Humerus And Elbow Fracture In Children

FRACTURES IN CHILDREN ELBOW HUMERUS

PRESENTER DR.AHSAN-UL-HAQ POST-GRADUATE RESIDENT Lahore General Hospital

Ossification Centres 

There are 6 ossification centres around the elbow joint.



The ossification centers always appear in a strict order. Come-Read-My-Tale-OfLove (Capitellum - Radius medial epicondyle Trochlea - Olecranon lateral epicondyle).



As a general guide remember 1-3-5-7-9-11 years.

ELBOW JOINT FRACTURES AND DISLOCATIONS 

Radial Head and Neck Fractures  





4 to 14 years Ossification of the radial head usually does not begin before 5 years of age Most fractures in children are of the radial neck and not the radial head Usually Salter-Harris type IV fractures.

Classification Radial Head and Neck Fractures  Wilkins  Type

A

 Salter-Harris

type I and II injuries of the proximal radial epiphyses

 Type

B

 Salter-Harris

type IV injuries of the proximal radial epiphyses

 Type

C

 Fractures

involving only the proximal radial metaphysis

Radial Head and Neck Fractures •

Type D •



Fractures occurring when a dislocated elbow is being reduced

Type E  Fractures

occurring in conjunction with the elbow dislocation

Acceptable Criteria  30

to 45 degrees of residual angulation usually is accepted in closed treatment with satisfactory results

Patterson Technique

Close Manipulation 

Neher and Torch modified the original closed reduction technique of Patterson.  



General anesthesia if needed and fluoroscopy An assistant stabilizes the radius distal to the fractured radial neck With the elbow in extension, the surgeon applies a varus stress with one hand on the elbow and lateral pressure directly over the radial head with the thumb of the other hand

Closed Reduction  Pesudo  Using

et al.

a percutaneous pin with the aid of an image intensifier to manipulate and reduce the angulation of the fracture fragments

Closed Reduction 

Metaizeau technique. 

Inserting a curved steel Kirschner wire that is sharply bent at the last 1.5 cm through the distal radial metaphysis into the medullary canal



The wire or nail is advanced until the point fixes in the epiphysis and elevates and replaces it under the lateral condyle. The pin is turned around its long axis through 180 degrees, producing a medial shift of the radial head and reducing it.

AFTERTREATMENT  The

arm is immobilized in a long-arm cast for 2 to 3 weeks.  The Kirschner wire is not removed until approximately 2 months later when the fracture has consolidated.

ORIF 

If a satisfactory closed reduction cannot be obtained, open reduction should be done



Surgery should be performed within 5 to 7 days of injury to prevent myositis ossificans of the elbow,



Before skeletal maturity is reached, radial head resection may result in proximal radioulnar synostosis, cubitus valgus, and radial deviation of the hand

Complications After Open Reduction Include

Loss of motion  Premature physeal closure  Nonunion of the radial neck  Osteonecrosis of the radial head  Radioulnar synostosis  Myositis ossificans  Injury to the posterior interosseous nerve 

Radial Head Dislocation (Pulled Elbow)  Age:

usually 1 to 4 years old  History of “pull” on the elbow  In 50%: no history of a "pull" on the arm

Examination  Not

using the affected limb  Elbow in extension and the forearm in pronation  Marked resistance and pain with supination of the forearm

Reduction Technique

Olecranon Fractures  Pure

physeal fractures of the olecranon are extremely rare  Has secondary ossification centre  The epiphysis fuses to the metaphysis at about age 14.

Grantham and Kiernan and Wilkins  The

first type is purely physeal  The second type occurs in older children and has a large metaphyseal fragment attached to the epiphysis

Papavasiliou et al.  Intraarticular

(Group A)

Simple

crack fractures Fractures with minimal displacement Complete fractures of the olecranon involving the articular cartilage and with slight dorsal displacement of the proximal fragment Grossly displaced fractures 

Extraarticular (Group B) Greenstick

fracture

Evans and Graham  If

displacement, especially intraarticular, is more than 3 to 4 mm, open reduction and internal fixation are indicated

 Regardless

of the type of fracture, if significant displacement persists after attempts at closed reduction, open reduction and internal fixation should be performed

Methods of ORIF  Tension

band

wiring  Axial pins  Oblique screws

Fractures of the Coronoid Process  Regan

and Morrey classification  Type a



I

small chip fracture;

Type II a

fracture involving less than 50% of the process;



Type III a

fracture involving more than 50% of the process

Treatment Options  Closed Type

 Open

treatment I and II fractures

reduction and internal fixation

Type

III fractures

Elbow Dislocations  Acute

Dislocations

 Most

pure dislocations are posterior  But they can occur anteriorly, medially, or laterally



 

Regardless of the type, most elbow dislocations can be reduced closed Under GA, longitudinal traction Immobilization for approximately 6 weeks

Indications for open reduction  Inability

to obtain a closed reduction  Open dislocation  Medial epicondyle fracture  Radial neck fracture  Arterial injuries

Chronic Recurrent Elbow Dislocations 

Four primary underlying causes 1.

2. 3.

4.

Shallow trochlear notch that allows easy dislocation of the olecranon from the trochlea Medial, lateral, or combined capsular laxity of the elbow Intraarticular fractures that cause medial or lateral instability of the olecranon in the trochlea Congenital laxity of the medial and lateral ligaments around the elbow.

Evaluation  Anteroposterior

and lateral radiographs of

both elbows  Any osseous loose bodies or articular fractures also can be noted  Varus and valgus stress radiographs of both elbows to determine any medial or lateral ligamentous instability  Arthrogram or MRI  suspected

intraarticular condylar fracture

 Fluoroscopic

examination

Treatment  Surgical

procedure should be selected to correct the specific condition  If

plain radiographs reveal a shallow trochlear notch Transfer

of the biceps or triceps tendon or both Reichenheim  Biceps

tendon onto the coronoid process of the ulna, suturing it to the periosteum on the anterior aspect of the coronoid process with two smooth wires

King  Passing

the tendon through a drill hole in the coronoid to the subcutaneous border of the ulna, where it was sutured

Treatment Kapel  Threading

a strip of biceps tendon through a drill hole in the small partition of bone separating the coronoid and olecranon fossae and suturing it to the tip of the olecranon; a central slip of triceps tendon was pulled through the same hole and sutured to the coronoid process.

If

stress radiographs reveal significant ligamentous laxity Capsular

repair and imbrication

Old Unreduced Elbow Dislocations  Satisfactory

functional result can be obtained by an open reduction upto 03 months  Campbell posterolateral approach  Free subperiosteally all muscle attachments  Release the attachments of the joint capsule around the humeral condyles.  Detach the collateral ligaments from their proximal insertions

Old Unreduced Elbow Dislocations  If

the triceps is tight, preventing reduction or limiting flexion to about 30 degrees after reduction, lengthen the muscle using Speed's V-Y muscle-plasty  Do not reattach the ligaments to bone to avoid making the repair too tight.  If the ulnar nerve is tight or was compressed preoperatively, transpose it anteriorly  Check the stability of the reduction manually at 90 degrees of flexion

AFTERTREATMENT

The

cast and any Kirschner wires are removed at 2 to 3 weeks. Active mobilization of the elbow is started slowly and is encouraged.

Distal Humeral Fractures

Capitellar Fractures

Classification of fractures of the Capitellum 

 





Depends on the size of the articular fragment and its comminution. A good quality Lateral view Type 1 fracture  a large fragment of bone and articular cartilage Type 2 fracture  a small shell of bone and articular cartilage Type 3 fracture  comminuted fracture

Treatment options 

Closed reduction 



Open reduction with and without internal fixation    



usually not successful

Type I & II (large fragment) Kirschner wire Herbert screws cannulated screws

Excision of the fragments 

Most of type III fractures.

Lateral Condylar Fractures  Fracture

 Occur

of necessity

at approximately age 6 years

Mechanism of injury  When

a varus force is applied to the extended elbow.  They tend to be unstable and become displaced because of the pull of the forearm extensors.  Since these fractures are intraarticular they are prone to nonunion because the fracture is bathed in synovial fluid.

Milch Classification 

Type I fracture, 



The fracture line courses medially to the trochlea through and into the capitellartrochlear groove

Type II fracture, 

The fracture line extends into the area of the trochlea and produces inherent instability of the elbow

 Lateral

condylar fractures also have been classified according to the amount of displacement:

(1) Undisplaced, (2) Moderately displaced, (3) Completely displaced and rotated

Finnbogason et al.  Type

A

 Fracture

through the lateral humeral condyle with minimal lateral gap  A stable fracture

 Type

B

 Fracture

through the lateral humeral condyle to the epiphyseal cartilage with a lateral gap

A

fracture with undefinable risk

 Type

C

 Fracture

through the lateral humeral condyle with the fracture gap as wide laterally as medially  A fracture with high risk of later displacement

MRI  MRI

distinguishes the potentially unstable fracture (Type II) from the stable, minimally displaced fracture (Type I).

Treatment Options 

 

Mostly closed manipulation and POP casting Percutanious K wire fixation Open reduction and internal fixation

1) suture fixation, which is inadequate; 2) smooth pin fixation, preferably with two pins, through the epiphysis or through the metaphyseal spike 3) screw fixation, preferably through the metaphyseal area.

Aftertreatment  Immobilization

for approximately 6

weeks.  Gentle active motion of the elbow usually is resumed intermittently out of the splint.  The splint is not removed permanently until the radiographs show solid union.

Complications  Physeal

arrest  Physeal stimulation  Osteonecrosis  Nonunion with resultant cubitus valgus

Bone Grafting for Nonunion or Delayed Union  Open

Reduction and Internal Fixation with Bone Grafting for Nonunion or Delayed Union of Minimally Displaced Fractures

Aftertreatment  The

limb is immobilized in plaster with the elbow at 90 degrees of flexion and the forearm in neutral rotation for 12 weeks. The pin or screw is removed, and active exercises are begun

Established Nonunion with Cubitus Valgus  Occur,

not from premature closure of the capitellar physis, but from nonunion with proximal migration of the lateral condyle  Masada et al. concluded

that osteosynthesis is indicated for the treatment of nonunion of the lateral humeral condyle only if The

patient has severe pain in the elbow or is apprehensive about using the elbow because of lateral instability

Treatment  Milch

devised two osteotomies for nonunion of the lateral condyle; with each, internal fixation and bone grafting are recommended.

Osteotomy 

In Milch type I fractures 

Opening wedge lateral osteotomy as described by Milch



A closing wedge medial osteotomy as described by Speed

Osteotomy  In

Milch Type II fractures, there is significant lateral displacement of the fragment and some rotation  Milch

recommended an opening wedge displacement osteotomy

Technique    



Patient prone Posterior muscle-splitting incision Identify the ulnar nerve Perform transverse osteotomy at the level of the intersection of the forearm axis with the lateral cortex of the humerus Notch the inferior surface of the proximal fragment to receive the apex of the superior surface of the distal fragment, which is moved laterally

Technique  When

correction is satisfactory, fix the fragments by inserting two smooth crossed Kirschner wires  Carefully flex the elbow, and immobilize it in plaster at 90 degrees

Aftertreatment  The

cast is left on for 6 to 12 weeks, depending on the age of the child and evidence of bony union. The wires are removed, and motion is encouraged at that time.

Kim Osteotomy  



Step-Cut Translation Osteotomy with a Y-Shaped Humeral Plate Perform the initial osteotomy 0.5 cm superior to the olecranon fossa, perpendicular to the axis of the humeral shaft, with an electrical saw. Place the triangular template over the proximal portion of the humerus, and mark the area Osteotomize the proximal part of the humerus according to the drawn line

Step-cut Translation Osteotomy. 







A, After humerus-elbow-wrist angle is determined on anteroposterior radiograph, initial transverse osteotomy line is made about 0.5 to 1 cm superior to olecranon fossa and perpendicular to axis of humerus. Triangular area indicates area to be resected. B and C, Cubitus varus is corrected by rotating distal fragment and translating it medially after completing initial transverse osteotomy. Triangular overlapping of proximal and distal humeral portions means that resection is indicated. For cubitus varus, degree of correction increases as location of apex moves medially. D and E, Cubitus valgus is corrected by rotating distal part of humerus medially and translating it laterally according to anatomical shape of normal elbow. F, Fixation of osteotomy site.

Medial Epicondylar Fractures 



Most fractures of the medial epicondylar epiphysis are acute avulsion injuries caused by overpull of the forearm flexor tendon Can occur in dislocation of the elbow, and the fragment may or may not become caught in the joint

Treatment 



Most nondisplaced or minimally displaced fractures can be treated by closed methods Indications for open reduction include 



 

(1) rotation and displacement of more than 1 cm because of the resulting weakness of the forearm flexors or cosmetic deformity (2) persistent entrapment of a fracture fragment in the joint after reduction of an elbow dislocation, (3) ulnar nerve dysfunction (4) valgus instability

Treatment 

The medial epicondyle should be identified and its location noted after every elbow dislocation



If the fragment remains caught within the joint, a closed reduction should be attempted with the forearm supinated and stressed in valgus with the patient under general anesthesia



Passive dorsiflexion of the fingers may help put traction on the epiphysis.

Treatment If closed methods fail, open reduction is required with removal of the fragment from the joint and excision or reduction and internal fixation of the fragment through k wire or screw  Small fragment can be excised and muscles to be sutured to humerus metaphysis 

Aftertreatment  The

splint is worn for 4 weeks. Next, the arm is supported by a sling permitting active motion of the elbow but preventing forced dorsiflexion of the wrist or supination of the forearm.  At 6 weeks, the wire or screw is removed, and normal activities are resumed gradually.

Medial Condylar Fractures  

Least common injuries of the elbow Kilfoyle described three types 

Type I

 Greenstick

fracture



or impacted

Type II

 Fracture

through the humeral condyle into the joint with little or no displacement



Type III  An

epiphyseal fracture that is intraarticular and involves the medial condyle with the fragment displaced and rotated

Treatment  Type

I and undisplaced type II fractures

 Observation

and posterior splinting

 Type

II fractures

 Type

III fractures

 Open

reduction and internal fixation are appropriate to avoid growth disturbance and nonunion.

 Open

 Early

reduction and internal fixation.

diagnosis, accurate reduction, and internal fixation are essential to avoid growth disturbance, articular roughening, functional disability, nonunion, and osteonecrosis

Open Reduction and Internal Fixation  Medial

incision just distal to the fractured condyle  Extend it proximally 7.5 cm parallel to the long axis of the humerus  Isolating the ulnar nerve and retracting it posteriorly  Gently reduce the fracture, and hold it with a towel clip  Insert two smooth Kirschner wires through the condylar fragment and into the humerus in a proximal and lateral direction.  Close the wound and apply a plaster splint with the elbow flexed 90 degrees

Supracondylar Fractures  

Observations (1)  



(2) 



Most occurred in boys, especially between ages 5 and 8 years

(3) 



97.7% extension type only 2.2% were of the flexion type

Volkmann ischemic contracture occurred in 0.5% of the fractures;

(4) 

The radial, median, and ulnar nerves were involved in that order of frequency.

Mechanism of injury  Fall

on outstretched hand

Know basic landmarks on lateral view to give clues to distinguish fracture from normal



Anterior humeral line —middle 1/3 capitellum

Know basic landmarks on lateral view to give clues to distinguish fracture from normal



Radiocapitellar line —points directly to capitellum

Gartland Classification  Type 

I

undisplaced;

 Type

II

 displaced

with intact posterior cortex

 Type

III

 displaced

with no cortical contact.

 The

three most common reasons for residual cubitus varus or valgus deformity are (1) The inability to interpret poor radiographs and acceptance of less than adequate reduction, (2) The inability to interpret good radiographs because of a lack of knowledge of the pathophysiology of the fracture, (3) The loss of reduction

Jones view  Anteroposterior

plane should be taken properly with the elbow flexed maximally, the cassette underneath the elbow, and the tube at a 90degree angle to the cassette  An anterior spike on the lateral view usually implies rotation rather than posterior displacement.

crescent sign

Crescent sign. A, Normal lateral view of elbow. B, In varus deformity, part of ulna overlies distal humeral epiphyses, producing crescent sign



Baumann angle. a, Midline diaphysis of humeral shaft.  b, Line perpendicular to midline.  c, Line through physis of lateral condyle. 





Angle A is original Baumann angle. Angle B is more commonly used currently. A change of 5 degrees in the Baumann angle corresponds to a 2-degree change in the clinical carrying angle.

O'Brien et al  Metaphyseal-

diaphyseal angle was more accurate than the Baumann angle in determining the adequacy of reduction

 Varus

tilting is reduced by pronation of the forearm that closes the fracture laterally

Criteria for closed reduction  Easy

reduction  Stable fracture  Minimal swelling  No vascular compromise

Conservative treatment  Skeletal

traction using an olecranon pin or screw  advantages

are increased mobility, decreased pain and swelling, and improved alignment.

.

Percutanious pin fixation  Most

displaced Gartland type II and reducible type III fractures are treated by percutaneous pinning

Closed Reduction and Percutaneous Pinning  Different

options of wire fixations 2

parallel pins  Divergent pins  Crossed pins  Medial and lateral pins

 Skaggs

et al. noted an incidence of 4% ulnar nerve palsy with use of a medial pin and 15% ulnar nerve palsy when the elbow was acutely flexed with insertion of a medial pin  Resolve spontaneously

Royce et al.  For

comminuted or unstable fractures, medial and lateral pins are used.  To prevent nerve injury when a medial pin is used, small incision over the medial epicondyle is given and placing a drill guide on the bone, through which the wire is inserted.  The pins should be angulated superiorly approximately 40 degrees and posteriorly 10 degrees.

AFTERTREATMENT A

long arm posterior plaster splint is worn for 3 weeks  The pins are removed at 3 weeks, and another posterior splint is applied.  At 4 weeks, the splint is removed, intermittent active range-of-motion exercises are started

Open Reduction and Internal Fixation  Indications Closed

reduction is unsatisfactory Type III displaced fracture with no cortical contact After one or two attempts at closed reduction Neurovascular deficit Open fractures that require irrigation

Approaches  Anterior  Medial  Anteromedial  Posterior  Lateral Depending

upon complications/fracture configuration

Early Complications  Neurological

compromise 3% to 22%  Injury to the brachial artery 10%  Compartment syndrome

Late Complications  Cubitus

varus (gunstock deformity)  Cubitus valgus rare  Myositis ossificans

Causes of cubitus varus  Medial

displacement and rotation of the distal fragment  Varus tilting of the distal fragment  Overgrowth of the lateral condyle  Malunited supracondylar fractures

Osteotomies  Medial

opening wedge osteotomy with a bone graft  Oblique osteotomy with derotation  Lateral closing wedge osteotomy

 Three-dimensional

osteotomy

 Lateral

closing wedge osteotomy is the easiest, safest, and inherently the most stable osteotomy. Procedures Two

screws and a wire attached between them Plate fixation Compression fixation Crossed Kirschner wires Staples

Voss et al technique

French technique

Derosa and Graziano

Separation Of Entire Distal Humeral Epiphysis  In

younger children the entire distal humeral epiphysis may separate from the humerus  It is weaker because it is epiphyseal cartilage  Group A fracture  Salter-Harris

type I physeal injuries  can be mistaken for elbow dislocations  can occur as a birth injury or in newborns  usually can be reduced satisfactorily and immobilized in a posterior plaster splint

 Group

B fractures

 Between

the ages of 1 and 3 years  May be Salter-Harris type I or II fracture  Group

C fractures

 Older

children and produce a large metaphyseal fragment,  Closed reduction with the patient under general anesthesia and cast immobilization  If reduction was unsatisfactory, open reduction and internal fixation with smooth pins were carried out.

Fractures of Shaft and Proximal End of Humerus  Fractures

of shaft are rare  Unite in cast  Rarely need open reduction.

Fractures of Shaft and Proximal End of Humerus 



 

Fractures of the proximal humerus are usually physeal Most commonly Salter-Harris type II injuries Classified according to displacement A grade I fracture is displaced less than 5 mm, whereas a grade IV fracture involves total displacement.

 Salter-Harris

classification of proximal humeral physeal injurie

Fractures of Shaft and Proximal End of Humerus 







Open reduction is indicated if the distal fragment is buttonholed completely through the deltoid muscle and is impinging against the skin Cannot be repositioned by closed method Displaced Salter-Harris types III and IV fractures Interposition of the biceps tendon

Fracture Dislocations  Fracture-

dislocations  Needs ORIF