Common Pediatric Elbow Fractures

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Erin S. Hart ▼ Allison Turner ▼ Maurice Albright ▼ Brian E. Grottkau

Fractures of the elbow are a very common injury in children. condyle fractures. Because 80% of the longitudinal The most common mechanism of injury is a fall on an out- growth in the arm occurs proximally (proximal stretched upper extremity during play. Ranging in complex- humerus), only appositional growth occurs at the elbow. ity from low-energy nondisplaced occult fractures to high- This limits the ability for elbow fractures to completely energy fractures with associated severe soft-tissue and remodel and therefore makes anatomic reductions necessary even in young skeletally immature individuals (Do neurovascular injuries, elbow fractures are a challenging & Herrera-Soto, 2003). problem for all pediatric healthcare providers. Because of the wide spectrum of fracture severity and associated bony and ligamentous injury, a very diverse spectrum of treatment Supracondylar Humerus Fracture modalities is necessary for optimal results. Management is Supracondylar humerus fractures are the most common based on fracture pattern, patient age and bone quality, elbow injury in children (Kasser & Beatty, 2006). They extent of soft tissue damage, functional needs of the patient, account for approximately 50% to 70% of all elbow frac- and the presence of associated injuries. This article will give tures in children (Farnsworth, Silva, & Mubarak, 1998). a brief overview of 4 common pediatric fractures, current This injury occurs most often in boys between the ages of treatment algorithms, and frequent complications associ- 4 and 7 and most frequently occurs after a fall on an out- stretched upper extremity. Supracondylar humerus frac- ated with these injuries. tures are usually divided into extension and flexion types with extension types being far more common (~97%–99%). Clinical findings include pain, elbow lbow fractures account for approximately 5% to swelling or effusion, deformity, and bruising/ecchymosis 10% of all fractures in children. It is often help- (see Figure 2). It is usual to have a fairly rapid onset of ful to address elbow fractures from an anatomic significant swelling with this type of elbow fracture. perspective, as each specific fracture has its own Providers should note the presence of skin puckering that Eunique challenges in diagnosis and treatment. The elbow usually results from the fracture fragment piercing the joint is a complex articulation of three bones (humerus, brachialis muscle and is a sign of considerable soft tissue radius, and ulna) that allows motion in all three planes damage. Any bleeding or break in the skin associated (see Figure 1). The radial-humeral articulation allows with the SCH fracture should be considered an open frac- pronation and supination of the forearm, and the ulnar- ture and treated accordingly. It is important to assess humeral articulation allows flexion and extension of the neurovascular status (both sensory and motor function) elbow (Herring, 2002). It is often very difficult to distin- thoroughly in every patient with a suspected or known guish fractures from the six normal secondary ossifica- elbow fracture. It is also important to evaluate the entire tion centers in the elbow. The six ossification centers ac- extremity, as forearm fractures can occur in association tually develop in a systematic, fairly predictable fashion with SCH fractures and can significantly increase the risk in children. The mnemonic CRMTOL is helpful in re- membering the progression of the radiographic appearance of the ossification centers about the elbow (see Table 1). This stands for Capitellum, Radial head, Medial Erin S. Hart, MS, RN, CPNP, Massachusetts General Hospital for Children, Department of Orthopaedic Surgery, Yawkey Center for epicondyle, Trochlea, Olecranon, and Lateral epicondyle Outpatient Care, Boston, MA. (Waters, 2006). In general, the capitellum appears radi- Alison Turner, MS, RN, CPNP, Massachusetts General Hospital for ographically at around 2 years of age and the remaining Children, Department of Orthopaedic Surgery, Yawkey Center for ossification centers appear sequentially every 2 years. Outpatient Care, Boston, MA. The appearance of the various ossification centers might Maurice Albright, MD, Massachusetts General Hospital for Children, vary slightly with girls often maturing earlier than boys. Department of Orthopaedic Surgery, Yawkey Center for Outpatient However, the overall sequence generally stays the same. Care, Boston, MA. If it is difficult to distinguish a normal secondary center Brian E. Grottkau, MD, Massachusetts General Hospital for Children, of ossification from a fracture, it may be useful to obtain Department of Orthopaedic Surgery, Yawkey Center for Outpatient comparison radiographs (x-rays) from the contralateral Care, Boston, MA. elbow. The most common elbow fractures in children in- The authors have disclosed that they have no financial interests to any clude supracondylar humerus (SCH) fractures, lateral commercial company related to this educational activity condyle fractures, radial neck fractures, and medial epi- DOI:10.1097/NOR.0b013e31820574c6

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FIGURE 1. Elbow joint anatomy showing humerus, radius, and ulna bone. FIGURE 2. Large elbow joint effusion/swelling status post of compartment syndrome (Blakemore, Cooperman, supracondylar humerus fracture. Thompson, Wathey, & Ballock, 2000). Most nerve injuries occur secondary to contusion and traction ischemia at the displaced fracture (Waters, 2006). cortex. Type III SCH fractures are completely displaced Unless the patient presents with an ischemic hand, (no cortical contact between fragments) and have the an open fracture or significant skin tenting, the upper highest rate of neurovascular compromise (see Figures extremity should be immobilized “as it lies” with a sim- 3A and B; Waters, 2006). SCH Type II and III are gener- ple splint (posterior long arm or sugar tong splint), ally treated with closed or open reduction and percuta- while awaiting definitive treatment (Herring, 2002). If neous pinning. Simanovsky, Lamdon, Mosheiff, and the distal extremity is ischemic, a gentle attempt to bet- Simanovsky, (2007) demonstrated the importance of ter align the fracture fragments is done to restore circu- reduction when treating displaced SCH fractures. Their lation to the hand. All patients should be kept from hav- study found that patients who healed with some degree ing food or drink by mouth until a definitive treatment of extension developed limited elbow flexion. Reductions plan has been outlined. are usually done in the operating room with the patient under general anesthesia. Malunions generally occur CLASSIFICATION when the reduction is attempted in the emergency department or clinic, when the initial angulation is not The Gartland classification system of SCH fractures is recognized, and when the cast is applied without any re- generally the most commonly accepted and used system duction attempt (Simanovsky et al., 2007). (see Table 2). Type I fractures are nondisplaced and are Radiographs of nondisplaced (Type I) SCH fractures generally treated with a course of short-term immobi- often show normal results or may have subtle signs such lization (~3- to 6-week long-arm cast). Type II fractures are displaced but often have an intact hinged posterior

TABLE 2. GARTLAND CLASSIFICATION SYSTEM FOR TABLE 1. OSSIFICATION CENTERS IN THE PEDIATRIC ELBOW SUPRACONDYLAR HUMERUS FRACTURES CRMTOL Type I—nondisplaced, treated with immobilization in long C: Capitellum arm cast R: Radial head Type II—displaced with posterior hinge, usually treated with M: Medial epicondyle closed reduction and percutaneous pinning T: Trochlea Type III—completely displaced (no cortical contact between O: Olecranon fracture fragments), treated with closed/open reduction L: Lateral epicondyle and percutaneous pinning

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geons currently recommend reduction and pinning for any displaced SCH fracture. The treatment will vary by fracture type and pattern, but the goal remains the same—which is to maintain alignment of the fracture to allow full functional recovery (Omid, Choi, & Skaggs, 2008). Although much debate exists over the placement of percutaneous pins, two lateral pins are generally used for most Type II and Type III SCH fractures. Kocher, Kasser, and Waters (2007) studied the efficacy of lateral entry pin fixation with that of crossed (medial and lateral) pins for completely displaced (Type III) SCH fractures. A prospective randomized trial was performed with 52 patients. There was no major loss of reduction in either group and no difference in the rate of minor loss of reduction. There was also no statistical difference between groups radi- ographically or clinically (range of motion, carrying angle, return to function, complication rate). Many other studies, however, have shown an increased risk of ulnar nerve injury associated with medial pin placement (Brauer, Lee, Bae, Waters, & Kocher, 2007; Skaggs et al., 2001). In their systemic review, Brauer et al. (2007) found that patients requiring medial pinning for SCH fractures were 5.04 times more likely to have ulnar nerve injury. Similarly, Skaggs, Cluck, Mostofi, Flynn, and Kay (2001) found a 7% incidence of iatrogenic ulnar nerve injury when crossed Kirschner wires were used and there was no difference in the stability of the fracture when compared with lateral pins alone. Following closed or open reduction, the fracture is usually held with two or three Kirscher wires with the elbow in approximately 40Њ–70Њ of ﬂexion (see Figure 4;

FIGURE 3. Anteroposterior/Lateral x-rays of Type III displaced supracondylar humerus fracture.

as a small joint effusion or elevation of the anterior or posterior fat pad. Positive anterior and posterior fat pad sign generally indicates a joint effusion/hematoma and is generally treated as a nondisplaced or occult fracture. Approximately 70% of the time, posterior fat pads sug- gest an occult fracture of the supracondylar region, radial neck, or olecranon (Skaggs & Mirzayan, 1999). Type I SCH fractures are generally treated with immobilization in a long-arm cast with the elbow in approximately 70Њ–100Њ of ﬂexion. Flexing the elbow more than 100Њ has been shown to increase the risk of ischemia and compartment syndrome (Battaglia, Armstrong, & Schwend, 2002). These fractures are very stable because the periosteum is intact circumferentially. The differen- tiation between Type I and Type II SCH fractures is often made by evaluating the position of the capitellum (distal end of the humerus) relative to the anterior humeral line. In Type II fractures, the capitellum falls posterior to the anterior humeral line. Occasionally, ob- taining a contralateral elbow x-ray ﬁlm can be useful to detect subtle injuries.

TREATMENT OF TYPE II AND III SCH FRACTURES The treatment of Type II SCH fractures is more con- FIGURE 4. Anteroposterior x-ray of left elbow status post closed troversial, although most pediatric orthopaedic sur- reduction and percutaneous pinning with two Kirscher wires.

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Abzug & Kozin, 2008). The cast and/or splint is usually verses the capitellum and falls lateral to the trochlea, and removed after 3–4 weeks, and the pins are removed in a Type 2, in which the fracture line extends further medi- clinic setting. Activities are usually restricted until full ally to the trochlear groove. A newer and slightly simpler range of motion and strength are achieved (generally classification system for lateral condyle fractures is based 6–8 weeks after fracture). solely on the degree of displacement. Type 1 fractures are nondisplaced, Type 2 fractures are displaced less than 2 mm, and Type 3 fractures are displaced and malrotated Complications (Rutherford, 1985). The difficulty in treating lateral Complications of SCH fractures include loss of reduc- condyle fractures is in differentiating “stable nondis- tion, neurovascular injury, pin track infection, malu- placed” fractures from potentially “unstable, minimally nion, nonunion, compartment syndrome, Volkmann’s displaced” fractures (Mirsky, Karas, & Weiner, 1997). ischemia, and decreased range of motion (Abzug & The treatment of lateral condyle fractures depends Kozin, 2008). Vascular injury occurs in approximately on the degree of fracture displacement. There is a slight 2.5% of Type III SCH fractures and neural impairment controversy regarding the treatment of nondisplaced can occur in 17% (Gosens & Bongers, 2003). The most and minimally displaced lateral condyle fractures. Most commonly injured nerve following SCH fractures is the pediatric orthopaedic surgeons will choose operative anterior interosseous branch of the median nerve treatment of lateral condyle fractures displaced more (Lyons, Quinn, & Stanitski, 2000). Anterior interosseous than 2 mm (see Figure 5). Displaced lateral condyle nerve palsy is probably underreported because it is not fractures are generally treated with an open reduction associated with a sensory loss. Nearly all nerve injuries and pinning (see Figure 6). Open reduction is usually associated with SCH fractures recover spontaneously performed through an anterior lateral approach in chil- and require no treatment other than close monitoring. If dren. The blood supply of the lateral humeral condyle normal function has not returned within 8 to 12 weeks, arises from the posterior soft tissues of the distal frag- it may be useful to obtain nerve conduction and elec- ment, so it is important that there be minimal dissection tromyographic studies for further evaluation (Herring, of the posterior soft tissues (Herring, 2002). Smooth 2002). Battle and Carmichael (2007) evaluated the infec- Kirshner percutaneous pins are generally used for frac- tion rate with the use of smooth Kirschnew wires in 202 ture fixation and the elbow is immobilized for 4–6 weeks patients presenting with a SCH fracture. They found an postoperatively. overall infection rate of 2% and that the infection rate The most common complications from lateral condyle did not correlate to the type of fracture or the length of fractures include delayed union, nonunion, malunion, treatment (Simanovsky et al., 2007). Malunion resulting cubitus varus, stiffness, and avascular necrosis of the in cubitus varus or cubitus valgus are also known com- lateral condyle (Launay, Leet, Jacopin, Luc-Jouvre, plications of SCH fractures. Although functional deficits Bollini, & Sponseller, 2004). The most frequent problem- are rare with these deformities, there may be slightly atic complication of lateral condyle fractures is delayed limited range of motion and unacceptable cosmesis. union or nonunion (Herring, 2002). The difficulty in Because there is limited potential for remodeling in the achieving union of lateral condyle fractures can be ex- distal humerus, the best treatment of malunion deformi- plained by the fact that it is an intra-articular fracture ties is early avoidance. (constant exposure to synovial fluid), and this area of

Lateral Condyle Fractures Lateral condyle fractures of the distal humerus involve the both physis and the articular surface. The diagnosis of condylar fractures can be very difficult in children because much of the elbow remains cartilaginous and is often not visualized well on plain radiographs (Horn, Herman, Crisci, Pizzutillo, & MacEwen, 2002). They are the second most common elbow fracture in children (~10%–20% of all elbow fractures) and can be difficult to diagnose and treat. This type of fracture commonly occurs in children between the ages of 4 and 10 with a peak incidence around 5 to 6 years of age (Abzug & Kozin, 2008). The diagnosis of lateral condyle fractures in children may be quite obvious or frustratingly subtle. Most lateral condyle fractures require surgical reduction and stabilization. Similar to SCH fractures, lateral condyle fractures are classified by the degree of displacement. Unlike SCH fractures, however, lateral condyle fractures often require open rather than closed reduction and percutaneous pinning. The most commonly used classification system for lateral condyle fractures is that of Milch (1964), which dif- FIGURE 5. Anteroposterior x-ray of left elbow status post percu- ferentiates between Type 1, in which the fracture line tra- taneous pinning for Type II lateral condyle fracture.

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FIGURE 8. Anteroposterior/Lateral x-ray of displaced medial FIGURE 6. Status-post open reduction and percutaneous pin- epicondyle fracture. ning for displaced lateral condyle fracture.

bone has a relatively poor blood supply. The stiffness as- fractures, the treatment of radial neck fractures is based sociated with lateral condyle fractures is likely due to the on the degree of displacement. In children, the cartilagi- articular nature of the fracture and the fact that a longer nous radial head is resistant to fracture, and therefore period of immobilization is often required (Do & radial neck fractures are much more common than ra- Herrera-Soto, 2003). The incidence of stiffness, however, dial head fractures (Waters, 2006; see Figure 7). Radial has been decreasing significantly recently because of im- neck fractures often have subtle clinical and radi- proved stability associated with newer methods of fixa- ographic findings. There may be mild local swelling, tion that allows for shorter periods of immobilization. tenderness, and ecchymosis over the radial neck. Although flexion and extension of the elbow will often be limited, pain with supination and pronation is actu- Radial Neck Fractures ally much more common in radial neck fractures. The Radial neck fractures comprise approximately 6% of pe- mechanism of injury is typically a fall on an out- diatric elbow fractures. Similar to all pediatric elbow stretched hand with the elbow in extension and valgus. Radial neck fractures can also be seen in young patients with an associated elbow dislocation. There is controversy regarding the acceptable alignment of a radial neck fracture; however, most pediatric orthopaedic surgeons agree that up to 30Њ of malalign- ment and one-third displacement may be acceptable in radial neck fractures (Waters, 2006). Closed reduction is

FIGURE 9. Anteroposterior/Lateral x-ray of elbow s/p open reduction and internal ﬁxation of displaced medial epicondyle FIGURE 7. Anteroposterior x-ray of displaced radial neck fracture. fracture.

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attempted first and is usually successful for most dis- as each specific fracture has its own unique challenges in placed radial neck fractures. If closed reduction is inad- diagnosis, management, and potential complications. equate, an open reduction through a posterolateral Most children who sustain an elbow fracture can be ex- approach with as little dissection as possible is done. pected to have a full functional recovery with appropriate Fixation is generally achieved with smooth K-wires treatment. Because of the numerous potential pitfalls placed percutaneously from distal to proximal across and complications associated with pediatric elbow frac- the fracture site. tures, it is important to respond in a timely manner with Complications associated with radial neck fractures appropriate vigilance and technical skill. included malunion, stiffness, nonunion, radial head overgrowth, avascular necrosis, and early joint degener- REFERENCES ation. Loss of motion is the most common and problem- Abzug, J. M., & Kozin, S. H. (2008). Pediatric upper ex- atic complication following radial neck fractures. tremity trauma. Pediatric upper extremity trauma. Rotation of the forearm is affected with loss of prona- Current Orthopaedic Practice, 19(5), 485–490. tion greater than supination. Severely displaced and Battaglia, T. C., Armstrong, D. G., & Schwend, R. M. late presenting fractures requiring open reduction and (2002). Factors affecting forearm compartment pres- internal fixation or pinning are more likely to develop sures in children with supracondylar fractures of the stiffness and avascular necrosis (Milbrandt & Copley, humerus. Journal of Pediatric Orthopaedics, 22, 431–439. 2004). Battle, J., & Carmichael, K. D. (2007). Incidence of pin track infections in children’s fractures treated with Kirschner wire fixation. Journal of Pediatric Orthopaedics, 27, 154–158. Medial Epicondyle Fractures Blakemore, L. C., Cooperman, D. R., Thompson, G. H., Wathey, C., & Ballock, T. R. (2000). Compartment syn- Medial epicondyle fractures account for approximately drome in ipsilateral humerus and forearm fractures in 10% of all pediatric elbow fractures and occur most children. Clinical Orthopaedics and Related Research, commonly between the ages of 7 and 15 years (Herring, 376, 32–38. 2002). Approximately 50% to 60% of all medial epi- Brauer, C., Lee, B., Bae, D., Waters, P. M., & Kocher, M. S. condyle fractures are associated with a concurrent (2007). A systemic review of medial and lateral entry elbow dislocation. The mechanism of injury is usually pinning vs. lateral entry pinning for supracondylar frac- excessive valgus stress which is why this fracture is tures of the humerus. Journal of Pediatric Orthopaedics, often seen in baseball pitchers (significant valgus stress 27, 181–186. Do, T, & Herrera-Soto, J. (2003). Elbow injuries in chil- on their elbow with pitching). dren. Current Opinion in Orthopaedics, 15, 68–73. The operative treatment of medial epicondyle frac- Farnsworth, C. L., Silva, P. D., & Mubarak, S. J. (1998). tures is somewhat controversial. Nondisplaced and Etiology of supracondylar humerus fractures. Journal of minimally displaced (Ͻ5 mm) fractures are usually Pediatric Orthopaedics, 18, 38–42. treated conservatively with immobilization/casting for a Gosens, T., & Bongers, K. J. (2003). Neurovascular compli- period of 4–6 weeks. Because this fracture is also fre- cations and functional outcome in displaced supra- quently associated with stiffness, the period of immobi- condylar fractures of the humerus in children. Injury, lization in a cast should be minimized as much as possi- 34(4), 267–73. ble (3–4 weeks). Fractures displaced more than 5 mm Herring, J. A. (2002). Upper extremity injuries. In will usually require open reduction and internal fixation Tachdjian’s pediatric orthopaedics (3rd ed.). Philadelphia: WB Saunders Company: pp 2139–2197. (see Figure 8; Do & Herrera-Soto, 2003). Serious over- Hines, R. F., Herndon, W., & Evans, P. J. (1987). Operative head athletes require special consideration with this treatment of medial epicondyle fractures in children. type of fracture. Even minimally displaced medial epi- Clinical Orthopaedic & Related Research, 223, 170–174. condyle fractures can lead to valgus instability and de- Horn, D. B., Herman, M. J., Crisci, D., Pizzutillo, P., & creased throwing velocity. Anatomic reduction via open MacEwen, D. G. (2002). Fractures of the lateral humeral reduction and internal fixation is generally recom- condyle: Role of the cartilage hinge in fracture stability. mended in these patients (see Figure 9). Most surgeons Journal of Pediatric Orthopaedics, 22(1), 8–11. prefer open reduction and fixation (often with cannu- Kasser, J. R., & Beaty, J. H. (2006). Supracondylar frac- lated screw fixation) over closed reduction and percuta- tures of the distal humerus. In Beaty JH, Kasser JR, neous pinning to ensure that the ulnar nerve is not dam- Wilkins KE, & Rockwood CE (Eds.), Rockwood and Wilkins’ fractures in children (6th ed., pp. 543–589). aged (Herring, 2002). Philadelphia: Lippincott Williams & Wilkins. Complications from medial epicondyle fractures in- Kocher, M., Kasser, J., & Waters, P. (2007). Lateral entry clude stiffness, ulnar nerve injury, nonunion, and malu- compared with medial and lateral entry pin fixation for nion (Hines, Herndon, & Evans, 1987). Stiffness is the completely displaced supracondylar humeral fractures most common complication associated with medial epi- in children. A randomized clinical trial. Journal of Bone condyle fractures. It is best avoided by decreased immobi- and Joint Surgery, 89, 706–712. lization time and early gentle range-of-motion exercises. 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