FRACTURES IN

CHILDREN
ELBOW
HUMERUS

PRESENTER
DR.AHSAN-UL-HAQ
POST-GRADUATE RESIDENT
Lahore General Hospital
 Ossification Centres

 There are 6 ossification

centres around the elbow
joint.

 The ossification centers

always appear in a strict
order.
Come-Read-My-Tale-Of-
Love (Capitellum - Radius -
medial epicondyle -
Trochlea - Olecranon -
lateral epicondyle).

 As a general guide
remember 1-3-5-7-9-11
years.
 ELBOW JOINT FRACTURES AND
DISLOCATIONS
 Radial Head and
Neck Fractures
 4 to 14 years
 Ossification of the
radial head usually
does not begin
before 5 years of age
 Most fractures in
children are of the
radial neck and not
the radial head
 Usually Salter-Harris
type IV fractures.
 Classification Radial Head
and Neck Fractures
 Wilkins
 Type A
 Salter-Harris type I
and II injuries of the
proximal radial
epiphyses
 Type B
 Salter-Harris type IV
injuries of the
proximal radial
epiphyses
 Type C
 Fractures involving
only the proximal
radial metaphysis
 Radial Head and Neck
Fractures
• Type D
• Fractures
occurring when a
dislocated elbow
is being reduced

 Type E
 Fractures occurring
in conjunction with
the elbow
dislocation
 Acceptable Criteria
 30 to 45 degrees of
residual angulation
usually is accepted
in closed treatment
with satisfactory
results
Patterson Technique
 Close Manipulation
 Neher and Torch
modified the original
closed reduction
technique of Patterson.
 General anesthesia if
needed and fluoroscopy
 An assistant stabilizes
the radius distal to the
fractured radial neck
 With the elbow in
extension, the surgeon
applies a varus stress
with one hand on the
elbow and lateral
pressure directly over
the radial head with the
thumb of the other
hand
 Closed Reduction
 Pesudo et al.
 Usinga
percutaneous pin
with the aid of an
image intensifier to
manipulate and
reduce the
angulation of the
fracture fragments
 Closed Reduction
 Metaizeau technique.

 Inserting a curved steel

Kirschner wire that is
sharply bent at the last 1.5
cm through the distal
radial metaphysis into the
medullary canal

 The wire or nail is

advanced until the point
fixes in the epiphysis and
elevates and replaces it
under the lateral condyle.
The pin is turned around
its long axis through 180
degrees, producing a
medial shift of the radial
head and reducing it.
 AFTERTREATMENT
 The arm is immobilized in a long-arm
cast for 2 to 3 weeks.
 The Kirschner wire is not removed
until approximately 2 months later
when the fracture has consolidated.
 ORIF
 If a satisfactory closed reduction cannot be
obtained, open reduction should be done

 Surgery should be performed within 5 to 7 days of

injury to prevent myositis ossificans of the elbow,

 Before skeletal maturity is reached, radial head

resection may result in proximal radioulnar
synostosis, cubitus valgus, and radial deviation of
the hand
 Complications After Open
Reduction
Include
 Loss of motion
 Premature physeal closure
 Nonunion of the radial neck
 Osteonecrosis of the radial head
 Radioulnar synostosis
 Myositis ossificans
 Injury to the posterior interosseous
nerve
 Radial Head Dislocation
(Pulled Elbow)
 Age: usually 1 to 4
years old
 History of “pull” on
the elbow
 In 50%: no history
of a "pull" on the
arm
 Examination
 Not using the
affected limb
 Elbow in extension
and the forearm in
pronation
 Marked resistance
and pain with
supination of the
forearm
Reduction Technique
 Olecranon Fractures
 Pure physeal
fractures of the
olecranon are
extremely rare
 Has secondary
ossification centre
 The epiphysis fuses
to the metaphysis
at about age 14.
 Grantham and Kiernan and
Wilkins
 The first type is
purely physeal
 The second type
occurs in older
children and has a
large metaphyseal
fragment attached
to the epiphysis
 Papavasiliou et al.
 Intraarticular (Group A)
Simple crack fractures
Fractures with minimal displacement
Complete fractures of the olecranon
involving the articular cartilage and with
slight dorsal displacement of the
proximal fragment
Grossly displaced fractures
 Extraarticular (Group B)
Greenstick fracture
 Evans and Graham

 If displacement, especially
intraarticular, is more than 3 to 4
mm, open reduction and internal
fixation are indicated
 Regardless of the
type of fracture, if
significant
displacement
persists after
attempts at closed
reduction, open
reduction and
internal fixation
should be
performed
 Methods of ORIF

 Tension band
wiring
 Axial pins
 Oblique screws
Fractures of the Coronoid
Process
 Regan and
Morrey
classification
 Type I
a small chip fracture;
 Type II
a fracture involving
less than 50% of the
process;
 Type III
a fracture involving
more than 50% of
the process
 Treatment Options
 Closed treatment
Type I and II fractures
 Open reduction and internal fixation
Type III fractures
 Elbow Dislocations
 Acute Dislocations

 Most pure
dislocations are
posterior
 But they can occur
anteriorly, medially,
or laterally
 Regardless of the
type, most elbow
dislocations can be
reduced closed
 Under GA, longitudinal
traction
 Immobilization for
approximately 6
weeks
 Indications for open
reduction
 Inability to obtain a closed reduction
 Open dislocation
 Medial epicondyle fracture
 Radial neck fracture
 Arterial injuries
 Chronic Recurrent Elbow
Dislocations
 Four primary underlying causes
1. Shallow trochlear notch that allows easy
dislocation of the olecranon from
the trochlea
2. Medial, lateral, or combined capsular
laxity of the elbow
3. Intraarticular fractures that cause medial
or lateral instability of the olecranon in
the trochlea
4. Congenital laxity of the medial and
lateral ligaments around the elbow.
 Evaluation
 Anteroposterior and lateral radiographs of
both elbows
 Any osseous loose bodies or articular
fractures also can be noted
 Varus and valgus stress radiographs of both
elbows to determine any medial or lateral
ligamentous instability
 Arthrogram or MRI
 suspected intraarticular condylar fracture
 Fluoroscopic examination
 Treatment
 Surgicalprocedure should be selected
to correct the specific condition
 Ifplain radiographs reveal a shallow
trochlear notch
Transfer
of the biceps or triceps tendon or both
Reichenheim
 Biceps tendon onto the coronoid process of the ulna,
suturing it to the periosteum on the anterior aspect
of the coronoid process with two smooth wires
King
 Passingthe tendon through a drill hole in the
coronoid to the subcutaneous border of the ulna,
where it was sutured
 Treatment
Kapel
 Threading a strip of biceps tendon through a drill
hole in the small partition of bone separating the
coronoid and olecranon fossae and suturing it to
the tip of the olecranon; a central slip of triceps
tendon was pulled through the same hole and
sutured to the coronoid process.
If stress radiographs reveal significant
ligamentous laxity
Capsular repair and imbrication
 Old Unreduced Elbow
Dislocations

 Satisfactoryfunctional result can be

obtained by an open reduction upto 03
months
 Campbell posterolateral approach
 Free subperiosteally all muscle
attachments
 Release the attachments of the joint
capsule around the humeral condyles.
 Detach the collateral ligaments from their
proximal insertions
 Old Unreduced Elbow
Dislocations
 If the triceps is tight, preventing reduction
or limiting flexion to about 30 degrees after
reduction, lengthen the muscle using
Speed's V-Y muscle-plasty
 Do not reattach the ligaments to bone to
avoid making the repair too tight.
 If the ulnar nerve is tight or was
compressed preoperatively, transpose it
anteriorly
 Check the stability of the reduction
manually at 90 degrees of flexion
 AFTERTREATMENT

The cast and any Kirschner wires are

removed at 2 to 3 weeks.
Active mobilization of the elbow is
started slowly and is encouraged.
Distal Humeral Fractures
Capitellar Fractures
Classification of fractures of
the Capitellum
 Depends on the size of the
articular fragment and its
comminution.
 A good quality Lateral view
 Type 1 fracture
 a large fragment of
bone and articular
cartilage
 Type 2 fracture
 a small shell of bone
and articular cartilage
 Type 3 fracture
 comminuted fracture
 Treatment options
 Closed reduction
 usually not successful
 Open reduction with
and without
internal fixation
 Type I & II (large
fragment)
 Kirschner wire
 Herbert screws
 cannulated screws
 Excision of the
fragments
 Most of type III
fractures.
Lateral Condylar Fractures

 Fracture of necessity

 Occurat
approximately age 6
years
 Mechanism of injury
 When a varus force is applied to the
extended elbow.
 They tend to be unstable and
become displaced because of the
pull of the forearm extensors.
 Since these fractures are intra-
articular they are prone to nonunion
because the fracture is bathed in
synovial fluid.
 Milch Classification
 Type I fracture,
 The fracture line
courses medially to the
trochlea through and
into the capitellar-
trochlear groove

 Type II fracture,
 The fracture line
extends into the area of
the trochlea and
produces inherent
instability of the elbow
 Lateral
condylar fractures also have
been classified according to the
amount of displacement:

(1) Undisplaced,
(2) Moderately displaced,
(3) Completely displaced and rotated
 Finnbogason et al.
 Type A
 Fracture through
the lateral humeral
condyle with
minimal lateral gap
 A stable fracture
 Type B
 Fracture through
the lateral humeral
condyle to the
epiphyseal cartilage
with a lateral gap

A fracture with
undefinable risk
 Type C
 Fracture through
the lateral humeral
condyle with the
fracture gap as
wide laterally as
medially
 A fracture with high
risk of later
displacement
 MRI
 MRIdistinguishes
the potentially
unstable fracture
(Type II) from the
stable, minimally
displaced fracture
(Type I).
 Treatment Options
 Mostly closed
manipulation and POP
casting
 Percutanious K wire
fixation
 Open reduction and
internal fixation
1) suture fixation, which is
inadequate;
2) smooth pin fixation,
preferably with two
pins, through the
epiphysis or through
the metaphyseal spike
3) screw fixation,
preferably through the
metaphyseal area.
 Aftertreatment
 Immobilization for approximately 6
weeks.
 Gentle active motion of the elbow
usually is resumed intermittently out
of the splint.
 The splint is not removed
permanently until the radiographs
show solid union.
 Complications
 Physeal arrest
 Physeal stimulation
 Osteonecrosis
 Nonunion with
resultant cubitus
valgus
 Bone Grafting for Nonunion or
Delayed Union

 Open Reduction
and Internal
Fixation with Bone
Grafting for
Nonunion or
Delayed Union of
Minimally
Displaced
Fractures
 Aftertreatment

 The limb is immobilized in plaster

with the elbow at 90 degrees of
flexion and the forearm in neutral
rotation for 12 weeks. The pin or
screw is removed, and active
exercises are begun
 Established Nonunion with
Cubitus Valgus
 Occur, not from premature closure of
the capitellar physis, but from
nonunion with proximal migration of
the lateral condyle
 Masada et al.
concluded that osteosynthesis is
indicated for the treatment of nonunion
of the lateral humeral condyle only if
The patient has severe pain in the elbow or
is apprehensive about using the elbow
because of lateral instability
 Treatment

 Milchdevised two osteotomies for

nonunion of the lateral condyle; with
each, internal fixation and bone
grafting are recommended.
 Osteotomy

 In Milch type I
fractures
 Opening wedge lateral
osteotomy as described
by Milch

 A closing wedge medial

osteotomy as described
by Speed
 Osteotomy
 InMilch Type II
fractures, there is
significant lateral
displacement of
the fragment and
some rotation
 Milch recommended
an opening wedge
displacement
osteotomy
 Technique
 Patient prone
 Posterior muscle-splitting
incision
 Identify the ulnar nerve
 Perform transverse
osteotomy at the level of
the intersection of the
forearm axis with the
lateral cortex of the
humerus
 Notch the inferior surface
of the proximal fragment
to receive the apex of the
superior surface of the
distal fragment, which is
moved laterally
 Technique
 When correction is
satisfactory, fix the
fragments by
inserting two
smooth crossed
Kirschner wires
 Carefully flex the
elbow, and
immobilize it in
plaster at 90
degrees
 Aftertreatment
 Thecast is left on for 6 to 12 weeks,
depending on the age of the child
and evidence of bony union. The
wires are removed, and motion is
encouraged at that time.
 Kim Osteotomy
 Step-Cut Translation Osteotomy with a Y-Shaped
Humeral Plate
 Perform the initial osteotomy 0.5 cm superior to
the olecranon fossa, perpendicular to the axis of
the humeral shaft, with an electrical saw. Place
the triangular template over the proximal portion
of the humerus, and mark the area
 Osteotomize the proximal part of the humerus
according to the drawn line
 Step-cut Translation
Osteotomy.
 A, After humerus-elbow-wrist angle is
determined on anteroposterior
radiograph, initial transverse
osteotomy line is made about 0.5 to 1
cm superior to olecranon fossa and
perpendicular to axis of humerus.
Triangular area indicates area to be
resected.
 B and C, Cubitus varus is corrected by
rotating distal fragment and
translating it medially after completing
initial transverse osteotomy.
Triangular overlapping of proximal and
distal humeral portions means that
resection is indicated. For cubitus
varus, degree of correction increases
as location of apex moves medially.
 D and E, Cubitus valgus is corrected
by rotating distal part of humerus
medially and translating it laterally
according to anatomical shape of
normal elbow.
 F, Fixation of osteotomy site.
Medial Epicondylar Fractures
 Most fractures of the
medial epicondylar
epiphysis are acute
avulsion injuries
caused by overpull of
the forearm flexor
tendon
 Can occur in
dislocation of the
elbow, and the
fragment may or may
not become caught in
the joint
 Treatment
 Most nondisplaced or
minimally displaced
fractures can be treated by
closed methods
 Indications for open
reduction include
 (1) rotation and
displacement of more than
1 cm because of the
resulting weakness of the
forearm flexors or cosmetic
deformity
 (2) persistent entrapment of
a fracture fragment in the
joint after reduction of an
elbow dislocation,
 (3) ulnar nerve dysfunction
 (4) valgus instability
 Treatment
 The medial epicondyle should be identified and
its location noted after every elbow dislocation

 If the fragment remains caught within the joint,

a closed reduction should be attempted with
the forearm supinated and stressed in valgus
with the patient under general anesthesia

 Passive dorsiflexion of the fingers may help put

traction on the epiphysis.
 Treatment
 If closed methods fail, open reduction is
required with removal of the fragment from the
joint and excision or reduction and internal
fixation of the fragment through k wire or screw
 Small fragment can be excised and muscles to
be sutured to humerus metaphysis
 Aftertreatment
 The splint is worn for 4 weeks. Next,
the arm is supported by a sling
permitting active motion of the elbow
but preventing forced dorsiflexion of
the wrist or supination of the
forearm.
 At 6 weeks, the wire or screw is
removed, and normal activities are
resumed gradually.
Medial Condylar Fractures
 Least common injuries
of the elbow
 Kilfoyle described
three types
 Type I
 Greenstick or impacted
fracture
 Type II
 Fracture through the
humeral condyle into
the joint with little or
no displacement
 Type III
 An epiphyseal fracture
that is intraarticular
and involves the
medial condyle with
the fragment displaced
and rotated
 Treatment
 Type I and undisplaced type II fractures
 Observation and posterior splinting
 Type II fractures
 Open reduction and internal fixation are
appropriate to avoid growth disturbance and
nonunion.
 Type III fractures
 Open reduction and internal fixation.

 Early diagnosis, accurate reduction, and

internal fixation are essential to avoid
growth disturbance, articular
roughening, functional disability,
nonunion, and osteonecrosis
Open Reduction and Internal
Fixation
 Medial incision just distal to the fractured
condyle
 Extend it proximally 7.5 cm parallel to the
long axis of the humerus
 Isolating the ulnar nerve and retracting it
posteriorly
 Gently reduce the fracture, and hold it with
a towel clip
 Insert two smooth Kirschner wires through
the condylar fragment and into the humerus
in a proximal and lateral direction.
 Close the wound and apply a plaster splint
with the elbow flexed 90 degrees
Supracondylar Fractures
 Observations
 (1)
 97.7% extension type
 only 2.2% were of the
flexion type
 (2)
 Most occurred in boys,
especially between
ages 5 and 8 years
 (3)
 Volkmann ischemic
contracture occurred in
0.5% of the fractures;
 (4)
 The radial, median, and
ulnar nerves were
involved in that order of
frequency.
 Mechanism of injury
 Fallon
outstretched hand
Know basic landmarks on lateral view to give clues to
distinguish fracture from normal

 Anterior humeral line

—middle 1/3
capitellum
Know basic landmarks on lateral view to give clues to
distinguish fracture from normal

 Radiocapitellar line
—points directly to
capitellum
 Gartland Classification
 Type I
 undisplaced;
 Type II
 displaced with
intact posterior
cortex
 Type III
 displaced with no
cortical contact.
 The three most common reasons for
residual cubitus varus or valgus
deformity are
(1) The inability to interpret poor
radiographs and acceptance of less
than adequate reduction,
(2) The inability to interpret good
radiographs because of a lack of
knowledge of the
pathophysiology of the fracture,
(3) The loss of reduction
 Jones view
 Anteroposterior plane should be
taken properly with the elbow flexed
maximally, the cassette underneath
the elbow, and the tube at a 90-
degree angle to the cassette
 An anterior spike on the lateral view
usually implies rotation rather than
posterior displacement.
 crescent sign

Crescent sign. A, Normal lateral view of elbow. B, In varus

deformity, part of ulna overlies distal humeral epiphyses, producing
crescent sign
 Baumann angle.
 a, Midline diaphysis of
humeral shaft.
 b, Line perpendicular to
midline.
 c, Line through physis of
lateral condyle.
 Angle A is original
Baumann angle. Angle B is
more commonly used
currently.
 A change of 5 degrees in
the Baumann angle
corresponds to a 2-degree
change in the clinical
carrying angle.
 O'Brien et al
 Metaphyseal-
diaphyseal angle
was more accurate
than the Baumann
angle in
determining the
adequacy of
reduction
 Varus tilting is
reduced by
pronation of the
forearm that closes
the fracture
laterally
 Criteria for closed reduction
 Easy reduction
 Stable fracture
 Minimal swelling
 No vascular compromise
 Conservative treatment
 Skeletaltraction
using an olecranon
pin or screw
 advantages are
increased mobility,
decreased pain and
swelling, and
improved
alignment.
.
 Percutanious pin fixation
 Most displaced
Gartland type II
and reducible type
III fractures are
treated by
percutaneous
pinning
 Closed Reduction and
Percutaneous Pinning
 Differentoptions of
wire fixations
2 parallel pins
 Divergent pins
 Crossed pins
 Medial and lateral
pins
 Skaggs et al. noted an incidence of
4% ulnar nerve palsy with use of a
medial pin and 15% ulnar nerve
palsy when the elbow was acutely
flexed with insertion of a medial pin
 Resolve spontaneously
 Royce et al.
 For comminuted or unstable fractures,
medial and lateral pins are used.
 To prevent nerve injury when a medial pin
is used, small incision over the medial
epicondyle is given and placing a drill
guide on the bone, through which the wire
is inserted.
 The pins should be angulated superiorly
approximately 40 degrees and posteriorly
10 degrees.
 AFTERTREATMENT
A long arm posterior plaster splint is
worn for 3 weeks
 The pins are removed at 3 weeks,
and another posterior splint is
applied.
 At 4 weeks, the splint is removed,
intermittent active range-of-motion
exercises are started
 Open Reduction and Internal
Fixation
 Indications
Closed reduction is unsatisfactory
Type III displaced fracture with no
cortical contact
After one or two attempts at closed
reduction
Neurovascular deficit
Open fractures that require irrigation
 Approaches
 Anterior
 Medial
 Anteromedial
 Posterior
 Lateral
Depending upon complications/fracture
configuration
 Early Complications
 Neurological compromise 3% to 22%
 Injury to the brachial artery 10%
 Compartment syndrome
 Late Complications
 Cubitus varus
(gunstock
deformity)
 Cubitus valgus rare
 Myositis ossificans
 Causes of cubitus varus
 Medial displacement and rotation of
the distal fragment
 Varus tilting of the distal fragment
 Overgrowth of the lateral condyle
 Malunited supracondylar fractures
 Osteotomies
 Medial opening wedge osteotomy
with a bone graft
 Oblique osteotomy with derotation
 Lateral closing wedge osteotomy
 Three-dimensional
osteotomy
 Lateral
closing wedge osteotomy is
the easiest, safest, and inherently
the most stable osteotomy.
Procedures
Two screws and a wire attached between
them
Plate fixation
Compression fixation
Crossed Kirschner wires
Staples
Voss et al technique
French technique
Derosa and Graziano
 Separation Of Entire Distal
Humeral Epiphysis
 In younger children the entire distal
humeral epiphysis may separate from the
humerus
 It is weaker because it is epiphyseal
cartilage
 Group A fracture
 Salter-Harristype I physeal injuries
 can be mistaken for elbow dislocations
 can occur as a birth injury or in newborns
 usually can be reduced satisfactorily and
immobilized in a posterior plaster splint
 Group B fractures
 Between the ages of 1 and 3 years
 May be Salter-Harris type I or II fracture
 Group C fractures
 Older children and produce a large
metaphyseal fragment,
 Closed reduction with the patient under
general anesthesia and cast immobilization
 If reduction was unsatisfactory, open reduction
and internal fixation with smooth pins were
carried out.
 Fractures of Shaft and
Proximal End of Humerus
 Fractures of shaft are rare
 Unite in cast
 Rarely need open reduction.
 Fractures of Shaft and
Proximal End of Humerus
 Fractures of the
proximal humerus are
usually physeal
 Most commonly
Salter-Harris type II
injuries
 Classified according to  Salter-Harris
displacement
classification of
 A grade I fracture is
displaced less than 5 proximal humeral
mm, whereas a grade physeal injurie
IV fracture involves
total displacement.
 Fractures of Shaft and
Proximal End of Humerus
 Open reduction is
indicated if the distal
fragment is
buttonholed
completely through
the deltoid muscle and
is impinging against
the skin
 Cannot be
repositioned by closed
method
 Displaced Salter-Harris
types III and IV
fractures
 Interposition of the
biceps tendon
 Fracture Dislocations
 Fracture-
dislocations
 Needs ORIF