Supracondylar

Introduction:  

• One of the most common pediatric fractures seen, mechanism tends to be fall on an outstretched hand
  • extension type most common (95-98%)
  • flexion type less common (<5%)
• When reviewing x-rays of the elbows, consider ossification/appearance and age of fusion (two independent events)
  • C-R-I-T-O-E mnemonic to remember age of ossification

Classification:

• Type 1: Non-displaced (posterior fat pad sign on lateral view of x-ray)
  • Treated with posterior long arm splint in ED
  • Urgent Orthopedics follow up for cast immobilization x 3-4 weeks
• Type 2: Displaced (“hinge” fracture with posterior cortex intact)
  • Treated with cast immobilization in the ED
  • Urgent Orthopedics follow up radiographs in 1-2 weeks
• Type 3: Completely displaced (+/- distraction)
  • Treated with closed reduction and percutaneous pinning by orthopedics
  • Non-emergent (overnight) operation unless neurovascular compromise

Complications:

• Vascular compromise (<20%)
  • often maintains circulation secondary to rich collateral supply
• Associated distal radius fracture
  • consider routine forearm x-rays with elbow pathology 

• Anterior interosseous nerve (AIN) neuropraxia (most common)
  • unable to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger (can’t make A-OK sign)
• Radial nerve neuropraxia (second most common)
  • • inability to extend wrist, MCP joints, thumb IP joint
• Median nerve neuropraxia
  • • • loss of sensation over volar index finger
• Ulnar nerve neuropraxia (tends to be flexion-type injuries)

Lateral Condyle

Introduction:  

• Second most common fracture in the pediatric elbow and are characterized by a higher risk of nonunion, malunion, and avascular-necrosis than other pediatric elbow fractures.
  • <20% of all pediatric distal humerus fractures
  • “Pull-off” mechanism: avulsion fracture from the pull of the common extensor musculature
  • “Push-off” mechanism: fall onto an outstretched hand causes impaction of radial head to the lateral condyle
• When reviewing x-rays of the elbows, consider ossification/appearance and age of fusion (two independent events)
  • last ossification center to appear (around 12 years of age)
  • need internal oblique view (fracture is posterolateral)

Classification:

• Type 1: <2 mm fracture displacement
  • Treated with cast immobilization in the ED
  • Urgent orthopedics follow up in 1 week for radiographs
• Type 2: Between 2 and 4 mm fracture displacement
  • Treated with closed reduction and fixation
• Type 3: >4 mm fracture displacement
  • Treated with open reduction and fixation

Complications:

• Stiffness (most common complication)
  • can be a early sign of non-union or delayed union
• Nonunion (higher incidence than other elbow fractures)
  • risk factors include nonsurgical management
• AVN (occurs up to three years after fracture)
  • risk factors include posterior dissection
• Lateral overgrowth/prominence
  • up to 50% regardless of treatment
  • spurring is correlated with greater initial fracture displacement

Medial Condyle

Introduction:  

• Third most common fracture in the pediatric elbow and are increasing in incidence due to increased athletic demands of children
  • 75% occur in boys between 9-14 years old
  • Avulsion mechanism: avulsion fracture from the pull of the ulnar collateral ligament
  • Direct trauma
• 50-60% associated with elbow dislocations
• When reviewing x-rays of the elbows, consider ossification/appearance and age of fusion (two independent events)
  • last and final ossification center to fuse (around 16 years of age)
  • need internal oblique view

Classification:

• Acute
  • Nondisplaced, displaced, or fragment entrapped in joint
• Chronic
  • related to tension stress injuries
• Treatment is nonoperative with cast immobilization
  • ORIF if displacement with entrapment of medial epicondyle fragment in joint

Complications:

• Stiffness (most common complication)
• Nonunion (majority are asymptomatic)
• Neuropraxia/Nerve Injury (ulnar nerve)

Alternative Diagnosis:

• Little League Elbow (medial epicondyle stress fracture)
  • Risk factors include: >80 pitches per game, >8 months of competitive pitching per year, Fastball speed >85 mph
  • Pain with valgus stress and tenderness to palpation of medial elbow
  • Treatment is rest, activity modifications, and physical therapy

Olecranon

Introduction:  

• Uncommon fracture of children
  • <5% of all pediatric fractures
  • FOOSH mechanism with elbow in flexion OR extension
  • Direct trauma mechanism
• Olecranon avulsion fractures are highly suspicious for Osteogenesis Imperfecta
• When reviewing x-rays of the elbows, consider ossification/appearance and age of fusion (two independent events)
  • fusion of the olecranon occurs from anterior to posterior
  • partial closure may be mistaken for olecranon fracture

Classification:

• Acute
  • Nondisplaced
• Chronic
  • related to tension stress injuries
• Treatment is nonoperative with cast immobilization
  • ORIF if displacement or unstable fracture

Complications:

• Stiffness (most common complication)
• Nonunion 
• Delayed union
• Neuropraxia (ulnar nerve)

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Other Helpful Resources

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• PEM Currents
• Orthobullets
• PEMPlaybook
• Don’t Forget The Bubbles