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Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick, MD; August 2006 Joshua Klatt, MD; Albert Pendleton, MD ; November 2011

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Page 1: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Fractures and Dislocationsabout the Elbow

in the Pediatric Patient

Joshua Klatt, MD

Original Author: Kevin Shea, MD; March 2004

Revised:

Steven Frick, MD; August 2006

Joshua Klatt, MD; Albert Pendleton, MD ; November 2011

Page 2: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Elbow Fractures in Children

• Very common injuries (approximately 65% of pediatric trauma)

• Radiographic assessment - difficult for non-orthopaedists, because of the complexity and variability of the physeal anatomy and development

• A thorough physical examination is essential, because neurovascular injuries can occur before and after reduction

• Compartment syndromes are rare with elbow trauma, but can occur

Page 3: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Elbow FracturesPhysical Examination

• Children will usually not move the elbow if a fracture is present, although this may not be the case for non-displaced fractures

• Swelling about the elbow is a constant feature, except for non-displaced fracture

• Complete vascular exam is necessary, especially in supracondylar fractures– Doppler may be helpful to document vascular status

• Neurologic exam is essential, as nerve injuries are common– In most cases, full recovery can be expected

Page 4: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Elbow FracturesPhysical Examination

• Neurological exam may be limited by the child’s ability to cooperate because of age, pain, or fear.

• Thumb extension – EPL– Radial – PIN branch

• Thumb flexion – FPL– Median – AIN branch

• Cross fingers/scissors - Ad/Abductors– Ulnar

Page 5: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Elbow FracturesPhysical Examination

• Always palpate the arm and forearm for signs of compartment syndrome

• Thorough documentation of all findings is important – A simple record of “neurovascular status is intact” is

unacceptable (and doesn’t hold up in court…)

– Individual assessment and recording of motor, sensory, and vascular function is essential

Page 6: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Elbow FracturesRadiographs

• AP and Lateral views are important initial views– In trauma these views may be less than ideal, because

it can be difficult to position the injured extremity

• Oblique views may be necessary– Especially for the evaluation of suspected lateral

condyle fractures

• Comparison views frequently obtained by primary care or ER physicians– Although these are rarely used by orthopaedists

Page 7: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Elbow FracturesRadiograph Anatomy/Landmarks

• Baumann’s angle is formed by a line perpendicular to the axis of the humerus, and a line that goes through the physis of the capitellum

• There is a wide range of normal for this value– Can vary with rotation of the radiograph

• In this case, the medial impaction and varus position reduces Bauman’s angle

-Baumann E. Beitrage zur Kenntnis der Frakturen am Ellbogengelenk: Unter besonderer Berucksichtigung der Spatfolgen. I. Allgemeines und Fractura supra condylica. Beitr Klin Chir 1929;146:1-50.-Mohammad. The Baumann angle in supracondylar fractures of the distal humerus in children. J Pediatr Orthop. 1999;19:65–69.

Page 8: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

• Anterior Humeral Line– Drawn along the

anterior humeral cortex

– Should pass through the middle of the capitellum

– Variable in very young children

-Rogers. Plastic bowing, torus and greenstick supracondylar fractures of the humerus: radiographic clues to obscure fractures of the elbow in children. Radiology. 1978;128:145.-Herman. Relationship of the anterior humeral line to the capitellar ossific nucleus: variability with age. J Bone Joint Surg. 2009;91:2188.

Elbow FracturesRadiograph Anatomy/Landmarks

Page 9: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

• The capitellum is angulated anteriorly about 30 degrees.

• The appearance of the distal humerus is similar to a hockey stick. 30

Elbow FracturesRadiograph Anatomy/Landmarks

Page 10: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

• The physis of the capitellum is usually wider posteriorly, compared to the anterior portion of the physis

Wider

Elbow FracturesRadiograph Anatomy/Landmarks

Page 11: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

• Radiocapitellar line should intersect the capitellum in all views

• Make it a habit to evaluate this line on every pediatric elbow film

Elbow FracturesRadiograph Anatomy/Landmarks

Page 12: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Supracondylar Humerus Fractures

• Most common fracture around the elbow in children– 60 percent of elbow fractures

• 95 percent are extension type injuries– Produces posterior angulation/displacement of the distal

fragment

• Occurs from a fall on an outstretched hand– Ligamentous laxity and hyperextension of the elbow are

important mechanical factors

• May be associated with a distal radius or forearm fractures

Omid. Supracondylar Humeral Fractures in Children. J Bone Joint Surg. 2008;90:1121.

Page 13: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Supracondylar Humerus FracturesClassification

• Type 1– Non-displaced

• Type 2– Angulated/displaced

fracture with intact posterior cortex

• Type 3– Complete displacement,

with no contact between fragments

Gartland. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959;109:145-54.

Page 14: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Type 1Non-displaced

• Note the non- displaced fracture (Red Arrow)

• Note the posterior fat pad (Yellow Arrows)

-Skaggs. The posterior fat pad sign in association with occult fracture of the elbow in children. J Bone Joint Surg Am. 1999;81:1429. -Bohrer. The fat pad sign following elbow trauma. Its usefulness and reliability in suspecting “invisible” fractures. Clin Radiol. 1970;21:90.

Page 15: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Type 2Angulated/displaced fracture with intact

posterior cortex

Page 16: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

• In many cases, the type 2 fractures will be impacted medially– Leads to varus angulation

• The varus malposition must be considered when reducing these fractures– Apply a valgus force for

realignment

Type 2Angulated/displaced fracture with intact

posterior cortex

Page 17: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Type 3Complete displacement, with no contact

between fragments

Page 18: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Supracondylar Humerus Fractures Associated Injuries

• Nerve injury incidence is high, between 7 and 16 % – Median, radial, and/or ulnar nerve

• Anterior interosseous nerve injury is most commonly injured nerve

• In many cases, assessment of nerve integrity is limited– Children can not always cooperate with the exam

• Carefully document pre-manipulation exam, – Post-manipulation neurologic deficits can alter decision making

Cramer. Incidence of anterior interosseous nerve palsy in supracondylar humerus fractures in children. J Pediatr Orthop. 1993;13:502.

Page 19: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Supracondylar Humerus Fractures Associated Injuries

• 5% have associated distal radius fracture

• Physical exam of distal forearm

• Radiographs if needed• If displaced pin radius

also– Difficult to hold

appropriately in splint

Page 20: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Supracondylar Humerus Fractures Associated Injuries

• Vascular injuries are rare, but pulses should always be assessed before and after reduction

• In the absence of a radial and/or ulnar pulse, the fingers may still be well-perfused, because of the excellent collateral circulation about the elbow

• Doppler device can be used for assessment

White. Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric supracondylar humerus fractures and results of a POSNA questionnaire. J Pediatr Orthop. 2010;30:328.

Page 21: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Supracondylar Humerus Fractures Associated Injuries

• Type 3 supracondylar fracture– Absent ulnar and

radial pulses– Fingers had capillary

refill less than 2 seconds.

• The pink, pulseless extremity

White. Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric supracondylar humerus fractures and results of a POSNA questionnaire. J Pediatr Orthop. 2010;30:328.

Page 22: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Supracondylar Humerus Fractures Anatomy

• The medial and lateral columns are connected by a thin wafer of bone– Approximately 2-3 mm wide in the central

portion

• If the fracture is malreduced, it is inherently unstable – The medial or lateral columns displace easily

into varus or valgus

Page 23: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

• Type 1 Fractures– In most cases, these can be treated with

immobilization for approximately 3 weeks, at 90 degrees of flexion

– If there is significant swelling, do not flex to 90 degrees until the swelling subsides

Supracondylar Humerus Fractures Treatment

Page 24: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Supracondylar Humerus Fractures Treatment

• Type 2 Fractures: Posterior Angulation– If minimally displaced (anterior humeral line hits part

of capitellum)• Immobilization for 3 weeks. • Close follow-up is necessary to monitor for loss of reduction

– Displaced (anterior humeral line misses capitellum)• Reduction may be necessary• The degree of posterior angulation that requires reduction is

controversial• Check opposite extremity for hyperextension

– If varus/valgus malalignment exists, most authors recommend reduction.

Fitzgibbons. Predictors of failure of nonoperative treatment for type-2 supracondylar humerus fractures. J Pediatr Orthop. 2011;31:372.

Page 25: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Type 2 FracturesTreatment

• Reduction of these fractures is usually not difficult– Maintaining reduction usually requires flexion beyond 90°

• Excessive flexion may not be tolerated because of swelling– May require percutaneous pinning to maintain reduction

• Most authors suggest that percutaneous pinning is the safest form of treatment for many of these fractures– Pins maintain the reduction and allow the elbow to be

immobilized in a more extended position

Fitzgibbons. Predictors of failure of nonoperative treatment for type-2 supracondylar humerus fractures. J Pediatr Orthop. 2011;31:372.

Page 26: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Supracondylar Humerus Fractures Treatment

• Type 3 Fractures– These fractures have a high risk of neurologic and/or

vascular compromise– Can be associated with a significant amount of swelling– Current treatment protocols use percutaneous pin

fixation in almost all cases– In rare cases, open reduction may be necessary

• Especially in cases of vascular disruption

Page 27: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Supracondylar Humerus FracturesOR Setup

• The monitor should be positioned across from the OR table, to allow easy visualization of the monitor during the reduction and pinning

-Thometz. Techniques for direct radiographic visualization during closed pinning of supracondylar humerus fractures in children. J Pediatr Orthop. 1990;10:555.-Tremains. Radiation exposure with use of the inverted-c-arm technique in upper-extremity surgery. J Bone Joint Surg Am. 2001;83-A:674.

Page 28: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Supracondylar Humerus FracturesOR Setup

• The C-Arm fluoroscopy unit can be inverted, using the base as a table for the elbow joint

– All personnel in the room should be adequately shielded, as radiation exposure is significantly increased with inverted c-arm

• Also can use radiolucent board • The child should be positioned

close to the edge of the table, to allow the elbow to be visualized by the c-arm– Make sure to secure patient’s head

and body

-Thometz. Techniques for direct radiographic visualization during closed pinning of supracondylar humerus fractures in children. J Pediatr Orthop. 1990;10:555.-Tremains. Radiation exposure with use of the inverted-c-arm technique in upper-extremity surgery. J Bone Joint Surg Am. 2001;83-A:674.

Page 29: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Supracondylar Elbow FracturesType 2 with Varus Malalignment

• During reduction of medially impacted fractures, valgus force should be applied to address this deformity.

Page 30: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Type 3Supracondylar Fracture

Page 31: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Type 3Operative Reduction

• Closed reduction with flexion

• AP view with elbow held in flexed position to maintain reduction.

Page 32: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Brachialis SignProximal Fragment Buttonholed through Brachialis

Page 33: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Milking ManeuverMilk Soft Tissues over Proximal Spike

Archibeck. Brachialis muscle entrapment in displaced supracondylar humerus fractures: a technique of closed reduction and report of initial results. J Pediatr Orthop. 1997;17:298.

Page 34: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Adequate Reduction?

• No varus/valgus malalignment

• Anterior humeral line should be intact

• Minimal rotation• Mild translation is

acceptable

From: Rang’s children’s fractures. Edited by Dennis R. Wenger, MD, and Maya E. Pring, MD. Philadelphia: Lippincott Williams & Wilkins, 2004.

Page 35: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Medial Impaction Fracture

Type II fracture with medial impaction – not recognized and varus / extension not reduced

Page 36: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Medial Impaction Fracture

Cubitus varus 2 years later

Page 37: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Lateral Pin Placement

AP and Lateral views with 2 pins

Page 38: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Pin Configuration

Lee. Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop. 2002;22:440.

Page 39: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

C-arm Views

Oblique views with the C-arm can be useful to help verify the reduction.

Note slight rotation and extension on medial column (right image).

Page 40: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Supracondylar Humerus FracturesPin Fixation

• Different authors have recommended different pin fixation methods

• The medial pin can injury the ulnar nerve– Some advocate 2 or 3 lateral pins to avoid injuring the

median nerve• Space pins as widely as possible

– If the lateral pins are placed close together at the fracture site, the pins may not provide much resistance to rotation and further displacement

• Some recommend one lateral, and one medial pin

Sankar. Loss of pin fixation in displaced supracondylar humeral fractures in children: causes and prevention. J Bone Joint Surg Am. 2007;89:713.

Page 41: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Pitfalls of Pin Placement

• Pins Too Close together• Instability• Fracture displacement• Get one pin in lateral and

one in medial column

Page 42: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Supracondylar Humerus FracturesPin Fixation

• Even many children have anterior subluxation of the ulnar nerve with hyperflexion of the elbow

• Some recommend place two lateral pins, assess fracture stability

• If unstable then extend elbow to take tension off ulnar nerve and place medial pin

Eberl. Iatrogenic ulnar nerve injury after pin fixation and after antegrade nailing of supracondylar humeral fractures in children. Acta Orthop. 2011;82:606.

Page 43: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Supracondylar Humerus Fractures

• After stable reduction and pinning– Elbow can be extended to review the AP radiograph – Baumann’s angle can be assessed on these radiographs

• Remember there can be a wide range of normal values for this measurement

• With the elbow extended, the carrying angle of the elbow should be reviewed, and clinical comparison as well as radiograph comparison can be performed to assure an adequate reduction.

Page 44: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Supracondylar Humerus Fractures

• If pin fixation is used, the pins are usually bent and cut outside the skin

• The skin is protected from the pins by placing Xeroform and a felt pad around the pins

• The arm is immobilized• The pins are removed in the

clinic 3 to 4 weeks later– After radiographs show periosteal

healing• In most cases, full recovery of

motion can be expected

Page 45: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Supracondylar Humerus Fractures: Indications for Open Reduction

• Inadequate reduction with closed methods

• Vascular injury• Open fractures

Page 46: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Supracondylar Humerus Fractures:Complications

• Compartment syndrome

• Vascular injury/compromise

• Loss of reduction/malunion– Cubitus varus

• Loss of motion

• Pin track infection

• Neurovascular injury with pin placement

Bashyal. Complications after pinning of supracondylar distal humerus fractures. J Pediatr Orthop. 2009;29:704.

Page 47: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Supracondylar Humerus Fractures Flexion type

• Rare, only 2%

• Distal fracture fragment anterior and flexed

• Ulnar nerve injury more common

• Reduce with extension

• Often requires 2 sets of hands in OF– Hold elbow at 90 degrees after

reduction to facilitate pinning

Mahan. Operative management of displaced flexion supracondylar humerus fractures in children. J Pediatr Orthop. 2007;27:551.

Page 48: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Flexion Type

Page 49: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Flexion TypePinning

Page 50: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Distal Humeral Complete Physeal Separation

• Often in very young children• May be sign of NAT• Swollen elbow,“muffled

crepitance” on exam• Through area of wider cross

sectional area than SC humerus fx

• Restore alignment, may need pinning

Peterson. Physeal injuries of the distal humerus. Orthopedics. 1992;15:799. Shrader. Pediatric supracondylar fractures and pediatric physeal elbow fractures. Orthop Clin North Am. 2008;39:163.

Page 51: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Lateral Condyle Fractures

• Common fracture, representing approximately 15% of elbow trauma in children

• Usually occurs from a fall on an outstretched arm

Landin. Elbow fractures in children. An epidemiological analysis of 589 cases. Acta Orthop Scand. 1986;57:309.

Page 52: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Lateral Condyle Fractures Jakob Classification

• Type 1– Non-displaced fracture– Fracture line does not cross through the articular surface

• Type 2– Minimally displaced– Fracture extends to the articular surface, but the

capitellum is not rotated or significantly displaced

• Type 3– Completely displaced– Fracture extends to the articular surface, and the

capitellum is rotated and significantly displaced

Jakob. Observations concerning fractures of the lateral humeral condyle in children. J Bone Joint Surg Br. 1975;57:430.

Page 53: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Lateral Condyle Fractures Jakob Type 1

• Oblique radiographs may be necessary to confirm that this is not displaced. Frequent radiographs in the cast are necessary to ensure that the fracture does not displace in the cast.

Page 54: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Lateral Condyle Fractures Jakob Type 2

• Displaced more than 2 mm– On any radiograph

(AP/Lateral/Oblique views)– Reduction and pinning– Closed reduction can be attempted,

but articular reduction must be anatomic

• If residual displacement and the articular surface is not congruous– Open reduction is necessary Fracture line exiting posterior metaphysis

(arrow) typical for lateral condyle fractures

Flynn. Prevention and treatment of non-union of slightly displaced fractures of the lateral humeral condyle in children. An end-result study. J Bone Joint Surg Am. 1975;57:1087.

Page 55: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Lateral Condyle Fractures Jakob Type 3

• ORIF is almost always necessary

• A lateral Kocher approach is used for reduction, and pins or a screw are placed to maintain the reduction

• Careful dissection needed to preserve soft tissue attachments (and thus blood supply) to the lateral condylar fragment, especially avoiding posterior dissection

-Foster. Lateral humeral condylar fractures in children. J Pediatr Orthop. 1985;5:16. -Song. Closed reduction and internal fixation of completely displaced and rotated lateral condyle fractures of the humerus in children. J Orthop Trauma. 2010;24:434.

Page 56: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Lateral Condyle ORIF

Page 57: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Lateral Condyle FracturesComplications

• Non-union– This usually occurs if the

patient is not treated, or the fracture displaces despite casting

– Well-described in fractures which were displaced more than 2 mm and not treated with pin fixation

– Late complication of progressive valgus and ulnar neuropathy reported

Skak. Deformity after fracture of the lateral humeral condyle in children. J Pediatr Orthop B. 2001;10:142.

Page 58: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Lateral Condyle FracturesComplications

• AVN can occur after excessive surgical dissection

• Cubitus varus can occur, may be because of malreduction or a result of lateral column overgrowth

Foster. Lateral humeral condylar fractures in children. J Pediatr Orthop. 1985;5:16.

Page 59: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Medial Epicondyle Fractures

• Represent 5% to 10% of pediatric elbow fractures

• Occurs with valgus stress to the elbow, which avulses the medial epicondyle

• Frequently associated with an elbow dislocation

Landin. Elbow fractures in children. An epidemiological analysis of 589 cases. Acta Orthop Scand. 1986;57:309.

Page 60: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Medial Epicondyle FracturesClassification

• No good systematic method of classification

• Studies vary on how to measure displacement

• Should take into consideration displacement on both the AP and lateral

• Amount of rotational displacement is also important

Pappas. Intraobserver and interobserver agreement in the measurement of displaced humeral medial epicondyle fractures in children. J Bone Joint Surg Am. 2010;92:322.

Page 61: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Medial Epicondyle FracturesTreatment

• Nondisplaced and minimally displaced– Less than 5 mm of

displacement– May be treated without

fixation– Early motion to avoid

stiffness (3 to 4 weeks)

Page 62: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Medial Epicondyle FracturesTreatment

• Displaced more than 5 mm– Treatment is controversial– Some recommending operative,

others non-operative treatment– Some have suggested that surgery

is indicated in the presence of valgus instability, or in patients who are throwing athletes.

• Only absolute indication is entrapped fragment after dislocation with incongruent elbow joint

– First attempt closed reduction• Long term studies favor

nonoperative treatment

Kamath. Operative versus non-operative management of pediatric medial epicondyle fractures: a systematic review. J Child Orthop. 2009;3:345. Farsetti. Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am. 2001;83-A:1299.

Page 63: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Medial Epicondyle FractureElbow dislocation with Medial Epicondyle Avulsion

Medial EpicondyleAvulsion

After attempted elbow reduction, medial epicondyleavulsion fragment is obvious

Page 64: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Medial Epicondyle FractureElbow dislocation with Medial Epicondyle Avulsion

Treated with ORIF

Page 65: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Medial Epicondyle FractureExample of Nonoperative Treatment

• 12 year old female UE weight bearing athlete

• Treated nonoperatively

• Full motion, no valgus instability at 6 weeks

• Returned to competition at 8 weeks

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Olecranon Fractures

• Relatively rare fracture in children– Increased incidence in children with OI

– May be associated with elbow subluxation/ dislocation, or radial head fracture

• The diagnosis may be difficult in a younger child– Olecranon does not ossify until 8-9 years

• In older children, the fracture may occur through the olecranon physis

• Anatomic reduction is necessary in displaced fractures to restore normal elbow extension.

Caterini. Fractures of the olecranon in children. Long-term follow-up of 39 cases. J Pediatr Orthop B. 2002;11:320.

Page 67: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Olecranon Fractures

• Olecranon fracture treated with ORIF in 14 year old, with tension band fixation.

Parent. Displaced olecranon fractures in children: a biomechanical analysis of fixation methods. J Pediatr Orthop. 2008;28:147.

Page 68: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Rare Distal Humeral Fractures

• Lateral Epicondyle– Rare– Usually represent a small

avulsion fracture– Treated with early mobilization

• T-Condylar fractures– Occur in patients that are almost

skeletally mature– Treatment similar to adult intra-

articular elbow fractures• Medial Condyle

– Rare– Treated with ORIF if displaced

Beaty JH. Elbow fractures in children and adolescents. Instr Course Lect. 2003;52:661–665.

Page 69: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Proximal Radius Fractures

• 1% of children’s fractures

• 90% involve physis or neck

• Normally some angulation of head to radial shaft (0-15 degrees)

• No ligaments attach to head or neck

• Much of radial neck extraarticular (no effusion with fracture)

Vocke. Displaced fractures of the radial neck in children: long-term results and prognosis of conservative treatment. J Pediatr Orthop B. 1998;7:217.

Page 70: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Proximal Radius FracturesTypes

• Valgus fractures– Salter I or II– Intra-articular fractures

rare

• Metaphyseal fractures• Associated with elbow

dislocations or proximal ulna fractures

• Can be completely displaced, rotated

Vocke. Displaced fractures of the radial neck in children: long-term results and prognosis of conservative treatment. J Pediatr Orthop B. 1998;7:217.

Page 71: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Proximal Radius Fractures Treatment

• Greater than 30° angulation– Attempt manipulation– Usually can obtain

acceptable reduction in fractures with less than 60° angulation

– Traction, varus force in supination & extension, flex and pronate

– Ace wrap or Esmarch reduction

Evans. Radial neck fractures in children: a management algorithm. J Pediatr Orthop B. 1999;8:93.

Page 72: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Proximal Radius Fractures Treatment

• Unable to reduce closed– Percutaneous pin

reduction

– Intramedullary pin reduction

– Open reduction via lateral approach

-Vocke. Displaced fractures of the radial neck in children: long-term results and prognosis of conservative treatment. J Pediatr Orthop B. 1998;7:217.-Metaizeau. Reduction et fixation des fractures et decollements épiphyssaires de la tête radial par broche centromedullaire. Rev Chir Ortop 1980;66:47-9.-González-Herranz. Displaced radial neck fractures in children treated by closed intramedullary pinning (Metaizeau technique). J Pediatr Orthop. 1997;17:325.

Page 73: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Completely Displaced, Malrotated Radial Neck Fracture

After closed reduction the articular surface (arrow) is facing distally, 180 degrees malrotated

Page 74: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Proximal Radial Fractures Complications

• Loss of forearm rotation

• Radial head overgrowth

• Premature physeal closure – valgus

• Nonunion of radial neck rare

• AVN

• Proximal synostosis

Vocke. Displaced fractures of the radial neck in children: long-term results and prognosis of conservative treatment. J Pediatr Orthop B. 1998;7:217.

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100% Displaced Failed Closed Reduction

Page 76: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Open “closed” reductionBlunt pin to push radial head back onto neck

Page 77: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Pin fixation augmented by cast for 3 weeks

Page 78: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Monteggia LesionsUlnar Fracture-Radial Head Dislocation

Bado Classification

• Type I – anterior radial head dislocation

• Type II – posterior radial head dislocation

• Type III – lateral radial head dislocation

• Type IV – associated fracture of radius

Bado JL. The Monteggia lesion. Clin Orthop Relat Res. 1967;50:71–86. Wilkins. Changes in the management of monteggia fractures. J Pediatr Orthop. 2002;22:548.

Page 79: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Monteggia Lesions

• Most important is to make the diagnosis initially

• Radiocapitellar line critical

• A commonly missed diagnosis

• Every ulna fracture should have good elbow joint radiographs to avoid missing Monteggia lesion

Page 80: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Monteggia Lesions

• Be wary of plastic deformation of ulna or minimally displaced ulna fracture with radial head dislocation

• On lateral radiograph the ulna should be straight Note anterior bow of ulnar

shaft, and anterior radial head dislocation

Page 81: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Monteggia LesionsInitial Treatment

• Closed reduction of ulnar angulation

• Direct pressure over radial head

• Usually will reduce with palpable clunk

• Immobilize in reduced position

• Supinate forearm for anterior dislocations

• Frequent radiographic follow-up to document maintenance of reduction

Wilkins. Changes in the management of monteggia fractures. J Pediatr Orthop. 2002;22:548.

Page 82: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Monteggia Lesions

• If unable to obtain or maintain reduction of radial head– Operative stabilization of

ulnar fracture to correct angulation

– Oblique fractures may need plate fixation

– Assess radial head stability

– Flexion may help for anterior dislocation

Wilkins. Changes in the management of monteggia fractures. J Pediatr Orthop. 2002;22:548.

Page 83: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Missed Monteggia Lesion

Healed prox ulna fx with anterior bow

Anterior radial head dislocation and heterotopic ossification

Page 84: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Missed Monteggia LesionsPossible Long Term Sequelae

• Progressive valgus

• Proximal radial migration with disruption of normal forearm and distal radioulnar joint mechanics

• Posterior interosseous nerve traction palsy

• Collateral ligament instability

Nakamura. Long-term clinical and radiographic outcomes after open reduction for missed Monteggia fracture-dislocations in children. J Bone Joint Surg. 2009;91:1394.

Page 85: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Missed Monteggia Lesions Treatment Options

• Annular ligament reconstructions– Bell-Tawse

– Fascia lata

– Peterson

• Ulnar osteotomy

• Combination

• Transcapitellar pinning

• Be wary of possible pin breakage

-Nakamura. Long-term clinical and radiographic outcomes after open reduction for missed Monteggia fracture-dislocations in children. J Bone Joint Surg. 2009;91:1394.-Wilkins. Changes in the management of monteggia fractures. J Pediatr Orthop. 2002;22:548.

Page 86: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Missed Monteggia LesionsUlnar Osteotomy and Radiocapitellar Pin

Page 87: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Bibliography• Archibeck MJ, Scott SM, Peters CL. Brachialis muscle entrapment in displaced supracondylar humerus fractures: a

technique of closed reduction and report of initial results. J Pediatr Orthop. 1997 Apr.;17(3):298–302.

• Bado JL. The Monteggia lesion. Clin Orthop Relat Res. 1967;50:71–86.

• Baumann E. Beitrage zur Kenntnis der Frakturen am Ellbogengelenk: Unter besonderer Berucksichtigung der Spatfolgen. I. Allgemeines und Fractura supra condylica. Beitr Klin Chir 1929;146:1-50.

• Bashyal RK, Chu JY, Schoenecker PL, Dobbs MB, Luhmann SJ, Gordon JE. Complications after pinning of supracondylar distal humerus fractures. J Pediatr Orthop. 2009 Sep.;29(7):704–708.

• Beaty JH. Elbow fractures in children and adolescents. Instr Course Lect. 2003;52:661–665.

• Bohrer SP. The fat pad sign following elbow trauma. Its usefulness and reliability in suspecting “invisible” fractures. Clin Radiol. 1970 Jan.;21(1):90–94.

• Caterini R, Farsetti P, D'Arrigo C, Ippolito E. Fractures of the olecranon in children. Long-term follow-up of 39 cases. J Pediatr Orthop B. 2002 Oct.;11(4):320–328.

• Cramer KE, Green NE, Devito DP. Incidence of anterior interosseous nerve palsy in supracondylar humerus fractures in children. J Pediatr Orthop. 1993 Jun.;13(4):502–505.

• Eberl R, Eder C, Smolle E, Weinberg AM, Hoellwarth ME, Singer G. Iatrogenic ulnar nerve injury after pin fixation and after antegrade nailing of supracondylar humeral fractures in children. Acta Orthop. 2011 Oct.;82(5):606–609.

• Evans MC, Graham HK. Radial neck fractures in children: a management algorithm. J Pediatr Orthop B. 1999 Apr. 1;8(2):93–99.

• Farsetti P, Potenza V, Caterini R, Ippolito E. Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am. 2001 Sep. 1;83-A(9):1299–1305.

• Fitzgibbons PG, Bruce B, Got C, Reinert S, Solga P, Katarincic J, et al. Predictors of failure of nonoperative treatment for type-2 supracondylar humerus fractures. J Pediatr Orthop. 2011 Jun.;31(4):372–376.

Page 88: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Bibliography• Flynn JC, Richards JF, Saltzman RI. Prevention and treatment of non-union of slightly displaced fractures of the

lateral humeral condyle in children. An end-result study. J Bone Joint Surg Am. 1975 Dec.;57(8):1087–1092.

• Foster DE, Sullivan JA, Gross RH. Lateral humeral condylar fractures in children. J Pediatr Orthop. 1985;5(1):16–22.

• Gartland. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959;109:145-54.

• González-Herranz P, Alvarez-Romera A, Burgos J, Rapariz JM, Hevia E. Displaced radial neck fractures in children treated by closed intramedullary pinning (Metaizeau technique). J Pediatr Orthop. 1997;17(3):325–331.

• Herman MJ, Boardman MJ, Hoover JR, Chafetz RS. Relationship of the anterior humeral line to the capitellar ossific nucleus: variability with age. J Bone and Joint Surg. 2009 Sep.;91(9):2188–2193.

• Jakob R, Fowles JV, Rang M, Kassab MT. Observations concerning fractures of the lateral humeral condyle in children. J Bone Joint Surg Br. 1975 Nov.;57(4):430–436.

• Kamath AF, Baldwin K, Horneff J, Hosalkar HS. Operative versus non-operative management of pediatric medial epicondyle fractures: a systematic review. J Child Orthop. 2009 Oct. 1;3(5):345–357.

• Landin LA, Danielsson LG. Elbow fractures in children. An epidemiological analysis of 589 cases. Acta Orthop Scand. 1986 Aug.;57(4):309–312.

• Lee SS, Mahar AT, Miesen D, Newton PO. Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop. 2002 Jun.;22(4):440–443.

• Mahan ST, May CD, Kocher MS. Operative management of displaced flexion supracondylar humerus fractures in children. J Pediatr Orthop. 2007 Jun.;27(5):551–556.

• Metaizeau JP, Prevot J, Schmitt M. [Reduction and fixation of fractures of the neck of the radious be centro-medullary pinning. Original technic]. Rev Chir Orthop Reparatrice Appar Mot. 1980;66(1):47–49.

Page 89: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Bibliography• Mohammad S, Rymaszewski LA, Runciman J. The Baumann angle in supracondylar fractures of the distal humerus

in children. J Pediatr Orthop. 1999;19(1):65–69.

• Nakamura K, Hirachi K, Uchiyama S, Takahara M, Minami A, Imaeda T, et al. Long-term clinical and radiographic outcomes after open reduction for missed Monteggia fracture-dislocations in children. J Bone and Joint Surg. 2009 Jun.;91(6):1394–1404.

• Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. The Journal of Bone and Joint Surgery. 2008 May;90(5):1121–1132.

• Pappas N, Lawrence JT, Donegan D, Ganley T, Flynn JM. Intraobserver and interobserver agreement in the measurement of displaced humeral medial epicondyle fractures in children. J Bone Joint Surg Am. 2010 Feb. 1;92(2):322–327.

• Parent S, Wedemeyer M, Mahar AT, Anderson M, Faro F, Steinman S, et al. Displaced olecranon fractures in children: a biomechanical analysis of fixation methods. J Pediatr Orthop. 2008 Mar.;28(2):147–151.

• Rang’s children’s fractures. Edited by Dennis R. Wenger, MD, and Maya E. Pring, MD. Philadelphia: Lippincott Williams & Wilkins, 2004.

• Rogers. Plastic bowing, torus and greenstick supracondylar fractures of the humerus: radiographic clues to obscure fractures of the elbow in children. Radiology. 1978;128:145.

• Sankar WN, Hebela NM, Skaggs DL, Flynn JM. Loss of pin fixation in displaced supracondylar humeral fractures in children: causes and prevention. J Bone Joint Surg Am. 2007 Apr.;89(4):713–717.

• Skaggs DL, Mirzayan R. The posterior fat pad sign in association with occult fracture of the elbow in children. J Bone Joint Surg Am. 1999 Oct.;81(10):1429–1433.

Page 90: Fractures and Dislocations about the Elbow in the Pediatric Patient Joshua Klatt, MD Original Author: Kevin Shea, MD; March 2004 Revised: Steven Frick,

Bibliography• Skak SV, Olsen SD, Smaabrekke A. Deformity after fracture of the lateral humeral condyle in children. J Pediatr

Orthop B. 2001 Apr.;10(2):142–152.

• Thometz JG. Techniques for direct radiographic visualization during closed pinning of supracondylar humerus fractures in children. J Pediatr Orthop. 1990 Jun.;10(4):555–558.

• Tremains MR, Georgiadis GM, Dennis MJ. Radiation exposure with use of the inverted-c-arm technique in upper-extremity surgery. J Bone Joint Surg Am. 2001 May;83-A(5):674–678.

• Vocke AK, Laer von L. Displaced fractures of the radial neck in children: long-term results and prognosis of conservative treatment. J Pediatr Orthop B. 1998 Jul. 1;7(3):217–222.

• White L, Mehlman CT, Crawford AH. Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric supracondylar humerus fractures and results of a POSNA questionnaire. J Pediatr Orthop. 2010 Jun.;30(4):328–335.

• Wilkins KE. Changes in the management of monteggia fractures. J Pediatr Orthop. 2002;22(4):548–554.

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