Review Article

Approaching Unusual Pediatric

Distal Humerus Fracture Patterns

Abstract
Jason B. Anari, MD Pediatric distal humerus fractures are common, and numerous
Alexandre Arkader, MD variations can occur depending on patient’s age, position of the
extremity at the time of injury, and energy of impact. Classic injury
David A. Spiegel, MD
patterns include the flexion/extension supracondylar humerus,
Keith D. Baldwin, MD, MSPT, medial epicondyle, lateral condyle, and the transphyseal distal
MPH
humerus. We describe our treatment philosophy for pediatric elbow
fractures and how these principles were applied to some unusual
fractures that presented to our institution.

P ediatric distal humerus fractures

From the Department of Pediatric
Orthopaedic Surgery, Children’s
Hospital of Philadelphia, Philadelphia,
PA.
Dr. Spiegel or an immediate family
member serves as a board member,
owner, officer, or committee member
of the Pediatric Orthopaedic Society of
North America Global Courses
Committee and the American
Academy of Orthopaedic Surgeons
International Committee, Board of
Directors, and Orthopaedics
Overseas. Dr. Baldwin or an
immediate family member serves as a
paid consultant to Pfizer and Synthes
Trauma and has stock or stock
options held in Pfizer. Neither of the
following authors nor any immediate
family member has received anything
of value from or has stock or stock
options held in a commercial company
or institution related directly or
indirectly to the subject of this article:
Dr. Anari and Dr. Arkader.
J Am Acad Orthop Surg 2018;00:1-11
DOI: 10.5435/JAAOS-D-17-00326
Copyright 2018 by the American
Academy of Orthopaedic Surgeons.
are responsible for 5% to 10% of
all pediatric fractures.1 Injury patterns
vary with the direction and magni-
tude of forces applied and the degree
of skeletal maturation. Common dis-
tal humerus fractures in children
include supracondylar humerus frac-
tures, transphyseal fractures, lateral
condyle fractures, and medial epi-
condyle fractures.2,3 This article
reviews a treatment philosophy for
these elbow fractures while focusing
on fracture patterns seen with less
frequency, including the “high” su-
pracondylar fractures; “adult” frac-
ture patterns in patients who are
yet to reach skeletal maturity; and
combination injuries.
Clinical Evaluation
The clinical evaluation proceeds in a
step-wise manner, and care should be
taken to avoid the temptation to
evaluate imaging studies first. Ideally,
the child should be as calm as possible,
with their parents or a caregiver to
comfort them. The history focuses
on mechanism and energy of injury,
and the physical assessment includes
observation and palpation, as well as a
thorough neurovascular assessment.
Neurovascular injuries associated
with extension-type supracondylar
humerus fractures are the anterior
interosseous nerve and the radial
nerve palsies, whereas the ulnar nerve
palsies should be suspected in flexion-
type injuries. The treating physician
must pay particular attention to the
complete median nerve palsy which
may mask the clinical findings of a
silent compartment syndrome. The
entire limb should be examined,
including the shoulder and wrist, and
this should be done before examining
the known injury to ensure no con-
current injuries are missed as these are
indicative of higher energy injuries.4
The patient can be asked to point to
the area of discomfort with the tip
of a finger to try and isolate the lo-
cation of injury. Observation focuses
on areas of swelling/bruising, whereas
palpation of all structures around the
elbow will identify the site or sites
of discomfort. It may be difficult to
accurately grade muscle strength in
younger children, especially if they are
in pain. Therefore, it may be better
to document what is specifically ob-
served rather than assigning a subop-
timal assessment for muscle strength.
An abbreviated motor assessment

Month 2018, Vol 00, No 00 1

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Unusual Distal Humerus Fractures in Kids
might include asking each child to
extend their thumb firing the exten-
sor pollicis longus to check for radial
nerve function, flex the interpha-
langeal joint of the thumb through
flexor pollicis longus for median
nerve function, and abduct their
digits via the dorsal interossei for
ulnar nerve function.5 Sensation may
be assessed over the dorsal aspect of
the thumb (radial nerve), palmar
aspect of the index finger (median
nerve), and palmar aspect of the
small finger (ulnar nerve). Distal
perfusion is evaluated by palpating
a radial pulse or checking for a
Doppler signal if unable to be pal-
pated.6 Assessing for compartment
syndrome in a child is generally done
via the “3 A’s”, which are anxiety,
agitation, and an increasing analge-
sia requirement.7
Imaging
Orthogonal views of the elbow are
essential, and on many occasions,
oblique radiographs (45°) will pro-
vide essential information, such as
when evaluating displacement in
intra-articular humeral condylar
fractures.8,9 Common parameters
assessed on standard AP and lateral
radiographs include the anterior
humeral line (Figure 1), humer-
ocapitellar angle, position of the
radius relative to the capitellum
(Figure 1), the long axes of the ulna
compared with the humerus (Figure
1), Baumann’s angle (Figure 1), the
posterior fat pad, or the anterior
“sail sign.”10 Traction views for
T-condylar distal humerus fractures
can help define the local fracture
anatomy, in the assessment of the
articular block, and in the estimation
of comminution.11,12 Like the trac-
tion view, varus and valgus stress
radiographs are often not well tol-
erated unless adequate analgesia
or sedation has been provided but
may help one appreciate the stability
2 Journal of the American Academy of Orthopaedic Surgeons
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
of fracture fragments and physeal
involvement, as well as evaluate stress
fractures.9 Arthrography may be re-
quired to evaluate displacement at the
cartilaginous surfaces of the radio-
capitellar and ulnohumeral joints
and/or guide reduction and stabiliza-
tion of the fracture, especially with
lateral condylar fractures and trans-
physeal separations.12 CT, MRI, and
ultrasonography are all useful modal-
ities providing additional information
about the injured pediatric elbow in
select settings.13,14 For example, a CT
scan to identify an intercondylar split
or an ultrasound to evaluate a dis-
placed transphyseal fracture in a
newborn. In Figure 2, we detail an
algorithmic approach using various
imaging modalities to evaluate pedi-
atric elbow injuries.
Treatment Principles
Pediatric fractures are unique because
of progressive ossification, thicker
periosteum in comparison with adults,
and different mechanical properties of
bone, which leads to mostly extra-
articular injuries. However, similar to
adults, remodeling is extremely limited
in the distal humerus, and it occurs
mainly in the sagittal plane; thus,
greater emphasis must be placed on
achieving and maintaining normal
alignment. A stable elbow joint allows
for early motion that should maximize
the likelihood of a return to full range
of motion. Common pediatric distal
humerus injuries rarely require physi-
cal therapy postoperatively, and it ap-
pears as this conviction holds true for
the more complex injury patterns as
well at 1-year follow-up.13
Management of the child’s elbow
injury is undertaken with the fol-
lowing seven treatment principles:
(1) Prevent further bony or soft-
tissue injury by timely treatment
and accurate diagnosis.
(2) Restore the anatomic axis of the
joint on AP and lateral views to
prevent motion loss and post-
injury deformity.
(3) Restore the “triangle of stability”
of the distal humerus: the trans-
verse articular block, the medial
column of the humerus, and the
lateral column of the humerus
(Figure 3).
(4) Re-create a perfect articular
surface in the case of articular
fractures.
(5) Provide the appropriate amount
of stability for the patient’s age.
(6) Understand acceptable parame-
ters for alignment and remodeling
and minimize the temptation to
achieve radiographic perfection.
(7) Use the periosteal hinge that may
be inferred from the injury films
and place implants to achieve
stability where the periosteum is
torn.
Injury Patterns
Supracondylar Humerus
Supracondylar humerus fractures
most commonly result from a fall on
an outstretched hand, hyperextending
the elbow and causing impaction of
the olecranon at the distal humerus.
Less commonly, a fall directly on the
flexed elbow results in a flexion-type
injury (5%). With extension injuries
(Figure 4), the periosteum is located
on the posterior aspect of the hu-
merus and can be tensioned by
flexion of the elbow; hence, a flexion-
distraction maneuver is most com-
mon with various degrees of rotation
or translation imparted as the intra-
operative fluoroscopy suggests.
Flexion-type injuries (Figure 4) gen-
erally require the opposite as the
periosteum is generally intact ante-
riorly, although many flexion in-
juries have no periosteal hinge and
therefore are globally unstable.15 The
most common extension-type pattern
results in posterolateral displacement
putting the median nerve at risk,
whereas posteromedial displacement
 Jason B. Anari, MD, et al

Figure 1

Lateral (A, B) and AP (C, D) radiographs of the pediatric elbow depicting radiographic assessment lines used when
evaluating a pediatric elbow injury.

Figure 2

Treatment algorithm for pediatric elbow injuries. *Intraoperative modality; **MRI ordered when multiple-view digital
radiographs are inconclusive and in high-end athletes with normal XR and persistent medial elbow pain.

causes radial nerve stretch. Although
most fractures may be treated by
closed manipulation and percutane-
ous fixation, a subset will require an
open reduction: those that are open,
irreducible, and/or associated with a
poorly perfused extremity and/or
nerve injury.16 Flynn et al17 recently
reported that 60% of patients with a
flexion-type supracondylar humerus
fracture in the setting of an ulnar
nerve palsy required open reduction.
Although no “best approach” exists,
the anterior approach is most useful
when vessel injury needs to be
explored and is extensile. A medial or
lateral approach has also been sug-
gested based on the location of the

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Unusual Distal Humerus Fractures in Kids
Figure 3
Triangle of stability. Columns include
medial, lateral, and transverse
columns. Goal of distal humerus
surgery is to restore and stabilize the
columns. (Reproduced with permission
from AO Foundation, Switzerland.
Source: AO Surgery Reference [www.
aosurgery.org].)
proximal fragment which is often
tenting the skin.18 The posterior
approach has been advocated by
many, particularly for older children
or adolescents with articular in-
volvement, but is more likely to result
in scarring and loss of motion.18 In
general, the medial and lateral col-
umns are disrupted and must be re-
established, whereas the transverse
column is intact (Figure 5). The lit-
erature supports use of lateral pins
construct alone and consideration
may be given to use larger implants,
such as 5/64 inch Steinmann pins
(Figure 5).19,20 However, biome-
chanically, the crossed pin configu-
ration confers superior stability
compared with divergent lateral pin
configuration.21 The use of a medial
pin has diminished owing to the risk
of ulnar nerve injury; however, a mini-
open approach or the placement of
the pin with the arm in mild extension
can minimize risks during medial pin
placement in circumstances where it is
deemed essential, such as when medial
column comminution is present or in
reverse obliquity patterns which
compromises stability with a lateral-
4 Journal of the American Academy of Orthopaedic Surgeons
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Figure 4
Extension- (A) and flexion- (B) type supracondylar humerus fractures
demonstrating direction of the periosteal hinge.
only pin construct. An intraoperative
check for the stability of fractures after
lateral pinning is key to ensuring no
reduction will be lost while immobi-
lized in a long arm cast until callous
forms; this can be done with internal
rotation stress views and lateral views
at zero, 30°, 60°, and 90° of flexion.
Pins are removed and motion starts as
soon as the callus is evident generally
at 3 to 4 weeks.22
Lateral Condyle
Lateral condyle fractures account for
12% to 20% of pediatric elbow frac-
tures.10,23,24 These injuries result
from a fall on an outstretched hand
with a valgus moment at the elbow.
The key issues from a management
standpoint are to define whether the
fracture extends completely into the
elbow joint (presence of cartilaginous
hinge) and whether it is displaced.
Treatment focuses on realigning the
joint surface and the physis. Stability
of the fragment is the key information.
Although nondisplaced fractures are
usually managed conservatively in a
cast with the forearm in supination,
a subset of these fractures extends
completely into the joint and therefore
may displace, suggesting the need for
close radiographic follow-up during
the first 2 to 3 weeks after the injury.
In some cases, it may be advantageous
to remove the cast for reimaging if
a concern for displacement exists.
Regardless of the treatment method,
immobilization is recommended for
4 weeks minimum and many advocate
for longer periods, given the articular
nature of the fracture. The presence of
an intact cartilaginous hinge enhances
stability and can be used as a medial
fulcrum point for percutaneous fixa-
tion of the fracture. If the fracture
is displaced/angulated but retains a
hinge at the articular surface, an ar-
throgram can help confirm the in-
tegrity of the articular surface and
facilitate reduction and pinning. The
triangle of stability is restored by
placing one percutaneous pin in the
lateral column and one in the trans-
verse column, with a third pin often
added for supplementary fixation. If
the articular surface is displaced, a
lateral approach to the elbow is used.
A rent in the brachioradialis often
provides direct visualization of the
fracture fragment, whereas a head-
lamp and a blunt Hohmann retractor
are helpful for articular visualization.
Then generally pin fixation is under-
taken as described earlier. Alternative
fixation strategies include a meta-
physeal compression screw placed
from posterolateral to anteromedial
or a screw in the lateral and trans-
verse column in older children.25,26
Proposed advantages include faster

Figure 5
Hardware configurations demonstrating the triangle of stability concept. In each, the medial and lateral columns are captured
and the transverse column is intact.
time to union and less lateral over-
growth; however, this technique re-
quires a second intervention for screw
removal. Lateral condyle fractures are
associated with several complications,
including stiffness, nonunion, spur
formation from periosteal new bone,
growth acceleration (varus) or retar-
dation (valgus), and very rarely os-
teonecrosis of the trochlea causing a
“fishtail” deformity. The fishtail is not
unique to lateral condyle fractures and
has even been seen in nondisplaced
supracondylar fractures. This defor-
mity is commonly associated with
stiffness and pain and often proximal
migration of the ulna, causing over-
load at the radiocapitellar joint.
Medial Epicondyle
Injuries of the medial epicondyle con-
stitute 20% of all pediatric elbow
fractures, and approximately 60%
of these injuries are associated with
an elbow dislocation.23,27,28 The
indications for nonsurgical versus
surgical treatment are based on the
amount of displacement and presence
Month 2018, Vol 00, No 00
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
of associated injuries. One of the main
issues is that standard AP and lateral
views fail to accurately capture the
magnitude of displacement, which is
further elucidated via advanced imag-
ing such as CT or MRI.29 Both inter-
nal oblique and the “distal humerus
axial view” have been reported to
increase the accuracy of displacement
measurement compared with the
standard elbow radiographs.30,31
Absolute indications for surgery
include an open fracture, incarceration
of the epicondyle fragment within
the joint, and post-reduction ulnar
neuropathy (when fracture is associ-
ated with an elbow dislocation).11
Controversy remains regarding the
“relative” indications for surgery
because a number of studies have
found no difference in clinical out-
comes between surgical and nonsur-
gical management, although those
managed surgically achieve union
faster.32 Patient demands have been
used by some to advocate for surgical
stabilization, namely those such as
throwers or gymnasts who have
notable anticipated loading or func-
Jason B. Anari, MD, et al
tional demands. Nonsurgical man-
agement necessitates a long arm cast
with the elbow at 90° for 4 weeks.
Many fixation options are possible;
Kirschner wires are often used in
younger children, whereas a com-
pression screw is used in older chil-
dren.11 A mini frag tension band plate
can be used in cases where the medial
epicondyle is too damaged to accept a
screw or if screw fixation fails. Surgical
compression at the fracture site yields
higher union rates but questionably
better clinical outcomes. Excision of
the fragment has yielded poor out-
comes and is not recommended.32
Stable fixation allows for early range
of motion, with the hope of limiting
postoperative elbow stiffness.
Transphyseal Separation
Transphyseal injuries are fractures
through the distal humerus physis,
often occurring in children younger
than 3 years, and they are often mis-
taken for elbow dislocations, given
the appearance on radiograph.33 The
caveat is the identification of an intact
5
Unusual Distal Humerus Fractures in Kids

Figure 6

AP radiograph (A) of the elbow preoperatively appears innocuous but represents a transphyseal separation. An arthrogram
(B and C) used intraoperatively aid in the visualization to confirm adequate reduction and fixation.

Figure 7

AP injury radiograph (A) and intraoperative radiograph (B) showing transverse column fixation with a partially threaded
cannulated screw and Kirschner wire fixation of the medial and lateral columns. Final AP radiograph (C) after hardware
removal showing healed fracture and a mild straightening of Baumann’s angle.

radiocapitellar relationship (if cap-
itellum is ossified). In this young age
group, the physis is weaker than the
bone ligament interface. The injury
pattern is commonly seen in new-
borns from traumatic deliveries and
in patient’s subject to nonaccidental
trauma.33 There should always be an
index of suspicion for nonaccidental
trauma, and the orthopaedic surgeon
will often initiate the appropriate
evaluation to rule out this diagnosis.
The treatment principles of these
fractures are similar to the ones of
supracondylar humerus fractures, but
an arthrogram may be necessary for
better visualization of the distal
fragment during pinning to assess the
reduction (Figure 6). Reduction must
be carefully watched as these frac-
tures can re-displace. Long-term
common pitfalls to avoid include cu-
bitus varus, growth arrest, and medial
condyle osteonecrosis.33
Case Examples
Case 1: Adult-type Patterns
Presenting in Children or
Adolescents: T-Condylar
This 9-year-old boy fell off a slide
on an outstretched hand. Physical

6 Journal of the American Academy of Orthopaedic Surgeons

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Figure 8
Preoperative lateral radiograph (A) sagittal section of a CT (B), and postoperative lateral radiograph (C) from the right elbow
revealing a capitellar shear intra-articular injury.
examination showed global soft-
tissue swelling and tenderness at the
elbow. He was seen in our emer-
gency department and found to have
an intact neurovascular examination.
The arm was swollen and globally
tender at the elbow. AP and lateral
radiographs were obtained (Figure 7).
The patient was taken to the operating
room the next day for closed reduc-
tion and percutaneous pinning and a
compression screw in the transverse
column. At 4 weeks, the pins were
pulled and range of motion started. At
12 weeks, the patient had full range of
motion and no pain. The final films
showed mild straightening (80°) of
Baumann’s angle (Figure 7).
Discussion: “T”-condylar humerus
fractures are rare in the skeletally
immature and result from a fall with
the arm flexed at 90°. They involve
disruption of all three columns. In
younger patients in whom the peri-
osteum is robust, there is rarely
notable displacement and/or com-
minution of the intercondylar frac-
ture line, thereby negating the need
for an open reduction. Thus, the
transverse column can usually be
fixed with a percutaneous compres-
sion screw, and then, the medial and
lateral columns can be fixed with
Steinmann pins. In adolescents and
Month 2018, Vol 00, No 00
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
adults, the condylar fragments rotate
toward the midline and may require
open reduction with bi-columnar
plating. Adolescents with more
complex fracture patterns are gen-
erally treated similar to adults, but a
Morrey slide approach is favored
over the typical olecranon osteotomy
by most pediatric orthopaedic sur-
geons.34 Consideration can be given
to simply retracting the triceps ten-
don medially and laterally rather
than mobilizing by a Morrey slide or
an olecranon osteotomy, when the
trochlear articular surface (no com-
minution) need not be fully visual-
ized. Although stiffness is less likely
in children, it happens occasionally
with T-condylar fractures because of
joint involvement.13 Fixation should
be stable enough to enable range of
motion within 3 to 4 weeks because
this allows for earlier return of motion.
Case 2: Capitellar Shear
This 7-year-old girl fell from a slide and
had pain over the lateral aspect of her
elbow. Her neurovascular examina-
tion was intact. She was imaged with
radiograph and a CT in the emergency
department (Figure 8). The fracture
was stabilized by a headless compres-
sion screw using a Kocher approach,
Jason B. Anari, MD, et al
the author’s preferred approach to the
radiocapitellar joint (Figure 8). A cast
was placed for 3 weeks, and motion
was restored by 3 months postinjury.
Discussion: Capitellar shear frac-
tures are rare in general and even more
so in children. Because the fracture is
intra-articular, direct reduction and
compressive internal fixation is neces-
sary even in younger children. Open
reduction necessitates rigid internal
fixation with compression, which can
allow for early motion to prevent
stiffness. Murthy et al35 recently de-
veloped a classification system for the
problematic pediatric capitellar frac-
tures, and their treatment algorithm
supports advanced imaging in diag-
nosing the injury and developing a
treatment plan.
Case 3: Medial Condyle
This 7-year-old boy fell off a play-
ground equipment and presented with
pain and medial soft-tissue swelling.
Radiographs revealed (Figure 9) a
medial condyle fracture, and he
underwent open reduction and per-
cutaneous pinning (Figure 9). At
2 months from injury, he had re-
gained functional range of motion
and the fracture was healing but was
left with a small bump on the medial
7
Unusual Distal Humerus Fractures in Kids

Figure 9 creating a fracture line that creates a

AP preoperative (A) and intraoperative (B) radiographs demonstrating an intra-
articular injury that underwent open reduction and percutaneous pinning.
aspect of his elbow. Though clinically
healed, the radiographs showed in-
complete union of the fracture.
Discussion: Medial condyle fractures
are extremely rare injuries in the pedi-
atric elbow, with very few case reports
documenting their incidence. Fowles
estimated the rate of medial condyle
fractures in children at 1.4%, and a few
estimates have been available since
then.36,37 These rare injuries involve
the articular surface and occur by
falling onto an outstretched arm
with a varus moment at the elbow or
by directly landing on the elbow. The
olecranon is thought to act as a wedge
more medial fracture (Figure 9) or a
valgus stress that can create a more
lateral fracture line. Medial-sided soft-
tissue swelling with a misplaced
trochlea ossification center are radio-
graphic clues to a possible medial
condyle fracture. An arthrogram
could be performed intraoperatively to
confirm the diagnosis before opening
the fracture. Approach and fixation
construct depend on age: younger
patients being treated with medial
approaches and percutaneous pins,
whereas adolescents treated with a
posterior approach and plate fixation.
The medial approach lies between the
triceps and brachialis proximally and
the pronator teres and brachialis
distally.
Case 4: Atypical
Supracondylar Humerus
(High Supracondylar)
This 5-year-old boy fell off the
monkey bars and sustained a su-
pracondylar fracture at the meta-
diaphyseal junction and was treated

Figure 10

AP radiographs preoperative (A), intraoperative (B), and postoperative (C) following hardware removal of a higher than
usual extension Gartland type III supracondylar humerus fracture.

8 Journal of the American Academy of Orthopaedic Surgeons

Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Jason B. Anari, MD, et al

Figure 11

AP preoperative (A), intraoperative (B), and postoperative (C) radiographs following hardware removal demonstrating a complex
elbow injury treated with closed reduction and pinning of the supracondylar humerus fracture and open reduction and internal
fixation of the medial epicondyle performed in that sequence. Patient had full range of motion and returned to sports at 3 months.

by both lateral and medial pins; the
medial pins were placed using a
small incision (Figure 10). Patient
lost some rotation and the fracture
healed in slight varus (Baumann’s—
79°), however, at 3 months, he had
regained full painless range of
motion and was happy with the
outcome.
Discussion: The high supracondylar
fracture can be challenging because
the fracture line is above the olecranon
fossa and it is difficult to obtain ade-
quate fixation as the cross-sectional
area of the bone is much smaller in this
area, and the pins tend to cross at
the fracture site, reducing axial sta-
bility. As such, a more stable plan,
such as cross pinning, and more pins
spread across the fracture site are
desirable. Intramedullary pins are
acceptable, but at least one medial pin
and one lateral pin should be bicort-
ical. We found that these fractures
require a close follow-up because
they tend to spin off and develop sag-
ittal and coronal deformity more than
the typical supracondylar humerus
fractures.
Case 5: Poly-elbow Trauma:
Medial Epicondyle With an
Ipsilateral Supracondylar
Humerus
This 10-year-old girl presented after
falling off the monkey bars at school.
On presentation, her arm was
markedly swollen; however, she
was neurovascular intact. AP and
lateral radiographs revealed a mul-
tifaceted elbow injury (Figure 11).
The supracondylar humerus frac-
ture was addressed first, via a closed
reduction and percutaneous pin-
ning, followed by stabilization of
the displaced medial epicondyle
fracture, via open reduction and
internal fixation with a cannulated
screw (Figure 11). In this case, ob-
taining stability at the supra-
condylar level conferred stability of
the medial and lateral columns to
allow fixation across the transverse
column to be obtained more easily.
In this case, the medial epicondyle
fragment contained a small portion of
the medial condyle, and compression
across the vertical fragment was
obtained more easily with a trans-
versely oriented screw. Pins were
removed at 4 weeks postoperatively,
and range of motion was initiated.
The patient regained full range of
motion and returned to sport at
3 months, whereas the cannulated
screw was removed electively at
6 months.
Discussion: Combined elbow in-
juries such as the medial epicondyle/
supracondylar humerus are chal-
lenging, and a number of issues
should be addressed, such as whether
to fix one or both and when to begin
rehabilitation. Our algorithm for
order of fixation considers which
fracture would confer a stable plat-
form to use to fix the remainder of the
injury. For example, in this case, the
medial epicondyle would have been
very difficult to fix if the supra-
condylar portion was not stabilized,
and therefore, we stabilized that injury
first. Where possible, we attempt to
provide fixation which allows for
motion in 4 weeks to avoid any
iatrogenic stiffness that may occur
from a cast.

Month 2018, Vol 00, No 00 9

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Unusual Distal Humerus Fractures in Kids
Conclusion
Pediatric elbow injuries can be
daunting to diagnose and confusing
to treat even to the well-trained eye
and experienced orthopaedic sur-
geon. The rare, more complex in-
juries may at first seem daunting to
treat; however, by following an
algorithmic approach to working up
the injury and general fracture care
principles, the treating orthopaedic
surgeon should be able to manage
even unusual variants of pediatric
distal humerus fractures.
References
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, reference 19
is a level I study. References 20 and
31 are level II studies. References 17,
22, and 26 are level III studies.
References 1-4, 6-11, 13, 15, 21, 23-
25, 29-30, 32, and 34-37 are level IV
studies. References 5, 8, 12, 14, 16,
18, 27-28, and 33 are level V studies.
References printed in bold type are
those published within the past 5
years.
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