Elbow Fracture

in Pediatric

By, R. Kalaichelvi

Introduction
Elbow fractures are common childhood injuries,
accounting for about 10% of all childhood
fractures.
In many cases, a simple fracture will heal well
with conservative cast treatment.
Some types of elbow fractures, however,
including those in which the pieces of bone are
significantly out of place, may require surgery.
Other structures in the elbowsuch as nerves,
blood vessels, and ligamentsmay also be
injured when a fracture occurs and require
treatment, as well.

Anatomy
Articulations
Ulnohumeral, Radiocapitellar, Proximal radioulnar
Stability
Ulnar and lateral collateral ligament complexes
Anterior bundle - medial stability
Lateral ulnar collateral - lateral stability

Muscles
Origins /Insertions
Lateral epicondyle
Extensor (wrist/finger)
Medial epicondyle
Forearm flexors
Pronators
Olecranon
Extensor (elbow)

Vasculature

Nerves

Ossification Centres
Age at appearance Age at Closure
Capitellum

1-2

14

Radius

16

Internal
Epicondyle

15

Trochlea

14

Olecranon

14

External
epicondyle

11

16

Ossification Centres
Mnemonic CRITOE
C - capitellum
R - radial head
I - Internal Epicondyle
T - Trochlea
O - Olecranon
E - External Epicondyle

Elbow Fractures
Physical Examination
Children will usually not move the elbow if a fracture
is present
Swelling about the elbow is a constant feature,
except for non-displaced fracture
Complete vascular exam is necessary, especially in
supracondylar fractures
Doppler may be helpful to document vascular status

Neurologic exam is essential, as nerve injuries are

common
In most cases, full recovery can be expected

Elbow Fractures
Physical Examination
Neurological exam may be limited by the
childs ability to cooperate because of age,
pain, or fear.
Thumb extension EPL
Radial PIN branch

Thumb flexion FPL

Median AIN branch

Cross fingers/scissors - Ad/Abductors

Ulnar

Elbow Fractures
Physical Examination
Always palpate the arm and forearm for signs of
compartment syndrome

Radiography
Views
AP
Lateral
Oblique
External
Internal

AP and lateral are usually sufficient

Radiography
AP
Supination and full extension at elbow with slight flexion
of fingers
Visualize

Epicondyles
Carrying angle (10-12)
Articulations
Baumanns angle (75)

Radiography
Lateral
Rest on table
Elbow flexed at 90
Thumb up

Radiography
Oblique
Visualize condyles
Internal - medial epicondyle and coronoid
External - capitellum and radial head

The 8 Step Approach

1.
2.
3.
4.
5.
6.
7.
8.

Figure of 8
Anterior Fat Pad
Posterior Fat Pad
Anterior humeral line
Radio-capitellar line
Inspect radial head
Distal humerus examination
Ulna/Olecranon examination

Approach
Figure of Eight
To determine if true
lateral
Otherwise unable to
adequately assess fat
pads, anterior humeral
line

Approach
Anterior Fat Pad
Barely visible on normal film
Trauma - fracture
Children - supracondylar
Adults - Occult radial head

Atraumatic - inflammation

Approach
Posterior Fat Pad
ALWAYS ABNORMAL

Approach
Anterior humeral line
Passes through middle
third of the capitellum
Disruption suggests
supracondylar fracture

Approach
Radio-capitellar line
On any plain film view
Bisects the capitellum
Disruption represents
radial head/neck# or
dislocation

Approach
Inspect radial head
Disruption in cortical surface

Inspect distal humerus

Disruption in cortical surface

Inspect ulna/olecranon
Disruption in cortical surface

Elbow Fractures
Radiograph Anatomy/Landmarks
Baumanns angle is formed by a line
perpendicular to the axis of the
humerus, and a line that goes
through the physis of the capitellum
There is a wide range of normal for
this value
Can vary with rotation of the radiograph

In this case, the medial impaction

and varus position reduces Baumans
angle

TYPES OF
FRACTURES

Supracondylar Humerus Fractures

Most common fracture around the elbow in
children
60 percent of elbow fractures
Occurs from a fall on an outstretched hand
Ligamentous laxity and hyperextension of
the elbow are important mechanical factors
May be associated with a distal radius or
forearm fractures

Supracondylar Humerus Fractures

Classification
Type 1
Non-displaced

Type 2
Angulated/displaced fracture
with intact posterior cortex

Type 3
Complete displacement, with
no contact between
fragments

Type 1
Non-displaced
Note the nondisplaced fracture
(Red Arrow)

Note the posterior

fat pad (Yellow Arrows)

Type 2
Angulated/displaced fracture with intact
posterior cortex

Type 2
Angulated/displaced fracture with intact
posterior cortex
In many cases, the type 2
fractures will be impacted
medially
Leads to varus angulation

The varus malposition

must be considered when
reducing these fractures
Apply a valgus force for
realignment

Type 3
Complete displacement, with no contact
between fragments

Complications
Neurovascular injury in ~12%
displacement increases incidence

Mostly neuropraxias that resolve in months

Extension - median nerve and brachial artery
Flexion - ulnar nerve

Supracondylar Humerus Fractures

Treatment
Type 1 Fractures
In most cases, these can be treated with
immobilization for approximately 3 weeks, at 90
degrees of flexion
If there is significant swelling, do not flex to 90
degrees until the swelling subsides

Supracondylar Humerus Fractures

Treatment
Type 2 Fractures: Posterior Angulation
If minimally displaced (anterior humeral line hits
part of capitellum)
Immobilization for 3 weeks.
Close follow-up is necessary to monitor for loss of
reduction

Displaced (anterior humeral line misses capitellum)

Reduction may be necessary
The degree of posterior angulation that requires
reduction is controversial
Check opposite extremity for hyperextension

If varus/valgus malalignment exists, most authors

recommend reduction.

Type 2 Fractures
Treatment
Reduction of these fractures is usually not difficult
Maintaining reduction usually requires flexion beyond 90

Excessive flexion may not be tolerated because of

swelling
May require percutaneous pinning to maintain reduction

Most authors suggest that percutaneous pinning is

the safest form of treatment for many of these
fractures
Pins maintain the reduction and allow the elbow to be
immobilized in a more extended position

Supracondylar Humerus Fractures

Treatment
Type 3 Fractures
These fractures have a high risk of neurologic and/or
vascular compromise
Can be associated with a significant amount of swelling
Current treatment protocols use percutaneous pin fixation
in almost all cases
In rare cases, open reduction may be necessary
Especially in cases of vascular disruption

Lateral Condyle Fractures

Common fracture,
representing
approximately 15% of
elbow trauma in
children
Usually occurs from a
fall on an outstretched
arm

Lateral Condyle Fractures

Jakob Classification
Type 1
Non-displaced fracture
Fracture line does not cross
through the articular surface

Type 2
Minimally displaced
Fracture extends to the
articular surface, but the
capitellum is not rotated or
significantly displaced

Type 3
Completely displaced
Fracture extends to the
articular surface, and the
capitellum is rotated and
significantly displaced

Lateral Condyle Fractures

Jakob Type 1
Oblique radiographs
may be necessary to
confirm that this is not
displaced. Frequent
radiographs in the cast
are necessary to
ensure that the
fracture does not
displace in the cast.

Lateral Condyle Fractures

Jakob Type 2
Displaced more than 2 mm
On any radiograph
(AP/Lateral/Oblique views)
Reduction and pinning
Closed reduction can be
attempted, but articular reduction
must be anatomic

If residual displacement and the

articular surface is not
congruous
Open reduction is necessary

Lateral Condyle Fractures

Jakob Type 3
ORIF is almost always
necessary
A lateral Kocher
approach is used for
reduction, and pins or
a screw are placed to
maintain the reduction

Lateral Condyle Fractures

Complications
Non-union
This usually occurs if the
patient is not treated, or
the fracture displaces
despite casting
Well-described in
fractures which were
displaced more than 2
mm and not treated with
pin fixation

Lateral Condyle Fractures

Complications
AVN can occur after
excessive surgical
dissection
Cubitus varus can
occur, may be because
of malreduction or a
result of lateral
column overgrowth

Medial Epicondyle Fracture

~12% of paeds elbow fractures

Common between 10-14 years, majority male
Associated with dislocations ~50%
Mechanism
Avulsion of epicondyle by forearm flexors with
valgus stress

Medial Epicondyle Fracture

Classification
Degree of displacement (< or > 5 mm)
+/- trapped fragment
+/- dislocation of elbow

Medial Epicondyle Fracture

Management
Minimally displaced
Long arm splint
1-2 weeks with early ROM

Displaced >5mm
Conservative or operative

Intra-articular fragment
Surgical removal of fragment

Medial Epicondyle Fracture

Complications
Ulnar nerve injury 10-16%
More common if intraarticular fragment

Radial Head and Neck Fractures

Radial neck > head fractures
Often minimal physical findings
Mechanism
FOOSH
Elbow extended and in valgus

Associated with other injuries in ~ 50% of cases

Radial Head and Neck Fractures

Classification
By degree of angulation

Type I
< 30 angulation

Type II
30 -60 angulation

Type III
> 60 angulation

Radial Head and Neck Fractures

Management
Angulation>15 - closed reduction
Type I
Sling/posterior splint X 1-2 weeks

Type II and III

Percutaneous pining if closed reduction not
adequate (<30)

Radial Head and Neck Fractures

Complications
AVN of radial head ~ 10 -20%
Loss of ROM
rotation

Olecranon Fracture

~ 5% of elbow fractures
More common with increasing age
Associated with other injuries (50%)
Mechanism
Direct blow
Shear
Indirect due to forceful contraction of triceps
while elbow flexed in fall
Hyperextension

Olecranon Fracture
Management
Extra-articular
Displaced <3 mm
3-4 immobilization

Displaced >3 mm
Closed reduction
Immobilize
Hyperextension/Shear - cast in flexion
Hyperflexion - cast in extension

Intra-articular
ORIF

Olecranon Fracture
Complications
Missed injuries
Ulnar nerve injury
Non-union
Arthritis
Poor extensor strength

Conclusion
Be vigilant
Use a thorough approach

Look for associated injuries

Think about mechanism
Know how it is treated in your centre

Thank You
very much