Fractures and Dislocations
about the Elbow
in the Pediatric Patient
Joshua Klatt, MD
Original Author: Kevin Shea, MD; March 2004
Revised:
Steven Frick, MD; August 2006
Joshua Klatt, MD; Albert Pendleton, MD ; November 2011
Elbow Fractures in Children
• Very common injuries (approximately 65% of
pediatric trauma)
• Radiographic assessment - difficult for nonorthopaedists, because of the complexity and
variability of the physeal anatomy and
development
• A thorough physical examination is essential,
because neurovascular injuries can occur before
and after reduction
• Compartment syndromes are rare with elbow
trauma, but can occur
Elbow Fractures
Physical Examination
• Children will usually not move the elbow if a fracture is
present, although this may not be the case for nondisplaced fractures
• Swelling about the elbow is a constant feature, except for
non-displaced fracture
• Complete vascular exam is necessary, especially in
supracondylar fractures
– Doppler may be helpful to document vascular status
• Neurologic exam is essential, as nerve injuries are common
– In most cases, full recovery can be expected
Elbow Fractures
Physical Examination
• Neurological exam may be limited by the
child’s ability to cooperate because of age,
pain, or fear.
• Thumb extension – EPL
– Radial – PIN branch
• Thumb flexion – FPL
– Median – AIN branch
• Cross fingers/scissors - Ad/Abductors
– Ulnar
Elbow Fractures
Physical Examination
• Always palpate the arm and forearm for signs of
compartment syndrome
• Thorough documentation of all findings is
important
– A simple record of “neurovascular status is intact” is
unacceptable (and doesn’t hold up in court…)
– Individual assessment and recording of motor, sensory,
and vascular function is essential
Elbow Fractures
Radiographs
• AP and Lateral views are important initial views
– In trauma these views may be less than ideal, because
it can be difficult to position the injured extremity
• Oblique views may be necessary
– Especially for the evaluation of suspected lateral
condyle fractures
• Comparison views frequently obtained by primary
care or ER physicians
– Although these are rarely used by orthopaedists
Elbow Fractures
Radiograph Anatomy/Landmarks
• Baumann’s angle is formed by a line
perpendicular to the axis of the
humerus, and a line that goes through
the physis of the capitellum
• There is a wide range of normal for
this value
– Can vary with rotation of the radiograph
• In this case, the medial impaction and
varus position reduces Bauman’s
angle
-Baumann E. Beitrage zur Kenntnis der Frakturen am
Ellbogengelenk: Unter besonderer Berucksichtigung der Spatfolgen. I.
Allgemeines und Fractura supra condylica. Beitr Klin Chir
1929;146:1-50.
-Mohammad. The Baumann angle in supracondylar fractures of the
Elbow Fractures
Radiograph Anatomy/Landmarks
• Anterior Humeral Line
– Drawn along the
anterior humeral cortex
– Should pass through
the middle of the
capitellum
– Variable in very young
children
-Rogers. Plastic bowing, torus and greenstick supracondylar fractures
of the humerus: radiographic clues to obscure fractures of the elbow
in children. Radiology. 1978;128:145.
-Herman. Relationship of the anterior humeral line to the capitellar
ossific nucleus: variability with age. J Bone Joint Surg. 2009;91:2188.
Elbow Fractures
Radiograph Anatomy/Landmarks
• The capitellum is
angulated
anteriorly about
30 degrees.
• The appearance
of the distal
humerus is
similar to a
hockey stick.
30
Elbow Fractures
Radiograph Anatomy/Landmarks
• The physis of the
capitellum is
usually wider
posteriorly,
compared to the
anterior portion of
the physis
Wider
Elbow Fractures
Radiograph Anatomy/Landmarks
• Radiocapitellar
line should
intersect the
capitellum in all
views
• Make it a habit to
evaluate this line
on every pediatric
elbow film
Supracondylar Humerus Fractures
• Most common fracture around the elbow in
children
– 60 percent of elbow fractures
• 95 percent are extension type injuries
– Produces posterior angulation/displacement of the distal
fragment
• Occurs from a fall on an outstretched hand
– Ligamentous laxity and hyperextension of the elbow
are important mechanical factors
• May be associated with a distal radius or forearm
fractures
Omid. Supracondylar Humeral Fractures in Children. J Bone Joint Surg. 2008;90:1121.
Supracondylar Humerus Fractures
Classification
• Type 1
– Non-displaced
• Type 2
– Angulated/displaced
fracture with intact
posterior cortex
• Type 3
– Complete displacement,
with no contact between
fragments
Gartland. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959;109:145-54.
Type 1
Non-displaced
• Note the nondisplaced fracture
(Red Arrow)
• Note the posterior
fat pad (Yellow Arrows)
-Skaggs. The posterior fat pad sign in association with occult fracture
of the elbow in children. J Bone Joint Surg Am. 1999;81:1429.
-Bohrer. The fat pad sign following elbow trauma. Its usefulness and
reliability in suspecting “invisible” fractures. Clin Radiol. 1970;21:90.
Type 2
Angulated/displaced fracture with intact
posterior cortex
Type 2
Angulated/displaced fracture with intact
posterior cortex
• In many cases, the type 2
fractures will be impacted
medially
– Leads to varus angulation
• The varus malposition
must be considered when
reducing these fractures
– Apply a valgus force for
realignment
Type 3
Complete displacement, with no contact
between fragments
Supracondylar Humerus Fractures
Associated Injuries
• Nerve injury incidence is high, between 7 and 16 %
– Median, radial, and/or ulnar nerve
• Anterior interosseous nerve injury is most commonly
injured nerve
• In many cases, assessment of nerve integrity is limited
– Children can not always cooperate with the exam
• Carefully document pre-manipulation exam,
– Post-manipulation neurologic deficits can alter decision making
Cramer. Incidence of anterior interosseous nerve palsy in supracondylar
humerus fractures in children. J Pediatr Orthop. 1993;13:502.
Supracondylar Humerus Fractures
Associated Injuries
• 5% have associated
distal radius fracture
• Physical exam of
distal forearm
• Radiographs if needed
• If displaced pin radius
also
– Difficult to hold
appropriately in splint
Supracondylar Humerus Fractures
Associated Injuries
• Vascular injuries are rare, but pulses should
always be assessed before and after reduction
• In the absence of a radial and/or ulnar pulse, the
fingers may still be well-perfused, because of the
excellent collateral circulation about the elbow
• Doppler device can be used for assessment
White. Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric
supracondylar humerus fractures and results of a POSNA questionnaire. J Pediatr Orthop. 2010;30:328.
Supracondylar Humerus Fractures
Associated Injuries
• Type 3
supracondylar
fracture
– Absent ulnar and
radial pulses
– Fingers had capillary
refill less than 2
seconds.
• The pink, pulseless
extremity
White. Perfused, pulseless, and puzzling: a systematic review of vascular injuries in pediatric
supracondylar humerus fractures and results of a POSNA questionnaire. J Pediatr Orthop. 2010;30:328.
Supracondylar Humerus Fractures
Anatomy
• The medial and lateral columns are
connected by a thin wafer of bone
– Approximately 2-3 mm wide in the central
portion
• If the fracture is malreduced, it is inherently
unstable
– The medial or lateral columns displace easily
into varus or valgus
Supracondylar Humerus Fractures
Treatment
• Type 1 Fractures
– In most cases, these can be treated with
immobilization for approximately 3 weeks, at
90 degrees of flexion
– If there is significant swelling, do not flex to 90
degrees until the swelling subsides
Supracondylar Humerus Fractures
Treatment
• Type 2 Fractures: Posterior Angulation
– If minimally displaced (anterior humeral line hits
part of capitellum)
• Immobilization for 3 weeks.
• Close follow-up is necessary to monitor for loss of
reduction
– Displaced (anterior humeral line misses capitellum)
• Reduction may be necessary
• The degree of posterior angulation that requires reduction
is controversial
• Check opposite extremity for hyperextension
– If varus/valgus malalignment exists, most authors
recommend reduction.
Fitzgibbons. Predictors of failure of nonoperative treatment for type-2
supracondylar humerus fractures. J Pediatr Orthop. 2011;31:372.
Type 2 Fractures
Treatment
• Reduction of these fractures is usually not difficult
– Maintaining reduction usually requires flexion beyond
90°
• Excessive flexion may not be tolerated because of
swelling
– May require percutaneous pinning to maintain reduction
• Most authors suggest that percutaneous pinning is
the safest form of treatment for many of these
fractures
– Pins maintain the reduction and allow the elbow to be
immobilized in a more extended position
Fitzgibbons. Predictors of failure of nonoperative treatment for type-2
supracondylar humerus fractures. J Pediatr Orthop. 2011;31:372.
Supracondylar Humerus Fractures
Treatment
• Type 3 Fractures
– These fractures have a high risk of neurologic and/or
vascular compromise
– Can be associated with a significant amount of swelling
– Current treatment protocols use percutaneous pin
fixation in almost all cases
– In rare cases, open reduction may be necessary
• Especially in cases of vascular disruption
Supracondylar Humerus Fractures
OR Setup
• The monitor should be
positioned across from
the OR table, to allow
easy visualization of
the monitor during the
reduction and pinning
-Thometz. Techniques for direct radiographic visualization during closed pinning
of supracondylar humerus fractures in children. J Pediatr Orthop. 1990;10:555.
-Tremains. Radiation exposure with use of the inverted-c-arm technique in
upper-extremity surgery. J Bone Joint Surg Am. 2001;83-A:674.
Supracondylar Humerus Fractures
OR Setup
• The C-Arm fluoroscopy unit can
be inverted, using the base as a
table for the elbow joint
– All personnel in the room should be
adequately shielded, as radiation
exposure is significantly increased with
inverted c-arm
• Also can use radiolucent board
• The child should be positioned
close to the edge of the table, to
allow the elbow to be visualized by
the c-arm
– Make sure to secure patient’s head
and body
-Thometz. Techniques for direct radiographic visualization during closed pinning
of supracondylar humerus fractures in children. J Pediatr Orthop. 1990;10:555.
-Tremains. Radiation exposure with use of the inverted-c-arm technique in
upper-extremity surgery. J Bone Joint Surg Am. 2001;83-A:674.
Supracondylar Elbow Fractures
Type 2 with Varus Malalignment
• During reduction of
medially impacted
fractures, valgus
force should be
applied to address
this deformity.
Type 3
Supracondylar Fracture
Type 3
Operative Reduction
• Closed reduction with
flexion
• AP view with elbow
held in flexed
position to maintain
reduction.
Brachialis Sign
Proximal Fragment Buttonholed through Brachialis
Milking Maneuver
Milk Soft Tissues over Proximal Spike
Archibeck. Brachialis muscle entrapment in displaced supracondylar humerus fractures: a
technique of closed reduction and report of initial results. J Pediatr Orthop. 1997;17:298.
Adequate Reduction?
• No varus/valgus
malalignment
• Anterior humeral line
should be intact
• Minimal rotation
• Mild translation is
acceptable
From: Rang’s children’s fractures. Edited by Dennis R. Wenger, MD, and
Maya E. Pring, MD. Philadelphia: Lippincott Williams & Wilkins, 2004.
Medial Impaction Fracture
Type II fracture with medial impaction – not
recognized and varus / extension not reduced
Medial Impaction Fracture
Cubitus varus 2 years later
Lateral Pin Placement
AP and Lateral views with 2 pins
Pin Configuration
Lee. Displaced pediatric supracondylar humerus fractures: biomechanical
analysis of percutaneous pinning techniques. J Pediatr Orthop. 2002;22:440.
C-arm Views
Oblique views with the C-arm can be useful to help verify the
reduction.
Note slight rotation and extension on medial column (right image).
Supracondylar Humerus Fractures
Pin Fixation
• Different authors have recommended different pin
fixation methods
• The medial pin can injury the ulnar nerve
– Some advocate 2 or 3 lateral pins to avoid injuring the
median nerve
• Space pins as widely as possible
– If the lateral pins are placed close together at the
fracture site, the pins may not provide much resistance
to rotation and further displacement
• Some recommend one lateral, and one medial pin
Sankar. Loss of pin fixation in displaced supracondylar humeral fractures
in children: causes and prevention. J Bone Joint Surg Am. 2007;89:713.
Pitfalls of Pin Placement
• Pins Too Close
together
• Instability
• Fracture
displacement
• Get one pin in lateral
and one in medial
column
Supracondylar Humerus Fractures
Pin Fixation
• Even many children have anterior
subluxation of the ulnar nerve with
hyperflexion of the elbow
• Some recommend place two lateral pins,
assess fracture stability
• If unstable then extend elbow to take
tension off ulnar nerve and place medial pin
Eberl. Iatrogenic ulnar nerve injury after pin fixation and after antegrade nailing
of supracondylar humeral fractures in children. Acta Orthop. 2011;82:606.
Supracondylar Humerus Fractures
• After stable reduction and pinning
– Elbow can be extended to review the AP radiograph
– Baumann’s angle can be assessed on these radiographs
• Remember there can be a wide range of normal values for this
measurement
• With the elbow extended, the carrying angle of the
elbow should be reviewed, and clinical
comparison as well as radiograph comparison can
be performed to assure an adequate reduction.
Supracondylar Humerus Fractures
• If pin fixation is used, the pins
are usually bent and cut outside
the skin
• The skin is protected from the
pins by placing Xeroform and a
felt pad around the pins
• The arm is immobilized
• The pins are removed in the
clinic 3 to 4 weeks later
– After radiographs show periosteal
healing
• In most cases, full recovery of
motion can be expected
Supracondylar Humerus Fractures:
Indications for Open Reduction
• Inadequate reduction
with closed methods
• Vascular injury
• Open fractures
Supracondylar Humerus Fractures:
Complications
• Compartment syndrome
• Vascular injury/compromise
• Loss of reduction/malunion
– Cubitus varus
• Loss of motion
• Pin track infection
• Neurovascular injury with
pin placement
Bashyal. Complications after pinning of supracondylar
distal humerus fractures. J Pediatr Orthop. 2009;29:704.
Supracondylar Humerus Fractures
Flexion type
• Rare, only 2%
• Distal fracture fragment anterior
and flexed
• Ulnar nerve injury more
common
• Reduce with extension
• Often requires 2 sets of hands in
OF
– Hold elbow at 90 degrees after
reduction to facilitate pinning
Mahan. Operative management of displaced flexion supracondylar
humerus fractures in children. J Pediatr Orthop. 2007;27:551.
Flexion Type
Flexion Type
Pinning
Distal Humeral Complete Physeal
Separation
• Often in very young children
• May be sign of NAT
• Swollen elbow,“muffled
crepitance” on exam
• Through area of wider cross
sectional area than SC
humerus fx
• Restore alignment, may need
pinning
Peterson. Physeal injuries of the distal humerus. Orthopedics.
1992;15:799.
Shrader. Pediatric supracondylar fractures and pediatric
physeal elbow fractures. Orthop Clin North Am. 2008;39:163.
Lateral Condyle Fractures
• Common fracture,
representing
approximately 15% of
elbow trauma in children
• Usually occurs from a
fall on an outstretched
arm
Landin. Elbow fractures in children. An epidemiological
analysis of 589 cases. Acta Orthop Scand. 1986;57:309.
Lateral Condyle Fractures
Jakob Classification
• Type 1
– Non-displaced fracture
– Fracture line does not cross
through the articular surface
• Type 2
– Minimally displaced
– Fracture extends to the
articular surface, but the
capitellum is not rotated or
significantly displaced
• Type 3
– Completely displaced
– Fracture extends to the
articular surface, and the
capitellum is rotated and
significantly displaced
Jakob. Observations concerning fractures of the lateral humeral
condyle in children. J Bone Joint Surg Br. 1975;57:430.
Lateral Condyle Fractures
Jakob Type 1
• Oblique radiographs
may be necessary to
confirm that this is not
displaced. Frequent
radiographs in the cast
are necessary to ensure
that the fracture does
not displace in the
cast.
Lateral Condyle Fractures
Jakob Type 2
• Displaced more than 2 mm
– On any radiograph
(AP/Lateral/Oblique views)
– Reduction and pinning
– Closed reduction can be
attempted, but articular reduction
must be anatomic
• If residual displacement and the
articular surface is not
congruous
– Open reduction is necessary
Fracture line exiting posterior metaphysis
(arrow) typical for lateral condyle fractures
Flynn. Prevention and treatment of non-union of slightly displaced fractures of the lateral
humeral condyle in children. An end-result study. J Bone Joint Surg Am. 1975;57:1087.
Lateral Condyle Fractures
Jakob Type 3
• ORIF is almost always
necessary
• A lateral Kocher approach is
used for reduction, and pins or
a screw are placed to maintain
the reduction
• Careful dissection needed to
preserve soft tissue attachments
(and thus blood supply) to the
lateral condylar fragment,
especially avoiding posterior
dissection
-Foster. Lateral humeral condylar fractures in children. J Pediatr Orthop. 1985;5:16.
-Song. Closed reduction and internal fixation of completely displaced and rotated
lateral condyle fractures of the humerus in children. J Orthop Trauma. 2010;24:434.
Lateral Condyle ORIF
Lateral Condyle Fractures
Complications
• Non-union
– This usually occurs if the
patient is not treated, or the
fracture displaces despite
casting
– Well-described in fractures
which were displaced more
than 2 mm and not treated
with pin fixation
– Late complication of
progressive valgus and ulnar
neuropathy reported
Skak. Deformity after fracture of the lateral humeral
condyle in children. J Pediatr Orthop B. 2001;10:142.
Lateral Condyle Fractures
Complications
• AVN can occur after
excessive surgical
dissection
• Cubitus varus can
occur, may be because
of malreduction or a
result of lateral
column overgrowth
Foster. Lateral humeral condylar fractures in children. J Pediatr Orthop. 1985;5:16.
Medial Epicondyle Fractures
• Represent 5% to 10% of pediatric elbow
fractures
• Occurs with valgus stress to the elbow,
which avulses the medial epicondyle
• Frequently associated with an elbow
dislocation
Landin. Elbow fractures in children. An epidemiological
analysis of 589 cases. Acta Orthop Scand. 1986;57:309.
Medial Epicondyle Fractures
Classification
• No good systematic
method of classification
• Studies vary on how to
measure displacement
• Should take into
consideration
displacement on both the
AP and lateral
• Amount of rotational
displacement is also
important
Pappas. Intraobserver and interobserver agreement in the measurement of displaced
humeral medial epicondyle fractures in children. J Bone Joint Surg Am. 2010;92:322.
Medial Epicondyle Fractures
Treatment
• Nondisplaced and
minimally displaced
– Less than 5 mm of
displacement
– May be treated without
fixation
– Early motion to avoid
stiffness (3 to 4 weeks)
Medial Epicondyle Fractures
Treatment
•
Displaced more than 5 mm
– Treatment is controversial
– Some recommending operative,
others non-operative treatment
– Some have suggested that surgery
is indicated in the presence of
valgus instability, or in patients
who are throwing athletes.
•
Only absolute indication is
entrapped fragment after
dislocation with incongruent elbow
joint
– First attempt closed reduction
•
Long term studies favor
nonoperative treatment
Kamath. Operative versus non-operative management of pediatric medial epicondyle fractures: a systematic review. J Child Orthop. 2009;3:345.
Farsetti. Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am. 2001;83-A:1299.
Medial Epicondyle Fracture
Elbow dislocation with Medial Epicondyle Avulsion
Medial
Epicondyle
Avulsion
After attempted
elbow reduction,
medial epicondyle
avulsion fragment
is obvious
Medial Epicondyle Fracture
Elbow dislocation with Medial Epicondyle Avulsion
Treated with ORIF
Medial Epicondyle Fracture
Example of Nonoperative Treatment
• 12 year old female UE
weight bearing athlete
• Treated
nonoperatively
• Full motion, no valgus
instability at 6 weeks
• Returned to
competition at 8 weeks
Olecranon Fractures
• Relatively rare fracture in children
– Increased incidence in children with OI
– May be associated with elbow subluxation/
dislocation, or radial head fracture
• The diagnosis may be difficult in a younger child
– Olecranon does not ossify until 8-9 years
• In older children, the fracture may occur through
the olecranon physis
• Anatomic reduction is necessary in displaced
fractures to restore normal elbow extension.
Caterini. Fractures of the olecranon in children. Long-term follow-up of 39 cases. J Pediatr Orthop B. 2002;11:320.
Olecranon Fractures
• Olecranon fracture treated with ORIF in 14
year old, with tension band fixation.
Parent. Displaced olecranon fractures in children: a biomechanical
analysis of fixation methods. J Pediatr Orthop. 2008;28:147.
Rare Distal Humeral Fractures
• Lateral Epicondyle
– Rare
– Usually represent a small
avulsion fracture
– Treated with early mobilization
• T-Condylar fractures
– Occur in patients that are almost
skeletally mature
– Treatment similar to adult intraarticular elbow fractures
• Medial Condyle
– Rare
– Treated with ORIF if displaced
Beaty JH. Elbow fractures in children and adolescents. Instr Course Lect. 2003;52:661–665.
Proximal Radius Fractures
• 1% of children’s fractures
• 90% involve physis or neck
• Normally some angulation of head to radial
shaft (0-15 degrees)
• No ligaments attach to head or neck
• Much of radial neck extraarticular (no
effusion with fracture)
Vocke. Displaced fractures of the radial neck in children: long-term results
and prognosis of conservative treatment. J Pediatr Orthop B. 1998;7:217.
Proximal Radius Fractures
Types
• Valgus fractures
– Salter I or II
– Intra-articular fractures
rare
• Metaphyseal fractures
• Associated with elbow
dislocations or proximal
ulna fractures
• Can be completely
displaced, rotated
Vocke. Displaced fractures of the radial neck in children: long-term results
and prognosis of conservative treatment. J Pediatr Orthop B. 1998;7:217.
Proximal Radius Fractures
Treatment
• Greater than 30°
angulation
– Attempt manipulation
– Usually can obtain
acceptable reduction in
fractures with less than
60° angulation
– Traction, varus force in
supination & extension,
flex and pronate
– Ace wrap or Esmarch
reduction
Evans. Radial neck fractures in children: a
management algorithm. J Pediatr Orthop B. 1999;8:93.
Proximal Radius Fractures
Treatment
• Unable to reduce
closed
– Percutaneous pin
reduction
– Intramedullary pin
reduction
– Open reduction via
lateral approach
-Vocke. Displaced fractures of the radial neck in children: long-term results and
prognosis of conservative treatment. J Pediatr Orthop B. 1998;7:217.
-Metaizeau. Reduction et fixation des fractures et decollements épiphyssaires de la
tête radial par broche centromedullaire. Rev Chir Ortop 1980;66:47-9.
-González-Herranz. Displaced radial neck fractures in children treated by closed
intramedullary pinning (Metaizeau technique). J Pediatr Orthop. 1997;17:325.
Completely Displaced, Malrotated
Radial Neck Fracture
After closed reduction the articular
surface (arrow) is facing distally,
180 degrees malrotated
Proximal Radial Fractures
Complications
•
•
•
•
•
•
Loss of forearm rotation
Radial head overgrowth
Premature physeal closure – valgus
Nonunion of radial neck rare
AVN
Proximal synostosis
Vocke. Displaced fractures of the radial neck in children: long-term results
and prognosis of conservative treatment. J Pediatr Orthop B. 1998;7:217.
100% Displaced
Failed Closed Reduction
Open “closed” reduction
Blunt pin to push radial head back onto neck
Pin fixation augmented by cast for 3 weeks
Monteggia Lesions
Ulnar Fracture-Radial Head Dislocation
Bado Classification
• Type I – anterior radial
head dislocation
• Type II – posterior radial
head dislocation
• Type III – lateral radial
head dislocation
• Type IV – associated
fracture of radius
Bado JL. The Monteggia lesion. Clin Orthop Relat Res. 1967;50:71–86.
Wilkins. Changes in the management of monteggia fractures. J Pediatr
Orthop. 2002;22:548.
Monteggia Lesions
• Most important is to make
the diagnosis initially
• Radiocapitellar line
critical
• A commonly missed
diagnosis
• Every ulna fracture should
have good elbow joint
radiographs to avoid
missing Monteggia lesion
Monteggia Lesions
• Be wary of plastic
deformation of ulna or
minimally displaced
ulna fracture with
radial head dislocation
• On lateral radiograph
the ulna should be
straight
Note anterior bow of ulnar
shaft, and anterior radial
head dislocation
Monteggia Lesions
Initial Treatment
•
•
•
•
•
•
Closed reduction of ulnar angulation
Direct pressure over radial head
Usually will reduce with palpable clunk
Immobilize in reduced position
Supinate forearm for anterior dislocations
Frequent radiographic follow-up to
document maintenance of reduction
Wilkins. Changes in the management of monteggia
fractures. J Pediatr Orthop. 2002;22:548.
Monteggia Lesions
• If unable to obtain or
maintain reduction of
radial head
– Operative stabilization of
ulnar fracture to correct
angulation
– Oblique fractures may need
plate fixation
– Assess radial head stability
– Flexion may help for
anterior dislocation
Wilkins. Changes in the management of monteggia
fractures. J Pediatr Orthop. 2002;22:548.
Missed Monteggia Lesion
Anterior radial head
dislocation and
heterotopic ossification
Healed prox ulna fx
with anterior bow
Missed Monteggia Lesions
Possible Long Term Sequelae
• Progressive valgus
• Proximal radial migration with
disruption of normal forearm
and distal radioulnar joint
mechanics
• Posterior interosseous nerve
traction palsy
• Collateral ligament instability
Nakamura. Long-term clinical and radiographic outcomes after open reduction for
missed Monteggia fracture-dislocations in children. J Bone Joint Surg. 2009;91:1394.
Missed Monteggia Lesions
Treatment Options
• Annular ligament
reconstructions
– Bell-Tawse
– Fascia lata
– Peterson
•
•
•
•
Ulnar osteotomy
Combination
Transcapitellar pinning
Be wary of possible pin
breakage
-Nakamura. Long-term clinical and radiographic outcomes after open reduction for missed
Monteggia fracture-dislocations in children. J Bone Joint Surg. 2009;91:1394.
-Wilkins. Changes in the management of monteggia fractures. J Pediatr Orthop. 2002;22:548.
Missed Monteggia Lesions
Ulnar Osteotomy and Radiocapitellar Pin
Bibliography
•
•
•
•
•
•
•
•
•
•
•
•
Archibeck MJ, Scott SM, Peters CL. Brachialis muscle entrapment in displaced supracondylar humerus fractures: a
technique of closed reduction and report of initial results. J Pediatr Orthop. 1997 Apr.;17(3):298–302.
Bado JL. The Monteggia lesion. Clin Orthop Relat Res. 1967;50:71–86.
Baumann E. Beitrage zur Kenntnis der Frakturen am Ellbogengelenk: Unter besonderer Berucksichtigung der
Spatfolgen. I. Allgemeines und Fractura supra condylica. Beitr Klin Chir 1929;146:1-50.
Bashyal RK, Chu JY, Schoenecker PL, Dobbs MB, Luhmann SJ, Gordon JE. Complications after pinning of
supracondylar distal humerus fractures. J Pediatr Orthop. 2009 Sep.;29(7):704–708.
Beaty JH. Elbow fractures in children and adolescents. Instr Course Lect. 2003;52:661–665.
Bohrer SP. The fat pad sign following elbow trauma. Its usefulness and reliability in suspecting “invisible”
fractures. Clin Radiol. 1970 Jan.;21(1):90–94.
Caterini R, Farsetti P, D'Arrigo C, Ippolito E. Fractures of the olecranon in children. Long-term follow-up of 39
cases. J Pediatr Orthop B. 2002 Oct.;11(4):320–328.
Cramer KE, Green NE, Devito DP. Incidence of anterior interosseous nerve palsy in supracondylar humerus
fractures in children. J Pediatr Orthop. 1993 Jun.;13(4):502–505.
Eberl R, Eder C, Smolle E, Weinberg AM, Hoellwarth ME, Singer G. Iatrogenic ulnar nerve injury after pin fixation
and after antegrade nailing of supracondylar humeral fractures in children. Acta Orthop. 2011 Oct.;82(5):606–609.
Evans MC, Graham HK. Radial neck fractures in children: a management algorithm. J Pediatr Orthop B. 1999 Apr.
1;8(2):93–99.
Farsetti P, Potenza V, Caterini R, Ippolito E. Long-term results of treatment of fractures of the medial humeral
epicondyle in children. J Bone Joint Surg Am. 2001 Sep. 1;83-A(9):1299–1305.
Fitzgibbons PG, Bruce B, Got C, Reinert S, Solga P, Katarincic J, et al. Predictors of failure of nonoperative
treatment for type-2 supracondylar humerus fractures. J Pediatr Orthop. 2011 Jun.;31(4):372–376.
Bibliography
•
•
•
•
•
•
•
•
•
•
•
Flynn JC, Richards JF, Saltzman RI. Prevention and treatment of non-union of slightly displaced fractures of the
lateral humeral condyle in children. An end-result study. J Bone Joint Surg Am. 1975 Dec.;57(8):1087–1092.
Foster DE, Sullivan JA, Gross RH. Lateral humeral condylar fractures in children. J Pediatr Orthop. 1985;5(1):16–
22.
Gartland. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959;109:14554.
González-Herranz P, Alvarez-Romera A, Burgos J, Rapariz JM, Hevia E. Displaced radial neck fractures in children
treated by closed intramedullary pinning (Metaizeau technique). J Pediatr Orthop. 1997;17(3):325–331.
Herman MJ, Boardman MJ, Hoover JR, Chafetz RS. Relationship of the anterior humeral line to the capitellar
ossific nucleus: variability with age. J Bone and Joint Surg. 2009 Sep.;91(9):2188–2193.
Jakob R, Fowles JV, Rang M, Kassab MT. Observations concerning fractures of the lateral humeral condyle in
children. J Bone Joint Surg Br. 1975 Nov.;57(4):430–436.
Kamath AF, Baldwin K, Horneff J, Hosalkar HS. Operative versus non-operative management of pediatric medial
epicondyle fractures: a systematic review. J Child Orthop. 2009 Oct. 1;3(5):345–357.
Landin LA, Danielsson LG. Elbow fractures in children. An epidemiological analysis of 589 cases. Acta Orthop
Scand. 1986 Aug.;57(4):309–312.
Lee SS, Mahar AT, Miesen D, Newton PO. Displaced pediatric supracondylar humerus fractures: biomechanical
analysis of percutaneous pinning techniques. J Pediatr Orthop. 2002 Jun.;22(4):440–443.
Mahan ST, May CD, Kocher MS. Operative management of displaced flexion supracondylar humerus fractures in
children. J Pediatr Orthop. 2007 Jun.;27(5):551–556.
Metaizeau JP, Prevot J, Schmitt M. [Reduction and fixation of fractures of the neck of the radious be centromedullary pinning. Original technic]. Rev Chir Orthop Reparatrice Appar Mot. 1980;66(1):47–49.
Bibliography
•
•
•
•
•
•
•
•
•
Mohammad S, Rymaszewski LA, Runciman J. The Baumann angle in supracondylar fractures of the distal humerus
in children. J Pediatr Orthop. 1999;19(1):65–69.
Nakamura K, Hirachi K, Uchiyama S, Takahara M, Minami A, Imaeda T, et al. Long-term clinical and radiographic
outcomes after open reduction for missed Monteggia fracture-dislocations in children. J Bone and Joint Surg. 2009
Jun.;91(6):1394–1404.
Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. The Journal of Bone and Joint Surgery.
2008 May;90(5):1121–1132.
Pappas N, Lawrence JT, Donegan D, Ganley T, Flynn JM. Intraobserver and interobserver agreement in the
measurement of displaced humeral medial epicondyle fractures in children. J Bone Joint Surg Am. 2010 Feb.
1;92(2):322–327.
Parent S, Wedemeyer M, Mahar AT, Anderson M, Faro F, Steinman S, et al. Displaced olecranon fractures in
children: a biomechanical analysis of fixation methods. J Pediatr Orthop. 2008 Mar.;28(2):147–151.
Rang’s children’s fractures. Edited by Dennis R. Wenger, MD, and Maya E. Pring, MD. Philadelphia: Lippincott
Williams & Wilkins, 2004.
Rogers. Plastic bowing, torus and greenstick supracondylar fractures of the humerus: radiographic clues to obscure
fractures of the elbow in children. Radiology. 1978;128:145.
Sankar WN, Hebela NM, Skaggs DL, Flynn JM. Loss of pin fixation in displaced supracondylar humeral fractures
in children: causes and prevention. J Bone Joint Surg Am. 2007 Apr.;89(4):713–717.
Skaggs DL, Mirzayan R. The posterior fat pad sign in association with occult fracture of the elbow in children. J
Bone Joint Surg Am. 1999 Oct.;81(10):1429–1433.
Bibliography
•
•
•
•
•
•
Skak SV, Olsen SD, Smaabrekke A. Deformity after fracture of the lateral humeral condyle in children. J Pediatr
Orthop B. 2001 Apr.;10(2):142–152.
Thometz JG. Techniques for direct radiographic visualization during closed pinning of supracondylar humerus
fractures in children. J Pediatr Orthop. 1990 Jun.;10(4):555–558.
Tremains MR, Georgiadis GM, Dennis MJ. Radiation exposure with use of the inverted-c-arm technique in upperextremity surgery. J Bone Joint Surg Am. 2001 May;83-A(5):674–678.
Vocke AK, Laer von L. Displaced fractures of the radial neck in children: long-term results and prognosis of
conservative treatment. J Pediatr Orthop B. 1998 Jul. 1;7(3):217–222.
White L, Mehlman CT, Crawford AH. Perfused, pulseless, and puzzling: a systematic review of vascular injuries in
pediatric supracondylar humerus fractures and results of a POSNA questionnaire. J Pediatr Orthop. 2010
Jun.;30(4):328–335.
Wilkins KE. Changes in the management of monteggia fractures. J Pediatr Orthop. 2002;22(4):548–554.
If you would like to volunteer as an author for
the Resident Slide Project or recommend
updates to any of the following slides, please
send an e-mail to ota@aaos.org
E-mail OTA
Questions/Comments
Return to
Pediatrics
Index