THE ELBOW IN CHILDREN :Point of anatomy :- The elbow is a complex hinge, providing sufficient mobility to permit the upper

limb to reach through wide ranges of flexion, extension & rotation, yet also enough stability to support the necessary gripping, pushing, pulling &carrying activities of daily life. Its stability is due largely to the shape & fit of the bones that make up the joint-especially the humeo-ulnar component -& this is liable to be compromised by any break in the articulating structures. The surrounding soft-tissue structures also are important, especially the capsular & collateral ligaments & to a lesser extent, the muscles. Ligament disruption is also, there fore a destabilizing factor.
-The forearm is normally in slight valgus in relation to the upper arm, the average carrying angle in children being about 15 degree. (Published measurements range from 5 to 25 degrees!) When the elbow is flexed, the forearm comes to lie directly upon the upper arm. Doubts about the normality of these features can usually be resolved by comparing the injured with the normal arm. (Next slide)

- With the elbow flexed, the tips of the medial & lateral epicondyles & the olecranon prominnence form an isosceles triangle; with the elbow extended, they lie transversely in line with each other. -Though all the epiphyses are in some part cartilaginous, the secondary ossific centres can be seen on x-ray; they should not be mistaken for fracture fragments! The average ages at which the ossific centres appear are easily remembered by the mnemonic

CRITOE:
- Capitulum - 2 years. - Radial head 4 years. - Internal (medial) epicondyle 6 years. - Trochlea 8 years. - Olecranon 10 years. - External (lateral) epicondyle 12 years. Obviously epiphyseal displacements will not be detactable on x-ray before these ages. Fracture displacement & accuracy of reduction can be inferred from radiographic indices such as Baumanns angle. (Next slide)

:SUPRACONDYLAR FRACTUE OF THE HUMERUS :

Defination :- Breaks just above the condyles of the humerus is called supracondylar fractue. This is the commonest fractures in children. The distal fragment may be displaced either posteriorly or anteriorly.

Mechanism of injury :(a) Posterior angulation or displacement (95% of all cases) - Suggests a hyperextension injury. - It is usually due to a fall on the outstretched hand. - The distal fragment is pushed backwards and twisted inwards. - The jagged end of the proximal fragment pokes in to the soft tissues anteriorly. - Sometimes injuring brachial artery or median nerve. (b) Anterior displacement is rare (about 5% of all cases) - It is thought to be due to direct violence (e.g a fall on the point of elbow) with the joint in flexion. (Next slide)

Classification :Supracondylar fractures may be classified according to severity and the degree of displacement (wilkins 1984). -Type 1 is an undisplaced fracture. - Type 2 is an angulated fracture with the posterior cortex still in continuity. Type 2A being less severe and merely angulated. Type 2B being less severe & both angulated & malrotated. - Type 3 is a completely displaced fracture.

Clinical features :- History of fall - The child/Patient is in pain - The elbow is swollen - The S-shaped deformity of the elbow - The bony landmarks are abnormal - May be impairment of the pulse capillary return - The wrist & the hand should be examined for evidence of nerve injury.

X-ray:- Lateral & A/P Views

- The fracture is seen most clearly in the lateral view.

In the common posteriorly displaced fracture the fracture line runs obliquely downwards & forwards & the distal fragment is tilted backwards and/or shifted backwards. In the anteriorly displaced fracture the crack runs downwards & the fragment is tilted forwards.

- An anteroposterior view the distal fragment is

( Next slide)

shifted or tilted sideways & rotated (usually medially). Measurement of Baumanns angle is useful in assessing the degree of medial angulations before & after reduction.

TREATMENT:- If there is even a suspicion of a fracture the elbow is gently splinted in 30 of flexion to prevent movement & possible neurovascular injury during the x-ray examination.

The definitive treatment recommended are as follows

Type 1: UNDISPLACED FRACTURE

-The elbow is immobilized at 90 degree & neutral rotation in a lightweight splint or cast & the arm is supported by a sling. -Check x-ray to be done after 5-7 days to see the displacement. -The splint is retained for 3 weeks & supervised movement is then allowed. ( Next slide)

Type 2 A: POSTERIORLY ANGULATED FRACTURE- Mild

- In these cases swelling is usually not serve & the risk of vascular injury is low. - If the posterior cortices are in continuity - The fracture can be reduced under G/A- by the following step wise manoeuvre: (1) Traction for 2-3 minutes in the length of the arm with counter-traction above the elbow. (2) Correction of any sideways tilt or shift & rotation (in comparison with the arm). (3) Gradual flexion of the elbow to 120 degree & pronation of the forearm, while maintaining traction & exerting finger pressure behind the distal fragment to correct posterior tilt. -Then feel the pulse & check the capilarry return- if the distal circulation is suspect, immediately relax the amount of elbow flexion until it improves. Check x-ray to be done to see the reduction (to see varus or valgus angulation deformity)

(Next slide)

Following reduction
The arm is held in a collar & cuff. The circulation should be checked repeatedly during the first 24 hours. Do the check x-ray after 3-5 days . The splint is retained for 3 weeks, after which movements are begun. If the reduction is unstable, the fracture should be fixed with percutaneous crossed kirschner wires

TYPES 2B & 3: ANGULATED & MALROTATED POSTERIORLY DISPLACED:- Usually associated with severe swelling. - Difficult to reduce & are often unstable - Risk of neurovascular injury or circulatory compromise due to swelling. - The fracture should be reduced under G/A as soon as possible. - Held with percutaneous crossed kirschner wires.
OPEN REDUCTION:- Sometimes necessary for (1) When fracture simply cannot be reduced closed. (2) An open fracture (3) Fracture associated with vascular damage. ( Next slide)

CONTINUOUS TRACTION:- Through the Olecranon(1) If the fracture is severely displaced & cannot be reduced by manipulation (2) If , with the elbow flexed 100 degree. The pulse is obliterated & image intensification is not available to allow pinning & then straightening of the elbow. (3) For severe open injuries or multiple injuries of the limb. Once the swelling reduction. TREATMENT OF ANTERIORLY DISPLACED FRACTURES:-This is rare injury - posterior fracture are sometimes converted to anterior ones by excessive traction & manipulation. *The fracture is reduced by pulling on the forearm with the elbow semi flexed, applying thumb pressure over the front of the distal fragment & then extending the elbow fully. * A posterior slab is bandaged on & retained for 3 weeks. * Thereafter, the child is allowed to regain flexion gradually.

( Next slide)

COMPLICATIONS OF SUPRACONDYL. FRACTURE HUMERUS

(A)

EARLY:-

- Vascular injury:- The great danger of supracondylar fracture is injury to the brachial artery (Less than 1% of cases). Peripheral ischaemia may be immediate & severe. More commonly the injury is complicated by forearm oedema & mounting compartment syndrome which leads to necrosis of the muscle & nerves without causing peripheral gangrene. - Nerve injury:- The median nerve (recovery can be expected in 6-8 weeks).
(Next slide)

(B) LATE:- Malunion: Malumon is common* Cubitus Varus ( most common) is disfiguring. * Cabitus valgus (rare) may cause late ulnar palsy. - Stiffness of the elbow joint & - Myositis ossificans. -:--:-:--:--:-:--:--:-:-

DR M A BASED

PRINCIPLES OF CLOSED FRACTURE TREATMENT

There are four fundamental principles of treatment of fracture.- (4R ) 1. Recognition :- Diagnosis and assessment of fractures. 2. Reduction of fractures :- If necessary. 3. Retention :-Immobilization of fractures by P.O.P cast , slab, fixators (Ext. + Int.) 4. Rehabilitation :- Functional activity. Recognition :- Diagnosis and assessment History, C/F,+ Radiological examination. Points should be kept in mind for treatment i) The site of fracture ii) Shape of fracture.

Reduction of fracture
It is the restoration of fracture fragment in acceptable position. Acceptable positions are i) Perfect alignment ii) Perfect apposition.

Methods of Reduction and Immobilization :1. Conservative :- a) Closed reduction by manipulation and external immobilization with plaster of paris with other mechanical aids. b) Closed reduction by continuous traction and counter traction by mechanical device . eg Thomas splints , brown vonlar split :- which is followed by external immobilization with P.O.P or brace. 2. Open reduction and internal fixation ( O.R.I.F ) 3. Closed reduction and ext skeletal fixation or percuteneus K-wire fixation. 4. Excision and prosthetic replacement in adult. e.g. N.O.F.

THE END