Tag: Paediatric fractures

• Extra-articular fracture involving proximal humerus proximal to the bicipital tuberosity.
• Usually a physeal injury either Salter-Harris I or II.
• 1% of pediatric fractures and 5-10% of pediatric elbow injuries.
• Major concerns are vascularity of proximal fragment, risk of growth arrest and proximal radioulnar and radiocapitellar malalignment.

Anatomy

• Radial head has 15⁰ lateral angulation on AP view and 5⁰ angulation on lateral views.
• Secondary centre for ossification appears at 4 years of age. Ultrasound, MRI or arthrography may be necessary in those younger than 4 years for diagnosis.
• Stabilized by annular ligament and lateral ligament complex.
• Radial nerve passes anteriorly and the posterior interosseous nerve enters the supinator muscle 2.5cm below the radial head.

Classification

Wilkin’s classification

Type I- Valgus injury

• Salter Harris I or II
• Salter Harris III or IV
• Metaphyseal

Type II- With elbow dislocation

• Occurred with initial injury (Radial head anterior)
• Occurred during reduction (Radial head posterior)

O’Brien classification

I – <30⁰ angulation

II- 30-60⁰ angulation

III- >60⁰ angulation

Judet classification

I- Undisplaced

II- Less than 30⁰ angulated

III- 30-60⁰ angulation

IV A- 60-80⁰angulation

IV B- >80⁰ angulation

Treatment

• Ligament injury especially ulnar collateral ligament seen in 30-50%.
• Prognosis depends on the age, amount of displacement, associated injury, body mass index and treatment method.
• Poor prognosis factors
  • Age more than 10 years
  • Displacement more than 100%
  • Obesity
  • Open reduction
  • Associated dislocation of elbow
  • Delayed surgery
• Closed treatment is recommended if the displacement is less than 3mm, angulation less than 45⁰ if there is no block to forearm rotations and elbow movement.
• Indications for surgery
  • Angulation is more than 30⁰
  • Displacement more than 3mm
  • Age more than 9 years
• Every effort should be made to reduce by closed or percutaneous methods as open reduction is associated with higher incidence of complications.
• Reduction ladder
  • Closed reduction
  • Percutaneous reduction
  • Open reduction
• Kaufman or Israeli technique
  • Done under C-arm.
  • Flex elbow to 90⁰.
  • Supinate and pronate to identify the plane of maximum angulation.
  • With the thumb milk the head from distal to proximal to reduce the fracture.
• Patterson technique
  • Done under C-arm.
  • Traction in extended position.
  • Supination and varus force.
  • Digital pressure over the radial head to reduce the fracture.
• Metaizeau technique
  • Done under C-arm
  • Pass a titanium elastic nail proximal to the distal radius physis.
  • Drive the nail into the radial head under image guidance
  • Rotate the nail to reduce the fracture.
• Immediate open reduction indications
  • Open fractures
  • Neurovascular compromise
  • >100% displacement
• Transcapitellar pins associated with higher complications
• Complications
  • Seen in 30%.
  • May go up to 50% in severely displaced fractures
  • Loss of pronation more than supination.
  • Osteonecrosis
  • Heterotopic ossification
  • Nonunion
  • Growth arrest
  • Radioulnar synostosis