approach to pediatric elbow nicole kirkpatrick march 27, 2008 ach
TRANSCRIPT
Approach to Pediatric Approach to Pediatric ElbowElbow
Nicole KirkpatrickNicole Kirkpatrick
March 27, 2008March 27, 2008
ACHACH
ObjectivesObjectives
Anatomy of the elbowAnatomy of the elbow Approach to pediatric elbow XRsApproach to pediatric elbow XRs Practice ApproachPractice Approach Management/Complications of some Management/Complications of some
elbow fractureselbow fractures
AnatomyAnatomy Articulations Articulations
Ulnohumeral, Radiocapitellar, Proximal radioulnar Ulnohumeral, Radiocapitellar, Proximal radioulnar StabilityStability
Ulnar and lateral collateral ligament complexesUlnar and lateral collateral ligament complexes Anterior bundle - medial stabilityAnterior bundle - medial stability Lateral ulnar collateral - lateral stabilityLateral ulnar collateral - lateral stability
Origins and insertionsOrigins and insertions Lateral epicondyleLateral epicondyle
Extensor (wrist/finger)Extensor (wrist/finger) Medial epicondyleMedial epicondyle
Forearm flexorsForearm flexors PronatorsPronators
OlecranonOlecranon Extensor (elbow)Extensor (elbow)
VasculatureVasculature
NervesNerves
Ossification CentresOssification Centres
Mnemonic CRITOEMnemonic CRITOE C - capitellumC - capitellum R - radial headR - radial head I - Internal EpicondyleI - Internal Epicondyle T - TrochleaT - Trochlea O - OlecranonO - Olecranon E - External EpicondyleE - External Epicondyle
Ossification CentresOssification Centres
Age at appearance Age at Closure
Capitellum 1-2 14
Radius 3 16
Internal Epicondyle
5 15
Trochlea 7 14
Olecranon 9 14
External epicondyle
11 16
HistoryHistory
Elbow injuriesElbow injuries FOOSHFOOSH Direct traumaDirect trauma Repetitive injuryRepetitive injury
Physical examPhysical exam
InspectionInspection PalpationPalpation ROMROM VascularVascular
Brachial, Radial, UlnarBrachial, Radial, Ulnar Neurologic Neurologic
Median, Ulnar, Radial, MusculocutaneousMedian, Ulnar, Radial, Musculocutaneous StabilityStability
Stress ulnar collateral ligament in valgus in full Stress ulnar collateral ligament in valgus in full extension and 30 degrees of flexionextension and 30 degrees of flexion
RadiographyRadiography
Views Views APAP LateralLateral ObliqueOblique
ExternalExternal InternalInternal
AP and lateral are usually sufficientAP and lateral are usually sufficient Lateral view is most usefulLateral view is most useful
RadiographyRadiography
APAP Supination and full extension at elbow with slight Supination and full extension at elbow with slight
flexion of fingersflexion of fingers Visualize Visualize
EpicondylesEpicondyles Carrying angle (10°-12°)Carrying angle (10°-12°) ArticulationsArticulations Baumann’s angle (75°)Baumann’s angle (75°)
RadiographyRadiography
Lateral Lateral Rest on table Rest on table Elbow flexed at 90°Elbow flexed at 90° Thumb upThumb up
RadiographyRadiography
ObliqueOblique Visualize condylesVisualize condyles
Internal - medial epicondyle and Internal - medial epicondyle and coronoidcoronoid
External - capitellum and radial headExternal - capitellum and radial head
The 8 Step ApproachThe 8 Step Approach
1.1. Figure of 8Figure of 82.2. Anterior Fat PadAnterior Fat Pad3.3. Posterior Fat PadPosterior Fat Pad4.4. Anterior humeral lineAnterior humeral line5.5. Radio-capitellar lineRadio-capitellar line6.6. Inspect radial headInspect radial head7.7. Distal humerus examinationDistal humerus examination8.8. Ulna/Olecranon examinationUlna/Olecranon examination
ApproachApproach
Figure of EightFigure of Eight To determine if true To determine if true
laterallateral Otherwise unable to Otherwise unable to
adequately assess fat adequately assess fat pads, anterior humeral pads, anterior humeral lineline
ApproachApproachAnterior Fat PadAnterior Fat Pad
Barely visible on normal Barely visible on normal filmfilm
Trauma - fractureTrauma - fracture Children - supracondylarChildren - supracondylar Adults - Occult radial headAdults - Occult radial head
Atraumatic - inflammationAtraumatic - inflammation Gout, effusion, arthritisGout, effusion, arthritis
ApproachApproach
Posterior Fat PadPosterior Fat Pad ALWAYS ABNORMALALWAYS ABNORMAL
ApproachApproach
Anterior humeral lineAnterior humeral line Passes through Passes through
middle third of the middle third of the capitellumcapitellum
Disruption suggests Disruption suggests supracondylar supracondylar fracturefracture
ApproachApproach
Radio-capitellar lineRadio-capitellar line On any plain film viewOn any plain film view Bisects the capitellumBisects the capitellum Disruption represents Disruption represents
radial head/neck# or radial head/neck# or dislocationdislocation
ApproachApproach
Inspect radial headInspect radial head Disruption in cortical surfaceDisruption in cortical surface
Inspect distal humerusInspect distal humerus Disruption in cortical surfaceDisruption in cortical surface
Inspect ulna/olecranonInspect ulna/olecranon Disruption in cortical surfaceDisruption in cortical surface
Case 1Case 1
Figure of eightFigure of eight Anterior fat padAnterior fat pad Posterior fat padPosterior fat pad Anterior humeral lineAnterior humeral line Radiocapitellar lineRadiocapitellar line Radial headRadial head Distal humerusDistal humerus Ulna/olecranonUlna/olecranon
Supracondylar FractureSupracondylar Fracture
Most common paeds elbow fracture Most common paeds elbow fracture (~50%)(~50%)
One third of paeds limb fracturesOne third of paeds limb fractures Usually between 3 and 10 years oldUsually between 3 and 10 years old Uncommon after 15 yearsUncommon after 15 years MechanismMechanism
FOOSHFOOSH
Supracondylar FractureSupracondylar Fracture
2 classifications2 classifications ExtensionExtension
~95% of supracondylar fractures~95% of supracondylar fractures FOOSHFOOSH
FlexionFlexion ~5% of supracondylar fractures~5% of supracondylar fractures Direct trauma to posterior aspect of flexed Direct trauma to posterior aspect of flexed
elbowelbow
Supracondylar FractureSupracondylar Fracture
Gartland Classification SystemGartland Classification System
Type IType I Non-displacedNon-displaced Often only clinically suspected or fat pads visualizedOften only clinically suspected or fat pads visualized
Type IIType II Angulated and displaced but posterior cortex intactAngulated and displaced but posterior cortex intact
Type IIIType III Completely displaced distal fragment with disruption Completely displaced distal fragment with disruption
of posterior cortexof posterior cortex
Type IIIType III
Flexion SupracondylarFlexion Supracondylar
ManagementManagement
Type IType I Posterior splint (wrist to axilla), elbow flexion 90° Posterior splint (wrist to axilla), elbow flexion 90°
forearm neutralforearm neutral 3 weeks3 weeks Ortho f/uOrtho f/u
Type IIType II Ortho consultOrtho consult
Closed reduction vs. ORIFClosed reduction vs. ORIF Splint at 110° of flexionSplint at 110° of flexion
Type IIIType III Ortho consultOrtho consult
Closed vs. open reductionClosed vs. open reduction
ComplicationsComplications
Neurovascular injury in ~12%Neurovascular injury in ~12% displacement increases incidencedisplacement increases incidence
Mostly neuropraxias that resolve in Mostly neuropraxias that resolve in monthsmonths Extension - median nerve and brachial arteryExtension - median nerve and brachial artery Flexion - ulnar nerveFlexion - ulnar nerve
Case 2Case 2
Figure of eightFigure of eight Anterior fat padAnterior fat pad Posterior fat padPosterior fat pad Anterior humeral lineAnterior humeral line Radiocapitellar lineRadiocapitellar line Radial headRadial head Distal humerusDistal humerus Ulna/olecranonUlna/olecranon
Lateral Condylar FractureLateral Condylar Fracture
Second most common paeds elbow fracture (15%)Second most common paeds elbow fracture (15%) Common between 4-10 yearsCommon between 4-10 years Considered intra-articularConsidered intra-articular MechanismMechanism
Fall on supinated arm, condylar fragment avulsed by Fall on supinated arm, condylar fragment avulsed by extensorsextensors
Fall on palm with flexed elbow compresses radial Fall on palm with flexed elbow compresses radial head into lateral condylehead into lateral condyle
Disruption of radiocapitellar line can occurDisruption of radiocapitellar line can occur Thurston-Holland fragment may be presentThurston-Holland fragment may be present
Posteriorly displaced metaphyseal fragmentPosteriorly displaced metaphyseal fragment
Lateral Condylar FractureLateral Condylar Fracture
Largely cartilaginous Largely cartilaginous Size and location difficult to appreciateSize and location difficult to appreciate Internal oblique viewsInternal oblique views
Classification Classification Previous Milch classification systemPrevious Milch classification system Now based on displacementNow based on displacement
Type IType I < 2 mm displacement< 2 mm displacement Can be complete or incompleteCan be complete or incomplete
Type IIType II 2-4 mm displacement2-4 mm displacement
Type IIIType III Complete displacement and rotationComplete displacement and rotation
Lateral Condylar FractureLateral Condylar Fracture
Management Management Type IType I
Conservative but may be prolonged (6-12w of Conservative but may be prolonged (6-12w of immobilization)immobilization)
Type IIType II ORIF vs. Closed reduction & pinningORIF vs. Closed reduction & pinning
Type IIIType III ORIFORIF
ComplicationsComplications NV rarely injuredNV rarely injured
Lateral Condylar FractureLateral Condylar Fracture
Case 3Case 3
Figure of eightFigure of eight Anterior fat padAnterior fat pad Posterior fat padPosterior fat pad Anterior humeral lineAnterior humeral line Radiocapitellar lineRadiocapitellar line Radial headRadial head Distal humerusDistal humerus Ulna/olecranonUlna/olecranon
Medial Epicondyle FractureMedial Epicondyle Fracture
~12% of paeds elbow fractures~12% of paeds elbow fractures Common between 10-14 years, majority Common between 10-14 years, majority
malemale Associated with dislocations ~50%Associated with dislocations ~50% MechanismMechanism
Avulsion of epicondyle by forearm flexors with Avulsion of epicondyle by forearm flexors with valgus stressvalgus stress
Medial Epicondyle FractureMedial Epicondyle Fracture
ClassificationClassification Degree of displacement (< or > 5 mm)Degree of displacement (< or > 5 mm) +/- trapped fragment+/- trapped fragment +/- dislocation of elbow+/- dislocation of elbow
Medial Epicondyle FractureMedial Epicondyle Fracture
ManagementManagement Minimally displacedMinimally displaced
Long arm splint Long arm splint 1-2 weeks with early ROM1-2 weeks with early ROM
Displaced >5mmDisplaced >5mm Conservative or operativeConservative or operative
Intra-articular fragmentIntra-articular fragment Surgical removal of fragmentSurgical removal of fragment
Medial Epicondyle FractureMedial Epicondyle Fracture
ComplicationsComplications Ulnar nerve injury 10-16%Ulnar nerve injury 10-16%
More common if intraarticular fragmentMore common if intraarticular fragment
Case 4Case 4
Figure of eightFigure of eight Anterior fat padAnterior fat pad Posterior fat padPosterior fat pad Anterior humeral lineAnterior humeral line Radiocapitellar lineRadiocapitellar line Radial headRadial head Distal humerusDistal humerus Ulna/olecranonUlna/olecranon
Radial Head and Neck Radial Head and Neck FracturesFractures
Radial neck > head fracturesRadial neck > head fractures Often minimal physical findingsOften minimal physical findings MechanismMechanism
FOOSHFOOSH Elbow extended and in valgusElbow extended and in valgus
Associated with other injuries in ~ 50% of casesAssociated with other injuries in ~ 50% of cases
Radial Head and Neck Radial Head and Neck FracturesFractures
Classification Classification By degree of angulationBy degree of angulation
Type IType I < 30° angulation< 30° angulation
Type IIType II 30° -60° angulation30° -60° angulation
Type IIIType III > 60° angulation> 60° angulation
Radial Head and Neck Radial Head and Neck FracturesFractures
ManagementManagement Angulation>15º - closed reductionAngulation>15º - closed reduction Type IType I
Sling/posterior splint X 1-2 weeksSling/posterior splint X 1-2 weeks
Type II and IIIType II and III Percutaneous pining if closed reduction not Percutaneous pining if closed reduction not
adequate (<30°)adequate (<30°)
Radial Head and Neck Radial Head and Neck FracturesFractures
Complications Complications AVN of radial head ~ 10 -20%AVN of radial head ~ 10 -20% Loss of ROMLoss of ROM
rotationrotation
Case 5Case 5
Figure of eightFigure of eight Anterior fat padAnterior fat pad Posterior fat padPosterior fat pad Anterior humeral lineAnterior humeral line Radiocapitellar lineRadiocapitellar line Radial headRadial head Distal humerusDistal humerus Ulna/olecranonUlna/olecranon
Olecranon FractureOlecranon Fracture
~ 5% of elbow fractures~ 5% of elbow fractures More common with increasing ageMore common with increasing age Associated with other injuries (50%)Associated with other injuries (50%) MechanismMechanism
Direct blowDirect blow ShearShear Indirect due to forceful contraction of triceps Indirect due to forceful contraction of triceps
while elbow flexed in fallwhile elbow flexed in fall HyperextensionHyperextension
Olecranon FractureOlecranon Fracture
ManagementManagement Extra-articular Extra-articular
Displaced <3 mmDisplaced <3 mm 3-4 immobilization3-4 immobilization
Displaced >3 mmDisplaced >3 mm Closed reductionClosed reduction ImmobilizeImmobilize
Hyperextension/Shear - cast in flexionHyperextension/Shear - cast in flexion Hyperflexion - cast in extensionHyperflexion - cast in extension
Intra-articularIntra-articular ORIFORIF
Olecranon FractureOlecranon Fracture
ComplicationsComplications Missed injuriesMissed injuries Ulnar nerve injuryUlnar nerve injury Non-unionNon-union ArthritisArthritis Poor extensor strengthPoor extensor strength
ConclusionConclusion
Be vigilant Be vigilant Use a thorough approachUse a thorough approach
Look for associated injuriesLook for associated injuries Think about mechanismThink about mechanism Know how it is treated in your centreKnow how it is treated in your centre
Other fracturesOther fractures
HumeralHumeral SupracondylarSupracondylar TranscondylarTranscondylar IntercondylarIntercondylar CondylarCondylar EpicondylarEpicondylar Articular surface (trochlea/capitellum)Articular surface (trochlea/capitellum)
Radial head/neckRadial head/neck UlnarUlnar
OlecranonOlecranon CoronoidCoronoid
ReferencesReferences
Wheeless’ Textbook of OrthopaedicsWheeless’ Textbook of Orthopaedics
www.radiologyassistant.nlwww.radiologyassistant.nl
www.uptodate.com
http://nypemergency.org/imaging/elbow.html
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
Rosen’sRosen’s
TintinalliTintinalli
Carson S, et al. Pediatric Upper Extremity Injuries. Pediatr Clin N Am 2006;53:41-67.Carson S, et al. Pediatric Upper Extremity Injuries. Pediatr Clin N Am 2006;53:41-67.
Benjamin HJ, et al. Common Acute Upper Extremity Injuries in Sport. Pediatric Emergeny Benjamin HJ, et al. Common Acute Upper Extremity Injuries in Sport. Pediatric Emergeny Medicine 2007: 15-30.Medicine 2007: 15-30.
Gogola GR. Pediatric Humeral Condyle Fractures. Hand Clin 2006;22:77-85. Gogola GR. Pediatric Humeral Condyle Fractures. Hand Clin 2006;22:77-85.
Baratz M, et al. Pediatric Supracondylar Fractures. Hand Clin 2006;22:69-75.Baratz M, et al. Pediatric Supracondylar Fractures. Hand Clin 2006;22:69-75.
Tamai J, et al. Pediatric Elbow Fractures: Pearls and Pitfalls. UPOJ 2002;15:43-51.Tamai J, et al. Pediatric Elbow Fractures: Pearls and Pitfalls. UPOJ 2002;15:43-51.