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Elbow Fractures in Children

N.H. Jidveianu, P. Nicolcescu, O. Vonica

Department of Pediatric Surgery and Orthopedics

Pediatrics Hospital, Sibiu, Romania

 

Correspondence:

Dr. Horea Jidveianu

Department of Pediatric Surgery and Orthopedics, Pediatrics Hospital
Str. Gheorghe Baritiu 1-3, Sibiu, Romania

Tel: 0040.269.230.260. Fax: 0040.269.230.045, E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Background: The elbow is a common site of orthopaedic injury in the paediatric population. Fracture patterns vary considerably among different age groups.

Material and Methods: We studied a group of 258 cases of elbow fractures treated in the Department of Pediatric Surgery and Orthopedics of Sibiu between January 2005 - January 2006. They were 66,2% boys and 33,8% girls, aged between 0-18 years old. The types of fractures were the following: 174 supracondylar fractures (67.44%), 46 medial epicondyl fractures ( 26.43%), 9 lateral epicondyl fractures ( 3.48%), 5 radial head fractures (1.93%), 21 olecranon fractures ( 8.14%) and 3 Monteggia fractures (1.16%).

The treatment management varied: simple immobilization for non displaced fractures, manipulative closed reduction followed by immobilization for displaced fractures, manipulative closed reduction, maintaining the reduction with percutaneous pins and immobilization for unstable fractures, open reduction and internal fixation, followed by immobilization for complicated fractures, unsuccessfully reduced, cominutives and open fractures, fractures with intra-articular displace.

Results: Most cases had a favourable evolution, with quickly and complete recovery of the elbow mobility, without special recovery treatment. In 2 cases, the recovery was difficult, even with physical therapy.

Conclusions: Open reduction and internal fixation or closed reposition and pin fixation gave the best results.

Key words: elbow injury, children, type of fracture, treatment.

  

Introduction

Elbow joints are composed of 3 distinct articulations: radiocapitellar, ulnatrochlear and proximal radioulnar, all contained in 1 synovial-lined capsule. The radiohumeral articulation functions as a pivot, allowing flexion, extension, and rotation. It is stabilized by the lateral collateral ligament and the annular ligament. The ulnohumeral articulation is characterized as a hinge/ginglymus joint , allowing flexion and extension. Its stability is enhanced by the congruence of the articular surfaces, as well as by the medial collateral and lateral ulnar collateral ligaments

The elbow is a common site of orthopaedic injury in the paediatric population. Fracture patterns vary considerably among different age groups. The capsule typically encases hemarthrosis following injury. The median nerve is the most commonly injured nerve.

Table 1. Distribution by age groups

below 1 year 7 cases 4 boys 3 girls
1-5 years 76 cases 45 boys 31 girls
5-15 years 156 cases 108 boys 48 girls
15-18 years 19 cases 14 boys 5 girls

Table 2 Elbow fractures

Distal humerus fractures 229 cases 149 boys 80 girls
Radial head/neck fractures 5 cases 3 boys 2 girls
Olecranon fractures 21 cases 16 boys 5 girls
Monteggia fractures 3 cases 3 cases -

Table 3 Distal humerus fractures

Supracondylar fractures 174 cases 109 boys 65 girls
Medial epicondyl fractures 46 cases 33 boys 13 girls
Lateral epicondyl fractures 9 cases 7 boys 2 girls

The brachial artery is the most commonly injured artery. The number of these injuries continues to rise following increased levels of participation in paediatric recreational and competitive sports. Injury patterns for children and adults are quite different. At emergency the physicians must recognize whether fractures require admission, immediate orthopedic evaluation, or only immobilisation. Direct trauma or a fall into an outstretched hand is responsible for most elbow fractures. Triceps muscle insertion on the olecranon often causes its displacement following fracture

elbow fr 1 

Figure 1. Distribution by age groups

Material and Methods

We present a prospective study of the pattern of elbow fractures in 258 children and teenagers between 0-18 years, during the period January 2005 - January 2006. They are divided by the following criteria: age, sex, type of fracture, complications, treatment management and results.

The distribution according to the age groups is shown in table 1 and figure 1.The number of the cases for each type of fracture is presented in table 2 and figure 2. The distal humerus fractures are detailed in table 3 and figure 3.The treatment of fractures according to the age and type was as follows:

  • Below 1 year old group: 7 supracondylar fractures (4 boys, 3 girls), non displaced
  • 1-5 years old group:

- 60 supracondylar fractures (32 boys, 28 girls): 15 operated, 18 closed reduced, 27 non displaced

- 7 medial epicondyl fractures (6 boys, 1 girl) operated

- 1 lateral epicondyl fractures (boy), operated

- 7 olecranon fractures (5 boys, 2 girls): 1 operated (hobanaj) and 6 non displaced

- 1 supracondylar fracture complicated with osteitis (5 year girl), operated: evacuation, lavatory, drainage, immobilization

Supracondylar humerus fractures are most common in children aged 4-10 years because of this age group’s relative strength of surrounding ligaments in comparison to bone.

  • 5-15 years old group:

- 99 supracondylar fractures (68 boys, 31 girls): 26 operated, 21 close reduction and 52 non displaced

- 34 medial epicondyl fractures ( 23 boys, 11 girls): 25 operated and 9 non displaced; 21 internal fixated with Kirschner wire and 4 with medial epicondylar apophysis resection + ulnar nerve transposition

- 8 lateral epicondyl fractures (6 boys, 2 girls): 4 operated and 4 non displaced

- 4 radial head fractures, operated

- 12 olecranon fractures (9 boys, 3 girls): 3 operated (2 hobanaje, 1 internal fixation.) and 9 non displaced

- 3 Monteggia fractures (boys), operated

- 1 supracondylar fracture and 1 lateral epicondyl fracture, both vicious consolidated, operated (osteotomy, reposition of the lateral epicondyl, internal fixation)

  • 15-18 years old group:

- 8 supracondylar fractures (5 boys, 3 girls): 3 operated, 2 close reduced and 3 non displaced

- 8 medial epicondyl fractures (7 boys, 1 girl), operated: 6 with internal fixations and 2 with medial epicondylar apophysis resection + ulnar nerve transposition

- 3 olecranon fractures (boys) operated (1 hobanaj, 2 internal fixation with Kirschner wire.)

Table 4. Elbow fractures 1-5 years

Supracondylar fractures 60 cases 15 operated 18 closed reduction 27 non displaced
Medial epicondyl
fractures
7 cases 7 operated - -
Lateral epicondyl
fractures
1 case 1 operated - -
Olecranon fractures 7 cases 1 operated - 6 non displaced

Results

Most cases had a favourable evolution, with quickly and complete recovery of the elbow mobility, without special recovery treatment. In 2 cases, the recovery was difficult, even with physical therapy. The incidence of serious complications was low. Open reduction and internal fixation or closed reposition and pin fixation gave the best results

elbow fr 2elbow fr 3

Figure 2. Distribution by anatomical regions

Discusions

While the goals are the same, treatment guidelines for children and adults differ slightly. Patient is unable to fully extend elbow, pain is present with pronation/supination of the forearm and performing careful shoulder and wrist examinations, with all elbow is very important.

Medical/Legal pitfalls:

• Failure to document a neurovascular exam in a child with a supracondylar fracture

• Failure to re-examine and document neurovascular exam following application of a splint. Elbow flexion greater than 90° may obliterate pulse or compromise neurological function

• Failure to pad olecranon when splinting an olecranon fracture may lead to skin breakdown and iatrogenic open fracture

• Failure to maintain prolonged immobilization of radial head fractures leads to permanently decreased range of motion

• Failure to recognize a radial head dislocation associated with a fracture of the proximal ulna (Monteggia fracture or dislocation).

Studies have shown that immediate internal fixation of both bone forearm with early range of motion provide the patient with a stable construct, that allows for accelerated rehabilitation and return to function[1]. Operative management of supracondylar humerus fractures consists in fixation with a rigid plate, nail, screws or K wire. These techniques allow for stable fixation of the fracture site and provide the best chance for union. Rigid fixation of these injuries leads for early range of motion of all joints in the affected extremity. This permits easier rehabilitation of concomitant injuries. In children, the treatment of supracondylar humerus fractures is closed (open if needed) reduction and percutaneous pinning.

In children, acceptable results have been achieved with closed reduction of the forearm fracture, with or without percutaneous pinning. The surgeon should base the treatment decision on the stability of the fracture reduction and the likelihood of achieving union without angulation. The opportunity for skeletal remodelling is also a factor into this decision, as well as the type of fixation required. Tailor rehabilitation to the individual injury pattern, with advancement of activity as fracture union progresses and muscle function returns[19, 21]. To determine the management of each type of fracture and soft-tissue coverage is done on a case-by-case basis. Some surgeons may elect to span the fractures with an external fixator until other patient care issues can be resolved. Others may elect to stage the procedures or fix both fracture complexes at once. All of these options are acceptable as long as the primary fracture principles are respected.

Table 5 Elbow fractures 5-15 years

Supracondylar fractures 99 cases 26 operated 21 close reduction 52 non displaced
Medial epicondyl
fractures
34 cases 25 operated - 9 non displaced
Lateral epicondyl
fractures
8 cases 4 operated - 4 non displaced
Radial head/neck
fractures
4 cases 4 operated - -
Olecranon fractures 12 cases 3 operated - 9 non displaced
Monteggia fractures 3 cases 3 cases - -

 

Neurological deficit is a point of controversy, especially in those with a mid or distal shaft humerus fracture. When deciding whether to explore a nerve that presents with a deficit, a number of factors should be taken into consideration, including the mechanism of injury, location of fracture or fractures and their personality, approach to surgical intervention and when the deficit was discovered (before or after reduction)[5].

Complications of treatment for floating elbow mirror those of other complex fracture treatment problems[2,3,4]. Significant neurovascular injury may accompany these lesions. These range from simple isolated nerve palsy to complex brachial plexus lesions with axillary/brachial artery injury/disruption. The cumulative incidence of some type of associated neurovascular injury in children and adults is 25-45%[6,7]. Loss of range of motion in the elbow and forearm axis is not uncommon, even with anatomic restoration of all fractures[8].

Infection is a notable complication, especially in those who present open fractures and require debridement and immediate internal fixation. A delay in definitive fixation until the soft tissues are in a condition in which appropriate skeletal management can be defined may be wise. Malunion and nonunion can result from a number of factors, including persistent infection, inadequate fixation, poor soft-tissue envelope, and poor technique[9].

Conservative treatment of unstable forearm fractures in childhood leads to disappointing results in up to 50%[10].Therefore the indication for a primary operative treatment is given. In the early 1990s the ORIF (open reduction and internal fixation) procedure was the commonly practiced treatment. Nowadays elastic stable intramedullary nailing (ESIN) is increasingly recommended[11].

The functional outcomes of these injuries vary in children and adult patients. Pediatric injuries historically have had better results than those of their adult counterparts, largely due to children’s ability to remodel skeletal deformity with time[12]. In Stanitski’s series of 6 patients, [13] all had an excellent outcome with respect to range of motion and carrying angle. Papavasiliou reviewed 24 cases and found similar results using the same treatment principles [10]. Templeton studied 8 subjects with similar clinical presentation and found 7 had good or excellent results and 1 had a poor result (cubitus varus with limited but functional supination/pronation) [14].

elbow fr 4elbow fr 5
Figure 3. Distal humerus fractures

Supracondylar fractures 8 cases 3 operated 2 closed reduction 3 non displaced
Medial epicondyl
fractures
8 cases 8 operated - -
Olecranon fractures 3 cases 3 operated - -

Table 6. Elbow fractures 15-18 years  

Conclusions

Current studies will serve as a baseline for future research to assess the success of specific interventions inreducing the incidence of elbow injury in the paediatric patient. Overall, in all patients we achieved a complete movement of the joint with or without physical therapy. The primarily overlooked fractures were corrected early. The best results in unstable fractures are obtained by close reduction and percutaneus pin fixation. Various osteosynthesis procedures were early performed in complicated fractures, open fractures and in failure of orthopedic treatment. A correct therapy, according to the clinical type of fracture, is the condition to obtain the best results .

 

 

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