Distal Humerus Cases
OTA RCFC 2.0
Presented by members of POSNA
Case 1: 5 yo girl fell off the monkey
bars. Dx.? Mech.?


AIN out.
Pink, pulseless hand.
Supracondylar Humerus
Fractures
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60% of elbow fractures in children under 7.
96% extension type, from fall on outstretched
arm with elbow hperextension.
4% flexion type, from fall on olecranon with
elbow flexed.
Case 1: 5 yo girl fell off the monkey
bars. Class.?


AIN out.
Pink, pulseless hand.
Classification-Gartland

Type I: Nondisplaced, +/- posterior fat pad
sign. Where is PFPS? Significance?
Posterior Fat Pad Sign


PFPS is predictive of occult fracture in 76% of
cases.
The fracture is a supracondylar humerus about
50% of the time.

Skaggs & Mirzayan, JBJS, 2001.
Classification-Gartland
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Type II: Angulated with intact posterior cortex.
Classification-Gartland
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Type II: Anterior humeral line anterior to
middle of capitellum.
Classification-Gartland
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Type III: Displaced.
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Usually posteromedially.
Classification-Gartland
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Type IV: Multidirectional Unstable.

Leitch, et al., JBJS, 2006.
Classification-Gartland
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Flexion type.
Case 1: 5 yo girl fell off the monkey
bars. How do you do a motor exam
in a child?


AIN out.
Pink, pulseless hand.
Quick and Dirty Pediatric NV
Exam

Rock-Paper-Scissors-OK
Rock: Median Nv.
 Paper: Radial Nv.
 Scissors: Ulnar Nv.
 OK: AIN.

Neurologic Injury
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Incidence: ~7%.
Anterior interosseous is most common nerve
injured.

Decreased thumb IP and index DIP flexion.
Neurologic Injury: Median Nv.
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May become entrapped in fracture.
May mask compartment syndrome, because of
associated forearm sensory loss.
Neurologic Injury: Ulnar Nv.
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Ulnar nerve injuries more common in flexion
supracondylar fractures.
Often iatrogenic.
Quantification of risk: “Number Needed to
Harm” = 28

For every 28 pts that have medial/lateral cross
pinning vs lateral pins only, one child will sustain an
iatrogenic ulnar nv injury.

Slobogean, et al., JPO, 2010.
Case 1: 5 yo girl fell off the monkey
bars. What else are you worried
about?
 AIN out.

Pink, pulseless hand.
Vascular Injury
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

Incidence: ~1% (0.5-5%).
Maintain high index of suspicion.
Perform careful physical exam.
Vascular Injury

Indications for exploration:
Clinically obvious ischemia (white, pulseless hand).
 Loss of palpable/dopplerable pulse after fracture
reduction.
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Use of arteriography controversial.
Treatment of “pink, pulseless” hand also
controversial.
Compartment Syndrome
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
May be difficult to diagnose in kids.
The Three A’s of compartment syndrome in
children:
Anxiety.
 Agitation.
 Increasing need for Analgesia.


May occur even in open fractures.
Case 1: 5 yo girl fell off the monkey
bars. Plan?


AIN out.
Pink, pulseless hand.
Treatment

Gartland I: Casting in situ.

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Long arm cast or splint in 90-110° flexion for 3-4
weeks.
Gartland II & III: Closed reduction and
percutaneous pinning.
Closed Reduction Technique
Percutaneous Pinning

Crossed pins vs. Lateral: No biomechanical difference
in stability if proper technique and pin placement
utilized.
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Skaggs, et al., JBJS, 2001.
Davis, et al., CORR, 2000.
Hamdi, et al., JPO, 2010.
Try to make the 2 lateral pins divergent.
Try not to have pins cross at the fracture site.
Size matters: Pins should be at least the thickness of the
cortex.
Closed Reduction/Percutaneous
Pinning: 2 Pins
Closed Reduction/Percutaneous
Pinning: 3 Pins
Closed Reduction/Percutaneous
Pinning: 3 Pins
Went to OR for CR/PP


Had white pulseless
hand after reduction.
Cap refill and weak
dopplerable pulse after
pinning.
 Now
what?
Vascular Surgery Consult in OR

Underwent duplex U/S:

Did well post op:
Pulse returned pod # 2.
 AIN back at 8 weeks.

Can you wait to operate? It
depends…
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Must have a normal N/V exam.
Must not have severe swelling.
Must still be considered urgent.
NPO status may be a factor in the decision.
Complications
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Ulnar nerve injury.
Cubitus Varus.
Loss of reduction.
Pin site problems (rare!)
Most complications can
be avoided with attention
to detail.
Case 2: 7 yo girl fell off monkey bars.
Diagnosis?
Lateral Condyle Fractures


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17% of elbow fxs. in
children.
Peak incidence: 5-10
years of age.
Mech: Varus stress to
extended elbow, with
forearm supinated.
Lateral Condyle Fractures: PE


Lateral swelling and
tenderness.
Much less prone to NV
injury than SCHFs.
Case 2: 7 yo girl fell off monkey bars.
Classification?
Lateral Condyle Fractures:
Jakob Classification

Stage I: Nondisplaced.

Stage II: Hinged.
Stage III: Rotated.

Case 2: 7 yo girl fell off monkey bars.
Treatment?
Lateral Condyle Fractures:
Treatment


Non-displaced fxs. can be treated with cast
immobilization at 90° flexion and supination.
Frequent follow-up and re-imaging is necessary,
to watch for late displacement and subsequent
need for operative Rx.
Healed uneventfully.
Fell off monkey bars again 5 mo
later. Class.? Rx.?
Lateral Condyle Fractures:
Treatment

Open reduction and
percutaneous pinning
for displaced fractures.

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It is necessary to
visualize the anterior
joint line/articular
surface prior to fixation.
2-3 lateral pins:

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Across capitellum to
medial epicondyle.
At 45° angle to first pin,
exiting medially and
proximally.
Lateral Condyle Fractures:
Treatment

Arthrogram may be
helpful in determining
extension into the joint
and need for open
reduction.
Underwent open reduction and
percutaneous pinning.
Critique?
Procedure/Positioning

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Patient supine on radiolucent table.
C-arm comes in perpendicular, from across the
table.
Alternatively, hand table with C-arm coming in
from the end may be used.
Procedure/Approach

Kocher Approach:
Slightly curvilinear incision centered over the lateral
condyle.
 Internervous plane between the extensor carpi
ulnaris and the anconeous.
 Stay anterior: avoid posterior stripping in order to
preserve trochlear/capitellar blood supply.
 Open capsule anteriorly and extend distally to radial
head.
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Procedure/Reduction & Fixation
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Clean fragment ends.
Reduce using dental pick or
towel clip.
2 pins placed percutaneously
from posterior to incision:
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Across capitellum to medial
epicondyle.
At 45° angle to first pin, exiting
medially and proximally.
At least 0.062” diameter.
Procedure/Tools

You must see all the way to the medial side of
the joint, to assess reduction at the most medial
extent of the fx. Useful tools to facilitate this:
Mini-Hohmanns or Chandlers.
 Dental Mirror.
 Head Lamp.
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Pearls & Pitfalls
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The fracture often performs the approach for you.
The distal fragment may flip…be certain you have the
articular cartilage oriented properly.
There is sometimes lateral metaphyseal communition
that appears as displacement…it is important to assess
reduction at the joint line, not the metaphysis.
Try to reapproximate lateral soft tissues to decrease
lateral spur formation.
Went on to non-union. Now
what?
Underwent bone grafting in situ and
internal fixation.
Lateral Condyle Fractures:
Complications
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Prone to:
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Late displacement.
Mal/Nonunion.
Growth disturbance.
Late deformity.
Loss of ROM.
Healed uneventfully.
Removal of hardware 6 mo later.
One year later, sustains SCHF on
contralateral side. Class.? Rx.?
Treated with closed reduction and
casting
Final f/u SCHF 8 mo post-injury
Final f/u lat con about 2 yrs postinjury

Did well clinically. With full ROM and no pain
bilaterally.
Case 3: 9 yo boy injured L. elbow
wrestling, 2 weeks ago. Dx.?
Medial Epicondyle Fractures
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10% of elbow fractures.
Peak incidence: 9-15 years of age.
Mech: Fall on extended elbow, with valgus
stress.
Medial Epicondyle Fractures
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Avulsion of medial
epicondyle from the distal
humerus by the wrist
flexors.
Usually a SH I or II.
Can be associated with an
elbow dislocation.
The medial epicondyle can
be entrapped in the joint.
Medial Epicondyle Fractures
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Reduction maneuver to
remove epicondyle
from joint:
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valgus stress on elbow.
supination of forearm.
dorsiflexion of wrist
and fingers.
He had been seen by an outside
MD, who got an MRI. Plan?
Medial Epicondyle Fractures

Need for reduction/fixation of epicondyle
controversial:
Displacement: >1cm.
 Angulation: >45°.
 Instability: +/- Stress film.
 Athletic ability/aspirations.
 Associated with elbow dislocation.
 ? Risk of tardy ulnar nv. palsy.
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Medial Epicondyle Fractures
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Reduction can be
closed or open.
Fixation can be
percutaneous or
open.
Fixation can be kwires or a screw.
Underwent ORIF.
Note how far posterior the medial epicondyle is: screw oriented P to A on lat xray!
Questions?