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Physeal Injuries Around the Elbow_ With Supracondylar

Apr 02, 2018

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    Physeal injuries aroundthe elbow

    Dr. Shridhar Shetty

    Dr. Karan Alva

    24.09.2012 AJIMS

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    Physeal injuries represent 15% to 30%of all fractures in children

    Distal humerus physeal injuries mostcommon after distal radius

    Although common, deformities are rare1 to 10% of all physeal injuries

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    The physis is connected tothe epiphysis and

    metaphysis by the zone ofRanvier and the perichondralring of LaCroix

    The first two zones have anabundant extracellularmatrix

    The third layer, thehypertrophic zone, contains

    scant extracellular matrixand is weaker most injuriesof the physis occur

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    CLASSIFICATION OF PHYSEALINJURIES

    Type I A transverse fracture through the growth plateType II A fracture through the growth plate and the metaphysis, sparing

    the epiphysisType III A fracture through growth plate and epiphysis, sparing the metaphysisType IV A fracture through all three elements of the bone, the growth plate,

    metaphysis, and epiphysisType V A compression fracture of the growth plate

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    Ossification centers around theelbow

    CRITOE

    capitellum

    Radius

    internal (or medial)epicondyle

    trochlea

    olecranon

    external (or lateral)epicondyle

    Starts with capitellum around 2yrs of age and appearssequentially every 2 yrs.

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    Supracondylar humerus fractures

    Transphyseal distal humerus fractures

    Lateral humeral condyle fractures

    Fractures of medial humeral epicondyle

    Fractures of radial head and neck

    Olecranon fractures

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    Supracondylar fracturesmost common type of elbow fracture in

    children and adolescents

    They account for 50% to 70% of all elbowfractures

    seen most frequently btw age of 3 and 10years

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    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 %

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    Classification Extension injuries

    Flexion injuries

    Three part classification GartlandType I - nondisplaced orminimally displaced.

    Type II - angulation of the

    distal fragment with onecortex remaining intact

    Type III - completelydisplaced, with bothcortices fractured

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    Wilkins subdivided type III injuriesaccording to the coronal plane displacementof the distal fragment

    A, Posteromediallydisplaced fracture.

    B, Posterolaterallydisplaced fracture(25%)

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    Mubarakand Davids subdivided type Ifractures into IA and IB

    Type IA - truly nondisplaced fractures, withno comminution, collapse, or angulation.

    Type IB - comminution or collapse of themedial column in the coronal plane and mayhave mild hyperextension in the sagittalplane

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    neurologic injury is present in 10% to15% of cases

    ipsilateral fractures occur in 5%(usually the distal radius)

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    Baumann's angle AP radiograph of distal humerus

    angle between the physeal line of the

    lateral condyle of the humerus and a linedrawn perpendicular to the long axis of thehumeral shaft

    normal angle varies from 8 to 28 degrees

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    Fat pad sign Presence of effusion within the elbow

    anterior fat pad is a triangularradiolucency anterior to the distal humeral

    diaphysis

    posterior fat pad is not normally visible

    when the elbow is flexed at right angles;however, if an effusion is present, it will alsobe visible posteriorly

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    Anterior Humeral Line

    Drawn along the anteriorhumeral cortex

    Should pass through themiddle of the capitellum

    Variable in very youngchildren

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    coronoid line

    a line projectedsuperiorly along the

    anterior border ofthe coronoid process

    should just touchthe anterior border

    of the lateralcondyle of thehumerus

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    Treatment

    Emergency Treatment

    Splint

    distal extremity is initially ischemic, anattempt to better align the fracturefragments should be made immediately

    distal circulation should always be checkedbefore and after the splint is applied

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    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 canbe converted to cast after satisfactory

    check Xray. Contient for further 2 to 3 weeks

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    Treatment - Displaced fractures

    Closed reduction tried till satistactory reductionnoted under C-arm

    Unstable - 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 offlexion in a posterior splint

    K-wires removed after 3 weeks and mobilisationadvised

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    Open reduction

    Indications : ischemic, pale hand that doesnot revascularize with reduction of thefracture, an open fracture, an irreducible

    fracture, and inability to obtain asatisfactory closed reduction

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    Transphyseal fracturesMost common in children below age of

    2 yrs

    History of abuse in upto 50% of cases

    In children of this age group, distalhumerus entirely cartilagenous

    making interpretation of x-rays difficult diagnosis difficult

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    Mechanism of injury usually a rotary or shear force associated

    with birth trauma or child abuse

    older children - most commonly ahyperextension force from a fall on anoutstretched hand

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    classificationDeLee et al three groups based on X-rays

    Based on presence or absence of secondaryoccification center of the radial head and the presenceand absence ofmetaphyseal fragment(Thurston Holland sign)

    Also classified according to Salter Harris

    classification In infants mostly type I

    In older children usually type II

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    Diagnosis distinguish a transphyseal fracture from an

    elbow dislocation

    radial headcapitellum relationship:

    elbow dislocation - the radial head does notarticulate with the capitellum

    transphyseal fracture - the radial head and capitellumremain congruous

    very young patient the capitellum may not beossified, which makes such distinction difficult

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    X-rays

    MRI

    Ultrasound

    Arthrography

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    Treatment Closed reduction and splinting with slab for

    2 to 3 weeks

    Closed reduction and k-wire fixation fortransphyseal seperations. Immobilised inrelative extension for 2 to 3 weeks following

    which k-wireare removed

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    Complications Incidence of neurovascular injuries are

    relatively less compared to supracondylar

    fracture

    Reinjury rate between 30 to 50%

    Delated complication of cubitus varus

    Sometimes, deformity secondary to AVNreported

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    Lateral Condyle fractureTransphyseal, intra-

    articular injuries

    Frequently require openreduction and fixation

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    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

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    Classification

    Milch classification

    Milch type I fracture - extends through the secondaryossification center of the capitellum and enters the joint

    lateral to the trochlear groove

    Milch type II fracture - extends farther medially, with thetrochlea remaining with the lateral fragment, thus making theulnohumeral joint unstable

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    Diagnosis Differntial diagnosis of transphyseal fractures,

    minimally displaced supracondylar or radial

    neck fractures, nursemaid's elbow, andinfection

    Pain Reduced ROM

    Isolated lateral tenderness

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    Xrays : posteriorly based Thurston-Holland fragment in the

    lateral view

    fracture line may be seen running

    parallel to the physis

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    Treatment - non displaced fractures

    immobilization in 90 degrees of flexion and neutral

    rotation Review at 1, 2, and 4 weeks after the injury for

    radiographic assessment

    Cast continued for 4 to 6 weeks

    Minimally displaced

    Closed reduction / percutaneous stabilisation

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    Treatment - displaced fractures controversy regarding the treatment of

    nondisplaced and minimally displaced fractures

    Open reduction and fixation for displaced lateralcondyle fractures

    Commonly , anterolateral approach Stabilsed with percutaneous pins

    Immobilised with elbow in 90 for 4 weeks

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    Medial epicondyle fractures

    50 % associated with elbowdislocations

    7 and 15 years of age

    10% of all children's elbow fractures

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    Mechanism of injury

    valgus stress producing traction on themedial epicondyle through the flexormuscles

    may become incarcerated in the joint at thetime of dislocation or reduction

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    Xray findings older patients (>6 or 7 years of age), the medial

    epicondylar fragment is usually easily identifiedradiographically

    younger patients may be difficult if the secondaryossification center is not yet ossified

    comparison views to establish the normal width ofthe cartilaginous space between the metaphysis andmedial epicondyle.

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    medial joint space widening may bepresent on the AP radiograph

    a nonconcentricallyreduced ulnohumeral joint on the

    lateral

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    Treatment

    Nondisplaced and Minimally DisplacedFractures

    immobilization in a posterior splint / long-armcast / sling for 1 to 2 weeks

    followed by early active range-of-motion exercises

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    intra-articular fragments should be removed acutely

    a single attempt at gentle manipulative reduction foracutely (

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    Treatment 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

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    Radial head and neck fractures

    children are more likely to sustain fracturesof the radial neck than fractures of thehead

    Almost 50% of radial neck fractures areassociated with other injuries to the elbow

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    Mechanism of injury fall onto an outstretched hand with the

    elbow in extension and valgus

    May be associated with avulsion of themedial epicondyle, rupture of the medial

    collateral ligament, or fracture of theolecranon, proximal ulna, or lateral condyle

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    Medial epicondyle

    Medial collateralligament

    Olecranon

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    May also occur as a result of dislocation

    radial neck may be fractured by impactagainst the inferior aspect of thecapitellum either at the time of posteriordislocation or at the time of spontaneous

    reduction

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    Classification O'Brien - degree of angular displacement of

    the superior articular surface from the

    horizontal

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    Diagnosis Local swelling

    Tenderness Ecchymosis lateral aspect of elbow

    Passive flexion and extension ROMrestriction

    Pronation / supination extremely painful

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    XraysThe child's inability to fully extend the

    elbow makes it difficult to obtain a true AP

    view of an acutely swollen elbow.

    if pathology of the proximal radius is

    suspected, an AP radiograph of the proximalradius rather than the elbow

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    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 (

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    Closed reduction

    Under sedation / general anasthesia

    elbow is fully extended

    assistant grasps the patient's arm proximal tothe elbow joint

    other hand medially over the patient's distal

    humerus - varus stress Surgeon - distal traction with the forearm

    supinated to relax the supinators and biceps

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    Percutaneous and IntramedullaryReduction

    In type II and type III, if angulation is not notreduced to

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    Open reduction Salter-Harris type III and IV injuries that remain

    significantly angled after attempts at closed reduction andminimally invasive techniques

    posterolateral approach

    Fixation is achieved with a K-wire placedpercutaneously in a proximal-to-distal directionacross the fracture site

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    Radial head excision

    ??

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    Complications

    Loss of motion (malunion ) joint incongruity

    Enlargement of radial head

    AVN - 10 to 20%

    Fibrous adhesions

    Proximal radioulnar synostosis

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    Olecranon fracturesUncommon

    Only 2 to 5 %

    associated with other elbow injuries(most commonly the medialepicondyle) in 20% to 50% of cases

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    Less common because

    olecranon is predominantly cartilage

    thick periosteum and relatively thin metaphyseal

    cortex

    Usually found as a minimally displacedgreenstick fracture

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    Mechanism of injury hyperextension injury most common

    direct blow to the flexed elbow hyperflexion injury

    a shear force

    Hyperextension injuries are frequentlyassociated with other elbow injuries

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    Classification Graves and Canale

    Displaced (5mm)

    Gaddy et al Displaced (3mm)

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    Diagnosis Swelling

    palpable defect posteriorly

    inability to extend the elbow

    Xrays Look for associated fractures

    Radial head or neck fractures seen in 1/3rd

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    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, and stable closed reduction and cast application

    Flexion injuries may require immobilization inextension

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    Intra-articular fractures with more than 3mm of displacement usually require openreduction and internal fixation

    tension band technique for displacedolecranon fractures

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    T Condylar fracturesseparation of the medial and lateral

    columns of the distal humerus from eachother and from the humeral shaft

    almost universally result in disruption of thearticular surface of the distal humerus

    Rare in children

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    Classification

    Toniolo and WilkinsType I - minimal displacement

    Type II - displaced without metaphyseal

    comminutionType III - displaced with comminution of the

    metaphysis

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    Treatment

    Closed Reduction and PercutaneousPinning

    most type I fractures and in some youngerpatients with type II and type III fractures

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    Open Reduction and Internal Fixation

    Posterior approach splitting the triceps

    Posteromedial approach triceps sparing

    Posterior approach - wide surgical exposure,allows rigid fixation, and permits early

    mobilization

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    Medial Condyle FracturesUncommon

    direct posterior blowto a flexed elbow

    avulsion from avalgushyperextension injury

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    Classification

    Milch based on location of fracture line

    type I injuries - the fracture exits at the trochlear notch

    type II injuries - the fracture extends more laterally

    through the capitellar ossification center

    Kilfoyle's classification

    nondisplaced (traditionally 4 mm)

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    Treatment

    Nondisplaced and minimally displacedfractures can be treated by simple castimmobilization

    Displaced fractures require open reductionand percutaneous fixation

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    CAPITELLAR FRACTURESrare 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

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    Coronoid fracturesmost commonly associated with elbow

    dislocations

    Hence frequently associated with fracturesof the medial epicondyle, olecranon,proximal radius, and lateral condyle

    Rarely displaced hence no additionalintervension required

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    Trochlear fractures Uncommon

    fracture is associated with dislocation

    open reduction with fixation intra-articular

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    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 bemisinterpreted as a displaced fracture

    Treated conservatively

    Entrapment of the fragment only indication for surgery

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    ReferencesTachdjians Paediatric Orthopaedics, 4th ed

    Rockwood and Wilkins Fractures in Children, 7th

    ed

    Paediatric orthopaedics in practice, Hefti

    Campbells Operative Orthopaedics, 11th ed

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