Pediatric Distal Humerus

Supracondylar Humerus Fractures 60% of elbow fractures in children under 7. 96% extension type, from fall on outstretched arm with elbow hperextension. 4% flexion type, from fall on olecranon with elbow flexed.

Classification-Gartland Type I: Nondisplaced, +/- posterior fat pad sign. Where is PFPS? Significance?

Posterior Fat Pad Sign PFPS is predictive of occult fracture in 76% of cases. The fracture is a supracondylar humerus about 50% of the time. Skaggs & Mirzayan, JBJS, 2001.

Classification-Gartland Type II: Angulated with intact posterior cortex.

Classification-Gartland Type II: Anterior humeral line anterior to middle of capitellum.

Classification-Gartland Type III: Displaced. Usually posteromedially.

Classification-Gartland Type IV: Multidirectional Unstable. Leitch, et al., JBJS, 2006.

Classification-Gartland Flexion type.

Quick and Dirty Pediatric NV Exam Rock-Paper-Scissors-OK Rock: Median Nv. Paper: Radial Nv. Scissors: Ulnar Nv. OK: AIN.

Neurologic Injury Incidence: ~7%. Anterior interosseous is most common nerve injured. Decreased thumb IP and index DIP flexion.

Neurologic Injury: Median Nv. May become entrapped in fracture. May mask compartment syndrome, because of associated forearm sensory loss.

Neurologic Injury: Ulnar Nv. Ulnar nerve injuries more common in flexion supracondylar fractures. Often iatrogenic. Quantification of risk: “Number Needed to Harm” = 28 For every 28 pts that have medial/lateral cross pinning vs lateral pins only, one child will sustain an iatrogenic ulnar nv injury. Slobogean, et al., JPO, 2010.

Vascular Injury Incidence: ~1% (0.5-5%). Maintain high index of suspicion. Perform careful physical exam.

Vascular Injury Indications for exploration: Clinically obvious ischemia (white, pulseless hand). Loss of palpable/dopplerable pulse after fracture reduction. Use of arteriography controversial. Treatment of “pink, pulseless” hand also controversial.

Compartment Syndrome May be difficult to diagnose in kids. The Three A’s of compartment syndrome in children: Anxiety. Agitation. Increasing need for Analgesia. May occur even in open fractures.

Treatment Gartland I: Casting in situ. Long arm cast or splint in 90-110° flexion for 3-4 weeks. Gartland II & III: Closed reduction and percutaneous pinning.

Closed Reduction Technique

Percutaneous Pinning Crossed pins vs. Lateral: No biomechanical difference in stability if proper technique and pin placement utilized. Skaggs, et al., JBJS, 2001. Davis, et al., CORR, 2000. Hamdi, et al., JPO, 2010. Try to make the 2 lateral pins divergent. Try not to have pins cross at the fracture site. Size matters: Pins should be at least the thickness of the cortex.

Closed Reduction/Percutaneous Pinning: 2 Pins

Closed Reduction/Percutaneous Pinning: 3 Pins

Closed Reduction/Percutaneous Pinning: 3 Pins

Can you wait to operate? It depends… Must have a normal N/V exam. Must not have severe swelling. Must still be considered urgent. NPO status may be a factor in the decision.

Complications Ulnar nerve injury. Cubitus Varus. Loss of reduction. Pin site problems (rare!) Most complications can be avoided with attention to detail.

Lateral Condyle Fractures 17% of elbow fxs. in children. Peak incidence: 5-10 years of age. Mech: Varus stress to extended elbow, with forearm supinated.

Lateral Condyle Fractures: PE Lateral swelling and tenderness. Much less prone to NV injury than SCHFs.

Case 2: 7 yo girl fell off monkey bars. Classification?

Lateral Condyle Fractures: Jakob Classification Stage I: Nondisplaced. Stage II: Hinged. Stage III: Rotated.

Lateral Condyle Fractures: Treatment Non-displaced fxs. can be treated with cast immobilization at 90° flexion and supination. Frequent follow-up and re-imaging is necessary, to watch for late displacement and subsequent need for operative Rx.

Lateral Condyle Fractures: Treatment Open reduction and percutaneous pinning for displaced fractures. It is necessary to visualize the anterior joint line/articular surface prior to fixation. 2-3 lateral pins: Across capitellum to medial epicondyle. At 45° angle to first pin, exiting medially and proximally.

Lateral Condyle Fractures: Treatment Arthrogram may be helpful in determining extension into the joint and need for open reduction.

Procedure/Positioning Patient supine on radiolucent table. C-arm comes in perpendicular, from across the table. Alternatively, hand table with C-arm coming in from the end may be used.

Procedure/Approach Kocher Approach: Slightly curvilinear incision centered over the lateral condyle. Internervous plane between the extensor carpi ulnaris and the anconeous. Stay anterior: avoid posterior stripping in order to preserve trochlear/capitellar blood supply. Open capsule anteriorly and extend distally to radial head.

Procedure/Reduction & Fixation Clean fragment ends. Reduce using dental pick or towel clip. 2 pins placed percutaneously from posterior to incision: Across capitellum to medial epicondyle. At 45° angle to first pin, exiting medially and proximally. At least 0.062” diameter.

Procedure/Tools You must see all the way to the medial side of the joint, to assess reduction at the most medial extent of the fx. Useful tools to facilitate this: Mini-Hohmanns or Chandlers. Dental Mirror. Head Lamp.

Pearls & Pitfalls The fracture often performs the approach for you. The distal fragment may flip…be certain you have the articular cartilage oriented properly. There is sometimes lateral metaphyseal communition that appears as displacement…it is important to assess reduction at the joint line, not the metaphysis. Try to reapproximate lateral soft tissues to decrease lateral spur formation.

Lateral Condyle Fractures: Complications Prone to: Late displacement. Mal/Nonunion. Growth disturbance. Late deformity. Loss of ROM.

Medial Epicondyle Fractures 10% of elbow fractures. Peak incidence: 9-15 years of age. Mech: Fall on extended elbow, with valgus stress.

Medial Epicondyle Fractures Avulsion of medial epicondyle from the distal humerus by the wrist flexors. Usually a SH I or II. Can be associated with an elbow dislocation. The medial epicondyle can be entrapped in the joint.

Medial Epicondyle Fractures Reduction maneuver to remove epicondyle from joint: valgus stress on elbow. supination of forearm. dorsiflexion of wrist and fingers.

Medial Epicondyle Fractures Need for reduction/fixation of epicondyle controversial: Displacement: >1cm. Angulation: >45°. Instability: +/- Stress film. Athletic ability/aspirations. Associated with elbow dislocation. ? Risk of tardy ulnar nv. palsy.

Medial Epicondyle Fractures Reduction can be closed or open. Fixation can be percutaneous or open. Fixation can be k-wires or a screw.