1. OTA RCFC 2.0 Presented by members of POSNA
Distal Humerus Cases
OTA RCFC 2.0
Presented by members of POSNA

2. Case 1: 5 yo girl fell off the monkey bars. Dx.? Mech.?
AIN out.
Pink, pulseless hand.

3. 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.

4. Case 1: 5 yo girl fell off the monkey bars. Class.?
AIN out.
Pink, pulseless hand.

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

6. 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.

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

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

9. Classification-Gartland
Type III: Displaced.
Usually posteromedially.

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

11. Classification-Gartland
Flexion type.

12. Case 1: 5 yo girl fell off the monkey bars
Case 1: 5 yo girl fell off the monkey bars. How do you do a motor exam in a child?
AIN out.
Pink, pulseless hand.

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

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

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

16. 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.

17. Case 1: 5 yo girl fell off the monkey bars
Case 1: 5 yo girl fell off the monkey bars. What else are you worried about?
AIN out.
Pink, pulseless hand.

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

19. 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.

20. 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.

21. Case 1: 5 yo girl fell off the monkey bars. Plan?
AIN out.
Pink, pulseless hand.

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

23. Closed Reduction Technique

24. 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.

25. Closed Reduction/Percutaneous Pinning: 2 Pins

26. Closed Reduction/Percutaneous Pinning: 3 Pins

27. Closed Reduction/Percutaneous Pinning: 3 Pins

28. Went to OR for CR/PP Now what?
Had white pulseless hand after reduction.
Cap refill and weak dopplerable pulse after pinning.
Now what?

29. Vascular Surgery Consult in OR
Underwent duplex U/S:
Did well post op:
Pulse returned pod # 2.
AIN back at 8 weeks.

30. 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.

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

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

33. 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.

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

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

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

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

38. 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.

39. Healed uneventfully.

40. Fell off monkey bars again 5 mo later. Class.? Rx.?

41. 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.

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

43. Underwent open reduction and percutaneous pinning.
Critique?

44. 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.

45. 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.

46. 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.

47. 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.

48. 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.

49. Went on to non-union. Now what?

50. Underwent bone grafting in situ and internal fixation.

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

52. Healed uneventfully.

53. Removal of hardware 6 mo later.

54. One year later, sustains SCHF on contralateral side. Class.? Rx.?

55. Treated with closed reduction and casting

56. Final f/u SCHF 8 mo post-injury

57. Final f/u lat con about 2 yrs post-injury

58. Did well clinically. With full ROM and no pain bilaterally.

59. Case 3: 9 yo boy injured L. elbow wrestling, 2 weeks ago. Dx.?

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

61. 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.

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

63. He had been seen by an outside MD, who got an MRI. Plan?

64. 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.

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

66. Underwent ORIF.
Note how far posterior the medial epicondyle is: screw oriented P to A on lat xray!

67. Questions?