Pediatric Elbow Research Articles

Incidence, Risk Factors, and Definition for Nonunion in Pediatric Lateral Condyle Fractures.

Lateral condyle fractures are a common pediatric elbow injury. Nonunion is a known complication of this injury but its incidence and causative risk factors are unknown. Further, a clear and consistent definition of nonunion for pediatric lateral condyle fractures does not exist. The purpose of this study is to determine the rate of nonunion, the risk factors associated with it and to provide a clear definition. A retrospective chart review of all pediatric lateral condyle fractures treated at an urban, tertiary pediatric care center between 2001 and 2014. Data collected included demographics, Weiss classification, type of treatment, follow-up, time from injury to surgery and complications. For patients with nonunions, additional treatments and final range of motion were also recorded. A nonunion was defined as lack of callus with fragment migration by 8 weeks after initiation of treatment. A total of 530 patients were identified of which 500 were available for review. There were 7/500 (1.4%) nonunions in the cohort. Nonunion occurred in 1.4% (2/140) of type I fractures, 0% (0 /178) of type II fractures, and 3% (5/168) of type III fractures. The only significant risk factor for nonunion was the presence of a type III fracture (P=0.05). Five patients with nonunion underwent revision surgery with a partially threaded cannulated cancellous screw. All of these patients went on to union. Four of the 5 patients had their screws removed after union. Nonunion after pediatric lateral condyle fracture is rare and is defined by lack of any callus with fragment migration at 8 weeks. The only significant risk factor for nonunion development was the presence of a type III fracture. Revision surgery with a partially threaded screw achieved union in all cases. Level IV-retrospective case review.

Using the Medial and Lateral Humeral Lines as an Adjunct to Intraoperative Elbow Arthrography to Guide Intraoperative Reduction and Fixation of Distal Humerus Physeal Separations Reduces the Incidence of Postoperative Cubitus Varus.

Distal humerus physeal separations are rare pediatric elbow fractures that are often misdiagnosed and difficult to treat. Adequate reduction is often technically challenging and up to 71% of children develop postoperative cubitus varus. We propose using the medial and lateral humeral lines as an adjunct to elbow arthrography in order to guide intraoperative fixation of distal humerus physeal separations to reduce the incidence of postoperative cubitus varus. From 2009 to 2014, all pediatric patients under the age of 3 diagnosed with a distal humerus physeal separation and treated surgically at our institution were included for analysis. Two senior pediatric orthopaedic surgeons separately reviewed the preoperative, intraoperative, and postoperative images of all patients and measured the position of the ulnar axis relative to the medial and lateral humeral lines. The medial and lateral humeral shafts were defined as parallel lines drawn along the medial and lateral humeral diaphysis. Adequate reduction was defined by reduction of the ulnar axis within the boundaries of the medial and lateral humeral lines. Patients were assessed at latest follow-up for cubitus varus and any other surgical complications. Thirteen patients fulfilled the inclusion criteria and were on average 1.70 years old, ranging from 0.62 to 3 years old. Intraoperatively and immediately postoperatively, all 13 patients (100%) were noted to have adequate reduction of the ulnar axis within the boundaries medial and lateral humeral lines. None of the patients required intraoperative arthrography (0%). At the date of latest follow-up, 12 patients (92.3%) had no angular deformities compared with the contralateral limb and 1 patient (7.7%) had developed cubitus varus. No surgical complications were noted (0%). Intraoperative reduction of the ulnar axis within the boundaries of the medial and lateral humeral lines is associated with a lower incidence of postoperative cubitus varus in the treatment of distal humerus physeal separations in children. Level IV.

LO44: Optimizing skill retention in radiograph interpretation: a multicentre randomized control trial

Introduction: Simulation-based education systems have increased physician skill in radiograph interpretation. However, the degree of skill retention and the factors that influence it are relatively unknown. The main objective of this research was to determine the rate and quantity of skill decay in post-graduate trainee physicians who completed a simulation-based learning intervention of radiograph interpretation. The impact of testing and refresher education on skill decay was also examined. Methods: This was a prospective, multicenter, analysis-blinded, four arm randomized control trial conducted from November 2014 to June 2016. Study interventions were administered using an on-line learning and measurement platform. Pediatric and emergency medicine residents in the United States and Canada were eligible for study participation. Participants were randomized to one of four groups. All participants completed an 80-case deliberately practiced learning set of pediatric elbow radiographs followed by an immediate 20-case post-test. Following this, Group 1 had no testing until 12 months; Groups 2, 3, and 4 had testing (20 cases without feedback) every 2 months until 12 months, but Group 3 also had refresher education (20 cases with feedback) at six months while Group 4 had refresher education at two, six, and ten months. The main outcome measure was accuracy at 12 months, adjusted for immediate post-test score, days to completion of 12 month test, and time on case. Based on prior data, we assumed the smallest important difference between groups in learning decay is 10%, a between-participant/within-group standard deviation of 17%, a type I error probability of 5%, a power of 80% and adjusted for three tests with a Bonferroni correction. For the primary analysis of Group 1 versus 2, 3, 4, this resulted in a minimal total sample size of 56, with 14 participants per group. Results: We enrolled 106 participants that completed all study interventions. The sample sizes in Groups 1, 2, 3, and 4 were 42, 22, 22, and 20 respectively. Overall, accuracy increased by 11.8% (95% CI 9.8, 13.8) with the 80-case learning set and then decreased by 5.5% (95% CI 2.5, 8.5) at 12 months. The difference in learning decay in Group 1 vs. Groups 2, 3, 4 was -8.1% (95% CI 2.5, 13.5), p=0.005. For Group 2 vs. Group 3 and 4, it was +0.8% (95% CI -7.2, 7.3), p=0.8, and between Group 3 vs. Group 4 it was +0.8% (95% CI -7.3, 10.1), p=0.8. Conclusion: Skill decay was significantly reduced by testing with 20 cases every two months. Refresher education had no additional effect to testing on reducing learning decay.

A Removable Long-arm Soft Cast to Treat Nondisplaced Pediatric Elbow Fractures: A Randomized, Controlled Trial.

The ideal type of immobilization for nondisplaced pediatric elbow fractures has not been established. We hypothesized that the use of a long-arm cylinder made of soft cast material will result in similar outcomes to those obtained with a traditional long-arm hard cast. We randomly assigned 100 consecutive children who presented with a closed, nondisplaced, type I supracondylar humeral fracture or an occult, closed, acute elbow injury, to 1 of 2 groups: group A (n=50) received a long-arm, traditional fiberglass (hard) cast. Group B (n=50) received a long-arm, soft fiberglass cast. After 4 weeks, the cast was removed in group A by a member of our staff using a cast saw, and in group B by one of the patient's parents by rolling back the soft fiberglass material. We compared the amount of fracture displacement and/or angulation, recovery of range of motion, elbow pain, and patient satisfaction. There were no instances of unplanned removal of the cast by the patient or parent. No evidence of fracture displacement or angulation was seen in either group. The final carrying angle of the affected elbow was nearly identical of that of the normal, contralateral elbow in both groups (P=0.64). At the latest follow-up appointment, elbows in groups A and B had a similar mean arc of motion (156 vs. 154 degrees; P=0.45), and had achieved identical relative arc of motion of 99.6% and 99.5% of that of the normal, contralateral side, respectively (P=0.94). Main pain scores were low and comparable over the study period. All patients in both groups reported the highest rate of satisfaction at the eighth week of follow-up. The results indicate that children with nondisplaced supracondylar humeral fractures can be successfully managed with the use of a removable long-arm soft cast, maintaining fracture alignment and resulting in comparable rates of range of motion, pain, and patient satisfaction. The use of a removable immobilization that can reliably maintain fracture alignment and result in similar outcomes, while minimizing the risk of noncompliance, could be advantageous. Although we elected to remove the soft cast during a scheduled follow-up, it appears that such immobilization could be removed easily and safely at home, potentially resulting in a lower number of patient visits, decreased health care costs, and higher patient/parent satisfaction. Level I.

Functional outcome of displaced intercondylar fractures of the humerus in children and adolescents

The main aim of this study was to retrospectively evaluate the clinical, functional, and radiographic outcome of displaced intercondylar fractures of the humerus in children and adolescents, and evaluate upper-extremity function with the short version of the Disabilities of the Arm, Shoulder and Hand outcome questionnaire (Quick DASH), the hypothesis being that intercondylar fractures have poorer functional outcome than do other upper-limb fractures. The mean age at the time of injury was 11.9±2.5 years (range: 7.5-15.8 years). The male-female ratio was 3.5 : 1. Using the Toniolo & Wilkins classification, 13 (72%) fractures were classified as type II and five (28%) as type III. The overall complication rate was 50%. The mean Quick DASH score was 9±11 (range: 0-31.8). Displaced intercondylar fractures of the humerus, although uncommon in skeletally immature patients, are characterized by poorer clinical and functional outcome compared with other pediatric humerus and elbow fractures. Minimally displaced fractures with articular surface displacement of less than 2 mm can be safely managed with closed reduction and percutaneous fixation, but any greater intra-articular displacement requires open reduction and internal fixation, which means a higher complication rate and poorer functional outcome should be expected, especially in patients older than 10 years.

Elbow injuries in the pediatric athlete

Chronic repetitive stress to the developing osteoligamentous structures of the elbow places the pediatric athlete at risk for a number of sports-related elbow injuries. The specific type of injury encountered is dependent on the sport as well as the developmental stage of the physes and apophyses. The most common pathologies encountered are medial sided injuries due to valgus overload, olecranon apophysitis and stress fractures, and osteochondral injuries of the capitellum. As youth sports participation continues to increase, so too does the incidence of pediatric elbow injuries. This review will focus on the diagnosis, treatment, and prevention of common elbow pathologies in young athletes.

What's New in Pediatric Upper Extremity Sports Injuries?

Sports injuries are common in pediatric and adolescent patients and the evaluation and treatment of these injuries continues to evolve. The purpose of this review is to provide a comprehensive appraisal of the most recent literature, highlighting updates on sports-related upper extremity injuries in pediatric patients. An electronic search of the PubMed, EMBASE, and Google Scholar databases was performed for keywords related to pediatric overhead athletes, osteochondritis dissecans (OCD) of the capitellum, medial epicondyle fractures, shoulder instability, and clavicle fractures. Search results were filtered by publication date to yield articles published electronically or in print on or after January 1, 2013 to May 30, 2017. Papers were selected based on expert opinion and consensus by the authors and included if deemed to have contributed important findings to the above topics. A total of 51 articles were deemed to have contributed significant findings to the literature: 11 overhead athlete, 9 OCD of the capitellum, 6 medial epicondyle fractures, 17 shoulder instability, and 8 clavicle fractures. The level of evidence for most studies was either Level III or IV. Overuse and traumatic conditions of the pediatric elbow including UCL tear, capitellar OCD, and medial epicondyle fractures represent a significant portion of injuries in the overhead athlete. Research in the prevention and treatment of primary and recurrent shoulder instability in young athletes continues to evolve. The operative treatment of clavicle fractures in adolescents has been increasing without a commensurate increase in the level of evidence supporting such treatment. Advances have been made in the treatment of sports-related upper extremity injuries in pediatric patients, however, high-level, comparative outcomes research in many areas is lacking and this review may help inform topics for future study. Level IV-Literature review.

Validity and comprehensibility of outcome measures in children with shoulder and elbow disorders: creation of a new Pediatric and Adolescent Shoulder and Elbow Survey (Pedi-ASES)

Valid patient-reported outcomes (PROs) for the shoulder and elbow do not exist for children. We assessed children's comprehension of the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire and the American Shoulder and Elbow Surgeons (ASES) standardized shoulder assessment form, identified response errors, and modified items to create a new pediatric shoulder and elbow PRO. We recruited 50 children (aged 10-18 years) with shoulder or elbow disorders from a children's hospital-based orthopedic clinic for this qualitative study. A trained researcher conducted cognitive interviews to identify children's comprehension of PROs. In phase 1, 40 children were purposefully sampled on the basis of age and gender, interviewed, and audiotaped. A behavioral scientist analyzed transcripts, modified items, and created the Pediatric and Adolescent Shoulder and Elbow Survey (Pedi-ASES). In phase 2, 10 children were interviewed to gather feedback on and to refine the Pedi-ASES. The average interview time was 25 minutes (range, 17-44 minutes). There were 242 comments generated about the QuickDASH; 51% of children struggled with complex terminology, and 35% did not understand "tingling." Children generated 309 comments about the ASES, primarily associated with narcotic medications (65%) and shoulder instability (42%). Time frame and format issues were noted. In phase 2, children found the new PRO easier to comprehend and answer. Modifications were needed in general instruction, language, format, and response mapping in the original PROs. Children had few difficulties with the Pedi-ASES. Designing PROs that are specific to children will enable researchers and clinicians to more accurately assess health status and clinical outcomes.

Anthropometric characterisation of elbow angles and lines among Tibetan children (3–13 years) seeking refugee in India: A comparison survey

Background: Various radiological criteria based on anthropometric parameters are used to understand injuries on paediatric elbow and for checking the degree of reduction after manipulation. The anthropometric parameters of Caucasians are different from European and mongoloids, their parameters cannot be applied across different population groups living in India. Hence, there is a need to characterise anthropometric parameters of elbow among children of different ethnicity living in Indian. Materials and Methods: The study population comprised of all cases of injury to the elbow joint between 3 and 13 years of age reporting to the Department of Orthopaedics during the study and belonging to Tibetan population seeking refuge in India. The X-rays films were preserved and the angles and lines (as anthropometric parameters) were drawn on the radiographs. Results: The mean value for Baumann angle in males was 72° with standard deviation (SD) of 2.75 and in girls was 73° with SD of 1.41. The mean lateral capitellohumeral angle in children from 3 to 13 years of age was 45.33° ± 3.97°. The anterior humeral line passed through middle one-third of capitellum in 86.6%. The radiocapitellar intersection occurred in 100% of the cases with radiocapitellar bisection reported on 86.6% of the X-rays films. Conclusion: As the values of two population; Indian and Tibetan differ, establishing comparisons can significantly affect the outcome while managing elbow injuries.

In-office Removal of Pediatric Elbow Pins: Increased Value in Orthopaedic Care

In-office Removal of Pediatric Elbow Pins: Increased Value in Orthopaedic Care

Incarcerated Coronoid Fracture at the Time of Pediatric Elbow Dislocation

Incarcerated Coronoid Fracture at the Time of Pediatric Elbow Dislocation

A systematic review and meta-analysis of adverse outcomes following non-buried versus buried Kirschner wires for paediatric lateral condyle elbow fractures.

PurposeFractures of the lateral condyle of the humerus in children are a common injury. If displaced or unstable they may require surgical reduction and fixation with Kirschner wires (K-wires). K-wires are placed using either an open or closed technique. The decision to bury or leave the ends extending through the skin is surgeon-dependent and based on factors including post-operative infection risk, bony union and ease of wire removal.MethodsWe performed a systematic review and meta-analysis of non-buried versus buried K-wires for lateral condyle elbow fractures in children in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. A comprehensive search strategy included Medline, Embase and CINAHL via NICE Evidence from database inception to June 2017. Two authors independently reviewed, included or excluded articles, extracted data and assessed for quality with the ROBINS-I tool. We performed direct comparison meta-analysis for all adverse events, post-operative infection and failure of bony union.ResultsThree studies were analysed comprising of 434 participants. There was a significantly reduced relative risk of adverse events in the non-buried group, equating to approximately 45% reduced risk (RR 0.55, 95% confidence interval 0.34 to 0.88). There were no significant differences in risk of post-operative infection or failure of bony union. All three cost-analyses in the included studies observed savings with non-buried K-wires.ConclusionNon-buried K-wires for lateral condyle elbow fractures convey a lower risk of adverse events and may be more cost-effective compared with buried K-wires. Non-buried K-wires do not appear to increase the risk of infection or failure of bony union. These findings are limited by a high risk of bias due to inherent methodological flaws in the design of included studies.

Epidemiologic features and management of elbow dislocation with associated fracture in pediatric population.

This study was conducted to explore epidemiologic features of traumatic elbow dislocation with associated fractures in pediatric population following appropriate treatment options.Incidence of elbow dislocation with associated fractures was analyzed in 67 children using elbow radiographs. Treatment for the displaced elbow joint was performed by closed reduction and proper immobilization. Surgical intervention was applied to restore the correct alignment of the fracture. Mayo Elbow Performance Score (MEPS) was used to measure elbow joint function.Incidence of pure dislocation was observed in 7 of 67 children (10.45%). Elbow dislocation was typically accompanied by a single or multiple fractures in 39 (58.21%) and 21 (31.34%) of 67 children, respectively. In contrast, lateral humeral condyle fracture and medial humeral epicondyle fracture accounted for 35.90% and 30.77% of pediatric elbow fractures. All children with elbow fracture-dislocations received surgical intervention by open reduction and internal fixation. During follow-up, 56% to 92% of children displayed significant recovery of elbow function with improving MEPS after the displaced elbow and fractured fragments were reduced and held in place for weeks. There were statistical differences in MEPS between the types of fractures (P < .05 or P < .01).Incidence of isolated elbow dislocation without fracture is low; rather, it is frequently associated with fractures. Early surgical intervention achieves stable fixation and bony union with utility in improving elbow function in the pediatric population.

Common Paediatric Elbow Injuries.

Background:Paediatric elbow injuries account for a large proportion of childrens’ fractures. Knowledge of common injuries is essential to understanding their assessment and correct management.Methods:A selective literature search was performed and personal surgical experiences are reported.Results:We have described the assessment and management of the five most common paediatric elbow injuries: supracondylar humeral fractures; lateral condyle fractures; medial epicondyle fractures; radial head and neck fractures; radial head subluxation.Conclusion:Understanding of the ossification centres around the paediatric elbow is essential to correctly assessing and managing the common injuries that we have discussed in the review. Outcomes after these injuries are usually favourable with restoration of normal anatomy.

Corrigendum: Paediatric doctors’ error rate in detection of paediatric elbow injuries in Rahima Moosa Mother and Child Hospital

No abstract available.

The Community Orthopaedic Surgeon Taking Trauma Call: Pediatric Supracondylar Humeral Fracture Pearls and Pitfalls.

Supracondylar humeral fractures are the most common type of pediatric elbow fracture. With proper treatment, these injuries usually heal well and the patients return to full function. However, a small percentage of these injuries may result in devastating complications and, thus, provoke anxiety in many surgeons treating them. This article provides tips for successful management of these injuries without complications and provides references for further study.

Early Outcomes of Pediatric Elbow Dislocation-Risk Factors Associated With Morbidity.

Ulnohumeral elbow dislocation is a rare elbow injury in children. We reviewed a large cohort of pediatric ulnohumeral elbow dislocations and sought to identify risk factors associated with poor functional outcomes. Medical charts and radiographs were reviewed for all acute pediatric ulnohumeral elbow dislocations evaluated at our facility during a 7-year period. Charts were abstracted for demographics, injury characteristics, treatments, and complications. Functional outcomes were assessed at minimum 6-week follow-up using a combination of symptoms and elbow range of motion (Roberts criteria). A total of 145 cases qualified for inclusion and were analyzed. The average age at injury was 11 years (range, 5 to 18 y), with equal distribution between male and female individuals. Concomitant elbow fractures were identified in 114 (80%) cases; the most common was the medial epicondyle (80/134, 60%). Treatment consisted of open reduction and fixation of associated fracture(s) in 59% of fracture cases. At an average follow-up of 3.7 months, the average range of motion was -5-degree extension to 126-degree flexion. Immobilization for longer than 2 weeks resulted in a loss of elbow extension (P<0.001). Functional outcomes as assessed by the Roberts criteria were good or excellent in 90% of cases. Risk factors associated with less than excellent functional outcomes included the presence of multiple fractures (P=0.001), the need for operative intervention (P=0.01), and the duration of immobilization (P=0.03). Complications requiring further treatment occurred in 16 cases (11%). Patients without complication resulted in a higher proportion of "excellent" functional outcomes (76%) compared with those with a complication (40%) (P<0.001). The majority of pediatric ulnohumeral elbow dislocations experience good to excellent functional outcomes by early follow-up. Risk factors associated with less than excellent functional outcomes include the presence of multiple associated fractures, operative intervention, and prolonged immobilization. Complications requiring operative intervention are not rare, and have a significant effect on functional outcomes. Level IV-prognostic.

Radiographically-Occult Injuries Associated with Pediatric Elbow Dislocations

Radiographically-Occult Injuries Associated with Pediatric Elbow Dislocations

Pediatric elbow arthroscopy: indications and safety

Elbow arthroscopy is a minimally invasive means by which to treat a variety of acute and chronic elbow conditions. Although the safety and efficacy is well documented in the adult population, comparatively little information is available about the role of elbow arthroscopy in the pediatric population. This study reports the indications for and safety of elbow arthroscopy in a series of pediatric patients. A retrospective review was performed from 2001 to 2015 of a surgical database at a single institution. All elbow arthroscopies performed in patients aged 18 years and younger were reviewed. Indications for surgery, perioperative and postoperative complications, further surgical intervention, and descriptive demographic information were recorded. We identified 64 elbow arthroscopic procedures in 59 patients. The average age at the time of surgery was 11.8 years. Indications for the arthroscopic surgery included contracture release (45.3%), closed reduction and fixation for fracture (20.3%), treatment of osteochondritis dissecans (20.3%), diagnostic arthroscopy (7.8%), and débridement (6.3%). The overall complication rate was 17.2%, with a major and minor complication rate of 6.3% and 10.9%, respectively. Elbow arthroscopy has applications in the pediatric population with an acceptable safety profile. The techniques and indications continue to evolve.

Validity and Comprehensibility of Current Shoulder &amp; Elbow Functional Outcomes Measures in Children

Objectives:To assess the comprehensibility of the Quick Disabilities of the Arm, the Shoulder and Hand Score (Quick DASH) and the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) in children, identify sources of response errors, and modify items, in order to develop an original, age-appropriate, validated pediatric shoulder and elbow patient-reported outcome (PRO) survey.Methods:49 children with shoulder and/or elbow disorders were recruited from a children’s hospital-based orthopedic outpatient clinic. A researcher, who was trained by a behavioral scientist in cognitive interviewing techniques, used a standardized protocol and conducted cognitive interviews to identify children’s comprehension of the QuickDASH and ASES surveys. In Phase One of the study, 39 children (46% female, mean age=15 years; range 10-18) were purposefully sampled based on age and gender, interviewed, and audiotaped. The questionnaires were given in varying sequential order. Interview probes focused on directions, formatting, item content and matching of responses and items. A behavioral scientist analyzed transcripts, modified items accordingly, and created an original pediatric shoulder and elbow PRO. In Phase Two, 10 children (40% female, mean age=15 years) were interviewed to gather feedback specifically on the original pediatric PRO.Results:The average interview time was 26 minutes (range=16 - 44 minutes). 255 comments were generated about the Quick DASH, identifying 60 issues related to item comprehension and 191 issues related to item response format. 51% of children struggled with complex terminology used to describe activities and 41% did not understand symptom-related items such as “tingling”. 294 comments were generated about the ASES, primarily associated with medications (76%) and shoulder instability (47%). Timeframe and format issues were also noted. The resulting original PRO was easy to comprehend, although 40% of children could not interpret a “loose shoulder or elbow”.Conclusion:Item comprehension issues were noted in approximately half of the children completing the Quick DASH and ASES. Specific areas of difficulty included items addressing medication use, activity level and symptoms such as shoulder instability and tingling. Modifications were also needed in general instruction, language, survey and item format, layout, and item response mapping. Based on the results of the cognitive interviews, children had minimal difficulty comprehending items and directions of the newly developed pediatric shoulder and elbow PRO. A subsequent study will assess this original PRO’s psychometric properties in an effort to continue its development and provide more comprehensive, methodologically rigorous validation of its use in this population.