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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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