Elbow In Children Research Articles

Radiographic Assessment in the Treatment of Supracondylar Humerus Fractures in Children

Introduction:Supracondylar humerus fractures are the most common fractures of the humerus at the elbow in children. The key role belongs to the age and immaturity of the humerus region. Treatment, even today represents the problem of bone and joint surgery. Gartland classification divides these fractures into four types. Analysis of radiographic parameters will serve as an indicator for treatment selection.Goal:To demonstrate the role of radiographic evaluation by measurement of default radiographic parameters and indicate the choice of treatment for supracondylar fractures of type I and II by Gartland.Material and methods:The study included 60 children aged 4-14 years, divided into two groups, first with initial radiographic analysis and the second one without radiographic analysis. All were treated at the Primary Health Care Center Novi Travnik and Nova Bila Hospital from 2009 to 2011. Analysis was performed using methods of descriptive statistics to calculate the mean and standard deviation, Student’s t-test and Chi-square test.Results:In patients from first group hospitalization, immobilization duration, as well as physical treatment was shorter and more frequently surgical treatment was applied (manual reduction with K-wire fixation) with statistically significant difference (p = 0.042).Conclusion:Radiographic evaluation is one way to choose methods of fracture treatment. The incidence of complications is low, with excellent outcome of treatment and a faster return of children to their daily activities.

Transient Osteochondrosis of the Capitellum in a Child After Humeral Supracondylar Fracture

Supracondylar fracture of the humerus is the most frequently encountered fracture around the elbow in children. Avascular necrosis is an uncommon complication after supracondylar fracture, but fishtail deformity after avascular necrosis of the trochlea is well known. However, transient osteochondrosis of the capitellum after a supracondylar fracture has not been previously reported in the English literature except 1 case abstract. The authors report their experience of transient osteochondrosis of the capitellum in a 3-year-old boy after the closed reduction and percutaneous pinning for a displaced supracondylar fracture of the distal humerus. No specific treatment was performed because there was no evidence of nonunion or of a progressing deformity. He had gained full range of motion of the elbow without pain by 6 months postoperatively. At 24 months after surgery, the ossification center of the capitellum began reossifying and enlarging in size. There was no evidence of growth disturbances, such as, angular or fishtail deformity, in this case.

Convergent type proximal radioulnar translocation complicating posterior elbow dislocation

Proximal radioulnar translocation associated with posterior dislocation of the elbow is an extremely rare combination of trauma to the elbow in children. We report on the successful and sequential closed reduction of both these dislocations in a 10-year-old girl in which the translocation of the forearm bones was initially missed. A concomitant fracture would have probably precluded an ideal outcome as we note from the literature review on this problem.

MR imaging findings and MR criteria for instability in osteochondritis dissecans of the elbow in children

Osteochondritis dissecans (OCD) of the elbow is an uncommon cause of elbow pain in adolescents and occurs at different locations in the elbow joint. Early diagnosis and treatment may prevent surgery. The aim of the study is to describe the MR imaging features of OCD at initial imaging, and to correlate these findings with surgical findings of stability and instability with arthroscopic findings as the reference standard. Patients were identified through a keyword search of the radiology information system from 2000 to 2009. Twenty-five patients (26 elbows) with OCD of the elbow were identified (age 10.4-18 years, mean age 14 years). MR studies were retrospectively reviewed by two radiologists in consensus to define MR imaging findings and to determine the presence of previously described MR imaging criteria for OCD instability (i.e., high T2 signal rim, surrounding cysts, high T2 signal fracture line, fluid-filled osteochondral defect). Sensitivity of the individual and combined criteria was calculated. OCD occurred in the capitellum in 24 patients (92%), in the trochlea in 2 patients (8%) and radial head in 1 patient (4%). Loose bodies were identified in 11 (42%) patients. Eighteen patients demonstrated MRI findings in keeping with unstable lesions. In all 11 patients who had surgery the surgical findings of instability correlated with the MRI findings. When combined, the MR criteria were 100% sensitive for instability of OCD lesions of the elbow. The vast majority of OCD of the elbow occurs in the capitellum. When used together, the MR criteria for instability were 100% sensitive for evaluation OCD lesions of the elbow.

Type III Monteggia fracture with ipsilateral epiphyseal injury of the distal radius

Ipsilateral elbow and wrist injuries are uncommon in children. We present a case of Bado type III Monteggia fracture dislocation with ipsilateral Salter Harris type I epiphyseal injury of distal radius in a 10-year-old boy. A good result was achieved with early closed reduction and percutaneous K wire fixation. This case emphasizes that whenever a fracture is detected around wrist and elbow in children, early anatomical reduction is required for good functional outcome.

Surgical Treatment of Posterolateral Rotatory Instability of the Elbow in Children

Posttraumatic instability of the elbow in children can be a very challenging problem to diagnose and treat. Posterolateral rotatory instability (PLRI) has been well described with regard to diagnosis and treatment in adults but best clinical practices are less clear for pediatric cases. Children with PLRI can present with unusual signs and symptoms and poorly documented, vague trauma. The need for and safety of formal reconstruction of the lateral ulnar collateral ligament in children has been somewhat controversial in the past; however, with careful consideration the diagnosis of PLRI in children can be recognized and successfully treated with ligamentous repair or reconstruction. This report presents an overview of the current practice in the diagnosis and treatment of PLRI in the pediatric population. Indications for surgical treatment and step-by-step surgical instructions for both ligamentous repair and reconstruction are presented.

Mr imaging findings of haemophilic arthropathy of the elbow in children

Haemophilic arthropathy of the elbow is a rare cause of elbow pain in children and adolescents. The purpose of this study is to determine the MR appearance of the spectrum of lesions found in haemophilic arthropathy of the elbow at initial MR imaging. It is important to be aware of the early changes in this entity, since early diagnosis and treatment of the disease may prevent progressive joint destruction.

Tuberculosis of the Elbow Joint in Children

There is scarce information regarding osteoarticular tuberculosis of the elbow in children, even in countries where tuberculosis is endemic. We report our experience with ten patients who were managed nonoperatively. We retrospectively assessed ten children with elbow tuberculosis with regard to their presentation, diagnosis, management, response to standard antitubercular drugs, and outcome at the completion of antitubercular therapy. All patients were managed nonoperatively with splinting for as long as six weeks, followed by mobilization along with multidrug antitubercular medication for twelve months. Swelling of the elbow that did not respond to initial treatment was the most common cause for referral to our clinic. The proximal ulnar metaphysis was most commonly involved. The average duration of follow-up was twenty-six months. The average time for healing of draining sinuses was twelve weeks (range, four to fourteen weeks). Lytic lesions, including coke-like sequestrum, healed radiographically at an average of 7.4 months (range, six to nine months). Range of motion improved with treatment, but some motion restriction always persisted, depending on the extent of joint destruction. In the Indian subcontinent, the presentation of elbow tuberculosis is usually exudative with abscess formation, and the disease is fairly advanced at the time of diagnosis. An "ice cream scoop" appearance of the proximal part of the ulna in children should raise suspicion for tuberculosis. Elbow tuberculosis in children can be treated adequately with use of nonoperative means, regardless of the extent of osseous destruction, with a good outcome.

Monteggia-Verletzungen im Kindesalter

The Monteggia lesion is a rare injury of the elbow in children. This lesion is defined as a shaft fracture of the ulna combined with a luxation of the radial head. The primary problem in this injury is the proper diagnosis because the misalignment of the radial head is often missed. The purpose of this study was to retrospectively analyse the results after Monteggia lesions in children. Ten children between two and nine years of age (six boys and four girls) were clinically assessed using the Morrey score. They were treated in our department between December 1999 and October 2004. The Morrey score after 54 months (min.: 26/max.: 84) had a median value of 100 points with 100 being the maximum (min.: 95/max.: 100). We found two complications, a combined lesion of the radial and ulnar nerves which completely recovered after six months. In one case a k-wire dislocated, which was removed earlier. If the Monteggia lesion in children is correctly diagnosed and treated early enough, only good and very good results may be expected. After delayed diagnosis and treatment, the clinical results are not as good or even very poor.

Relationship of the Anterior Humeral Line to the Capitellar Ossific Nucleus: Variability with Age

The anterior humeral line is used to assess displacement and the adequacy of reduction of supracondylar humeral fractures in children. It is said to pass through the middle third of the capitellum in the elbow of a normal child. Few reports in the published literature have discussed this measurement, and the intra-rater and inter-rater reliability of the measurement is not known. The purposes of the present study were to define the position of the anterior humeral line in normal, skeletally immature elbows and to determine the intra-rater and inter-rater reliability of this parameter. On two occasions, three observers (a pediatric orthopaedic surgeon, a senior orthopaedic resident, and a senior medical student) recorded the location of the anterior humeral line as it passed through the capitellum as seen on the lateral radiographs of thirty normal elbows in children ranging in age from four months to three years and eleven months and thirty normal elbows in children ranging in age from four to nine years. For these measurements, the capitellum was divided into three regions: the anterior third, the middle third, and the posterior third. All observers received written instructions, and identical rulers were used to make the measurements. Each observer made 120 measurements. Overall, the anterior humeral line passed through the anterior third of the capitellum in 31% of the elbows, the middle third in 52%, and the posterior third in 18%. In children younger than four years of age, the line passed nearly equally through either the anterior or middle third of the capitellum. In older children, the anterior humeral line passed through the middle third in 62% of the elbows. Overall, intra-rater reliability and inter-rater reliability were moderate to substantial. The anterior humeral line passes through the middle third of the capitellum in the majority of normal children. In children younger than four years of age, it passes nearly equally through the anterior or middle third of the capitellum, whereas in older children it more consistently passes through the middle third of the capitellum. The surgeon must be aware of the variability of the location of the anterior humeral line with age when utilizing it to assess radiographs of the elbow in children after an injury or after the reduction of a displaced supracondylar fracture.

Nursemaid's Elbow

Pediatric trauma injuries account for 11 million hospitalizations annually with a significant percentage related to the musculoskeletal system. Nursemaid's elbow is a common injury in young children that can often be prevented. This injury occurs when the radial head subluxates from its normal position at the elbow joint. Activities such as swinging a child by the hands or pulling on the pronated upper extremity can cause nursemaid's elbow. Prevention of nursemaid's elbow in children may be accomplished with education of parents, daycare workers, and teachers on the mechanism of this common injury.

Inter- and intra-observer reliability of the Baumann angle of the humerus in children with supracondylar humeral fractures

The Baumann angle of the humerus has been commonly used as an outcome measure for supracondylar fractures in children. However, there is limited or no information about the reliability of this measurement. The purpose of this study was to determine the inter-observer reliability (IEOR) and intra-observer reliability (IAOR) of the Baumann angle of the humerus. The Baumann angle of the humerus was measured by five observers on the anteroposterior radiographs of 35 children’s elbows, all of which had sustained a nondisplaced supracondylar humeral fracture. The values of IEOR and IAOR were calculated using a Pearson coefficient of correlation. Ranges of differences in the measurement of the Baumann angle of the humerus were established, and the percentage of agreement between observers was then calculated using those ranges. The Baumann angle of the humerus is a simple, repeatable and reliable measurement that can be used for the determination of the outcome of supracondylar humeral fractures in the paediatric population. An excellent IEOR was found for the measurement of the Baumann angle (r = 0.78, p = 0.0001). When the difference between observers in the reported measurement of the Baumann’s angle was calculated to be within seven degrees of each other, at least four of the five observers agreed 100% of the time. Similarly, excellent values of IAOR were found for the measurement of the Baumann’s angle (r = 0.80, p = 0.0001). Level of evidence for this study was III.

Time of Return of Elbow Motion after Percutaneous Pinning of Pediatric Supracondylar Humerus Fractures

The most common treatment for displaced pediatric supracondylar humerus fractures is closed reduction and percutaneous pinning. However, the time for return of elbow motion after treatment of these injuries is not well documented. To describe the return of elbow motion after closed reduction and percutaneous pinning of these fractures we retrospectively reviewed 63 patients (age range, 1.6-13.8 years) with displaced supracondylar fractures of the humerus stabilized with either two or three lateral entry pins. Pins were removed by 3 to 4 weeks. No patient participated in formal physical therapy. At each followup, elbow range of motion (ROM) was recorded for the injured and uninjured extremities. Elbow ROM returned to 72% of contralateral elbow motion by 6 weeks after pinning and progressively increased to 86% by 12 weeks, 94% by 26 weeks, and 98% by 52 weeks. After closed reduction and percutaneous pinning of a displaced, uncomplicated, supracondylar humerus fracture, 94% of the child's normal elbow ROM should be expected by 6 months after pinning. Further improvement may occur up to 1 year postoperatively. This information may be helpful in advising parents what to expect after their child's injury. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Gender-specific pattern differences of the ossification centers in the pediatric elbow

Only a limited number of studies have investigated the age ranges in which the secondary centers of the elbow appear and ossify. Knowledge of sequence, gender differences and age ranges can aid in accurate assessment of radiographs, especially in cases of injury. To determine the sequence and general age ranges in which each ossification center both appears and fuses, and also to identify differences between genders. This study included 412 sets of radiographs of children's elbows that were analyzed prospectively by a single experienced pediatric radiologist. The presence as well as state of fusion of each ossification center was noted. The ages of the children ranged from 2 months to 17 years. In girls, the radial head and medial epicondyle appeared at the same age. In boys, there was a trend towards the radial head appearing earlier than the medial epicondyle. There was no statistically significant difference between the age at which the trochlea and olecranon appeared. Our results demonstrate a statistically significant difference between genders in both appearance and fusion. All centers both appeared and fused earlier in girls, with the exception of the appearance of the capitellum. The sequence of appearance and fusion was similar between genders. Ossification centers at the elbow both appear and fuse earlier in females but the normal range in age for the times of appearance and fusion of these centers is quite wide for both sexes.

Dynamics of the ulnar nerve after percutaneous pinning of supracondylar humeral fractures in children

This prospective study was performed to evaluate and compare the morphological changes and dynamics of the ulnar nerve after percutaneous cross-pinning with Kirshner wire (group 1; 13, mean age 8.3 years, 10 male and three female children) and only lateral pinning (group 2; eight, mean age 7.6 years, six male and two female children) of displaced unilateral supracondylar fractures in children's elbows using ultrasonography in comparison with the contralateral healthy elbows. Postoperative evaluation revealed that ulnar nerve movement was reduced and the major axis diameter of elbow flexion and ulnar nerve was larger (P<0.05) than the major axis diameter in the elbow extension in group 1 than group 2. We think that the treatment of the displaced supracondylar fracture of the humerus in children with only a lateral Kirshner wire would be safer and more convenient.

Transepiphyseal Elbow Injuries: An Approach To Diagnosis And Literature Review

An eight year old boy was admitted following direct trauma to the elbow sustained following a fall. The elbow was oedematous, deformed and tender with decreased range of movement. The initial impression, clinically and on X-rays was that of elbow dislocation. Intraoperatively, he was found to have a transepiphyseal injury which was treated with K-wiring. Radiological appearances can be deceptive in the diagnosis of transepiphyseal injuries. We looked at previous literature on similar cases and aim to define the features suggestive of a transepiphyseal injury. We further suggest pre-operative and intra-operative methods to differentiate common elbow pathologies which present similarly. INTRODUCTION Fractures around the elbow in children are often difficult to diagnose. Transepiphyseal elbow injuries are rare injuries and can be easily misinterpreted on radiographs. Various traumatic pathologies around the elbow present similarly and encompass a wide spectrum including the pulled elbow to difficult Transepiphyseal dislocations. We present the case of an eight year-old boy, who sustained an epiphyseal injury to the left elbow following a fall and look at the ways to diagnose this injury with the aid of Schematic diagrams to illustrate the anatomical relationships in a normal elbow (Fig 1). Transepiphyseal Elbow Injuries: An Approach To Diagnosis And Literature Review 2 of 6 Figure 1 Figure 1: Normal elbow CASE REPORT An eight year old boy fell onto his left elbow and presented in casualty with a painful deformed elbow without any distal neuro-vascular deficits. Radiographs on admission were interpreted and reported as a dislocation of the elbow (fig 2a & b). Figure 2 Figure 2a: Lateral pre-op Figure 3 Figure 2b: AP pre-op Intraoperative radiographic screening revealed a transepiphyseal fracture without a dislocation of the elbow, Transepiphyseal Elbow Injuries: An Approach To Diagnosis And Literature Review 3 of 6 as shown in the schematic diagram (fig 2c). Figure 4 Figure 2c: Schematic diagram The fracture was treated by open reduction and internal fixation with Kirschner wires (figs 3a & b). The fracture united and the wires were removed at six weeks. Figure 5 Figure 3a: AP after fixation Transepiphyseal Elbow Injuries: An Approach To Diagnosis And Literature Review 4 of 6 Figure 6 Figure 3b: Lat post fixation DISCUSSION In 1850 RW Smith first described this injury and differentiated it from supracondylar fracture and elbow dislocation. Clinical examination is often not possible due to the pain and the swelling associated with the injury. On a plain radiograph it is important to distinguish transepiphyseal injury from lateral condyle fracture (fig 4) and dislocation of the elbow. Figure 7 Figure 4: Lateral condyle fracture The difficulty lies in being unable to visualize the cartilaginous distal humeral epiphysis on plain radiograph. Mizuno et al2 used the relationship of the capitellum to the axis of the head of the radius and to the humerus. In transepiphyseal injury the capitellum maintains its relationship to the head of the radius but not with the humerus, whereas in the fracture of the lateral condyle the axes of the humerus to the forearm is maintained and the relationship of the condylar fragment to the radial head may be altered depending on the displacement of the fracture. In elbow dislocation the relationship of the capitellum to the radius is changed while its relationship to the humerus is maintained. Another difference seen is that the displacement in transepiphyseal injury is commonly postero-medial1 whereas it is most often postero-lateral in dislocation of the elbow. The diagnosis can further be confirmed with an Transepiphyseal Elbow Injuries: An Approach To Diagnosis And Literature Review 5 of 6 arthrogram intraoperatively2. The principle in the management of such fractures lies in early reduction (closed1 or open2) and internal fixation. CONCLUSION As in our case transepiphyseal injuries are often misinterpreted on plain radiographs. A mental impression of the distal humerus including its cartilaginous portion and knowledge of the anatomical relationship of the various ossific nuclei is helpful in the diagnosis of the injury.

Anterior Displacement of Ulnar Nerve at the Elbow in Children Based on Ultrasonography

This study involved evaluation of the elbows of 50 children between 4 to 14 years of age. Clinical examination for elbow flexion, extension, range of motion and carrying angle were performed, followed by ultrasonographic examination to determine position of the ulnar nerve in relation to the medial epicondyle upon elbow flexion and extension. Thirty-one elbows showed anterior displacement of the ulnar nerve, of which 14 were due to subluxation and 17 to dislocation. We found that anterior translation of ulnar nerve is present in the elbows up to 31% of children, especially those with increased range of elbow motion.

Mechanical Distraction for the Treatment of Posttraumatic Stiffness of the Elbow in Children and Adolescents

Elbow contracture is a recognized sequela of elbow injuries in children and adolescents, but previous studies of operative treatment with formal capsular release have demonstrated unpredictable outcomes and unfavorable results. Over a period of five years, fourteen children and adolescents with a mean age of fourteen years who had posttraumatic stiffness of the elbow were managed according to a prospective protocol. Eleven patients had undergone a mean of three previous operative procedures before the index operation. After intraoperative distraction with an external fixator, there was a relaxation phase for six days followed by mobilization of the elbow joint under distraction in the fixator for a mean of seven weeks. Intraoperative range of motion under distraction reached a mean of 100 degrees . Open arthrolysis was not performed, but in four children impinging heterotopic bone was removed through a limited approach. Decompression of the ulnar nerve was performed in seven patients. The mean preoperative arc of total elbow motion was 37 degrees . The mean pronation was 46 degrees , and the mean supination was 56 degrees . After a mean duration of follow-up of thirty-four months, all patients but two had achieved an arc of motion of 100 degrees . The mean arc of flexion-extension was 108 degrees (range, 75 degrees to 130 degrees ). The mean range of pronation was 73 degrees (range, 20 degrees to 90 degrees ), and the mean range of supination was 75 degrees (range, 10 degrees to 90 degrees ). There were no pin-track infections or deep infections, and all elbows were stable. At the time of follow-up, three patients had radiographic evidence of humeroulnar degeneration. Closed distraction of the elbow joint with use of a monolateral external fixation frame with motion capacity yields more favorable results than other previously reported options for the treatment of posttraumatic elbow contractures in children and adolescents.

Mechanical Distraction for the Treatment of Posttraumatic Stiffness of the Elbow in Children and Adolescents

Mechanical Distraction for the Treatment of Posttraumatic Stiffness of the Elbow in Children and Adolescents

Elbow range of motion and clinical carrying angle in a healthy pediatric population

Many conditions including trauma can affect the range of motion and carrying angle of the elbow in children. The method employed was cross-sectional clinical measurement of 600 elbows (300 patients) range of motion and carrying angle in normal children. We found significant increases in range of motion and carrying angle with age (P<0.01) and significantly increased range of motion and carrying angle in females as compared with males (P<0.01). In conclusion, elbow joint range of motion and carrying angle increase with age. This is the first cross-sectional analysis of range of motion and carrying angle to our knowledge in the pediatric population. Increased elbow extension may contribute to the increased carrying angle seen in females compared with males.