Approach to Pediatric Approach to Pediatric ElbowElbow

Nicole KirkpatrickNicole Kirkpatrick

March 27, 2008March 27, 2008

ACHACH

ObjectivesObjectives

Anatomy of the elbowAnatomy of the elbow Approach to pediatric elbow XRsApproach to pediatric elbow XRs Practice ApproachPractice Approach Management/Complications of some Management/Complications of some

elbow fractureselbow fractures

AnatomyAnatomy Articulations Articulations

Ulnohumeral, Radiocapitellar, Proximal radioulnar Ulnohumeral, Radiocapitellar, Proximal radioulnar StabilityStability

Ulnar and lateral collateral ligament complexesUlnar and lateral collateral ligament complexes Anterior bundle - medial stabilityAnterior bundle - medial stability Lateral ulnar collateral - lateral stabilityLateral ulnar collateral - lateral stability

Origins and insertionsOrigins and insertions Lateral epicondyleLateral epicondyle

Extensor (wrist/finger)Extensor (wrist/finger) Medial epicondyleMedial epicondyle

Forearm flexorsForearm flexors PronatorsPronators

OlecranonOlecranon Extensor (elbow)Extensor (elbow)

VasculatureVasculature

NervesNerves

Ossification CentresOssification Centres

Mnemonic CRITOEMnemonic CRITOE C - capitellumC - capitellum R - radial headR - radial head I - Internal EpicondyleI - Internal Epicondyle T - TrochleaT - Trochlea O - OlecranonO - Olecranon E - External EpicondyleE - External Epicondyle

Ossification CentresOssification Centres

Age at appearance Age at Closure

Capitellum 1-2 14

Radius 3 16

Internal Epicondyle

5 15

Trochlea 7 14

Olecranon 9 14

External epicondyle

11 16

HistoryHistory

Elbow injuriesElbow injuries FOOSHFOOSH Direct traumaDirect trauma Repetitive injuryRepetitive injury

Physical examPhysical exam

InspectionInspection PalpationPalpation ROMROM VascularVascular

Brachial, Radial, UlnarBrachial, Radial, Ulnar Neurologic Neurologic

Median, Ulnar, Radial, MusculocutaneousMedian, Ulnar, Radial, Musculocutaneous StabilityStability

Stress ulnar collateral ligament in valgus in full Stress ulnar collateral ligament in valgus in full extension and 30 degrees of flexionextension and 30 degrees of flexion

RadiographyRadiography

Views Views APAP LateralLateral ObliqueOblique

ExternalExternal InternalInternal

AP and lateral are usually sufficientAP and lateral are usually sufficient Lateral view is most usefulLateral view is most useful

RadiographyRadiography

APAP Supination and full extension at elbow with slight Supination and full extension at elbow with slight

flexion of fingersflexion of fingers Visualize Visualize

EpicondylesEpicondyles Carrying angle (10°-12°)Carrying angle (10°-12°) ArticulationsArticulations Baumann’s angle (75°)Baumann’s angle (75°)

RadiographyRadiography

Lateral Lateral Rest on table Rest on table Elbow flexed at 90°Elbow flexed at 90° Thumb upThumb up

RadiographyRadiography

ObliqueOblique Visualize condylesVisualize condyles

Internal - medial epicondyle and Internal - medial epicondyle and coronoidcoronoid

External - capitellum and radial headExternal - capitellum and radial head

The 8 Step ApproachThe 8 Step Approach

1.1. Figure of 8Figure of 82.2. Anterior Fat PadAnterior Fat Pad3.3. Posterior Fat PadPosterior Fat Pad4.4. Anterior humeral lineAnterior humeral line5.5. Radio-capitellar lineRadio-capitellar line6.6. Inspect radial headInspect radial head7.7. Distal humerus examinationDistal humerus examination8.8. Ulna/Olecranon examinationUlna/Olecranon examination

ApproachApproach

Figure of EightFigure of Eight To determine if true To determine if true

laterallateral Otherwise unable to Otherwise unable to

adequately assess fat adequately assess fat pads, anterior humeral pads, anterior humeral lineline

ApproachApproachAnterior Fat PadAnterior Fat Pad

Barely visible on normal Barely visible on normal filmfilm

Trauma - fractureTrauma - fracture Children - supracondylarChildren - supracondylar Adults - Occult radial headAdults - Occult radial head

Atraumatic - inflammationAtraumatic - inflammation Gout, effusion, arthritisGout, effusion, arthritis

ApproachApproach

Posterior Fat PadPosterior Fat Pad ALWAYS ABNORMALALWAYS ABNORMAL

ApproachApproach

Anterior humeral lineAnterior humeral line Passes through Passes through

middle third of the middle third of the capitellumcapitellum

Disruption suggests Disruption suggests supracondylar supracondylar fracturefracture

ApproachApproach

Radio-capitellar lineRadio-capitellar line On any plain film viewOn any plain film view Bisects the capitellumBisects the capitellum Disruption represents Disruption represents

radial head/neck# or radial head/neck# or dislocationdislocation

ApproachApproach

Inspect radial headInspect radial head Disruption in cortical surfaceDisruption in cortical surface

Inspect distal humerusInspect distal humerus Disruption in cortical surfaceDisruption in cortical surface

Inspect ulna/olecranonInspect ulna/olecranon Disruption in cortical surfaceDisruption in cortical surface

Case 1Case 1

Figure of eightFigure of eight Anterior fat padAnterior fat pad Posterior fat padPosterior fat pad Anterior humeral lineAnterior humeral line Radiocapitellar lineRadiocapitellar line Radial headRadial head Distal humerusDistal humerus Ulna/olecranonUlna/olecranon

Supracondylar FractureSupracondylar Fracture

Most common paeds elbow fracture Most common paeds elbow fracture (~50%)(~50%)

One third of paeds limb fracturesOne third of paeds limb fractures Usually between 3 and 10 years oldUsually between 3 and 10 years old Uncommon after 15 yearsUncommon after 15 years MechanismMechanism

FOOSHFOOSH

Supracondylar FractureSupracondylar Fracture

2 classifications2 classifications ExtensionExtension

~95% of supracondylar fractures~95% of supracondylar fractures FOOSHFOOSH

FlexionFlexion ~5% of supracondylar fractures~5% of supracondylar fractures Direct trauma to posterior aspect of flexed Direct trauma to posterior aspect of flexed

elbowelbow

Supracondylar FractureSupracondylar Fracture

Gartland Classification SystemGartland Classification System

Type IType I Non-displacedNon-displaced Often only clinically suspected or fat pads visualizedOften only clinically suspected or fat pads visualized

Type IIType II Angulated and displaced but posterior cortex intactAngulated and displaced but posterior cortex intact

Type IIIType III Completely displaced distal fragment with disruption Completely displaced distal fragment with disruption

of posterior cortexof posterior cortex

Type IIIType III

Flexion SupracondylarFlexion Supracondylar

ManagementManagement

Type IType I Posterior splint (wrist to axilla), elbow flexion 90° Posterior splint (wrist to axilla), elbow flexion 90°

forearm neutralforearm neutral 3 weeks3 weeks Ortho f/uOrtho f/u

Type IIType II Ortho consultOrtho consult

Closed reduction vs. ORIFClosed reduction vs. ORIF Splint at 110° of flexionSplint at 110° of flexion

Type IIIType III Ortho consultOrtho consult

Closed vs. open reductionClosed vs. open reduction

ComplicationsComplications

Neurovascular injury in ~12%Neurovascular injury in ~12% displacement increases incidencedisplacement increases incidence

Mostly neuropraxias that resolve in Mostly neuropraxias that resolve in monthsmonths Extension - median nerve and brachial arteryExtension - median nerve and brachial artery Flexion - ulnar nerveFlexion - ulnar nerve

Case 2Case 2

Figure of eightFigure of eight Anterior fat padAnterior fat pad Posterior fat padPosterior fat pad Anterior humeral lineAnterior humeral line Radiocapitellar lineRadiocapitellar line Radial headRadial head Distal humerusDistal humerus Ulna/olecranonUlna/olecranon

Lateral Condylar FractureLateral Condylar Fracture

Second most common paeds elbow fracture (15%)Second most common paeds elbow fracture (15%) Common between 4-10 yearsCommon between 4-10 years Considered intra-articularConsidered intra-articular MechanismMechanism

Fall on supinated arm, condylar fragment avulsed by Fall on supinated arm, condylar fragment avulsed by extensorsextensors

Fall on palm with flexed elbow compresses radial Fall on palm with flexed elbow compresses radial head into lateral condylehead into lateral condyle

Disruption of radiocapitellar line can occurDisruption of radiocapitellar line can occur Thurston-Holland fragment may be presentThurston-Holland fragment may be present

Posteriorly displaced metaphyseal fragmentPosteriorly displaced metaphyseal fragment

Lateral Condylar FractureLateral Condylar Fracture

Largely cartilaginous Largely cartilaginous Size and location difficult to appreciateSize and location difficult to appreciate Internal oblique viewsInternal oblique views

Classification Classification Previous Milch classification systemPrevious Milch classification system Now based on displacementNow based on displacement

Type IType I < 2 mm displacement< 2 mm displacement Can be complete or incompleteCan be complete or incomplete

Type IIType II 2-4 mm displacement2-4 mm displacement

Type IIIType III Complete displacement and rotationComplete displacement and rotation

Lateral Condylar FractureLateral Condylar Fracture

Management Management Type IType I

Conservative but may be prolonged (6-12w of Conservative but may be prolonged (6-12w of immobilization)immobilization)

Type IIType II ORIF vs. Closed reduction & pinningORIF vs. Closed reduction & pinning

Type IIIType III ORIFORIF

ComplicationsComplications NV rarely injuredNV rarely injured

Lateral Condylar FractureLateral Condylar Fracture

Case 3Case 3

Figure of eightFigure of eight Anterior fat padAnterior fat pad Posterior fat padPosterior fat pad Anterior humeral lineAnterior humeral line Radiocapitellar lineRadiocapitellar line Radial headRadial head Distal humerusDistal humerus Ulna/olecranonUlna/olecranon

Medial Epicondyle FractureMedial Epicondyle Fracture

~12% of paeds elbow fractures~12% of paeds elbow fractures Common between 10-14 years, majority Common between 10-14 years, majority

malemale Associated with dislocations ~50%Associated with dislocations ~50% MechanismMechanism

Avulsion of epicondyle by forearm flexors with Avulsion of epicondyle by forearm flexors with valgus stressvalgus stress

Medial Epicondyle FractureMedial Epicondyle Fracture

ClassificationClassification Degree of displacement (< or > 5 mm)Degree of displacement (< or > 5 mm) +/- trapped fragment+/- trapped fragment +/- dislocation of elbow+/- dislocation of elbow

Medial Epicondyle FractureMedial Epicondyle Fracture

ManagementManagement Minimally displacedMinimally displaced

Long arm splint Long arm splint 1-2 weeks with early ROM1-2 weeks with early ROM

Displaced >5mmDisplaced >5mm Conservative or operativeConservative or operative

Intra-articular fragmentIntra-articular fragment Surgical removal of fragmentSurgical removal of fragment

Medial Epicondyle FractureMedial Epicondyle Fracture

ComplicationsComplications Ulnar nerve injury 10-16%Ulnar nerve injury 10-16%

More common if intraarticular fragmentMore common if intraarticular fragment

Case 4Case 4

Figure of eightFigure of eight Anterior fat padAnterior fat pad Posterior fat padPosterior fat pad Anterior humeral lineAnterior humeral line Radiocapitellar lineRadiocapitellar line Radial headRadial head Distal humerusDistal humerus Ulna/olecranonUlna/olecranon

Radial Head and Neck Radial Head and Neck FracturesFractures

Radial neck > head fracturesRadial neck > head fractures Often minimal physical findingsOften minimal physical findings MechanismMechanism

FOOSHFOOSH Elbow extended and in valgusElbow extended and in valgus

Associated with other injuries in ~ 50% of casesAssociated with other injuries in ~ 50% of cases

Radial Head and Neck Radial Head and Neck FracturesFractures

Classification Classification By degree of angulationBy degree of angulation

Type IType I < 30° angulation< 30° angulation

Type IIType II 30° -60° angulation30° -60° angulation

Type IIIType III > 60° angulation> 60° angulation

Radial Head and Neck Radial Head and Neck FracturesFractures

ManagementManagement Angulation>15º - closed reductionAngulation>15º - closed reduction Type IType I

Sling/posterior splint X 1-2 weeksSling/posterior splint X 1-2 weeks

Type II and IIIType II and III Percutaneous pining if closed reduction not Percutaneous pining if closed reduction not

adequate (<30°)adequate (<30°)

Radial Head and Neck Radial Head and Neck FracturesFractures

Complications Complications AVN of radial head ~ 10 -20%AVN of radial head ~ 10 -20% Loss of ROMLoss of ROM

rotationrotation

Case 5Case 5

Figure of eightFigure of eight Anterior fat padAnterior fat pad Posterior fat padPosterior fat pad Anterior humeral lineAnterior humeral line Radiocapitellar lineRadiocapitellar line Radial headRadial head Distal humerusDistal humerus Ulna/olecranonUlna/olecranon

Olecranon FractureOlecranon Fracture

~ 5% of elbow fractures~ 5% of elbow fractures More common with increasing ageMore common with increasing age Associated with other injuries (50%)Associated with other injuries (50%) MechanismMechanism

Direct blowDirect blow ShearShear Indirect due to forceful contraction of triceps Indirect due to forceful contraction of triceps

while elbow flexed in fallwhile elbow flexed in fall HyperextensionHyperextension

Olecranon FractureOlecranon Fracture

ManagementManagement Extra-articular Extra-articular

Displaced <3 mmDisplaced <3 mm 3-4 immobilization3-4 immobilization

Displaced >3 mmDisplaced >3 mm Closed reductionClosed reduction ImmobilizeImmobilize

Hyperextension/Shear - cast in flexionHyperextension/Shear - cast in flexion Hyperflexion - cast in extensionHyperflexion - cast in extension

Intra-articularIntra-articular ORIFORIF

Olecranon FractureOlecranon Fracture

ComplicationsComplications Missed injuriesMissed injuries Ulnar nerve injuryUlnar nerve injury Non-unionNon-union ArthritisArthritis Poor extensor strengthPoor extensor strength

ConclusionConclusion

Be vigilant Be vigilant Use a thorough approachUse a thorough approach

Look for associated injuriesLook for associated injuries Think about mechanismThink about mechanism Know how it is treated in your centreKnow how it is treated in your centre

Other fracturesOther fractures

HumeralHumeral SupracondylarSupracondylar TranscondylarTranscondylar IntercondylarIntercondylar CondylarCondylar EpicondylarEpicondylar Articular surface (trochlea/capitellum)Articular surface (trochlea/capitellum)

Radial head/neckRadial head/neck UlnarUlnar

OlecranonOlecranon CoronoidCoronoid

ReferencesReferences

Wheeless’ Textbook of OrthopaedicsWheeless’ Textbook of Orthopaedics

www.radiologyassistant.nlwww.radiologyassistant.nl

www.uptodate.com

http://nypemergency.org/imaging/elbow.html

http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html

Rosen’sRosen’s

TintinalliTintinalli

Carson S, et al. Pediatric Upper Extremity Injuries. Pediatr Clin N Am 2006;53:41-67.Carson S, et al. Pediatric Upper Extremity Injuries. Pediatr Clin N Am 2006;53:41-67.

Benjamin HJ, et al. Common Acute Upper Extremity Injuries in Sport. Pediatric Emergeny Benjamin HJ, et al. Common Acute Upper Extremity Injuries in Sport. Pediatric Emergeny Medicine 2007: 15-30.Medicine 2007: 15-30.

Gogola GR. Pediatric Humeral Condyle Fractures. Hand Clin 2006;22:77-85. Gogola GR. Pediatric Humeral Condyle Fractures. Hand Clin 2006;22:77-85.

Baratz M, et al. Pediatric Supracondylar Fractures. Hand Clin 2006;22:69-75.Baratz M, et al. Pediatric Supracondylar Fractures. Hand Clin 2006;22:69-75.

Tamai J, et al. Pediatric Elbow Fractures: Pearls and Pitfalls. UPOJ 2002;15:43-51.Tamai J, et al. Pediatric Elbow Fractures: Pearls and Pitfalls. UPOJ 2002;15:43-51.