elbow fracture case presentations - children's …...•an elbow joint effusion was also...

Elbow Fracture Case Presentations

Children’s Mercy

Kansas City, MO

Mark Sinclair, MD

12 month old with abnormal elbow

• 12 month old female presented to outside institution with a swollen right elbow

• Her aunt, who has had guardianship since 9 months of age, noticed she wasn’t holding her bottle with her right hand like she usually would

• Evaluation at that time included xrays, which were read as normal.

• A blood culture was done, which turned positive at two days. The child was subsequently referred to Children’s Mercy for suspicion of a septic elbow

12 month old with abnormal elbow

12 month old with abnormal elbow

• The xrays were over-read at CMH with “periosteal reaction of the right humerus consistent with osteomyelitis”

• An elbow joint effusion was also identified on the xrays, and was subsequently confirmed with an ultrasound

• She was afebrile, HR 150, BP 123/83

• WBC 13.4 with no left shift, CRP 2.0, ESR 30

• Decision was made the night of admission to bring to the OR for drainage of suspected septic elbow

12 month old with abnormal elbow

• At time of surgery, the posterior displacement of the capitellumwas noted, as was the limit of flexion to 110 degrees

• A lateral arthrotomy of the elbow was performed, and a bloody effusion was identified

• Cultures were sent, and all were no growth

• Blood cultures from CMH were no growth

• The positive blood culture from the referring institution later turned out to be a contaminant

• A skeletal survey was obtained

Left proximal tibia fracture

Left proximal humerus fracture

12 month old with abnormal elbow

• Child abuse assessment was made

• Child was treated with antibiotics for three weeks in case any infectious etiology was possible

• No metabolic abnormalities were identified on work-up

• Child followed annually by orthopaedics for assessment of growth

5 months after injury

18 months after injury

2 ½ years post injury. Full flexion and extension of the elbow.

Carrying angles symmetric. Discharged from follow up.

6 y 2 mo old male fell

at school on

playground and

sustained a Gartland

Type 2 supracondylar

humerus fracture

Otherwise healthy

Limb neurologically

and vascularly intact

Non-dominant hand

Underwent closed

reduction and

percutaneous pinning

the night of the injury

with two divergent

.062” K-wires

4 weeks

post op, the

cast and

pins are

removed

Returns 8 weeks post op.

Pins sites are healed. He

has near full flexion and

near full extension. Full

pronation and supination.

No pain.

He is discharged from

care to return as needed

Type 2 supracondylar humerusfracture s/p CRPP• He returns 7 years later at age 13 y 6 mo

• Now a 5‘ 10‘’ eighth grader active in sports

• Notices pain in his elbow with push-ups at gym class

• Notes pain when he repeatedly swings a bat during baseball season

• On exam, he lacks the last 10 degrees of extension and the last 10 degrees of flexion of the elbow

• He has full pronation and supination of the forearm

• His left humerus is slightly shorter than the right

MRI/Arthrogram demonstrates

the AVN of the lateral half of the

trochlea with a possible loose

fragment of cartilage

• 6 y 1 mo male fell off monkey bars onto his right arm

• Right hand dominant

• Fusiform swelling of right elbow

• Neurovascularly intact on exam

• Xrays show a Gartland type 2 supracondylar humerusfracture that is extended but has no varus/valgus angulation

Initial one

week follow

up shows

no change

in alignment

in cast

• Seen back in follow up 3 weeks after injury

• Xrays done out of cast show increased extension of the fracture with early fracture callus

• Patient brought to the OR later that day for closed reduction and percutaneous pinning of his supracondylar humerusfracture

Seen one

month post op for

cast and pin

removal

Lateral Condyle Fractures

9 y o male falls

while jumping

over a creek

and sustains

an injury to

right elbow

Splinted in ER

and referred

to ortho clinic

Seen in clinic 10 days

post injury. After

review of these xrays,

he is placed in a cast

2 weeks later, he returns

for follow up. He is taken

out of his cast and xrays

are obtained. He was

placed back in a long

arm cast.

6 weeks out from

his injury, he

returns for follow

up. Xrays out of

cast are obtained.

Immobilization is

removed and ROM

initiated

He returns 3

months out from his

original injury.

After these xrays

obtained, a CT

scan is performed

later that day

AP Lateral Internal oblique

The next week, an

open reduction and

percutaneous pinning

was performed. He

was placed back in a

cast.

2 months post op (5

months post injury), he

has another CT to

evaluate his healing.

He has a persistant

non-union. Another

surgical procedure is

performed.

In situ internal

fixation of his

nonunion is

performed with

autogenous bone

marrow aspiration

and injection into

the non-union.

His in situ screw

starts to back out

within a month, and 6

months after his

original injury, he

undergoes his 3rd

surgical procedure to

heal his lateral

condyle fracture:

open reduction and

internal fixation with

autograft harvested

from ulna

Two years post

op from his

internal fixation

with bone

autograft of his

non-union, he is

healed. He has

full flexion and

extension and full

pronation and

supination. He

has returned to all

activities. And

has never been

seen again…

• 6 year old male fall off monkey bars onto outstretched left arm

• Right hand dominant

• Swelling and tenderness to palpation about elbow; neurovascularly intact

• Xrays demonstrate a lateral condyle fracture of the distal humerus

Internal oblique view

performed

Closed reduction and

percutaneous pinning

was performed the

following day in the

trauma room

No pre or post reduction

arthrogram performed

• 10 days post op

• One month post op after pins removed

• 3 y 3 mo old male fell off bed at home and sustained an injury to the left elbow

• Lateral swelling of elbow

• Neurovascular exam intact

• Xrays demonstrate a lateral condyle fracture of distal humerus

Oblique view obtained

Splinted in ER and referred

to ortho clinic

• Seen in ortho clinic 5 days post injury and xrays out of splint were obtained

• Brought to the operating room the following day for open reduction and percutaneous pinning

3 weeks

post op,

pins

removed

and re-

casted

7 weeks

post op

full

extension,

lacks

last 10-15

degrees of

flexion

No pain

Released

to regular

activity

10 y 2 mo old male fell on

outstretched left arm while

playing basketball and sustained

a completely displaced left

supracondylar humerus fracture

Radial, median, and ulnar nerve

motor exam intact

Radial pulse not palpable but

dopplerable. Good capillary refill

in fingers (<2 seconds)

Taken to the OR the night of the

injury for reduction and pinning

of his fracture

Underwent closed reduction

And percutaneous pinning with

5/64th Steinman pins

After reduction, the hand

appeared white and pulseless.

The arm was warmed and the

hand became pink with good

capillary refill and a Dopplerable

but not palpable radial pulse

Patient admitted to hospital for

overnight observation

• On rounds the next morning, the patient continued to have a warm hand with good capillary refill, but did not have a normal biphasic Doppler signal over radial artery at wrist

• He also had an anterior interosseous nerve palsy that he did not have pre-operatively

• Decision was made to go back to the OR and explore the median nerve and brachial artery at the fracture site

Median nerve

Brachial artery

• The brachial artery and vein were entrapped in the fracture site

• The median nerve was entrapped in the fracture site

• The percutaneous pin fixation was taken down and these structures were teased out of the fracture

• These structures were intact after extraction from the fracture site

• The fracture was reduced and pinned again with an open reduction

• A palpable pulse and strong biphasic Doppler signal was audible at the wrist and into the palmar arch

Xrays one

week

Post op from

antecubital

exploration and

revision of

percutaneous

fixation

4 weeks post op

Palpable radial

pulse at wrist with

good

capillary refill

AIN nerve function

still abnormal

Pin sites benign

Pins pulled, and

cast

immobilization

discontinued

Referred to physical

• Returns 6 weeks post op with draining pin site and pyogenic granuloma

• Range of motion very limited (90-110 degrees)

• AIN function starting to improve

• For next 6 weeks, patient treated with local wound care

• Continued with physical therapy and extension bracing and casting was done to improve motion of arm

• Then elbow became increasingly swollen and drainage increased

• Xrays were done

• Patient seen in Infectious Disease clinic and labs and cultures performed:

• WBC: 7.47• CRP: 1.1• ESR: 81• Cultures: Pseudomonas aeruginosa

• MRI and CT confirmed chronic osteomyelitis of distal humerus and septic arthritis of elbow

• Patient admitted for IV antibiotics and brought to the OR for drainage of infection and debridement

Debridement of the distal humerus and

elbow joint occurred

After irrigation and cleaning, the bone

defect was packed with calcium sulfate

mixed with tobramycin

Wound was closed over drains

One surgical culture grew

Pseudomonas aeruginosa.

Remainder negative

Subsequently discharged on

Ciprofloxacin

Seen 3 weeks after

debridement

Wound closed and

without drainage

Range of motion

improving

ESR normalizing

Calcium sulfate

absorption occurring

radiographically

Continues on

ciprofloxacin and

PT/OT

• 5 y 0 mo male fell off monkey bars his first week of kindergarten and injured his right elbow

• Swelling and deformity of elbow

• Neurovascular exam intact

• Xrays show a displaced right distal humerusfracture

• Brought to the OR the following day and underwent closed reduction and percutaneous pinning

• Cross pinning attempted, but adequate fixation could not be obtained with the medial pin

• 3 lateral pins were utilized for fixation

• Seen 2 weeks post op

• Did well initially post op but has had increasing pain the last couple of days prior to clinic visit

• One pin had migrated under the skin but was able to be retrieved in clinic

• Neurovascular exam remained intact

• Subsequently re-casted

• 4 week post op visit

• Xrays show interval callus formation without further loss of fixation

• Pins removed

• 3 months post op

• Right elbow range of motion from 0 to 130 degrees

• Solid bony union of fracture with early remodeling

• Returned to full activity and follow up as needed

END

PB 1592625: what are the indications for a medial pin?

• 5 year old male fall off trampoline onto right arm

• Physical Exam: Diffuse swelling about elbow, neurovascularly intact

• X-rays show a type III supracondylar humerusfracture

• Three 0.062 K-wires

• 1 week post op

• Xrays show intact hardware with maintained alignment and position of supracondylar humerus fracture

• Neurovascularly intact

• 3 weeks post op

• Xrays show interval callus formation with maintained hardware

• Neurovascularly intact

• Pins pulled

LV 1489966 SCH fx requiring open reduction

• 6 yo M, unwitnessed fall from couch onto left arm

• Closed injury, neurovascular exam unremarkable

• Extension type II SCH

• Admit, closed vs open reduction and percutaneous pinning

12/20/2012

SCH fx requiring open reduction

• Failed closed reduction, anterior comminution (radial head?, loose body?)

• After opening, comminutionfrom proximal fragment attached to periosteum

• Open reduction, perc pinning, long arm cast applied

• f/u 2 weeks

12/20/2012

SCH fx requiring open reduction

• 1/4/2013 (2 wkspost-op)

• Pin sites c,d,I

• Neurovascular exam unremarkable

• New long arm cast applied

• f/u 2 weeks

SCH fx requiring open reduction

• 1/18/2013 (4 wks post-op)

• Pin sites c,d,I

• Neurovascular exam unremarkable

• d/c immobilization

• f/u 4 weeks

SCH fx requiring open reduction

• 2/8/2013 (7 wks post-op)

• Incision, pin sites well healed

• Neurovascular exam unremarkable

• Lacks ~10 deg extension and ~30 deg flexion

• PT for elbow ROM

• F/u 6 weeks/PRN

AC 1245913 malunion of SCH fx that required distal humeral osteotomy

• A good case to follow is SP 1514348_ bad elbow that had an open reduction and pinning and did well. Perhaps AC would have done better with an open reduction…

END

KK 1245828 flexion supracondylar requiring open reduction

• 6 yo F, ground level fall onto flexed left arm

• Closed injury, neurovascular exam unremarkable

• Admit, closed vs. open reduction percutaneous pinning

11/25/2012

flexion supracondylar requiring open reduction

• Failed closed reduction

• Soft tissue interposition found after opening

• Long arm cast aaplied

• F/u 2 weeks

11/26/2012

flexion supracondylar requiring open reduction

• 12/7/12

• Migration of middle pin

• Plan to remove middle pin, replace long arm cast

• f/u 2 weeks

flexion supracondylar requiring open reduction

• 12/21/12 (3.5 weeks post-op)

• Cast removed, pin sites c,d,I

• Neuroovascular exam unremarkable

• Pins removed, long-arm waterproof cast

• f/u 2 weeks

flexion supracondylar requiring open reduction

• 01/04/13 (5.5 weeks post-op)

• Alignment maintained

• Interval healing

• D/c immobilization

• f/u 6 weeks

flexion supracondylar requiring open reduction• 02/08/2013

• Incision, pin sites well healed

• Lacks about 10-15 deg of extension and 10 deg of flexion

• Full pronosupination

• Neurovascular exam unremarkable

• Return to PE/recess, out of gymnastics for 1 more month

• f/u PRN

JC 1633402 Child abuse kid with happy ending