Children`s Orthopaedics

Distal humeral physeal separation
In newborn & young children ( around 2-4 years old )
Less common > 6 year old
Need to rule out child abuse in newborn

Clinical
Grossly swollen elbow

Radiology
Distal fragment is posteromedially displaced
Radiocapitullar relationship is maintained

Treatment
Closed reduction and pinning

Lateral condyle fracture
Fracture including the lateral epicondyle(extraarticular) & capitullum

3 types
I - undisplaced

II - gap

III - flipped

Mitch Classification

i - fracture extend lateral to lateral trochlear ridge

II - fracture extend medial to lateral trochlear ridge

Clinical
Local swelling and tenderness at lateral condyle
Less hyperextended elbow

Radiology
Loss of radiocapitullar relationship

Treatment
Anatomical reduction & pinning

Supracondylar fracture
Around 6-9 year old

Radiograph

AP - visible fracture line over the metaphysis above the condyle
AP - Altered bowman angle ( N= 85-90 degrees)

Lateral

• The lateral view is the most useful in diagnosing supracondylar fractures.
• A clearly defined teardrop is visible on a true lateral view of the lower humerus.
• The lateral condyle represented by the capitellum forms a 40^o angle with the humeral shaft.
• A number of lines have been described which help in the diagnosis of a supracondylar fracture on lateral X-rays
• Normally anterior humeral line crosses center of capitulum. Line appears anterior to capitulum in supracondylar #
• The coronoid line projects proximally from the coranoid process and should form a tangent with the capitellum. Loss of tangle association in supracondylar #
• Cresent sign( outline of articular olecrenon overlaps with the capitullum )

Acute management

Arterial injury

The significance of an absent radial pulse following a supracondylar fracture is controversial.

Fracture reduction is imperative as an initial manoeuvre. If capillary refilling returns at this stage, despite the absence of a radial pulse many surgeons adopt a wait-and-see approach. The abundant collateral circulation around the elbow maintains distal perfusion.

If, however, following closed reduction distal perfusion remains compromised open exploration of the brachial artery is indicated. Arteriography is not of benefit.

The only sequela of note following loss of the radial pulse in a supracondylar fracture which has adequate distal perfusion is cold intolerance.
Complication

Gunstock deformity
Due to malreduction and malunion ( 95%). So not improving and but static
Lesser extent will have physeal arrest (5%). So deformity may worsen
3 planes

• medial rotation
• extension
• medial displacement/angulation
• (distal fragment having displaced posteromedially, internally rotating and tilting in the coronal plane)

Osteotomy - most common- lateral closing wedge osteotomy.
Performed just proximal to the olecranon fossa and a wedge removed to correct the varus deformity.
The distal fragment should be displaced medially simultaneously to prevent the lateral condyle being excessively prominent
Complications following osteotomy are delayed union and failure to correct the deformity. Injury to the ulnar nerve, infection and stiffness are rare.

Fishtail Deformity.

Thought to be due to avascular necrosis of with a resultant central growth deficiency of the distal humerus
The distal humerus develops a characteristic concave shape.
Occur with all distal humeral injuries except of medial epicondyle injuries.
Proximal migration of the ulna may occur with subluxation of the radial head.
Impingement of the olecranon on the humerus - extension loss.
Excision of the tip of the olecranon may regain ROM

This entry was posted on Sunday, December 23rd, 2007 at 7:43 am and is filed under Injuries Around Elbow. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.