Pediatric elbow fracture Orthopedic pediatric trauma

1. Tachdjian’s Pediatric Orthopaedic
Chapter 29
“Fractures About The Elbow”
Ananda Halim Aditya

2. Case Discussion

3. Identitas
• Name : AF
• Age : 4 y.o.
• Sex : Girl
• Occupation : Housewife (mother)
• No. RM : 02234992

4. Anamnesis
Chief complaint : Pain on the right elbow, inability to fully flex and extend the elbow
March 5th 2024
Patient fell on an outstretched hand while
playing on her father’s motorcycle. She
complained of pain on the right elbow, and
was unable to move her arm for a week. Her
parents saw her elbow swollen, went to the
nearest hospital and was told that her right
elbow is fractured, but didn’t want to
undergo surgery, then they were discharged
March 29th 2024
The patient was already active, but
sometimes still complaints of pain on her
right elbow, and was also unable to fully
flex and extend the affected elbow.
She went to another hospital and was
referred to Sardjito General Hospital to be
treated by a Pediatric Orthopaedic Surgeon
April 1st 2024
The patient was presented at the
Orthopaedic and Traumatology outpatient
clinic at Sardjito General Hospital, and was
then admitted for an elective surgery on
April 4th 2024

5. Past History of Illness :
Asthma (-), Alergy (-), Congenital diseases (-)
ANAMNESIS

6. PHYSICAL EXAMINATION
General condition : Good, Compos mentis
Vital Signs. HR : 98 x/menit VAS : 1
RR : 20 x/menit T. : 36.5 o C SpO2 : 99% RA
Head : CA (-/-) , SI (-/-)
Neck : JVP (-)
Thorax
I : Simetris, ketinggalan gerak (-)
P : Vokal Fremitus kanan = kiri
P : Sonor kanan = kiri
A : Vesikuler +/+, ronkhi -/-, wheezing -/-
Abdomen
I : Flat
A : Peristaltik (+) Normal
P : Timpani ( + )
P : Supel, nyeri tekan (-)

7. Local status of the right elbow :
Look
Swelling (-) deformity (+) flexed position,
wound (-) scar (-) redness (-)
Feel
Tenderness (+), NVD (-)
Move
ROM limited due to pain
PHYSICAL EXAMINATION

8. HASIL LABORATORIUM
Lab Normal 01/04/24
Eritrosit 4.00 – 6.00 4.47
Hb 11.0 – 18.0 11.7
Hematokrit 35.0 – 49.0 35.7
Leukosit 4.50 – 11.50 6.2
Trombosit 150 – 450 276
Albumin 3.40 – 5.00 4.53
Bilirubin Total ≤1.20 0.24
Bilirubin Direk 0.00 – 0.20 0.16
Bilirubin Indirek 0.00 – 0.20 0.08
Lab Normal 01/04/24
SGOT 10 – 50 39
SGPT 10 – 50 15
BUN 6 – 20 11
Creatinin 0.67 – 1.17 0.38
GDS 74 – 106 122
APTT 25.1 – 36.5 36.3
PPT 9.4 – 12.5 12.0
Na 136 – 145 138
K 3.5 – 5.1 4.0
Cl 98 – 107 102
HBsAg NR NR

9. Elbow x-ray from previous hospital (March 5th 2024)

10. Elbow x-ray (April 1st 2024)

11. • Neglected close fracture of lateral condyle of the right humerus Milch type II
DIAGNOSIS

12. Fractures About The Elbow

13. INTRODUCTION
• Elbow fractures : 5% to 10% of all fractures in children
• Frequent problem? Distinguishing fractures from the six normal
secondary ossification centers
• The most common : Supracondylar fractures (50% - 70%, mostly age 3 – 10
years) -> high incidence of residual deformity and potential NVD
• Fractures of the lateral humeral condyle are transphyseal, intraarticular
injuries -> the second most common

14. ELBOW OSSIFICATION CENTER
CRITOE mnemonics!
• The capitellum appears radiographically at
approximately 2 years of age
• The remaining ossification centers appear
sequentially every 2 years
• Girls mature earlier

15. Anatomy
The elbow joint is a complex articulation of three bones that allows motion in all
three planes

16. Anatomy

17. Anatomy
• In extension supracondylar fractures, the
brachialis muscle usually shields the anterior
neurovascular structures from injury.
• In severely displaced fractures, the proximal
fragment may perforate the brachialis muscle
and contuse, occlude, or lacerate the vessel
or nerve
• The vessels or median nerve may also become
trapped and compressed between the
fracture fragments
Anatomy

18. MECHANISM OF INJURY
• Usually the result of FOOSH
• As the elbow hyperextends, the
olecranon serves as a fulcrum to
produce the fracture
• Supracondylar fractures are usually
located at the level of the olecranon
fossa (thinnest area)

19. GARTLAND CLASSIFICATION
(Supracondylar fractures)
• Type I : fractures are nondisplaced or
minimally displaced
• Type II : fractures have angulation of the
distal fragment (posteriorly in extension
injuries and anteriorly in flexion injuries),
with one cortex remaining intact (the
posterior in extension and the anterior in
flexion)
• Type III : injuries are completely displaced,
with both cortices fractured

20. MILCH CLASSIFICATION
(Lateral condyle fractures)
• Type I : extends through the secondary
ossification center of the capitellum and
enters the joint lateral to the trochlear
groove
• Type II : extends farther medially, with the
trochlea remaining with the lateral
fragment, thus making the ulnohumeral
joint unstable

21. Perform a thorough examination to
assess for other injuries, as well as
possible neurologic & vascular injuries,
as well as compartment syndrome.
Neurologic injury is present in 10% to
15% of cases of elbow fractures
DIAGNOSIS

22. • Gunstock deformity in malunion fractures
• Inability to fully flex the elbow
CLINICAL APPEARANCE

23. • Closed reduction extension-type fracture
• Longitudinal traction and elbow in extension
• Maintained with percutaneous pinning
• Closed reduction flexion-type fracture
• Longitudinal traction and elbow in extension
• Maintained with percutaneous pinning
• Open reduction
• When closed reduction failed
• Open fractures
• Compartment syndrome
• NVD that needs exploration
TREATMENT

24. • Closed reduction and pinning for all types IB and IIB supracondylar humeral
fractures
• Closed reduction and cast treatment for very minimally extended IIA fractures
• For type III fractures if the skin is intact and not tented, the swelling is minimal,
and the neurovascular examination is normal, an 8-to 10-hour delay is allowed
TREATMENT SUPRACONDYLAR FRACTURE

25. • Blood supply of the lateral humeral
condyle arises from the posterior soft
tissues of the distal fragment, it is
important that there be minimal dissection
of the posterior soft tissues; thus we prefer
an anterolateral approach.
• Fixation is generally achieved with smooth
percutaneous pins, although screws and
bioabsorbable pins have been used
TREATMENT LATERAL CONDYLE FRACTURE

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27. • Skin incisions should be planned to avoid compromised skin that may cause
necrosis or problems with wound healing
• The surgical approach can be anterior, medial, or lateral, and is based on the
location of the metaphyseal spike.
SURGICAL APPROACH
(SUPRACONDYLAR FRACTURE)

28. • The anterior approach has the most utility as it allows for exploration of the
neurovascular bundle in extension-type fractures (with lazy-S incision)
• The medial approach is used for posterolaterally displaced fractures as well as
flexion type fractures that cannot be reduced due to entrapment of the ulnar
nerve or other soft tissue
• The posterior approach has increased risk of postoperative stiffness, the
potential for disruption of the blood supply
SURGICAL APPROACH
(SUPRACONDYLAR FRACTURE)

29. SURGICAL APPROACH
(SUPRACONDYLAR FRACTURE)
• Percutaneous pin fixation yields the most predictable results with the fewest
complications and is the preferred technique for immobilization of displaced
supracondylar humeral fractures
• Involves the placement of two or three 0.62-inch (1.4 – 1.6mm) smooth K-wires
(smaller K-wires may be used in patients younger than 2 years)

30. SURGICAL APPROACH
(SUPRACONDYLAR FRACTURE)
For successful all-lateral pin construct several objectives must be achieved:
(1) Two or more pins must engage both fracture fragments
(2) All pins must achieve bicortical fixation
(3) Pins must have maximal pin separation at the fracture site, ideally with one in
the medial column and one in the lateral column
(4) Use of a third lateral-entry pin if more stability is required

31. SURGICAL APPROACH
(SUPRACONDYLAR FRACTURE)
• The elbow should be held at less than 80 degrees of
flexion when placing a medial pin, and after pinning,
the elbow should not be flexed past 90 degrees to
avoid tethering of the ulnar nerve
• The starting position for a medial pin is the inferior
most aspect of the medial epicondyle. The pin
should be started as far anteriorly as possible.
• The surgeon can often palpate the ulnar nerve
subcutaneously, just proximal to the medial
epicondyle.

32. Pin placement for optimum stability :
Two lateral based entry pins divergently
engage both the medial cortex, lateral cortex.
A third pin placed in the middle through the
olecranon fossa increases stability of the
construct.
Bicortical fixation is achieved with all three
pins.

33. • Pin placement configuration unfortunately still continues to be debated. Although
several biomechanical studies have shown that crossed pins are the most stable
configuration, a number of reports have shown good clinical results with parallel
lateral pin fixation
• Two lateral-entry pins in type II fractures and three lateral-entry pins in type III
fractures
• Place a medial pin if the fracture demonstrates continued instability after three
lateral-entry pins or if the fracture is a very proximal fracture or obliquely
oriented pattern
PIN PLACEMENT

34. • The arm is immobilized in 60 to 85 degrees of flexion in a posterior splint or
widely split or bivalved cast
• Potential complications of percutaneous pinning : pin tract inflammation or
infection, iatrogenic ulnar nerve injury, and loss of reduction.
• In cases of malreduced/malunion : remanipulation of supracondylar fractures
after delays of 2 to 3 weeks is shown to be successful
POST SURGERY CARE

35. • The most common complications after lateral
condyle fractures include cubitus varus, lateral
spur formation, delayed union, and nonunion
with or without cubitus valgus, avascular necrosis
• Growth arrest and fishtail deformity of the distal
humerus can also occur but are rarely found to
be clinical problems
• Stiffness is common at the end of immobilization
COMPLICATIONS

36. Thank You