Freih Odeh Abu Hassan F.R.C.S.(Eng.),F.R.C.S.(Tr.&Orth)

Professor Of Orthopaedics

University Of Jordan

Pearls and Pitfalls

1= High rate of complications

2= Results of non operative R/ are

not always good.

3= > skeletally immature ( 5-10 y)

4=The child’s elbow is well

vascularized # healing very

quickly.

Different from many other pediatric injuries!!!

C

O

R

I

They enter the post. portion of the lat

condyle lat. to the origin of the capsule

& proximal to the articular cartilage,

they are end vessels

1- Normal Elbow

Radiographic parameters

64-81

2- Check med.& lat. Column for

translation or comminution

3-The humeral–ulnar angle is the

most accurate in determining the true

carrying angle of the elbow.

4-Pseudofracture

The O.C of the trochlea may be

irregular, producing a fragmented

appearance

5-Oblique view

Direction of displacement

-=Post.medial # - 75%

=Post.lateral # - 25%

Post.lateral # are more

associated with NV injury.

Principles of treatment

1-Avoid catastrophes

e.g Vascular lesion, C. synd.

2-Minimize embarrassment

e.g Cubitus varus,

Iatrogenic N injury

Emergency Room R/

1-Simple splint in the same

position then x-ray

2-In limb ischaemia align #

3-Avoid flexion

4- Record pulse & sensation

1A- Long arm splintremove 1w

X-ray Splint for 2 w

1B (med.column collapse) CR+cast

=Avoid elbow flexion > 90°

=Insist on elevation

=Missed inj.

=Med.column collapse

Type I fracture

Med.column collapse

1B

=CR and Percut. Pins ,why ?

=Long-arm cast for 3 w

= 77% do well without pins

Type II fractures

Hyperflexion

Type II , medial impaction.

CR and percut. pins

(Cross-wires)

=CR + Percut. Pins + 3 w cast

Medial and lateral cross-pin technique

is the gold standard, but it places the

ulnar nerve at risk.

Type III fractures

Traction in extended

elbow and forearm

supination

1

Correct varus or

valgus and rotation

2

Elbow flexion +

pressure on

olecranon then

forearm

pronation

3

4

Post med

Med Pin insertion

5

30-40 degree

1-Compound #

2-Arterial inj

3-Compartment synd.

4-Absent pulse after MUA

5-Irreducible #

Irreducible #

1-Arterial injury (5–12%)

A pulseless but pink hand can be observed.

Decrease flexion

2-C.Syndrome

3-Nerve Palsy

A pulseless white hand after CR and

pinning open exploration with a

vascular surgeon.

The anteromedial approach provides

good exposure for the vascular repair

and OR.

Nerve injuries

Loss of sensation & sweating

= 5–19% always neurapraxias.

= 3–6 months to resolve .

=The anterior interosseous N

AIN palsy

1=VIC due to immobilization in

hyperflexion

2=Malunion =Due to rotation “gunstock”

deformity (cubitus varus).

=Inadequate correction of medial

collapse.

= Wait 2years then correct

after repeated MUA

3-M.Ossificans

Associated with

-Vascular inj.

-VIC

-OPEN #

CR or OR + Pins

= Be aware of the *Fracture patterns,

*Relevant anatomy - blood supply

*Risk of nonunion,

*Postop. follow-up in order to assess

potential deformity and neurologic

sequelae.

Diagnosis AP + Lat. + Oblique view

Milch Type I Travels from the metaphysis of the distal

humerus through the distal lateral epiph.

and through the trochleocapitellar groove.

Milch Type II Travels from the distal lateral

humeral metaphysis above the

epiphysis and exits through the

trochlea.

S-IV S-II

I II

DISPLACEMENT: (Rutherford(

Stage I Posterior splint vs. long arm cast

CLOSE FOLLOW-UP

because of high incidence of late

displacement and eventual

non\malunion .

Stage II/III CR + percut. pins if reducible closed.

If not, ORIF + percut. pins

Post-operative Management

Long arm cast at 90 degrees until

radiographic healing

Polyglycolic acid pins

=Exposure bet. Brachio R + Triceps.

= Avoid post. dissection of the

fragment to preserve the vascular

supply.

=Careful elevation of the ant. capsule

and dissection to the medial extent

of the fracture fragment.

Stage I

4w

Stage II

After 7days

Stage III

Cubitus Varus Secondary to malunion

or capitellar overgrowth

Non Union

AVN due to extensive dissection

Not involve the joint surface or

growth cartilage.

The medial epicondyle is a postero-

medial structure that serves as the

origin of the flexor–pronator muscle

mass + medial collateral lig. complex

= Associated injuries:

*Elbow dislocation - 50%

*Ulnar neurapraxia.

Non-surgical R/ of isolated medial

epicondyle # with 5 –15 mm

displacement yielded results

similar to those obtained with

ORIF

Farsetti P, etal

JBJS-A 2001.

Operative R/ of med. epicondyle #

= < 10 y old ORIF (K-wire) and

remove at 3 w.

= In older children single partially

threaded cannulated screw

Early motion is strongly suggested

Fracture - dislocation

=1%

= Dislocation of the radial head and

ulnar fracture ( proximal 1/3 )

Ulnar bow sign

Normal

Type I Monteggia

Type I - Anterior dislocation,

Type II- Posterior dislocations.

Type III -Lateral dislocation.

Type IV Radial + Ulnar #

+ radial head dislocation

The most reliable method to

recognize Monteggia fracture

“Monteggia equivalents.”

1= Ulnar plastic deformation -17%

2= Pulled elbow syndrome

3=Both–bone forearm fractures

4=Isolated radial neck fractures

5=Dislocation of the elbow with an ulnar

diaphyseal fracture

8-17% of Monteggia # have

a neurapraxia of the PIN

Recovery of nerve function takes

several days to 2 months after injury

The goal of treatment

= Correct the ulnar deformity

= Restoring ulnar length and realigning

the radiocapitellar joint.

=Reduction of the ulnar fracture often

reduces the radial head .

=It is essential to confirm maintenance

of reduction.

OR is necessary for unstable fractures

or when closed treatment fails.

Internal fixation of the ulna with an IM

Kirshner wire may allow reduction of the

radial head.

This method is better than plate fixation

The Kocher (posterolateral) approach

is often utilized for open reduction of the

radial head.

Missed injury = Limited elbow ROM

=Arthrosis,

=Nerve complications

Ulnar osteotomy + OR of the

radial head and reconstruction of

the annular ligament.

Open surgical treatment

44% obtained a functional arc of motion

of 30° to 130°.