Paediatric Orthopaedic Injuries
Pulled elbow
Definition: subluxation of radial head
Sx: history of being pulled; decr mvmt arm after
Examination: undistressed at rest; no tenderness; clinical diagnosis
Investigation: Xray appears normal
Mng: if unable to reduce, most will spontaneous reduce in 48hrs; recurrence rate 25-40%
Supination/flexion technique: hold arm with thumb on radial head  supinate and flex arm
Hyperpronation method: hold elbow  hyperpronate forearm with other hand; 95% success rate
Salter Harris
injuries
Epidemiology: 15% long bone fractures in children occur at
epiphyseal plate
Pathology: epiphyseal plate is less strong than bone, ligaments
and tendon
II most common; V may be hard to diagnose; early reduction
better; young children have greater growth disturbance;
internal fixation across epiphysis incr risk of growth
retardation
I:
II:
III:
IV:
V:
Separate: through epiphysis , 5-7%
reduction easy  POP and ortho FU
 prognosis excellent
Above: through epiphysis and metaphysis
Most common, 75%
reduction easy if <48hrs
 prognosis excellent
Low: intra-articular # into epiphysis, 7-10%
accurate reduction needed, needs ortho review
 prognosis good
Thru: intra-articular # into epiphysis and metaphysis, 10%
accurate reduction needed, usually open reduction and internal fixation
 prognosis OK
Eeek: crush inj to epiphysis; usually of knee / ankle; often joint effusion, significant MOI, <1%
POP and ortho FU
 prognosis poor
Torus #
= buckle #; buckling of periosteum but no # line
POP and ortho FU 1/52
Greenstick #
Cortical disruption and periosteal tearing on convex side of bone, with
intact periosteum on concave side
Plastric
deformities
= bowing / bending fractures; no disruption of periosteum / cortex; usually assoc with # elsewhere; needs ortho
review for reduction and realignment
Paediatric
elbow
C apitellum
R adial head
I nt epicondyle
T rochlea
O lecranon
L at epicondyle
Appears
1-3yrs
3-4yrs
5-6yrs
7-9yrs
9-10yrs
11-12yrs
Closes
14yrs
16yrs
15yrs
14yrs
14yrs
16yrs
XR interpretation:
1. Ant humeral line should bisect capitellum in middle 1/3 on
lateral; abnormal in supracondylar #, lat condyle
2. Angle between line through centre of capitellum and ant
humeral line should be 30-45deg
3. Radio-capitellar line: Radial head should point towards
capitellum on all views; abnormal in lat condyle, radial neck,
Monteggia, elbow dislocation
4. Baumann angle: angle between physeal line of lat condyle of
humerus and line perpendicular to long axis of humeral shaft =
8-28degs; decr angle  varus deformity; abnormal in
supracondylar #
5. Bowing of anterior fat pad
6. Any posterior fat pad
Supracondylar
fracture
humerus
Epidemiology: peak incidence 5-8yrs; most common paeds
elbow fracture; most common # <8yrs; usually FOOSH (flexion
type from fall of flexed elbow, rare)
Pathology: distal fragment displaced posteriorly; significantly
displaced # are surgical emergency (brachial art, median / radial
/ ulnar nerve at risk; nerve involvement in 6-16%  Volkmann’s
ischaemic contracture); risk of cmptmt syndrome
Gartland classification: # in distal 1/3 of humerus
Type I: undisplaced # with evidence of jt effusion; ant and post periosteum intact; prognosis good
Type II: displaced, but intact post periosteum; # visible anteriorly, hinging posteriorly; prognosis good
IIb: as above + rotation; prognosis bad, need OT
Type III: displaced ant and post periosteum; no continuity between shaft and distal humerus; can displace postmed,
postlat, antlat; prognosis bad, need OT
Mng: urgent ortho review if NV compromise; immediate ED reduction if cool / pale hand; ortho review if no pulse, but
hand otherwise OK; to manipulate – traction at 20deg flexion  flexion as far as possible while still retaining radial
pulse
Type I: wrist-shoulder backslab with elbow flexed 90deg for 4/52; OT preferred in adults as stiffness common, but
otherwise not generally recommended; ortho FU within 48hrs
Type II and III: need closed / open reduction by ortho
Indications for reduction / manipulation: evidence of NV compromise / <50% bony apposition / dorsal angulation
>15 deg / lat or medial tilt >10 deg / any rotational deformity / any varus or valgus deformity / compound
Epicondylar
fractures of
humerus
Other #’s
?NAI
Medial epicondyle (appears at 5-6yrs): 3rd most common paeds elbow #; most common 9-14yrs; 50% assoc with
elbow dislocation; risk of medial epicondyle becoming trapped in jt, esp in spontaenously reduced elbow dislocation;
needs OT if >1cm of articular surface, or ulnar nerve involvement; needs ortho review
Lateral condyle (appears at 11-12yrs): tend to be unstable; often also involves all of capitellum and ½ of trochlea; due
to varus stress on extended arm in supination; Milch I = Salter Harris IV; Milch II = Salter Harris II (into jt and lat part of
trochlea), most common; OT if displaced, often required; ulnar nerve involvement; needs ortho review
Clavicle: OT needed if medial 1/3, displaced lateral 1/3
Prox humerus: more common in adolescents; manipulate if >30deg displacement
Mid humerus: assess radial nerve; uncommon; usually just POP
Olecranon (appears at 9-10yrs): from fall on elbow; needs ortho review; OT if displaced >5mm; assoc with radial
head/neck #
Radial head/neck #: uncommon in children; neck >head; OT if >60deg angulation or >50% displacement; need ortho
review
Elbow dislocation: neuro inj in 10%; post most common; ulnar / median nerve inj
Radial / ulnar shaft: OT if any rotational deformity, >10deg angulation >8yrs, >15-20deg angulation <8yrs; prox shaft
injs are more unstable
GRIMUR: Galeazzi #: radial shaft # + dislocation of inferior (ie. Distal) radio-ulnar joint
Monteggia #: ulnar #
+ dislocation of radial head
Hip #: high risk of AVN and growth arrest; dislocations <10yrs can occur with low E trauma
Femoral shaft #: peak in late-toddler and mid-teenage years; will not be cause of hypotension in young child
# distal femoral physis: popliteal artery and peroneal nerve inj
Tibial / fibula shaft #: OT if >10deg angulation
Toddler’s #: isolated spiral # of distal tibia; may not be obvious history of trauma; 1/3 most common long bone
fracture in children
Clavicular # <2yrs, mid-humerus # in small children; femoral shaft # if not yet walking
Notes from: Dunn, TinTin
BONES: remember mnemonic Suspect Harm from Mother or Father (3
fractures each, 12 types in total)
S: Sternum, scapular, spine or vertebrae
H: Humerus (other than supracondylar), hand (non-ambulating), head (skull
fractures – multiple, non-parietal, complex, with associated brain injury)
M: Multiple fractures, metaphyseal corner fractures, metaphyseal bucket
handle fractures
F: Foot (non-ambulating), femur (non-ambulating), fractured ribs
tone tone