PEDIATRIC ELBOW FRACTURES.

Transcription

1 PEDIATRIC ELBOW FRACTURES

2 INCIDENCE SECOND MOST COMMON PEDIATRIC INJURY

3 OSSIFICATION 1. CAPITELLUM (6 mo. - 2 yrs.) 2. MED. EPICONDYLE (5-9 yrs.) 3. TROCHLEA (7-13 yrs.) 4. LAT. EPICONDYLE (8-13 YRS.)

4 OSSIFICATION 5. CAPITELLUM AND TROCHLEA FUSE AT ABOUT 12 YRS. 6. EPIPHYSIS AND METAPHYSIS FUSE AT ABOUT YRS. 7. MEDIAL EPICONDYLE APOPHYSIS FUSES AT YRS.

5 BLOOD SUPPLY RICH SUPPLY OF COLLATERALS OFF THE BRACHIAL ARTERY SUP/INFER. ULNAR COLLATERALS ANT/LAT. RADIAL COLLATERALS RADIAL RECURRENT ULNAR RECURRENT

6 MUSCLE ORIGINS MEDIAL EPICONDYLE: FLEXORS LATERAL EPICONDYLE: EXTENSORS

7 X-RAY APPEARANCE LOOK AT THE ALIGNMENT OF THE OSSIFICATION CENTERS AND THE RADIAL, ULNAR, AND HUMERAL SHAFTS. ANT. HUMERAL LINE BAUMAN S S ANGLE ANT. CORONOID LINE

8 ANT. HUMERAL LINE LINE DRAWN ALONG THE ANT. HUMERAL CORTEX SHOULD BISECT THE CAPITELLUM. DEMONSTRATES SUPRACONDYLAR AND LAT. CONDYLE FX.

9 BAUMANS ANGLE INTERSECTION OF A LINE PERPENDICULAR TO THE LONG AXIS OF THE HUMERUS, AND A LINE ALONG THE PHYSIS OF THE CAPITELLUM. CAN DETERMINE VARUS MAL- ALIGNMENT NL. IS 73.5 DEGREES

10 ANT. CORONOID LINE DRAWN ALONG THE ANT. SURFACE OF THE CORONOID, IT SHOULD JUST TOUCH THE CAPITELLUM ANTERIORLY.

11 CARRYING ANGLE CLINICAL MEASUREMENT WITH ELBOW EXTENDED, FULL SUPPINATION VARIABLE, COMPARE TO NL. SIDE

12 SUPRACONDYLAR FRACTURES FLEXION EXTENSION

13 SUPRACONDYLAR FRACTURES TRANSVERSE FRACTURE THROUGH THE OLECRONON FOSSA MOST COMMON FRACTURE IN CHILDREN < 8 YRS. MOST COMMON PEDIATRIC ELBOW FRACTURE EXTENSION - 97% FLEXION - 3%

14 MECHANISM OF INJURY EXTENSION: FALL ON OUTSTRETCHED HAND (FOOSH) FLEXION: FALL ON FLEXED ELBOW

15 CLASSIFICATION Gartland, 1959 TYPE I: NON-DISPLACED TYPE II: ANGULATED WITH AN INTACT POST. CORTEX TYPE III: COMPLETELY DISPLACED, USUALLY POSTERO-MEDIAL

16 TYPE I ALL PERIOSTEUM IS INTACT IMMOBILIZE FOR 3-4 WEEKS

17 TYPE II ANTERIOR CORTEX BROKEN DEBATE EXISTS OVER TX. SOME AUTHORS RECOMMEND OPERATIVE TX. SOME REC. CLOSED REDUCTION SOME REC. IMMOBILIZATION ALONE

18 TYPE II Mann, T. S. JBJS, 1963: Up to 10 degrees of posterior angulation can be expected to remodel completely Younger will remodel more Varus angulation will not remodel at all, but this deformity is rarely progressive DeBoek JPO, 1995: Decreased rate of cubitus varus with closed reduction and pinning

19 TYPE II TREATMENT MILD ANGULATION: Closed, or no reduction and immobilize for 3-44 weeks MEDIAL COMPRESSION, MARKED ANGULATION: Closed reduction and pinning MARKED SWELLING, N / V CHANGES: Closed red. and pinning

20 TYPE THREE ANT. AND POST. CORTICES DISRUPTED ANT PERIOSTEUM TORN POST PERIOSTEUM INTACT VERY UNSTABLE SIGNIFICANT SOFT TISSUE INJURY AND SWELLING

21 TYPE THREE TREATMENT FEW ARGUMENTS AGAINST OPERATIVE TREATMENT IN THE LITERATURE PINNING ALLOWS THE ELBOW TO BE HELD EXTENDED, REDUCING RISK OF N / V INJURY

22 TYPE THREE TREATMENT OLECRONON TRACTION: SHOWN TO WORK WELL REQUIRES HOSPITALIZATION EXPENSIVE STRAIN ON CHILD AND FAMILY

23 TYPE III TREATMENT CLOSED REDUCTION AND PERCUTANEUS PINNING MOST COMMON TREATMENT SHORT HOSPITAL STAY LOW MORBIDITY CROSSED Vs LATERAL PINS RARELY ORIF IS NEEDED

24 TYPE III TREATMENT Zionts, L, et. al. JBJS, 1994: Medial and lateral crossed pins are biomechanically stronger than two lateral pins in cadavers. Topping, R.E. JPO, 1995: no clinical difference between crossed and lateral pins. one of 27 in crossed pin group had a transient ulnar nerve palsy, no nerve injuries in the lateral pin group.

25 COMPLICATIONS MOST COMMON IN TYPE THREE NEUROVASCULAR INJURY VOLKMAN S S ISCHEMIA CUBITUS VARUS

26 COMPLICATIONS NERVE INJURY 7% OVERALL, UP TO 15% OF TYPE III Brown, et. al. JPO, 1995: 162 displaced fx s at UCLA with 23 nerve injuries 12 Radial(61%) 6 Ulnar (4 iatrogenic from medial pins) 3 AIN 2 Median All resolved spontaneously in mths.

27 COMPLICATIONS NERVE INJURIES Other series have similar numbers Non-iatrogenic: least 3 mths before exploration Iatrogenic: Remove offending pin, or explore.

28 COMPLICATIONS VASCULAR VASCULAR INJURY ACUTE BRACHIAL ARTERY INJURY (rare) VOLKMAN S S ISCHEMIA ABSENT PULSE: CLOSED REDUCTION AND PINNING, SPLINT < 90 DEGREES WHITE HAND - EXPLORATION PERFUSED, PULSELESS HAND - OBSERVE VERY CLOSELY

29 COMPLICATIONS VASCULAR PINK PULSELESS HAND Wright, JPO, 1996 and Sabberwal, JPO, 1997 OBSERVE CLOSELY ANGIOGRAM, OR EXPLORATION IF WORSENING N/V EXAM, OR NO IMPROVEMENT IN HRS Shoenecker et. al., and Doreman et. al. Jpo, 1996 both rec. earlier exploration

30 COMPLICATIONS CUBITUS VARUS MOST COMMON MAL-REDUCTION, LOSS OF REDUCTION MEDIAL TILT OF DISTAL FRAGMENT PRIMARILY COSMETIC NO FUNCTIONAL DEFECITS IN MULTIPLE SERIES DEFORMITY IS NON-PROGRESSIVE WILL NOT REMODEL

31 COMPLICATIONS CUBITUS VARUS MALROTATION WILL KEEP THE MEDIAL COLUMN FRAGS. OUT OF CONTACT Wenger, et. al. JPO, 1994: reports five cases of lateral condyle fractures in patients with cubitus varus deformity

32 CUBITUS VARUS TREATMENT Coventry, Rocky Mtn. Med. Jl, 1956 described a lateral closing wedge osteotomy for correction Hall, et. al. JPO, 1994 Good, or excellent results in 35 of 36 patients treated with this technique, fixed with two lateral pins One loss of reduction Levine, et. al. JPO, 1996 rec. an ex-fix, rather than pins for 8 weeks

33 FLEXION S.C. FRACTURES ONLY 3% TX AS EXTENSION TYPE MORE STABLE IN EXTENSION

34 EPIPHYSEAL SEPERATION RARE SHEAR INJURY AGE: BIRTH - 4 YRS MECHANISM: 1. BIRTH TRAUMA 2. FALL FROM HEIGHT 3. CHILD ABUSE DeLee, et. al. JBJS, 1963: The cause in 6 of 16

35 EPIPHYSEAL SEPERATION X-RAY MAY LOOK LIKE AN ELBOW DISLOC. IN INFANTS DIFF. ITH ARTHROGRAM, MRI THURSTON-HOLLAND HOLLAND FRAGMENT WAFER OF METAPH. BONE S.H II FRACTURE CAPITELLUM IN LINE WITH THE RADIAL HEAD, HUMERUS LATERAL (USUALLY) TO BOTH

36 EPIPHYSEAL SEPERATION TREATMENT NON AND MINIMALLY DISPLACED CLOSED RED. AND SPLINT FOR 3 WEEKS DISPLACED CLOSED RED. AND PINNING HIGH RATE OF CUBITUS VARUS IF TREATED NON-OPERATIVELY OPERATIVELY MORE STABLE THAN S.C. FRACTURES SECONDARY TO THE INCREASED SURFACE AREA OF THE PHYSIS

37 LATERAL CONDYLE FX 17% OF PEDI ELBOW FX s SECOND MOST COMMON AGE: 5-10 YEARS MECHANISM: AVULSION Varus stress to an extended elbow in suppination. The force is transmitted through the extensor muscles, resulting in an avulsion S.H. TYPE IV VS. TYPE II

38 LATERAL CONDYLE FX MILCH CLASSIFICATION TYPE I: FX PASSES LATERAL TO TROCHLEAR GROOVE TYPE II: FX PASSES MEDIAL TO THE TROCHLEAR GROOVE RADIUS AND ULNA CAN BE MEDIALLY DISPLACED

39 LATERAL CONDYLE FX CLASSIFICATION Jakob, et. al. JBJS-B, B, 1975 TYPE I: INCOMPLETE, DOES NOT ENTER THE ARTICULAR SURFACE. TYPE II: < 2 mm DISPLACEMENT, INTRA- ARTICULAR, NO MAL-ROTATION TYPE THREE: CAPITELLUM DISPLACED AND ROTATED

40 LATERAL CONDYLE FX TYPE I: MAY NEED AN OBLIQUE X-X RAY IN INTERNAL ROTATION TO SEE IT ARTHROGRAM MAY HELP X-RAY

41 LATERAL CONDYLE FX TREATMENT TYPE I: IMMOBILSE IN FLEXION AND SUPINATION FOR 3-4 WKS. FOLLOW WEEKLY X-RAYS X AS UP TO 10% CAN DISPLACE IN PLASTER ANY DOUBT, OR LATE DISPLACEMENT, TX AS A STABLE TYPE II

42 LATERAL CONDYLE FX TREATMENT TYPE II, STABLE TO VARUS STRESS PERC. PINNING TYPE II, UNSTABLE ORIF WITH AFT ALIGNMENT OF ARTICULAR SURFACE 2 LATERAL K-WIRESK Finbogaten, et. al. JPO, TYPE II FX s s TX CLOSED, 11 DISPLACED

43 LATERAL CONDYLE FX TREATMENT

44 LATERAL CONDYLE FX TYPE III REQUIRES ORIF, UNANIMOUSLY STRIPPING OF THE POSTERIOR FRAGMENTS CAN LEAD TO AVN OF THE DISTAL FRAGMENT TREATMENT

45 LATERAL CONDYLE FX COMPLICATIONS NON-UNION: HIGH RATE WITH INTRA- ARTICULAR FRACTURES AS SYNOVIAL FLUID ENTERS THE FRACTURE, EVEN TYPE II s s HAVE A HIGH RATE IF NOT PINNED TX WITH BONE GRAFT AND IN SITU PINNING EARLY ON (8 WKS) IF MIN DISPLACED TX WITH ORIF AND BONE GRAFT IF SIG DISPLACEMENT

46 LATERAL CONDYLE FX COMPLICATIONS CUBITUS VALGUS: RESULT OF MAL-UNION, OR NON-UNION PROGRESSIVE DEFORMITY MAY LEAD TO TARDY ULNAR N. PALSY APPEARS 22 YEARS POST INJURY ELBOW INSTABILITY

47 MEDIAL EPICONDYLE FX 10 % OF PEDI ELBOW FRACTURES AGE: YRS 75 % ARE IN BOYS MECHANISM: AVULSION VALGUS FORCE ALONG WITH FLEXION OF FOREARM FLEXORS CONCURRENT ELBOW DISLOCATION IS COMMON

48 MEDIAL EPICONDYLE FX CLASSIFICATION Bede, et. al. Can. Jl. Surg TYPE I: NON-DISPLACED TYPE II: DISPLACED < 5 mm TYPE III: DISPLACED > 5 mm NO DISLOCATION, EPICONDYLE OUTSIDE JOINT NO DISLOCATION, INCARCERATED IN THE JOINT WITH ELBOW DISLOCATION

49 MEDIAL EPICONDYLE FX COMPARISON OF CONTRALATERAL SIDE HELPFUL WIDENED APOPHYSIS MAY SEE APOPHYSIS IN JOINT X-RAY

50 MEDIAL EPICONDYLE FX TREATMENT DISPLACED < 5 mm, IMMOBILIZATION AND EARLY ROM TYPE III: CONTROVERSIAL THERE IS NO REAL CONSENSUS EUA TO EVAL VALGUS INSTABIL. MAY HELP IN STABLE ELBOWS, UP TO 15 mm OF DISPLACEMENT IS ACCEPTABLE ASSYMPTOMATIC NON-UNION IN 50%

51 MEDIAL EPICONDYLE FX INDICATIONS FOR ORIF INTRA-ARTICULAR ARTICULAR ENTRAPMENT SEVERE DISPLACEMENT VALGUS INSTABILITY (+ / -) TREATMENT MORE LIKELY REQUIRED IN A THROWING ATHLETE

52 MEDIAL CONDYLE FX < 2 % OF PEDI ELBOW FRACTURES MECHANISM: FOOSH WITH ELBOW EXTENDED, OR FALL ON OLECRONON

53 MEDIAL CONDYLE FX CLASSIFICATION Kilfoyle, et. al. CORR, 1965 TYPE I: NON-DISPLACED, EXTRA- ARTICULAR < 5 YEARS OLD TYPE II: INTRA-ARTIC. ARTIC. NON-DISPLACED TYPE III: DISPLACED AND ROTATED > 7 YEARS OLD

54 MEDIAL CONDYLE FX X-RAY MAY SEE A FLECK OF METAPHYSEAL BONE DIFFICULT IF TROCHLEA NOT OSSIFIED ARTHROGRAM, MRI MAY HELP

55 MEDIAL CONDYLE FX TREATMENT TYPE I: IMMOBILIZE AT 90 DEGREES TYPE II: CLOSED RED. AND PINNING IF ALIGNMENT GOOD, OTHERWISE ORIF TYPE III: ORIF LEAVE PINS IN 3-44 WKS SIMILAR TO LAT. EPICONDYLE FX