Elbow Fractures Paediatric Elbow X-Ray Interpretati on Supracondyla r Fracture of Humerus Peak incidence 5-8yrs; most common paediatric elbow fracture; most common fracture <8yrs; >95% FOOSH (flexion type, <5%, from fall on flexed elbow, rare, will C Fat Pads: anterior displacement in 50% radial head / neck fractures; if posterior present, fracture in >95% Anterior humeral line: should bisect capitellum in middle 1/3 on lateral; abnormal in supracondylar fracture, lateral condyle Radio-capitellar line: line drawn through centre of radial shaft should transect radial head and capitellum; abnormal in lateral condyle, radial neck, Monteggia, Epi- demiology R I T O L Capitellum Radial head Internal Trochlea Olecranon Lateral 1-3yrs 3-4yrs 5-6yrs 7-9yrs 9-10yrs 11- Appears 14yrs 16yrs 15yrs 14yrs 14yrs 16yrs Closes Distal fragment displaced posteriorly; significantly displaced fractures are surgical emergencies (brachial artery, median / radial / ulnar nerve at risk; nerve Pathology
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Elbow fractures - Web viewEpi-demiology. Peak incidence 5-8yrs; most common paediatric elbow fracture; most common . fracture 95% FOOSH (flexion type,
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Elbow Fractures
Paediatric Elbow
X-Ray Interpretation
Supracondylar Fracture of Humerus
Peak incidence 5-8yrs; most common paediatric elbow fracture; most common fracture <8yrs; >95% FOOSH (flexion type, <5%, from fall on flexed elbow, rare, will have volar displacement)
C
Fat Pads: anterior displacement in 50% radial head / neck fractures; if posterior present, fracture in >95%Anterior humeral line: should bisect capitellum in middle 1/3 on lateral; abnormal in supracondylar fracture, lateral condyleRadio-capitellar line: line drawn through centre of radial shaft should transect radial head and capitellum; abnormal in lateral condyle, radial neck, Monteggia, elbow dislocationBaumann Angle: angle between physeal line of lateral condyle of humerus and line perpendicular to long axis of humeral shaft = 8-28°; angle varus deformity; abnormal in supracondylar fracturesAngle between line through centre of capitellum and anterior humeral line should be 30-45°
Epi-demiology
R
I
T
O
L
Capitellum
Radial head
Internal epicondyle
Trochlea
Olecranon
Lateral epicondyle
1-3yrs
3-4yrs
5-6yrs
7-9yrs
9-10yrs
11-12yrs
Appears
14yrs
16yrs
15yrs
14yrs
14yrs
16yrs
Closes
Distal fragment displaced posteriorly; significantly displaced fractures are surgical emergencies (brachial artery, median / radial / ulnar nerve at risk; nerve involvement in 6-16% Volkmann’s ischaemic contracture); risk of compartment syndrome
Pathology
Undisplaced fracture with evidence of joint effusion; antetior and posterior periosteum intact; prognosis good; wrist-to-shoulder backslab with elbow flexed 90° for 4/52; OT preferred in adults as stiffness common, but otherwise not generally recommended; ortho FU within 48hrs
Gartland Classification
Urgent ortho review: NV compromise (eg. Altered pulse)Immediate ED reduction: cool / pale handManipulation: traction at 20° flexion flexion as far as possible while still retaining radial pulseIndications for manipulation: NV compromise / <50% bony apposition / dorsal angulation >15° / lateral or medial tilt >10° / any rotational deformity / any vagus or valgus deformity / compound fracture
Manage-ment
Supracondylar Fracture of Humerus
I
II
IIb
III
Displaced (usually posteriorly), but intact posterior periosteum; fracture visible anteriorly, hinging posteriorly; prognosis good; needs closed / open reduction by ortho
As above + rotation; prognosis bad, needs OT
Displaced anterior and posterior periosteum; no continuity between shaft and distal humerus; can displace postmed, postlat, antlat; prognosis bad, need OT
Radial (postmed) / median (postlat, especially anterior interosseous nerve which is motor only) / ulnar (less common) nerve (7%); Volkmann ischaemic contracture, compartment syndrome, non / malunion, myositic ossificans; absence of radial pulse initially in children is usually due to vasospasm
Comp-lications
Intercondylar Fracture of Humerus
Most common in adults; classified as T / Y / H depending on segments; associated with severe soft tissue injury
Epicondylar Fracture of Humerus
(beware ulnar nerve)
Medial epicondyle: 3rd most common paediatric elbow fracture; most common 9- 14yrs; 50% associated with elbow dislocation; risk of medial epicondyle becoming trapped in joint, especially in spontaenously reduced elbow dislocation; needs OT if >1cm of articular surface, or ulnar nerve involvement; needs ortho review
Lateral condyle: tend to be unstable; often also involves all of capitellum and ½ of trochlea; due to varus stress on extended arm in supination Milch I = Salter Harris IVMilch II = Salter Harris II (into joint and lateral part of trochlea), most commonOT if displaced, often required; ulnar nerve involvement; needs ortho review
Elbow Dislocation
90% postero-lateral; 85% have good functional outcome; 3rd most common large joint dislocationMOI: hyperextension, abduction Incomplete anterior and posterior ligamentous components ruptured Complete anterior, posterior and medial collateral ligaments ruptured
Reduce with traction, correction of medial / lateral displacement, downward pressure on forearm and flexion with thumbs pushing on olecranon; may fail if radial head fracture; backslab in 90° flexion and sling for 1-2/52; should have FROM post-reduction – concern if locking / clicking Re: # / capsule tear etc…
Manage-ment
1/3 have fracture (eg. Coronoid process, radial head); 15% have medial epicondyle fracture (may become entrapped post-reduction, especially in children); 5-13% have NVI; 8% have brachial artery injury; 15% ulnar nerve injury (usually resolves with conservative treatment); radial and median nerve injury also occur; “terrible triad” = dislcoation + radial head and coronoid fracture