PEDIATRIC ELBOW PEDIATRIC ELBOW FRACTURESFRACTURES

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INCIDENCEINCIDENCE

SECOND MOST COMMON PEDIATRIC SECOND MOST COMMON PEDIATRIC INJURYINJURY

OSSIFICATIONOSSIFICATION

1. CAPITELLUM (6 1. CAPITELLUM (6 mo. mo. -- 2 yrs.)2 yrs.)2. MED. 2. MED. EPICONDYLE (5 EPICONDYLE (5 -- 9 9 yrs.)yrs.)3. TROCHLEA (7 3. TROCHLEA (7 --13 13 yrs.)yrs.)4. LAT. 4. LAT. EPICONDYLE (8 EPICONDYLE (8 -- 13 13 YRS.)YRS.)

OSSIFICATIONOSSIFICATION

5. CAPITELLUM AND TROCHLEA FUSE 5. CAPITELLUM AND TROCHLEA FUSE AT ABOUT 12 YRS.AT ABOUT 12 YRS.6. EPIPHYSIS AND METAPHYSIS FUSE 6. EPIPHYSIS AND METAPHYSIS FUSE AT ABOUT 12 AT ABOUT 12 -- 13 YRS.13 YRS.7. MEDIAL EPICONDYLE APOPHYSIS 7. MEDIAL EPICONDYLE APOPHYSIS FUSES AT 14 FUSES AT 14 -- 17 YRS.17 YRS.

BLOOD SUPPLYBLOOD SUPPLY

RICH SUPPLY OF COLLATERALS OFF RICH SUPPLY OF COLLATERALS OFF THE BRACHIAL ARTERYTHE BRACHIAL ARTERYSUP/INFER. ULNAR COLLATERALSSUP/INFER. ULNAR COLLATERALSANT/LAT. RADIAL COLLATERALSANT/LAT. RADIAL COLLATERALSRADIAL RECURRENT RADIAL RECURRENT ULNAR RECURRENTULNAR RECURRENT

MUSCLE ORIGINSMUSCLE ORIGINS

MEDIAL EPICONDYLE: FLEXORSMEDIAL EPICONDYLE: FLEXORSLATERAL EPICONDYLE: EXTENSORSLATERAL EPICONDYLE: EXTENSORS

XX--RAY APPEARANCERAY APPEARANCE

LOOK AT THE ALIGNMENT OF THE LOOK AT THE ALIGNMENT OF THE OSSIFICATION CENTERS AND THE OSSIFICATION CENTERS AND THE RADIAL, ULNAR, AND HUMERAL RADIAL, ULNAR, AND HUMERAL SHAFTS.SHAFTS.ANT. HUMERAL LINEANT. HUMERAL LINEBAUMANBAUMAN’’S ANGLES ANGLEANT. CORONOID LINEANT. CORONOID LINE

ANT. HUMERAL LINEANT. HUMERAL LINE

LINE DRAWN LINE DRAWN ALONG THE ANT. ALONG THE ANT. HUMERAL CORTEX HUMERAL CORTEX SHOULD BISECT SHOULD BISECT THE CAPITELLUM.THE CAPITELLUM.DEMONSTRATES DEMONSTRATES SUPRACONDYLAR SUPRACONDYLAR AND LAT. CONDYLE AND LAT. CONDYLE FX.FX.

BAUMANS ANGLEBAUMANS ANGLE

INTERSECTION OF A LINE INTERSECTION OF A LINE PERPENDICULAR TO THE LONG AXIS PERPENDICULAR TO THE LONG AXIS OF THE HUMERUS, AND A LINE ALONG OF THE HUMERUS, AND A LINE ALONG THE PHYSIS OF THE CAPITELLUM.THE PHYSIS OF THE CAPITELLUM.CAN DETERMINE VARUS MALCAN DETERMINE VARUS MAL--ALIGNMENTALIGNMENTNL. IS 73.5 DEGREES NL. IS 73.5 DEGREES

ANT. CORONOID LINEANT. CORONOID LINE

DRAWN ALONG THE ANT. SURFACE DRAWN ALONG THE ANT. SURFACE OF THE CORONOID, IT SHOULD JUST OF THE CORONOID, IT SHOULD JUST TOUCH THE CAPITELLUM TOUCH THE CAPITELLUM ANTERIORLY.ANTERIORLY.

CARRYING ANGLECARRYING ANGLE

CLINICAL MEASUREMENT WITH CLINICAL MEASUREMENT WITH ELBOW EXTENDED, FULL ELBOW EXTENDED, FULL SUPPINATIONSUPPINATIONVARIABLE, COMPARE TO NL. SIDEVARIABLE, COMPARE TO NL. SIDE

SUPRACONDYLAR SUPRACONDYLAR FRACTURESFRACTURES

FLEXIONFLEXION

EXTENSIONEXTENSION

SUPRACONDYLAR SUPRACONDYLAR FRACTURESFRACTURES

TRANSVERSE FRACTURE THROUGH TRANSVERSE FRACTURE THROUGH THE OLECRONON FOSSATHE OLECRONON FOSSAMOST COMMON FRACTURE IN MOST COMMON FRACTURE IN CHILDREN < 8 YRS.CHILDREN < 8 YRS.MOST COMMON PEDIATRIC ELBOW MOST COMMON PEDIATRIC ELBOW FRACTUREFRACTUREEXTENSION EXTENSION -- 97%97%FLEXION FLEXION -- 3%3%

MECHANISM OF INJURYMECHANISM OF INJURY

EXTENSION: FALL ON EXTENSION: FALL ON OUTSTRETCHED HAND (FOOSH)OUTSTRETCHED HAND (FOOSH)FLEXION: FALL ON FLEXED ELBOW FLEXION: FALL ON FLEXED ELBOW

CLASSIFICATIONCLASSIFICATIONGartland, 1959Gartland, 1959

TYPE I: NONTYPE I: NON--DISPLACEDDISPLACEDTYPE II: ANGULATED WITH AN TYPE II: ANGULATED WITH AN INTACT POST. CORTEXINTACT POST. CORTEXTYPE III: COMPLETELY DISPLACED, TYPE III: COMPLETELY DISPLACED, USUALLY POSTEROUSUALLY POSTERO--MEDIALMEDIAL

TYPE ITYPE I

ALL PERIOSTEUM IS INTACTALL PERIOSTEUM IS INTACTIMMOBILIZE FOR 3 IMMOBILIZE FOR 3 -- 4 WEEKS4 WEEKS

TYPE IITYPE II

ANTERIOR CORTEX BROKENANTERIOR CORTEX BROKENDEBATE EXISTS OVER TX.DEBATE EXISTS OVER TX.SOME AUTHORS RECOMMEND SOME AUTHORS RECOMMEND OPERATIVE TX. OPERATIVE TX. SOME REC. CLOSED REDUCTIONSOME REC. CLOSED REDUCTIONSOME REC. IMMOBILIZATION ALONESOME REC. IMMOBILIZATION ALONE

TYPE IITYPE II

Mann, T. S. JBJS, 1963: Up to 10 Mann, T. S. JBJS, 1963: Up to 10 degrees of posterior angulation can be degrees of posterior angulation can be expected to remodel completelyexpected to remodel completelyYounger will remodel moreYounger will remodel moreVarus angulation will not remodel at all, Varus angulation will not remodel at all, but this deformity is rarely progressivebut this deformity is rarely progressiveDeBoek JPO, 1995: Decreased rate of DeBoek JPO, 1995: Decreased rate of cubitus varus with closed reduction and cubitus varus with closed reduction and pinningpinning

TYPE IITYPE IITREATMENTTREATMENT

MILD ANGULATION: Closed, or no MILD ANGULATION: Closed, or no reduction and immobilize for 3 reduction and immobilize for 3 --4 weeks4 weeksMEDIAL COMPRESSION, MARKED MEDIAL COMPRESSION, MARKED ANGULATION: Closed reduction and ANGULATION: Closed reduction and pinningpinningMARKED SWELLING, N / V CHANGES: MARKED SWELLING, N / V CHANGES: Closed red. and pinningClosed red. and pinning

TYPE THREETYPE THREE

ANT. AND POST. CORTICES ANT. AND POST. CORTICES DISRUPTEDDISRUPTEDANT PERIOSTEUM TORNANT PERIOSTEUM TORNPOST PERIOSTEUM INTACTPOST PERIOSTEUM INTACTVERY UNSTABLEVERY UNSTABLESIGNIFICANT SOFT TISSUE INJURY SIGNIFICANT SOFT TISSUE INJURY AND SWELLINGAND SWELLING

TYPE THREETYPE THREETREATMENTTREATMENT

FEW ARGUMENTS AGAINST FEW ARGUMENTS AGAINST OPERATIVE TREATMENT IN THE OPERATIVE TREATMENT IN THE LITERATURELITERATUREPINNING ALLOWS THE ELBOW TO BE PINNING ALLOWS THE ELBOW TO BE HELD EXTENDED, REDUCING RISK OF HELD EXTENDED, REDUCING RISK OF N / V INJURYN / V INJURY

TYPE THREETYPE THREETREATMENTTREATMENT

OLECRONON TRACTION:OLECRONON TRACTION:SHOWN TO WORK WELLSHOWN TO WORK WELLREQUIRES HOSPITALIZATIONREQUIRES HOSPITALIZATION

EXPENSIVEEXPENSIVESTRAIN ON CHILD AND FAMILYSTRAIN ON CHILD AND FAMILY

TYPE IIITYPE IIITREATMENTTREATMENT

CLOSED REDUCTION AND CLOSED REDUCTION AND PERCUTANEUS PINNINGPERCUTANEUS PINNINGMOST COMMON TREATMENTMOST COMMON TREATMENTSHORT HOSPITAL STAYSHORT HOSPITAL STAYLOW MORBIDITYLOW MORBIDITYCROSSED Vs. 2 CROSSED Vs. 2 --3 LATERAL PINS3 LATERAL PINSRARELY ORIF IS NEEDED RARELY ORIF IS NEEDED

TYPE IIITYPE IIITREATMENTTREATMENT

Zionts, L, et. al. JBJS, 1994: Medial and Zionts, L, et. al. JBJS, 1994: Medial and lateral crossed pins are biomechanically lateral crossed pins are biomechanically stronger than two lateral pins in cadavers. stronger than two lateral pins in cadavers. Topping, R.E. JPO, 1995: no clinical Topping, R.E. JPO, 1995: no clinical difference between crossed and lateral difference between crossed and lateral pins. one of 27 in crossed pin group had a pins. one of 27 in crossed pin group had a transient ulnar nerve palsy, no nerve transient ulnar nerve palsy, no nerve injuries in the lateral pin group.injuries in the lateral pin group.

COMPLICATIONSCOMPLICATIONS

MOST COMMON IN TYPE THREEMOST COMMON IN TYPE THREENEUROVASCULAR INJURYNEUROVASCULAR INJURYVOLKMANVOLKMAN’’S ISCHEMIAS ISCHEMIACUBITUS VARUSCUBITUS VARUS

COMPLICATIONSCOMPLICATIONS

NERVE INJURYNERVE INJURY–– 7% OVERALL, UP TO 15% OF TYPE III7% OVERALL, UP TO 15% OF TYPE III–– Brown, et. al. JPO, 1995: 162 displaced fxBrown, et. al. JPO, 1995: 162 displaced fx’’s s

at UCLA with 23 nerve injuriesat UCLA with 23 nerve injuries12 Radial(61%)12 Radial(61%)6 Ulnar (4 iatrogenic from medial pins)6 Ulnar (4 iatrogenic from medial pins)3 AIN3 AIN2 Median2 MedianAll resolved spontaneously in 2All resolved spontaneously in 2--6 mths.6 mths.

COMPLICATIONSCOMPLICATIONS

NERVE INJURIESNERVE INJURIES–– Other series have similar numbersOther series have similar numbersNonNon--iatrogenic: watch @ least 3 mths iatrogenic: watch @ least 3 mths before explorationbefore explorationIatrogenic: Remove offending pin, or Iatrogenic: Remove offending pin, or explore.explore.

COMPLICATIONSCOMPLICATIONSVASCULARVASCULAR

VASCULAR INJURYVASCULAR INJURY–– ACUTE BRACHIAL ARTERY INJURY (rare)ACUTE BRACHIAL ARTERY INJURY (rare)–– VOLKMANVOLKMAN’’S ISCHEMIAS ISCHEMIAABSENT PULSE: CLOSED REDUCTION ABSENT PULSE: CLOSED REDUCTION AND PINNING, SPLINT < 90 DEGREESAND PINNING, SPLINT < 90 DEGREESWHITE HAND WHITE HAND -- EXPLORATIONEXPLORATIONPERFUSED, PULSELESS HAND PERFUSED, PULSELESS HAND --OBSERVE VERY CLOSELYOBSERVE VERY CLOSELY

COMPLICATIONSCOMPLICATIONSVASCULARVASCULAR

““PINK PULSELESS HANDPINK PULSELESS HAND””Wright, JPO, 1996 and Sabberwal, JPO, Wright, JPO, 1996 and Sabberwal, JPO, 19971997–– OBSERVE CLOSELYOBSERVE CLOSELY–– ANGIOGRAM, OR EXPLORATION IF ANGIOGRAM, OR EXPLORATION IF

WORSENING N/V EXAM, OR NO WORSENING N/V EXAM, OR NO IMPROVEMENT IN 12 IMPROVEMENT IN 12 --24 HRS24 HRS

ShoeneckerShoenecker et. al., and Doreman et. al. et. al., and Doreman et. al. Jpo, 1996 both rec. earlier explorationJpo, 1996 both rec. earlier exploration

COMPLICATIONSCOMPLICATIONSCUBITUS VARUSCUBITUS VARUS

MOST COMMONMOST COMMONMALMAL--REDUCTION, LOSS OF REDUCTION, LOSS OF REDUCTIONREDUCTION–– MEDIAL TILT OF DISTAL FRAGMENTMEDIAL TILT OF DISTAL FRAGMENTPRIMARILY COSMETICPRIMARILY COSMETIC–– NO FUNCTIONAL DEFECITS IN MULTIPLE NO FUNCTIONAL DEFECITS IN MULTIPLE

SERIESSERIES–– DEFORMITY IS NONDEFORMITY IS NON--PROGRESSIVEPROGRESSIVE–– WILL NOT REMODELWILL NOT REMODEL

COMPLICATIONSCOMPLICATIONSCUBITUS VARUSCUBITUS VARUS

MALROTATION WILL KEEP THE MALROTATION WILL KEEP THE MEDIAL COLUMN FRAGS. OUT OF MEDIAL COLUMN FRAGS. OUT OF CONTACTCONTACTWenger, et. al. JPO, 1994: reports five Wenger, et. al. JPO, 1994: reports five cases of lateral condyle fractures in cases of lateral condyle fractures in patients with cubitus varus deformitypatients with cubitus varus deformity

CUBITUS VARUSCUBITUS VARUSTREATMENTTREATMENT

Coventry, Rocky Mtn. Med. Jl, 1956Coventry, Rocky Mtn. Med. Jl, 1956–– described a lateral closing wedge osteotomy described a lateral closing wedge osteotomy

for correctionfor correctionHall, et. al. JPO, 1994Hall, et. al. JPO, 1994–– Good, or excellent results in 35 of 36 patients Good, or excellent results in 35 of 36 patients

treated with this technique, fixed with two treated with this technique, fixed with two lateral pinslateral pins

One loss of reductionOne loss of reduction

Levine, et. al. JPO, 1996Levine, et. al. JPO, 1996–– rec. an exrec. an ex--fix, rather than pins for 8 weeksfix, rather than pins for 8 weeks

FLEXION S.C. FRACTURES FLEXION S.C. FRACTURES

ONLY 3%ONLY 3%TX AS EXTENSION TYPETX AS EXTENSION TYPEMORE STABLE IN EXTENSIONMORE STABLE IN EXTENSION

EPIPHYSEAL SEPERATIONEPIPHYSEAL SEPERATION

RARERARESHEAR INJURYSHEAR INJURYAGE: BIRTH AGE: BIRTH -- 4 YRS4 YRSMECHANISM:MECHANISM:–– 1. BIRTH TRAUMA1. BIRTH TRAUMA–– 2. FALL FROM 2. FALL FROM

HEIGHTHEIGHT–– 3. CHILD ABUSE3. CHILD ABUSE

DeLee, et. al. JBJS, DeLee, et. al. JBJS, 1963: The cause in 6 1963: The cause in 6 of 16 of 16

EPIPHYSEAL SEPERATIONEPIPHYSEAL SEPERATIONXX--RAYRAY

MAY LOOK LIKE AN ELBOW DISLOC. IN MAY LOOK LIKE AN ELBOW DISLOC. IN INFANTSINFANTS–– DIFF. ITH ARTHROGRAM, MRIDIFF. ITH ARTHROGRAM, MRITHURSTONTHURSTON--HOLLAND FRAGMENTHOLLAND FRAGMENT–– WAFER OF METAPH. BONEWAFER OF METAPH. BONE–– S.H II FRACTURES.H II FRACTURECAPITELLUM IN LINE WITH THE CAPITELLUM IN LINE WITH THE RADIAL HEAD, HUMERUS LATERAL RADIAL HEAD, HUMERUS LATERAL (USUALLY) TO BOTH(USUALLY) TO BOTH

EPIPHYSEAL SEPERATIONEPIPHYSEAL SEPERATIONTREATMENTTREATMENT

NON AND MINIMALLY DISPLACEDNON AND MINIMALLY DISPLACED–– CLOSED RED. AND SPLINT FOR 3 WEEKSCLOSED RED. AND SPLINT FOR 3 WEEKSDISPLACEDDISPLACED–– CLOSED RED. AND PINNINGCLOSED RED. AND PINNING–– HIGH RATE OF CUBITUS VARUS IF HIGH RATE OF CUBITUS VARUS IF

TREATED NONTREATED NON--OPERATIVELY OPERATIVELY –– MORE STABLE THAN S.C. FRACTURES MORE STABLE THAN S.C. FRACTURES

SECONDARY TO THE INCREASED SECONDARY TO THE INCREASED SURFACE AREA OF THE PHYSISSURFACE AREA OF THE PHYSIS

LATERAL CONDYLE FXLATERAL CONDYLE FX

17% OF PEDI ELBOW FX17% OF PEDI ELBOW FX’’ss–– SECOND MOST COMMONSECOND MOST COMMONAGE: 5 AGE: 5 -- 10 YEARS10 YEARSMECHANISM: AVULSIONMECHANISM: AVULSION–– Varus stress to an extended elbow in Varus stress to an extended elbow in

suppination. The force is transmitted through suppination. The force is transmitted through the extensor muscles, resulting in an avulsionthe extensor muscles, resulting in an avulsion

S.H. TYPE IV VS. TYPE IIS.H. TYPE IV VS. TYPE II

LATERAL CONDYLE FXLATERAL CONDYLE FXCLASSIFICATIONCLASSIFICATION

MILCHMILCH–– TYPE I: FX PASSES LATERAL TO TYPE I: FX PASSES LATERAL TO

TROCHLEAR GROOVETROCHLEAR GROOVE–– TYPE II: FX PASSES MEDIAL TO THE TYPE II: FX PASSES MEDIAL TO THE

TROCHLEAR GROOVETROCHLEAR GROOVERADIUS AND ULNA CAN BE MEDIALLY RADIUS AND ULNA CAN BE MEDIALLY DISPLACED DISPLACED

LATERAL CONDYLE FXLATERAL CONDYLE FXCLASSIFICATIONCLASSIFICATION

Jakob, et. al. JBJSJakob, et. al. JBJS--B, 1975B, 1975–– TYPE I: INCOMPLETE, DOES NOT ENTER TYPE I: INCOMPLETE, DOES NOT ENTER

THE ARTICULAR SURFACE.THE ARTICULAR SURFACE.–– TYPE II: < 2 mm DISPLACEMENT, INTRATYPE II: < 2 mm DISPLACEMENT, INTRA--

ARTICULAR, NO MALARTICULAR, NO MAL--ROTATIONROTATION–– TYPE THREE: CAPITELLUM DISPLACED TYPE THREE: CAPITELLUM DISPLACED

AND ROTATEDAND ROTATED

LATERAL CONDYLE FXLATERAL CONDYLE FXXX--RAYRAY

TYPE I: MAY NEED TYPE I: MAY NEED AN OBLIQUE XAN OBLIQUE X--RAY IN INTERNAL RAY IN INTERNAL ROTATION TO SEE ROTATION TO SEE ITITARTHROGRAM MAY ARTHROGRAM MAY HELPHELP

LATERAL CONDYLE FXLATERAL CONDYLE FXTREATMENTTREATMENT

TYPE I: IMMOBILSE IN FLEXION AND TYPE I: IMMOBILSE IN FLEXION AND SUPINATION FOR 3 SUPINATION FOR 3 -- 4 WKS.4 WKS.–– FOLLOW WEEKLY XFOLLOW WEEKLY X--RAYS AS UP TO 10% RAYS AS UP TO 10%

CAN DISPLACE IN PLASTERCAN DISPLACE IN PLASTER–– ANY DOUBT, OR LATE DISPLACEMENT, TX ANY DOUBT, OR LATE DISPLACEMENT, TX

AS A STABLE TYPE IIAS A STABLE TYPE II

LATERAL CONDYLE FXLATERAL CONDYLE FXTREATMENTTREATMENT

TYPE II, STABLE TO VARUS STRESSTYPE II, STABLE TO VARUS STRESS–– PERC. PINNINGPERC. PINNINGTYPE II, UNSTABLETYPE II, UNSTABLE–– ORIF WITH ORIF WITH ““AFTAFT”” ALIGNMENT OF ALIGNMENT OF

ARTICULAR SURFACEARTICULAR SURFACE–– 2 LATERAL K2 LATERAL K--WIRESWIRESFinbogaten, et. al. JPO, 1995Finbogaten, et. al. JPO, 1995–– 47 TYPE II FX47 TYPE II FX’’s TX CLOSED, 11 s TX CLOSED, 11

DISPLACEDDISPLACED

LATERAL CONDYLE FXLATERAL CONDYLE FXTREATMENTTREATMENT

LATERAL CONDYLE FXLATERAL CONDYLE FXTREATMENTTREATMENT

TYPE IIITYPE III–– REQUIRES ORIF, REQUIRES ORIF,

UNANIMOUSLY UNANIMOUSLY –– STRIPPING OF THE STRIPPING OF THE

POSTERIOR POSTERIOR FRAGMENTS CAN FRAGMENTS CAN LEAD TO AVN OF LEAD TO AVN OF THE DISTAL THE DISTAL FRAGMENTFRAGMENT

LATERAL CONDYLE FXLATERAL CONDYLE FXCOMPLICATIONSCOMPLICATIONS

NONNON--UNION: HIGH RATE WITH INTRAUNION: HIGH RATE WITH INTRA--ARTICULAR FRACTURES AS SYNOVIAL ARTICULAR FRACTURES AS SYNOVIAL FLUID ENTERS THE FRACTURE, EVEN FLUID ENTERS THE FRACTURE, EVEN TYPE IITYPE II’’s HAVE A HIGH RATE IF NOT s HAVE A HIGH RATE IF NOT PINNEDPINNED–– TX WITH BONE GRAFT AND IN SITU TX WITH BONE GRAFT AND IN SITU

PINNING EARLY ON (8 WKS) IF MIN PINNING EARLY ON (8 WKS) IF MIN DISPLACEDDISPLACED

–– TX WITH ORIF AND BONE GRAFT IF SIG TX WITH ORIF AND BONE GRAFT IF SIG DISPLACEMENTDISPLACEMENT

LATERAL CONDYLE FXLATERAL CONDYLE FXCOMPLICATIONSCOMPLICATIONS

CUBITUS VALGUS:CUBITUS VALGUS:–– RESULT OF MALRESULT OF MAL--UNION, OR NONUNION, OR NON--UNIONUNION–– PROGRESSIVE DEFORMITYPROGRESSIVE DEFORMITY–– MAY LEAD TO TARDY ULNAR N. PALSYMAY LEAD TO TARDY ULNAR N. PALSY

APPEARS 22 YEARS POST INJURYAPPEARS 22 YEARS POST INJURY

ELBOW INSTABILITYELBOW INSTABILITY

MEDIAL EPICONDYLE FXMEDIAL EPICONDYLE FX

10 % OF PEDI ELBOW FRACTURES10 % OF PEDI ELBOW FRACTURESAGE: 10AGE: 10--14 YRS14 YRS75 % ARE IN BOYS75 % ARE IN BOYSMECHANISM: AVULSIONMECHANISM: AVULSION–– VALGUS FORCE ALONG WITH FLEXION VALGUS FORCE ALONG WITH FLEXION

OF FOREARM FLEXORSOF FOREARM FLEXORS–– CONCURRENT ELBOW DISLOCATION IS CONCURRENT ELBOW DISLOCATION IS

COMMONCOMMON

MEDIAL EPICONDYLE FXMEDIAL EPICONDYLE FXCLASSIFICATIONCLASSIFICATION

Bede, et. al. Can. Jl. Surg. 1975Bede, et. al. Can. Jl. Surg. 1975–– TYPE I: NONTYPE I: NON--DISPLACEDDISPLACED–– TYPE II: DISPLACED < 5 mmTYPE II: DISPLACED < 5 mm–– TYPE III: DISPLACED > 5 mmTYPE III: DISPLACED > 5 mm

NO DISLOCATION, EPICONDYLE OUTSIDE NO DISLOCATION, EPICONDYLE OUTSIDE JOINTJOINTNO DISLOCATION, INCARCERATED IN THE NO DISLOCATION, INCARCERATED IN THE JOINTJOINTWITH ELBOW DISLOCATIONWITH ELBOW DISLOCATION

MEDIAL EPICONDYLE FXMEDIAL EPICONDYLE FXXX--RAYRAY

COMPARISON OF COMPARISON OF CONTRALATERAL CONTRALATERAL SIDE HELPFULSIDE HELPFULWIDENED WIDENED APOPHYSISAPOPHYSISMAY SEE MAY SEE APOPHYSIS IN APOPHYSIS IN JOINTJOINT

MEDIAL EPICONDYLE FXMEDIAL EPICONDYLE FXTREATMENTTREATMENT

DISPLACED < 5 mm , IMMOBILIZATION DISPLACED < 5 mm , IMMOBILIZATION AND EARLY ROMAND EARLY ROMTYPE III: CONTROVERSIALTYPE III: CONTROVERSIAL–– THERE IS NO REAL CONSENSUSTHERE IS NO REAL CONSENSUS–– EUA TO EVAL VALGUS INSTABIL. MAY EUA TO EVAL VALGUS INSTABIL. MAY

HELPHELP–– IN STABLE ELBOWS, UP TO 15 mm OF IN STABLE ELBOWS, UP TO 15 mm OF

DISPLACEMENT IS ACCEPTABLEDISPLACEMENT IS ACCEPTABLEASSYMPTOMATIC NONASSYMPTOMATIC NON--UNION IN 50%UNION IN 50%

MEDIAL EPICONDYLE FXMEDIAL EPICONDYLE FXTREATMENTTREATMENT

INDICATIONS FOR INDICATIONS FOR ORIFORIF–– INTRAINTRA--ARTICULAR ARTICULAR

ENTRAPMENTENTRAPMENT–– SEVERE SEVERE

DISPLACEMENT DISPLACEMENT –– VALGUS VALGUS

INSTABILITY (+ / INSTABILITY (+ / --))MORE LIKELY MORE LIKELY REQUIRED IN A REQUIRED IN A THROWING ATHLETETHROWING ATHLETE

MEDIAL CONDYLE FXMEDIAL CONDYLE FX

< 2 % OF PEDI ELBOW FRACTURES< 2 % OF PEDI ELBOW FRACTURESMECHANISM:MECHANISM:–– FOOSH WITH ELBOW EXTENDED, OR FOOSH WITH ELBOW EXTENDED, OR

FALL ON OLECRONONFALL ON OLECRONON

MEDIAL CONDYLE FXMEDIAL CONDYLE FXCLASSIFICATIONCLASSIFICATION

Kilfoyle, et. al. CORR, 1965Kilfoyle, et. al. CORR, 1965–– TYPE I: NONTYPE I: NON--DISPLACED, EXTRADISPLACED, EXTRA--

ARTICULARARTICULAR< 5 YEARS OLD< 5 YEARS OLD

–– TYPE II: INTRATYPE II: INTRA--ARTIC. NONARTIC. NON--DISPLACEDDISPLACED–– TYPE III: DISPLACED AND ROTATEDTYPE III: DISPLACED AND ROTATED

> 7 YEARS OLD > 7 YEARS OLD

MEDIAL CONDYLE FXMEDIAL CONDYLE FXXX--RAYRAY

MAY SEE A FLECK OF METAPHYSEAL MAY SEE A FLECK OF METAPHYSEAL BONEBONEDIFFICULT IF TROCHLEA NOT DIFFICULT IF TROCHLEA NOT OSSIFIEDOSSIFIEDARTHROGRAM, MRI MAY HELPARTHROGRAM, MRI MAY HELP

MEDIAL CONDYLE FXMEDIAL CONDYLE FXTREATMENTTREATMENT

TYPE I: IMMOBILIZE AT 90 DEGREESTYPE I: IMMOBILIZE AT 90 DEGREESTYPE II: CLOSED RED. AND PINNING TYPE II: CLOSED RED. AND PINNING IF ALIGNMENT GOOD, OTHERWISE IF ALIGNMENT GOOD, OTHERWISE ORIFORIFTYPE III: ORIFTYPE III: ORIFLEAVE PINS IN 3 LEAVE PINS IN 3 --4 WKS4 WKSSIMILAR TO LAT. EPICONDYLE FXSIMILAR TO LAT. EPICONDYLE FX