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Dr. Shridhar Shetty Dr. Karan Alva
injuries represent 15% to 30% of all fractures in children Distal humerus physeal injuries most common after distal radius Although common, deformities are rare 1 to 10% of all physeal injuries
The physis is connected to the epiphysis and metaphysis by the zone of Ranvier and the perichondral ring of LaCroix The first two zones have an abundant extracellular matrix The third layer, the hypertrophic zone, contains scant extracellular matrix and is weaker – most injuries of the physis occur
sparing the epiphysis Type III – A fracture through growth plate and epiphysis.CLASSIFICATION OF PHYSEAL INJURIES Type I – A transverse fracture through the growth plate Type II – A fracture through the growth plate and the metaphysis. metaphysis. the growth plate. sparing the metaphysis Type IV – A fracture through all three elements of the bone. and epiphysis Type V – A compression fracture of the growth plate .
Ossification centers around the elbow CRITOE • capitellum • Radius • internal (or medial) epicondyle • • trochlea olecranon epicondyle • external (or lateral) Starts with capitellum around 2yrs of age and appears sequentially every 2 yrs. .
Supracondylar humerus fractures Transphyseal distal humerus fractures Lateral humeral condyle fractures Fractures of medial humeral epicondyle Fractures of radial head and neck Olecranon fractures .
Supracondylar fractures most common type of elbow fracture in children and adolescents They account for 50% to 70% of all elbow fractures seen most frequently btw age of 3 and 10 years .
Mechanism of injury • fall on an outstretched hand that causes hyperextension of the elbow • extension-type 95 to 98 % • Direct blow on the posterior aspect of a flexed elbow – anterior displacement of the distal fragment • Flexion – type 2 to 5 % .
with both cortices fractured .nondisplaced or Three part classification – Gartland minimally displaced.angulation of the distal fragment with one cortex remaining intact Type III .completely displaced. Type II .Classification • Extension injuries • Flexion injuries Type I .
• Wilkins subdivided type III injuries according to the coronal plane displacement of the distal fragment A. B. Posteromedially displaced fracture. Posterolaterally displaced fracture (25%) .
• Type IB .truly nondisplaced fractures. or angulation. collapse. with no comminution.comminution or collapse of the medial column in the coronal plane and may have mild hyperextension in the sagittal plane .• Mubarak and Davids subdivided type I fractures into IA and IB • Type IA .
neurologic injury is present in 10% to 15% of cases ipsilateral fractures occur in 5% (usually the distal radius) .
Baumann's angle • AP radiograph of distal humerus • angle between the physeal line of the lateral condyle of the humerus and a line drawn perpendicular to the long axis of the humeral shaft • “normal angle” varies from 8 to 28 degrees .
if an effusion is present. Fat pad sign • Presence of effusion within the elbow • anterior fat pad is a triangular radiolucency anterior to the distal humeral diaphysis • posterior fat pad is not normally visible when the elbow is flexed at right angles. it will also be visible posteriorly . however.
Anterior Humeral Line • Drawn along the anterior humeral cortex • Should pass through the middle of the capitellum • Variable in very young children .
coronoid line • a line projected superiorly along the anterior border of the coronoid process • should just touch the anterior border of the lateral condyle of the humerus .
Treatment • Emergency Treatment • Splint • distal extremity is initially ischemic. an attempt to better align the fracture fragments should be made immediately • distal circulation should always be checked before and after the splint is applied .
Non displaced fractures • long-arm slab / cast immobilization for 3 weeks • Elbow flexion and in neutral position • Reviewed after first 5 to 10 days when can be converted to cast after satisfactory check Xray. • Contient for further 2 to 3 weeks .
Treatment .percutaneous pin fixation • 2 or 3 k-wires distally to proximally in a crossed or parallel fashion • The arm is immobilized in 30 to 60 degrees of flexion in a posterior splint • K-wires removed after 3 weeks and mobilisation advised .Displaced fractures • Closed reduction tried till satistactory reduction noted under C-arm • Unstable .
Open reduction • Indications : ischemic. an open fracture. and inability to obtain a satisfactory closed reduction . an irreducible fracture. pale hand that does not revascularize with reduction of the fracture.
distal humerus entirely cartilagenous – making interpretation of x-rays difficult – diagnosis difficult .Transphyseal fractures Most common in children below age of 2 yrs History of abuse in upto 50% of cases In children of this age group.
Mechanism of injury • usually a rotary or shear force associated with birth trauma or child abuse • older children .most commonly a hyperextension force from a fall on an outstretched hand .
classification DeLee et al – three groups based on X-rays • Based on presence or absence of secondary occification center of the radial head and the presence and absence of metaphyseal fragment (Thurston – Holland sign) Also classified according to Salter Harris classification • In infants mostly type I • In older children usually type II .
the radial head does not articulate with the capitellum • transphyseal fracture . Diagnosis • distinguish a transphyseal fracture from an elbow dislocation • radial head–capitellum relationship: • elbow dislocation . which makes such distinction difficult .the radial head and capitellum remain congruous • very young patient the capitellum may not be ossified.
X-rays MRI Ultrasound Arthrography .
Treatment • Closed reduction and splinting with slab for 2 to 3 weeks • Closed reduction and k-wire fixation for transphyseal seperations. Immobilised in relative extension for 2 to 3 weeks following which k-wireare removed .
deformity secondary to AVN reported . Complications • Incidence of neurovascular injuries are relatively less compared to supracondylar fracture • Reinjury rate between 30 to 50% • Delated complication of cubitus varus • Sometimes.
Lateral Condyle fracture Transphyseal. intraarticular injuries Frequently require open reduction and fixation .
Mechanism of injury • Fall on outstretched arm • Varus stress avulses the lateral condyle or • a valgus force in which the radial head directly pushes off the lateral condyle .
extends through the secondary ossification center of the capitellum and enters the joint lateral to the trochlear groove Milch type II fracture . thus making the ulnohumeral joint unstable . with the trochlea remaining with the lateral fragment.extends farther medially.Classification • Milch classification Milch type I fracture .
Diagnosis • Differntial diagnosis of transphyseal fractures. nursemaid's elbow. minimally displaced supracondylar or radial neck fractures. and infection • Pain • Reduced ROM • Isolated lateral tenderness .
Xrays : • posteriorly based Thurston-Holland fragment in the lateral view • fracture line may be seen running parallel to the physis .
non displaced fractures • immobilization in 90 degrees of flexion and neutral rotation • Review at 1. Treatment . and 4 weeks after the injury for radiographic assessment • Cast continued for 4 to 6 weeks Minimally displaced • Closed reduction / percutaneous stabilisation . 2.
Treatment . anterolateral approach • Stabilsed with percutaneous pins • Immobilised with elbow in 90 ̊for 4 weeks .displaced fractures • controversy regarding the treatment of nondisplaced and minimally displaced fractures • Open reduction and fixation for displaced lateral condyle fractures • Commonly .
Medial epicondyle fractures 50 % associated with elbow dislocations 7 and 15 years of age 10% of all children's elbow fractures .
Mechanism of injury • valgus stress producing traction on the medial epicondyle through the flexor muscles • may become incarcerated in the joint at the time of dislocation or reduction .
the medial epicondylar fragment is usually easily identified radiographically • younger patients may be difficult if the secondary ossification center is not yet ossified • comparison views to establish the “normal” width of the cartilaginous space between the metaphysis and medial epicondyle. Xray findings • older patients (>6 or 7 years of age). .
medial joint space widening may be present on the AP radiograph a nonconcentrically reduced ulnohumeral joint on the lateral .
Nondisplaced and Minimally Displaced Fractures
• immobilization in a posterior splint / long-arm
cast / sling for 1 to 2 weeks
• followed by early active range-of-motion exercises
• intra-articular fragments should be removed acutely
• a single attempt at gentle manipulative reduction for
acutely (<24 hours after injury) entrapped fragments.
• opening the joint with a valgus stress and then
supinating the forearm and dorsiflexing the wrist and fingers to stretch the flexors and extract the medial epicondylar apophysis from the joint
– Displaced fractures (>5mm) :
• Open reduction preferred to prevent injury to ulnar nerve • medial longitudinal skin incision • fixation with a partially threaded screw, often using a cannulated
system to achieve temporary fixation
• immobilize the elbow in flexion for 1 to 3 weeks • active range-of-motion exercises are initiated
Radial head and neck fractures children are more likely to sustain fractures of the radial neck than fractures of the head Almost 50% of radial neck fractures are associated with other injuries to the elbow .
or fracture of the olecranon. rupture of the medial collateral ligament.Mechanism of injury • fall onto an outstretched hand with the elbow in extension and valgus • May be associated with avulsion of the medial epicondyle. proximal ulna. or lateral condyle .
Medial epicondyle Medial collateral ligament Olecranon .
May also occur as a result of dislocation radial neck may be fractured by impact against the inferior aspect of the capitellum either at the time of posterior dislocation or at the time of spontaneous reduction .
degree of angular displacement of the superior articular surface from the horizontal . Classification • O'Brien .
Diagnosis • Local swelling • Tenderness • Ecchymosis lateral aspect of elbow • Passive flexion and extension ROM restriction • Pronation / supination – extremely painful .
an AP radiograph of the proximal radius rather than the elbow . • if pathology of the proximal radius is suspected. Xrays • The child's inability to fully extend the elbow makes it difficult to obtain a true AP view of an acutely swollen elbow.
Treatment • educate the parents at the time of injury that significant loss of motion occurs in 30% to 50% of patients Immobilisation • Nondisplaced or minimally displaced fractures (<30 degrees of angulation. posterior splint. minimal translation) may be managed by simple immobilization of the elbow in a sling. or above-elbow cast for 1 to 2 weeks .
varus stress • Surgeon . Closed reduction • Under sedation / general anasthesia • elbow is fully extended • assistant grasps the patient's arm proximal to the elbow joint • other hand medially over the patient's distal humerus .distal traction with the forearm supinated to relax the supinators and biceps .
if angulation is not not reduced to <30 ̊ . Percutaneous and Intramedullary Reduction • In type II and type III.
Open reduction • Salter-Harris type III and IV injuries that remain significantly angled after attempts at closed reduction and minimally invasive techniques • posterolateral approach • Fixation is achieved with a K-wire placed percutaneously in a proximal-to-distal direction across the fracture site .
Radial head excision • ?? .
10 to 20% • Fibrous adhesions • Proximal radioulnar synostosis . Complications • Loss of motion (malunion ) – joint incongruity • Enlargement of radial head • AVN .
Olecranon fractures Uncommon Only 2 to 5 % associated with other elbow injuries (most commonly the medial epicondyle) in 20% to 50% of cases .
• Less common because • olecranon is predominantly cartilage • thick periosteum and relatively thin metaphyseal cortex • Usually found as a minimally displaced greenstick fracture .
Mechanism of injury • hyperextension injury – most common • direct blow to the flexed elbow • hyperflexion injury • a shear force • Hyperextension injuries are frequently associated with other elbow injuries .
Classification • Graves and Canale • Displaced (<5mm) • Undisplaced (>5mm) • Gaddy et al • Displaced (<3mm) • Undisplaced (>3mm) .
Diagnosis • Swelling • palpable defect posteriorly • inability to extend the elbow Xrays • Look for associated fractures • Radial head or neck fractures seen in 1/3rd .
and stable – closed reduction and cast application • Flexion injuries may require immobilization in extension . Treatment • Nondisplaced or minimally (3 mm or less) displaced fractures can generally be managed by simple cast immobilization for 3 to 4 weeks • displaced (>3 mm). extra-articular.
• Intra-articular fractures with more than 3 mm of displacement usually require open reduction and internal fixation • tension band technique for displaced olecranon fractures .
T Condylar fractures separation of the medial and lateral columns of the distal humerus from each other and from the humeral shaft almost universally result in disruption of the articular surface of the distal humerus Rare in children .
Classification Toniolo and Wilkins • Type I .minimal displacement • Type II .displaced with comminution of the metaphysis .displaced without metaphyseal comminution • Type III .
Treatment • Closed Reduction and Percutaneous Pinning • most type I fractures and in some younger patients with type II and type III fractures .
and permits early mobilization . allows rigid fixation.wide surgical exposure.• Open Reduction and Internal Fixation • Posterior approach – splitting the triceps • Posteromedial approach – triceps sparing Posterior approach .
Medial Condyle Fractures Uncommon direct posterior blow to a flexed elbow avulsion from a valgus hyperextension injury .
the fracture extends more laterally through the capitellar ossification center • Kilfoyle's classification • nondisplaced (traditionally <2 mm) • minimally displaced (traditionally 2 to 4 mm) • displaced (traditionally >4 mm) . Classification • Milch – based on location of fracture line • type I injuries .the fracture exits at the trochlear notch • type II injuries .
Treatment • Nondisplaced and minimally displaced fractures can be treated by simple cast immobilization • Displaced fractures require open reduction and percutaneous fixation .
CAPITELLAR FRACTURES rare in children and occur most commonly in adolescents capitellum is nearly all cartilaginous. it is resistant to stress Treatment • Open reduction • Posterior approach • If fragment extremely small / comminuted – excision advised .
and lateral condyle Rarely displaced – hence no additional intervension required . proximal radius.Coronoid fractures most commonly associated with elbow dislocations Hence frequently associated with fractures of the medial epicondyle. olecranon.
Trochlear fractures Uncommon fracture is associated with dislocation open reduction with fixation – intraarticular .
Lateral epicondyle fractures Least common lateral condylar apophysis ossifies laterally to medially. which creates a space between the secondary ossification center and the metaphysis that can be misinterpreted as a displaced fracture Treated conservatively Entrapment of the fragment – only indication for surgery .
7th ed Paediatric orthopaedics in practice. 4th ed Rockwood and Wilkins Fractures in Children.References Tachdjian’s Paediatric Orthopaedics. Hefti Campbell’s Operative Orthopaedics. 11th ed .
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