Elbow Fractures in Children: Diagnosis and Management

Wrist and elbow fracture detection and segmentation by artificial intelligence using point-of-care ultrasound

PURPOSE

Distal radius (wrist) and supracondylar (elbow) fractures are common in children presenting to Pediatric Emergency Departments (EDs). These fractures are treated conservatively or surgically depending on deformity severity. Radiographs are typically used for diagnosis but can increase wait times due to the need for radiation-safe rooms. Ultrasound (US) offers a radiation-free, faster alternative that can be performed at triage, but its noisy images are challenging to interpret.

METHODS

We developed an artificial intelligence (AI) technique for the automatic diagnosis of fractures at the wrist and elbow. While most AI for diagnosis focuses on classification results only, we applied a more explainable pipeline that used US bony region segmentation from a CNN as the basis of fracture detection. Our approach was validated on 3,822 wrist US images and 1487 elbow US images. We compared the fracture detection results from classification models and multi-channel segmentation models.

RESULTS

Combining the segmentation results with the original images showed superior performance in fracture detection at the individual patient level, achieving an accuracy of 0.889 and 0.750, sensitivity of 0.818 and 1.000, and specificity of 1.000 and 0.714 on the wrist and elbow dataset respectively. Besides, the multi-channel U-Net architecture effectively detected bony fracture regions in wrist US images.

CONCLUSION

These findings demonstrate that AI models can enable reliable, automatic wrist and elbow fracture detection in pediatric EDs, potentially reducing wait times and optimizing medical resource use.

Ipsilateral Supracondylar and Medial Epicondyle Humerus Fractures in Pediatric Patients: A Retrospective Analysis of Incidence, Epidemiology, Treatment, and Outcomes

BACKGROUND

Pediatric supracondylar humerus (SCH; AO/OTA13-M/3.1) and medial epicondyle fractures (AO/OTA13u-M/7.1) are common. Concomitant SCH with ipsilateral medial epicondyle fractures remain scarcely reported. We investigated the epidemiology, treatment, and outcomes of this rare, combined injury.

METHODS

A retrospective review of pediatric patients with concomitant SCH and medial epicondyle fractures at a level 1 hospital from 2010 to 2020 was performed. Patient data, treatments, and outcomes were assessed. Radiographs were reviewed for fracture classification and alignment. Patients aged above 18 years and those with inaccessible imaging were excluded. Descriptive statistics were performed.

RESULTS

Of 3344 patients undergoing surgery for SCH fractures, 14 (6 females, mean: 10.59 y) with concomitant SCH and medial epicondyle fractures were included. Overall, 28.6% of patients exhibited preoperative nerve palsies (3 PIN, 1 median nerve). There was 1 flexion type and 13 Gartland type III SCH fractures. Medial epicondyle fracture displacement averaged 4.13 mm (range: 2 to 7 mm). Thirteen medial epicondyle fractures occurred medial to the physis with 1 through the physis. Eight patients (57.1%) had medial fixation-7 medial pins, 1 medial screw-which captured both the medial epicondyle and medial column of the SCH fracture. Six medial epicondyles were treated closed. The average time to pin pull was 33.1 days (range: 27 to 51 d) with average follow-up of 138.6 days (range: 27 to 574 d). Overall, 50% of patients completed physical therapy (PT). Complications occurred in 4 cases: prominence of a medial pin, 1 patient required additional PT and dynamic splinting for loss of functional extension, 1 patient underwent a manipulation under anesthesia 3.5 months postoperatively for flexion contracture, and 1 patient developed medial epicondyle nonunion and SCH malunion that underwent corrective osteotomy 10.5 months postoperatively.

CONCLUSIONS

Concurrent SCH and medial epicondyle fractures exhibited a high rate of nerve palsy (28.6%) and complications (28.6%) and were frequently referred to physical therapy. While patients treated without medial fixation went on to union, this combined injury might represent a relative indication for medial pinning of the SCH fracture. Further studies on this rare injury pattern are needed to determine optimal treatment methods.

LEVEL OF EVIDENCE

Level IV-therapeutic.

Gartland type III extension supracondylar humerus fracture in a 10-year-old child. A surgical case report of an infrequent technique of medial and lateral column stabilization

INTRODUCTION AND IMPORTANCE

Supracondylar humeral fractures in children are the most common fractures of the elbow accounting for 16 % of all pediatric fractures. The treatment depends on age, the degree of displacement, and the presence of additional injuries.

PRESENTATION OF CASE

A case reports a 10-year-old girl with a Gartland type III supracondylar humeral fracture accompanied by anterior interosseous nerve neurapraxia preoperatively. The patient was treated operatively with medial and lateral column cross-pinning using four K-wires due to unsatisfactory closed reduction and lateral pinning only. Follow-up examinations performed in 1 and 6 months postoperatively revealed a 10° flexion contracture of the elbow with good functional and radiological results otherwise.

CLINICAL DISCUSSION

The main intervention was not focused on the AIN neuropraxia itself but on unsatisfactory closed reduction followed by cross-fixation with lateral pinning only. A standard anterior approach to visualize the fracture line, free interposing tissues, and perform stabilization was utilized. The unusual use of an additional medial pin formed a cross-frame to adequately support the medial cortex.

CONCLUSION

Closed reduction and percutaneous pinning are the preferred treatment options for most displaced supracondylar fractures. The open reduction via anterior approach and pinning for Gartland type III fracture gives good outcomes. Medial pinning is mandatory in particular fracture patterns and in case of unsatisfactory closed reduction. In the presented case medial and lateral column cross-pinning technique using four K-wires guaranteed no subsequent displacement on follow-up assessment and good results.

Using the radiocoronoid line for diagnosis of elbow dislocation

The radiocapitellar line (RCL) has been widely used to diagnose elbow dislocation. However, there are limitations to the RCL, with the cartilaginous portion of bone making interpretation of radiographs difficult. The study aims to show that the radiocoronoid line, which connects two points on the medial aspect of the radius, proximal to the radial tuberosity, is more suited to diagnose elbow dislocations in the anterior-posterior projection. This study also observes factors affecting accuracy of the radiocapitellar line. The radiographs of 50 normal and 17 laterally dislocated elbows were obtained. An unbiased independent reviewer drew the radiocoronoid and radiocapitellar line (RCL). Four other blinded independent reviewers drew the RCL and the radiocoronoid line for 20 radiographs and repeated the process a week later. The accuracy of the RCL was assessed using distance away from bisection point of capitellum, and ratio (distance from the point where line crosses capitellum to lateral aspect of capitellum over the total width of capitellum). The relationship of the radio-coronoid line and the lateral aspect of coronoid fossa was assessed, with dislocation being the line lateral to it and normal being medial to or on it. The radiocoronoid line had a higher accuracy (95.5%) compared to RCL (32.8%), higher specificity (94%) compared to RCL (10%) as well as higher positive predictive value (85%) compared to RCL (27.4%). There was no intra- or inter-observer variability for the radio-coronoid line. Skeletal age statistically predicted the ratio for the male population ( P < 0.05), however, the independent variables did not statistically predict the dependent variables for the female and total population. The radiocoronoid line serves as an additional method to assess radiocapitellar joint lateral dislocation. It is more accurate and reliable than the radiocapitellar line in the anterior-posterior projection. Sex and skeletal age also influence the accuracy of the radiocapitellar line with the radiocapitellar line nearing the bisection point as skeletal age in males increases.

Learning Curve of Closed Reduction and Internal Fixation for Supracondylar Fractures of the Humerus in Children

BACKGROUND

This study aimed to identify the threshold for success in supracondylar humeral fracture surgery by describing the learning curve for beginners and exploring the relationship between the learning curve and the prognosis of supracondylar fractures of the humerus.

METHODS

Surgical information was collected of the first 100 humeral fractures treated by four pediatric orthopedic surgeons. The relationship between operation time, wire placement success rate, and surgical experience was determined using the restricted cubic strip (RCS). The inflection point in the curve and other risk factors that may affect fracture prognosis were collected and subjected to multiple logistic regression to clarify the relationship between the learning curve and prognosis of supracondylar fractures of the humerus. After the training, the four fresh surgeons were interviewed in the form of questionnaires to get feedback from the trainees.

RESULTS

A total of 400 supracondylar fractures of the humerus from four pediatric orthopedists were included in the study. On an RCS analysis, 65 surgical experiences were the inflection point of the learning curve. Before and after these 65 surgical experiences, there were significant differences in the patients' anatomical reduction (186 vs. 122, P < 0.001), conversion to incision (33 vs. 6, P = 0.008), and supervising physician guidance (28 vs. 2, P < 0.001). In the multiple logistic regression analysis, functional recovery after supracondylar fractures of the humerus was significantly associated with surgical experience, intraoperative conversion to incision, and post-operative infection. Four surgeons and a supervisor were interviewed. They believed that self-confidence establishment requires the experience accumulation of about 30 operations. The most critical surgical technique is the reduction of fractures.

CONCLUSIONS

Although the accumulated experience of 30 operations can establish the self-confidence of trainers, fresh surgeons must accumulate experience with 65 operations to master closed reduction and internal fixation for supracondylar fractures. Surgical experience significantly impacts the post-operative recovery of patients with fractures.

LEVEL OF EVIDENCE

Level III.

Humerus trochlear angle (HTa)-a possible alternative for Baumann angle in the reduction of supracondylar humerus fractures

BACKGROUND

The supracondylar humerus fractures are the most common fracture in children's elbows. Generally, close reduction and percutaneous pinning can provide satisfactory outcomes after adequate reduction. Baumann angle is commonly used to evaluate reduction quality, however, it may fail to assess reduction well when the elbow is in flexion and/or when the patient is young. We conducted this study to evaluate the potential value of the humerus trochlear angle (HTa) for the reduction evaluation and compare it with the Baumann angle.

METHODS

We retrospectively reviewed supracondylar humerus fractures in our trauma center from 2016 to 2019. Patients were grouped as followed: in the HTa group, an arthrogram was used to evaluate the HTa angle and reduction (HTa, defined by the intersection of the axis of the humerus shaft and the tangent of the articular surface of the trochlear); In the Baumann group, the Baumann angle was used to assess the reduction. Baumann angle ratio (BA of injured side/BA of contralateral side) was calculated to evaluate the reduction quality between groups. Flynn's grading criteria were utilized to evaluate both function and cosmetic outcomes in two groups during the follow-up. Operation time, fluoroscopy shots, complications and Flynn's grading scores were compared between groups.

RESULTS

A total of 57 patients with an average age of 4.62 years and follow-up duration of 21.49 ± 5.40 months were included in the analysis. The gender and age distributions were similar in the two groups. Fluoroscopy shots in the HTa group were significantly less than in Baumann group (16.17 ± 0.73 vs. 21.85 ± 0.78, p < 0.0001), and operation time were also less in HTa group (45.78 ± 1.96 min vs. 62.21 ± 1.58 min, p < 0.0001). Baumann ratio showed no significant difference between the two groups (1.002 ± 0.023 in the Baumann group and 1.01 ± 0.023 in HTa group, p < 0.0001). Length of hospitalization, complications, and Flynn's grading scores were similar between groups. The HTa angle was positively correlated with Baumann angle in the HTa group (R-value is 0.71 and P = 0.0002).

CONCLUSIONS

There was no significant difference in reduction quality and Flynn's scores between HTa and Baumann groups. Furthermore, HTa was associated with shorter operation time and less radiation exposure in this investigation. Therefore, HTa may be a convenient and reliable parameter that could guide the reduction of supracondylar humerus fractures, especially for young children.

Monteggia type-I equivalent fracture in a fourteen-month-old child: A case report

BACKGROUND

Monteggia and equivalent lesions are relatively rare but result in severe injuries in childhood, typically affecting children between 4 and 10 years old. The diagnosis and treatment of an equivalent Monteggia lesion is more complicated than those of a typical Monteggia fracture. This type of lesion may be challenging and may lead to serious complications if not treated properly. Pediatric Monteggia equivalent type I lesions have been reported in a few reports, all of which the patients were all over 4 years old.

CASE SUMMARY

A 14-mo-old boy was referred to our clinic after falling from his bed 10 d prior. With regard to the clinical examination, an obvious swollen and angular deformity was noted on his right forearm. Plain radiographs and reconstructed computed tomography scans showed a Monteggia type I fracture and dislocation. Magnetic resonance imaging (MRI) confirmed a type I Monteggia equivalent lesion consisting of ulnar fracture and Salter-Harris type I injury in the proximal radius. The radial head was still in the joint, and only the radial metaphysis was displaced anteriorly. Open reduction and pinning of both displaced radial and ulnar fractures achieved an excellent result with full function.

CONCLUSION

We recommend MRI examination or arthrography during reduction, especially if the secondary ossification center has not appeared.

Biomechanical Analysis of Sagittal Plane Pin Placement Configurations for Pediatric Supracondylar Humerus Fractures

Anterior to posterior (AP) pinning is the recommended sagittal pin configuration in divergent lateral entry coronal pinning of pediatrics supracondylar fractures. However, there was still a lack of evidence regarding alternative sagittal pins configurations. We aimed to compare the construct stiffness of alternative sagittal pin configurations by using synthetic bone models. Sixty synthetic pediatric humeri were osteotomized to create a supracondylar fracture. After the fracture reduction, all specimens were fixed in the coronal plane with divergent lateral entry pin configurations in four different patterns in the sagittal plane: AP, crossed, divergent and parallel sagittal pin configuration. Each configuration was tested with five loading patterns. The AP sagittal pin had significantly lower construct stiffness than the divergent (p = 0.003) and the parallel sagittal pin configuration (p = 0.005) in external rotation loading tests. The divergent sagittal pin had the highest construct stiffness in extension, valgus, and external rotation loads, but the parallel sagittal pin had lower construct stiffness under extension load than the divergent and crossed sagittal pin configurations. The divergent sagittal pin configuration provides greater construct stiffness than other sagittal pin configurations due to the maximal pin spreading distance at the fracture site and the pin angle lock mechanism.

A Practical Method for Obtaining True Lateral Elbow X-rays in a Paediatric Age Group: Lateral Elbow X-ray in the Standing Salute Position

INTRODUCTION

Paediatric elbow fractures constitute 10% of all paediatric fractures. Radiological interpretation of the immature elbow is difficult due to its cartilaginous structure. We aimed to describe an X-ray technique in paediatric patients to obtain true lateral elbow X-rays and to prevent the repeat X-ray shots.

MATERIALS AND METHODS

Radiographs of 39 children, with a mean age of 48.17 months (range; 7-84 months), with elbow trauma were included. All elbow lateral radiographs were taken in the 90º flexion position. In the first group, radiographs were taken using the standard technique(lateral radiographs in shoulder internal rotation). In the second group, lateral radiographs of the elbow were taken while the patient was standing and the forearm was elevated passively with 90° shoulder abduction and 90° elbow flexion (standing salute position). Three criteria were examined from the graphs to determine the true lateral elbow graphy.

RESULTS

In group 1 (n = 20) and group 2 (n = 19), lateral elbow radiographs were evaluated. No statistically significant differences were found between the groups, in terms of mean age and distal humeral fractures. In group 2; the presence of humeroulnar joint space, partial coronoid superposition of the radius head and presence of the hourglass formation were significantly higher.

DISCUSSION

It is clear that radiographs taken in appropriate positions decreases diagnostic errors. In our study, the ratio of correct lateral radiographs was significantly higher in the radiograph group in the standing salute position, suggesting this method was safe for accurate lateral radiographs, in accordance with our hypothesis.

Bilateral Supracondylar Humerus Fracture in Pediatric after a Fall on an Outstretched Hand

Background. Supracondylar humerus fracture (SCH) is common in the pediatric age group 5-7 years, mostly due to a fall on an outstretched hand. However, a bilateral SCH is rarely observed in this age group. Management of SCH is either surgical or conservative based on the following factors: patient age, fracture pattern and neurovascular involvement. Complications of a displaced SCH can be dramatically reduced by early surgical fixation. Acute complications include: neurovascular injury and compartment syndrome, and long term complications include: stiffness, infections and angular deformities. In this article, we present a rare case of bilateral supracondylar humerus fractures with a six-months follow-up.

Approaching Unusual Pediatric Distal Humerus Fracture Patterns

Pediatric distal humerus fractures are common, and numerous variations can occur depending on patient's age, position of the extremity at the time of injury, and energy of impact. Classic injury patterns include the flexion/extension supracondylar humerus, medial epicondyle, lateral condyle, and the transphyseal distal humerus. We describe our treatment philosophy for pediatric elbow fractures and how these principles were applied to some unusual fractures that presented to our institution.

Current Approach to the Management of Forearm and Elbow Dislocations in Children

Pediatric orthopedic injuries are a common reason for presentation to the emergency department. This article sequentially discusses 2 important upper extremity injuries that require prompt management in the emergency department. Radial head subluxations are discussed with a focus on current evidence for imaging, reduction techniques, and follow-up. Elbow dislocations, although less common than radial head subluxations, are also addressed, highlighting imaging, reduction, immobilization, and follow-up recommendations.

Biomechanical Assessment of Torsional Stiffness in a Supracondylar Humerus Fracture Model

BACKGROUND

We assessed the effect on the torsional stability by different pin diameters and varied pin configurations in a biomechanical supracondylar humerus fracture model.

METHODS

After scanning a model of a pediatric humerus, the image was imported into software. Variable pin trajectories were planned. Acrylonitrile butadiene styrene plastic models were 3-dimensionally printed with predetermined pin trajectories. Models were osteotomized and potted with a polyurethane resin. Five-pin configurations were designed to test coronal and sagittal patterns of pin placement. Each included 3 lateral pins and a medial pin. Pin diameters of 1.6, 2.0, and 2.4 mm were tested in all configurations. Three models for each pin diameter/configuration were tested to ensure uniformity. Stability of the construct was tested to determine the torque needed to deflect the osteotomy 10 degrees in internal/external rotation. Each model was tested 3 times.

RESULTS

In all models/configurations, the 2.4 mm pin diameter was statistically stiffer than 1.6 mm diameter pins; this lost statistical significance in certain patterns when comparing 2.0- and 2.4-mm pins. When comparing a divergent to a parallel configuration in the coronal plane, there was no significant difference in stability when pin diameter or number were controlled. The convergent pin configuration was, in general, the least stable pattern. Use of a medial pin conferred statistically significant stiffness throughout most models as demonstrated with pin deletion. Use of 2 pins was significantly less stiff than most 3-pin models.

CONCLUSIONS

Larger pin diameters confer greater stiffness among all patterns. The use of 3 lateral and 1 medial pin was not statistically different than 2 lateral and 1 medial pin in our models. Both patterns were stiffer than 3 lateral pins only or other fewer pin constructs. The alignment of pins in the sagittal plane did not affect overall construct stiffness.

Ossification of the Proximal and Middle Phalangeal Condyles: Radiographic Aid in Phalangeal Neck Fracture Reduction

BACKGROUND

Phalangeal neck fractures are commonly dorsally displaced and angulated. Surgical treatment is often necessary to restore the retrocondylar recess. The purpose of this study was to determine whether radiographic landmarks can serve as a reference tool for assessing phalangeal neck fracture alignment based on age and sex.

METHODS

In total, 1061 lateral finger radiographs that were interpreted as "normal" by pediatric radiologists in children aged 1 to 18 years were retrospectively reviewed. The proximal and middle phalanges of each digit had a line drawn along the volar cortex [termed the volar phalangeal line (VPL)] and a second perpendicular line was drawn at the level of the phalangeal condyle. A ratio of the anterior to posterior aspects of the phalangeal condyle was determined at the intersection of these lines. Sex of the patients was noted to determine whether it influenced the temporal course of ossification. A linear regression model was utilized to determine the annual coefficient of growth for the phalangeal condyles.

RESULTS

There is a temporal course of ossification of the proximal and middle phalangeal condyles. As children increase in age, the VPL will intersect the phalangeal condyle more dorsally due to the eccentric ossification. In children above 9 years of age, the VPL will reliably intersect the middle one third of the phalangeal condyle. No clinically significant difference exists between the ratios of the proximal and middle phalanges. Sex was not associated with a difference in growth. The greatest growth increase was observed in the 8 to 9-year-old interval.

CONCLUSIONS

The phalangeal condyles ossify in an eccentric manner and the VPL will intersect the phalangeal condyle more dorsally with increasing age. The VPL and knowledge of where it should intersect the phalangeal condyle can be used as a reference guide for evaluating the reduction of proximal and middle phalangeal neck fractures in children.

LEVEL OF EVIDENCE

Level III.

Using the Medial and Lateral Humeral Lines as an Adjunct to Intraoperative Elbow Arthrography to Guide Intraoperative Reduction and Fixation of Distal Humerus Physeal Separations Reduces the Incidence of Postoperative Cubitus Varus

BACKGROUND

Distal humerus physeal separations are rare pediatric elbow fractures that are often misdiagnosed and difficult to treat. Adequate reduction is often technically challenging and up to 71% of children develop postoperative cubitus varus. We propose using the medial and lateral humeral lines as an adjunct to elbow arthrography in order to guide intraoperative fixation of distal humerus physeal separations to reduce the incidence of postoperative cubitus varus.

METHODS

From 2009 to 2014, all pediatric patients under the age of 3 diagnosed with a distal humerus physeal separation and treated surgically at our institution were included for analysis. Two senior pediatric orthopaedic surgeons separately reviewed the preoperative, intraoperative, and postoperative images of all patients and measured the position of the ulnar axis relative to the medial and lateral humeral lines. The medial and lateral humeral shafts were defined as parallel lines drawn along the medial and lateral humeral diaphysis. Adequate reduction was defined by reduction of the ulnar axis within the boundaries of the medial and lateral humeral lines. Patients were assessed at latest follow-up for cubitus varus and any other surgical complications.

RESULTS

Thirteen patients fulfilled the inclusion criteria and were on average 1.70 years old, ranging from 0.62 to 3 years old. Intraoperatively and immediately postoperatively, all 13 patients (100%) were noted to have adequate reduction of the ulnar axis within the boundaries medial and lateral humeral lines. None of the patients required intraoperative arthrography (0%). At the date of latest follow-up, 12 patients (92.3%) had no angular deformities compared with the contralateral limb and 1 patient (7.7%) had developed cubitus varus. No surgical complications were noted (0%).

CONCLUSION

Intraoperative reduction of the ulnar axis within the boundaries of the medial and lateral humeral lines is associated with a lower incidence of postoperative cubitus varus in the treatment of distal humerus physeal separations in children.

LEVEL OF EVIDENCE

Level IV.

The Utility of Routine Postoperative Radiographs After Pinning of Pediatric Supracondylar Humerus Fractures

BACKGROUND

The purpose of this study was to determine the frequency with which postoperative radiographs resulted in a change in management following closed reduction and percutaneous pinning of displaced pediatric supracondylar humerus fractures. We hypothesize that only the initial postoperative radiograph will lead to changes in management of operative supracondylar humerus fractures.

METHODS

A retrospective review was performed at 2 level I pediatric trauma centers. Inclusion criteria were patients below 18 years of age who sustained supracondylar humerus fractures (Gartland type II, III, IV) who were operatively treated from 2008 to 2013 with adequate radiographic follow-up. Patients with flexion type, intra-articular, transphyseal, and open fractures were excluded from the study. Routine radiographs were taken at initial follow-up (1 wk postoperatively) and at pin removal (3 to 4 wk postoperatively).

RESULTS

The final analysis included 572 patients. Initial postoperative radiographs changed treatment in 9 patients (1.6%), including revision surgeries, 2 pin adjustments, and 2 early pin removals. At the time of pin removal, 20 (3.5%) patients required further immobilization. There were no changes to the initial plan for continued nonoperative treatment at final follow-up (6 to 8 wk postoperatively).

CONCLUSIONS

In this large retrospective series of patients treated with closed reduction and percutaneous pinning of displaced supracondylar humerus fractures, radiographs at 3 weeks do not reveal a need to return to the operating room or other significant pathology. These findings suggest that radiographs should be obtained within 7 to 10 days postoperatively for type III fractures and may only need to be repeated if the clinical situation warrants it, such as severe fracture pattern, persistent pain, or clinical deformity.

LEVEL OF EVIDENCE

Level IV-case series.

Significance of the Lateral Humeral Line for Evaluating Radiocapitellar Alignment in Children

BACKGROUND

The radiocapitellar line (RCL) was originally described for evaluation of the alignment of the RC joint on lateral images of the elbow. Although, many authors have translated the utilization of RCL into coronal imaging, previous studies have not been performed to confirm validity. The purpose of this paper was to identify an accurate way of evaluating pediatric RC alignment in the coronal plane.

METHODS

Thirty-seven anteroposterior (AP) radiographs of 37 children were evaluated to determine the position of the RC joint in the coronal plane. All had acceptable magnetic resonance imaging (MRI) studies available for comparison. The lateral humeral line (LHL), consisting of a line along the lateral edge of the ossified condyle of the distal humerus parallel to the axis of the distal humeral shaft, was studied as it related to the lateral cortex of the radial neck. Three children with a confirmed diagnosis of a Bado III, lateral displaced radius, Monteggia fracture were also evaluated.

RESULTS

The LHL passed along the edge of or lateral to the radial neck on all AP radiographs and all MRI studies. The RCL failed to intersect the capitellum on 2 AP radiographs. On MRI, the RCL also passed lateral to the capitellar ossification center in 3 patients. In addition, the RCL was seen passing through the capitellum at a mean of the lateral 30% (range, 0% to 64%) on AP radiographs and 26% (range, 0% to 48%) on MRI. For all 3 children with a Bado III Monteggia fracture, the LHL crossed the radial neck and the RCL did not intersect the capitellum.

CONCLUSIONS

The RCL can fail to intersect the capitellar ossification center on AP radiographs and MRI in pediatric elbows without injury. The LHL consistently lies lateral to the radial neck in normal elbows and medial to the lateral aspect of the radial neck on all Bado III fracture-dislocations. It, therefore, can be used as an adjunct in evaluating the RC joint on AP imaging. The RCL most commonly intersects the lateral one third of the ossification center on both plain radiographs and MRIs.

LEVEL OF EVIDENCE

Level III-diagnostic.

Fracture Supracondylar Humerus: A Review

Fracture supracondylar humerus is one of the most common fractures encountered in pediatric age group at all levels (both rural and urban). Thus it needs a special review in its management protocol as per the changing trend. Modified Gartland classification is the most accepted classification and has its importance in decision making regarding management and prognosis. Neurovascular complications are mostly associated with Type III A, III B and Type IV variety and they most of the time need surgical intervention for stabilization, exploration of brachial artery, sometimes median nerve exploration and reduction of fracture. Cubitus varus is the most common associated deformity associated with this fracture (especially in Type III A). The aim of the review was to develop an insight for the understanding of variations in presentation and management of supracondylar fracture of the humerus (both simplicity and complexity) and the flowing trend in addition to the recent advances to deal with this particular pediatric orthopaedic entity which often presents as an emergency.

Elbow Pain After a Fall: Nursemaid's Elbow or Fracture?

Nursemaid's elbow and elbow fractures are both common causes of acute elbow pain, but the mechanism of injury is quite different. In children, falls frequently go unwitnessed and children are often inaccurate when recounting the sequences of a fall, making the mechanism difficult to ascertain. A common clinical mistake is to treat all elbow injuries as a nursemaid's elbow. When the mechanism of injury is unknown, radiographs should be used to help make the diagnosis. Occult fractures, also known as "hairline" elbow fractures, may not be visible on initial X-rays, but clues to the diagnosis, especially the posterior fat pad, can be helpful in evaluation. When an occult fracture is suspected based on history and radiographic findings, the patient's elbow should be immobilized, not manipulated. This article also reviews successful reduction maneuvers for nursemaid's elbow. [Pediatr Ann. 2016;45(6):e214-e217.].

Variability of the Anterior Humeral Line in Normal Pediatric Elbows

BACKGROUND

The anterior humeral line (AHL) is considered a valuable radiographic tool in the assessment of pediatric elbow sagittal plane alignment following injury. However, few studies exist that examine the validity of the AHL. The purpose of this study is to report the variability of the AHL in skeletally immature children with normal elbows.

METHODS

A total of 124 true lateral elbow radiographs of normal pediatric elbows were retrospectively identified and examined for the relationship of the AHL to the capitellum. The percentage of AHLs falling outside the middle third of the capitellum was compared among different age and sex groups using Fisher exact tests.

RESULTS

In 100% of patients, the AHL touched the ossific nucleus of the capitellum. In 100% (52/52) of patients ≥5 years the AHL goes through the middle third of the capitellum, but this is significantly different from patients less than 5 years of age in whom 25% (18/72) of patients the AHL fell outside of the middle third of the capitellum (P<0.001). In children less than 2 years of age, the AHL was in the anterior third in 30% of the cases.

CONCLUSIONS

Traditional teaching that the AHL touches the capitellum on a lateral radiograph of a normal elbow in a child is correct, so if the AHL does not touch the capitellum it is appropriate to look for pathology. Similarly, in children 5 years and older the AHL goes through the middle third of the capitellum in all patients, so if it does not, it is appropriate to look for pathology. However, with decreasing age variability increases, with the AHL touching the anterior third of the capitellum in almost 1/3 of children.

LEVEL OF EVIDENCE

Level III.

Results of displaced supracondylar humerus fractures treated with open reduction and internal fixation after a mean 22.4 years of follow-up

BACKGROUND

The aim of this study was to evaluate the long-term functional and cosmetic results as well as the sagittal and coronal plane remodeling of displaced supracondylar humerus fractures treated with open reduction and internal fixation.

METHODS

In total, 49 patients (11 boys and 38 girls) with Gartland type III supracondylar humerus fractures treated with open reduction and cross-pin fixation were retrospectively evaluated. The mean follow-up time was 22.4 years (range, 10.6-37.5 years). The Flynn criteria were used to assess the cosmetic and functional outcomes. Baumann's angle, the lateral rotational percentage, the humerus-elbow-wrist angle, and the humeral condylar angle were obtained from follow-up radiographs. The flexion and extension deficits compared with the uninjured side were measured at the last follow-up.

RESULTS

According to the Flynn criteria, the cosmetic outcomes were satisfactory in 93.9% of the patients, and the functional outcomes were satisfactory in 83.7% of the patients. The average flexion deficit was 5° ± 8°, and the average extension deficit was 4° ± 5°. At the final follow-up, the mean difference in the humerus-elbow-wrist angle and the humeral condylar angle between the injured and uninjured sides was -4° ± 7° and 0° ± 3°.

CONCLUSIONS

We identified the remodeling in the sagittal plane in supracondylar humerus fractures that had been united in flexion. Satisfactory functional and cosmetic results were obtained with the open reduction and internal fixation of displaced supracondylar fractures of the humerus, and no degenerative changes were observed at the long-term follow-up.

A line drawn along the radial shaft misses the capitellum in 16% of radiographs of normal elbows

BACKGROUND

The radiocapitellar line (RCL) is a routinely referenced radiographic measurement for evaluating injury of the pediatric elbow, such as a Monteggia fracture. It is most commonly described as a line drawn along the radius that should intercept the center of the capitellum in a normal elbow. However, the RCL has not been rigorously defined or validated in young children.

METHODS

The RCL was drawn out on the anteroposterior and lateral radiographs of 116 normal pediatric elbows by 3 examiners. On each radiograph, lines were drawn along the longitudinal center of the radial neck as well as the radial shaft. The distance from each of these lines to the center of the capitellum was defined as the line-capitellar distance (LCD). The LCD was standardized to the patient size and correlated with patient variables.

RESULTS

Of the 2052 RCLs drawn, 50% (1029/2052) fell outside the middle third of the capitellum and 8.6% (176/2052) missed the capitellum completely. Lines drawn along the radial neck in the anteroposterior and lateral views missed the capitellum less frequently (1.2% vs. 12.7%, P<0.0001) and passed through its central third less (77.8% vs. 44.7%, P<0.0001) when compared with lines drawn using the radial shaft. Lines along the radial neck intersected the capitellum significantly more often on the lateral view than on the anteroposterior view (98.8% vs. 96.8%, P=0.06) and were more likely to pass through the center third of the capitellum (77.8% vs. 55.5%, P<0.0001). With both techniques of drawing the RCL, the percent of measurements falling within the middle third of the capitellum was higher in patients above 5 years of age (P<0.001). The RCL is more reliable in older patients and shows considerable variation in infants.

CONCLUSIONS

The RCL does not invariably bisect or fall within the middle third of the capitellum in normal pediatric elbows. Therefore, an abnormal RCL is suggestive but not pathognomonic for injury such as Monteggia fracture. An RCL drawn along the radial shaft will miss the capitellum in 15.6% of elbows. The most consistent RCL is drawn along the radial neck on the lateral view. Patient variables such as age and sex should be considered in the ability of the RCL to identify elbow injury.

LEVEL OF EVIDENCE

Diagnostic Level 3.

The approach to elbow pain in the pediatric and adolescent throwing athlete

Elbow pain in pediatric throwing athletes can be very concerning and challenging to diagnose. Diagnosis involves determining whether the injury is chronic or acute in nature and the anatomical location of the pain. Physicians should be aware of the sport-specific forces that predispose athletes with immature skeletons to injury and should be familiar with the common presentations of these injuries. In order to narrow the diagnosis, physicians should gather a detailed history of how and when the pain occurred in addition to performing a thorough physical exam that includes tests, such as the modified milking maneuver and the moving valgus stress test. Appropriate imaging helps physicians to confirm the diagnosis and elucidates any associated pathology in patients. In most cases, the treatment given to patients is conservative and involves rest, ice, non-steroidal anti-inflammatory drugs for pain, and an appropriate physical therapy regimen with a progressive return to play when symptoms have resolved. When patients fail to respond to conservative treatment, surgical intervention may be needed. Knowing when to refer patients for orthopedic evaluation helps athletes return to play quickly and safely.

Biomechanical analysis of posterior intrafocal pin fixation for the pediatric supracondylar humeral fracture

BACKGROUND

Controversy remains regarding the optimal fixation for displaced pediatric supracondylar humeral fractures. The clinical results of a recently described technique using a posterior intrafocal pin have been good to excellent. The aim of our study was to compare, in a cadaveric model, the stiffness provided by posterior intrafocal pin fixation versus crossed medial and lateral pin fixation and divergent lateral entry pin fixation for the treatment of Gartland-Wilkins type 3 supracondylar humeral fractures.

METHODS

In 15 pairs of nonosteoporotic adult cadaver specimens, simulated Gartland-Wilkins type 3 supracondylar fractures were created and stabilized using: (1) the posterior intrafocal pin method; (2) medial and lateral crossed pins; or (3) 2 divergent lateral entry pins. Specimens were then subjected to internal rotation to measure the fixation stiffness of each construct. The effects of treatment and cycle number on torsional stiffness and peak torque were assessed for significance using a linear regression model with random effects to account for specimen pairing. Significance was set at P<0.05.

RESULTS

The stiffest fixation was provided by crossed pins (2.4 N m/degree), followed by divergent lateral pins (1.9 N m/degree) and the posterior intrafocal pin (1.9 N m/degree), but none of the differences was statistically significant (P>0.9). Peak torque was not significantly different between fixations, although the trend suggested that crossed pins were strongest (34.6 N m), followed by divergent lateral pins (30.3 N m) and then posterior intrafocal pin fixation (26.1 N m).

CONCLUSIONS

Our results suggest that posterior intrafocal pin fixation offers resistance to internal rotation equivalent to that of crossed medial and lateral pins and divergent lateral entry pins.

CLINICAL RELEVANCE

The current biomechanical study supports the use of the posterior intrafocal posterior Kirschner pin for rotationally unstable supracondylar fractures because it is not significantly more compliant than standard techniques.

LEVEL OF EVIDENCE

Level III.

Factors predictive of early radiographic failure after closed reduction of Gartland type II supracondylar humeral fractures

OBJECTIVES

Supracondylar humerus fractures are the most common elbow fractures seen in the pediatric population. The American Academy of Orthopedic Surgeons Board of Directors recently published clinical practice guidelines recommending surgical treatment for all displaced fractures. We sought to identify predictive factors to assist the orthopedic surgeon in identifying which type II fractures are more likely to fail closed reduction and immobilization without pinning.

DESIGN

This was a retrospective cohort study.

SETTING

This study was conducted at a pediatric medical center in the Midwestern United States.

PATIENTS

This study analyzed 29 patients who underwent closed reduction and immobilization for significantly displaced, type II supracondylar humerus fractures.

MAIN OUTCOME MEASUREMENTS

We compared the lateral capitellar humeral angle, Baumann angle, and anterior humeral line index at the time of presentation, postreduction, and at final follow-up.

RESULTS

Two statistically similar groups were identified based on the amount of initial displacement. Variables were examined between the 2 groups including age, gender, initial displacement, quality of initial reduction, treatment in cast or splint, and position of immobilization. Forty-eight percent of the patients failed closed reduction and immobilization, with an average 71% loss of initial reduction at final follow-up. None of the examined variables were statistically significant or had any predictive value for failure.

CONCLUSIONS

Our study suggests that type II fractures should be viewed as a spectrum of injury. Our data show that a significantly displaced type II fracture that requires a reduction to obtain satisfactory alignment has a 48% chance of losing that reduction without percutaneous pinning.

Limitations of the radiocapitellar line for assessment of pediatric elbow radiographs

BACKGROUND

The radiocapitellar line (RCL) is recommended for evaluating radiocapitellar alignment in skeletally immature elbows, yet its parameters have not been clearly defined. This study systematically assesses the RCL relationship in normal elbows, investigating the impacts of radiographic view, choice of anatomic landmarks, patient age, forearm position, and observer bias on the manner in which the RCL intersects the capitellum.

METHODS

On radiographs of 20 normal elbows (age range, 1 to 8 y), 3 pediatric orthopaedic surgeons, blinded to clinical history, drew lines (RCLs) on anteroposterior and lateral projections, along the radial shaft and neck, and with and without the capitellum visible. Line placement was repeated 2 weeks later. The relationship of each RCL to the capitellum was assessed continuously using the perpendicular distance to the center of the capitellum, normalized to capitellar width [line-capitellar distance (LCD)], and categorically as passing through the middle third, outer two-thirds, or outside the capitellum.

RESULTS

Of the 480 RCLs drawn, 23 (5%) missed the capitellum and 224 (47%) missed the middle third. More radial neck than shaft lines intersected the middle third on both anteroposterior and lateral views (P < 0.05, Fisher exact test), with the lowest LCD values for neck lines on the lateral view (P < 0.05, analysis of variance (ANOVA)). More RCLs intersected the middle third when the capitellum was visible than when it was obscured (P = 0.03, Fisher exact test), suggesting an effect of observer bias. Patient age correlated inversely with LCD (P < 0.001). The angle between the neck and shaft lines correlated positively with LCD (P < 0.001), suggesting an impact of forearm rotation position. Intraobserver and interobserver reliability was moderate-to-substantial (κ = 0.40-0.75).

CONCLUSIONS

The RCL best defines normal radiocapitellar alignment when the line is drawn along the radial neck on the lateral view, although this relationship is affected by bias, patient age, and forearm rotation position. The RCL does not reliably intersect the middle third of the capitellum, arguing against its sufficiency for assessing precise radiocapitellar alignment.

LEVEL OF EVIDENCE

Diagnostic Level 3.

Pediatric supracondylar fractures of the distal humerus

Supracondylar fractures of the humerus are a common pediatric elbow injury that are historically associated with morbidity due to malunion, neurovascular complications, and compartment syndrome. True anteroposterior and lateral radiographs are essential not only for an accurate diagnosis, but also for creating a treatment plan for these injuries. A staging system (based on the lateral radiograph) for classifying the severity of the fracture helps guide definitive management. Nondisplaced fractures are treated initially with a posterior splint, followed by a long-arm casting. Closed reduction and percutaneous pinning is the preferred treatment for displaced or unstable fractures. If there is any question about fracture stability, patients should be seen within 5 days postoperatively for repeat radiographs to ensure that the reduction and pin fixation has been maintained. Understanding the anatomy, radiographic findings, management options, and complications associated with this fracture allow physicians to limit the morbidity associated with this relatively common pediatric injury.

Prospective, surgeon-randomized evaluation of crossed pins versus lateral pins for unstable supracondylar humerus fractures in children

Controversy exists concerning pin placement for supracondylar humerus fractures in children. Both crossed pin and lateral only pin configurations have shown good results; however, prospective studies are lacking. We present a prospective, surgeon-randomized study comparing crossed pin (group A, n = 20) versus preferential lateral only pin (group B, n = 20) fixation for displaced supracondylar humerus fractures. There was no difference in Baumann's angle (P>0.75), the humerotrochlear angle (P>0.85), or final elbow range of motion (P>0.25). Both groups had stable reductions and clinically normal alignment. The only complication in both groups was a transient ulnar nerve irritation, despite no intraoperative evidence of nerve violation with a nerve stimulator. One patient in each group required modification of the operative plan. In group B, one patient had a medial pin inserted because of medial comminution extending proximally limiting available lateral pin placement. In group A, the surgeon elected to use lateral pins only because of an obviously subluxating ulnar nerve. In conclusion, we recommend orthopedic surgeons treating unstable pediatric supracondylar humerus fractures be facile with both medial and lateral pin placement.

The measurements and standardization of humerocondylar angle in children

BACKGROUND

Supracondylar fractures of the humerus in children are very common. However, the literature regarding measurements of normal anatomical relationships of the distal humerus in sagittal plane is sparse.

METHOD

We reviewed the radiographs of normal elbow joints in 142 children treated in our hospital over 2 years. No history of previous trauma of distal humerus was found. The children were separated into 3 age groups (<5, 5-10, and 10-15 years old), and measurement of the humerocondylar angle (HCA) in sagittal plane was performed.

RESULTS

The mean age of children in group 1 was 3 years 1 month; in group 2, 7 years 8 months; and in group 3, 12 years. There were 99 boys and 43 girls. The mean HCA was 41.6 degrees (range, 30-70 degrees). No statistically significant influence on HCA by age, sex, or side was found. We found a small number of extreme variants in HCA (down to 30 degrees and up to 70 degrees) in children without any history of previous trauma and having a normal range of elbow motion.

CONCLUSIONS

We found that HCA is close to the well-accepted figure of 40 degrees. Interestingly, this value remains the same in all age groups. That means that the geometry of the distal humerus in sagittal plane is established very early during the growth and remains constant. Due to significant individual variations of HCA, it alone cannot be sufficient for final decisions in evaluation and treatment of supracondylar fractures.

Arthroscopic-assisted reduction and percutaneous external fixation of lateral condyle fractures of the humerus

Lateral condyle fractures in children are the second most common fracture about the elbow. Anatomic reduction of intra-articular displacement is considered a priority. Most experts agree that the treatment of choice of mildly displaced (>2 mm) lateral condyle fractures is open reduction-internal fixation or intraoperative arthrography followed by closed reduction and percutaneous pinning. In this report we described an alternative approach using closed arthroscopic-assisted reduction. Arthroscopy was performed by use of a 30 degree, 4.5-mm arthroscope through a proximal anteromedial portal with no pump, and a proximal anterolateral portal was created for instrumentation. The fracture line was easily visualized after blood, fibrin, and loose articular debris were irrigated from the joint. The fracture was manually manipulated and reduced by use of a periosteal elevator placed through the proximal anterolateral portal into the fracture and via rotation until there was no step in the articular cartilage. Two lateral Kirschner wires were placed percutaneously, which result in firm fixation of the fracture. We think that the advantages of arthroscopy are further superior to intraoperative arthrography because arthroscopy not only allows for better anatomic reduction and visualization with minimal surgical trauma and less radiation time but also provides a valid diagnostic and treatment alternative for associated injuries.

Biomechanical analysis of pinning techniques for pediatric supracondylar humerus fractures

BACKGROUND

Closed reduction and percutaneous pin fixation is the recommended treatment of displaced (Gartland types 2 and 3) supracondylar humerus fractures. The need for a medial pin for maximal stability remains controversial. The purpose of this study was to develop a model of supracondylar humerus fractures simulating medial column comminution and to evaluate the torsional stability of various pin configurations recommended in the current literature.

METHODS

Transverse cuts were made in synthetic humeri with a wedge taken from the medial aspect of the proximal fracture fragment in one half of the specimens to simulate medial column comminution. Each fracture was then reduced and fixed with 1 of 4 pin configurations using 0.062 in K-wires. The fixed specimens were then subjected to a torsional load producing internal rotation of the distal fragment. Rotation in degrees and the corresponding torque was recorded for statistical analysis.

RESULTS

Specimens with the medial wedge removed demonstrated less torsional stability than their identically fixed counterparts with the intact medial column. In specimens with the intact medial column, the greatest torsional stability was achieved with the 2 lateral divergent and medial cross pin configuration followed by 3 lateral pins, then standard crossed pins with 2 lateral divergent pins demonstrating the least torsional stability. For the medial comminution group the 2 lateral, 1 medial pin construct again had the greatest torsional stability and 2 lateral pins the least. The standard crossed pin and 3 lateral pin constructs were not significantly different in the presence of medial comminution.

CONCLUSIONS

In a synthetic humerus model of supracondylar humerus fractures, medial comminution was shown to reduce torsional stability significantly in all pin configurations. There was no statistical difference in torsional stability between 3 lateral pins and standard crossed pins in specimens with medial comminution.

Upper extremity injuries in the paediatric athlete

Injuries to the upper extremity in paediatric and adolescent athletes are increasingly being seen with expanded participation and higher competitive levels of youth sports. Injury patterns are unique to the growing musculoskeletal system and specific to the demands of the involved sport. Shoulder injuries include sternoclavicular joint injury, clavicle fracture, acromioclavicular joint injury, osteolysis of the distal clavicle, little league shoulder, proximal humerus fracture, glenohumeral instability and rotator cuff injury. Elbow injuries include supracondylar fracture, lateral condyle fracture, radial head/neck fracture, medial epicondyle avulsion, elbow dislocation and little league elbow. Wrist and hand injuries include distal radius fracture, distal radial physeal injury, triangular fibrocartilage tear, scaphoid fracture, wrist ligamentous injury thumb metacarpalphalangeal ulnar collateral ligament injury, proximal and distal interphalangeal joint injuries and finger fractures. Recognition of injury patterns with early activity modification and the initiation of efficacious treatment can prevent deformity/disability and return the youth athlete to sport.

Supracondylar humerus fractures in children

Supracondylar fractures of the humerus are the most common fractures in children that require surgery. A significant advancement in the field of pediatric orthopedics has been closed reduction and percutaneous pinning of these fractures. This technique, using high quality fluoroscopic imaging, allows for a near anatomical reduction of fractures without the need for an open surgical procedure or prolonged traction. Supracondylar fractures in children are often associated with neurologic and vascular damage that must be recognized before fracture reduction. Nursing staff members' skill with pediatric patients can greatly aid the surgeon in the timely and safe treatment of these fractures.