Elbow trauma

Question 1

What is this?

Answer 1

• An type 3 Garland supracondylar fx
• fall onto outstretched hand
• consisis of more than 1/2 of all paediatric elbow fx
• Extension type more common 95-98%

Question 2

what are the assoc injuires with supracondylar fx?

Answer 2

• Anterior interosseous N neurapraxia ( branch median n)
  
  • most common nerve palsy seen w SC fx
  • weakness FDP index, FPL thumb- can’t make ok sign, weak FDP middle & pronator quadratus
• Radial N palsy
  
  • 2nd common neurapraxia
• Ulna N palsy
  
  • seen w flexion type SC- hand instrinsic weakness
• nearly all types of neurapraxia assoc with SC resolve spontaneously, so further dx studies not required
• Vascular injury 1%
  
  • Rich collateral circulation can maintain despite vascular injury

Question 3

Describe the age of ossification of the elbow epiphysis?

Answer 3

• Capitellum 1yr
• Radial head 4 yrs
• Internal (medial) epicondyle 6yrs
• Trochlear 8 yrs
• Olecranon 10 years
• Lateral Epicondyle 12 yr

** CRITOL**

Question 4

Describe the classification of elbow fx?

Answer 4

• Gartland
• Extension or Flexion type
• Type 1
  
  • non displaced
• Type 2
  
  • displaced, posterior cortex intact- see pic
• Type 3
  
  • completely displaced- open reduction & PP
• Type 4
  
  • complete periosteal disruption with instability in flexion/extension

Question 5

what are the signs of supracondylar fx?

Answer 5

• AIN neurapraxia
  
  • unable to flex IPJ of thumb and DIPJ of index finger - OK sign
• Radial n palsy
  
  • inability to extend wrist or digits
• Vascular status
  
  • at presentation 5-17%
  • defined as cold, pale & pulseless hand
  • a warm pink pulseless hand does not qualify as vascular insufficiency
  • tx with immediate reduction and pinningi Theatre. attempted closed reduction in ER first

Question 6

What are you looking for on radiographs with a SC fx?

Answer 6

• Anterior humeral line should intersect the middle third of the capitellum
• Capetilum moves posteriorly to this reference line in an Extension type SC fx
• Baumann angle
  
  • created by a line perpendicular to humeral shaft adn a line along the lateral condylar physis as viewed on ap image
  • normal 85-89 degrees cf contralteral side
  • deviation of 5 degrees= coronal plane deformity & should not be accepted

Question 7

What is the tx of Sc fx?

Answer 7

Non operative

• type 1
• type 2- ant humeral line insects capitellum, minimal swelling, no medial comminution
• Posterior moulded splint then long arm cast at 90^o or less
• typically for 3 weeks

​Surgery

• Closed reduction & percutanous pinning
  
  • _​ _most supracondylar fx
  • Lateral fragments- supinatn w hyperflexion
  • medial fragments- pronation w hyperflexion
  • 2 lateral pins usually sufficient
  • confirm stability
  • crossed pins
    
    • strongest to torsional stress in expt studies
    • > risk of ulnar n injury 3-8%
  • remove pins 3 weeks
• Open reduction and percutanous pinning
  
  • reduction not obtained closed
  • anterior approach

Question 8

Describe the tx of pulseless, cool hand or floating elbow from Sc fx?

Answer 8

• Immediate closed reduction and percutaneous pinning
  
  • check vascular status after reduction
  • explore if pulse if lost after reduction or if pulseless, plae hand persists after reduction
  • anteriography is typically not indicated

Question 9

Describe the complications of Sc fx?

Answer 9

• Pin migration
  
  • most common complication 2%
• Infection
  
  • 1%
  • superfically, oral antibiotics
• Cubitus Valgus
  
  • caused by fx malunion
  • -> tardy ulnar nerve palsy
• ​Cubitus varus
  
  • ​gunstock deformity
  • caused by fx malunion
  • -> fx, cosmetic issue w little functional limitation
• ​Recurvatum
  
  • _​_common w non op Type 2/3 fx
• Nerve palsy
  
  • usually resolves
• Vascular injury
• Volkmann ischaemic contracture
  
  • rare
  • normally result of brachial artery compression and tx utilzing elbow hyperflexion and casting then true arterial injury
  • increase in forearm compartment pressures and loss of radial pulse w elbow flexed greater than 90^o
• ^​Post op stiffness

Question 10

What is a floating elbow?

Answer 10

• ipislateral supracondylar humerus and a forearm fracture
• must be operated on emergency to reduce risk of compartment syndrome
• wrist pinned first to allow fulcrum for reduction of supracondylar fx

Question 11

Which is the last apophysis to fuse in the elbow?

Answer 11

• Medial epicondyle
• aged 16-19 years

Question 12

What is this?

Answer 12

• A Milch 2 lateral condylar fx
• 2nd most common pediatric elbow fx
• 6 yrs most common
• prognosis:
  
  • outcomes have been historically worse than Supracondylar fx
  • articular nature, missed dx, higher risk of malunion/nonunion

Question 13

What is the classification of lateral condyle fx?

Answer 13

• Milch
• Type 1
  
  • fracture line is lateral to trochlear groove
  • considered SH IV
• Type 2
  
  • FX line INTO trochlear Groove
  • Consider SH 2 fx

Question 14

What are the signs and symptoms of lateral condyle fx?

Answer 14

• elbow pain
• swelling and tenderness limited to lateral side

Question 15

What images are useful in lat condyle fx?

Answer 15

• Xrays
• Ap
• lateral
• internal oblique view= shows max displacement & fx pattern

Question 16

What is the for lateral condyle fx?

Answer 16

Non operative

• if <2mm displacement
• cartilagenous hinge intact
• weekly FU

Surgery

• ​Closed reduction & percutaneous pinning
  
  • ​w no evidence of intra-articular incongruity
  • divergent pin placed most stable
• ​Open reduction and percutanous pinning
  
  • ​if >2mm displacement
  • any joint incongruity
  • direct lateral approach
  • avoid dissesction of posterior aspect of lateral condyle ( source of vascularisation)

Question 17

What are the complications from lateral condyle fx?

Answer 17

• AVN
  
  • posterior dissection -> lat condyle necrosis
  • may also occur at trochlea
• Non union/malunion
  
  • caused a delay in diagnosis and improper tx
  • -> cubital valgus and tardy ulna n palsy
  • if symptomatic screw fix & bone graft non union
• ​Lateral overgrowth/prominence spurring
  
  • ​in up to 50% cases reagrdless of tx
  • lateral periosteal alignment will prevent this from occuring
  • prsence of spurring is correlatd with greater intial fx displacement
• Growth arrest w /wout angular deformity
• unsatisfactory appearance of surgical scar