Paediatric Elbow Injuries Flashcards
Salter-Harris classification:
Growth plate (physeal) fractures
‘SALTER’
I Seperated
II Above - Most common
Good prognosis
____________
III Lower
IV Through Everything
IV Rammed
Poorer prognosis:
- Growth arrest
- Asymmetry
- Intraarticular (arthritis)
Age and mechanism of supracondylar #?
5-8 yo
FOOSH with straight arm
Gartlan Classification
Extension-type supracondylars
Predicts risk of NV injury
________
I
- Undisplaced
- Can be subtle: always assess anterior humeral line on XR
- Cast
II
- Posterior hinge intact
- Reduce and cast
III
- Displaced. No cortical contact.
CRPP or ORIF
Main associated injury/ complications of supracondylar #?
1- Neuropraxia
Median (anterior interosseus)
–> “Okay” sign
Radial
–> Wrist drop
Ulnar rare (mainly flexion-type)
Neuropraxia RARELY permanent.
2- Vascular
- Incl compartment syndrome
- Brachial inj with Volkmann’s contracture
3- Cubitus varus
- From malunion
Describe examination in supracondylar #:
Neurovascular is IMPERATIVE
Vascular:
- Warmth, colour, cap refill
- Radial and ulnar pulses
Motor:
Quick and dirty
Thumbs up (radial)
Okay (median)
+ benediction (ant interosseus)
Spread (ulnar)
Sensory:
Dorsal 1st webspace (radial)
Palmar middle tip (median)
Palmar pinky tip (ulnar)
Compartment:
?pain on passive finger movement
______________
THINK:
- Compartment Sx
- Neuropraxia
- Brachial artery injury
How should paediatric elbow # be cast:
Above-elbow slab
Generous- axillae to MCP
90 degrees
Sling
Milch classification:
Lateral condylar #
Milch I
- # extends into capitellum oss centre/ misses trochlea
- Rare
Milch II
- # misses capitellum oss centre\ disrupts trochlea
Note: on paeds XR, won’t actually SEE whoel # line. Capitellum will look free-floating
Lateral CONdyle #
Next most common after supracondylar
FOOSH with elbow bent
Significant: high risk non-union
Milch classification
+
Undisplaced
- Slab
- CLOSE follow up (day7 XR)
<2mm displac
- Slab OR OT
>2mm displac
- OT for CRPP or ORIF
Medial EPIcondyle #:
Avulsion from flexors or
High association with elbow DISLOCATION
- Ulnar nerve injury
- Fragment in joint
<5mm displac
- Slab
>10mm displac
- OT
(In between is discretionary: age, sport, ulnar nerve etc.)
MONTEGGIA
- Radial head dislocation
AND
- Ulnar #
Type 1: ANT displaced rad head
Type 2: POST displaced rad head
Type 3: LAT displaced rad head
Type 4: PROX radius also #
_______
If you see one injury, look for the other
All need urgent reduction
Actually very good outcomes IF FOUND.
Main thing is not missing it!
What nerve injuries are associated with Monteggia?
Posterior interosseus (radial)
–> Forearm extensors
–> Wrist drop, weak finger extension (at MCP)/ thumb up
Usually only neuropraxia
Olecranon #
High association with other injuries
—> scrutinise XR!!!
Check for extension (triceps insertion)
If isolated, minimally displaced (<2mm) and extensor intact —> slab and sling. (most need OT)
RADIAL NECK #
Important because:
- 50% chance other injury
- Risk avascular necrosis of radial head
- Articular
- Compartment Sx uncommon
Isolated and <30 deg angulation, doesn’t need reduction. Slab and home.
Reduce all others (closed or open).
High index suspicion- may not see on XR, but Tx as same
Pulled elbow:
Subluxation of radial head out of annular ligament
Typically 2-3yo (1-6yo)
- Not in pain
- Not using arm
- Pain with sup/pronation
- No trauma/ bruising/ deformity
REDUCTION:
Pressure to radial head, then:
Method 1
Fully pronate
if not in —> fully supinate
if not in—> fully flex
Method 2
Supinate and flex up all in one motion
Will use arm within 10min
If fails:
- Reconsider need for XR (?#)
- Reassure most spontaneously reduce. Discharge in sling. Follow up next day.
CRITOE:
Age at which ossification centres about elbow appear
