NOR200175.qxd 1/7/11 5:01 AM Page 11 Common Pediatric Elbow Fractures 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 nec- essary 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 appear- ance 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 Orthopaedic Nursing • January/February 2011 • Volume 30 • Number 1 11 Copyright © 2011 National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. NOR200175.qxd 1/7/11 5:01 AM Page 12 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 in- juries occur secondary to contusion and traction is- chemia 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 de- partment 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 12 Orthopaedic Nursing • January/February 2011 • Volume 30 • Number 1 Copyright © 2011 National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. NOR200175.qxd 1/7/11 5:01 AM Page 13 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 frac- ture 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 frac- tures. Kocher, Kasser, and Waters (2007) studied the efficacy of lateral entry pin fixation with that of crossed (medial and lateral) pins for completely dis- placed (Type III) SCH fractures. A prospective ran- domized 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 place- ment (Brauer, Lee, Bae, Waters, & Kocher, 2007; Skaggs et al., 2001). In their systemic review,