Pediatric Elbow Fractures A Clinical

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Pediatric
Elbow Fractures
A Clinical Guide to
Management

Joshua M. Abzug
Martin J. Herman
Scott Kozin
Editors

123
Pediatric Elbow Fractures
Joshua M. Abzug • Martin J. Herman
Scott Kozin
Editors

Pediatric Elbow
Fractures
A Clinical Guide to Management
Editors
Joshua M. Abzug, MD Martin J. Herman, MD
Departments of Orthopedics and St. Christopher’s Hospital for Children
Pediatrics Drexel University College of Medicine
University of Maryland School of Philadelphia, PA
Medicine USA
Baltimore, MD
USA

Scott Kozin, MD
Shriners Hospitals for Children
Philadelphia, PA
USA

Additional material to this book can be downloaded from https://link.springer.com/

book/10.1007/978-3-319-68004-0.

ISBN 978-3-319-68002-6    ISBN 978-3-319-68004-0 (eBook)

https://doi.org/10.1007/978-3-319-68004-0

Library of Congress Control Number: 2017964091

© Springer International Publishing AG 2018

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
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The publisher, the authors and the editors are safe to assume that the advice and information in
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The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Preface

Fractures about the elbow are extremely common in the pediatric and adoles-
cent populations. However, many clinicians find them to be quite challenging
to diagnose and accurately treat due to the complex nature of the elbow as
well as the developmental anatomy of a child’s elbow. The aim of this com-
prehensive book focused on pediatric elbow trauma is to provide the clinician
with an understanding of the developmental anatomy of the child’s elbow as
well as to familiarize the clinician with the various injuries that occur.
Each chapter highlighted in this book covers the necessary information to
accurately diagnose and treat pediatric elbow fractures. Numerous radio-
graphic images will aid the reader in familiarizing themselves with the specif-
ics of each fracture, while the indications for the various treatment modalities
will aid in determining the appropriate treatment.

Baltimore, MD, USA Joshua M. Abzug, MD

Philadelphia, PA, USA Martin J. Herman, MD
Philadelphia, PA, USA Scott Kozin, MD

v
Contents

Part I Anatomy, Examination and Imaging of the Pediatric Elbow

1 Anatomy and Development of the Pediatric Elbow��������������������    3

Julio J. Jauregui and Joshua M. Abzug
2 Physical Examination of the Pediatric Elbow ����������������������������   13
Matthew Varacallo, Kush S. Mody, Darshan Parikh, and
Martin J. Herman
3 Radiographic Evaluation of the Pediatric Elbow������������������������   23
Ryan Hoffman, John Prodromo, and Martin J. Herman

Part II Acute Injuries of the Pediatric Elbow

4 Supracondylar Humerus Fractures ��������������������������������������������   37

Stephanie A. Russo and Joshua M. Abzug
5 Pediatric Distal Humerus Transphyseal Fractures��������������������   65
Jonathan Klaucke and Joshua M. Abzug
6 Lateral Condyle Fractures������������������������������������������������������������   75
Sania Mahmood, Karan Dua, and Joshua M. Abzug
7 Medial Epicondyle Fractures��������������������������������������������������������   95
Randle W. Ramsey and Martin J. Herman
8 T-Condylar Distal Humerus Fractures���������������������������������������� 111
Richard Chen, Michael Kwon, and Martin J. Herman
9 Coronal Shear Fractures �������������������������������������������������������������� 123
Scott H. Kozin
10 Proximal Radius Fractures in Children�������������������������������������� 133
Arun Hariharan and Joshua M. Abzug
11 Pediatric Olecranon Fractures ���������������������������������������������������� 151
Nicholas Grimm and Martin J. Herman
12 Pediatric Elbow Dislocations: Acute Management�������������������� 169
Matthew Varacallo, Darshan Parikh, Kush Mody, and Martin
J. Herman

vii
viii Contents

13 Acute Monteggia Fractures in Children�������������������������������������� 185

William P. Hennrikus (Son), David G. Fanelli, Zachary P.
Winthrop, and William L. Hennrikus (Father)

Part III Chronic Issues of the Pediatric Elbow

14 Chronic Monteggia Injuries���������������������������������������������������������� 197

Francisco Soldado and Scott H. Kozin
15 Cubitus Varus�������������������������������������������������������������������������������� 209
Scott H. Kozin
16 Cubitus Valgus�������������������������������������������������������������������������������� 217
Scott H. Kozin
17 Elbow Stiffness ������������������������������������������������������������������������������ 225
Scott H. Kozin
18 Elbow Instability���������������������������������������������������������������������������� 237
Scott H. Kozin
Index�������������������������������������������������������������������������������������������������������� 251
Contributors

Joshua M. Abzug, MD Departments of Orthopedics and Pediatrics,

University of Maryland School of Medicine, Baltimore, MD, USA
Richard Chen, BA Drexel University College of Medicine, Philadelphia,
PA, USA
Karan Dua, MD Department of Orthopaedic Surgery and Rehabilitation
Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
David G. Fanelli, MD Geisinger Health Systems, Danville, PA, USA
Nicholas Grimm, DO Department of Orthopedic Surgery, Philadelphia
College of Osteopathic Medicine, Philadelphia, PA, USA
Arun Hariharan, MD, MS University of Maryland Medical Center,
Baltimore, MD, USA
William L. Hennrikus (Father), MD Division of Gastrointestinal Surgery,
Department of Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
William P. Hennrikus (Son), BA Division of Gastrointestinal Surgery,
Department of Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
Martin J. Herman, MD Drexel University College of Medicine, St
Christopher’s Hospital for Children, Philadelphia, PA, USA
Ryan Hoffman, BS, MD Department of Orthopedic Surgery, Albert Einstein
Medical Center, Philadelphia, PA, USA
Julio J. Jauregui, MD Department of Orthopaedics, University of Maryland
Medical Center, Baltimore, MD, USA
Jonathan Klaucke, MD Department of Orthopaedics, University of
Maryland School of Medicine, Baltimore, MD, USA
Scott H. Kozin, MD Shriners Hospital for Children—Philadelphia,
Philadelphia, PA, USA
Michael Kwon, MD Drexel University College of Medicine, St. Christopher’s
Hospital for Children, Philadelphia, PA, USA
Sania Mahmood, MD Orthopedic Surgery, Cleveland Clinic Foundation,
Cleveland, OH, USA

ix
x Contributors

Kush S. Mody, BS Drexel University College of Medicine, Philadelphia,

PA, USA
Darshan Parikh, BS Drexel University College of Medicine, Philadelphia,
PA, USA
John Prodromo, MD Department of Orthopedic Surgery, Drexel University
College of Medicine, Philadelphia, PA, USA
Randle Ramsey, DO Department of Orthopedic Surgery, Philadelphia
College of Osteopathic Medicine, Philadelphia, PA, USA
Stephanie A. Russo, MD, PhD Department of Orthopaedic Surgery,
University of Pittsburgh Medical Center—Hamot, Erie, PA, USA
Francisco Soldado, MD, PhD Hospital Sant Joan de Deu, Barcelona, Spain
Matthew Varacallo, MD Department of Orthopedic Surgery, Drexel
University College of Medicine, Philadelphia, PA, USA
Zachary P. Winthrop, BS Penn State College of Medicine, Hershey, PA,
USA
 Part I
Anatomy, Examination and Imaging
of the Pediatric Elbow
 Anatomy and Development
of the Pediatric Elbow
1
Julio J. Jauregui and Joshua M. Abzug

Introduction movement, the radiohumeral articulation provid-

ing a pivoting movement, and the proximal radio-
Trauma and injury to skeletally immature patients ulnar joint providing a rotational movement
represent a common challenge to the orthopedic (Fig. 1.1). As opposed to simple joints, a com-
surgeon. Of these, injuries to the pediatric elbow plex joint, such as the elbow, can give way to
are extremely common in children, representing more stress being placed on adjacent joints.
from 15 to over 40% of all fractures observed in While variations are seen in timing for every
children [1]. Although relatively common, these individual due to gender/race, etc., there is an
injuries can be one of the most elusive to detect.
Therefore, understanding the anatomy and devel-
opment of the pediatric elbow will aid in the detec-
tion of fractures, even in their subtle form [2]. This
chapter will discuss the anatomy of the pediatric
elbow as well as its ossification development.

Background: Elbow Development

The elbow joint includes three types of articula-

tions making it a complex joint. These are the
ulnohumeral articulation providing a hinge-type

J.J. Jauregui, M.D.

Department of Orthopaedics, University of Maryland
Medical Center, 110 South Paca Street, 6th Floor,
Suite 300, Baltimore, MD 21201, USA
e-mail: JJauregui@umoa.umm.edu
J.M. Abzug, M.D. (*) Fig. 1.1 Lateral radiograph of an elbow depicting the
Departments of Orthopedics and Pediatrics, various motions about the elbow including flexion-­
University of Maryland School of Medicine, extension through the ulnohumeral articulation and fore-
Baltimore, MD, USA arm rotation through the proximal radioulnar articulation
e-mail: jabzug@umoa.umm.edu (Courtesy of Joshua M. Abzug, MD)

© Springer International Publishing AG 2018 3

J.M. Abzug et al. (eds.), Pediatric Elbow Fractures, https://doi.org/10.1007/978-3-319-68004-0_1
4 J.J. Jauregui and J.M. Abzug

Table 1.1 Order for sequential appearance and fusion of the ossification centers in the elbow
Mnemonic Site Age at appearance (years) Age at physeal fusion (years)
C Capitellum 1 14
R Radial head 4–5 16
I (M) Medial (internal) epicondyle 6–7 15
T Trochlea 8–10 14
O Olecranon 10 14
E (L) Lateral (external) epicondyle 11 16

overall predictable pattern of ossification in the
pediatric elbow [3, 4]. Between the ages of 6 and
12 months, the capitellum ossification center is
visible on plain radiographs. Girls tend to have
their ossification centers visible earlier than boys,
and their physes may close anytime up to 2 years
sooner than in boys. Although there is up to a
2-year disparity between males and females, the
elbow ossification patterns are well known and
follow the mnemonics described by Hansman,
Garn, and Girdany [5–7]. The sequence of ossifi-
cation follows the mnemonic word CRITOE, in
which the first center to ossify is the Capitellum
at a mean of 3 months, then the Radial head at
5 years, the Internal (medial) epicondyle at
7 years, the Trochlea at 9 years, the Olecranon at
11 years, and the External (lateral) epicondyle at
13 years (Table 1.1). In general it is thought that
the fusion of the elbow growth centers is c­ omplete
by 13 years of age in girls and 15 years of age in
boys [8] (Figs. 1.2 and 1.3).
There are subtle variations by gender in which
these ossification centers develop, whereas they
typically develop sequentially in boys and more
often do not develop simultaneously in girls. The
capitellum fuses first with the trochlea and lateral
condyle. Later in development, there is fusing of
the olecranon, radial head, and lastly the medial
epicondyle. The closure of the medial epicondyle
apophysis is the final growth center about the
pediatric elbow to fuse, which typically occurs
between 15 and 20 years of age, marking skeletal
maturity of the elbow [3] (Table 1.1).
Motion
There are many studies evaluating the range of
motion in pediatric patients with acquired or
genetic conditions, but only a paucity of studies
have described elbow range of motion in the non-­
pathologic pediatric elbow. A recent study by
Barad et al. [9] recorded motion data on 1361
normal pediatric elbows. These patients had a
mean age of 4.9 years (range, 1–16 years; SD,
2.6 years), with a mean weight of 47.5 lb (range,
12–183 lb; SD, 19.8 lb). The mean amount of
flexion was 142° (range, 125°–155°; SD: 4.0°),
and the mean extension was −11° (range, −35° to
0°; SD, 4.3°). The mean total arc of motion was
153° (range, 127°–175°; SD, 6.0°).
When stratified by gender, boys had a mean
amount of flexion, extension, and total arc of
motion of 141°, −11°, and 152°, respectively.
1 Anatomy and Development of the Pediatric Elbow 5

a c

b
d

Fig. 1.2 Radiographs at various developmental ages
demonstrating the progression of ossification. (a) AP and
(b) lateral elbow radiographs of an 18-month-old child.
(c) AP and (d) lateral elbow radiographs of a 3-year-old
child. (e) AP and (f) lateral elbow radiographs of a 6-year-­
old child. (g) AP and (h) lateral elbow radiographs of a
9-year-old child. (i) AP and (j) lateral elbow radiographs
of a 12-year-old child. (k) AP and (l) lateral elbow radio-
graphs of a 15-year-old child (Courtesy of Joshua
M. Abzug, MD)
6 J.J. Jauregui and J.M. Abzug

e g

Fig. 1.2 (continued)

1 Anatomy and Development of the Pediatric Elbow 7

i k

l
j

Fig. 1.2 (continued)

8 J.J. Jauregui and J.M. Abzug

Fig. 1.3 Schematic

showing the various
ossification centers
about the elbow and
Age for Ossification
their average age of Pediatric Elbow
appearance on plain
radiographs (Courtesy of
Joshua M. Abzug, MD)

Medial epicondyle
6–7 years Lateral epicondyle
11–12 years

Capitellum
Olecranon 1 year
10 years
Radial head
4 years
Trochlea
8–10 years

In girls, the mean amount of elbow flexion, exten-
sion, and arc of motion was higher, at 143°, −12°,
and 154°, respectively (p < 0.01). Although sig-
nificantly different, the authors concluded that
these differences were not clinically relevant as
they are all under 2°. The authors also described
that the range of motion when plotted by age
increased until 6 years for boys and until 8 years
for girls; however these findings were not statisti-
cally significant. In contrast, a study by Golden
et al. [10] analyzed the measurements of range of
motion of 600 elbows from 300 children and con-
cluded that the amount of elbow flexion corre-
lated positively with age, whereas the amount of
elbow extension did not.
Specific Development and Anatomy
Bony Anatomy
Three articulations make up the elbow joint.
First, the distal humerus articulates with the
ulna at the trochlea. The trochlea groove of
the ulna articulates at the distal humerus’
medial articular end and is characterized by its
rounded and grooved appearance. The trochlea
groove of the ulna is composed of articular car-
tilage and is bounded proximally by the olecra-
non process and distally by the coronoid
process. Flexion and extension of the elbow
occur through this ulnohumeral or ­ulnotrochlear
1 Anatomy and Development of the Pediatric Elbow
joint. This motion occurs in a single plane due
to this hinged articulation. It is noteworthy
to point out that the ulna fractures in a differ-
ent pattern than many other pediatric and
­adolescent bones about the elbow, with frac-
tures occurring in the metaphysis as opposed to
about a physis [2].
The next articulation is the capitellum met
by the radius’ concave head. The capitellum
forms the distal humerus’ convex lateral artic-
ular surface. In this articulation, the proximal
radius moves in relation to the distal humerus
by a paired concavity and convexity, thus
­p ermitting a pivoting motion. The last articu-
lation about the elbow is the proximal radio-
ulnar joint, where the radial head articulates
with the proximal ulna. This permits rotation
of the forearm with the aid of the interosseous
membrane and distal radioulnar joint [11]
(Fig. 1.1).
Anatomy: Muscles and Ligaments
Integrated stabilization is provided to the
elbow joint when muscles of the arm and fore-
arm transverse the elbow. Stemming from the
medial ­epicondyle is the flexor-pronator mus-
cle group, which aids in resisting valgus stress.
Static stability of the elbow is accomplished by
Ligaments of the Pediatric Elbow
Anterior capsule
Radial collateral
ligament
Annular ligament
Transverse ligament Posterior capsule
Fig. 1.4 Schematic of the elbow depicting the ligamentous structures. The drawing on the left is looking at the lateral
structures, and the drawing on the right depicts the medial structures (Courtesy of Joshua M. Abzug, MD)
9
the bony and ligamentous structures about the
elbow (Fig. 1.4). This stability primarily comes
from the ulnohumeral articulation and the
medial and lateral collateral ligaments. At 90°
of flexion, approximately 55% of the valgus
stability of the elbow occurs due to the ulnar
collateral ligament (UCL). This ligament origi-
nates from the medial epicondyle and is com-
posed of three main elements; the anterior,
posterior, and transverse bundles. The main
valgus stabilizing bundle of the elbow is the
anterior bundle of the UCL, which is dis-
tinctly separate from the anterior joint cap-
sule. The anterior bundle of the UCL is
comprised of anterior and posterior bands that
function separately. While the tightness and
stability in extension is due to the anterior
band, as the elbow is flexed, there is increas-
ing stability provided by the fan-­shaped poste-
rior band [3] (Fig. 1.4).
In contrast, varus stress is resisted mainly by
the bony articulation of the radiocapitellar joint
in flexion and extension, as the lateral collateral
ligament (LCL) only contributes a minimal
amount of stability (9–14%). The lateral collat-
eral ligament complex originates from the lateral
epicondyle and is comprised of the radial collat-
eral ligament, lateral ulnar collateral ligament,
accessory lateral collateral ligament, and annular
ligament [3] (Fig. 1.4).
Anterior bundle (MCL)
Annular ligament
Transverse bundle (MCL)
Posterior bundle (MCL)
10
Centers of Ossification
Many studies have evaluated the formation of the
growth centers within the pediatric elbow [4, 12].
Of these, a recent study by Dwek utilized pediat-
ric elbow images to evaluate multiple growth cen-
ters about the elbow. There are four secondary
ossification centers seen in the distal humerus: (1)
the capitellum, (2) the trochlea, (3) the medial epi-
condyle, and (4) the lateral epicondyle. It is worth
pointing out that at birth, not one of these centers
is ossified [5, 6]. In terms of laterality, studies
describe no difference in timing or ossification
pattern between the right and left elbow [4].
A single smooth center is how the capitellum
develops with ossification. A jagged and non-­
regular appearance is seen in the trochlear ossifi-
cation. A single center is seen in development for
the medial epicondyle; however, this physis is a
spherical growth plate that engulfs the whole
medial epicondyle, which allows for the normal
circumferential growth to take place [12]. A sin-
gle elongated center or even multiple centers can
be seen in the ossification of the lateral epicon-
dyle. The ossification center of the radial head
starts out oval and later becomes disk shape and
flat. The olecranon commonly starts as two sec-
ondary centers which ossify into the olecranon
but can also start as multiple centers which should
not be mistaken for fracture fragments [4, 11]
(Figs. 1.2 and 1.3).
The lateral condyle forms from the fusion of
the lateral epicondyle to the distal humeral epiph-
ysis, which then later fuses to the metaphysis.
The fusion of the epiphysis and metaphysis is the
last step of the lateral epicondyle’s ossification,
which is a peripheral process. This forms a large
gap between the lateral epicondyle ossification
center and the lateral condyle, with the former
having a linear pattern and the latter often mis-
taken for an avulsion fracture.
Soft Tissue
Multiple fat pads exist about the elbow and are
typically located within bony fossae that exist
to permit flexion and extension of the elbow.
J.J. Jauregui and J.M. Abzug
These fat pads can be pushed up and outward
from the fossae when the joint space is filled
with fluid, such as blood following a fracture.
There are many studies that have evaluated this
finding and have described that the posterior fat
pad sign could be predictive of an occult frac-
ture of the elbow following trauma. Skaggs and
Mirzayan described this fat pad sign in a pro-
spective series of 45 children with a traumatic
history about the elbow who had an elevated
posterior fat pad and had no other radiographic
evidence of fracture. The authors reimaged the
elbows in these children and noted that perios-
teal reaction from an occult fracture was pres-
ent in 76% of patients [13].
Nerve Anatomy
The nerve anatomy of the pediatric elbow is
similar to that of the adult counterpart. In pedi-
atric patients, the ulnar nerve crosses the elbow
posterior to the medial epicondyle, the median
nerve crosses the elbow with the brachial
artery, and the radial nerve runs between the
brachialis and brachioradialis muscles before
crossing the elbow and penetrating the supina-
tor muscle. The radial and median nerves are
vulnerable to injury following supracondylar
humerus fractures which occur after an elbow
hyperextension injury. In contrast, the ulnar
nerve is vulnerable to injury after a supracon-
dylar fracture with elbow hyperflexion or when
a direct blow to the posterior aspect of the
elbow occurs.
Pediatric patients may have instability of the
ulnar nerve, which is important to recognize
due to the potential risk for nerve injury during
medial percutaneous pinning of supracondylar
humerus fractures. Zaltz et al. [14] evaluated
328 ulnar nerves (164 children) and noted that
17.7% of children between the ages of 0–5 had
ulnar nerve instability. 7.7% of the children
between 6 and 10 years of age and 5.7% of the
children between 11 and 18 years of age had
ulnar nerve instability. The rate of ulnar nerve
instability is significantly increased in children
with ligamentous laxity.
1 Anatomy and Development of the Pediatric Elbow
Vascular Anatomy
The brachial artery runs superficial to the brachia-
lis muscle along the anteromedial aspect of the
humerus. Subsequently, this artery passes anterior
to the distal humerus while an extensive collateral
circulation develops. As the artery extends into
the forearm, it splits into the radial and ulnar arter-
ies. Following a supracondylar humerus fracture,
the brachial artery is especially prone to injury.
The distal extent of the proximal bony fragment
may cause intimal damage to the vessel leading to
subsequent thrombosis and vascular insufficiency.
Due to the extensive collateral circulation present
at the elbow, arm ischemia caused by complete
occlusion of the brachial artery is infrequent.
Conclusion
Knowledge of the development of the pediat-
ric elbow is necessary for the proper manage-
ment of children with an elbow fracture.
References
1. Shrader MW. Pediatric supracondylar fractures and
pediatric physeal elbow fractures. Orthop Clin North
Am. 2008;39(2):163–71, v.
2. John SD, Wherry K, Swischuk LE, Phillips
WA. Improving detection of pediatric elbow fractures
by understanding their mechanics. Radiographics.
1996;16(6):1443–60; quiz 63–4.
11
3. Tisano BK, Estes AR. Overuse injuries of the pediat-
ric and adolescent throwing athlete. Med Sci Sports
Exerc. 2016;48(10):1898–905.
4. Cheng JC, Wing-Man K, Shen WY, Yurianto H, Xia
G, Lau JT, et al. A new look at the sequential devel-
opment of elbow-ossification centers in children. J
Pediatr Orthop. 1998;18(2):161–7.
5. McCarthy SM, Ogden JA. Radiology of postnatal
skeletal development. VI. Elbow joint, proximal
radius, and ulna. Skeletal Radiol. 1982;9(1):17–26.
6. McCarthy SM, Ogden JA. Radiology of postnatal
skeletal development. V. Distal humerus. Skeletal
Radiol. 1982;7(4):239–49.
7. Garn SM, Rohmann CG, Silverman FN. Radiographic
standards for postnatal ossification and tooth calcifi-
cation. Med Radiogr Photogr. 1967;43(2):45–66.
8. Dimeglio A, Charles YP, Daures JP, de Rosa V,
Kabore B. Accuracy of the Sauvegrain method in
determining skeletal age during puberty. J Bone Joint
Surg Am. 2005;87(8):1689–96.
9. Barad JH, Kim RS, Ebramzadeh E, Silva M. Range of
motion of the healthy pediatric elbow: cross-­sectional
study of a large population. J Pediatr Orthop B.
2013;22(2):117–22.
10. Golden DW, Jhee JT, Gilpin SP, Sawyer JR. Elbow
range of motion and clinical carrying angle in a
healthy pediatric population. J Pediatr Orthop B.
2007;16(2):144–9.
11. Delgado J, Jaramillo D, Chauvin NA. Imaging the
injured pediatric athlete: upper extremity. Radiographics.
2016;36(6):1672–87.
12. Dwek JR. A segmental approach to imaging of sports-­
related injuries of the pediatric elbow. Sports Health.
2012;4(5):442–52.
13. Skaggs DL, Mirzayan R. The posterior fat pad sign in
association with occult fracture of the elbow in chil-
dren. J Bone Joint Surg Am. 1999;81(10):1429–33.
14. Zaltz I, Waters PM, Kasser JR. Ulnar nerve instability
in children. J Pediatr Orthop. 1996;16(5):567–9.
 Physical Examination
of the Pediatric Elbow
Matthew Varacallo, Kush S. Mody, Darshan Parikh,
and Martin J. Herman
Pediatric Elbow Injuries
The pediatric and adolescent elbow is subject to
both acute and chronic injuries. In general, the
injury patterns seen are related to the relative
weakness of the developing physes in compari-
son to the surrounding soft tissue stabilizers [1,
2] and the rapid turnover of the bone in the
metaphysis of the distal humerus, proximal
radius, and proximal ulna that particularly make
the elbow susceptible to fracture. Overall, elbow
injuries account for 1–3% of all pediatric and
adolescent emergency department (ED) visits
[3]. These numbers are expected to increase with
increasing participation in youth sports as well as
the advent of extreme sports [4]. Competitive
sports participation with younger athletes is esti-
mated at seven million in the United States alone,
M. Varacallo, M.D.
Department of Orthopedic Surgery, Drexel University
College of Medicine, Philadelphia, PA, USA
e-mail: Born2run.4@gmail.com
K.S. Mody, B.S. • D. Parikh, B.S.
Drexel University College of Medicine,
Philadelphia, PA, USA
e-mail: Ksmody2255@gmail.com; Djp337@drexel.edu
M.J. Herman, M.D. (*)
Drexel University College of Medicine,
St. Christopher’s Hospital for Children,
3601 A Street, Philadelphia, PA 19134, USA
e-mail: MARTIN1.Herman@tenethealth.com
© Springer International Publishing AG 2018
J.M. Abzug et al. (eds.), Pediatric Elbow Fractures, https://doi.org/10.1007/978-3-319-68004-0_2
2
and year-round sport participation has generated
substantial increases of certain types of chronic
overuse injuries [5, 6]. The annual incidence of
elbow pain in youths playing baseball, aged
9–12 years old, is approximately 50–70% [7].
High rates of pediatric elbow injuries also occur
in tennis and gymnastics [4].
Elbow fractures are among the most com-
mon injuries seen in pediatrics, second only to
fractures of the distal forearm [8–10]. Fractures
of the elbow comprise 5–10% of all fractures in
the pediatric population, and they account for
up to 85% of the operatively treated pediatric
injuries in some series [11]. Supracondylar
humerus (SCH) fractures account for the major-
ity of pediatric elbow fractures and in total
account for around 3% of all pediatric fractures
[12, 13]. Lateral condyle and medial epicon-
dyle fractures make up the second and third
most common types of pediatric elbow frac-
tures, respectively [14].
Pediatric elbow injuries often present a diag-
nostic dilemma for the treating physician. The
unique anatomy of the elbow in the growing child
along with the narrow therapeutic window and
relatively high complication rates associated with
certain types of fracture patterns creates a chal-
lenging diagnostic environment for the clinician.
Moreover, injury patterns change with the growth
and development of the elbow into adolescence
and young adulthood [15]. Understanding the
context and chronicity of the injury helps guide
13
14
the clinician through a comprehensive physical
examination and establishes the appropriate diag-
nostic framework to successfully treat pediatric
and adolescent patients presenting with a wide
variety of elbow pathology.
Clinical Assessment
The History
Acute Injury
The initial approach to the pediatric or adoles-
cent patient with a suspected injury or fracture
about the elbow follows a standard approach to
assessing any type of musculoskeletal pathology.
An accurate and complete history should be
obtained from the patient if possible. The wide
variety of potential injuries, in addition to the
potential difficulty with radiographic interpreta-
tion, makes obtaining an accurate and compre-
hensive history imperative.
The location, quality, and duration of the pain,
if any, should be elicited as best as possible. Time
of onset as well as any history of similar episodes
or injuries helps guide the working differential
diagnosis. Any previous interventions or associ-
ated injuries or symptoms should be taken into
consideration as well [4]. Finally, referred pain
from the cervical spine, shoulder, hand, and/or
wrist should be ruled out by asking specifically
about limitation of motion or pain in these other
areas, radiation of pain, and sensory and motor
changes in the extremity [2, 16].
For acute fractures about the elbow, the his-
tory is usually indicative of a high-energy trauma
or a fall from height on an outstretched hand
with the elbow extended [11, 17–19]. In these
situations, it is important to consider a complex
fracture dislocation or associated neurovascular
injuries, which may complicate the overall man-
agement, although the majority of injuries are
isolated elbow fractures [20]. The age of the
patient and their degree of skeletal maturity
also influence the type of fracture pattern sus-
tained. Knowledge of the normal growth pat-
tern and expected ages of reference for sequential
ossification center appearance, ­ development,
M. Varacallo et al.
and fusion is critical for appropriate evaluation
and management of these injuries.
In general, the younger the child at the time of
the injury, the more difficult the assessment can be
in many cases. In younger patients or patients with
developmental delays in which the clinician must
rely solely on the parents and/or caregivers, child
abuse must be in the working differential diagno-
sis. Although beyond the scope of this chapter, all
health providers taking care of children should be
able to distinguish between abusive and accidental
injury in settings when the stated cause is not con-
sistent with the injury [21, 22].
Chronic Injury
In chronic overuse injuries, asking about sports
participation is critical [2, 23]. This includes an
accurate description with respect to seasonal activ-
ity, duration of play, year-round schedules, and any
periods of rest from participation. A careful assess-
ment of the overall effect on the child and the
importance of sports in his or her daily life can
influence potential overreporting or underreporting
of symptoms [2]. Little league baseball pitchers
and other overhead athletes most commonly pres-
ent with medial elbow pain, which can be either
constant or intermittent with increasing activity
[24]. The age of the patient helps provide clues for
the potential diagnosis. Patients in early childhood
and in whom the secondary ossification centers
have yet to appear have pain likely from repetitive
injury to the ossification center and apophysis of
the medial epicondyle. In adolescents, however, the
pain is more likely from the muscle attachments
pulling on the medial epicondyle repetitively and
eventually resulting in a medial epicondyle avul-
sion injury [25] or ulnar collateral ligament incom-
petence, a much less common scenario in children
younger than 12 years of age.
Physical Examination
of the Injured Arm
Observation and Inspection
Observation is a key component when examining
younger patients and should not be overlooked.
2 Physical Examination of the Pediatric Elbow
Assessing the child’s demeanor and if he or she is
able to use the extremity adds to the clinical pic-
ture and suspected diagnostic considerations. In
addition, comparing how the child is using the
injured side to the contralateral, uninjured side
can help provide an appropriate frame of refer-
ence. During the inspection, the skin should be
checked for any ecchymosis, abrasions, tissue
loss, or swelling indicating an acute injury. Signs
of an open fracture such as small puncture sites,
intermittent oozing of blood or frank bleeding,
and exposed bone must also be assessed. In
patients with chronic symptoms, more long-­
standing changes such as hypertrophy or atrophy
of the surrounding musculature and joint contrac-
tures should also be noted.
For patients able to comfortably extend the
elbow, the overall axial alignment of the limb at
the elbow, also known as the carrying angle
(Fig. 2.1), is assessed and compared to the
a b
Fig. 2.1 Carrying angle. (a) Normal carrying angle. The
carrying angle is defined as an angle made by the axes of
the arm and the forearm, with the elbow in full extension
and the palm facing anteriorly. In most children and
adults, the normal angle varies between 5° and 15° of val-
gus (distal segment pointing away from the midline).
Females generally have an increased carrying angle com-
pared to males. (b) Cubitus varus. A child with cubitus
15
c­ ontralateral side. The carrying angle is deter-
mined clinically by the angle formed between
the long axis of the humerus and forearm at the
elbow joint itself [26, 27]. Typically, the carry-
ing angle measures between 11° and 14° of
valgus; overhead throwers often demonstrate
an increased carrying angle secondary to repet-
itive valgus stresses, which can cause medial
epicondyle hypertrophy [27, 28]. Variations in
the carrying angle may also be secondary to
previous trauma, the most common of which is
cubitus varus or “gunstock” deformity, the
result of varus malunion of a supracondylar
humerus fracture. Genetic syndromes that are
associated with congenital abnormalities of the
elbow, such as a congenital radial head disloca-
tion causing cubitus valgus, as well as ligamen-
tous hyperlaxity, and neuromuscular diseases,
among other etiologies, are associated with
abnormal carrying angles.
c
varus, also known as “gunstock deformity,” has less than
0° of valgus. It is usually the most common complication
following a supracondylar fracture. (c) Asymmetric carry-
ing angle. This child had two supracondylar fractures of
the left elbow and now has asymmetry of the carrying
angle with more valgus on the left than the right but has no
functional deficits. Cubitus valgus is usually greater than
15° from the midline
16
Palpation
The next component of the physical exam involves
palpating the anatomic landmarks about the
elbow, starting first with the asymptomatic areas
and progressing toward the symptomatic ones.
Bony landmarks that can be palpated at the elbow
include the distal humeral metaphysis, the medial
and lateral epicondyles, the olecranon process and
proximal ulna, and the radial head and capitellum
at the radiocapitellar articulation. The osseous
points from the epicondyles form a triangle with
equal lengths to each side connecting the olecra-
non inferiorly. Palpation in the lateral soft spot
between the capitellum, radial head, and olecra-
non may demonstrate soft tissue fullness indicat-
ing a possible joint effusion. Focal areas of
tenderness may be indicative of fracture or other
acute injuries and warrant further investigation.
Palpation of the soft tissues of the upper arm
and forearm is useful if severe trauma or the
development of compartment syndrome is of con-
cern. The volar upper arm, and in particular the
biceps muscle, is rarely the site of compartment
syndrome but, in our experience, may occur. The
volar forearm, however, is the most common site
of compartment syndrome development after
supracondylar fractures and other severe injuries
of the elbow. While subjective, tenderness along
the muscle of the arm and foreman as well as
tenseness of the compartments must be included
in the initial examination and afterward if the sus-
picion for the diagnosis is raised. This part of the
exam is often coupled with assessment of pain
when passively stretching the fingers of the
affected arm. While pain with passive stretch is a
potential sign of compartment syndrome, in chil-
dren this determination may be unreliable because
of anxiety and preexisting discomfort from the
fracture and subjective, similar to the determina-
tion of the “tenseness” of compartments.
Provocative Maneuvers
Provocative maneuvers can also be combined
with palpation to aid in diagnosis. Pain caused by
M. Varacallo et al.
pressure directly over the radiocapitellar joint
combined with axial loading and forearm prona-
tion and supination can be indicative of Panner’s
disease, an osteochondrosis of the capitellar ossi-
fication center in preadolescent children; once
adolescence is reached, similar findings more
often correlate with a capitellar OCD lesion [25,
29, 30]. Palpation of the radial head while pronat-
ing and supinating the forearm may also elicit a
sensation of radial head instability in patients
with a missed radial head dislocation or missed
Monteggia fracture.
Tenderness to palpation at or around the
lateral epicondyle may be indicative of lateral
epicondylitis or apophysitis, depending on the
age of the patient; resisted wrist extension,
which puts on stretch the wrist extensors
which originate from the lateral epicondyle,
provokes the patient’s pain. A similar approach
is applied on medial palpation. Tenderness can
be elicited around the medial epicondyle sec-
ondary to apophysitis (chronic medial epicon-
dylitis) or ulnar collateral injury depending on
the age of the patient; resisted wrist flexion
may illicit pain because the flexor-pronator
mass originates at the medial epicondyle.
While skeletally immature patients may have a
combination of apophysitis and ligament ten-
derness, which is difficult to determine on
exam alone, older patients with a completely
fused medial epicondyle are more likely to
have pathology related strictly to the ulnar col-
lateral ligament.
The Posterior Elbow
To exam for posterior pathology, the elbow is
positioned in 25°–30° of flexion to “unlock” the
olecranon from the humerus and relax the tri-
ceps. The posteromedial and posterolateral
aspects of the olecranon fossa are then palpated
for fullness or tenderness; adolescent overhand
throwers can present with pain posteriorly sec-
ondary to valgus extension overload, termed
posterior impingement. Olecranon apophysitis
and proximal ulna stress reactions may also be
2 Physical Examination of the Pediatric Elbow
seen in the scenario of overuse, signaled by
point tenderness at the olecranon process and
along the triceps insertion. In older adolescents,
repetitive stresses posteriorly can result in
osteophyte formation in the olecranon fossa,
causing a painful mechanical block to full
elbow extension [27].
Range of Motion and Stability
Normal range of motion (ROM) is defined as
unopposed motion of the forearm with flexion,
extension, supination, and pronation at the
elbow joint, with all four types of motions ide-
ally evaluated both actively and passively.
Although normal range values exist to describe
range of motion with respect to the skeletally
mature elbow, normative data for healthy
pediatric patients is somewhat lacking and
controversial [25, 31]. Several recent studies
have been conflicting regarding age and
gender-specific differences with respect to
flexion at the elbow in particular [30, 32].
Despite these minor discrepancies, normal
ROM in the flexion-extension plane is gener-
ally described as 140° of flexion to extension
of 0 to −10° of hyperextension, with the
assessment made with the patient holding the
forearm supinated. Normal forearm pronation
and supination are typically 75° and 85°,
respectively [33]. Passive rotation of the fore-
arm is best determined by grasping the distal
forearm and rotating it into supination and
pronation, thereby eliminating carpal rotation;
active measures of forearm rotation that use
the hand or thumb position to assess motion
may lead to overestimation of true forearm
rotation because of carpal mobility.
In patients with acute injuries, assessing
active motion first assures that the examiner
does not cause discomfort by attempting to
passively move an injured arm; lack of full
active motion after an injury is an indication
for elbow imagining. For patients with chronic
complaints of elbow pain, flexion contracture
is a common presentation for many overuse
17
pathologies. It is important to compare elbow
extension to that of the contralateral extremity
because subtle loss of extension may not be
appreciated without direct comparison; an
asymptomatic 10°–15° flexion contracture
may be a sign of early apophysitis, OCD lesion
of the capitellum, or posterior impingement
syndrome.
Stability Tests
Elbow instability can be difficult to determine in
the younger patient while in the office, while
adolescents tend to be more cooperative with cer-
tain types of provocative exam maneuvers. In the
setting of acute injury, these are especially diffi-
cult for patients to tolerate and, in our practice,
rarely applied in this scenario. To test the lateral
ligamentous complex, slight varus stress and
internal rotation are applied to the elbow with the
joint positioned in about 25°–35° of flexion. In a
similar fashion, the medial complex is tested by
applying a valgus moment combined with an
external rotational stress with the elbow held at
25°–35° of flexion [27]. The posterolateral pivot
shift test, a provocative maneuver used to assess
stability of the posterolateral ligamentous com-
plex of the elbow, is performed by applying a
valgus and axial load to the elbow while flexing
the elbow with the forearm held in supination and
the arm positioned overhead; the test is most reli-
able when performed with anesthesia. A positive
test demonstrates a clunk with greater than 40° of
flexion [34].
These examination maneuvers can be helpful
in evaluating certain types of chronic elbow
pathologies. For example, valgus instability may
develop secondary to nonunion or malunion of a
previous medial epicondyle fracture or avulsion
injury. Posterolateral rotatory instability (PLRI),
diagnosed by the posterolateral pivot shift test,
may be seen in patients sustaining an elbow dis-
location who develop secondary lateral collateral
ligament deficiency or in adults who have resid-
ual cubitus varus after a supracondylar fracture
sustained as child.
18
Neurovascular Assessment
A thorough neurovascular examination of the
upper extremity must be performed for patients
with both acute and chronic complaints. In the
setting of a high-energy injury especially, but
even after isolated elbow trauma, immediate
assessment of the neurovascular structures to the
limb is imperative and helps guide the short-term
management of the injury. Assessment of
younger patients in the setting of acute trauma
may be a difficult task secondary to pain and anx-
iety [35]. Using a gentle approach and starting
with the uninjured side help reassure the patient
that cooperating with the exam will not be pain-
ful. A systematic approach to the motor and sen-
sory function of the nerves (median, ulnar, and
radial nerves) of the arm should be undertaken.
Motor Testing
A simple way to assess the motor function of the
anterior interosseous nerve, a segment of the
a b
Fig. 2.2 The physical exam of the injured upper extrem-
ity includes a motor examination of the hand by individu-
ally testing median, ulnar, and radial nerve function.
Playing the children’s game “rock-paper-scissors” is one
method of examining the younger child. (a) Median nerve
function: “rock”. “Rock” (making a fist) grossly tests the
median nerve, which innervates the finger and forearm
flexors. Injury to the median nerve can decrease flexor
M. Varacallo et al.
median nerve that has no sensory component and
is the most commonly injured nerve when exten-
sion supracondylar fractures occur, is to ask the
child to make an “ok” sign [36]; this movement
requires both flexion of the second finger DIP
joint and the IP joint of the thumb that are pow-
ered by this nerve. Ulnar nerve motor function
can be tested by having the child “claw” the ring
and little fingers or to ask the child to flex the
fifth finger while holding the PIP joint extended,
effecting isolating FDP function powered by the
ulnar nerve. The posterior interosseous nerve, a
segment of the radial nerve with no sensory
component, is tested by asking the child to give
a “thumbs up” or having the child extend the
MCP joints of the fingers while holding the PIP
and DIP joints flexed. Having the child play
rock-­paper-­scissors (Fig. 2.2) is another classic
method that is often used to adequately assess
motor function in pediatric patients [37].
Forming the “paper” tests radial nerve motor
function, cutting with “scissors” tests ulnar
nerve motor function, and making the “rock”
tests median nerve motor function.
c
function and affect the thenar muscles of the thumb. (b)
Radial nerve function: “paper”. “Paper” (finger extension)
grossly tests the radial nerve, which innervates the finger
and forearm extensors. (c) Ulnar nerve function: “scis-
sors”. “Scissors” (actively spreading the extended index
and middle fingers) tests the ulnar nerve, which innervates
the intrinsic hand muscles, such as the interossei and
lumbricals
2 Physical Examination of the Pediatric Elbow
Sensory Exam
The sensory examination should be performed
in all three nerve distributions: median, ulnar,
and radial nerves (Fig. 2.3). Light touch is pri-
marily tested in the setting of acute injury by
gently stroking the skin; two-point discrimina-
tion testing and pinprick are not tested routinely
except in the setting of chronic nerve injury or
in the setting of surgical nerve repair and recov-
ery. The median nerve is best tested by stroking
the palmar index middle fingers. The ulnar
nerve is best tested along the lateral (ulnar) bor-
der of the fifth finger. Radial nerve sensation is
assessed by stroking the skin of the first dorsal
web space and lateral (radial) thumb. Most chil-
dren younger than 3–4 years of age are able to
participate in the exam without difficulty and
are able to verbalize and distinguish differences
between the injured and non-injured limbs.
Younger patients and patients with develop-
mental delays present more of a challenge but
can be examined by observing them doing
activities, participating in games, or presenting
them objects to grasp or giving them tasks such
as holding a pencil that require different motor
and sensory input. Pinching or applying nox-
ious stimuli along the nerve distribution may
bring about a withdrawal response and is sug-
gestive of normal sensation [8] but is ­sometimes
a b
Fig. 2.3 The sensory examination of the hand assesses
areas that are innervated by a single nerve. Light touch
can be assessed even in young children, while two-point
discrimination is more difficult to assess. (a) Median
nerve innervation. Sensation in the palmar index finger at
the level of the distal phalanx shows innervation by the
19
difficult to ascertain and may lead to discomfort
which makes the remainder of the exam more
difficult.
Vascular Exam
Finally, the vascular exam is an essential compo-
nent of the examination (Fig. 2.4). The exam starts
by assessing the color of the extremity, noting a nor-
mal pink tone of the palmar hand and fingers as
opposed to the whitish or pale appearance of the
dysvascular limb. Feeling the fingertips of the
affected limb and comparing the general sense of
warmth compared to the uninvolved limb is another
way of determining flow but may be influenced by
the method of immobilization, the ambient temper-
ature, and other factors, making this assessment
especially subjective. Palpation of the radial pulse is
the most common way to assess flow and is easier to
find compared to the ulnar pulse in many children.
A rich collateral circulation that takes its origin
proximal to the elbow provides adequate perfusion,
however, for many children even if the brachial
artery is in spasm or is disrupted yielding no palpa-
ble distal pulses, such as after a supracondylar frac-
ture. Doppler studies are not routinely used but are
helpful when the limb is severely swollen and diffi-
cult to assess or the physical exam is equivocal. The
vascular status is generally reported as in the table.
c
median nerve. (b) Radial nerve innervation. Sensation on
the dorsum of the thumb in the first web space can mea-
sure innervation by the radial nerve. (c) Ulnar nerve inner-
vation. Sensation in the palmar and lateral small finger at
the level of the distal phalanx shows innervation by the
ulnar nerve
20
a b
c
Vascular status Radial pulse
Normal present
Pink, pulseless absent
Dysvascular absent
Fig. 2.4 Vascular assessment of the upper extremity. (a)
Distal blood flow. The vascular assessment includes pal-
pating for the radial pulse. Doppler ultrasound may also
be used to assess distal flow. (b) Capillary refill. Normal
capillary refill is less than 3 s in children in normal ambi-
ent room temperature; it is used to indicate adequate
hydration and distal blood perfusion to tissues. (c)
Vascular status. The vascular assessment is generally
­classified into three broad types for children with a supra-
Summary
A careful assessment of the injured limb includes
observation and assessment of deformity, palpa-
tion for tenderness and signs of severe swelling in
the compartments, and elbow range of motion
­assessment actively and passively when tolerated
by the patient. A thorough motor and sensory
examination should focus on the median, ulnar,
and radial nerves. Vascular assessment is critical to
distinguish between the normal exam, the limb
that has perfusion but is pulseless, and the dysvas-
cular hand.
M. Varacallo et al.
Finger perfusion Temperature
pink warm
pink warm
white cool
condylar fracture based on the examination. The radial
pulse is determined by palpation but may also be assessed
by Doppler ultrasound; comparison of the result to the
uninjured limb is useful for separating flow patterns that
result from collateral circulation versus normal radial
artery flow. The finger perfusion is considered normal if
the capillary refill is normal and the palmar digits and nail
beds are pink. Temperature is determined by comparing
the injured limb to the uninjured limb and is subjective
References
1. Malanga GA, Ramirez JA. Common injuries of the
foot and ankle in the child and adolescent athlete.
Phys Med Rehabil Clin N Am. 2008;19:347–71.
2. Miller MD, Thompson SR, DeLee J, Drez D. DeLee &
Drez’s orthopaedic sports medicine. 4th ed. Elsevier/
Saunders; 2015.
3. Freed GL, Gafforini S, Carson N. Age distribution
of emergency department presentations in Victoria.
Emerg Med Australas. 2015;27(2):102–7.
4. Arora R, Fichadia U, Hartwig E, Kannikeswaran
N. Pediatric upper-extremity fractures. Pediatr Ann.
2014;43(5):196–204.
5. McLeod TCV, Decoster LC, Loud KJ, Micheli LJ, Parker
JT, Sandrey MA, White C. National Athletic Trainers’
2 Physical Examination of the Pediatric Elbow
Association position statement: prevention of pediatric
overuse injuries. J Athl Train. 2011;46(2):206–20.
6. Dizdarevic I, Low S, Curie DW, Comstock RD,
Hammoud S, Atanda A Jr. Epidemiology of elbow
dislocations in high school athletes. Am J Sports Med.
2016;44(1):202–8.
7. Ireland ML, Hutchinson MR. Upper extrem-
ity injuries in young athletes. Clin Sports Med.
1995;14(3):533–69.
8. Wingfield JJ, Ho CA, Abzug JM, et al. Open
reduction techniques for supracondylar frac-
tures in children. J Am Acad Orthop Surg.
2015;23(12):e72–80.
9. Simanovsky N, Lamdan R, Mosheiff R, Simanovsky
N. Underreduced supracondylar fracture of the
humerus in children: clinical significance at skeletal
maturity. J Pediatr Orthop. 2007;27(7):733–8.
10. Lanson AN, Garg S, Weller A, et al. Operative treat-
ment of type II supracondylar humerus fractures:
does time to surgery affect complications? J Pediatr
Orthop. 2014;34(4):382–7.
11. Badkoobehi H, Choi PD, Bae DS, Skaggs
DL. Management of the pulseless pediatric supracon-
dylar humeral fracture. J Bone Joint Surg Am. 2015
Jun 3;97(11):937–43.
12. Cheng JC, Lam TP, Maffuli N. Epidemiological
features of supracondylar fractures of the
humerus in Chinese children. J Pediatr Orthop B.
2001;10(1):63–7.
13. Scanell BP, Jackson JB 3rd, Bray C, et al. The per-
fused, pulseless supracondylar humeral fracture:
intermediate-term follow-up of vascular status and
function. J Bone Joint Surg Am. 2013;95(21):1913–9.
14. Landin LA, Danielesson LG. Elbow fractures in chil-
dren: an epidemiological analysis of 589 cases. Acta
Orthop Scand. 1986;57:309–12.
15. Crowther M. Elbow pain in pediatrics. Curr Rev
Musculoskelet Med. 2009;2(2):83–7.
16. Goldberg C. Musculoskeletal examination general
principles and detailed evaluation of the knee &
shoulder. The Regents of the University of California;
2011.
17. Omid R, Choi PD, Skaggs DL. Supracondylar
humeral fractures in children. J Bone Joint Surg Am.
2008;90(5):1121–32.
18. Lee SS, Mahar AT, Miesen D, Newton PO. Displaced
pediatric supracondylar humerus fractures: biome-
chanical analysis of percutaneous pinning techniques.
J Pediatr Orthop. 2002;22(4):440–3.
19. Farnsworth CL, Silva PD, Mubarak SJ. Etiology of
supracondylar humerus fractures. J Pediatr Orthop.
1998;18(1):38–42.
20. Kazakos CJ, Galanis VG, Verettas DJ,
Dimitrakopoulou A, Polychronidis A, Simopoloulos
C. Unusual patterns of Monteggia fracture-­dislocation.
J Orthop Surg. 2006;1:12.
21
21. Swoboda SL, Feldman KW. Skeletal trauma in child
abuse. Pediatr Ann. 2013;42(11):236–43.
22. Flaherty EM, Perez-Rossello JM, Levine MA,
Hennrikus WL. Evaluating children with fractures for
child physical abuse. Am Acad Pediatr. 2014;133:2.
23. Difiori P, Benjamin HJ, Brenner J, Gregory A,
Jayanthi N, Landry GL, Luke A. Overuse injuries and
burnout in youth sports: a position statement from the
American Medical Society for Sports Medicine. Clin
J Sport Med. 2014;24:3–20.
24. Kramer DE. Elbow pain and injury in young athletes.
J Pediatr Orthop. 2010;30:S7–S12.
25. Dwek JR. A structural and mechanism-based perspec-
tive toward understanding pediatric and adult sports
injuries. AJR Am J Roentgenol. 2016;206(5):980–6.
26. Golden DW, Jhee JT, Gilpin SP, Sawyer JR. Elbow
range of motion and clinical carrying angle in a
healthy pediatric population. J Pediatr Orthop B.
2007;16(2):144–9.
27. Hsu SH, Moen TC, Levine WN, Ahmad CS. Physical
examination of the Athlete’s elbow. Am J Sports Med.
2012;40:699.
28. O’Holleran JD, Altchek DW. The Thrower’s elbow:
arthroscopic treatment of valgus extension overload
syndrome. HSS J. 2006;2(1):83–93.
29. Kramer DE, Yen YM, Simoni MK, Miller PE,
Micheli LJ, Kocher MS, Heyworth BE. Surgical
management of osteochondritis dissecans
lesions of the patella and trochlea in the pediat-
ric and adolescent population. Am J Sports Med.
2015;43(3):654–62.
30. Chen NC. Osteochondritis dissecans of the elbow. J
Hand Surg Am. 2010;35(7):1188–9.
31. Barad JH, Kim RS, Ebramzadeh E, Silva M. Range of
motion of the healthy pediatric elbow: cross-­sectional
study of a large population. J Pediatr Orthop B.
2013;22(2):117–22.
32. Da Paz SN, Stalder A, Berger S, Ziebarth K. Range
of motion of the upper extremity in a healthy pediat-
ric population: introduction to normative data. Eur J
Pediatr Surg. 2016;26(5):454–61.
33. Berme N, Engin AE, Correia da Silva KM
Biomechanics of normal and pathological human
articulating joints. NATO ASI Series. 1985;3:123.
34. Fedorka CJ, Oh LS. Posterolateral rotatory insta-
bility of the elbow. Curr Rev Musculoskelet Med.
2016;9(2):240–6.
35. Shrader MW. Pediatric supracondylar fractures and
pediatric physeal elbow fractures. Orthop Clin North
Am. 2008;39(2):163–71.
36. Robertson JS, Marsh AG, Huntley JS. Neurological
status in paediatric upper limb injuries in the emer-
gency department current practice. BMC Res Notes.
2012;5:324.
37. Davidson AW. Rock-paper-scissors. Injury. 2003;​
34(1):61–3.
 Radiographic Evaluation
of the Pediatric Elbow
Ryan Hoffman, John Prodromo,
and Martin J. Herman
Introduction
Pediatric elbow fractures are difficult clinical
challenges to manage for many reasons. For the
inexperienced surgeon, however, interpretation
of x-rays of the injured child’s elbow is perhaps
the most daunting of tasks. The elbow is a com-
plex joint with three articulations that allow
flexion-­extension of the elbow joint as well as
pronation-supination of the forearm. The devel-
opmental bony anatomy is also complex, as
ossification centers form sequentially over time.
Starting out as cartilaginous anlagen, the distal
humerus, proximal radius, and proximal ulna
progress through skeletal maturity via a predict-
able pattern of ossification. These sequential
bony changes make the radiographic appear-
ance of the pediatric elbow appear differently
R. Hoffman, B.S., M.D.
Department of Orthopedic Surgery, Albert Einstein
Medical Center, 5501 Old York Road,
Philadelphia, PA, USA
e-mail: Rah94@drexel.edu
J. Prodromo, M.D.
Department of Orthopedic Surgery, Drexel University
College of Medicine, Philadelphia, PA, USA
e-mail: prodromo.john@gmail.com
M.J. Herman, M.D. (*)
Drexel University College of Medicine,
St. Christopher’s Hospital for Children,
3601 A Street, Philadelphia, PA 19134, USA
e-mail: MARTIN1.Herman@tenethealth.com
© Springer International Publishing AG 2018
J.M. Abzug et al. (eds.), Pediatric Elbow Fractures, https://doi.org/10.1007/978-3-319-68004-0_3
3
year-to-­year, making x-ray interpretation com-
plicated and fraught with errors of both under-
and overdiagnosis of injuries.
Mastery of the radiographic assessment of the
pediatric elbow is critical to success of care of
pediatric elbow trauma and an important goal for
the young surgeon [1].
Basic Anatomy
Bony Anatomy
The elbow is a ginglymus joint—a stabilized
articulation providing motion strictly in a sin-
gle plane—resembling that of a hinge. This
joint is primarily responsible for flexion, supi-
nation, and pronation of the forearm relative to
the arm. The elbow is constructed on a founda-
tion of three articulations—the humeroradial,
humeroulnar, and radioulnar. The humerus dis-
tally transitions from the diaphyseal shaft into
two columns of metaphyseal bone that are sepa-
rated by the olecranon fossa, an oval depression
in the posterior surface of the bone where the
tip of the olecranon fits when the elbow is
extended. Distal to this, these separate bony
columns coalesce and terminate in the distal
humeral articulation, two convex surfaces of
bone covered with hyaline cartilage separated
in the middle by a shallow cleft that creates a
spool-like appearance to the bone’s end. The
23
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Cambridge Gulf Tribes, x, 51, 62, 65, 74, 93, 99, 101, 226, 238,
282, 288, 375, 377, 405
camel, ochre drawing of, 329
Campbell, John, 344
camp, clearing a site for, 100;
life, 100-119;
occupations while in, 112, 113;
selection of, 91
camptocnemia, 15
cannibalism, 21, 189
canoes, 160-164;
dug-outs, 164;
housing of, 162;
with outriggers, 164;
with sail, 164
capacity of skull, 37
Cape York, 93, 104
caravan travelling, 1
caries, 31
Carpentaria Gulf, 50, 93, 128, 129, 151, 160, 161, 162, 164,
189, 201, 266, 287, 375
carpentry taught boys, 85
carrying, dogs, 67;
infants, methods of, 66, 67
carved bone, 313;
grave posts, 207, 309-310;
pearl shell, 313;
 trees, 308, 309;
weapons, 310
carvings in rock, 299-308
Cassia, branch used as an emblem of peace, 2;
used for headgear, 280
casus belli, 183
caterpillar, 122;
totemic designs of, 350, 352
Caucasian, 58, 59;
derived from Australoid, 59
cave drawings, 314, 315, 322 et seq.;
of Glenelg River, 333, 343-345;
inspiration given by natural feature, 331, 332
celestial “walk-about,” 296
ceremonial dance, drawing of, 332, 338
ceremony of welcome, 379
character of aboriginal, 227
characteristics of race, 5-17
charcoal drawing, method of, 323;
of ceremonial dance, 338, 332;
of crows, 319, 335, 336;
of buffalo hunter, 325, 337;
of kangaroo hunter, 326, 337
cheek bone, 30
chief of tribe, 226
chignon, 47
child decorations, 84, 85
childhood, 69-90
children, entertainment of, 69, 70, 71;
position of at ceremonials, 84, 85;
playing with sand and mud, 73-75;
running after wind-driven seeds, 76;
taught to sing and dance, 70;
taught to draw and imitate tracks, 71, 72, 73;
tobogganing, 75
chin, 29
Christianity, 257
cicadae and crickets, musical powers envied, 384
cicatrices, 236-238, 250
circle-within-circle designs, 351, 353
circumcision, 239-244;
drastic treatment of shirkers, 243
clubbing the initiate, 242
clubs, 168, 169, 170;
in warfare, 188
club-rule, 222-223
“coal sack,” 332
cockatoo, kept as pet, 89
colour, artificially applied to body when hunting, 142;
of aboriginal’s skin, 40-45;
affected by climate, 45, 49, 59
composition, in aboriginal art, 338
conception, ideas about, 284, 285
conventional designs, 346 et seq.
conventional representation of human figure, 353-358
conversation, actions aiding, 395;
by song, 385
conversationalist, the aboriginal as, 371, 395
Coo-ee, 2. See also “käu,” 142
cooking, methods of, 108
cooleman, 92
Coopers Creek, 50, 83, 92, 102, 114 (Barcoo), 121, 127, 150,
155, 169, 170, 190 (Barcoo), 200, 237, 362, 376
cores, stone, 364
corrobboree, 377
cosmetics, 115
Cossus moth (witchedy), 122, 204
cotton tree (Bombatt malabaricum), 249
council of old men, 225, 226
Crocker Island, 131, 191
Crocodile, carvings of, 331;
ceremony of, 377;
eggs of, 126;
floating log to simulate, 159;
hunting the, 134
cradle, food-carrier taking the place of, 65
“cratch-cradle,” 84
crawfish, 128
cremation, not practised, 204
crossed boomerangs, the symbol of strife, 347, 351
crows, ceremony of, 378, 379;
drawing of, 319, 335, 336
“cutting” the shadow, 175
Cunningham, Professor D. J., 24
Cyperus rotundus (“yelka”), 148
Cyrena, acting as a pigment dish, 319;
used as a scraper, 162

D
“dabba,” stone knife, 367
daggers, 172
Daly River spear types, 196, 197, 198
“damatba” throwing weapon, 170
“dangorra,” the great emu in the sky, 315, 333, 349
Darwin, Charles, 33
dead person’s name not mentioned, 211, 212
death, tracing the cause of a, 208, 209
dental rudiments, 33
de Rougemont, 133
desert surroundings, 1
dialects, variety of, 387, 388
“didjeridoo” drone pipe, 375, 376, 379, 380
Dieri Tribe, xiv, 4, 76, 82, 83, 92, 111, 121, 150, 155, 170, 172,
190, 205, 206, 218, 237, 242, 271, 282, 289, 290, 361, 362,
376, 386, 396, 400
diminutive expressions, 396, 400
“dindula,” hair ornament, 47
dingo, the wild dog of Australia, 119;
hunting the, 141;
mythical dingo or “knullia” people, 342
Diprotodon, 52, 54;
associated with other bones, 119;
carving of spoor, 307
disc throwing, 76
discipline, 85
diseases, the cause of rapid decline of aborigines, xiv
dog, the constant companion of aboriginal, 118, 119
dolichocephaly, 35
dolls, 79, 80
down-decoration of ground, 282, 326
Dravidians, 58
drawings, in sand, 70-73;
of “totem,” 339-343
dress, mode of, 113, 114, 115
drinking, methods of, 98, 99
drone pipe, 375, 376, 379, 380
drought, trying conditions of, 117
Dubois, Professor, 55
Duboisia Hopwoodi, 155
Duckworth, Professor, W. L. H., 33
duels, 165-174;
 boomerang, 168;
chivalry displayed in, 174;
club, 168-170;
damatba, 170;
heavy spear, 172, 173;
kutturu, 165-168;
reed spears, 171;
stone dagger, 172;
shield used in, 173
dugong, hunting the, 134-137;
sung to during initiation, 19
dugout canoes, 164
Durham Downs, 237

E
ear, 29, 30
echidna designs, 336, 346, 347
eggs, of birds, 125, 126;
of reptiles, 126
“Elaija,” a sacred ancestor, 283
“elbola,” bark headgear, 280
“elenba,” wooden hair pins, 47
elopement, 223
emu, in the sky, 315, 332, 333, 334, 349;
carved in boabab, 309, 330;
carving on boomerang, 317;
 ceremony, 274-280, 377, 378;
game, 81, 82;
gum leaves imitating the rustle of, 374;
hunting the, 129-140;
neck in the sky (“Yirrerri”), 334
enemy, corrobboree portraying the slaying of, 383, 384
“engulba,” pitjuri, 155
ensellure, 7
epipteric bone, 36
“Erinnja,” an evil spirit, 294
“erriakutta” (yelka) ceremonial drawing, 282, 327
erythrism, 48
escort of natives, 2
Etheridge, R., x
ethmoid, 25
“Etominja,” sacred ground design, 282, 326
Eucalyptus corymbosa (Bloodwood), 98, 152;
dumosa (water mallee), 98;
miniata (woolly butt), 161;
rostrata (red gum), 147;
tetradonta (stringy bark), 161
Eugenia, leaf poultice applied to breast, 20
evil spirit, 291, 292, 294, 299, 314, 385
exchange of wives, 224
exclamations, 398, 399
external angular process, 25
extremities, length of, 10
eye, 23, 25

F
Face, 22-30
fat of emu and goanna, 115
fatty tissue scant in aboriginal, 5, 6
fatty tumours, 6
feather wig, 50
femur, 14, 15
feet, evolution and use of, 10 et seq.;
“hand-like” form of Berringin tribesman, 11
fibula, 16
fight, corrobboree of, 382
figure contrast between aboriginal and European, 5 et seq.
fire-fly, artificial, 376
fire ceremony (“Ngardaddi”), 261, 263
fire, 108;
shovels, 109, 110;
saw, 111, 202;
sores, 110;
stick, 110, 112;
whisk, 110, 111;
the precursor of civilization, 258, 260;
legend concerning origin on earth, 259, 260
fireless cooking, 80
fire walking, 236
firewood, gathered by women, 107
fish, barriers, 129;
designs, 350;
hooks, 132;
nets, 129, 130, 131;
nooses, 129;
ochre drawings of, 328;
spears, 131, 132
fishing, in parties, 127, 128, 129;
line, 132;
methods, 127, 128;
races, 128
flatfoot, 12
Flinders, Matthew, 117
Flinders Ranges, burial customs in the, 206;
ochre mine, 316;
rock carvings, 299, 303-308
flying fox design, 345, 350
foetal elements (“rattappa”), 287
food-carrier, used as cradle, 64, 65, 66
food restrictions, 250, 251
foot of Tasmanian, 14
footmarks in caves, 322
fourth molar, 32, 33
forehead, 23, 35
Fowler’s Bay, 64, 76, 295, 383
Fraipont’s method, 28, 29
frog, corrobboree of, 379
frog dance of children, 70
frog designs, 335, 346
frontal bone, 35, 36
frontal suture, 34
Frontispiece, 145
funeral chant, 211

G
gagging the initiate, 242, 246
Garner, Professor, 405
Genyornis, carving of track, 308
geological antiquity, 49, 52, 53, 54
gesture language, 388-394
“gibba,” chewed bone, 176
“Gibberi,” circumcision, 242
Gibraltar skull, 23, 32
Ginmu Tribe, 4, 253
girls accompany women instructors, 85
Glenelg River, xi, 159, 288, 312, 333, 344
goanna, 127
Gondwana, 55, 56
Good Spirit, 294, 295
goose hunting, 138, 139
“gorri,” a game played on the Humbert River, 76, 77
gouge, bone, 314
grasshopper, 387
grass tree, cover when emu hunting, 140;
flower stalks used for making spear shafts, 195
grave posts, 207
Great Australian Bight, 66, 141, 169, 192, 199
great emu ceremony, 274 et seq.
Grey, Sir George, xi, 219, 272, 340, 343, 344
Gribble, E. R., 17
Groote Island, 101, 164, 197
ground drawings, 282, 326, 327
grubs, 122-125
gruesome rite, 247, 290
“gummanda,” cicatrices, 238

H
habitations, 101-105
half-castes, 59, 60
hailstone (“Imbodna”), mythical stone, 264
hair, 46, 47;
belts, 116;
cutting of, 117;
pins (wooden), 47
Hakea bark, charcoal used for blackening hair, 285
hammers, stone, 360
hand-ball, 77
hand-like feet, 10-12
hand-prints in caves, 321, 322
hand-mills, 319, 361
hardening the child, 236
hatchets, stone, 362, 363
hawk traps, 137, 138
head-biting during initiation, 244, 245
head-dress, of emu ceremony, 277;
of “tjilba purra” (phallic) ceremony, 287
head-rests, 105
height of aboriginal, 16, 17
Helix perinflata, 121
Hickson, Sydney, 49
hide and seek, 78, 79
Higgin, A. J., 157
hollow trees used as shelters, 102
honey, wild bees’, 145;
drink, 153, 154
honey-ant, 146, 147
Howitt, Dr. A. W., 295
human chain-pattern, 353, 354, 355
human form, pictographic representation of, 353-358
Humbert River, 76, 320, 324, 336, 337, 352, 353, 403
Humboldt, Alexander von, 20
humerus, 16
hunt, objects of the, 121
hunting, 120-147;
buffalo, 144, 145;
crocodile, 134;
dingo, 141;
dugong, 134-137;
emu, 129-140;
geese, 138, 139;
hawks, 137, 138;
kangaroo, 141-144;
opossum, 140, 141;
turtle, 132, 133;
whistling duck, 139;
wallaby, 141;
wombat, 141
hunting instinct, 120, 121
hunting with fire, 126
huts, 102-105
Huxley, Thomas, 24
hypertrichosis, 46

I
“ilbarinam,” tjuringa, xi
“ilja-imbadja,” hand marks in caves, 321
“ilgarukna,” venesection, 275
“illiya tjuringa,” emu ceremony, 274 et seq.
“ilpalinja,” sun worship, 265-267
“Iltdana,” evil spirit, 292
Ilyauarra Tribe, 4, 205
“Imbodna,” a mythical hailstone, 264
“Imboromba,” a spirit father’s mate, 287
imitation, of the plovers’ call, 70, 265, 379, 386;
of the dingo’s howl, 70;
of the jungle fowl’s call, 380;
of the crow’s call, 378;
of the crocodile, 377;
of the emu, 279, 378
“Indorida,” the mate of Rukkutta, 291
infant betrothal, 221
infant, treatment of, 64-68;
rubbing milk and charcoal over body of, 65;
singeing hair of, with fire stick, 65
“ingada,” a chief, 226
Ingada Ladjia Knaninja, leader of yam ceremony, 281
“ingwitega,” munyeroo, 150
inion, 36
initiation, 230-256;
amputation of finger-joints, 253, 254;
of the female, 252, 253;
origin of, 251, 252;
without mutilation, 249
instinct for locating water, 96
interment, 205-207
internal angular process, 25
interrogatives, 403
intitjuma, ceremonies, 274
intoxicating drink, 153, 154
introduction to a tribe, 1-3
iris, 25
“irr,” 171;
expression of disgust, 118
“irriakutta,” yelka, 149

J
“jarrulge,” mulga apple, 152
Jewish features, 26
“jingardti,” a chief, 226
Joyce, Capt. T. A., x
judge of character, 228
“judja,” a chief, 226
jungle fowl, corrobboree of, 380, 381
jus primae noctis, 256
justice, idea of, 227

K
“kadabba,” phallus, 283, 284
Kai Kai, an old medicine man, 180
“kaidi,” tjuringa, 270
kaili (boomerang), used as musical instrument, 383;
miniature, for practice, 82
Kaitidji (Kaitish) Tribe, 4, 92, 364
Kakera, marriage group, 220
Kakatu Tribe, 4, 267
“kaleya pubanye,” the sitting emu (coal sack), 332
“kaloa,” raft, 160;
toy models of, 82
“kalumba,” nardoo, 150
“kalunuinti,” phallus, 288
“kanbanna,” paddles, 159
kangaroo, charcoal drawings of, 321, 326, 336, 337;
conventional representation of, 350;
corrobboree of, 381;
hunt, 141-144;
ochre drawings of, 327, 328;
origin of “arre,” its name, 387;
tjuringa design of, 349, 352
“kapa” or “kadje,” water lily, 151
“kapi wiyinna,” magic water stick, 264
“karru,” milky way, 349
“karwinnunga,” shield, 173
“käu,” vide Coo-ee, 142
“käu-käu,” chewed bone, 176
“kaula,” native pear, 152
Keith, Sir Arthur, x
kidney fat and marrow of dead warriors eaten, 189
Killalpaninna, 290;
“killa wulpanna,” 290, 291
King Sound natives, 50, 82, 88, 132, 151, 159, 283, 309, 311,
330, 358, 363, 396
kitchen-middens, 121, 122
Klaatsch, Professor Hermann, x, 25, 28, 29, 42, 50
“Knaninja,” xi, 265, 271, 274, 280, 281, 282, 285, 327, 341, 352,
353
“Knaninja Arrerreka,” mythical sun creature, 265;
ceremonies of, 274
knives, stone, 364
“knudda” (fat) of witchedy, 342
“Knurriga Tjilba Purra” (phallus), 286;
head of the Kukadja, 285
kobong, xi, 219, 226, 232, 269, 271, 272, 340
Kochia bush, used for making vegetable-down, 276
Kolaia Tribe, 4, 65
“kolldürr,” stone spear-head, 370
Kukadja, 285, 286, 292, 293
Kukata Tribe, 4, 32, 81, 82, 87, 184, 200, 205, 236, 241, 242,
248, 255, 288, 296, 318, 361, 362
“kukerra,” playing stick, 82, 83
Kumara marriage group, 220
Kunapippi, a mythical witch, 271
Kurdaitja, an evil creature, 71, 72
“kurreke tata,” the plover, 70, 265, 386
“kutturu,” fighting stick, practice, 87;
duels, 165-168;
embodied in head-gear, 280
Kuyanni Tribe, 4, 362
“Kwatje,” water, ceremonies, 274
“Kwatje purra,” magic water stick, 264

L
lachrymal bone, 25
lactation, artificial, 20
“ladjia,” or yam tjuringa, 280 et seq., 337;
design of, 347
Lake Eyre, 50
lances, 193
“langa langa,” a shell knife used for “cutting the shadow,” 175
“langu,” native pear, 152
language, xii, 386-405
lanugo, 46, 49
La Perouse, 107
Larrekiya Tribe, 4, 62, 77, 111, 130, 131, 139, 142, 163, 164,
170, 196, 201, 202, 205, 207, 208, 210, 230, 249, 252, 332,
374, 379, 384
legs, 14
Lemuria, 55, 56
lerp manna, 147
leucoderma, 43
licentiousness, 224, 254
“lionila,” a club, 170
lipomas, 6
lips, 31
living skeletons, 21
lizards, 126;
designs of, 334, 335
lobulus, piercing of, 30
log rafts, 158-160
“lorngai,” feather wig, 50
lumbo-sacral curve, 9
“lurra,” a lipoma, 6

M
MacDonnell Ranges, 50, 92, 127, 146, 153, 155, 218, 226, 285,
291, 341, 362, 364, 405
Maiyarra’s conception, 61;
accouchement, 63
Malay bêche-de-mer fishers, 57
manna, 147
mastoid process, 30
“marimba,” wallaby bone used for loosening a tooth, 236
marine molluscs, 121, 122
marital relationships between man and woman, 222, 223
marriage systems, 218, 219, 220, 221;
allotment of infant, 221, 222
“marriwirri,” wooden sword, 170