Paediatric

Elbow Trauma
by Group F
• 72195 Diyanah Ruqaiyah bt Zulfahmy
• 72514 Nur Athirah binti Mannuil
• 73574 Muhammad Shahrulnizam Bin Hatity
• 73712 Nur Fatini Amini Binti Mohd Fauzi
• 73726 Nur Munirah Haziqah Binti Muhammad Hisyam
• 74218 Avvy Kon Ying Zhi
• 74900 Gerard Anak Josiah
• 77192 Wong Jia Xin
• 77242 Yvonne Siew Wei
 Contents
1. Anatomy of elbow
2. Aetiology
3. Clinical features
4. Differential diagnosis
5. Investigation
6. Treatment and management
7. Complications
● A 7-year-old girl presented to ETD with left elbow pain
and swelling one hour after a fall from a monkey bar on
her outstretched hand (FOOSH).
● She was previously healthy and had no history of fractures.
● On examination, vital signs and body built was normal.
No dysmorphic features were noted.
● She had left elbow swelling with ecchymoses, but no wound
and no features of compartment syndrome.
● Distal pulses were palpable. Sensory and motor examination
of median, ulnar and radial nerves were normal.
● What is FOOSH
 Anatomy of elbow

01 02 03 04

Joint & Bone Muscle & Blood Innervation

ligament supply
 Elbow Joint
❑ Synovial joint (hinge-type)
o Humeroradial and humeroulnar articulations (flexion & extension)
o Proximal radioulnar joint (pronation and supination of forearm)
❑ Made of 3 bones:
Humerus
Radius
Ulna
 Muscle
● Flexors (3B's Bend the elbow)
○ Biceps brachii
○ Brachialis Musculocutaneous nerve
○ Brachioradialis ---- Radial nerve
● Extensors
○ Triceps brachii
Radial nerve
○ Anconeus
● Pronation
○ Pronator quadratus Median nerve +
○ Pronator teres Anterior interosseous nerve ( PQ)
● Supination
○ Supinator (aid by biceps brachii) ~ posterior interosseous nerve
 Ligaments of Elbow Joint
• Collateral ligament
• Ulnar and radial collateral ligament
• (for valgus and varus stability of elbow)
• Annular ligament (surrounds proximal radioulnar joint

• Encircles and holds head of radius in radial notch of ulna

• Clinical relevance: Nursemaid's elbow (trapped ligament)
 Innervation to elbow joint

❑ Anterior
Median nerve – pronators of forearm
Musculocutaneous nerve – elbow flexors excl.
Brachioradialis
Radial nerve – elbow extensors & brachioradialis

❑ Posterior
Ulnar nerve
Blood Supply of elbow joint
● Periarticular anastomoses of the elbow joint
(The collateral and recurrent branches of the
brachial, profunda brachii, radial and ulnar
artery)
● Proximal to elbow joint:
Brachial artery ---> superior and inferior ulnar
collateral artery.
Profunda brachii ----> middle & radial collateral
artery
● Distal to elbow joint:
Radial artery ---> radial recurrent artery
Ulnar artery ---> anterior and posterior ulnar
recurrent arteries
Mechanism of Injury
Mechanism of Injury
 Clinical Features

Sign and Symptoms

1. Elbow pain
2. Swelling around elbow
3. Deformity of elbow
4. Ecchymoses

Associated Neurovascular Injuries

1. Median nerve (anterior interosseous branch) injury,
radial nerve injury, ulnar nerve injury
2. Brachial artery injury
 Clinical Features

A. Lateral view of the elbow demonstrates

an S-shaped deformity.

B. Anterior view demonstrates

antecubital fossa ecchymosis
 Clinical Features
• Medial epicondyle / condyle fracture of humerus – tenderness and swelling at the medial
aspect of the elbow.

• Lateral condyle fracture – pain, limited elbow range of motion (ROM) and swelling at the
lateral aspect of the elbow.

• Fracture in the neck of humerus – pain, tenderness, and swelling over the lateral aspect
of the elbow and decreased forearm rotation (pronation/supination).

• Deformity is not typically a feature unless there are associated injuries (e.g. elbow joint
dislocation, ulnar shaft fracture).
 Differential diagnosis

● Supracondylar fracture (most common)

● Lateral condylar fracture
● Medial epicondylar fracture
● Radial head and neck fracture
Types of elbow fracture Introduction Clinical features Classification & Treatment
Imaging

Supracondylar fracture Most common elbow Symptoms: Classification: Based on degree of

fracture • Elbow pain • Gartland displacement
Types: 5-7 years old* • Refusal to move classification
Extension-type vs Pathophysiology: • Modified Gartland Type I: Treated with
flexion-type Fall onto outstretched Signs: classification cast immobilization x
hand with the elbow in • S-deformity of the 3-4wks, with
a position of extension elbow in Imaging: radiographs at 1 week
or hyperextension posteriorly Radiograph:
Associated condition: displaced fracture • Posterior ‘fat pad’ Type II: Typically
• Ipsilateral distal or “sail’ sign treated with CRPP
radius fractures • Displacement of
• Neuropraxia anterior humeral Type III and IV: Treated
• AIN line most commonly with
neurapraxia • Increased CRPP or open
• Radial nerve Baumann’s angle reduction if needed
palsy (normal<80°)
• Ulnar nerve
palsy
Types of Elbow Introduction Clinical features Classification & Treatment
fracture Imaging

Lateral condylar Second most common Symptoms: Classification Based on stage of the
fracture paediatric elbow fracture • Lateral elbow pain • Milch classification fracture
<7 years old and swelling • Jakob classification
Higher risk of non-union, (maybe subtle if Stage 1 (<2 mm of
malunion and AVN fracture is Imaging displacement):
Pathophysiology: minimally • Radiograph: AP, Conservative
• Pull-off theory: avulsion displaced) lateral and internal management with
fracture of the lateral oblique view – immobilisation with
condyle that results from Signs: fracture fragment above elbow cast to 90°
the pull of the common • Swelling and most often lies
extensor musculature tenderness are posterolateral Stage 2 and 3 (>2 mm
• Push-off theory: fall usually limited to • Arthrogram with or without
onto an outstretched the lateral side • CT scan rotation):
hand causes impaction • Lateral ecchymosis • MRI Closed reduction with
of the radial head into implies a tear in the percutaneous pinning
the lateral condyle aponeurosis of the or open reduction with
causing fracture brachioradialis and screw fixation
signals an unstable
fracture
Types of elbow fracture Introduction Clinical features Classification Imaging & Treatment

Medial epicondylar Third most common Symptoms: Classification 3 views of X-ray:

fracture elbow fracture type in • Medial elbow pain Based on degree of • AP and lateral
children displacement • Internal oblique
9-14 years old Signs: • Distal humeral
M>F • Valgus instability Acute subtypes:
Pathophysiology: • Ecchymosis at the • Non-displaced Reason:
Fall onto outstretched medial aspect • Minimally • To identify the
arm during valgus especially with displaced degree of
stress with contraction trauma • Displaced displacement
of flexor-pronator • Ulnar nerve • Fragment • TRO incarcerated
mass* dysfunction – motor entrapped joint medial epicondyle
Associated condition: and sensory should • Fracture through in the joint
Elbow dislocation be documented in epicondyle • TRO medial
all cases apophysis condylar fracture*
• Generalised
swelling – elbow Chronic: CT: most accurate but
dislocation • Related to tension associated with
stress injuries increased radiation
Treatment of medial epicondylar fracture
Types of elbow Introduction Clinical features Classification and Imaging Treatment
fracture

Radial head and Common traumatic Symptoms: Classification Based on degree of

neck fracture injuries that usually • Elbow pain • O'Brien Classification displacement/
affect the radial neck * • Refusal to move • Judet Classification angulation
9-10 years old • Chambers Classification
M=F Signs: (rarely used) Type 1 (< 30°):
Pathophysiology: • Swelling around Conservative with
associated with an the elbow, Imaging (AP and lateral view) immobilisation in a
extension and valgus especially on the • Loss of normal smooth collar and cuff
loading injury of the lateral aspect curves of radial nerve
elbow • Tenderness • Posterior fat pad sign (elbow Other types (>30°) –
Associated particularly over joint effusion) worse outcome:
conditions: the radial head • Closed reduction
• Elbow dislocation • Pain on any and immobilisation
• Olecranon movement • Closed
fracture especially percutaneous
• Median supination and reduction
epicondyle pronation • Open reduction
fracture
• Forearm
compartment
syndrome
Supracondylar fracture Lateral condylar fracture
Gartland classification Gartland Milch classification Milch
•Type 1: minimal or no • Type 1: fracture line
displacement of the fracture. transverses lateralto
There is a normal anterior capitello-trochlear groove;
relationship between
humeral line on the X-ray.
humerus and forearm is
Often only abnormality is
intact; stable elbow
abnormal fat pads. • Type 2: fracture passes
•Type 2: with posterior through the capitello-
displacement, the posterior trochlear groove; unstable
cortex remains intact and with Jakob classification elbow
Modified Gartland anterior displacement, the Jakob
classification anterior cortex remains intact. • Stage 1: <2mm
•Type 3: completely displaced displacement, which
with complete cortical indicates intact cartilaginous
disruption.2 hinge
•Type 4: The periosteum is • Stage 2: 2-4mm of
displacement
completely torn and is the
• Stage 3: > 4mm
most unstable type of fracture displacement with rotation
(can only be diagnosed of the fragment
intraoperatively).
Radial head and neck fracture
O’Brien classification O’ Brien
Type I: <30 degrees displacement
Type II: 30-60 degrees displacement
Type III: >60 degrees displacement

Judet classification:
Type I: undisplaced
Type II: <30 degrees displacement
Type III: 30-60 degrees displacement
Type IVa: 60-80 degrees displacement
Type IVb: >80 degrees displacement
Judet classification
Differential Points support Points against
diagnosis
Supracondylar ❑ Left elbow pain -
fracture ❑ Left elbow swelling with ecchymosis
❑ History of fall on outstretched hand
❑ Clinical signs of non-displaced/ minimal displaced
supracondylar fracture:
➢ No dysmorphic feature
➢ Distal pulses present
➢ Normal sensory and motor examination of ulnar, median and
radial nerve

Lateral ❑ Left elbow pain ❑ No left lateral side elbow pain &
condylar ❑ History of fall on outstretched hand swelling with ecchymosis (limited to
fracture ❑ No dysmorphic feature lateral side)
❑ Distal pulses present (type 1 Milch – rare) ❑ No absent of distant pulses (type 2
Milch – common)
Medial ❑ Left elbow pain ❑ No medial elbow pain (no specific)
epicondylar ❑ Left elbow swelling with ecchymosis ❑ No ulnar nerve dysfunction
fracture ❑ History of fall on outstretched hand
❑ Distal pulses present
Radial neck ❑ Left elbow pain ❑ No lateral left elbow swelling
fracture ❑ History of fall on outstretched hand ❑ No feature of compartment syndrome
❑ Pain usually refer to wrist
 Investigations
Rule of two:

2 views 2 limbs 2 joints 2 injuries 2 occasions

• AP & Lateral • X-rays of • Joints above • Severe force • Early fracture

view X- uninjured & below may cause may be
ray MUST be limbs MUST should be injuries at >1 difficult to
obtained be taken for included level detect &
comparison visible a week
or two later
 Normal paediatric elbow x-ray
Olecranon
fossa
Humeral
shaft

Supracondylar
ridge
Medial
Anterior epicondyle
fat pad Lateral
Radial epicondyle
head

Humero-
Radia Lateral view ulnar joint Ulna AP view Radio-
l neck humeral joint
Radius
 Supracondylar fracture

Lateral view AP view

No
displacement of Gartland Type 1
the fracture
Tiny line of
fracture at the
distal humerus
 Supracondylar fracture

Fracture is displaced
but posterior cortex Gartland Type 2
still intact

AP view Lateral view

 Supracondylar fracture

Completely displaced
fracture with no
contact between the
Gartland Type 3
fragments

AP view Lateral view

 Lateral condyle fracture

The commonest
starting in the
metaphysis and
running along the
physis of the lateral
condyle into the
trochlea

Lateral view

AP view Milch Type 2

 Lateral condyle fracture

AP view Milch Type 2 Lateral view

Less common fracture is a fracture running right through the lateral condyle to reach
the articular surface in the capitulotrochlear groove
Medial epicondyle fracture

AP view Lateral view

 Radial head and neck fracture

Left radial head is

displaced and tilted O`Brien type
III/Judet type IVa

AP view Lateral view

 Treatment and management:
Supracondylar fracture

Type I: Undisplaced fracture

• Immobilize the elbow at 90 degrees and neutral rotation in a lightweight
splint or cast and the arm is supported by a sling.
• obtain an x-ray 5–7 days later
• splint is retained for 3 weeks
• supervised movement is then allowed
 Treatment and management:
Supracondylar fracture
Type II A: Posteriorly angulated fracture –mild
• If the posterior cortices are in continuity, fracture can be reduced under general
anaesthesia:
(1) traction for 2–3 minutes in the length of the arm with counter-traction above
the elbow

traction of the fractured arm

 Treatment and management:
Supracondylar fracture
Type II A: Posteriorly angulated fracture –mild
(2)correction of any sideways tilt or shift and rotation (in comparison with the other
arm)

correcting lateral shift and tilt correcting rotation

 Treatment and management:
Supracondylar fracture
Type II A: Posteriorly angulated fracture –mild
(3) gradual flexion of the elbow to 120 degrees, and pronation of the forearm, while
maintaining traction and exerting finger pressure behind the distal fragment to
correct posterior tilt.

correcting backwards shift and tilt

 Treatment and management:
Supracondylar fracture
Type II A: Posteriorly angulated fracture –mild
(4) feel the pulse and check the capillary return – if the distal circulation is suspect,
immediately relax the amount of elbow flexion until it improves.

(5) Take X-rays to confirm reduction, no varus or valgus angulation, no rotational

deformity
 Treatment and management:
Supracondylar fracture
Type II A: Posteriorly angulated fracture –mild
(4) feel the pulse and check the capillary return – if the distal circulation is suspect,
immediately relax the amount of elbow flexion until it improves.

(5) Take X-rays to confirm reduction, no varus or valgus angulation, no rotational

deformity
 Treatment and management:
Supracondylar fracture
Type II A: Posteriorly angulated fracture –mild
(6) If the acutely flexed position cannot be maintained without disturbing the
circulation, or if the reduction is unstable: fixed the fracture with percutaneous
crossed K-wires
• After reduction, arm is held in collar and cuff.
• Check circulation repeatedly in the first 24 hours.
• Obtained X-ray 3-5 days later (confirm that the fracture has not slipped)
• Retained splint for 3 weeks.
 Treatment and management:
Supracondylar fracture

Type II B and III: angulated and malrotated or posteriorly displaced

• Fracture should be reduced under general anaesthesia ASAP, by the
method described above→ held with percutaneous crossed K-wires
• Same post-op management as Type II A
 Treatment and management:
Supracondylar fracture

Open reduction
Indications:
(i) fracture which simply cannot be reduced closed
(ii) open fracture
(iii) fracture associated with vascular damage
• The fracture is exposed (preferably through two incisions, one on each side of
the elbow)
• haematoma is evacuated
• fracture is reduced and held by two crossed K-wires
 Treatment and management:
Supracondylar fracture

Continuous traction
• Traction through a screw in the olecranon, with the arm held overhead
• Indications:
(i) if the fracture is severely displaced and cannot be reduced by manipulation
(ii) if, with the elbow flexed 100 degrees, pulse is obliterated and image
intensification is not available to allow pinning and then straightening of the
elbow
(iii) for severe open injuries or multiple injuries of the limb
• Once the swelling subsides, a further attempt can be made at closed reduction
 Treatment and management:
Supracondylar fracture
Anteriorly displaced fractures
• rare injury (less than 5 % of supracondylar fractures)
• ‘posterior’ fractures are sometimes inadvertently converted to ‘anterior’ ones by
excessive traction and manipulation
• fracture is reduced by pulling on the forearm with the elbow semi-flexed, applying
thumb pressure over the front of the distal fragment and then extending the elbow
fully
• Crossed percutaneous pins are used if unstable.
• A posterior slab is bandaged on and retained for 3 weeks.
• child is allowed to regain flexion gradually.
Treatment and management:Lateral
condyle fracture
No displacement fracture
• Splint the arm in a backslab with the elbow flexed 90 degrees, the
forearm neutral and the wrist extended (this position relaxes the extensor
mechanism which attaches to the fragment).
• repeat the x-ray after 5 days
• splint is removed after 2 weeks and exercises are encouraged
Treatment and management:Lateral
condyle fracture

Displacement fracture
• accurate reduction and internal fixation
• If the fragment is only moderately displaced (hinged), it may be possible
to manipulate it into position by extending the elbow and pressing upon
the condyle, and then fixing the fragment with percutaneous pins.
• If fails, and for all separated fractures: open reduction and internal
fixation with pins. Arm is immobilized in a cast; cast and pins are
removed after 3 or 4 weeks.
Treatment and management:Medial
condyle fracture
Undisplaced fractures
• splintage
• x-rays are repeated until the fracture has healed

Displaced fractures
• either closed reduction (sometimes with percutaneous pinning) or by
open reduction and fixation with pins

Postoperative management is similar to that of lateral condyle fractures.

 Treatment and management: Radial
head & neck fracture
Nonoperative
(1) immobilization alone (long arm cast or splint without reduction)
•Indications
- <30 degrees of angulation
- <3mm translation
•Follow-up
•7 days of immobilization followed by early range of motion
(2) closed reduction and immobilization
•Indications
- >30 degrees of angulation
- closed reduction followed by immobilization in long arm cast or splint if an adequate
reduction is achieved

Avoid open reduction due to high risk of avascular necrosis of radial head.
Complication
 Complications

Early Late

▪ Vascular injury ▪ Non-union

▪ Nerve injury ▪ Malunion
▪ Elbow stiffness
▪ Recurrent dislocation
 Vascular injury

▪ Injury to brachial artery (especially if it’s supracondylar fracture).

▪ Can lead to peripheral ischaemia (immediate/severe) or pulse may fail to
return after reduction.
▪ More commonly complicated by forearm oedema + compartment
syndrome leading to necrosis of muscles and nerves without causing
peripheral gangrene
 Nerve injury

● Radial nerve, median nerve or ulnar nerve may be injured.

● Loss of function is typically temporary and recovery can be expected in
3-4 months.
● If nerve is intact prior to manipulation but then found to be
compromised after manipulation —> suspect entrapment in the fracture.
 Nonunion

▪ More common in lateral condyle fractures.

▪ Causes may be multifactorial and may involve intra-articular nature of
the fracture, poor blood supply of epiphyseal fragment and the pull of
the common forearm extensor tendon.
 Malunion
▪ Uncorrected angulation and internal rotation of distal fragment—>
cubitus varus deformity (gunstock deformity: may cause ulnar tunnel
syndrome) [supracondylar #]
▪ Causes:
o Failure to hold reduction while healing proceeds.
o Gradual collapse of comminuted/osteoporotic bone.
o Failure to reduce fracture adequately.
 Elbow stiffness

▪ Is an ever-present risk with elbow injuries.

▪ Extension may take months to recover and some loss of extension is
common but unlikely to affect function.
▪ Passive elbow stretch should be avoided as it tends to increase stiffness
and increase risk of heterotopic ossification.
▪ Otherwise, it is a rare complication.
 Recurrent dislocation

▪ Occasionally, condylar displacement can lead to posterolateral

dislocation of the elbow.
▪ The only effective way is to reconstruct the bony and soft tissues on the
lateral side.
THANK YOU