment because this isthe entrance of the blood vessel supplying the lateral condylar epiphysis. The wites are buried under the skin and motion is begun early (2 weeks); wites are removed at3 10 4 weeks after injury Nonunion of lateral humeral condy- Jar fractures can result in cubitus valgus deformity and tardy ulnar nerve palsy Surgical treatment generally is appropti= ate for nonunions in optimal postion: large metaphyseal fragment, displace- ment of less than 1 cm from the joint and a normal lateral condylar physis. A modified open reduction, serew fixation, and a bateralextra-articuar iliac crest bone paft are recommended, Medial Epicondylar Fractures Fractures of the medial epicondyle can be caused by a direct blow or by avulsion and extension mechanisms (valgus stress) sustained in a fall on the outstretched ari, Chronic tension stress injries ean occur (litle leaguer’s elbow), and isolated avulsion can occur in adolescents while Pitching a baseball, Many of these in= jjries are associated with an elbow dislo~ cation that may or may not have reduced spontancously.* Fracture of the medial epicondyle may be mistaken for facture of the medi- al condylar physi, especially if the sec~ ondary ossification centers are not pre= sent, Widening or irregularity of the apophyseal line may be the only clue i fractures that are only slighty displaced ‘or nondisplaced. Ifthe fragments signif= icantly displaced, the diagnosis usually is ‘obvious on radiographs; however, ifthe fragment is totally incarcerated in the joing, it may be hidden by the overlying ‘ulna or distal humerus, The clue here is the total absence of the epicondyle from its. normal position just medial to the ‘medial metaphysis. Even displaced frac~ tures of the medal epicondyle may not produce positive fit pad signs, so a high index of suspicion is necessary to ensure thata fracture does not remain wnrecog- nized. Arthrography or MRI can be help- ful in evaluating medial condylar frac tures in young children, Nonsurgical treatment generally is recommended for nondisplaced and minimally displaced fractures and even significantly displaced (1 em) fractures patients with low upper extremity fine~ tional demands." An absolute indication for surgical treatment is a facture that ‘eannot be reduced because of an incar- cerated fragment in the joint. Open reduction also may be indicated for frac- tures with more than 1 cm of displace- rent, ulnar nerve dysfunction, and pa- tients with high upper extremity fumc~ tional demands such as baseball pitchers, tennis players, football quarterbacks, ‘wrestles, and gymnasts. Fixation must be stable enough to allow early motion, and most patients with these ffactures are mature enough so that the fragment can be secured with a threaded or cannulated screw, Because stiffness is the most com= ‘mon complication of this injury, especial- ly with a concomitant elbow dislocation, ‘early active motion should be encouraged AOS Instructional Course Lectures, Volume 52, 2003, Chapter 56 Fractures of the capitellum are rare in cil- dren and have most often been reported in adolescent athletes.” This fracture often is difficult wo diagnose because there is litte ossitied tissue. It is composed main- ly of articular cartilage from the capitel- lum and essentially nonossiied cartilage from the secondary ossification center of the lateral condyle, In young children, arthrography or MRI may be necessary for diagnosis. Treatment of this injury is either excision or open reduction and reattachment ofthe fragment, Ifthe frag ‘ment is large (J em or larger), acute, and an anatomic reduction can be obtained ‘with a minimum of open dissection or manipulation, i¢ should be reattached ‘with two small compression or Herbert screws inserted from posterior to anterior through a lateral approach. [fit is an old fracture, if any comminution of the frag iments present, orf there is ttle bone in which to engage the screw threads, exci- sion of the fragment and early motion probably are more appropriate Radial Head and Neck Fractures Fractures ofthe radial head and neck are relatively inftequent, accounting for only 5% of all elbow fractures; most are sus- tained in fll Treatment should be non surgical if possible, but varying amounts of angulation and displacement can be accepted. Most agree that percutaneous ‘manipulation or open reduction and fisa~ tion are required if angulation is more than 45° and displacement more than 5096," Closed reduction can be attempted by applying a varus siress to the pronated forearm (Paterson technique). A unique opportunity to reduce radial neck frac tures by application ofa tourniquet alone has also been described. If unsuccessful, percutaneous pin reduction with the use ‘fluoroscopy or intramedullary pin reduction can be attempted. Fisation with oblique Kirschner wires is preferred if ‘open reduction is required; transcapitel= lar wires should be avoided if possible 663Pediatrics Fig. 3.A staight line drawn through the radial head should passthrough the center ofthe ‘apitllum, regardless of the degree of flexion or extension of the elbow, (Reproduced with per= inission from Beaty JH, Chambers HG, Toniolo RM: Fractures and clslacations of the elbow cegion, in Rockwood CA f, Wilkins KE, Beaty JH (eds: Factores in Chien, ed 4, Philadephia, PA These fractures may be difficult to see on radiographs before ossification is complete, and variants in the ossification process can resemble a fracture. Radio graphs should be carefully scrutinized because late treatment of these injuries is dificult and often unsuccessful. Monteggia Fracture-Dislocations Monteggia fracture-dislocations involve dislocations of the radial head associated swith fractures of the ulna and are most often classified according to the direction ofthe dislocation ofthe radial head: type I, anterior; type TL, posterior; eype If, lat- cand type IV, anterior with radial shaft fracture below the level ofthe ulnar Fac~ ture." Types I and Ill (anterior and lter= aldislocations) are most common.2° Most of these fractures can be treated with closed reduction ofthe ulnar fracture and the dislocated radial head and cast immo~ bilization in a stable position for 6 weeks. Concentric reduction can be confirmed boy drawing a straight line through the radial head; in any position, this line 664 LippincottRaven, 1996, p 651.) should pass through the center of the capitllum®" Fig. 3), ‘Open reduction is required for sofi- tissue interposition that makes radial hhead reduction impossible; an- unstable ulnar fracture (not out to length and straight) may require fixation with 2 plate and screw device or an intramedullary rod. Intramedullary rod fixation is becoming more popular option as more ‘experience is gained with this technique, “Transcapitellar pinning should be avoid- ced, The pitfall with this injury isthe vari= cty of Montegyia-equivalent variants, If the Monteggiafracture-tislocation is discovered late, options for treatment are observation, excision of the radial Ihead at skeletal maturity, and late recon struction with ulnar lengthening angula- tion osteotomy and annular ligament reconstruction. Thisis a challenging pro- cedure and experience is equited. Summary Most fractures about the elbow in chil- dren can be treated with immobilization only, but some require surgical reduction and fixation t0 prevent complications such as nonunion and malunion. Closed reduction and percutaneous pinning can provide adequate fixation for many elbows fractures in children and adolescents ‘Open reduction generally is required for irreducible fractures, open fractures, or fractures accompanied by neurovascular injury. Careful physical and radiographic evaluation will help determine the appro- priate creatment for each fracture. References 1. Cheng JC, Wing-Mian K, Shon WY, ea: A nes Henk the equal development af t= ‘oto cemers in en. J ar Orda 19-1 2 Slog DL, Mitzayan The poser Gt pd sign section wi vel act ofthe loin children, Be oS 1959381 108-105, | Donelly LF, Klstermeer TF, Kiseomn LA rua elbow esos in pede pats Arwowse acres the rk? FRA Renn! 1 TT 2G-28, 4 Beaty JH, Kase The bow en: Geer ones th patie pte, Bet JB, sr (th Re and Fs” Pons fn Cie, 5, Padi, PA, Lippe ‘Willan Wilkins, 2101, pp 863575 5. Kose J, Bet He Supracondyar actres o ‘he dal ers, a Beaty J, Keser J (et ak nd ii Pata Chie, ‘ct, Phin, PA Lippincoe ans & ‘Wane. 2001p 877024 6 Gh fe Management of spacer ie tunes fe eras chien Sie Cec ‘Ob 1955100145134 1. Capley LA, Desa J, Davidson RS: Vise ‘nj nde segue in pedi sopra ‘onda mer acres: Tova gual of Preven. J Pi Oy [SG 1903. Doran J Squilame R, ne H: Ace neo= ‘vac coopictions with sepracond Trans tne len, lad Sy he 9520-8 9. Shaw BA, Kaser JR, Emans JB, Rand FF ‘Managencnt a wscuainjres n dpaced Sura: home curs witha s- ‘gap Onl Tan 19803825 29. 10, Cramer KE, Gen NE, Devito DP: Incidence ‘ofamterorintrsiens nerve pa in supe ‘oud unr tres cen fed Ong 1988 1550-505, 1. McGrane) ARbaria BA, Heel DE KeplesL, age RE; Newrlagel compixabons et ing fom supacndyie cts ft Ihueros wn ehen. J Paar Orop 6667-50 AAOS Instructional Course Lectures, Volume 52, 2003,Elbow Fractures in Children and Adolescents 2 Buel O, Beal H, Mad K, Vie P: Lael 16 Thera condor tse in aren: Arp. 87 ese J Pit On 98ST, 13. Peay JH Braces and dora bout the ther in hlen a Ct La 2 ”, ss 1H, Thoms DR, Howard AW, Cale WG, Hedéen DE Three woes of Krscinc i fation Alpacas tes he Tesi ie, Par Ona 2p 21 565-50 15, Fos JV, Slimane N, seb MT. Elbow dso ‘ot haul dealer on) Sy Br 190,72:102-108 Ws eset Poza V. Cats ppl Long-et estt of etmene of facts the el mer pond een, ie 1 Boot Sui ARSED ‘Beaty JH Kase JR: The eb: Pye fac~ ay te appl nies of eda umes iran ncros ofthe rach, and Tony larracers i Bea, Kaser Jo) Rac kin” ans Hide, Palin, PR Upper ins Wis, 20, pp 625-7085. 2 [Chasers HG Fractures of the rosin aos ii Beary J, Kaer JR fe Rind nd Wikia Chl, 85 ‘AAOS Instructional Course Lectures, Volume 52, 2003 Chapter 56 Plaga PA Lapin ‘Wilkin, 2001, pp 48508 dof: The Monts sion. Chit Ory ro ‘Say EA. des Gres JF: Moai acuse= dso nce, Bessy J, Kase J (eds) Rel kin Par he, ‘5 pin, PA, Lipincoee ian & ‘kin, 201, p53 Sth FM Chins lb igure: Fates tnd dilosdon, le lp 196730790, 665