UPPER EXTREMITY FRACTURES

Question 1

DDx ELBOW INJURIES

Answer 1

Pulled Elbow
Supracondylar Fracture
Lateral Condyle Fracture
Radial Neck Fracture
Monteggia

Question 2

DOCUMENTATION

Answer 2

NEUROVASCULAR EXAM

RADIAL:
Motor - Wrist / finger extension
Sensory - Dorsal thumb / first finger web space

ULNAR:
Motor - Flexor carpi ulnaris intrinsic hand muscles
Sensory - Fifth digit

MEDIAN:
Motor - Forearm/most wrist flexors/flexion and opposition of thumb
Sensory - Palmar thumb, first and second fingers

ANTERIOR INTEROSSEOUS (OFF MEDIAN):
Motor - Distal phalanx flexion (thumb and first finger)

AXILLARY:
Motor - Abduction of shoulder
Sensory - Lateral upper arm “regimental patch”

XRAY

Ossification centers

Fat pads:
-Sail Sign
-Posterior Fat Pad

Anterior Humeral Line:
Lateral: anterior cortex of the humerus should bisect the capitellum in the middle 1/3.

Radiocapitellar Line:
Line along central shaft of the proximal radius should pass through the capitellum on all views.

Question 3

PEDIATRIC OSSIFICATION CENTERS OF THE ELBOW

Answer 3

CRITOE

Capitellum: 1 yr

Radius: 3 yr

Internal (Medial)

Epicondyle: 5 yr

Trochlea: 7 yr

Olecranon: 9 yr

External (Lateral) Epicondyle: 11 yr

Question 4

DDx: abnormal radiocapitellar line

Answer 4

DDx if abnormal:
Radial head dislocation
Elbow dislocation
Lateral condyle fracture
Radial neck fracture

Question 5

RADIAL HEAD SUBLUXATION (PULLED ELBOW / NURSEMAID’s ELBOW):

Answer 5

MECHANISM:

Sudden axial traction on extended arm-> Radial head slips under the annular ligament

May be no history of trauma

CLINICAL FEATURES:

Child who suddenly refuses to use arm

Usually flex and pronated, may be supported by the other arm

No signs of swelling, erythema, deformity

Neurovascular assessment is normal

Clinical diagnosis - No imaging required. XRAY if >/2 unsuccessful reduction attempts

MANAGEMENT:

Bedside Reduction

Hyperpronation: 95% success rate. In-line traction on the extended elbow with concurrent hyperpronation

Supination - flexion: 85% success rate

May hear or feel a click

DISPOSITION

Observe for 30 min; child should use arm normally within 30 min

Question 6

SUPRACONDYLAR FRACTURE

Answer 6

MECHANISM

FOOSH

COMPLICATIONS

Beware of compartment syndrome, brachial arterial injury or median nerve injury

Always check median nerve function, perfusion, compartment syndrome

Check for skin tenting in antecubital fossa

Frequent NV checks for compartment syndrome

CLASSIFICATION

Occult: no displacement or fracture line but a visible posterior “fat pad” on X-ray and concerning history and physical exam

Immobilize in posterior long-arm splint. Neutral forearm rotation. Elbow flexed at 80-90. Follow up XRAY in 10-14 days.

GARTLAND CRITERIA / MANAGEMENT

TYPE 1:
non-displaced
-Fat pads prominent, slight disruption of the figure of 8

No reduction required, long arm back slab with elbow at 90 degrees with sling.

Outpatient fracture clinic.

TYPE 2
displaced
-Displacement of the anterior humeral line

TYPE 3:
displaced with no cortical contact

Reduction with gentle traction and elbow flexion to 20-40 degrees if poor perfusion.

Non-urgent follow up: Good perfusion without neurological deficits

Urgent Ortho Consult: Neurological deficits, floating elbow, open fracture

Emergent Ortho Consult: Pulseless, poor perfusion, signs of compartment syndrome

Orthopedic consultation for operative management for type 2 & 3

Question 7

Lateral Condyle Fractures:
Mechanism
Clinical Features
XRAY Features
Management

Answer 7

Varus stress to an extended elbow with forearm supination

Large amount of swelling on lateral aspect of the elbow

XRAY may look benign. Non displaced easily missed.

If clinical suspicion is high, get oblique view.

> 2 mm displacement require reduction and fixation

All unstable

Emergent orthopedic referral

Question 8

Radial Neck Fracture: Mechanism
Clinical Features
Classifications / XRAY Features and Management

Answer 8

MECHANISM

Fall on extended elbow with a valgus force to forearm -> radial head is cartiligenous in children therefore neck at risk of fracture

CLINICAL FEATURES
Tenderness over proximal radius

Painful and decreased forearm rotation

CLASSIFICATION & MANAGMENT

Type I: < 30 degrees angulation

Treat with immobilization, spint or sling 1-2 weeks

Type II: 30-60 degrees angulation

Reduction and orthopedics consult

Type III: > 60 degrees angulation

Reduciton & orthopedics consult

COMPLICATIONS

Non-Union

AVN of radial head

Premature growth plate closure

Loss of forearm rotation

Question 9

Monteggia’s Fracture - Dislocation: Mechanism,
Clinical Features
Classification / XRAY Features with Management

Answer 9

MECHANISM:
Ulnar fracture with radial head dislocation

CLINICAL FEATURES:
swelling, possible deformity, and ecchymosis. One must palpate over the radial head because spontaneous relocation is common.

Check to radial n palsy

CLASSIFICATION / XRAY

Bado Type I:
Anterior Dislocation of radial head

Splint 110 degrees of flexion and full supination

Orthopedics Consult

Bado Type II:
Posterior Dislocation of radial head

Splint in full extension

Orthopedics Consult

Bado Type III:
Lateral Dislocation of radial head

Splint in full extension and valgus mold

Orthopedics Consult

Bado Type IV:
Ulnar and radial fracture with anterior dislocation of the radial head

Operative

Surgical:
Unstable radial head following reduction
Unable to maintain ulnar length
Bado type IV
Open fracture

Question 10

Indications for urgent orthopedic consultation

Answer 10

Open fractures
Neurovascular compromise
Joint instability or unstable fractures
Complex fractures involving a physis
Fracture with compartment syndrome