ELBOW INJURIES IN CHILDREN

Transcription

1 ELBOW NJURES N CHLDREN The "RARE NJURES" that may present major problems Medial Epicondyle Radial Neck Olecranon KAYEE. WilKNS, M.D. Clinical Professor Departments of Orthopaedics & Pediatrics The University of Texas Health Science Ctr. at San Antonio, Texas

2 Elbow njuries in Children (The "RARE NJURES" that may present Major Problems) 2 ELBOW NJURES N CHLDREN The "RARE NJURES" that may present Major Problems include: ~ SM~~~pi~~ m) ~\ The Rare njuries... m~~ij.n~ Ji.~;Qi,~$~AA9~. THE MEDAL EPCONDYLE A. Anatomical Considerations 1. Structural Aspects a. t is an apophysis. b. t is posteromedial B. C. D. E. F. c. Serves as origin of ulnar collateral ligament which is the key to elbow stability. d. n the older child it is extra-articular. 2. Ossification a. Preosseous - Part of the total distal epiphysis. b. Ossification begins: 4-6 yrs. c. Last to fuse: years. ncidence 1. A later injury occurring between 9-14 years (correlates with dislocations). 2. Higher in boys % occur with elbow dislocation. Mechanisms of njury 1. Direct blow 2. Pure avulsion 3. Elbow dislocation Classification of Fractures 1. Acute njuries a. Undisplaced b. Minimally displaced c. Significantly displaced 1) Elbow not dislocated 2) Elbow dislocated d. Entrapment of fragment in joint 1) Elbow not dislocated 2) Elbow still dislocated e. Fractures through the epicondylar apophysis 1) Without displacement 2) With displacement f. Chronic Tension Stress njuries (Little League Elbow Syndrome) Diagnostic Dilemmas 1. Differentiate from Medial Condyle. a. Beware in young children! b. Elbow dislocation rare in first decade. c. Suspect if any metaphyseal bone. d. Entrapment can occur even if only a portion of epicondyle is avulsed. Treatment 1. Acute njuries (Operative vs. Non-operative) a. Myths regarding non-operative treatmentl131 1) Growth deformity 2) Painful non-union 3) Weakened forearm flexors 4) Late ulnar nerve symptoms b. The literature can support either operative or non-operative methods for routine fractures. 1) Operative Proponents: Hines and co-workers(21-96% excellent results 2) Non-operative management a) Joseffson and Danielson(31 - excellent results even with nonunion of fragment. b) Comparison studies by Bede1101and Fowles(l showed better results in those managed non-operatively.

3 Elbow njuries in Children (The "RARE NJURES" that may present Major Problems) 2 ELBOW NJURES N CHLDREN The "RARE NJURES" that may present Major Problems include: The Rare njuries """""'''''''''''''''''''''''''''''''''''''''''''''''' ""'.'..'.'.'.:::::::/::~'~tmifiit:iiji,_im::::/: J '". """"""""""""""""""""""'" """"""""""""... :::~::~:r::::::~~::::~~~~::::~::::~~/mi~j~i~:::n.'::~:::::m:::/':,:,: ::::: ~:~:~:~:J.m:~:::Q!~~.o'~::::~~~::~~~'~~:,:,:,:,:.. THE MEDALEPCONDYLE A. Anatomical Considerations 1. Structural Aspects a. b. t is an apophysis. t is posteromedial c. Serves as origin of ulnar collateral ligament which is the key to elbow stability. B. C. D. E. F. 2. d. n the older child it is extra-articular. Ossification a. Preosseous - Part of the total distal epiphysis. b. Ossification begins: 4-6 yrs. c. Last to fuse: years. ncidence 1. A later injury occurring between 9-14 years (correlates with dislocations). 2. Higher in boys % occur with elbow dislocation. Mechanisms of njury 1. Direct blow 2. Pure avulsion 3. Elbow dislocation Classification of Fractures 1. Acute njuries a. Undisplaced b. Minimallydisplaced c. Significantly displaced 1) Elbow not dislocated d. e. 2) Elbow dislocated Entrapment of fragment in joint 1) Elbow not dislocated 2) Elbow still dislocated Fractures through the epicondylar apophysis 1) Without displacement 2) With displacement f. Chronic Tension Stress njuries (little League Elbow Syndrome) Diagnostic Dilemmas 1. Differentiate from Medial Condyle. a. b. Beware in young children! Elbow dislocation rare in first decade. c. Suspect if any metaphyseal bone. d. Treatment Entrapment can occur even if only a portion of epicondyle is avulsed. 1. Acute njuries (Operative vs. Non-operative) a. Myths regarding non-operative treatment(131 1) 2) Growth deformity Painful non-union 3) Weakened forearm flexors b. 4) Late ulnar nerve symptoms The literature can support either operative or non-operative methods for routine fractures. 1) Operative Proponents: Hines and co-workers(2}- 96% excellent results 2) Non-operative management a) Joseffson and Danielson(31 - excellent results even with nonunion of fragment. b) Comparison studies by Bede(1O) and Fowles(1)showed better results in those managed non-operatively.

4 Elbow njuries in Children (The "RARE NJURES" that may present Major Problems) 3 c. d. e. Stiffness is a common sequelae. 1) Thus, it is important to start motion early regardless of operative or non-operative intervention. n most cases non-operative management is adequate. ndications for operative management. 1) Absolute 2) 3) a) ncarceration in the joint. b) Ulnar nerve dysfunction - may be relative? Relative a) Need for a stable elbow. (1) Necessary if there will be strong valgus forces across the joint in future activities such as: Baseball, Tennis, Technical (2) (3) Points Gymnastics or Heavy Labor. Less important in non-dominant extremity. Can use gravity valgus stress test to access elbow stability f. a) Stabilize with screw to allow early motion. ncarceration in Joint 1) Acute - extract surgically. Manipulation can injure ulnar nerve. 2) Late: a) Patrick(14) originally felt if after 4 weeks results equal if left alone. b) Fowles(4) has shown good results can be obtained where 2. Chronic Stress fragment is extracted in late cases. a. Rest and muscle strengthening are the key factors. b. Assess pitching techniques.. RADAL NECK FRACTURES A. Anatomical Considerations. 1. Normally pre-ossification the radial neck is angulated (pseudo fracture). 2. Ossification: 5-6 years (May be bipartite). 3. The proximal radioulnar joint is exactly congruous. a) Translocation can result in a CAM effect(17)[fgure 1]

5 Elbow njuries in Children (The "RARE NJURES" that may present Major Problems) 4 ---~ - FGURE 1 B. C. D. E. Mechanisms of njury 1. Their major categories a. Primary displacement of the head. b. Primary displacement neck. 2. c. Chronic stress forces across the growth centers of the proximal radius. Associated njuries a. Greenstick Olecranon b. Medial Epicondyle Classification 1. Related to mechanism of njury [TABLE 1] 2. Related to fracture pattern. (Valgus njuries - Figure 2) a) Pure metaphyseal neck fracture. b) Type - Salter-Harris c) Type V - Salter-Harris Displacement Patterns [FGURE4, Pg. 6] 1. Angulation 2. Translocations 3. Complete Displacement Diagnostic Dilemmas 1. n young children, radial head pain may be referred to the wrist. [ TABLE : CLASSFCATON OF FRACTURESNVOLVNG THE PROXMAL RADUS ]1 GROUP GROUP GROUP Primary displacement of the radial head. A. Valgus Fractures [FGURE 2. Pg. 5] 1. Type A: Salter-Harris Type and injuries of the proximal radial physis. 2. Type B: Salter-Harris Type V injuries of the proximal radial physis. B. 3. Type C: Fractures involving only the proximal radial metaphysis. Fractures associated with elbow dislocation [FGURE 3. Pg. 5] 1. Type D: Reduction injuries 2. Type E: Dislocation injuries Primary displacement of the radial neck. A. Angular injuries (Monteggia Type Variant) B. Torsional njuries Stress njuries A. Osteochondritis dissecans of the radial head. B. Physeal injuries with neck angulation.

6 Elbow njuries in Children (The "RARE NJURES" that may present Major Problems) 5 -- r..,.,,,,. A B C FGURE 2 ' i!~~ / F. 2. Accessory ossification centers may simulate fractures. f in doubt, get comparison films. The radiocapitellar view or an arthrogram may help better delineate the true location of the radial head and neck(18) Treatment 1. nitial Considerations a. Rem e m b era significantly dislocated radial head indicates more severe soft tissue b. c. injury. Warn the parents beforehand of the arim prognosis. This injury has a high incidence of poor results. / ~ [FGURE 3] 2. Non-operative Methods a. Manipulative closed reduction as purposed by Patterson(221 first line of management. [FGURE5, Pg. 6] f this fails the flexion pronation technique as purposed by Kaufmann, et al.(16)may be another effective method of closed reduction. Other methods of treatment. a. Use of the Ace wrap. n some cases wrapping the forearm tightly with an ace b. wrap may reduce the fragment. Finallyifallclosed methods fail, manipulating the fragment with a percutaneous Awl or other type of sharp instrument may provide a satisfactory reduction. Acceptable Limits a. Less than 30 probably does not need manipulation. b. 30 to 60 probably needs manipulation. c. Greater than 60 or with severe translocation may require open reduction. 1) t is also important to examine the patient clinically, under anesthesia. ---

7 Elbow njuries in Children (The "RARE NJURES" that may present Major Problems) 6 "nsulatlon Tran~location [FGURE41 Total (f~placl'm('nl [FGURE51 2) 50 of supination and pronation will result in a very functional extremity. 5. Open Reduction a. Can you improve function? b. A poor x-ray may function better than an anatomical reduction. c. nternal fixation may not be necessary. Often the fracture is stable once reeduced by methods. d. Transcapetellar pin is a no-no!! f fixation required, secure it to the adjacent olecranon. G. Complications 1. Loss of motion 2. Radial head overgrowth 3. Non-union 4. Avascular necrosis 5. Radioulnar synostosis

8 Elbow njuries in Children (The "RARE NJURES" that may present Major Problems) 7. OLECRANON FRACTURES A. Ossification Pattern [FGURE 6] Birth 8 years 12 years [FGURE 6) B. Classification 1. Two major categories a. Physeal Fractures b. Metaphyseal Fractures C. Physeal Fractures 1. Two Fracture Patterns [FGURE 7, Pg. 8] D. Metaphyseal Fractures 1. Types a. Flexion njuries [FGURE 8, Pg. 8] b. Extension njuries 1) Valgus Pattern [FGURE 9, Pg. 8] 2) Varus Patterns [FGURE 1, Pg. 8] c. Shear njuries 1) Elbow Extended [FGURE 11, Pg. 9] 2) Elbow Flexed [FGURE 12, Pg. 9] E. Treatment 1. Flexion njuries a. Murphy(231found a screw across the fracture site with tension band wire was shown to be the strongest. b. PDS (Polydioxanonee) suture can be used. instead of stainless wire for tension band. 2. n extension and some shear injuries, the intact posterior periosteum can serve as a tension band mechanism. a. Flexing the elbow tightens this band thus securing the fracture fragments together. F. Complications

9 Elbow njuries in Children (The "RARE NJURES" that may present Major Problems) 8 - t@ A~j~ 1. Rare 2. Delayed loss of reduction 3. Pseudoarthrosis - Don't confuse with congenital pseudoarthrosis of the olecranon. 4. Apophyseal Arrest - Probably of no clinical significance..~~, [FGURE 7) --- j f [FGURE 8) [FGURE 9) [FGURE 10)

10 Elbow njuries in Children (The "RARE NJURES" that may present Major Problems) 9 ~ [FGURE 11) _.. [FGURE 12] REFERENCES. MEDAL EPCONDYLE 1. Elbow Dislocation with Avulsion of the Medial Humeral Epicondyle. Fowles, J.V.; Slimane, N. & Kassab, M.T., J. Bone & Joint Surg., 72B: , Found that in those patients in which surgical intervention was added to the trauma of elbow dislocation, that the post-operative function was poorer than those who did not undergo surgery. 2. Operative Treatment of Medial Epicondyle Fractures in Children. Hines, R.F.; Herndon, W.A. & Evans, J.p.. Clin. Orthop. 223: ,1987. Epicondylar Elbow Cases: 35 years Follow-up of 56 Unreduced Cases. Josefsson, P.O. & Oanielsson, L.G., Acta Orthop. Scand., 57: ,1986. A long term study of non-operative managed fractures. Good results despite the fact that 60% demonstrated nonunion. Untreated ntra-articular Entrapment of the Medial Humeral Epicondyle. Fowles, J.V.; Kassab, M.T. & Moula, T., J. Bone & Joint Surg., 60B: , Demonstrated that extracti ng the fragment on up to fourteen weeks post injury can still result in resumption of at

11 Elbow njuries in Children (The "RARE NJURES" that may present Major Problems) least 80% of the elbow motion being regained. Fractures of the Medial Epicondyle of the Humerus: Bernstein, S.M., King, J.D. and Sanderson, R.A., Contemp. Orthop., The most recent large series of epicondylar fractures. Emphasizes good results with conservative measures. Biomechanics of Elbow nstability: The Role of the Medial Collateral Ligament. Schwab, G.H. et a., Clin. Orthop., 146:42-52, Elbow nstability and Medical Epicondyle Fracture. Woods, G.M. & Tullos, H.G., Am. J. Sports Med., 5:23-30, Two articles which define the true function of the various portions of the medial collateral ligament. Describes the valgus stress test to determine elbow stability after a fracture of the medial epicondyle. Little League Survey: The Houston Study. Sugenheim, J.J., et a., Am. J. Sports Med., 4: ,1976. Little League Elbow: The Eugene Study. Larson, R.L., et a., Am. J. Sports Med., 4: ,1976. Two consecutive articles detailing the long term effects of throwing on young individuals. Demonstrated that when moderation is practiced in games that the long term effects were minimal. Fractures of the Medial Humeral Epicondyle in Children. Bede, W.B.; Lefebure, A.R. & Rasmon, M.A., Can. J. Surg., 18: , Presented a series of comparison cases in which patients were treated operatively and non-operatively in the same institution. Those treated non-operatively, 90% had satisfactory results, versus 75% for those treated by surgical intervention. njury to the Throwing Arm. Adams, J.F., Calif. Med., 102: , First to warn about the detrimental clinical effects of excessive throwing in Little League pitchers. Little Leaguer's Elbow. Brogdon, B.J. & Crow, N.E., Am. J. Rengenol., 83: , The original radiographic description of chronic irritation of the medial epicondyle from excessive throwing in Little League pitchers. Medial Epicondyle njuries. Smith, F.M., J.A.M.A., 142: , A classic article reviewing a series of 143 cases of epicondylar fracture. His results discounted many of the previously held concepts regarding these fractures. He emphasizes that there are very few sequelae and indications for operative intervention. Fracture of the Medial Epicondyle with Displacement into the Elbow Joint. Patrick, J., J. Bone & Joint Surg., 28: ,1946. Describes the use of Fridic Stimulation of the flexor muscles to extract the epicondyle from the joint. Displacement of the nternal Epicondyle into the Joint. Roberts, N.W., Lancet, 2:78-79,1934. Describes a simple manipulative technique for extracting the medial epicondyle from the joint ll. RADAL NECK Closed Reduction of Fractures of the Proximal Radius in Children. Kaufman, B.; Rinott, & Tanzman, M., J. Bone & Joint Surg., 71 B:66-67, Describes a technique of reducing the fractures by pressure over the radial head with the elbow flexed at 90.' and forcibly pronating the forearm. This is a useful alternative technique when the standard Patterson technique fails. Displaced Fractures of the Neck of the Radius. Wedge, J.H. & Robertson, D.E., J. Bone & Joint Surg., 648:256, Was the first to describe the CAM effect that occurs with translocation of the radial head and demphasizes it's importance in correcting this type of deformity to allow resumption of full supination and pronation. The Radial Head-Capitellum View: Useful Technique in Elbow Trauma. Greenspan, A. & Normal, A., A.J.R., 138: , Describes in detail the radial capitellar view which outlines better the radial head and neck, and the coronoid process. A Proximal Radial Metaphyseal Fracture Presenting as Wrist Pain. Anderson, T.E. & Breed, A.L., Orthopedics, 5: , Points out the pitfall of referred pain of radial head fractures to the wrist. Can be source of an overlooked diagnosis. Displaced Radial Neck Fractures in Children. Newman, J.H., njury, 9: , Reports on a large series of 47 injuries. Divides them into five types. Describes radial neck fractures as occurring when an elbow dislocation is reduced. A good review of the complications. Fracture of the Head of the Radius in Children. Jeffrey, C.C., J. Bone Joint Surg., 53B: , Reviews the various mechanisms of injury. Divides mechanisms into valgus stress and those occurring with elbow dislocations. Outlines some good principles of treatment. Treatment of Displaced Transverse Fractures of the Neck of Radius in Children. Patterson, R.F., J. Bone & Joint Surg., 16: , Outlines the displacement forces that occur with fracture of the radial neck. Describes a manipulative technique. m. OLECRANON 23. Displaced Olecranon Fractures in Adults. Biomedical Analysis of Fixation Methods. Murphy, D.F.; Greene, W.B.; Gilbert, J.A. & Dameron, T.B., Clin. Orthop., 224: A comparison of the various fixation methods. Shows that a screw across the fracture site, combined with a tension band, provides the strongest fixation.

12 Elbow njuries in Children (The "RARE NJURES" that may present Major Problems) Some Vagaries of the Olecranon. Silberstein, J.J. et a., J. Bone & Joint Surg., 63A: , Defines in detail the normal ossification pattern of the olecranon. Delineates the differences between normal ossification and a fracture. The most recent and extensive review of olecranon fractures in children. Points out that many of these are part of a complex injury to the joint. Defines many of the complications associated with this injury. Divides the injuries into groups. 25. Fracture of the Olecranon in Children. Matthews, J.G.. njury, 12: ,1981.