Pediatric Elbow

Posted on: August 16, 2020, by :

Supracondylar

Introduction:  

  • One of the most common pediatric fractures seen, mechanism tends to be fall on an outstretched hand
    • extension type most common (95-98%)
    • flexion type less common (<5%)
  • When reviewing x-rays of the elbows, consider ossification/appearance and age of fusion (two independent events)
    • C-R-I-T-O-E mnemonic to remember age of ossification
Ossification centerYears at ossification (appear on xray) (1)Years at fusion (appear on xray) (1)
Capitellum112
Radial Head415
Internal (Medial) epicondyle616-18
Trochlea812
Olecranon1016
External (Lateral) epicondyle12 12
(1) +/- one year, varies between boys and girl
https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture–pediatric

Classification:

  • Type 1: Non-displaced (posterior fat pad sign on lateral view of x-ray)
    • Treated with posterior long arm splint in ED
    • Urgent Orthopedics follow up for cast immobilization x 3-4 weeks
  • Type 2: Displaced (“hinge” fracture with posterior cortex intact)
    • Treated with cast immobilization in the ED
    • Urgent Orthopedics follow up radiographs in 1-2 weeks
  • Type 3: Completely displaced (+/- distraction)
    • Treated with closed reduction and percutaneous pinning by orthopedics
    • Non-emergent (overnight) operation unless neurovascular compromise

Complications:

  • Vascular compromise (<20%)
    • often maintains circulation secondary to rich collateral supply
  • Associated distal radius fracture
    • consider routine forearm x-rays with elbow pathology 
  • Anterior interosseous nerve (AIN) neuropraxia (most common)
    • unable to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger (can’t make A-OK sign)
  • Radial nerve neuropraxia (second most common)
      • inability to extend wrist, MCP joints, thumb IP joint
  • Median nerve neuropraxia
        • loss of sensation over volar index finger
  • Ulnar nerve neuropraxia (tends to be flexion-type injuries)

Lateral Condyle

Introduction:  

  • Second most common fracture in the pediatric elbow and are characterized by a higher risk of nonunion, malunion, and avascular-necrosis than other pediatric elbow fractures.
    • <20% of all pediatric distal humerus fractures
    • “Pull-off” mechanism: avulsion fracture from the pull of the common extensor musculature
    • “Push-off” mechanism: fall onto an outstretched hand causes impaction of radial head to the lateral condyle
  • When reviewing x-rays of the elbows, consider ossification/appearance and age of fusion (two independent events)
    • last ossification center to appear (around 12 years of age)
    • need internal oblique view (fracture is posterolateral)

Classification:

  • Type 1: <2 mm fracture displacement
    • Treated with cast immobilization in the ED
    • Urgent orthopedics follow up in 1 week for radiographs
  • Type 2: Between 2 and 4 mm fracture displacement
    • Treated with closed reduction and fixation
  • Type 3: >4 mm fracture displacement
    • Treated with open reduction and fixation
https://www.orthobullets.com/pediatrics/4009/lateral-condyle-fracture–pediatric

Complications:

  • Stiffness (most common complication)
    • can be a early sign of non-union or delayed union
  • Nonunion (higher incidence than other elbow fractures)
    • risk factors include nonsurgical management
  • AVN (occurs up to three years after fracture)
    • risk factors include posterior dissection
  • Lateral overgrowth/prominence
    • up to 50% regardless of treatment
    • spurring is correlated with greater initial fracture displacement

Medial Condyle

Introduction:  

  • Third most common fracture in the pediatric elbow and are increasing in incidence due to increased athletic demands of children
    • 75% occur in boys between 9-14 years old
    • Avulsion mechanism: avulsion fracture from the pull of the ulnar collateral ligament
    • Direct trauma
  • 50-60% associated with elbow dislocations
  • When reviewing x-rays of the elbows, consider ossification/appearance and age of fusion (two independent events)
    • last and final ossification center to fuse (around 16 years of age)
    • need internal oblique view

Classification:

  • Acute
    • Nondisplaced, displaced, or fragment entrapped in joint
  • Chronic
    • related to tension stress injuries
  • Treatment is nonoperative with cast immobilization
    • ORIF if displacement with entrapment of medial epicondyle fragment in joint

Complications:

  • Stiffness (most common complication)
  • Nonunion (majority are asymptomatic)
  • Neuropraxia/Nerve Injury (ulnar nerve)

Alternative Diagnosis:

  • Little League Elbow (medial epicondyle stress fracture)
    • Risk factors include: >80 pitches per game, >8 months of competitive pitching per year, Fastball speed >85 mph
    • Pain with valgus stress and tenderness to palpation of medial elbow
    • Treatment is rest, activity modifications, and physical therapy

Olecranon

Introduction:  

  • Uncommon fracture of children
    • <5% of all pediatric fractures
    • FOOSH mechanism with elbow in flexion OR extension
    • Direct trauma mechanism
  • Olecranon avulsion fractures are highly suspicious for Osteogenesis Imperfecta
  • When reviewing x-rays of the elbows, consider ossification/appearance and age of fusion (two independent events)
    • fusion of the olecranon occurs from anterior to posterior
    • partial closure may be mistaken for olecranon fracture

Classification:

  • Acute
    • Nondisplaced
  • Chronic
    • related to tension stress injuries
  • Treatment is nonoperative with cast immobilization
    • ORIF if displacement or unstable fracture

Complications:

  • Stiffness (most common complication)
  • Nonunion 
  • Delayed union
  • Neuropraxia (ulnar nerve)

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Haroon Shaukat MD
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