Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified...
Transcript of Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified...
![Page 1: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/1.jpg)
Elbow Fracture Case Presentations
Children’s Mercy
Kansas City, MO
Mark Sinclair, MD
![Page 2: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/2.jpg)
12 month old with abnormal elbow
• 12 month old female presented to outside institution with a swollen right elbow
• Her aunt, who has had guardianship since 9 months of age, noticed she wasn’t holding her bottle with her right hand like she usually would
• Evaluation at that time included xrays, which were read as normal.
• A blood culture was done, which turned positive at two days. The child was subsequently referred to Children’s Mercy for suspicion of a septic elbow
![Page 3: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/3.jpg)
12 month old with abnormal elbow
![Page 4: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/4.jpg)
12 month old with abnormal elbow
• The xrays were over-read at CMH with “periosteal reaction of the right humerus consistent with osteomyelitis”
• An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound
• She was afebrile, HR 150, BP 123/83
• WBC 13.4 with no left shift, CRP 2.0, ESR 30
• Decision was made the night of admission to bring to the OR for drainage of suspected septic elbow
![Page 5: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/5.jpg)
12 month old with abnormal elbow
• At time of surgery, the posterior displacement of the capitellumwas noted, as was the limit of flexion to 110 degrees
• A lateral arthrotomy of the elbow was performed, and a bloody effusion was identified
• Cultures were sent, and all were no growth
• Blood cultures from CMH were no growth
• The positive blood culture from the referring institution later turned out to be a contaminant
• A skeletal survey was obtained
![Page 6: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/6.jpg)
Left proximal tibia fracture
Left proximal humerus fracture
![Page 7: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/7.jpg)
12 month old with abnormal elbow
• Child abuse assessment was made
• Child was treated with antibiotics for three weeks in case any infectious etiology was possible
• No metabolic abnormalities were identified on work-up
• Child followed annually by orthopaedics for assessment of growth
5 months after injury
![Page 8: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/8.jpg)
18 months after injury
![Page 9: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/9.jpg)
2 ½ years post injury. Full flexion and extension of the elbow.
Carrying angles symmetric. Discharged from follow up.
![Page 10: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/10.jpg)
6 y 2 mo old male fell
at school on
playground and
sustained a Gartland
Type 2 supracondylar
humerus fracture
Otherwise healthy
Limb neurologically
and vascularly intact
Non-dominant hand
![Page 11: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/11.jpg)
Underwent closed
reduction and
percutaneous pinning
the night of the injury
with two divergent
.062” K-wires
![Page 12: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/12.jpg)
4 weeks
post op, the
cast and
pins are
removed
![Page 13: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/13.jpg)
Returns 8 weeks post op.
Pins sites are healed. He
has near full flexion and
near full extension. Full
pronation and supination.
No pain.
He is discharged from
care to return as needed
![Page 14: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/14.jpg)
Type 2 supracondylar humerusfracture s/p CRPP• He returns 7 years later at age 13 y 6 mo
• Now a 5‘ 10‘’ eighth grader active in sports
• Notices pain in his elbow with push-ups at gym class
• Notes pain when he repeatedly swings a bat during baseball season
• On exam, he lacks the last 10 degrees of extension and the last 10 degrees of flexion of the elbow
• He has full pronation and supination of the forearm
• His left humerus is slightly shorter than the right
![Page 15: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/15.jpg)
![Page 16: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/16.jpg)
MRI/Arthrogram demonstrates
the AVN of the lateral half of the
trochlea with a possible loose
fragment of cartilage
![Page 17: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/17.jpg)
• 6 y 1 mo male fell off monkey bars onto his right arm
• Right hand dominant
• Fusiform swelling of right elbow
• Neurovascularly intact on exam
• Xrays show a Gartland type 2 supracondylar humerusfracture that is extended but has no varus/valgus angulation
![Page 18: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/18.jpg)
Initial one
week follow
up shows
no change
in alignment
in cast
![Page 19: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/19.jpg)
• Seen back in follow up 3 weeks after injury
• Xrays done out of cast show increased extension of the fracture with early fracture callus
![Page 20: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/20.jpg)
• Patient brought to the OR later that day for closed reduction and percutaneous pinning of his supracondylar humerusfracture
![Page 21: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/21.jpg)
Seen one
month post op for
cast and pin
removal
![Page 22: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/22.jpg)
Lateral Condyle Fractures
9 y o male falls
while jumping
over a creek
and sustains
an injury to
right elbow
Splinted in ER
and referred
to ortho clinic
![Page 23: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/23.jpg)
Seen in clinic 10 days
post injury. After
review of these xrays,
he is placed in a cast
![Page 24: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/24.jpg)
2 weeks later, he returns
for follow up. He is taken
out of his cast and xrays
are obtained. He was
placed back in a long
arm cast.
![Page 25: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/25.jpg)
6 weeks out from
his injury, he
returns for follow
up. Xrays out of
cast are obtained.
Immobilization is
removed and ROM
initiated
![Page 26: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/26.jpg)
He returns 3
months out from his
original injury.
After these xrays
obtained, a CT
scan is performed
later that day
![Page 27: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/27.jpg)
AP Lateral Internal oblique
![Page 28: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/28.jpg)
The next week, an
open reduction and
percutaneous pinning
was performed. He
was placed back in a
cast.
![Page 29: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/29.jpg)
2 months post op (5
months post injury), he
has another CT to
evaluate his healing.
He has a persistant
non-union. Another
surgical procedure is
performed.
![Page 30: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/30.jpg)
In situ internal
fixation of his
nonunion is
performed with
autogenous bone
marrow aspiration
and injection into
the non-union.
![Page 31: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/31.jpg)
His in situ screw
starts to back out
within a month, and 6
months after his
original injury, he
undergoes his 3rd
surgical procedure to
heal his lateral
condyle fracture:
open reduction and
internal fixation with
autograft harvested
from ulna
![Page 32: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/32.jpg)
Two years post
op from his
internal fixation
with bone
autograft of his
non-union, he is
healed. He has
full flexion and
extension and full
pronation and
supination. He
has returned to all
activities. And
has never been
seen again…
![Page 33: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/33.jpg)
• 6 year old male fall off monkey bars onto outstretched left arm
• Right hand dominant
• Swelling and tenderness to palpation about elbow; neurovascularly intact
• Xrays demonstrate a lateral condyle fracture of the distal humerus
![Page 34: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/34.jpg)
Internal oblique view
performed
![Page 35: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/35.jpg)
Closed reduction and
percutaneous pinning
was performed the
following day in the
trauma room
No pre or post reduction
arthrogram performed
![Page 36: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/36.jpg)
• 10 days post op
![Page 37: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/37.jpg)
• One month post op after pins removed
![Page 38: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/38.jpg)
• 3 y 3 mo old male fell off bed at home and sustained an injury to the left elbow
• Lateral swelling of elbow
• Neurovascular exam intact
• Xrays demonstrate a lateral condyle fracture of distal humerus
![Page 39: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/39.jpg)
Oblique view obtained
Splinted in ER and referred
to ortho clinic
![Page 40: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/40.jpg)
• Seen in ortho clinic 5 days post injury and xrays out of splint were obtained
![Page 41: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/41.jpg)
• Brought to the operating room the following day for open reduction and percutaneous pinning
![Page 42: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/42.jpg)
3 weeks
post op,
pins
removed
and re-
casted
![Page 43: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/43.jpg)
7 weeks
post op
full
extension,
lacks
last 10-15
degrees of
flexion
No pain
Released
to regular
activity
![Page 44: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/44.jpg)
10 y 2 mo old male fell on
outstretched left arm while
playing basketball and sustained
a completely displaced left
supracondylar humerus fracture
Radial, median, and ulnar nerve
motor exam intact
Radial pulse not palpable but
dopplerable. Good capillary refill
in fingers (<2 seconds)
Taken to the OR the night of the
injury for reduction and pinning
of his fracture
![Page 45: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/45.jpg)
Underwent closed reduction
And percutaneous pinning with
5/64th Steinman pins
After reduction, the hand
appeared white and pulseless.
The arm was warmed and the
hand became pink with good
capillary refill and a Dopplerable
but not palpable radial pulse
Patient admitted to hospital for
overnight observation
![Page 46: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/46.jpg)
• On rounds the next morning, the patient continued to have a warm hand with good capillary refill, but did not have a normal biphasic Doppler signal over radial artery at wrist
• He also had an anterior interosseous nerve palsy that he did not have pre-operatively
• Decision was made to go back to the OR and explore the median nerve and brachial artery at the fracture site
![Page 47: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/47.jpg)
Median nerve
Brachial artery
![Page 48: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/48.jpg)
• The brachial artery and vein were entrapped in the fracture site
• The median nerve was entrapped in the fracture site
• The percutaneous pin fixation was taken down and these structures were teased out of the fracture
• These structures were intact after extraction from the fracture site
• The fracture was reduced and pinned again with an open reduction
• A palpable pulse and strong biphasic Doppler signal was audible at the wrist and into the palmar arch
![Page 49: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/49.jpg)
![Page 50: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/50.jpg)
Xrays one
week
Post op from
antecubital
exploration and
revision of
percutaneous
fixation
![Page 51: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/51.jpg)
4 weeks post op
Palpable radial
pulse at wrist with
good
capillary refill
AIN nerve function
still abnormal
Pin sites benign
Pins pulled, and
cast
immobilization
discontinued
Referred to physical
![Page 52: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/52.jpg)
• Returns 6 weeks post op with draining pin site and pyogenic granuloma
• Range of motion very limited (90-110 degrees)
• AIN function starting to improve
![Page 53: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/53.jpg)
• For next 6 weeks, patient treated with local wound care
• Continued with physical therapy and extension bracing and casting was done to improve motion of arm
• Then elbow became increasingly swollen and drainage increased
• Xrays were done
![Page 54: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/54.jpg)
![Page 55: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/55.jpg)
• Patient seen in Infectious Disease clinic and labs and cultures performed:
• WBC: 7.47• CRP: 1.1• ESR: 81• Cultures: Pseudomonas aeruginosa
• MRI and CT confirmed chronic osteomyelitis of distal humerus and septic arthritis of elbow
• Patient admitted for IV antibiotics and brought to the OR for drainage of infection and debridement
![Page 56: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/56.jpg)
Debridement of the distal humerus and
elbow joint occurred
After irrigation and cleaning, the bone
defect was packed with calcium sulfate
mixed with tobramycin
Wound was closed over drains
One surgical culture grew
Pseudomonas aeruginosa.
Remainder negative
Subsequently discharged on
Ciprofloxacin
![Page 57: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/57.jpg)
Seen 3 weeks after
debridement
Wound closed and
without drainage
Range of motion
improving
ESR normalizing
Calcium sulfate
absorption occurring
radiographically
Continues on
ciprofloxacin and
PT/OT
![Page 58: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/58.jpg)
• 5 y 0 mo male fell off monkey bars his first week of kindergarten and injured his right elbow
• Swelling and deformity of elbow
• Neurovascular exam intact
• Xrays show a displaced right distal humerusfracture
![Page 59: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/59.jpg)
• Brought to the OR the following day and underwent closed reduction and percutaneous pinning
• Cross pinning attempted, but adequate fixation could not be obtained with the medial pin
• 3 lateral pins were utilized for fixation
![Page 60: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/60.jpg)
• Seen 2 weeks post op
• Did well initially post op but has had increasing pain the last couple of days prior to clinic visit
• One pin had migrated under the skin but was able to be retrieved in clinic
• Neurovascular exam remained intact
• Subsequently re-casted
![Page 61: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/61.jpg)
• 4 week post op visit
• Xrays show interval callus formation without further loss of fixation
• Pins removed
![Page 62: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/62.jpg)
• 3 months post op
• Right elbow range of motion from 0 to 130 degrees
• Solid bony union of fracture with early remodeling
• Returned to full activity and follow up as needed
![Page 63: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/63.jpg)
END
![Page 64: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/64.jpg)
PB 1592625: what are the indications for a medial pin?
• 5 year old male fall off trampoline onto right arm
• Physical Exam: Diffuse swelling about elbow, neurovascularly intact
• X-rays show a type III supracondylar humerusfracture
![Page 65: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/65.jpg)
• Three 0.062 K-wires
![Page 66: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/66.jpg)
• 1 week post op
• Xrays show intact hardware with maintained alignment and position of supracondylar humerus fracture
• Neurovascularly intact
![Page 67: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/67.jpg)
• 3 weeks post op
• Xrays show interval callus formation with maintained hardware
• Neurovascularly intact
• Pins pulled
![Page 68: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/68.jpg)
LV 1489966 SCH fx requiring open reduction
• 6 yo M, unwitnessed fall from couch onto left arm
• Closed injury, neurovascular exam unremarkable
• Extension type II SCH
• Admit, closed vs open reduction and percutaneous pinning
12/20/2012
![Page 69: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/69.jpg)
SCH fx requiring open reduction
• Failed closed reduction, anterior comminution (radial head?, loose body?)
• After opening, comminutionfrom proximal fragment attached to periosteum
• Open reduction, perc pinning, long arm cast applied
• f/u 2 weeks
12/20/2012
![Page 70: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/70.jpg)
SCH fx requiring open reduction
• 1/4/2013 (2 wkspost-op)
• Pin sites c,d,I
• Neurovascular exam unremarkable
• New long arm cast applied
• f/u 2 weeks
![Page 71: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/71.jpg)
SCH fx requiring open reduction
• 1/18/2013 (4 wks post-op)
• Pin sites c,d,I
• Neurovascular exam unremarkable
• d/c immobilization
• f/u 4 weeks
![Page 72: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/72.jpg)
SCH fx requiring open reduction
• 2/8/2013 (7 wks post-op)
• Incision, pin sites well healed
• Neurovascular exam unremarkable
• Lacks ~10 deg extension and ~30 deg flexion
• PT for elbow ROM
• F/u 6 weeks/PRN
![Page 73: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/73.jpg)
AC 1245913 malunion of SCH fx that required distal humeral osteotomy
• A good case to follow is SP 1514348_ bad elbow that had an open reduction and pinning and did well. Perhaps AC would have done better with an open reduction…
![Page 74: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/74.jpg)
END
![Page 75: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/75.jpg)
KK 1245828 flexion supracondylar requiring open reduction
• 6 yo F, ground level fall onto flexed left arm
• Closed injury, neurovascular exam unremarkable
• Admit, closed vs. open reduction percutaneous pinning
11/25/2012
![Page 76: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/76.jpg)
flexion supracondylar requiring open reduction
• Failed closed reduction
• Soft tissue interposition found after opening
• Long arm cast aaplied
• F/u 2 weeks
11/26/2012
![Page 77: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/77.jpg)
flexion supracondylar requiring open reduction
• 12/7/12
• Migration of middle pin
• Plan to remove middle pin, replace long arm cast
• f/u 2 weeks
![Page 78: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/78.jpg)
flexion supracondylar requiring open reduction
• 12/21/12 (3.5 weeks post-op)
• Cast removed, pin sites c,d,I
• Neuroovascular exam unremarkable
• Pins removed, long-arm waterproof cast
• f/u 2 weeks
![Page 79: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/79.jpg)
flexion supracondylar requiring open reduction
• 01/04/13 (5.5 weeks post-op)
• Alignment maintained
• Interval healing
• D/c immobilization
• f/u 6 weeks
![Page 80: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/80.jpg)
flexion supracondylar requiring open reduction• 02/08/2013
• Incision, pin sites well healed
• Lacks about 10-15 deg of extension and 10 deg of flexion
• Full pronosupination
• Neurovascular exam unremarkable
• Return to PE/recess, out of gymnastics for 1 more month
• f/u PRN
![Page 81: Elbow Fracture Case Presentations - Children's …...•An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound •She was afebrile,](https://reader034.fdocuments.us/reader034/viewer/2022052611/5f04a6e97e708231d40f081b/html5/thumbnails/81.jpg)
JC 1633402 Child abuse kid with happy ending