This document discusses several common types of paediatric elbow fractures including supracondylar fractures, lateral condyle fractures, medial epicondyle avulsion fractures, and proximal radius fractures. It provides details on the anatomy of the elbow, mechanisms of injury, classification systems used, and typical treatment approaches for each type of fracture. Common complications are also summarized. The document serves as a reference for orthopaedic practitioners treating elbow fractures in children.

1. Paediatric elbow fractures
By Nick Harper

2. • Anatomy
• Ossification
• General Prinicples
• Supracondylar Fractures
• Lateral Condyle Fractures
• Medial Epicondyle Avulsion
• Proximal Radius Fractures
• Radial head dislocations
• Nursemaid’s elbow
Paediatric elbow fractures

3. Anatomy – Adult Elbow

4. Anatomy – Adult Elbow

6. Ossification centers
1 C Capitulum
3 R Radial Head
5 I Internal Epicondyle
7 T Trochlea
9 O Olecranon
11 L Lateral Epicondyle

7. Ossification centers

8. Ossification centers
•The Trochlea has several ossification centers
•Can mimic loose bodies within the joint

9. General principles
Fat Pad sign
Lateral view, 90° flexion
NEGATIVE
Anterior Fat Pad

10. Fat Pad sign
Lateral view, 90° flexion
Anterior Fat Pad
POSITIVE
Posterior Fat Pad
In presence of trauma, predicts
fracture in 76% of cases
•Distension of the joint
capsule
•Joint effusion
•Haemarthrosis
General principles

11. Fat Pad Sign

12. Fat Pad Sign

13. Fat Pad Sign

14. Salter – Harris Classification
SALTR
S- Slipped
A- Above
L- Lower
T- Through
R- Ruined
Fractures involving the Physis (growth plate)

15. General Principles
Radiocapitellar line.
• “A line drawn from the centre of the radial
neck should pass through the center of the
capitulum in all views”
Anterior humeral line.
• “A line drawn along the anterior cortex of the
humerus in lateral view should pass through
the middle third of the capitulum.”

16. Radiocapitellar line
Anterior humeral line

18. Supracondylar
fractures
Supracondylar fractures

19. Supracondylar fractures
• >60% of all elbow fractures in children
• 95% are hyperextension injuries
• The elbow becomes locked in hyperextension

20. Supracondylar fractures
• >60% of all elbow fractures in children
• 95% are hyperextension injuries
• The elbow becomes locked in hyperextension

21. Supracondylar fractures
• >60% of all elbow fractures in children
• 95% are hyperextension injuries
• The elbow becomes locked in hyperextension

22. Supracondylar fractures
• >60% of all elbow fractures in children
• 95% are hyperextension injuries
• The elbow becomes locked in hyperextension

23. Supracondylar fractures
• Flexion – type fractures are uncommon (5%)
• Direct impact to the flexed elbow
• Ulnar nerve injury common
• More likely to be unstable than extension injuries

24. Supracondylar fractures
Gartland Classification Management
1 Minimally displaced fracture Conservative
2 Displaced with intact posterior cortex Closed reduction and percutaneous
fixation
3 Complete displacement (Posteromedial
75%, Posterolateral, 25%)
Closed/open reduction and fixation
IIII II

25. Supracondylar fractures
Complications
• Neurovascular compromise
• Malunion may cause cubitus varus “gunstock deformity”

26. Lateral Condyle
fractures
Lateral condyle fractures

27. Lateral condyle fractures
• 2nd
most common elbow
fracture in children (17%)
• Varus force to an extended elbow
• Localised swelling over the lateral
• Intrarticular
• Salter-Harris IV
• Instability due to forearm extensors
• Can be challenging to see
on radiograph

28. Lateral condyle fractures
Milch Classification
1. - Fracture line traverses lateral to capitello-trochlear groove
- Elbow is stable
2. - Fracture passes through the capitello-trochlear groove
- Elbow is unstable
Hard to classify on radiograph as fracture fragments are primarily cartilagenous

29. Lateral condyle fractures
• Displacement classification

30. Lateral condyle fractures
Displacement Classification Management
1 <2mm conservative
2 >2mm Surgical - Pins
3 Wide displacement and
rotation
Surgical - Open reduction,
Internal fixation
I II III

31. Lateral condyle fractures

32. Lateral condyle fractures

33. Complications
• Non union
• Malunion
• Excessive bone
formation
• Avascular necrosis of lateral condyle (iatrogenic)
• Ulnar nerve neuropathy (22 years post fracture,
Cubitus Valgus)
Lateral condyle fractures
Cubitus Varus Cubitus Valgus

34. Medial Epicondyle
Avulsion
Medial Epicondyle Avulsion

35. Medial Epicondyle Avulsion
• 3rd
most common elbow fracture
in children
• adolescent boys
• Acute valgus stress
(sometimes during armwrestling)
• Severe pain over medial aspect,
“pop” sound, Ulnar nerve irritation
• Elbow dislocations occur in 50% of cases

36. Medial Epicondyle Avulsion
• Avulsed medial epicondyle becoming
entrapped in the dislocated joint

37. Medial Epicondyle Avulsion
Management
Non displaced – Conservative
Displacement 5-15mm – Conservative/Surgical
Displacement>15mm - Surgical

38. Medial Epicondyle Avulsion
• Avulsed medial epicondyle becoming entrapped in the dislocated joint
• Don’t confuse with Trochlea ossification centers

39. Proximal Radius
fractures
Proximal Radius fractures

40. • Adults – articular surface of radial head
• Children – Radial neck (metaphyseal bone weaker due to
constant remodeling)
• Fall on extended and supinated outstretched hand
• 90% are Salter Harris II
Proximal Radius fractures

41. Management
Children under 4 have a normal valgus angulation
to the radial neck (Up to 15°)
<30° Conservative
>30° Closed reduction
K-wires used if closed reduction unsuccessful or
unable to pronate and supinate upto 60°
Proximal Radius fractures

42. Radial Head Dislocations
• Radiocapitellar line useful!
• Can be obvious or quite subtle
• Always look for associated injury
•Monteggia Fracture
•Dislocation of the radial head with fracture
of the proximal third of the ulnar
•Fall on outstretched hand with forearm in
excessive pronation

43. Monteggia Fracture

44. Nursemaid’s elbow
• Annular ligament poorly attached in children <5
• If the forearm is pulled, radial head moves distally. The annular
ligament slips over the radial head and becomes trapped in the
joint

45. Nursemaid’s elbow
• Sudden longitudinal force applied to the forearm
• Audible snap
• Limb held in extension
• Pain on moving the forearm
• Radiograph is often normal
• Treatment – manipulation
- Supination & Flexion
- Pronation

46. Summary
• Supracondylar
Fractures
• Lateral Condyle
Fractures
• Medial Epicondyle
Avulsion
• Proximal Radius
Fractures &
Dislocations

47. References
• Agur, A.M.R. & Dalley, A.F. Grant’s Atlas of Anatomy (12th
ed). Lippincott, Williams & Wilkins
• John Harris et al The Radiology of Emergency Medicine, 3rd
Ed, Williams and Wilkins, 1993, p 352
• http://www.radiologyassistant.nl/en/4214416a75d87
• http://emedicine.medscape.com/article/415822-overview
• http://www.wheelessonline.com/ortho/frx_of_the_lateral
_condyle_in_children
• http://orthoinfo.aaos.org/topic.cfm?topic=A00037
• http://www.joint-pain-expert.net/index.html