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Elbow fractures of the child

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Supracondylar humeral fractures

It is the second most common obstetric fracture. Treatment by tube traction for 10 days (Fig 13). With this “crafty” method, residual angulation is perfectly reshaped due to early age.

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Figure 14
. Depending on the degree of displacement, supracondylar humeral fractures fall into three types.


They are often associated with vascular and / or nerve damage. Therefore, a test for arterial pulses, along with a test assessing the function of the muscles of the hand are strongly advised.

The elbow should be immobilized in a 30-50 degrees flexion during transport to hospital or operating room (do NOT flex the elbow to 90 degrees, since there is a higher risk for arterial entrapment, which can potentlially lead to limb ischemia) (Fig. 14B) .
 

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Figure 14B. It is important, during transport, to not bend the elbow too much in a supracondylar fracture. In this case the splint keeps the elbow at 40 °, and we are assessing the arterial pulse.

Treatment:

  • Undisplaced fractures (Gartland I): immobilization with plaster splint for 3 weeks.
  • Displaced fractures (Gartland II-III) (Fig 15): closed reduction under anesthesia, Kirschner wire fixation, and immobilization with a plaster cast. In general, avoid the use of needles on the inner side of the elbow due to the risk of injury to the ulnar nerve. It is sometimes necessary to perform an open reduction (with skin incision).
  • The needles and the splint are removed after 3 weeks. Formal physical therapy is usually not required.
     

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Figure 15
. Supracondylar humeral fracture treated with closed reduction and Kirschner-wire fixation.


Complications:

Supracondylar fractures may present multiple complications if not properly treated. For this reason, pediatric orthopedists should be the ones managing these patients. Some of the most typical adverse events are:

Cubitus varus (Fig 16):

The fracture binds in an angled manner, with the forearm deflected inwards. This deformity is not corrected by remodeling capacity, and if severe it may cause elbow problems. It is surgically treated by an osteotomy: cutting the bone to properly align the forearm. Depending on age, the fracture is fixed by needles or a plate with screws.
 

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Figure 16
. Cubitus varus deformity, because of inadequate reduction of a supracondylar fracture.

Volkmann’s ischemia

Due to the fracture, or during the reduction, the brachial artery can get trapped, thus leading to a loss of the blood supply to the limb. It is therefore imperative to track pulses and capillary filling at all times in a supracondylar fracture: before, during and after surgery.


Lateral humeral condle fractures

It is a common fracture in children. The lateral side of the distal humerus is affected. Typically seen in children 4-10 years. It is a very unstable fracture because of the presence of strong muscle attachments, with a high incidence of non-union when conservatively treated. Therefore, non-displaced fractures treated conservatively require weekly radiographic control to ensure non-displacement.

Surgical treatment consists of reduction and Kirschner-wire fixation for 4-5 weeks (Fig 18).

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Figure 18 A
. Non-displaced humeral condyle fracture. Must be followed with thoroughly checks due to the inherent high risk of displacement.


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Figure 18B
. Humeral condyle fracture, treated surgically with two Kirschner-wires.


Medial epicondyle avulsion fractures (Fig 19)

Typically seen in children 9-13 years. 50% associated with a dislocated elbow. They present a great tendency to develop a flexion contracture of the elbow with immobilization; therefore, functional treatment with early mobilization and / or stable osteosynthesis (cannulated screws) is strongly recommended.

The indications for surgical treatment remain controversial.
 

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Figure 19A
. Avulsion fracture of the medial epicondyle of the elbow.


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Figure 19B
. Avulsion fracture of the medial epicondyle of the elbow treated with a screw after the reduction in the operating room.


Fractures of the neck of the radius

Treatment depends on the degree of angulation of the radial head:

  • <30 º - 90 º brachial immobilization, neutral position for 3 weeks (Figure 20A).
  • 30 ° - Closed reduction + intramedullary needle fixation according to Metaizeau technique + brachial splint for 3 weeks (Fig 20B).
  • Open reduction should be avoided, given the high incidence of developing elbow stiffness.
     

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Figure 20A
. Fracture of neck of radius, slightly angled. It does not require treatment, as it will eventually remodel over time.


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Figura 20B
. Fracture of neck of radius, significantly angled. Treated surgically with Meteizeau technique.

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