? Common Paediatric fractures
? Common Adult Injuries
? Develop evaluation of elbow injuries
? Diagnose and choose treatment
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Introduction
"Pity the young surgeon whose first case is a fracture around the elbow"
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Question 1- Identify this injury in a 3 yearsold boy
a) Dislocation elbow
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b)Supracondylar fracture Humerus
c) Separation distal humeral physis
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d)Lateral condyle Humerus fractureIntroduction- Elbow fractures
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? 5% to 10% of all fractures in children are fractures of the elbow.? High potential for complications-difficult to manage.
? Supracondylar fractures- 50% to 70% of all elbow fractures
? Frequently in children between the ages of 3- 10 years.
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CRITOE? Capitellum (2years)
? Radius(4years)
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? Internal (or medial) epicondyle(6years)
? Trochlea(8 years)
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? Olecranon(10 years)? External (or lateral) epicondyle(12
years)
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Common Fractures? The supracondylar Humerus
? The transphyseal distal Humerus
? The lateral humeral condyle
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? The medial humeral epicondyle (often associated with elbow dislocation)Uncommon FRACTURES
? The capitellum
? Coronoid
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? Medial condyle? Lateral epicondyle
? Intracondylar or T-condylar fractures
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Supracondylar Fractures of the Humerus? Devastating long-term complications.
? Anteriorly- the brachial artery and median nerve
? Laterally, the radial nerve crosses
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? The ulnar nerve passes behind the medial epicondyleANATOMY
Coronoid Fossa
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Olecranon Fossa
Classification -Supracondylar fracture
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? Extension type 97.7%
? Flexion type 2.3%
In extension type fracture line runs upwards
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and backwards
And in flexion type it runs downwards and
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backwardsExtension Type Fr
When forced into hyperextension, the olecranon can act as a fulcrum
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through which an extension force can propagate a fracture across the
medial and lateral columns
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Flexion Supraconylar Fr
A posteriorly applied force with the elbow in flexion creates a flexion-
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type supracondylar humeral fracture (arrow).CLASSIFICATION-Gartland Classification
? After initial classification as either extension or flexion injuries.
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? Classified according to the amount of radiographic displacement.--- Content provided by FirstRanker.com ---
Q 2- How Do You Classify?Flexion/Extension?
Gartland I,I ,I I?
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How Do You Classify?
Flexion/Extension?
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Gartland I,I ,I I?RADIOGRAPHIC FINDINGS
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? The elbow is painful and difficult tomove
? True AP and lateral radiographs of
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fractures are required
" Bad x-rays lead to bad decisions."
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TREATMENT - Goal"Avoid catastrophes"
? Vascular compromise
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?Compartment syndrome
"minimize embarrassments"
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?cubitus varus,?iatrogenic nerve palsies
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Emergency Treatment? Immobilized - simple splint(radiolucent splint).
? Contraindication- Ischemic hand or tented skin,
? Radiographs should be obtained before splinting,
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or should be used.
If distal extremity is initial y ischemic?
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? Align the fracture fragments? Re evaluaie vascularity
? Avoid Flexion >90 degrees
Treatment of Nondisplaced Fractures ?
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? Long-arm cast immobilization for 3 weeks .? Radiographs are repeated at one week ?Check
Extension Gartland III- Treatment?
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Treatment of Displaced Fractures (types II and II ).
? Require reduction.
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? Reduction can be accomplished in closed fashion.? Maintaining the reduction?
? Cast immobilization, traction, and percutaneous pin
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fixation.
? Adequate closed reduction cannot be achieved- open
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reduction pinningCR and K-wire fixation
Per op Images
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Healed fracture at 4 weeksCollateral circulation
Viable hand with abnormal pulses ?
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? Close observation.? Unidentified vascular pathology-thrombus formation- an
ischemic limb.
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? Pulse oximetry- valuable tool after closed reduction and pinning.? Pulseless, viable limb-ischemic- arteriography and thrombolytic
therapy
COMPLICATIONS
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Early complications? Vascular injury
? Peripheral nerve palsies
? Volkmann's ischemia (compartment syndrome).
Late complications
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? Malunion? Stiffness
? Myositis ossificans.
Vascular Injury-Spectrum?
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? A diminished pulse/Without a pulse/With an ischemic limb.
? Complete transection of the brachial artery
? An intimal tear
? Compression either between the fracture fragments or over
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the anteriorly displaced fragment.
? Indirect injury is usually the result of compression due to the
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swelling.Management
Thorough assessment of the skin and neurologic status
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If ischemic- manipulated into an extended position.If fails to provide distal circulation
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Closed reduction and pinning
Reduction of the fracture frequently restores the circulation
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Peripheral Nerve Injury? 10% to 15% of supracondylar humeral fractures.
? The anterior interosseous nerve is the most commonly
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injured nerve with extension-type supracondylar fractures? Usually recover spontaneously
? If within 8 to 12 weeks function is not returning-NCV/EMG
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nerve has not been transected.? Transected- reanastomosis with grafting or tendon transfers
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Compartment Syndrome?? Best managed by closed reduction and
pinning.
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? A fasciotomy is essential to decompress the
increased pressure
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? Splinting and active and passive range-of-motion exercises -essential to maintain
joint mobility until function returns.
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Volkmann's Ischemic Contracture (Chr
Compartment Syndrome)
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? Ischemic paralysis and contractureof the muscles of the forearm and
hand
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? Primarily resulted from obstruction
of arterial blood flow, resulting in
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death of the muscles which getreplaced by fibrous tissue
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Malunion: Cubitus Varus and Cubitus Valgus? Posteromedially displaced fractures tend to develop Cubitus varus
angulation-more common
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? Posterolaterally displaced fractures tend to develop valgus deviation.
T/T -Osteotomy and k-wire fixation
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Lateral Condyle Fractures
These fractures are the second most
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common children'selbow fracture to need operative treatment.
(1) The fracture heals slowly.
(2) Late deformity can occur.
(3) Non-union is a recognized complication
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Treatment
? Undisplaced lateral condyle- Long arm cast.
? Displaced fractures ? stabilized by Open reduction K-wire fixation.
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Complete Articular Fractures of the Distal
Humerus--T-Fracture
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Radial Neck
? 30 of angulation can be treated conservatively provided there is no
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Displaced fractures ?? Need to be reduced but closed reduction can be difficult
Post Op
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Injuries of Adult ElbowSpectrum
? Olecranon & Proximal Ulnar Fractures
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? Radial Head Fractures? Elbow Dislocations
Anatomy-Olecranon Fractures-
? The triceps attaches to the olecranon
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? Principle force which displaces the fracture.Symptoms
? H/O Trauma: Direct/Indirect
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? Pain? Swelling
? Inability to extend against gravity
? Tenderness
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Signs
? Swelling
? Contusion
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? Gap at fracture site? Extension lag
Mayo Classification
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? Type 1: Minimally displaced-Nonoperative? Type 2: Displaced without ulnohumeral instability-Surgery
? Type 3: Displaced with ulnohumeral instability-Surgery
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OR&IF- Tension band wiring
Post Op
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Complex fractures or fracture-dislocations
? Tension band wire constructs can fail- Plating is the choice
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RADIAL HEAD FRACTURES-Mechanism
? Fractures when it collides with the capitellum
? Fall onto the outstretched hand
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Classification- Mason
? Type 1- Nondisplaced fractures- nonoperative treatment
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? Type 2- Displaced fractures involving part of the radial head- Screws? Type 3- comminuted fractures -excision
Type 2
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SIMPLE ELBOW
DISLOCATIONS
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? Stable after manipulative reduction.? Acute redislocations and chronic recurrent dislocations are
uncommon.
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? Mobilization of the elbow within 2 weeks results in less stiffness andpain
Question 1- Identify this injury in a 3 years
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old boy?
a) Dislocation elbow
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b)Supracondylar fracture Humerusc) Separation distal humeral physis
d)Lateral condyle Humerus fracture
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