Pediatric Elbow Fractures Research Articles

Clinical Results of Surgically Treated Medial Humeral Epicondylar Apophyseal Avulsion Injury in Children and Adolescent.

Introduction: Fractures of the medial humeral epicondyle represent approximately 10% of all paediatric elbow fractures. Objective of our study was to assess treatment outcomes of children and adolescent with medial epicondylar fracture of the elbow using standard operative protocols.
 Methods: 20 surgically treated fractures of the medial humeral epicondyle were analysed & reviewed for their epidemiological, clinical and surgical parameters. A valgus stress test was performed under general anesthesia or sedation. All patients underwent open reduction internal fixation using a similar technique. The medial epicondylar fragment was anatomically reduced and fixed in all cases with screws, Kirshner wires or tension band wiring. At final evaluation, union (radiologically) and elbow function [MAYO elbow performance score (MEPS)] was assessed.
 Results: An evaluation of all of our patients after a mean follow-up of 8.75 months (SD=4.76) after initial surgery was possible. The mean age of patients at the time of injury was 10.8years (SD=2.3). Fifteen (75%) dominant elbows were injured in our study and 12(60%) elbows had an associated elbow dislocation. On examination in operating room post anaesthesia, all of the elbow injuries revealed some degree of valgus instability. All of our patients(n=20) showed good to excellent results in the MAYO elbow performance score (MEPS). Radiographically, union was achieved in all cases. Three patients developed postoperative ulnar nerve neuropraxia, all recovered at time of final follow up. One patient developed mild lateral heterotrophic ossification but did not require any additional surgical intervention.
 Conclusion: Our results suggest that open reduction internal fixation of displaced medial epicondyle fractures leads to satisfactory motion and function. A valgus stress test in operating room can reveal the true nature of joint instability that can warrant operative stabilization of medial epicondylar injuries.

190: Pediatric Elbow Fractures: Diagnostic Accuracy of the Combination of Point Tenderness with the Elbow Extension Test

190: Pediatric Elbow Fractures: Diagnostic Accuracy of the Combination of Point Tenderness with the Elbow Extension Test

Accuracy of the sonographic fat pad sign for primary screening of pediatric elbow fractures: a preliminary study

The purpose of this study was to evaluate the diagnostic accuracy of the sonographic fat pad sign (FPS) as a predictor for pediatric elbow fractures. This is a prospective study of children under 14years with suspected elbow fractures. All participants underwent at first ultrasonography focused on a FPS followed by standard elbow radiographs. US findings were compared to final fracture diagnosis. 38 out of 79 children had an elbow fracture. A sonographic FPS predicted an elbow fracture with a sensitivity/specificity of 97.3/90.5%, positive/negative likelihood ratios (LR) were 10.2/0.03 and correct/false classification rates were 93.7/6.3%. Primary US findings were later reviewed by a blinded physician giving a congruity of 96.2%. These secondary US findings predicted an elbow fracture with a sensitivity/specificity of 92.1/92.7%, positive/negative LRs were 12.6/0.09 and correct/false classification rates were 92.4/7.5%. The sonographic FPS could serve as a useful screening tool in primary evaluation of pediatric elbow injuries. If a fracture is unlikely after clinical and US evaluation, additional radiographs are dispensable, thereby potentially minimizing the radiation burden in childhood and reducing the length of stay in the Emergency Department.

Neurovascular injury in supracondylar fracture of Humerus

Introduction: Supracondylar fractures of the humerus are the commonest upper limb fractures in children, accounting for up to 70% of all pediatric elbow fractures. Supracondylar fractures of the humerus can be managed in outpatient setting but are often complicated by neurovascular injury. Methods: Retrospective study including 187 patients who had presented with supracondylar fracture of humerus with 47 neurovascular injuries during the period of July 2007 to June 2011. Out of 142 patients with Gartland type III fracture 107 underwent immediate open reduction, exploration and internal fixation. Results: Vascular injury is commonly associated with type II supracondylar fracture with posterior displacement. Twenty two patients had vascular injury and all of them had satisfactory outcome after surgery. Conclusion: A careful clinical evaluation, urgent surgical treatment and adequate fracture reduction can prevent lifelong handicap. DOI: http://dx.doi.org/10.3126/joim.v34i3.8909 Journal of Institute of Medicine, December, 2012; 34:12-16

Neurovascular injury in supracondylar fracture of Humerus

Introduction: Supracondylar fractures of the humerus are the commonest upper limb fractures in children, accounting for up to 70% of all pediatric elbow fractures. Supracondylar fractures of the humerus can be managed in outpatient setting but are often complicated by neurovascular injury. Methods: Retrospective study including 187 patients who had presented with supracondylar fracture of humerus with 47 neurovascular injuries during the period of July 2007 to June 2011. Out of 142 patients with Gartland type III fracture 107 underwent immediate open reduction, exploration and internal fixation. Results: Vascular injury is commonly associated with type II supracondylar fracture with posterior displacement. Twenty two patients had vascular injury and all of them had satisfactory outcome after surgery. Conclusion: A careful clinical evaluation, urgent surgical treatment and adequate fracture reduction can prevent lifelong handicap. DOI: http://dx.doi.org/10.3126/joim.v34i3.8909 Journal of Institute of Medicine, December, 2012; 34:12-16

Fishtail Deformity of the Distal Humerus

Osteonecrosis of the humeral trochlea is an uncommon but challenging complication of pediatric elbow fractures. The purpose of this investigation was to characterize the clinical and radiographic presentation of fishtail deformity and outline a treatment algorithm. Fourteen patients were treated at a tertiary children's hospital between 1995 and 2010. Mean age at presentation was 10 years (range, 2.5 to 12 y). Demographic, clinical presentation, radiographic, and treatment data were recorded. Mean follow-up was 3.9 years from recognition of fishtail deformity (range, 0.5 to 7.2 y). Average time from index injury to presentation of fishtail deformity was 4.7 years (range, 0.5 to 9 y). Twelve patients (80%) presented with pain and mechanical symptoms. Seven patients were initially treated with observation, of whom 2 eventually underwent arthroscopic debridement. Ultimately 7 patients underwent arthroscopic and 1 open debridement and loose body removal; 5 of these patients required further surgery for recurrent mechanical symptoms. One patient underwent arthroscopic debridement and epiphysiodesis to maintain radiographic alignment. After initial arthroscopic debridement, 6 of 7 patients (85%) had pain relief, and all patients demonstrated improved range of motion and/or relief of mechanical symptoms. At most recent follow-up, 6 patients (40%) had persistent pain, and only 2 (13%) had normal elbow motion. Four of the 5 patients who lost 20 or more degrees of extension had radial head subluxation or dislocation. The remaining 9 patients had a reduced radiocapitellar joint. Loss of extension in those with and without subluxation of the radial head was 32 and 6 degrees, respectively. Fishtail deformity is a rare but vexing complication of pediatric elbow fractures. Clinical presentation with loss of motion and/or pain is often delayed. Arthroscopic debridement may improve symptoms in the short term, but long-term prognosis is guarded. Subluxation of the radial head is associated with worse functional results. Early detection and surgical strategies to prevent proximal migration of the forearm and development of ulnotrochlear incongruity, radial head dislocation, and impingement may improve outcomes in patients with fishtail deformity.

Pediatric Terrible Triad Elbow Fracture Dislocations: Report of 2 Cases

An elbow dislocation associated with radial head and coronoid process fractures, the terrible triad injury, has an unpredictable outcome in adults and is rare in children. We present 2 such injuries in children, 1 combined with an olecranon fracture, and both with good early clinical outcomes. However, in 1 of the 2 cases, avascular necrosis of the proximal radius was evident on radiographs.

Ultrasound evaluation of elbow fractures in children.

Elbow fractures are a common pathology in any pediatric emergency unit. X-ray of the elbow is the standard diagnostic procedure. Previous studies have shown that fractures can also be visualized by ultrasound (US). The aim of our study was to evaluate the diagnostic accuracy of US in comparison to X-rays in diagnosing pediatric elbow fractures. Sixty-seven patients aged 1-13years with clinically suspected elbow fracture were first examined by US followed by standard two-plane radiographs. US examination was done with a 12-MHz linear probe from seven longitudinal positions across the distal humerus and additionally from longitudinal positions across the radial head and olecranon. The sonographic and radiological findings were compared in a contingency table, and sensitivity, specificity, and positive and negative predictive values of the US diagnostic procedure were calculated. With X-ray, we found 48 patients with an elbow fracture and 19 patients with no fracture. With US, we found 46 patients with an elbow fracture and 21 patients with no fracture. In comparison to X-ray diagnosis, we calculated for US diagnosis a sensitivity of 97.9%, a specificity of 95%, a negative predictive value of 95%, and a positive predictive value of 97.9%. Typical elbow fractures in children could also be visualized by US. A positive fat pad sign, in particular, serves as a strong indicator for elbow joint fractures and can be identified very sensitively by US. We confirm US as a valuable primary screening tool for elbow injuries in children. In the absence of US signs of fracture and in sonographically confirmed non-displaced fractures, standard X-rays are dispensable, thereby minimizing the X-ray burden in children without loss of diagnostic safety.

Klinische Ergebnisse bei operativ versorgten kindlichen Frakturen des Epicondylus humeri ulnaris

Fractures of the medial humeral epicondyle represent approximately 10 % of all paediatric elbow fractures. material and methods: Surgically treated paediatric fractures of the medial humeral epicondyle were analysed retrospectively for their epidemiological, clinical and surgical parameters. Re-evaluation included clinical function, satisfaction, pain level and MAYO elbow performance score (MEPS). 22 children could be included. A re-evaluation of 91 % of our patients after a follow-up of ∅ 4 years (range: 1-9 years; median: 4 years) after initial surgery was possible. Subjective outcome and objective function were good with moderate limitations. 85 % of our patients showed good to excellent results in the MEPS. Regarding our own good clinical results and potentially lower rates of pseudarthrosis - in comparison to conservatively treated patients - by trend we recommend internal fixation in paediatric fractures of the medial humeral epicondyle. However, operative or conservative treatment must be indicated individually together with the patient and his/her parents.

Ultrasound Performs Well, but Is Impractical for Identifying Pediatric Elbow Fractures

In a prospective, observational study of patients (age, <21 years) presenting to a pediatric emergency department with elbow injuries, investigators

Pediatric Elbow Fractures in a Major Trauma Center in Iran

BackgroundElbow fractures are one of the most common traumatic fractures in the pediatric population. Since severe complications may occur, appropriate diagnosis and treatment are imperative when dealing with this type of fracture.ObjectivesThe aim of this study was to evaluate the epidemiology of elbow fracture in children admitted in Alzahra hospital, Isfahan, IR Iran over a one year period.Patients and MethodsDuring a one year period, a prospective study was conducted on 300 patients under the age of 16 who had sustained elbow fractures. Data included age, gender, mechanism of trauma, type of elbow fractures, complications, and outcomes.ResultsThe mean age of the patients was 8.1 ± 2.31 years old. Boys were injured 2.6 times more often than the girls. Falling was the major cause of pediatric elbow fractures (86%). Supra condylar were the most common type of fracture. There was a significant association between gender and type of injury (P < 0.01).ConclusionsSupracondylar fracture is the most common fracture type resulting from 4 - 8 year old boys’ falls. Our findings indicate the critical nature of appropriate treatment in order to prevent severe complications.

Compared outcomes after percutaneous pinning versus open reduction in paediatric supracondylar elbow fractures

Supracondylar fractures of the elbow are common in children. Their treatment is controversial when displacement has occurred, although percutaneous pinning is usually advocated. In paediatric extension-type supracondylar fractures of the elbow, percutaneous pinning and crossed K-wire fixation after open reduction via the medial approach produce similar functional outcomes and complication rates. We retrospectively reviewed the medical charts of 58 children aged 2 to 15 years who underwent surgery for extension-type supracondylar elbow fractures between 2004 and 2008. Closed reduction and percutaneous pinning was used in 33 patients with a mean age of 7 years and 11 months; open reduction with cross-wiring in 25 patients with a mean age of 7 years. Functional outcomes were assessed using Flynn's criteria. Baumann's angle was determined and postoperative complications and sequelae were recorded. Outcomes were satisfactory in 30 (90.9%) patients treated with percutaneous pinning and in 23 (92%) patients treated with open reduction and cross-wiring. Mean Baumann's angle at last follow-up was 73.9±5.74° after percutaneous pinning and 74.76±4.07° after open reduction and cross-wiring. Postoperative complications consisted of reoperation in six (10.3%) patients and iatrogenic nerve injury in two (3.4%) patients. Cubitus varus occurred in two (6.06%) patients after closed treatment and in one (4%) patient after open treatment. In each group, three (5.1%) patients had greater than 15° of motion range limitation. In children with extension-type supracondylar elbow fractures, outcomes are similar with percutaneous pinning and with open reduction via the medial approach followed by cross-wiring. Level IV, retrospective study.

Occult posterolateral rotatory dislocation of the elbow with olecranon fracture in a child: a case report

IntroductionAcute posterolateral rotator elbow dislocation in a child is rare and can be easily misdiagnosed due to immaturity of the epiphysis. This is the first case of occult posterolateral rotator elbow dislocation in combination with an olecranon fracture. We report our experience with this case, which was not diagnosed correctly by plain radiographs.Case presentationAn 11-year-old Asian boy suffered severe pain and swelling of his right elbow after his outstretched arm hit a car dashboard in a motor vehicle accident. Plain radiographs showed only a minimally displaced olecranon fracture and a tiny lateral epicondylar avulsion fracture. However, stress radiographs under general anesthesia revealed severe posterolateral rotatory instability. During surgery, we found that the cartilaginous lateral epicondylar apophysis was much larger than the epicondylar fragment on the radiographs. After the lateral epicondylar osteochondral fragment and lateral collateral ligament complex were fixed, the instability disappeared.ConclusionOur experience with this case shows that it is important to check for instability with pediatric elbow fractures, because a tiny avulsion fracture was able to cause severe posterolateral rotatory instability in a child.

A simple tip to improve the accuracy of crossed K-wire placement in the management of displaced paediatric supracondylar fractures of the humerus

Using similar principles, we describe a simple technique to improve the accuracy of crossed K-wire placement in dis-placed paediatric supracondylar fractures of the humerus. Although not original, our technique is very useful and we believe it should be used more widely when dealing with paediatric elbow fractures as ac-curate wire placement can be difficult in the presence of swelling and the relative small size of the fracture components in children.

Paediatric elbow injuries

Summary This is the first article of a two part series to address simple elbow injuries in children. It will focus on assessment of the injured elbow, addressing techniques to overcome the challenges of examining young children and the features indicative of significant injury in this age group. A case study will be used to illustrate the most common features of a pulled elbow and how this injury is managed. The second article in the series will concentrate on the differences between children's and adults' bones, the radiographic features that are unique to the paediatric elbow and supracondylar fractures.

Analysis of the Pediatric Orthopedic Surgery Questions on the Orthopaedic In-Training Examination, 2002 through 2006

Pediatric orthopedics has been a frequently tested topic on the Orthopaedic In-Training Examination (OITE). Our goal was to provide direction for resident education efforts by: (1) analyzing the exam's number, topics, and types of pediatric orthopedic surgery questions; (2) examining references cited in the postexam answer packet supplied by the American Academy of Orthopaedic Surgeons; and (3) examining the efficacy of the Orthopaedic Knowledge Update (OKU): Pediatrics 3 book as a source for answers to the pediatric orthopedic questions. We reviewed 5 years (2002 through 2006) of OITEs and the associated American Academy of Orthopaedic Surgeons' answer packets and assessed the OKU: Pediatrics 3 book for topic relativity. Each question was classified into 1 of 6 categories and labeled with a cognitive taxonomy level: 1 (simple recall), 2 (interpretation of data), or 3 (advanced problem-solving). The 6 categories included: (1) pediatric orthopedic knowledge; (2) knowledge of treatment modalities; (3) diagnosis; (4) diagnosis with recognition of associated conditions; (5) diagnosis with further studies; and (6) diagnosis with treatment. The overall percentage of pediatric questions was 14.1%. The most commonly addressed were pediatric elbow fractures, osteomyelitis, and scoliosis. The most common question types were categories 1 (pediatric orthopedic knowledge) and 6 (diagnosis with treatment). The most frequently referenced textbooks were Lovell and Winter's Pediatric Orthopaedics (31%) and Tachdjian's Pediatric Orthopaedics (16%). The most frequently referenced journals were the Journal of Pediatric Orthopaedics (American) (29%) and the Journal of Bone and Joint Surgery (American) (19%). Using only the OKU: Pediatrics 3 review textbook, 65% of the questions could be answered. Knowledge of the topics more likely to be tested may help the orthopedic educator direct a didactic curriculum geared toward the OITE and American Board of Surgery examinations. Although the OKU: Pediatrics 3 book seems to be a good, concise resource for studying for the board examination and OITE, residents should be encouraged to supplement their studying with primary sources. Not applicable.

Rapid screening for the posterior fat pad sign in suspected pediatric elbow fractures using point-of-care ultrasound: a “FAST exam” for the traumatized elbow

Abstract Purpose Children with elbow injuries frequently present to the emergency department for evaluation. Fractures of the elbow are sometimes not visualized on plain radiographs and the only sign of an occult fracture is an elevated posterior fat pad that normally sits within the olecranon fossa. The elevated posterior fat pad sign is highly sensitive and its absence likely rules out fractures of the elbow and can be readily visualized by ultrasound. Lipohemarthrosis within an elevated fat pad can also be visualized by ultrasound, but not by X-ray. This finding with an elevated posterior fat pat adds additional specificity to rule in elbow fractures. Methods We report the use of point-of-care ultrasound to rapidly screen for the presence of the posterior fat pad sign and lipohemarthrosis in a series of children presenting with elbow injuries to the emergency department. Results Point-of-care ultrasound identified elevated and normal posterior fat pads that correlated with X-ray. Lipohemarthrosis within an elevated fat pad was also detectable by ultrasonography. Conclusions Knowledge of whether a posterior fat pad is elevated or not and noting the presence of lipohemarthrosis by using point-of-care ultrasound may be helpful to expedite diagnosis and treatment of these patients, especially in settings with no access to plain radiography.

Oral Midazolam for Removal of Kirschner Wires in the Children's Orthopaedic Outpatient Department: A Randomized Controlled Trial

Use of Kirschner wires (K-wires) is common in pediatric elbow fracture treatment. We investigate whether anxiety levels at removal of wires may be reduced using oral midazolam. This was a prospective randomized controlled trial with 2 groups, with midazolam and with placebo. Forty-two children with an average age of 7.1 years (range, 3.6-12.3 y) had complete documentation for analysis. The change in anxiety scores was not significantly different between the 2 groups. Forty-five percent of children in the midazolam group had reduced anxiety levels compared with 18% of children given placebo, but this difference was not significant (P=0.102). The anxiety scores before and after wire removal in the midazolam group were not significantly different from the placebo group scores. We do not recommend the routine administration of midazolam (0.2 mg/kg) to all children requiring K-wire removal in the outpatient department. I.

Delayed Presentation of a Brachial Artery Pseudoaneurysm After a Supracondylar Humerus Fracture in a 6-year-old Boy: A Case Report

Supracondylar fractures of the humerus are the most common elbow fractures in children, accounting for 60% to 70% of all pediatric elbow fractures. These fractures often have neurovascular complications because of deformity and the sharp nature of the fracture fragments. The management of patients who present with diminished or absent pulses, but a well-perfused extremity is a topic of debate. Between 3% and 14% of patients present with an altered vascular examination and a consistent treatment logarithm has not been proposed in the literature. To our knowledge, a brachial artery pseudoaneurysm presenting in a delayed fashion in the setting of a normal vascular examination has not been reported. We report a 6-year-old boy who had a delayed presentation of a brachial artery pseudoaneurysm after a supracondylar humerus fracture, which was repaired with a saphenous vein graft. This is to emphasize close neurological and vascular monitoring even in the setting of a well-perfused hand. In addition, this would suggest that closer postoperative evaluation in significantly displaced fractures should be performed, even beyond the fracture healing stage.

A Novel Adjunct to Closed Manipulation and Insertion of K-Wires to Paediatric Supracondylar Elbow Fractures

A Novel Adjunct to Closed Manipulation and Insertion of K-Wires to Paediatric Supracondylar Elbow Fractures