Elbow Region Fractures

Introduction

Upper limb fractures become common in children soon after they become ambulatory. This is so as children use their upper limbs to protect themselves when they fall. The most common fracture around the elbow is the supracondylar humeral fracture followed in frequency by the lateral condylar humeral fracture. Both have a peak incidence in the first decade of life.

Elbow region fracture present with some unique problems. Due to its complex anatomy and considerable swelling which follows a fracture of this region, there are difficulties in making a clinical diagnosis. The interpretation of radiographs is difficult on account of the presence of multiple ossification centers, which appear at different ages. All three major upper limb nerves as well as the brachial artery are vulnerable in their close proximity to the elbow. This is one of the favored sites for the development of distal compartment syndrome and myositis ossificans. In contrast to minimal procedures required to treat other fractures in children, fracture here requires aggressive management including surgery. Any errors in the treatment of elbow region fracture can have serious short and long term consequences.

Supracondylar Fracture

This is the second most common fracture in children (after the forearm fracture). According to Hanlon et al (1954), this fracture has the highest incidence of reduction, nerve injury and poor results compared to any other pediatric age group fracture. The patient presents with a swollen elbow, which is mild in an undisplaced fracture to huge with ecchymotic and blistered skin in a widely displaced fracture. The deformity is typically S-shaped when seen from the side. There are pain, tenderness, and refusal to handling. A gently elicited stretch pain is a definite cause for alarm and required urgent treatment.

Orthopedic management consists of radiographic fracture assessment and classification, careful evaluation of overlying skin, peripheral neurovascular status, and compartment pressure. The patient is taken up for a closed reduction of the fracture under anesthesia. Any residual side to side or AP displacement, which is so very obvious on radiographs, is acceptable. Any rotational and varus or valgus angulation which are subtly visible and difficult to assess on x-are grounds to reduce or open reduce the fracture. Open reduction involves a reduction of the fracture under vision and fixation by various configurations of smooth K-wires. At times, due to severe edema or poor skin condition, or a history of massage or multiple manipulations, many surgeons choose to treat the fracture conservatively in traction and accept whatever deformity that results. This is perfectly valid, as it is preferable to selectively correct the deformity at a later date by an osteotomy, thereby avoiding complications like wound dehiscence and infection and minimizing myositis and stiffness.

During the rehabilitative period, only the active range of motion exercises is instituted. No attempt must be made to force the joint as it results in myositis. Unless there has been a major complication, almost total functional recovery can be expected even if the reduction is suboptimal.

Stiffness is documented in 2% of all supracondylar fractures. 7% of these fractures are complicated by nerve injury, a radial nerve being the most commonly involved. Vascular injury is the most feared complication of this fracture, and the outcome can result in a Volkmann's contracture with or without motor sensory loss or gangrene. Myositis ossificans is rare in the western world but is commonly seen in our clinics, the principal cause being a vigorous massage and application of irritants by local osteopaths and healers. Cubitus varus is the most common complication and results from an inadequate reduction. Very rarely, cubitus valgus may result.

Lateral Condyle Fracture Of Humerus

This is the second most common fracture around the elbow joint, constituting 16.8% of all fractures of the distal humerus. The intraarticular extension of the fracture results in greater potential for elbow stiffness. Epiphyseal involvement makes growth disturbances more likely. The displacement which almost always occurs in this fracture makes operative treatment unavoidable. A poorly treated lateral condyle fracture may manifest with an unsatisfactory result months or years later and complications are not as responsive to surgical correction as in the case of a supracondylar humeral fracture.

Milch has classified this injury into two types. In type 1 injury, the fracture line runs lateral to the capitulotrochlear groove and shears off a portion of the lateral condylar epiphysis maintaining the joint as stable (partial retention of lateral column). However, this fracture has a greater potential for growth disturbances. In type 2 injury, the fracture line runs into the apex of the trochlea with a total loss of lateral support thereby rendering the elbow unstable. The lateral condyle fracture almost always displaces due to the attachment of the extensor group of muscles on the lateral epicondylar area. In its full and final displacement, the fragment is rotated 180 degrees coronally and 90 degrees in the horizontal plane such that the fracture surface faces outwards.

The patient has little soft tissue swelling in contrast to a supracondylar fracture, and most of it is concentrated on the lateral epicondylar area of the humerus. It may be possible to clearly feel the fracture and move the fragment. A radiographic study is confirmed.

Undisplaced fracture does not require anything other than an above elbow back slab with an elbow in 900 flexions and forearm in pronation for 3 weeks. However one must be certain on clinical examination that the fragment does not have the potential to displace. Any crepitus or huge soft tissue swelling points to instability and makes operative treatment a better choice. Open reduction and internal fixation have become the most widely accepted choice of treatment. Internal fixation is most commonly carried out using smooth K - wires in various configurations after obtaining an anatomical reduction. It is imperative to preserve soft-tissue attachments while carrying out the procedure. It is believed that when children present with fractures that are older then 3 weeks, it is best to leave them alone as they fare poorly if operated. However, we do not subscribe to this view.

A suboptimal reduction can result in a cosmetic deformity as well as functional loss. Other complications are delayed union, nonunion, epiphyseal growth arrest, lateral condyle overgrowth, valgus and varus deformity of elbow, immediate and tardy nerve palsy, myositis ossificans, trochlear fishtailing, and epiphyseal avascular necrosis.

Generally, a fresh fracture that is well reduced, adequately fixed, and managed well postoperatively gives excellent results in form of restored anatomical contours, resumption of normal growth, and regaining of a full range of motion.