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paediatric elbow fractures
- 1. Paediatric elbow fractures ByNick Harper
- 2. • Anatomy • Ossification •General Prinicples • Supracondylar Fractures • Lateral Condyle Fractures • Medial Epicondyle Avulsion • Proximal Radius Fractures • Radial head dislocations • Nursemaid’s elbow Paediatric elbow fractures
- 3. Anatomy – AdultElbow
- 4. Anatomy – AdultElbow
- 6. Ossification centers 1 CCapitulum 3 R Radial Head 5 I Internal Epicondyle 7 T Trochlea 9 O Olecranon 11 L Lateral Epicondyle
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- 8. Ossification centers •The Trochleahas several ossification centers •Can mimic loose bodies within the joint
- 9. General principles Fat Padsign Lateral view, 90° flexion NEGATIVE Anterior Fat Pad
- 10. Fat Pad sign Lateralview, 90° flexion Anterior Fat Pad POSITIVE Posterior Fat Pad In presence of trauma, predicts fracture in 76% of cases •Distension of the joint capsule •Joint effusion •Haemarthrosis General principles
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- 14. Salter – HarrisClassification SALTR S- Slipped A- Above L- Lower T- Through R- Ruined Fractures involving the Physis (growth plate)
- 15. General Principles Radiocapitellar line. •“A line drawn from the centre of the radial neck should pass through the center of the capitulum in all views” Anterior humeral line. • “A line drawn along the anterior cortex of the humerus in lateral view should pass through the middle third of the capitulum.”
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- 19. Supracondylar fractures • >60%of all elbow fractures in children • 95% are hyperextension injuries • The elbow becomes locked in hyperextension
- 20. Supracondylar fractures • >60%of all elbow fractures in children • 95% are hyperextension injuries • The elbow becomes locked in hyperextension
- 21. Supracondylar fractures • >60%of all elbow fractures in children • 95% are hyperextension injuries • The elbow becomes locked in hyperextension
- 22. Supracondylar fractures • >60%of all elbow fractures in children • 95% are hyperextension injuries • The elbow becomes locked in hyperextension
- 23. Supracondylar fractures • Flexion– type fractures are uncommon (5%) • Direct impact to the flexed elbow • Ulnar nerve injury common • More likely to be unstable than extension injuries
- 24. Supracondylar fractures Gartland ClassificationManagement 1 Minimally displaced fracture Conservative 2 Displaced with intact posterior cortex Closed reduction and percutaneous fixation 3 Complete displacement (Posteromedial 75%, Posterolateral, 25%) Closed/open reduction and fixation IIII II
- 25. Supracondylar fractures Complications • Neurovascularcompromise • Malunion may cause cubitus varus “gunstock deformity”
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- 27. Lateral condyle fractures •2nd most common elbow fracture in children (17%) • Varus force to an extended elbow • Localised swelling over the lateral • Intrarticular • Salter-Harris IV • Instability due to forearm extensors • Can be challenging to see on radiograph
- 28. Lateral condyle fractures MilchClassification 1. - Fracture line traverses lateral to capitello-trochlear groove - Elbow is stable 2. - Fracture passes through the capitello-trochlear groove - Elbow is unstable Hard to classify on radiograph as fracture fragments are primarily cartilagenous
- 29. Lateral condyle fractures •Displacement classification
- 30. Lateral condyle fractures DisplacementClassification Management 1 <2mm conservative 2 >2mm Surgical - Pins 3 Wide displacement and rotation Surgical - Open reduction, Internal fixation I II III
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- 33. Complications • Non union •Malunion • Excessive bone formation • Avascular necrosis of lateral condyle (iatrogenic) • Ulnar nerve neuropathy (22 years post fracture, Cubitus Valgus) Lateral condyle fractures Cubitus Varus Cubitus Valgus
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- 35. Medial Epicondyle Avulsion •3rd most common elbow fracture in children • adolescent boys • Acute valgus stress (sometimes during armwrestling) • Severe pain over medial aspect, “pop” sound, Ulnar nerve irritation • Elbow dislocations occur in 50% of cases
- 36. Medial Epicondyle Avulsion •Avulsed medial epicondyle becoming entrapped in the dislocated joint
- 37. Medial Epicondyle Avulsion Management Nondisplaced – Conservative Displacement 5-15mm – Conservative/Surgical Displacement>15mm - Surgical
- 38. Medial Epicondyle Avulsion •Avulsed medial epicondyle becoming entrapped in the dislocated joint • Don’t confuse with Trochlea ossification centers
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- 40. • Adults –articular surface of radial head • Children – Radial neck (metaphyseal bone weaker due to constant remodeling) • Fall on extended and supinated outstretched hand • 90% are Salter Harris II Proximal Radius fractures
- 41. Management Children under 4have a normal valgus angulation to the radial neck (Up to 15°) <30° Conservative >30° Closed reduction K-wires used if closed reduction unsuccessful or unable to pronate and supinate upto 60° Proximal Radius fractures
- 42. Radial Head Dislocations •Radiocapitellar line useful! • Can be obvious or quite subtle • Always look for associated injury •Monteggia Fracture •Dislocation of the radial head with fracture of the proximal third of the ulnar •Fall on outstretched hand with forearm in excessive pronation
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- 44. Nursemaid’s elbow • Annularligament poorly attached in children <5 • If the forearm is pulled, radial head moves distally. The annular ligament slips over the radial head and becomes trapped in the joint
- 45. Nursemaid’s elbow • Suddenlongitudinal force applied to the forearm • Audible snap • Limb held in extension • Pain on moving the forearm • Radiograph is often normal • Treatment – manipulation - Supination & Flexion - Pronation
- 46. Summary • Supracondylar Fractures • LateralCondyle Fractures • Medial Epicondyle Avulsion • Proximal Radius Fractures & Dislocations
- 47. References • Agur, A.M.R.& Dalley, A.F. Grant’s Atlas of Anatomy (12th ed). Lippincott, Williams & Wilkins • John Harris et al The Radiology of Emergency Medicine, 3rd Ed, Williams and Wilkins, 1993, p 352 • http://www.radiologyassistant.nl/en/4214416a75d87 • http://emedicine.medscape.com/article/415822-overview • http://www.wheelessonline.com/ortho/frx_of_the_lateral _condyle_in_children • http://orthoinfo.aaos.org/topic.cfm?topic=A00037 • http://www.joint-pain-expert.net/index.html
Editor's Notes
- #7 It is not uncommon for the ossification centers to appear out of order The ages are approximate, not exact One study showed these centers developed 2 years later in boys than in girls
- #8 Normal olecranon but fractured radial neck
- #18 Dislocation of radius and olecranon fracture Condyles displaced dorsally – ie supracondylar fracture
- #26 Red = brachial artery Green = Median nerve
- #33 Overprojection of the capitulum
- #34 AVN – aggressive open reduction Non union/malunion – pull of extensors
- #36 Valgus causes traction on medial epicondyle through flexors
- #37 Joint becomes locked
- #41 Radial neck fracture
- #44 Treatment of radial head dislocation is manipulation. Depends on if there is an associated fracture that makes the forearm stable. If so, needs to be repaired surgically. Giovanni Battista Monteggia Isolated radial head dislocation very rare in children. Much more common is subluxation…
- #46 Cochrane review on which method is best – conclusion is that it probably doesn’t make much difference