Birth Fractures

A fractured clavicle in a newborn may be difficult to diagnose because the infant is often asymptomatic. In a radiographic survey of 300 newborns, 5 unsuspected clavicle fractures were discovered. Fractures during delivery usually involve the clavicle, which is most anterior in the birth canal. The diagnosis is often made when the child has pseudoparalysis, or lack of active spontaneous movement of the limb.

The differential diagnosis includes brachial plexus palsy and acute osteoarticular infection. It is important to remember that brachial plexus palsy and clavicle fractures may coexist. Although the clinical diagnosis of a fractured clavicle may be straightforward, assessing the status of the brachial plexus is frequently difficult. Neonatal reflexes such as the Moro and fencing reflexes may be helpful in demonstrating active upper extremity muscle function. The diagnosis of osteoarticular infection in a newborn may also be difficult to make. Often there are few systemic signs, and bone scans are notoriously unreliable. Infection should be suspected in at-risk patients (e.g., those with indwelling catheters) or in the setting of radiographic lucencies in the metaphysis, diffuse swelling, or increasing pain. Frequently, needle aspiration is required to make the diagnosis. Occasionally, a birth fracture of the clavicle is accompanied by fracture of the upper humeral physis. Often this injury is not appreciated on the initial radiographs; however, on follow-up films, massive subperiosteal new bone formation will be seen and the condition may be mistaken for osteomyelitis. Fracture of the clavicle in a newborn may also be misdiagnosed as congenital muscular torticollis.

Midshaft Clavicle Fractures

In an infant or young child, clavicle fractures are often incomplete (greenstick) fractures. These greenstick fractures of the clavicle may escape notice until appearance of the developing callus. In these cases the fracture should not be mistaken for congenital pseudarthrosis of the clavicle, which is also painless. Radiographically, the distinction between congenital pseudarthrosis and acute fracture is straightforward. In congenital pseudarthrosis there is a wide zone of radiolucency, with smooth margins at the site of the defect and no evidence of callus formation.

Older children and adolescents usually have completely displaced fractures of the clavicle, which have a classic clinical appearance. The affected shoulder is lower than the opposite normal one and droops forward and inward. The child rests the involved arm against the body and supports it at the elbow with the opposite hand. The tension on the sternocleidomastoid muscle tilts the head toward the affected side and rotates the chin toward the opposite side ( Fig. 33-6 ). Any change in position of the upper limb or the cervical spine is painful. Local swelling, tenderness, and crepitation occur over the fracture site. In rare cases the spasm has been severe enough to result in atlantoaxial rotatory instability after a clavicular fracture.

Clinical appearance of a child with a clavicular fracture. The affected shoulder is displaced anteriorly and inferiorly.

Medial Physeal Separation (Pseudodislocation) of the Sternoclavicular Joint

Medial physeal separation, or pseudosubluxation, of the sternoclavicular joint may be manifested as anterior or posterior displacement. With anterior displacement of the metaphyseal fragment, the sternal end of the clavicle may be sharp and palpable immediately beneath the skin. The clavicular head of the sternocleidomastoid muscle is pulled anteriorly with the bone and is in spasm, which causes the patient’s head to tilt toward the affected side. ^#

# References .

References .

Lateral Physeal Separation and Acromioclavicular Joint Dislocation

When there is separation of the lateral physis of the clavicle, the clinical findings will depend on the type of injury. Rockwood has classified injuries to the distal clavicle in children according to the direction and degree of displacement (see Fig. 33-4 ). Types I and II injuries represent the classic mild acromioclavicular joint sprain. Patients complain of pain on all motions of the shoulder, and point tenderness and swelling are present over the acromioclavicular joint. Patients with types III and V injuries have complete disruption of the acromioclavicular joint. The clinical findings are similar to those in patients with types I and II injuries, but with more obvious deformity over the lateral clavicle. With type V injuries the skin may be tented. The posterior displacement of type IV injuries may be difficult to appreciate unless the patient is examined from above. Patients who sustain the rare, inferiorly displaced type VI injury have a prominent acromion and severe limitation of motion. ^†a

†a References .

Birth Fractures

An asymptomatic clavicle fracture in a neonate or young infant may be treated with benign neglect. It will unite without external immobilization, and any malalignment will gradually correct with growth. Nurses and parents should be instructed to handle the infant gently and avoid direct pressure over the broken clavicle.

When the fracture is painful and accompanied by pseudoparalysis, it may be necessary to splint the arm for 1 or 2 weeks. A soft cotton pad is placed in the axilla, and the upper limb is loosely swathed across the chest with two or three turns of an elastic bandage. The parents are instructed in skin care and bathing. Within 7 to 14 days, the pain will subside, the fracture will be united clinically, and the splint is removed. Parents should be warned about the palpable subcutaneous callus that will develop and later resolve.

Midshaft Clavicle Fractures

In children and adolescents, displaced fractures of the clavicle rarely require reduction. Malalignment and the bump of the callus will remodel and disappear within 6 to 9 months. Treatment consists of keeping the child comfortable with a figure-eight bandage or sling. Well-padded, premade, figure-eight clavicular supports are available commercially. The clavicular splints do not immobilize the fracture; their purpose is to provide patient comfort by holding the shoulders back. The fracture sling or harness is worn for 1 to 4 weeks until the pain subsides and the patient can resume normal use of the extremity. Some have suggested that clavicle fractures may not even require review by an orthopaedist.

In general, we attempt reduction of a clavicle fracture only when the fragments are displaced so significantly that the integrity of the skin is in jeopardy ( Fig. 33-8 ). The reduction may be done with the patient seated or supine. We prefer the supine position, with the patient under conscious sedation. The lower limbs and pelvis are anchored on the table with sheets. A padded sandbag is placed posteriorly between the shoulders, and the affected arm is allowed to hang in an extended position at the side of the table. The weight of the arm alone is generally sufficient to reduce the fracture; however, if necessary, the shoulders may be pushed posteriorly to reduce the fracture. In the sitting position, anesthesia is best achieved with a hematoma block. The shoulders are then pulled posteriorly and superiorly with the surgeon’s knee placed between the scapulae to serve as a fulcrum ( Fig. 33-9 ). Once the fracture is reduced, the stability of the fragments is assessed. If the reduction is stable, the patient may be treated symptomatically with a sling or figure-eight harness. If the reduction is unstable, an attempt can be made to immobilize the patient with a figure-eight harness or cast. We usually find external immobilization to be of little benefit. However, the combination of a reduction maneuver and external immobilization, albeit imperfect, is often adequate to remove the pressure on the overlying skin. If the fracture remains displaced to the point that the skin is still compromised, open reduction may be indicated.

Clinical photograph of a type V acromioclavicular joint injury that was not reduced. The superiorly displaced fragment eventually eroded through the skin.

A and B, Technique for closed reduction of displaced clavicle fractures. A fulcrum is placed between the shoulders and a posteriorly directed force is applied to the lateral end of the clavicle.

Open reduction of clavicle fractures in children has traditionally been considered to be rarely indicated. Even in adolescents, some have thought it better to accept angulation and deformity than to attempt open reduction. The operative scar may be more displeasing than the bony prominence of the malunited fracture. Generally, we consider open reduction of the clavicle only if there is a neurovascular injury or open injury that is unstable after irrigation and débridement. Other occasional indications are posterior displacement with impingement of the underlying structures and impending skin penetration by the fracture fragment. Usually, a one-third tubular plate provides adequate fixation. We have also been successful in stabilizing some clavicle fractures with no. 1 or 2 absorbable polydioxanone sutures used as a cerclage wire. This technique has the advantage of avoiding permanent hardware without the disadvantages of pin fixation in the shoulder region. We do not use percutaneous pin fixation about the clavicle because of visceral problems associated with pin migration. ^‡a

‡a References .

Medial Physeal Separation (Pseudodislocation) of the Sternoclavicular Joint

Because the physeal sleeve remains intact, a significant amount of remodeling can be expected with medial physeal injuries, and consequently conservative treatment is the rule. Patients with anterior displacement and those with posterior displacement without evidence of visceral injury to the mediastinal structures can be managed symptomatically with a sling or figure-eight harness.

If there is a significant cosmetic deformity, we may attempt closed reduction, which frequently achieves stability. If the reduction is lost, we generally accept the deformity and anticipate significant remodeling. If there is posterior displacement with evidence of airway, esophageal, or neurovascular impingement, we will attempt closed reduction on an emergency basis in the operating room. If closed reduction fails, we proceed immediately to open reduction, preferably with the assistance of a general trauma or thoracic surgeon. ^§a

§a References .

Lateral Physeal Separation and Acromioclavicular Joint Dislocation

Treatment depends on the degree of injury to the joint. All types I and II injuries and type III injuries in patients younger than 15 or 16 years can be managed symptomatically with a sling or harness until the patient can use the extremity comfortably. ^¶a

¶a References .

#a References .

Birth Fractures

A fractured clavicle in a newborn may be difficult to diagnose because the infant is often asymptomatic. In a radiographic survey of 300 newborns, 5 unsuspected clavicle fractures were discovered. Fractures during delivery usually involve the clavicle, which is most anterior in the birth canal. The diagnosis is often made when the child has pseudoparalysis, or lack of active spontaneous movement of the limb.

The differential diagnosis includes brachial plexus palsy and acute osteoarticular infection. It is important to remember that brachial plexus palsy and clavicle fractures may coexist. Although the clinical diagnosis of a fractured clavicle may be straightforward, assessing the status of the brachial plexus is frequently difficult. Neonatal reflexes such as the Moro and fencing reflexes may be helpful in demonstrating active upper extremity muscle function. The diagnosis of osteoarticular infection in a newborn may also be difficult to make. Often there are few systemic signs, and bone scans are notoriously unreliable. Infection should be suspected in at-risk patients (e.g., those with indwelling catheters) or in the setting of radiographic lucencies in the metaphysis, diffuse swelling, or increasing pain. Frequently, needle aspiration is required to make the diagnosis. Occasionally, a birth fracture of the clavicle is accompanied by fracture of the upper humeral physis. Often this injury is not appreciated on the initial radiographs; however, on follow-up films, massive subperiosteal new bone formation will be seen and the condition may be mistaken for osteomyelitis. Fracture of the clavicle in a newborn may also be misdiagnosed as congenital muscular torticollis.

Midshaft Clavicle Fractures

In an infant or young child, clavicle fractures are often incomplete (greenstick) fractures. These greenstick fractures of the clavicle may escape notice until appearance of the developing callus. In these cases the fracture should not be mistaken for congenital pseudarthrosis of the clavicle, which is also painless. Radiographically, the distinction between congenital pseudarthrosis and acute fracture is straightforward. In congenital pseudarthrosis there is a wide zone of radiolucency, with smooth margins at the site of the defect and no evidence of callus formation.

Older children and adolescents usually have completely displaced fractures of the clavicle, which have a classic clinical appearance. The affected shoulder is lower than the opposite normal one and droops forward and inward. The child rests the involved arm against the body and supports it at the elbow with the opposite hand. The tension on the sternocleidomastoid muscle tilts the head toward the affected side and rotates the chin toward the opposite side ( Fig. 33-6 ). Any change in position of the upper limb or the cervical spine is painful. Local swelling, tenderness, and crepitation occur over the fracture site. In rare cases the spasm has been severe enough to result in atlantoaxial rotatory instability after a clavicular fracture.

Clinical appearance of a child with a clavicular fracture. The affected shoulder is displaced anteriorly and inferiorly.

Medial Physeal Separation (Pseudodislocation) of the Sternoclavicular Joint

Medial physeal separation, or pseudosubluxation, of the sternoclavicular joint may be manifested as anterior or posterior displacement. With anterior displacement of the metaphyseal fragment, the sternal end of the clavicle may be sharp and palpable immediately beneath the skin. The clavicular head of the sternocleidomastoid muscle is pulled anteriorly with the bone and is in spasm, which causes the patient’s head to tilt toward the affected side. ^#

# References .

References .

Lateral Physeal Separation and Acromioclavicular Joint Dislocation

When there is separation of the lateral physis of the clavicle, the clinical findings will depend on the type of injury. Rockwood has classified injuries to the distal clavicle in children according to the direction and degree of displacement (see Fig. 33-4 ). Types I and II injuries represent the classic mild acromioclavicular joint sprain. Patients complain of pain on all motions of the shoulder, and point tenderness and swelling are present over the acromioclavicular joint. Patients with types III and V injuries have complete disruption of the acromioclavicular joint. The clinical findings are similar to those in patients with types I and II injuries, but with more obvious deformity over the lateral clavicle. With type V injuries the skin may be tented. The posterior displacement of type IV injuries may be difficult to appreciate unless the patient is examined from above. Patients who sustain the rare, inferiorly displaced type VI injury have a prominent acromion and severe limitation of motion. ^†a

†a References .

Birth Fractures

An asymptomatic clavicle fracture in a neonate or young infant may be treated with benign neglect. It will unite without external immobilization, and any malalignment will gradually correct with growth. Nurses and parents should be instructed to handle the infant gently and avoid direct pressure over the broken clavicle.

When the fracture is painful and accompanied by pseudoparalysis, it may be necessary to splint the arm for 1 or 2 weeks. A soft cotton pad is placed in the axilla, and the upper limb is loosely swathed across the chest with two or three turns of an elastic bandage. The parents are instructed in skin care and bathing. Within 7 to 14 days, the pain will subside, the fracture will be united clinically, and the splint is removed. Parents should be warned about the palpable subcutaneous callus that will develop and later resolve.

Midshaft Clavicle Fractures

In children and adolescents, displaced fractures of the clavicle rarely require reduction. Malalignment and the bump of the callus will remodel and disappear within 6 to 9 months. Treatment consists of keeping the child comfortable with a figure-eight bandage or sling. Well-padded, premade, figure-eight clavicular supports are available commercially. The clavicular splints do not immobilize the fracture; their purpose is to provide patient comfort by holding the shoulders back. The fracture sling or harness is worn for 1 to 4 weeks until the pain subsides and the patient can resume normal use of the extremity. Some have suggested that clavicle fractures may not even require review by an orthopaedist.

In general, we attempt reduction of a clavicle fracture only when the fragments are displaced so significantly that the integrity of the skin is in jeopardy ( Fig. 33-8 ). The reduction may be done with the patient seated or supine. We prefer the supine position, with the patient under conscious sedation. The lower limbs and pelvis are anchored on the table with sheets. A padded sandbag is placed posteriorly between the shoulders, and the affected arm is allowed to hang in an extended position at the side of the table. The weight of the arm alone is generally sufficient to reduce the fracture; however, if necessary, the shoulders may be pushed posteriorly to reduce the fracture. In the sitting position, anesthesia is best achieved with a hematoma block. The shoulders are then pulled posteriorly and superiorly with the surgeon’s knee placed between the scapulae to serve as a fulcrum ( Fig. 33-9 ). Once the fracture is reduced, the stability of the fragments is assessed. If the reduction is stable, the patient may be treated symptomatically with a sling or figure-eight harness. If the reduction is unstable, an attempt can be made to immobilize the patient with a figure-eight harness or cast. We usually find external immobilization to be of little benefit. However, the combination of a reduction maneuver and external immobilization, albeit imperfect, is often adequate to remove the pressure on the overlying skin. If the fracture remains displaced to the point that the skin is still compromised, open reduction may be indicated.

Clinical photograph of a type V acromioclavicular joint injury that was not reduced. The superiorly displaced fragment eventually eroded through the skin.

A and B, Technique for closed reduction of displaced clavicle fractures. A fulcrum is placed between the shoulders and a posteriorly directed force is applied to the lateral end of the clavicle.

Open reduction of clavicle fractures in children has traditionally been considered to be rarely indicated. Even in adolescents, some have thought it better to accept angulation and deformity than to attempt open reduction. The operative scar may be more displeasing than the bony prominence of the malunited fracture. Generally, we consider open reduction of the clavicle only if there is a neurovascular injury or open injury that is unstable after irrigation and débridement. Other occasional indications are posterior displacement with impingement of the underlying structures and impending skin penetration by the fracture fragment. Usually, a one-third tubular plate provides adequate fixation. We have also been successful in stabilizing some clavicle fractures with no. 1 or 2 absorbable polydioxanone sutures used as a cerclage wire. This technique has the advantage of avoiding permanent hardware without the disadvantages of pin fixation in the shoulder region. We do not use percutaneous pin fixation about the clavicle because of visceral problems associated with pin migration. ^‡a

‡a References .

Medial Physeal Separation (Pseudodislocation) of the Sternoclavicular Joint

Because the physeal sleeve remains intact, a significant amount of remodeling can be expected with medial physeal injuries, and consequently conservative treatment is the rule. Patients with anterior displacement and those with posterior displacement without evidence of visceral injury to the mediastinal structures can be managed symptomatically with a sling or figure-eight harness.

If there is a significant cosmetic deformity, we may attempt closed reduction, which frequently achieves stability. If the reduction is lost, we generally accept the deformity and anticipate significant remodeling. If there is posterior displacement with evidence of airway, esophageal, or neurovascular impingement, we will attempt closed reduction on an emergency basis in the operating room. If closed reduction fails, we proceed immediately to open reduction, preferably with the assistance of a general trauma or thoracic surgeon. ^§a

§a References .

Lateral Physeal Separation and Acromioclavicular Joint Dislocation

Treatment depends on the degree of injury to the joint. All types I and II injuries and type III injuries in patients younger than 15 or 16 years can be managed symptomatically with a sling or harness until the patient can use the extremity comfortably. ^¶a

¶a References .

#a References .

Scapulothoracic Dissociation

Scapulothoracic dissociation is a rare injury that is usually the result of a massive traction injury to the upper extremity. It represents a traumatic forequarter amputation and is almost universally associated with major neurovascular injury. Radiographically, lateral displacement of the scapula is noted on an AP chest radiograph. Patients frequently have other life- or limb-threatening injuries, and recognition of the extent of damage to the upper extremity may be delayed, with devastating consequences. Death has been reported in 10% to 20% of patients. Patients almost universally have a poor result, with a functionless extremity. ^§c

§c References .

Os Acromiale

An os acromiale represents failure of the apophysis of the acromion to close. Although considered a normal variant that is present in almost 10% of shoulders, os acromiale is occasionally symptomatic. It has been shown to be associated with pathology of the rotator cuff in some cases. Symptomatic os acromiale has been successfully treated with internal fixation and bone grafting, as well as arthroscopic subacromial decompression of the unstable fragment.

Grades I and II Injuries

Injuries with grades I and II displacement can be treated symptomatically without an attempt at reduction, regardless of the age of the patient. A simple arm sling or sling and swath or a hook and loop shoulder immobilizer should be worn until the pain subsides. Gentle pendulum exercises can be instituted in the second week, and most patients can resume some overhead activities within 4 to 6 weeks.

Grades III and IV Injuries

Indications for the treatment of more displaced proximal humeral physeal fractures (grades III and IV injuries) are controversial. Almost all researchers agree that displaced injuries in younger children (<6 years of age) can be treated symptomatically. ^#c

#c References .

Interestingly, in a review of 48 patients with displaced proximal humeral fractures (all grades III and IV), Beringer and colleagues reported an increased complication rate in patients treated operatively. Complications developed in three of the nine operative patients, whereas none developed in the 39 patients treated by closed reduction. Complications of operative treatment included fracture through a percutaneous pin site, symptomatic impingement requiring hardware removal, and osteomyelitis necessitating four operative débridement procedures. They further explored the functional results by comparing patients who maintained acceptable reduction with those in whom acceptable closed reduction could not be obtained or could not be maintained. No patient in either group had a functional deficit. To assess the results of closed treatment in patients near skeletal maturity, they examined the results of closed treatment in patients older than 15 years. Again, they found no functional limitations and no significant differences between patients with an acceptable reduction and those with persistent malposition. However, they did note an increased prevalence of minor abnormalities in patients with persistent malposition, although these differences were not functionally or cosmetically significant. They concluded that an attempt at maintaining anatomic closed reduction was beneficial, particularly in older adolescents, but that persistent malposition did not warrant open reduction.

Despite these excellent results with conservative treatment, a number of reports have advocated surgical treatment. Hutchinson and co-workers reviewed 50 cases, most with grade IV injuries, treated with closed or open reduction and fixed with percutaneous pins or intramedullary nails. The final Neer grades were improved and angulation was reduced from 44.4 to 12.6 degrees. Pin tract infection and pin migration occurred in 40% of those treated with pins. The intramedullary nail cases had greater blood loss and longer operative times but no significant complications. Their general indications for treatment were grade IV displacement in patients 12 years of age or older. Bahrs and co-workers compared results between 10 cases treated nonoperatively and 33 treated surgically. They noted that closed reduction was usually prevented by interposition of the biceps tendon and also by interposed periosteum. Fernandez and associates noted complications with intramedullary nails, including perforation through the humeral head, postoperative loss of reduction, and difficulties with nail removal. A review by Di Gennaro and colleagues of proximal fractures noted that 82 of 91 could be managed conservatively, with 15 requiring operative management.

Brachial plexus and major peripheral nerve palsies occasionally accompany proximal humerus fractures. Hwang and co-workers reported four patients with major nerve palsies, all of whom recovered slowly but had return of function between 5 and 9 months. All had neuropathic pain for at least 6 months after injury.

Our approach to the treatment of displaced proximal humeral physeal fractures parallels the recommendations of Beringer and colleagues. We attempt closed reduction under conscious sedation in the emergency department in all patients with grades III and IV displacement. Although these fractures generally reduce easily, the reduction is not always stable enough to be maintained ( Fig. 33-17 ). Thus, in younger patients, who have tremendous remodeling potential, we believe that the benefits of a stable closed reduction, primarily less pain and less immediate cosmetic deformity, must be weighed against the risks associated with conscious sedation in patients, regardless of age. The technique of closed reduction usually includes traction, abduction, forward flexion, and external rotation of the arm and forearm. Fluoroscopic guidance can be helpful during reduction, particularly if there is atypical displacement of the fracture. Once stable reduction has been achieved, the extremity is placed in a sling and swath or in a shoulder immobilizer for 2 to 3 weeks until the fracture fragments are sticky. At that point the immobilization can be discontinued and ROM exercises instituted.

The intact periosteum on the displaced side of a proximal humeral fracture ( A ) may enhance the stability of the fracture once the fracture has been reduced ( B ).

In patients in whom reduction can be achieved but is lost once the traction or abduction is removed, and in patients in whom we cannot obtain adequate closed reduction, the existing deformity is accepted and patients are managed symptomatically. The parents of these patients usually need a fair amount of reassurance that remodeling will provide an acceptable cosmetic and functional result.

We reserve operative treatment of displaced proximal humeral fractures for patients with intraarticular or open fractures or neurovascular injury. Also, we occasionally stabilize a proximal humeral fracture percutaneously in a polytraumatized patient who is undergoing operative treatment of other injuries because we believe that a stabilized extremity is easier to care for in an intensive care unit setting. Although rarer, avulsion fractures of the lesser tuberosity, which may be manifested as chronic shoulder pain without a definite injury, are another injury that could benefit from open reduction and internal fixation.

Intraarticular fractures require anatomic reduction, which can generally be performed through an anterior arthrotomy via a standard deltopectoral approach. Fixation can be achieved with a combination of screws and percutaneous pins. Every effort should be made to avoid crossing the physis with threaded fixation devices. Our goal for the operative treatment of nonarticular fractures is stabilization of the fracture to allow adequate management of concurrent injuries, whether they are neurovascular, soft tissue, or multiorgan injuries. We do not insist on anatomic reduction, and we usually stabilize the fracture with two percutaneous 0.062-inch Kirschner wires (K-wires; Fig. 33-18 ). We remove the K-wires after 2 to 3 weeks and limit motion of the extremity while they are in place in an attempt to minimize soft tissue complications. As with nonoperative treatment, ROM exercises are begun as soon as all percutaneous pins are removed and the patient is comfortable, generally in 2 to 3 weeks.

A, Anteroposterior (AP) radiograph of a displaced proximal humeral metaphyseal fracture. B, AP radiograph obtained after closed reduction and percutaneous pin fixation. Fracture stabilization eases nursing care in a polytraumatized patient.

Little League Shoulder

Little League shoulder, also termed proximal humeral epiphysiolysis, osteochondrosis of the proximal humerus, or traction apophysitis of the proximal humerus, is an overuse injury usually seen in pitchers but occasionally in other overhead athletes. * ^d

References .

A and B, Anteroposterior radiographs of both shoulders in an adolescent baseball player. Note the widened right proximal humeral epiphysis ( arrow in A ).

†d References .

Mechanism of Injury

Traumatic shoulder dislocation usually occurs as a result of an indirect force. Anterior dislocations represent more than 90% of glenohumeral dislocations. Anterior dislocation usually occurs when a force is applied to an arm in an abducted, extended, and externally rotated position. Traumatic shoulder dislocations may also occur posteriorly or inferiorly. Posterior dislocations may be the result of a direct blow to the anterior aspect of the shoulder, an indirect force with the arm in flexion, adduction, and internal rotation, or a massive muscle contraction, as occurs with an electrical shock or seizure. ^¶d

¶d References .

Anatomy

The elbow joint is a complex articulation of three bones that allows motion in all three planes. The distal humerus has unique articulations with the radius and ulna that make this mobility possible. The radial-humeral articulation allows pronation and supination of the forearm, whereas the ulnohumeral articulation allows flexion and extension of the elbow. The separate articulating surfaces of the distal humerus are attached to the humeral shaft via medial and lateral columns. These two columns are separated by a thin area of bone that consists of the coronoid fossa anteriorly and olecranon fossa posteriorly. This thin area is the weak link in the distal humerus and is where supracondylar humeral fractures originate. When forced into hyperextension, the olecranon can act as a fulcrum through which an extension force can propagate a fracture across the medial and lateral columns ( Fig. 33-30 ). Similarly, a force applied posteriorly with the elbow in flexion can create a fracture originating at the level of the olecranon fossa ( Fig. 33-31 ). Thus whether the result of an extension or flexion force, fractures of the supracondylar humerus are usually transverse and at the level of the olecranon fossa. For reasons that are unclear, older patients often have fractures that are oblique rather than transverse. Oblique fractures are less stable than transverse fractures because rotation produces additional angulation ( Fig. 33-32 ).

A, Supracondylar humeral fractures are usually the result of a fall onto an outstretched extremity, producing hyperextension of the elbow. B and C, As the elbow hyperextends, the olecranon serves as a fulcrum to produce the fracture. Thus supracondylar fractures are usually located at the level of the olecranon fossa.

A posteriorly applied force with the elbow in flexion creates a flexion-type supracondylar humeral fracture ( arrow ). This mechanism accounts for only 2% to 5% of all supracondylar humeral fractures.

Oblique fractures, which are more common in older patients, are less stable than transverse fractures.

Although the bony architecture of the distal humerus is responsible for the frequency of supracondylar humeral fractures, it is the soft tissue anatomy that has the potential to produce devastating long-term complications. Anteriorly, the brachial artery and median nerve traverse the antecubital fossa. Laterally, the radial nerve crosses from posterior to anterior just above the olecranon fossa. The ulnar nerve passes behind the medial epicondyle ( Fig. 33-33 ). In extension supracondylar fractures, the brachialis muscle usually shields the anterior neurovascular structures from injury. However, in severely displaced fractures, the proximal fragment may perforate the brachialis muscle and contuse, occlude, or lacerate the vessel or nerve. The vessels or median nerve may also become trapped and compressed between the fracture fragments.

Neurovascular anatomy around the elbow. The brachial artery and median nerve lie anteromedially. The radial nerve crosses from posterior to anterior, laterally proximal to the lateral condyle. The ulnar nerve lies posteromedially.

Even without direct injury, a severely displaced fracture can cause neurovascular injury simply from the stretch or traction associated with displacement. Similarly, the radial nerve may be injured by severe anterolateral displacement of the proximal fragment. With flexion-type injuries (anterior displacement of the distal fragment), the ulnar nerve is at risk because it may become tented over the posterior margin of the proximal fragment. Neurovascular problems can also develop in minimally displaced fractures as a result of hematoma formation or swelling. Hematomas generally spread anteriorly across the antecubital fossa deep to the fascia and can potentially compress the neurovascular structures.

Mechanism of Injury

Supracondylar humeral fractures may be the result of an extension or flexion force on the distal humerus. Usually they are the result of a fall on an outstretched hand, which causes hyperextension of the elbow. These extension-type supracondylar humeral fractures account for 95% to 98% of all supracondylar fractures. With hyperextension injuries the distal fragment will be displaced posteriorly. Flexion-type supracondylar fractures are rare and occur in only 2% to 5% of cases. The mechanism of flexion supracondylar fractures is usually a direct blow on the posterior aspect of a flexed elbow that results in anterior displacement of the distal fragment.

Classification

Supracondylar humeral fractures are usually initially classified as extension or flexion injuries and then according to the amount of radiographic displacement. This three-part classification system was first described by Gartland in 1959. It has been shown to be more reliable than most fracture classification systems. Type I fractures are nondisplaced or minimally displaced. Type II fractures have angulation of the distal fragment (posteriorly in extension injuries and anteriorly in flexion injuries), with one cortex remaining intact (the posterior in extension and the anterior in flexion). Type III injuries are completely displaced, with both cortices fractured ( Fig. 33-34 ).

Classification of extension supracondylar humeral fractures. Type I, the anterior cortex is broken. The posterior cortex remains intact, and there is no or minimal angulation of the distal fragment. Type II, the anterior cortex is fractured and the posterior cortex remains intact. However, plastic deformation of the posterior cortex, or greensticking, allows angulation of the distal fragment. Type III, the distal fragment is completely displaced posteriorly.

There have been several modifications of this scheme. Wilkins subdivided type III injuries according to the coronal plane displacement of the distal fragment ( Fig. 33-35 ). This modification is clinically helpful in identifying complications from the injury and problems with treatment. Posterolaterally displaced type III fractures, although less frequent and accounting for only 25% of extension supracondylar fractures, are more commonly associated with neurovascular injuries. Undoubtedly this is because the proximal fragment is displaced anteromedially in the direction of the neurovascular bundle ( Fig. 33-36 ). In extension supracondylar fractures, the coronal plane displacement of the distal fragment also helps predict the stability of the fracture at the time of reduction. In a classic study in monkeys, Abraham and colleagues demonstrated that the periosteal sleeve remains intact on the side to which the distal fragment is displaced. This periosteal sleeve helps stabilize the fracture when it is reduced. Pronation of the forearm tightens the medial sleeve to a greater extent than supination tightens the lateral sleeve; thus posterior medial fractures are usually more stable once reduced ( Fig. 33-37 ).

A, Posteromedially displaced fracture. B, Posterolaterally displaced fracture.

Posterolaterally displaced type III (extension-type) supracondylar humeral fracture. The proximal fragment displaces anteromedially, thus placing the brachial artery and median nerve at risk.

A, Posteromedially displaced fractures have an intact medial periosteal sleeve. B, Pronation of the forearm tightens the medial soft tissues and thereby stabilizes the reduction.

Mubarak and Davids subdivided type I fractures into IA and IB. Type IA injuries are truly nondisplaced fractures, with no comminution, collapse, or angulation. Type IB fractures are characterized by comminution or collapse of the medial column in the coronal plane and may have mild hyperextension in the sagittal plane ( Fig. 33-38 ). They expressed concern that if unreduced, these minimally displaced type IB fractures could lead to a cosmetically unacceptable result, particularly in children with a neutral or varus preinjury carrying angle.

Types IA and IB supracondylar humeral fractures. A, Type IA. There is no angulation in either plane. B, Type IB. There is medial column collapse, and there may be slight hyperextension in the sagittal plane.

Diagnosis

Supracondylar fractures may be inherently obvious or almost impossible to diagnose. The clinical findings in severely displaced fractures are generally so obvious that the most difficult part of the diagnosis is remembering to perform a thorough examination to assess for other injuries, as well as possible neurologic injury. This is particularly important given that neurologic injury is present in 10% to 15% of cases and ipsilateral fractures occur in 5% (usually the distal radius). ^§f

§f References .

‖f References .

The differential diagnosis of severely displaced supracondylar humeral fractures includes elbow dislocations and all conditions that mimic them, such as transphyseal distal humeral fractures and unstable lateral condylar fractures (Milch type II). True elbow dislocations are relatively uncommon. When elbow dislocations do occur, they are generally seen in older children and may be associated with medial epicondylar fractures. Transphyseal distal humeral fractures are more common than supracondylar fractures in children younger than 2 years but are uncommon in children older than 2 years. Transphyseal fractures have been reported to be associated with child abuse in as many as 50% of cases. Unstable lateral condylar fractures can be differentiated from supracondylar fractures most readily on the lateral radiograph. Supracondylar fractures usually originate at the olecranon fossa and are transverse or, less commonly, short oblique. Lateral condylar fractures originate more distally, often with only a small metaphyseal fragment visible on the lateral radiograph (Thurston-Holland sign; Fig. 33-39 ). On the AP view, an unstable lateral condyle fracture (Milch type II) may have a normal-appearing radial-capitellar joint but will demonstrate subluxation of the ulnar-trochlear joint. Conversely, a Milch type I lateral condyle fracture will have a disrupted radial-capitellar joint ( Fig. 33-40 ).

A, Lateral radiograph of a type II extension supracondylar humeral fracture. The fracture originates just proximal to the hourglass of the olecranon fossa ( arrowhead ). B, Lateral radiograph of a displaced lateral condylar fracture. The Thurston-Holland, or metaphyseal, fragment is at the posterior aspect of the metaphysis ( arrow ). The fracture originates distal to the hourglass of the olecranon fossa.

Elbow injuries in children. A, Normal alignment of structures in the elbow. B, Supracondylar humeral fracture. Radial-capitellar and ulnar-trochlear alignment remains intact but angled away from the humeral shaft. C, Milch’s type I lateral condyle fracture. Radial-capitellar alignment is disrupted, but the ulnar-trochlear relationship is normal. D, Milch’s type II lateral condyle fracture. The fracture extends medial to the trochlear groove, thus making the ulnohumeral joint unstable. However, the radius and capitellum maintain their relationship. E, Transphyseal fracture. The radius and capitellum maintain their alignment. If the secondary ossification center of the capitellum has not yet ossified, this injury may be difficult to distinguish from an elbow dislocation. F, Elbow dislocation. Both the radial-capitellar and ulnar-trochlear articulations are disrupted.

(Redrawn from DeLee JC, Wilkin KE, Rogers LF, et al: Fracture-separation of the distal humeral epiphysis, J Bone Joint Surg Am 62:48, 1980.)

The diagnosis of a minimally displaced supracondylar humeral fracture may be difficult to make. If seen soon after the injury, nondisplaced supracondylar fractures may have minimal swelling and can be difficult to differentiate from minimally displaced lateral condylar, medial epicondylar, or radial neck fractures. The most notable findings may be mild swelling and tenderness over the supracondylar region of the humerus. Careful clinical examination will reveal tenderness medially and laterally over the supracondylar ridges, whereas with lateral condylar fractures the tenderness is lateral and with medial epicondylar fractures it is medial. In radial neck fractures the tenderness is over the radial neck posterolaterally. However, a small child with a painful elbow does not always cooperate with such a careful examination. In these cases the definitive diagnosis may not be evident until the cast is removed several weeks later ( Fig. 33-41 ).

A, Lateral radiograph obtained after a hyperextension elbow injury in a child. Although there is no obvious fracture, there is a suggestion of a break in the anterior cortex ( arrow ), as well as some buckling posteriorly ( arrowhead ). B, Abundant periosteal reaction is evident 2 weeks later ( arrows ).

When the fracture cannot be seen clearly on radiographs, it is important to obtain a thorough history to ensure that there was indeed a witnessed fall and that the symptoms began immediately after the injury because patients with osteoarticular sepsis often have a swollen, painful elbow and a history of trauma. If the elbow pain did not begin immediately after a witnessed traumatic event, consideration should be given to the assessment of laboratory indices (e.g., complete blood cell count, differential, erythrocyte sedimentation rate, and C-reactive protein level) to ensure that the symptoms are not a result of occult infection.

Radiographic Findings

The diagnosis of a supracondylar humeral fracture is confirmed radiographically. Obtaining good-quality radiographs is complicated by the fact that the elbow is painful and difficult to move. Because of rotational displacement, it may be impossible to obtain true orthogonal views of severely displaced fractures. However, with proper instruction to the radiographer, true AP and lateral radiographs of fractures with moderate or minimal displacement can be obtained. Obtaining a true AP view of the elbow requires full elbow extension and is therefore seldom possible. Consequently, we obtain an AP view of the distal humerus, which can be achieved with any degree of elbow extension ( Fig. 33-42 ). The importance of obtaining a true lateral radiograph of the distal humerus cannot be overstated because most treatment decisions are made from assessment of the lateral radiograph. Although repeating radiographs is slow, tedious, and frustrating, it is worth the effort because, too often, “bad x-rays lead to bad decisions.” If a nondisplaced or minimally displaced fracture is suspected but the AP and lateral views do not show a fracture, oblique views may be useful.

Radiographic technique to obtain a true anteroposterior (AP) view of the distal humerus. A, If the elbow does not fully extend, an attempt to obtain an AP view of the entire elbow will produce an oblique view of the distal humerus and proximal radius and ulna. B, The distal humerus is placed on the cassette without extending the elbow, and a true AP view of the distal humerus is obtained. An AP view of the proximal radius and forearm can be obtained by placing the forearm on the cassette.

Several radiographic parameters are helpful for managing patients with supracondylar humeral fractures. One is Baumann’s angle, determined from an AP radiograph of the distal humerus. It is the angle between the physeal line of the lateral condyle of the humerus and a line drawn perpendicular to the long axis of the humeral shaft ( Fig. 33-43 ). A number of studies have assessed the use of Baumann’s angle in the management of supracondylar humeral fractures. ^¶f

Baumann’s angle is the angle created by the intersection of a line drawn down the proximal margin of the capitellar ossification center and a line drawn perpendicular to the long axis of the humeral shaft.

¶f References .

A, Anteroposterior (AP) and lateral ( B ) radiographs of a minimally displaced supracondylar humeral fracture. The importance of medial translation of the distal fragment on the AP view was not appreciated ( arrow in part A ), and the patient was managed in a long-arm cast. C and D, At the time of cast removal, the fracture had angulated further into varus and hyperextension.

There are also several important radiographic parameters on the lateral radiograph. A fat pad sign may alert the physician to the presence of an effusion within the elbow. The anterior fat pad is a triangular radiolucency anterior to the distal humeral diaphysis; it is seen clearly and, in the presence of elbow effusion, it is displaced anteriorly. The posterior fat pad is not normally visible when the elbow is flexed at right angles; however, if an effusion is present, it will also be visible posteriorly ( Fig. 33-45 ).

Fat pad sign. A, There is normally an anterior and posterior fat pad. These structures may be seen as radiolucencies adjacent to their respective cortices. B, In the presence of an effusion, the fat pad will be elevated, thereby creating a radiolucent “sail.”

There are several additional radiographic parameters to assess on the lateral radiograph ( Fig. 33-46 ). First, the distal humerus should project as a teardrop or hourglass. The distal part of the teardrop or hourglass is formed by the ossific center of the capitellum (see Fig. 33-46, A ). It should appear as an almost perfect circle. An imperfect circle or obscured teardrop or hourglass implies an oblique orientation of the distal portion of the humerus from an inadequate radiographic technique or fracture displacement. Second, the angle formed by the long axis of the humerus and the long axis of the capitellum should be approximately 40 degrees (see Fig. 33-46, B ). In supracondylar fractures with posterior tilting of the distal fragment (seen with extension fractures), the humerocapitellar angle will diminish, whereas with anterior tilting of the distal fragment (seen with less common flexion injuries) it will increase. Third, the anterior humeral line—a line drawn through the anterior cortex of the distal humerus—should pass through the middle third of the ossific nucleus of the capitellum (see Fig. 33-46, C ). In children younger than 4 years, the line may pass more anteriorly through the capitellum than in older children. With extension supracondylar fractures the anterior humeral line will pass anterior to the middle of the capitellum. Finally, the coronoid line, a line projected superiorly along the anterior border of the coronoid process, should just touch the anterior border of the lateral condyle of the humerus (see Fig. 33-46, D ). However, with extension supracondylar fractures, the coronoid line will pass anterior to the anterior border of the lateral condyle.

A, Circular appearance of the hourglass. B, Radiocapitellar angle. C, Anterior humeral line passing through the center of the capitellum. D, The coronoid line touching the anterior capitellar border.

Bahk and co-workers have noted that obliquity of the fracture line in extension supracondylar fractures may be predictive of problems with management. Those with more coronal obliquity were more often associated with comminution and rotational malunion. Those with greater sagittal obliquity (>20 degrees) were more likely to result in extension malunion.

Treatment

To quote Mercer Rang again, the goal of treatment of supracondylar humeral fractures is to “avoid catastrophes” (vascular compromise, compartment syndrome) and “minimize embarrassments” (cubitus varus, iatrogenic nerve palsies). With this goal in mind, treatment of supracondylar humeral fractures can be divided into a discussion of their management in the emergency department, care of nondisplaced fractures, and treatment of displaced fractures.

Emergency Treatment

It is important that the child and limb receive proper care while awaiting definitive treatment. Unless the patient has an ischemic hand or tented skin, the limb should be immobilized as it lies with a simple splint. If possible, radiographs should be obtained before splinting, or radiolucent splint material should be used. If the distal extremity is initially ischemic, an attempt to align the fracture fragments better should be made immediately in the emergency department. This can be accomplished by extending the elbow, correcting any coronal plane deformity, and reducing the fracture by bringing the proximal fragment posteriorly and the distal fragment anteriorly ( Fig. 33-47 ). Often, this simple maneuver immediately restores circulation to the hand. In extension-type fractures, flexion of the elbow should be avoided because it may cause further damage to the neurovascular structures. The distal circulation should always be checked before and after the splint is applied. Sensation, motor function, and skin integrity should also be carefully checked and recorded. Patients with open fractures should receive intravenous antibiotics and appropriate tetanus prophylaxis (see discussion of open fractures in Chapter 31 ). All patients should be kept from having any food or drink by mouth (NPO) until a definitive treatment plan has been outlined.

A, Ischemic limb. B, Simple realignment may reduce the tension on a vessel and restore the circulation.

Treatment of Nondisplaced Fractures

Treatment of nondisplaced fractures is straightforward and noncontroversial. It consists of long-arm cast immobilization for 3 weeks. We often initially treat the patient in the emergency department with a posterior splint, with figure-eight reinforcement. The position of the forearm in the long-arm cast has been the subject of a great deal of speculation. For truly nondisplaced fractures there is no theoretic advantage to pronation or supination. We generally immobilize nondisplaced fractures with the forearm in neutral position. The patient returns 5 to 10 days after injury for removal of the splint. Radiographs are repeated to ensure that no displacement has occurred, and the patient is placed in a long-arm cast for an additional 2 to 3 weeks, at which time immobilization is discontinued. After cast removal the parents are forewarned that normal use of the arm may not resume for 1 to 2 weeks, and that some pain and stiffness should be expected for the first 2 months. Children return 6 to 8 weeks after cast removal for review of their ROM. We have found that patients returning for an ROM check at 3 to 4 weeks may have mild residual deficits in extension or flexion, or both. This can be disconcerting to the parents, who expect everything to be normal at this visit. This parental anxiety (and the long discourse of reassurance) can be avoided by allowing the child to be out of the cast for a longer period before returning for the final checkup.

There are a few potential pitfalls in the management of nondisplaced supracondylar humeral fractures that merit further discussion. The first concerns the diagnosis. Sometimes the only visible radiographic abnormality is the presence of a fat pad sign. Frequently, after 1 to 3 weeks, the fracture, as well as the periosteal reaction associated with its healing, will be obvious (see Fig. 33-41 ). Failure to make this diagnosis at the outset is of little concern because the fracture is stable. Of more concern is the possibility of misdiagnosing an occult infection or nursemaid’s elbow as a nondisplaced supracondylar humeral fracture. A thorough history will suggest the correct diagnosis. At times, undisplaced fractures cause soft tissue swelling and may even result in compartment syndrome. Thus, we are careful to not immobilize the arm in more than 90 degrees of flexion, and we often use a posterior splint rather than a cast. If a cast is applied, it is generously split. The parents must be educated on the importance of edema control and watching for signs of increased swelling and pressure. Too often patients are discharged from the emergency department with instructions to elevate the arm and use a sling. It should not be surprising that a number of these patients return for follow-up with swollen extremities. Parents, in an effort to follow directions, are dogmatic about use of the sling. Unfortunately, this keeps the extremity in a dependent position and promotes swelling. Time should be taken in the emergency department to explain to the parents (and the nurses giving discharge instructions) that the extremity should be elevated with the fingers above the elbow and the elbow above the heart for the first 48 hours after the injury. The sling is for comfort after the swelling has subsided ( Fig. 33-48 ). Parents should be instructed to return immediately to the emergency department if it appears that the splint or cast is becoming too tight or the pain seems to be increasing inappropriately.

A, A sling holds the hand and elbow in a dependent position, thereby creating edema and pain. B, Parents (and patients) should be instructed about true elevation of the extremity, with the fingers above the elbow and the elbow above the heart.

Treatment of Displaced Fractures

Several treatment options are available for the management of displaced fractures (types II and III). By definition, all these fractures require reduction. Usually, even for severe type III injuries, reduction can be accomplished in a closed fashion. Options exist in regard to the method of maintaining the reduction until the fracture has healed, including cast immobilization, traction, and percutaneous pin fixation. If adequate closed reduction cannot be achieved, open reduction should be performed; this is almost universally followed by pin fixation.

Closed Reduction

Reduction of Extension-Type Fracture.

Under general anesthesia, the child is positioned at the edge of the operating table, with the arm over a radiolucent table to allow assessment of the reduction with an image intensifier ( Fig. 33-49 ). Some surgeons elect to use the image intensifier itself as the table. An assistant grasps the proximal humerus firmly to allow traction to be placed on the distal fragment. Traction should be applied with a steady continuous force, with the elbow in full extension. Once adequate traction has been applied, the coronal plane (varus-valgus) deformity is corrected while traction is maintained (see Fig. 33-49, B ). Continuing to maintain traction with the nondominant hand, the surgeon uses the fingers of the dominant hand to apply a posterior force to the proximal fragment. The thumb of the dominant hand is advanced along the posterior humeral shaft in an attempt to milk the distal fragment further distally. Once the thumb reaches the olecranon, it applies an anterior force to the distal fragment while the fingers continue to pull the proximal fragment posteriorly (see Fig. 33-49, C ). Concurrently, the nondominant hand flexes the elbow and pronates the forearm for posterior medially displaced fractures and supinates the forearm for posterior lateral fractures. (With the elbow in a flexed position, the patient’s thumb should point in the direction of the distal fragment’s initial displacement.) While the elbow is being flexed, the surgeon’s nondominant hand can continue to exert a distracting force on the distal fragment. With the elbow hyperflexed, the reduction is then assessed on AP and lateral views. The lateral image can be obtained by externally rotating the shoulder or rotating the image intensifier. With very unstable fractures the surgeon may need to rotate the image intensifier to avoid displacing the fracture. Once the reduction has been confirmed, the fracture can be immobilized with a cast, traction, or percutaneous pin fixation.

Technique for closed reduction and percutaneous pinning of supracondylar humeral fracture. A, Diagram of patient and C-arm positioning. B, Initially, traction is applied and the coronal plane (varus-valgus) deformity is corrected. C, The surgeon’s dominant hand is used to reduce the fracture in the sagittal plane while the nondominant hand flexes the elbow and pronates (posteromedially displaced fractures) or supinates (posterolaterally displaced fractures) the forearm. The fingers of the dominant hand are used to apply a posteriorly directed force to the proximal fragment while the thumb is slid posteriorly in a proximal to distal direction to milk the distal fragment anteriorly. D, Reduction is confirmed with the arm in a hyperflexed position. The Jones view is used to obtain an anteroposterior (AP) view ( D1 ). The lateral view may be obtained by externally rotating the shoulder ( D2 ) or rotating the image intensifier ( D3 ). E, The fracture is pinned with the arm in a hyperflexed position, and the reduction and pin placement are confirmed in the AP and lateral planes.

Several caveats to achieving successful closed reduction need mention. The first is that every effort should be made to avoid vigorous manipulations and remanipulations because they only damage soft tissue and elicit more swelling. The second is the management of extremely unstable fractures, which are often posterolaterally displaced. Maintenance of reduction is difficult because supination is not as effective at tightening the intact lateral soft tissue hinge as pronation is at stabilizing posteromedially displaced fractures (see Fig. 33-37 ). During reduction, as the elbow is placed into hyperflexion, these fractures occasionally displace into valgus. When valgus displacement is noted, a different reduction maneuver is required. Traction and the posteriorly directed force to the proximal fragment remain unchanged. However, as the elbow is flexed, a varus force is applied, and flexion is stopped at 90 degrees. The reduction is confirmed and usually stabilized with percutaneous pinning (see Fig. 33-49, D and E ).

Reduction of Flexion-Type Fractures.

Closed reduction is obtained with longitudinal traction and the elbow in extension; the distal fragment is reduced with a posteriorly directed force ( Fig. 33-50 ). Any coronal plane deformity is then corrected. Once adequate reduction has been confirmed, it is usually maintained with percutaneous pinning. Severely displaced flexion-type injuries are more likely to require open reduction than the more common extension-type fractures.

Lateral radiograph of a type III flexion supracondylar humeral fracture. Note the anterior displacement of the distal fragment.

Percutaneous Pinning.

The development of image intensifiers and power pin drivers has made percutaneous pin fixation of supracondylar humeral fractures a relatively simple procedure. Because percutaneous pin fixation yields the most predictable results with the fewest complications, it is our preferred technique for immobilization of displaced supracondylar humeral fractures. ^#f

#f References .

The technique for percutaneous pinning involves the placement of two or three 0.62-inch smooth K-wires (smaller K-wires may be used in patients younger than 2 years) distally to proximally in a crossed or parallel fashion. The use of a crossed pin or parallel pin technique has been the subject of considerable debate; see later, “Controversies in Treatment.” Once closed reduction has been achieved, the extremity is held in the reduced position by the surgeon’s nondominant hand or an assistant. We usually place the lateral pin first although occasionally, with an unstable posterolaterally displaced fracture, the initial pin may have to be placed medially. If two lateral pins are to be used, the first pin should be placed as close to the midline as possible (just lateral to the olecranon). If only one lateral pin is to be placed, the starting point is the center of the lateral condyle. After the first pin is placed, the second pin is inserted laterally (in the center of the lateral column) or medially. The relationship of the second pin to the first pin and the fracture is an important aspect of percutaneous pin fixation. The rotational stability of the fixation is enhanced if the second pin crosses the fracture line at a significant distance from the first pin. Careful attention must be given to ensure that the pins do not cross the fracture at the same point. This potential error can be made with crossed or parallel pins. We avoid this problem by attempting to divide the fracture into thirds with the pins ( Fig. 33-51 ).

Pin placement for optimal rotational stability. A, Schematic diagram of parallel lateral pins ( left ) and crossed medial and lateral pins ( right ). Ideally, the pins should be the greatest possible distance from each other at the fracture site. This can be accomplished with either technique. B, Anteroposterior radiographs demonstrating fractures fixed with parallel lateral pins ( left ) and crossed medial and lateral pins ( right ).

If a medial pin is used, care must be taken to ensure that the ulnar nerve is not injured. The starting position for a medial pin is the inferiormost aspect of the medial epicondyle (see Fig. 33-51 ). The pin should be started as far anteriorly as possible. It is often helpful for the surgeon holding the reduction to milk the soft tissue posteriorly, with the thumb left immediately posterior to the medial epicondyle to protect the ulnar nerve ( Fig. 33-52 ). If the elbow is extremely swollen, a small incision can be made to identify and protect the ulnar nerve. It is important to remember that flexion of the elbow displaces the ulnar nerve anteriorly. Thus it is safer to place a medial pin with the elbow in extension. Similarly, if the arm is immobilized in flexion, the nerve may be tented around the pin, thereby leading to ulnar nerve symptoms without direct penetration of the nerve by the pin ( Fig. 33-53 ).

The assistant holding the reduction protects the ulnar nerve by sweeping the soft tissues posteriorly away from the medial epicondyle.

A, Elbow flexion brings the ulnar nerve ( inset ) anteriorly, closer to the medial epicondyle, thereby placing it at greater risk during medial pin placement. Also, immobilization of the elbow in flexion may tent the nerve around the pin and produce ulnar nerve symptoms despite a properly placed pin. B, With the elbow in extension, the ulnar nerve lies in a safer position, posterior to the medial epicondyle.

Placement of K-wires percutaneously through the narrow distal humerus requires some finesse. As in all percutaneous procedures in orthopaedics, it is facilitated by knowing the anatomy and by reducing the task into two separate, two-dimensional problems. Appropriate pin placement is made easier by first lining up the pin driver in the AP plane, locking this angle in, and then lining up the pin driver in the lateral plane without changing the angle in the AP plane. Positioning the pin driver and subsequently the pin sequentially in only these two orthogonal planes simplifies a conceptually difficult task. The use of a pin driver rather than a drill, which requires a chuck key, also facilitates pin placement because the pin can be advanced more readily in the power driver.

Once the fracture has been stabilized with at least two pins, the elbow is extended, and the reduction and pin placement are confirmed on orthogonal radiographic views. If the reduction and pin placement are acceptable, the pins are bent, cut (it is best to leave a few centimeters of pin out of the skin to facilitate removal), and covered with sterile felt to decrease skin motion around the pin. The arm is immobilized in 30 to 60 degrees of flexion in a posterior splint or widely split or bivalved cast. The child is observed overnight and discharged with instructions on cast care and elevation. The child usually returns in 7 to 10 days for examination, and radiographs are generally taken to check for maintenance of reduction. At 3 weeks the radiographs are repeated, the pins are removed, and the immobilization is discontinued. The parents are instructed to expect gradual ROM and to avoid forced manipulation. Final follow-up is at 6 to 8 weeks to evaluate alignment and ROM.

As with all treatment methods, there are potential complications with percutaneous pinning, including pin tract inflammation or infection, iatrogenic ulnar nerve injury, and loss of reduction. Pin tract inflammation or infection occurs in 2% to 3% of patients in most large series of supracondylar humeral fractures treated by pin fixation. Fortunately these infections usually respond to removal of the pin and a short course of oral antibiotics, although osteomyelitis can develop. Ulnar nerve injury from a medially placed percutaneous pin is another potential complication. The true incidence of this problem is difficult to determine because not all ulnar nerve injuries are iatrogenic. However, the ulnar nerve is the least commonly injured nerve in supracondylar fractures; this type of injury occurs most frequently in the rare flexion injuries. If an ulnar nerve deficit is noted postoperatively and a medial pin is present, we recommend removal of the medial pin and observation. Fortunately, in most cases, the ulnar nerve makes a complete recovery. * ^g

References .

Loss of reduction can occur after closed reduction and percutaneous pinning of supracondylar humeral fractures ( Fig. 33-54 ). This complication is generally the result of inadequate surgical technique and can be minimized by close attention to detail to ensure that the pins are maximally separated at the fracture and have adequate purchase in the proximal fragment.

A, Immediate postoperative anteroposterior and lateral ( B ) radiographs of a type III supracondylar humeral fracture. The fracture is atypically proximal and oblique. Note that the most medial pin has very little purchase in the proximal fragment ( arrowhead in A ). C and D, The medial pin has lost its marginal purchase 18 days postoperatively, the lateral pin has bent, and the fracture has migrated into hyperextension and varus. E and F, Despite early callus formation, an attempt at closed osteoclasis was made. Note the improved alignment and addition of a medial pin. G and H, The fracture healed uneventfully.

Cast Immobilization.

The advantages of cast immobilization are that a cast is easy to apply, readily available, and familiar to most orthopaedists. Casting does not require sophisticated equipment, there is little chance of iatrogenic infection or growth arrest, and it can yield good results. Therefore some surgeons advocate closed reduction and cast immobilization as the initial treatment option for all displaced supracondylar humeral fractures and reserve percutaneous pinning for patients in whom cast management fails.

After closed reduction is obtained, treatment of displaced fractures with a cast is similar to treatment of a nondisplaced fracture, but with a few differences. First, the cast should be carefully applied to avoid compression in the antecubital fossa. Second, patients requiring reduction are admitted to the hospital overnight for observation. Again, it is imperative that the nursing staff and parents understand the importance and technique of edema control. The final and perhaps most significant difference in the management of displaced fractures with a cast is that the cast is not removed at the initial follow-up visit 7 to 10 days after the reduction; rather, radiographs are obtained with the arm in the cast. Again, the cast is maintained for 3 to 4 weeks after the reduction, and the parents are warned to expect a period of pain and stiffness after cast removal.

Cast immobilization is not without potential problems. Most displaced supracondylar fractures are stable only if immobilized in more than 90 degrees of flexion. Casting an injured elbow in hyperflexion may lead to further swelling, increased compartment pressure, and possibly the development of Volkmann’s ischemic contracture (compartment syndrome). Although Volkmann’s ischemic contracture can develop in any patient with a supracondylar humeral fracture, regardless of the treatment method, cast immobilization requires flexion of the elbow and a rigid circumferential dressing, both of which may exacerbate the condition. An A -frame cast that leaves the antecubital fossa free of casting material may reduce cast complications.

Loss of reduction is the other potential problem with cast immobilization. As the swelling subsides, a cast inevitably loosens and allows the elbow to extend, which may result in loss of reduction. Often this will occur after the first follow-up radiograph shows maintenance of the reduction. In this scenario, it is not until the cast is removed a few weeks later that the varus hyperextension malunion is discovered. Although good results can be obtained with cast immobilization, particularly with type II fractures, the necessity to immobilize the elbow in flexion and the unpredictable problem of loss of reduction have led us away from the use of cast immobilization of supracondylar fractures that require reduction.

Traction.

Traction also yields good results in the management of displaced supracondylar humeral fractures. Numerous traction techniques have been described, including overhead or lateral traction with skin or skeletal traction applied with an olecranon pin or screw ( Fig. 33-55 ). Traction has been advocated to maintain a closed reduction and achieve reduction of irreducible fractures. A period of traction preceding an attempt at closed reduction in a massively swollen arm has also been described. However, the most effective way to prevent local swelling, or to decrease it if the elbow is already swollen, is to achieve immediate reduction and stabilize the fracture and soft tissue.

A and B, Historically, supracondylar fractures were treated by traction. Traction techniques are rarely used now.

There are several drawbacks to skeletal traction that have led to a steady decline in its use, including the need for prolonged hospitalization, relative discomfort for the child until the fracture becomes sticky, pin inflammation and infection, potential for loss of reduction, and possible development of neurovascular complications, such as ulnar nerve injury from olecranon pins, compartment syndrome from excessive traction or circumferential bandages, and circulatory embarrassment from acute hyperflexion of the elbow while in traction. ^†g

†g References .

We do not use traction in the management of supracondylar humeral fractures. Its use is only described here for historical completeness. It may have a role in the rare fracture that cannot be managed routinely because of extenuating circumstances.

Open Reduction.

Indications for open reduction of a supracondylar humeral fracture include an ischemic pale hand that does not revascularize with reduction of the fracture, open fracture, irreducible fracture, and inability to obtain a satisfactory closed reduction. If the hand remains ischemic after reduction of the fracture, the brachial artery should be immediately explored through an anterior approach. Once the arterial pathology (entrapment, laceration, or compression) has been identified, the fracture should be reduced and percutaneously pinned. If necessary, the arterial pathology can then be addressed. ^‡g

‡g References .

Open fractures require emergency operative débridement. After débridement, the fracture can be reduced with an open technique and percutaneously pinned. With appropriate débridement, fracture stabilization, and antibiotic coverage, the complication rate of open fractures is not significantly different from that of severely displaced closed fractures.

Supracondylar fractures may be irreducible if the distal aspect of the proximal fragment buttonholes through the brachialis muscle. This buttonholing often produces a characteristic puckering of the skin over the displaced proximal fragment. The presence of this pucker sign is not in itself an indication for open reduction because closed reduction may be successful. However, this sign should alert the surgeon to a potentially refractory fracture that may require open reduction.

The decision that a closed reduction is unacceptable and an open reduction is indicated must be made on an individual basis. We accept mild angulation in the sagittal plane and translation in the coronal plane. A mild amount of valgus angulation in the coronal plane is also acceptable. However, varus angulation in the coronal plane, particularly if associated with a small amount of hyperextension in the sagittal plane or a contralateral carrying angle that is neutral or varus, is likely to yield a cosmetically poor result that will not remodel ( Fig. 33-56 ). If significant varus deformity exists after the best attempt at closed reduction, we proceed to open reduction. We usually approach the elbow from the side opposite the displaced distal fragment. This allows any interposed soft tissue to be removed from the fracture site. Once reduced with an open technique, the fracture is stabilized with percutaneous pins. Ersan and co-workers compared anterior to lateral open approaches and concluded that the anterior incision yields better anatomic access, with a smaller scar. Aktekin and associates found poor functional and cosmetic results when open reduction was performed through a posterior, triceps-sparing approach.

A, Anteroposterior radiograph of varus malunion. B, Clinical appearance.

Controversies in Treatment

Management of Minimally Displaced Fractures

There is debate regarding the necessity of closed reduction and pinning for all displaced supracondylar fractures, particularly minimally displaced type IB or II fractures. A number of studies have reported good results with closed reduction and casting of displaced fractures. However, other studies have noted superior results with closed reduction and pinning. ^§g

§g References .

Although we recognize that some minimally displaced fractures may be managed successfully without pin fixation, we think that there are several potential hazards with cast management of minimally displaced supracondylar fractures. Type IB fractures with medial column collapse or comminution are difficult, for several reasons. First, they may be more unstable than appreciated on initial radiographs ( Fig. 33-57 ). If treated by simple immobilization, these occultly unstable fractures are likely to displace into varus and hyperextension and lead to malunion and a cosmetically unacceptable result. Second, even if the fracture is stable, collapse of the medial column may produce enough varus and hyperextension to produce a poor result if the fracture is not reduced.

Unstable type IB supracondylar humeral fracture. Initial anteroposterior ( A ) and lateral ( B ) radiographs showing minimal medial comminution ( arrowhead ) and slight hyperextension. C and D, Intraoperative stress radiographs showing significant varus and hyperextension instability ( arrow ).

One study found that the degree of extension of the fracture, based on the anterior humeral line, correlated with the likelihood of failure of cast treatment. Also excess swelling was associated with failure of cast management. There are also two potential problems with closed reduction and cast management of type II fractures. The first is loss of reduction and the second is increased swelling and the potential development of compartment syndrome secondary to immobilization with the elbow in flexion. The difficulty with cast management of minimally displaced fractures was demonstrated in the study of Hadlow and colleagues. They reported good results in 37 of 48 type II fractures managed by closed reduction and casting without pin fixation. They concluded that pin fixation of all type II fractures would result in unnecessary pinning 77% of the time. However, they failed to acknowledge that cast treatment produces an unacceptable result in the remaining 23% of cases. Obviously, the problem is correctly identifying which fractures are at risk for malunion. To our knowledge, no reliable predictors of malunion exist, and many studies have reported superior results with percutaneous pinning of displaced supracondylar fractures. Therefore we prefer closed reduction and pinning for all types IB and II supracondylar humeral fractures. Although this aggressive management may lead to a few unnecessary pinnings, we believe that it also results in the fewest complications.

Pinning Technique and Iatrogenic Ulnar Nerve Injury

The technique of pin placement and management of iatrogenic ulnar nerve injury are also controversial topics. Although several biomechanical studies have shown that crossed pins are the most stable configuration, a number of reports have shown good clinical results with parallel lateral pin fixation. ^‖g

‖g References .

In a randomized trial, Kocher and co-workers found no difference in outcome comparing crossed pins with lateral pins, with no ulnar nerve injuries in either group. In follow-up, 5 of 8 surgeons at the originating institution had changed from crossed to lateral pin fixation. Although more stable, the crossed pin technique requires the placement of a medial pin, which may injure the ulnar nerve. ^¶g

¶g References .

A meta-analysis showed a 4.3-fold increased incidence of ulnar nerve injury with cross pinning. Slobogean and co-workers calculated a number needed to harm relative to ulnar nerve injury and proposed an iatrogenic ulnar nerve injury for every 28 patients treated with cross pinning. Skaggs and colleagues, in a review of 369 supracondylar fractures, reported that the incidence of ulnar nerve injury could be decreased from 15% to 2% by placing two lateral pins, followed by the selective use of medial pins only for fractures that remain unstable after placement of the lateral pins. In this technique, the lateral pins are placed in a parallel or divergent fashion to provide maximal rotational control. The arm is then extended and examined under fluoroscopy. If the fracture remains unstable, a third pin can be placed medially, with the arm in extension ( Fig. 33-58 ). This technique not only allows placement of the medial pin with the elbow in the safer extended position (see Fig. 33-53 ) but also provides a safety net of two lateral pins. If an iatrogenic ulnar nerve injury is noted postoperatively, the medial pin can be removed and two pins will still be present, usually providing adequate stability. Interesting variations in small series included a posterior to anterior pin, often augmented with a second lateral pin, a laterally placed external fixator, and the use of the prone position for standard pinning.

Anteroposterior radiograph showing a fracture pinned with two lateral pins, the selective medial pin technique.

We use the crossed pin and double lateral–selective medial pin techniques. We believe that the most important factor in the pinning technique is not where the pins are inserted but where they cross the fracture site. Stability is increased by maximizing the distance between the pins at the fracture sites. This can be accomplished by dividing the fracture into thirds with the pins, regardless of whether pin placement is lateral or medial (see Fig. 33-51 ).

Treatment of iatrogenic ulnar nerve injury is also controversial. Although iatrogenic ulnar nerve injury almost always recovers, there are case reports of permanent injury. Thus we believe that an ulnar nerve palsy associated with a medial pin requires immediate treatment. Initially we ensure that the elbow is immobilized in an extended position. Often the ulnar nerve is not directly injured by the K-wire but is stretched around the medial pin when the elbow is in a flexed position (see Fig. 33-53 ). If the elbow is adequately extended or if extension does not alleviate the ulnar nerve symptoms, we remove the medial pin immediately.

Management of a Viable, Pulseless Hand

Controversy exists regarding the best management of a pulseless pink hand. The elbow’s abundant collateral circulation allows the distal extremity to remain viable, despite complete disruption of the brachial artery ( Fig. 33-59 ). Recommendations for management of a viable but pulseless hand range from observation to arteriography to immediate surgical exploration. ^#g

The collateral circulation around the elbow may provide adequate circulation to the forearm and hand despite complete disruption of the brachial artery.

#g References .

Several groups have shown that the hand can remain viable and a radial pulse can even return after ligation of the brachial artery. Nevertheless some recommend aggressive surgical attempts to restore a normal pulse because of concern that conservative management of a pulseless viable extremity could lead to progressive ischemia as a result of thrombus formation or future problems with cold intolerance, exercise claudication, or growth discrepancy. * ^h

References .

Interestingly, although a number of reports have discussed cold intolerance and exercise claudication, only Marck and associates actually described a patient with either of these symptoms. They reported a patient who had normal function but cold intolerance 4 years after a supracondylar fracture associated with complete transection of the median nerve and brachial artery. The median nerve had been repaired but the artery was ligated because of good distal perfusion from collateral circulation. It is unclear whether the patient’s symptoms (cold intolerance) were caused by the vascular or neurologic injury. Blakey and colleagues reported a series of 26 children referred for care who had presented at other facilities with a pink pulseless extremity. Four had arterial exploration, one unsuccessfully, and the remaining 23 had well-established ischemic contractures. The denominator of this series is unknown.

The study by Sabharwal and associates is unique in that the investigators attempted to determine the fate of vascular interventions with noninvasive vascular studies, including magnetic resonance angiography. A normal pulse was restored in 13 patients with pulseless but viable extremities. Of these patients, 11 underwent follow-up that included noninvasive vascular studies. Of these 11 patients, a normal pulse was restored by open reduction in 4, by urokinase therapy in 3, and by surgical reconstruction in 4. At follow-up, all patients were asymptomatic and had a normal radial pulse. Five had hypertrophic antecubital scars. Noninvasive vascular studies were normal in 3 of the 4 patients treated by open reduction and mobilization of an entrapped brachial artery and in 2 of the 3 patients treated with urokinase but in only 1 of the 4 patients treated by surgical reconstruction. Another study followed 12 children who had vascular repair and were noted to have normal vascular function at an average 14-year follow-up.

Our approach to a viable hand with abnormal pulses is close observation. We believe that the lack of clinical studies documenting late problems, and the uncertain fate of aggressive surgical interventions, supports a conservative approach to most of these injuries. One group performed a literature review that showed that when the arm remained pulseless after fracture reduction, 70% were found to have an arterial injury. They compared this to a survey of POSNA members in which respondents estimated that only 17% would have such injuries. However, this fails to clarify the natural history of these arterial findings. It is important to realize that unidentified vascular pathology can lead to thrombus formation and subsequently to an ischemic limb, so continued close observation of these patients is of paramount importance. Although pulse oximetry is controversial, we have found it to be a valuable tool for monitoring these patients after closed reduction and pinning. If a pulseless viable limb becomes ischemic, arteriography and thrombolytic therapy may be useful adjuvants.

Management of Late-Presenting or Malreduced Fractures

Appropriate management of a patient who is initially evaluated 1 to 2 weeks after injury and found to have a nonreduced or unacceptably reduced fracture is often difficult to determine. Obviously the condition of the skin and neurovascular structures is an important factor to consider when determining treatment. Other factors include the age of the patient and the time since injury. Some surgeons advocate a wait and see approach to these fractures because attempts at manipulation once early callus begins to form may not improve the reduction and could risk increasing stiffness. This argument is strengthened by the knowledge that functional limitations are rare after nonunion. Others favor a more aggressive approach and attempt closed or even open reduction of these fractures. Unfortunately, there is little in the literature to guide the decision making process. Alburger and colleagues have shown that a 3- to 5-day delay before closed reduction and pinning is not deleterious. Lal and Bhan reported good results in 20 children treated by open reduction 11 to 17 days after injury. Vahvaven and Aalto performed routine remanipulation at 2 weeks for all redisplaced fractures, without adverse sequelae. Devnani recommended gradual reduction with skin traction.

We have had success with remanipulation of supracondylar fractures after delays of 2 to 3 weeks ( Fig. 33-60 ). Management of these injuries must be determined on an individual basis and must take into account factors such as the patient’s age, condition of the soft tissue, amount of residual deformity, and degree of radiographic healing. It is important that treatment decisions regarding these malreductions be made based on good information. Unfortunately, obtaining an adequate examination and radiographs in a young patient a few weeks after a displaced supracondylar fracture can be extremely difficult and may require examination under anesthesia. Although functional limitations are uncommon with malunion of supracondylar humeral fractures, these injuries have little potential to remodel. Even a small improvement in alignment may represent the difference between a cosmetically acceptable result and one that is unacceptable. If an attempt is made to improve the alignment of a supracondylar fracture in delayed fashion, an anatomic reduction may not be an achievable goal. In such cases, we usually accept an adequate nonanatomic reduction rather than proceed to open reduction.

A, Anteroposterior (AP) and lateral ( B ) radiographs of a type III supracondylar humeral fracture first seen 10 days after the injury. Despite radiographic evidence of early callus formation, closed reduction was attempted. C, Intraoperative radiograph showing percutaneous osteoclasis, which was necessary to improve the sagittal alignment. D, AP and lateral ( E ) radiographs obtained after reduction and pinning.

Complications

The complications of supracondylar humeral fractures can be categorized as early or late. Early complications include vascular injury, peripheral nerve palsies, and Volkmann’s ischemia (compartment syndrome). Late complications include malunion, stiffness, and myositis ossificans. Although attention to detail at the time of initial treatment may limit the long-term sequelae of early complications and minimize late complications, the severity of the injury and nature of the anatomy make problems from supracondylar fractures unavoidable.

Malunion: Cubitus Varus and Cubitus Valgus

Cubitus varus and cubitus valgus are the most common complications of supracondylar humeral fractures. The reported incidence ranges from 0% to 50%. ^#h

#h References .

In general, posteromedially displaced fractures tend to develop varus angulation, and posterolaterally displaced fractures tend to develop valgus deviation. Cubitus varus deformity is more commonly noted to be a problem than cubitus valgus, probably because posteromedial fractures are more common. However, varus deformity may be more frequently reported simply because it is more cosmetically noticeable. Although some have suggested that angular deformity is a result of growth imbalance, the consensus opinion is that cubitus varus and valgus are the result of malunion ( Fig. 33-61 ). * ⁱ

Malunion producing cubitus varus. A, The fracture has been reduced and pinned in varus. Note the shortening of the medial column ( arrow ). B, Varus malalignment persists 6 years after injury. C, Clinical appearance.

References .

Cubitus varus or valgus is assessed by measuring the carrying angle of the arm. This is the angle created by the medial border of the fully supinated forearm and medial border of the humerus, with the elbow extended ( Fig. 33-62 ). The carrying angle exhibits considerable individual variation. Thus, comparison should be made with the contralateral side rather than with any normal standard. As the elbow extends, the carrying angle decreases (more varus); thus hyperextension tends to accentuate a cubitus varus deformity, whereas a flexion contracture can create the appearance of cubitus valgus. Smith has demonstrated that changes in the carrying angle are a result of angular displacement or tilting of the distal fragment, not translation or rotation. However, rotation of the distal fragment can contribute to the cosmetic deformity of a malunion. A residual rotational deformity is almost always present after a corrective osteotomy for cubitus varus ( Fig. 33-63 ).

The carrying angle is the angle defined by the border of the fully supinated forearm and the long axis of the humerus when the elbow is fully extended.

Persistent rotational deformity. A, Preoperative clinical appearance. Note the significant cubitus varus. B, Postoperatively, the carrying angle is improved. However, there is still a significant rotational deformity on the lateral aspect of the distal end of the humerus.

Problems arising from cubitus varus or valgus include functional limitation, recurrent elbow fracture, and cosmetic deformity. Fortunately, functional problems are uncommon with either deformity. In cubitus valgus, functional problems may be related to a coexisting flexion contracture or, in extreme cases, to tardy ulnar nerve symptoms. With cubitus varus, functional problems are almost always related to limitation of flexion, although tardy ulnar nerve palsy and elbow instability have also been reported as functional complications of varus deformity. The limitation in flexion is a result of the hyperextension associated with varus malunion. Usually the arc of elbow motion remains constant. Thus, varus-hyperextension malunion creates a flexion deficit. If significant, this flexion deficit can interfere with activities of daily living. Lateral condyle fractures, distal humeral epiphyseal separation, and shoulder instability have also been described as potential complications of varus malunion. Davids and colleagues have shown that the torsional moment and shear force generated across the capitellar physis by a routine fall are increased by varus malalignment. However, cosmetic deformity is the most common problem associated with malunion of supracondylar fractures.

Unfortunately, because of the limited growth and the fact that deformity is usually perpendicular to the plane of motion, little potential exists for angular malunion of the distal humerus to remodel, so the best treatment of malunion of a supracondylar humeral fracture is avoidance. Awareness of the pitfalls associated with obtaining and maintaining adequate reduction will aid the orthopaedist in minimizing the occurrence of malunion and degree of deformity when it does occur. Because cubitus valgus and varus are primarily cosmetic deformities, mild degrees of malunion can be treated by simple reassurance. However, if the deformity is severe, cosmetic concerns or, less commonly, functional limitations may warrant surgical reconstruction.

The resultant cubitus varus deformity is a combined deformity of varus, extension, and internal rotation to various degrees. Most corrective osteotomies have focused on the correction of varus and extension deformity. The rotational deformity is well tolerated and best left untreated because rotation of the distal fragment makes the osteotomy unstable. Some studies have cited few complications, but earlier reports noted complication rates between 30% and 50%. Parents should understand that surgical reconstruction is a technically demanding procedure intended primarily to improve cosmesis and to regain elbow flexion when limited. ^†i

†i References .

Loss of fixation and persistent deformity are the most common complications after corrective supracondylar osteotomy. ^‡i

‡i References .

In an effort to limit these complications, a wide variety of osteotomy and fixation techniques have been described. Osteotomy techniques include medial or lateral closing wedge, step-cut, and dome osteotomies. Fixation has been described with crossed pins, staples, screws, screws and tension wires, plates and pins, and external fixation. ^§i

§i References .

Davids and co-workers have reported good results from a translational step-cut osteotomy done through a posterior, triceps-splitting approach. Banerjee and associates reported similar results with a dome osteotomy using a triceps-sparing approach. In selecting which of these techniques to use, it is important to consider the patient and the individual deformity. Most patients have a complex three-dimensional deformity that includes a significant component of rotational malunion of the distal fragment. Hyperextension in the sagittal plane is also frequently present. In our experience, the distal rotational deformity is not correctable with any of the techniques described. The sagittal plane deformity may be easily corrected, whereas sagittal correction of an extension deformity adds complexity. We usually use a lateral closing wedge osteotomy with a single-plane varus correction or an added component of flexion when needed, fixed with crossed pins ( Fig. 33-64 ). Mild medial displacement may improve the prominence of the lateral condyle. This technique is usually performed through a lateral incision and has the advantage of being stable and technically simple. Parents should be told that some prominence of the lateral elbow may be expected ( Fig. 33-65 ).

Technique for lateral closing wedge osteotomy for correction of posttraumatic cubitus varus. A, Skin incision. It is helpful to have the uninjured arm exposed in the anatomic position for intraoperative comparison. B, The lateral distal aspect of the humerus is approached between the triceps and common extensor origin. Care must be taken to avoid injury to the radial nerve with proximal exposure. Osteotomy sites are planned parallel to the joint and perpendicular to the humeral shaft. C, Medial and lateral pins are introduced before performing the osteotomies. A lateral wedge of bone is then removed. An attempt is made to preserve the medial cortex. D, The osteotomy site is closed and the pins are advanced into the proximal fragment.

Example of lateral closing wedge osteotomy for cubitus varus. Varus malunion—anteroposterior ( A ) and lateral ( B ) radiographs and clinical appearance ( C ). D and E, Intraoperative radiographs obtained after lateral closing wedge osteotomy. (A medial pin and lateral plate were used rather than crossed pins.) Note the prominence of the lateral condyle. F and G, Radiographic appearance and clinical appearance ( H ) 4 years postoperatively. Significant remodeling has occurred, and the clinical appearance has improved.

We have also used a medial opening wedge osteotomy with external fixation and no bone graft ( Fig. 33-66 ). This technique affords a more cosmetic medial incision and fixation that is stable enough to allow sagittal plane correction. Another advantage of this technique is that the alignment can be manipulated after the wound is closed. We have found this procedure to be particularly helpful for patients with significant hyperextension deformity ( Fig. 33-67 ).

Technique for medial opening wedge osteotomy with external fixation. A, Skin incision. It is helpful to have the uninjured arm exposed in the anatomic position for intraoperative comparison. B, The ulnar nerve is dissected and transposed anteriorly. The medial humerus is exposed along the intermuscular septum. C, Pins are introduced proximally, perpendicular to the humeral shaft. Distally, the pins are placed parallel to the joint and extend to the level of the medial epicondyle. The osteotomy can be made parallel to either group of pins. D, After completion of the osteotomy, the deformity is corrected in both planes and the correction is secured with the external fixator. The pins are brought out through the wound. The ulnar nerve is transposed into the flexor origin. Care should be taken to ensure that the ulnar nerve does not contact the proximal pins.

Medial opening wedge osteotomy to correct cubitus varus. A and B, Preoperative radiographs showing varus malunion with hyperextension. C to E, Preoperative clinical appearance. Note the significant hyperextension component of the deformity. F and G, Immediate postoperative films showing the opening wedge osteotomy without a bone graft. The external fixator allows sagittal plane correction. H, Anteroposterior and lateral ( I ) radiographs obtained 1 year postoperatively. Significant remodeling has occurred. J to L, Clinical appearance 1 year postoperatively.

Elbow Stiffness and Myositis Ossificans

These complications of supracondylar humeral fractures occur rarely. ^‖i

‖i References .

We usually assess elbow ROM 6 to 8 weeks after the cast has been removed. It is extremely unusual to identify more than a 10- to 15-degree difference in flexion or extension at this point. However, if significant stiffness is present, we begin a supervised home program of gentle ROM exercises and continue to monitor the patient’s progress on a monthly basis. Mild stiffness generally resolves with a few months of gentle therapy, although some patients need more intensive therapy, including a splinting program. Persistent stiffness requiring surgical release is extremely uncommon. Mih and associates reported an average 53-degree increase in ROM in nine pediatric patients who underwent capsular release through a lateral and, if necessary, medial approach.

Myositis ossificans is an extremely unusual complication. This has been found to resolve spontaneously over a period of 1 to 2 years ( Fig. 33-68 ).

Myositis ossificans after a type III supracondylar humeral fracture. A, Lateral radiograph obtained 3 months after injury. Note the significant calcification in the anterior soft tissues ( arrow ). B, The myositis has resolved without treatment 3 years after injury.

Anatomy

The anatomic considerations for distal humeral transphyseal fractures are the same as those for supracondylar fractures of the distal humerus. The young age and consequently small anatomy of the children who typically sustain these injuries may make diagnosis and treatment difficult. Interestingly, although transphyseal fractures share the same important anatomic considerations as supracondylar fractures, neurovascular complications are rarely reported with this type of injury.

Mechanism of Injury

The mechanism of injury depends on the age of the patient. In newborns and infants, there is usually a rotatory or shear force associated with birth trauma or child abuse. ^¶i

¶i References .

Classification

Although classification schemes for transphyseal separations exist, they are not clinically necessary. DeLee and colleagues separated transphyseal fractures into three groups based on their radiographic appearance. Their criteria included the presence or absence of the secondary ossification center of the radial head and the presence and size of the metaphyseal fragment (Thurston-Holland sign). These radiographic parameters correspond to the age of the patient but add little to clinical management. These fractures may also be classified according to the Salter-Harris classification of physeal injuries. In infants these injuries are usually Salter-Harris type I fractures. In older children they are usually type II injuries.

Diagnosis

The most difficult aspect of the diagnosis is distinguishing a transphyseal fracture from an elbow dislocation. Other injuries in the differential include lateral condylar and supracondylar fractures. The key to distinguishing transphyseal separation from true elbow dislocation is the radial head–capitellum relationship. In an elbow dislocation, the radial head does not articulate with the capitellum; however, in a transphyseal fracture, the radial head and capitellum remain congruous ( Fig. 33-69, A ). In a very young patient the capitellum may not be ossified, which makes this distinction difficult if not impossible. In such cases, the correct diagnosis can be made with a high degree of suspicion and the knowledge that physeal separations are more common than elbow dislocations in this age group. It may also be difficult to distinguish transphyseal separations from lateral condyle fractures that extend medial to the trochlear notch and consequently produce subluxation of the ulnohumeral joint (Milch type II fractures; see Fig. 33-40 ). In both these injuries, the radial head–capitellum relationship remains normal. Although oblique radiographs may assist in delineating these details, the distinction may require evaluation with arthrography or MRI in a small child with little ossification of the distal humeral epiphysis. Supracondylar fractures usually occur at the level of the olecranon fossa, whereas transphyseal separations are more distal (see Fig. 33-40 ).

A, Anteroposterior (AP) radiograph of transphyseal separation of the distal end of the humerus. The medial translation of the forearm gives the appearance of an elbow dislocation; however, the radius and capitellum remain congruent. B, Lateral radiograph of transphyseal separation. Note the small, posteriorly based metaphyseal (Thurston-Holland) fragment ( arrow ). The patient was treated by closed reduction and cast immobilization. C, AP radiograph 3 years after injury shows varus malunion. D, Clinical appearance 3 years after the injury.

Radiographic Findings

As with supracondylar fractures, obtaining good-quality radiographs of transphyseal separations is imperative but often difficult. Even under the best of circumstances, further evaluation may be required. Ultrasound, MRI, and arthrography have all been used in the evaluation of transphyseal separations. ^#i

#i References .

Treatment

The goal of treatment of transphyseal fractures is to achieve acceptable reduction and maintain it until the fracture unites, usually in 2 to 3 weeks. Some have advocated simple splint immobilization for transphyseal separations but a number of investigators, including some of those who advocate cast treatment, have reported cubitus varus after simple immobilization of transphyseal fractures. DeLee and associates noted that 3 of 12 patients, all younger than 2 years, had significant varus after closed treatment. Abe and colleagues noted varus in 15 of 21 patients, and Holda and co-workers in 5 of 7. Our experience has paralleled that of those who reported significant cubitus varus after cast immobilization, particularly in patients younger than 2 years (see Fig. 33-69 ). Consequently, we favor closed reduction and pin fixation for most patients with transphyseal separations. The technique for reduction and pinning is identical to that for supracondylar fractures (see Fig. 33-49 ). We have found arthrography helpful for delineating the pathology, and we do not hesitate to perform arthrography after pin fixation or, if necessary for diagnostic purposes, before reduction and pinning ( Fig. 33-70 ). After reduction and pinning, the arm is immobilized in relative extension for 2 to 3 weeks, at which time the cast and pins are discontinued.

A, Anteroposterior radiograph of transphyseal separation of the distal end of the humerus. The radius and capitellum remain congruent despite medial translation of the forearm. B, Arthrogram obtained after an initial attempt at closed reduction and pinning. Note the varus alignment of the joint surface ( open arrows ) and the dye spreading laterally between the metaphysis and distal fragment ( arrowhead ). C, Arthrogram obtained after remanipulation. The joint surface is now anatomically reduced ( arrows ).

Complications

In older children the mechanism of transphyseal separation is the same as for supracondylar fractures. Not surprisingly, the potential complications are similar, although neurovascular injuries are less common. In infants, this injury is usually the result of a rotatory or shear force applied by an adult. Thus the most devastating potential complication of transphyseal separation is failure to recognize the possibility of child abuse and to return a child to a dangerous environment. The re-injury rate of abused children is between 30% and 50%, and the risk of death is 5% to 10%.

The most significant and frequent orthopaedic complication of transphyseal separation is cubitus varus. The treatment of varus deformity after a transphyseal fracture is similar to that after a supracondylar fracture (see earlier, “ Supracondylar Fractures of the Humerus ”). Deformity secondary to avascular necrosis (AVN) has also been reported after transphyseal separation.

Anatomy

The pertinent anatomic considerations in lateral condyle fractures include the capitellum, lateral epicondyle, and soft tissues attached to it—namely, the extensors and supinator. The capitellum is the first secondary ossification center of the elbow to appear, usually around 2 years of age. The lateral epicondyle is the last, often not appearing until 12 or 13 years of age (see Fig. 33-29 ). The two ossification centers fuse at skeletal maturity. Fractures of the lateral humeral condyle originate proximally at the posterior aspect of the distal humeral metaphysis and extend distally and anteriorly across the physis and epiphysis into the elbow joint. The fracture line may extend through the ossification center of the capitellum or may continue more medially and enter the joint medial to the trochlear groove. If the fracture extends medially to the trochlear groove, the elbow may be unstable and dislocate.

Mechanism of Injury

Lateral condylar fractures are generally the result of a fall on an outstretched arm. The fall may produce a varus stress that avulses the lateral condyle or a valgus force in which the radial head directly pushes off the lateral condyle.

Classification

There are several schemes for classifying lateral condyle fractures. The best known is the one described by Milch. A Milch type I fracture extends through the secondary ossification center of the capitellum and enters the joint lateral to the trochlear groove. A Milch type II fracture extends farther medially, with the trochlea remaining with the lateral fragment, thus making the ulnohumeral joint unstable ( Fig. 33-71 ). Unfortunately, although widely known and frequently used, the Milch classification provides little prognostic information regarding treatment and potential complications.

Milch’s classification of lateral condyle fractures. A, Type I, the fracture extends through the secondary ossification center of the capitellum. B, Type II, the fracture crosses the epiphysis and enters the joint medial to the trochlear groove. Thus the ulnohumeral joint is potentially unstable. C, Anteroposterior (AP) radiograph of a Milch type I fracture. Note that the fracture extends through the secondary ossification center of the capitellum ( arrowheads ). D, AP radiograph of a Milch type II fracture of the lateral condyle. The medial displacement of the forearm gives the appearance of an elbow dislocation or a transphyseal fracture. Close examination reveals the radius to be grossly in line with the capitellum. However, the capitular articular surface is subtly rotated ( arrow ).

Lateral condyle fractures involve the physis of the distal humerus and therefore can also be classified according to the Salter-Harris classification. Some controversy exists regarding the appropriate Salter-Harris classification of lateral condyle fractures. We and Salter and Harris believe that all these fractures begin in the metaphysis, cross the physis, and exit through the epiphysis and should be classified as type IV injuries. However, others have classified the Milch type II fracture as a Salter-Harris II injury, arguing that the secondary ossification center of the epiphysis is not involved. We believe that the intraarticular transphyseal nature of these fractures mandates that they be treated as Salter-Harris type IV injuries, with restoration of the articular surface. Regardless, because growth arrest is relatively uncommon after this injury, the Salter-Harris classification also adds little useful clinical information.

Unfortunately the classification that provides the most useful information is not clinically viable. In a cadaver study, Jakob and colleagues reproduced lateral condyle fractures and discovered that the lateral fragment was occasionally hinged on intact medial cartilage. This explains the clinical behavior of lateral condyle fractures. Minimally displaced fractures with an intact medial hinge do not displace further and heal with simple immobilization. However, if the fracture extends completely into the joint, the fracture is at risk for late displacement and potentially nonunion ( Fig. 33-72 ). Thus the presence or absence of the medial hinge is the key diagnostic factor in lateral condyle fractures. Although a few studies have attempted to identify this hinge and classify lateral condyle fractures accordingly, to date there is no accepted, reproducible, clinically viable method to obtain this information. * ^j

Classification of lateral condyle fractures based on the presence of an intact articular hinge. Type A, the fracture extends through the metaphysis and physis, but a portion of the articular cartilage remains intact. These fractures are stable, will not displace, and heal with immobilization. Type B, the fracture extends completely through the articular surface. Radiographically, this fracture may be impossible to distinguish from the type A fracture. However, it is potentially unstable and at risk for late displacement and delayed union or nonunion. Type C, grossly displaced lateral condylar fragment (may be significantly rotated).

References .

Finally, lateral condyle fractures may be classified as nondisplaced (traditionally, <2 mm), minimally displaced (traditionally, 2 to 4 mm), or displaced (traditionally, >4 mm). ^†j

†j References .

Diagnosis

As with all elbow injuries, the diagnosis of lateral condyle fracture may be obvious or frustratingly subtle. A child with a minimally displaced fracture may have complaints of pain and decreased ROM. The differential diagnosis in these patients includes transphyseal fractures, minimally displaced supracondylar or radial neck fractures, nursemaid’s elbow, and infection. Close examination, which is often not possible in a child with a grossly displaced fracture, may reveal isolated lateral tenderness. A careful history should be elicited to ensure a clear, immediate, traumatic onset of the pain because a history of minor trauma is frequently associated with a delay in the diagnosis of an infectious process. Radiographically, it is often difficult to distinguish between transphyseal fractures and lateral condyle fractures. Both may have a posteriorly based Thurston-Holland fragment on the lateral radiograph ( Fig. 33-73 ; also see Fig. 33-69 ). The distinction is made by examining the AP radiograph (see Fig. 33-40 ). In transphyseal fractures, the radial head–capitellum relationship remains intact. In displaced lateral condyle fractures, the capitellum is laterally displaced in relation to the radial head. Also, transphyseal fractures are more likely to exhibit posteromedial displacement, and lateral condyle fractures are more likely to exhibit posterolateral displacement.

A, Lateral radiograph of a minimally displaced lateral condyle fracture. The small, posteriorly displaced metaphyseal fragment ( arrow ) is often difficult to see. B, Anteroposterior radiograph demonstrating the fracture line ( arrowheads ) running parallel to the physis. The fracture extends across the physis into the joint.

Radiographic Findings

The hallmark radiographic finding is a posteriorly based Thurston-Holland fragment in the lateral view (see Fig. 33-73, A ). In minimally displaced fractures, the AP radiograph may show little abnormality, although the fracture line may be seen running parallel to the physis (see Fig. 33-73, B ). Oblique radiographs or arthrograms are often helpful for identifying minimally displaced fractures. Sonography, CT, and MRI have been used to help identify which fractures are at risk for late displacement, but these techniques have not reached widespread clinical acceptance.

Treatment

Treatment of lateral condyle fractures depends on the amount of fracture displacement. The difficulty lies in differentiating stable nondisplaced fractures from potentially unstable, minimally displaced fractures. Unfortunately, there are currently no clinically applicable means of assessing the stability of the medial cartilaginous hinge. However, a careful clinical and radiographic examination may offer important information regarding the stability of fractures that appear to be minimally displaced radiographically. Oblique views are often helpful for assessing and monitoring nondisplaced or minimally displaced fractures. Fracture displacement often appears greater on oblique radiographs. We and others believe that classification as a nondisplaced fracture requires an oblique radiograph indicating less than 2 mm of displacement. Significant lateral soft tissue swelling identified radiographically or clinically should alert the surgeon to a potentially unstable fracture. The presence of lateral ecchymosis implies a tear in the aponeurosis of the brachioradialis and signals an unstable fracture, regardless of the radiographic appearance ( Fig. 33-74 ). Similarly, palpable crepitus between fragments signals an unstable fracture, irrespective of the radiographic appearance.

A, Anteroposterior radiograph of a minimally displaced lateral condyle fracture ( arrowhead ). However, significant soft tissue swelling occurs laterally ( arrows ), as well as an olecranon fracture ( open arrow ). Despite the minimally displaced radiographic appearance, this is an unstable lateral condyle fracture. B, Clinical photograph showing a large lateral ecchymosis associated with this unstable fracture.

Displaced Fractures

Although there is controversy regarding the treatment of nondisplaced and minimally displaced fractures, there is a consensus that displaced lateral condyle fractures require open reduction and fixation ( Fig. 33-75 ). Even though open reduction is usually performed through an anterolateral approach, a posterolateral approach has also been described. Because the blood supply of the lateral humeral condyle arises from the posterior soft tissues of the distal fragment, it is important that there be minimal dissection of the posterior soft tissues; thus we prefer the anterolateral approach. Occasionally, there is plastic deformation of the distal fragment, so it is important to judge the reduction at the apex of the articular surface rather than by the lateral metaphyseal fragment. Fixation is generally achieved with smooth percutaneous pins, although screws and bioabsorbable pins have been used ( Fig. 33-76 ). A biomechanical study on a bone model has shown that greater divergence, approximately 60 degrees, gives better stability compared with more parallel pins. Three pins gave added stability and were recommended if two gave inadequate fixation. Li and Xu compared pin fixation with screw fixation, noting a 17% incidence of pin infection and 30% incidence of lack of elbow extension compared with no such complications in the screw fixation group. The latter required a second procedure for implant removal. Patients are usually immobilized with the elbow at 90 degrees for 4 weeks postoperatively.

Technique for open reduction and fixation of a lateral condyle fracture. A, A sterile tourniquet is applied and an oblique posterolateral skin incision is made. B, Superficial dissection is carried out in the plane of the fracture hematoma until the distal lateral corner of the proximal fragment is identified. C, Once the metaphyseal side of the fracture has been identified, the dissection is carried across the joint to expose the medial articular surface. After exposure of the proximal fragment, the orientation of the distal fragment is defined and the soft tissues are sharply released off the anterior aspect of the distal fragment, with extension carried distally to the radial head. D, After irrigation and débridement of the fracture hematoma, the distal fragment is reduced with a towel clip. It is important to judge the reduction at the level of the articular surface rather than the metaphysis because plastic deformation or comminution of the metaphyseal fragment may be present. E, Pins (usually 0.062 inch) are placed percutaneously to secure the fracture.

A, Anteroposterior and lateral ( B ) radiographs demonstrating the technique of percutaneous pin fixation of lateral condyle fractures. The pins are widely divergent at the fracture line to provide maximum rotational stability.

Minimally Displaced Fractures

Management of minimally displaced lateral condyle fractures is more controversial. ^‡j

‡j References .

A number of authors have reported good results with conservative treatment. However, they all stressed the possibility of late displacement and, consequently, potential delayed union or nonunion ( Fig. 33-77 ). A report by Devito and colleagues stressed the feasibility of cast immobilization. Of 125 fractures, 82 had a fracture gap of 4 mm or less and were initially treated with a closed technique. Of these 82 fractures, 9 demonstrated late displacement, but only 2 required surgical treatment.

Radiographic example of a minimally displaced fracture that is displacing with cast immobilization. A, Anteroposterior radiograph at the time of injury showing a minimally displaced lateral condyle fracture ( arrow ). B, Significant displacement of the fracture ( arrow ) had occurred 1 week after injury. Cast immobilization was continued. C, Delayed union had developed 2 months after injury. D, The delayed union was treated by open reduction and stabilization. Note that the fracture was not reduced anatomically but was pinned in a position to provide maximal metaphyseal contact. E, The fracture has healed 6 years postoperatively, with minimal fishtail deformity of the distal humerus.

Others have advocated percutaneous fixation of minimally displaced lateral condyle fractures. Mintzer and colleagues reported good results in 12 patients who had more than 2 mm of displacement and were treated by closed reduction and percutaneous pinning. They recommended arthrography to confirm a reduced articular surface. We believe that treatment decisions for minimally displaced lateral condyle fractures must be made on an individual basis, and we use all three treatment techniques—casting, percutaneous fixation, and open reduction. Parents must thoroughly understand the importance of close follow-up if these fractures are to be treated conservatively. We have a low threshold for examination of these fractures under anesthesia with arthrography if necessary.

Complications

The most common complications after lateral condyle fractures include cubitus varus, lateral spur formation, delayed union, and nonunion with or without cubitus valgus. Growth arrest and fishtail deformity of the distal humerus can also occur but are rarely found to be clinical problems. Stiffness is common at the end of immobilization. One study showed that the relative arc of motion at cast removal was 44%, reaching 84% by week 12. By 24 weeks, 90% of motion had returned and full motion was present at 48 weeks, regardless of the type of treatment.

Cubitus Varus and Lateral Spur Formation

Cubitus varus is the usually reported complication after lateral condyle fractures; it occurred in 40% of patients in one series. The high incidence of cubitus varus is probably the result of the fact that true cubitus varus and lateral spur formation, which gives the appearance of varus deformity, are often reported as cubitus varus. Cubitus varus and lateral spur formation are multifactorial in origin. True cubitus varus may be the result of malunion, growth arrest, or growth stimulation of the lateral condylar physis, or a combination of factors. Lateral spur formation occurs in lateral condyle fractures treated with operative or nonoperative techniques ( Fig. 33-78 ). It is probably a result of slight displacement of the metaphyseal fragment in addition to disruption of the periosteal envelope. Apparent lateral condylar overgrowth has been noted in up to 77% of displaced fractures, regardless of treatment method.

Anteroposterior radiograph demonstrating lateral spur formation ( arrowhead ) after operative treatment of a displaced lateral condyle fracture. The prominent lateral spur creates the clinical appearance of mild cubitus varus.

Cubitus varus after lateral condylar fractures is rarely as severe as that after supracondylar fractures; usually it is only a coronal plane deformity and does not have the hyperextension and rotatory deformity present with supracondylar malunion. Because it is generally mild and asymptomatic, cubitus varus after lateral condylar fracture rarely requires treatment. Occasionally a progressive deformity, particularly if involving growth arrest, requires treatment. However, this common but mild complication can usually be treated simply by forewarning the parents at the time of initial treatment that their child may have a prominence on the lateral aspect of the elbow after the fracture has healed.

Delayed Union and Nonunion

Without question, the most frequent problematic complication of lateral condyle fractures is delayed union or nonunion. Several factors contribute to the difficulty in achieving union of lateral condyle fractures. First, the fracture is intraarticular and thus is constantly exposed to synovial fluid. Second, the lateral condyle has a poor blood supply. Finally, if not immobilized, there is constant motion at the fracture site from the pull of the wrist extensors on the distal fragment.

Fractures With Delayed Union.

We use the term delayed union to refer to a minimally displaced fracture that does not heal with 6 weeks of immobilization or an untreated fracture that is initially seen more than 2 weeks (but by convention less than 3 months) after the injury. If a conservatively treated fracture appears stable, with no progressive displacement, healing usually occurs without further intervention; however, persistent nonunion occasionally develops. Thus, it is important to observe these fractures until radiographic union has been achieved. If healing does not occur or if progressive displacement develops (see Fig. 33-77 ), we recommend surgical treatment. Generally union can be achieved simply by stabilizing the distal fragment with a screw through the metaphyseal fragment. We do not attempt to restore the articular surface anatomically, and bone grafting is not typically required. The surgical approach to delayed union or nonunion is the same as the surgical approach to an acute fracture (see Fig. 33-75 ). Care must be taken to ensure that all soft tissue dissection occurs anteriorly to avoid the blood supply of the distal fragment.

Late-Presenting Fractures.

Management of late-presenting fractures is controversial. Some have reported better results in patients treated with observation rather than delayed open reduction. However, a number of authors have reported good results with the surgical treatment of late-presenting (2 to 12 weeks) fractures, as well as established nonunion. ^§j

§j References .

Although Flynn initially recommended surgical treatment for late-presenting fractures that were in good position and had an open growth plate, others have described good results in skeletally mature patients with more displaced fractures. All warned of the potential for stiffness, osteonecrosis, and fishtail deformity if surgical treatment is undertaken. ^‖j

‖j References .

However, we favor surgical treatment of these fractures ( Fig. 33-79 ).

Treatment of a lateral condyle fracture initially seen 5 weeks after injury. A, An anteroposterior (AP) radiograph obtained at initial evaluation showed a displaced lateral condyle fracture ( arrow ). B, Open reduction with internal fixation was performed. Note that the fracture was not reduced anatomically but was placed in a position to maximize metaphyseal contact. A screw was used through the metaphyseal fragment because delayed healing was anticipated. A percutaneous pin provided initial rotational stability. C, AP radiograph obtained 18 months after treatment.

Nonunited Fractures.

We use the term nonunion to refer to a fracture that has not healed within 3 months. Clinically, nonunion can be manifested as one of three scenarios. ^¶j

¶j References .

The first is as a painful nonunion, which is the least common. The pain is usually related to activity. Older patients may have a feeling of lateral instability and apprehension. We manage these patients with an attempt at osteosynthesis. The goal of surgical treatment is to obtain union of the metaphyseal fragment, not restore the joint surface. Bone grafting may be required, and the posterior soft tissues must be avoided ( Fig. 33-80 ). The second manifestation of delayed union is a cosmetically unacceptable valgus deformity. These patients generally have an associated flexion contracture and can be managed with a corrective osteotomy, with or without attempts to achieve healing of the nonunion. Finally, delayed union may be manifested as cubitus valgus and a tardy ulnar nerve palsy. These patients should be managed by ulnar nerve transposition ( Fig. 33-81 ).

Symptomatic lateral condyle nonunion. A, Anteroposterior radiograph showing established nonunion of the lateral condyle. The patient had elbow pain with vigorous use of the extremity. B, Surgical treatment was directed toward achieving union of the distal fragment to the metaphysis. Articular congruity was not restored. C, The fracture has united 6 years postoperatively. A fishtail deformity is present ( arrow ).

Lateral condyle nonunion producing cubitus valgus and tardy ulnar nerve symptoms. A, Anteroposterior radiograph showing established nonunion of a lateral condyle fracture. B, Clinical appearance of cubitus valgus. The patient was treated by ulnar nerve transposition.

Fishtail Deformity and Avascular Necrosis

The cause of fishtail deformity of the distal humerus is uncertain. Rutherford noted this deformity in 9 of 10 patients who had unreduced lateral condyle fractures and hypothesized that malunion at the medial extent of the fracture results in growth arrest of the lateral trochlea. However, Morrissey and Wilkins noted it after a variety of fractures of the distal humerus and attributed it to AVN. In all likelihood, both causes are responsible. Mild deformity after lateral condyle fractures may occur more frequently than reported and is probably related to growth arrest. More severe deformities are most likely the result of vascular changes, often associated with surgical approaches to the elbow ( Fig. 33-82 ).

Anteroposterior radiograph showing a mild fishtail deformity in the distal end of the humerus after uncomplicated treatment of a lateral condyle fracture (also see the fishtail deformities in Fig. 33-80 ).

Anatomy

The ossification center of the medial epicondyle of the humerus appears between 5 and 7 years of age and unites with the humeral diaphysis between 18 and 20 years of age. The common tendon of the flexor muscles of the forearm and ulnar collateral ligament of the elbow insert on the medial epicondyle. The ulnar nerve runs in a groove in the posterior aspect of this epicondyle. The medial epicondyle is an apophysis and does not contribute to longitudinal growth of the humerus.

Mechanism of Injury

The mechanism of injury is a valgus stress producing traction on the medial epicondyle through the flexor muscles. The epicondyle may be minimally or severely displaced. If associated with an elbow dislocation, the fragment may become incarcerated in the joint at the time of dislocation or reduction. ^†k

†k References .

Classification

Unfortunately, no widely accepted classification of medial epicondyle fractures has been presented, and most investigators have described unique systems based on what they consider critical information. All the established classification systems consider whether the fracture is displaced or nondisplaced but there is no agreement on what constitutes a displaced fracture.

The important factors in prognosis and treatment include the amount of displacement (we use a threshold of 5 mm of displacement), presence of associated elbow injuries or fragment incarceration, and desired athletic endeavors of the patient.

Diagnosis

The physical findings depend on the degree of displacement of the medial epicondyle. Generally the elbow is held in flexion and any motion is painful. There is tenderness over the medial epicondyle that is exacerbated with valgus stress. Ulnar nerve paresis or dysesthesias may be present.

Radiographic Findings

In older patients (>6 to 7 years), the medial epicondylar fragment is usually easily identified radiographically. However, radiographic interpretation in younger patients may be difficult if the secondary ossification center is not yet ossified. One study has shown low interobserver agreement about the degree of displacement of these fractures. In either case, assessment of minimally displaced fractures may be facilitated by comparison views to establish the normal width of the cartilaginous space between the metaphysis and medial epicondyle. Fragments trapped in the joint may be difficult to identify, particularly in younger patients with minimal ossification. Although medial joint space widening may be present on the AP radiograph, a nonconcentrically reduced ulnohumeral joint on the lateral radiograph is often the only radiographic finding. Thus whenever a medial epicondyle fracture is suspected, it is imperative that a true lateral radiograph of the elbow be obtained. The inability to obtain a true lateral radiograph should raise suspicion of an entrapped medial epicondyle fragment ( Fig. 33-83 ).

Entrapped medial epicondylar fracture in an 11-year-old girl. A, Anteroposterior radiograph obtained at the time of injury. The expected secondary ossification center at the medial epicondyle was not present. B, A lateral radiograph obtained at the time of injury was misinterpreted as normal. Note that the ulnohumeral joint is nonconcentrically reduced ( arrowheads ). The entrapped medial epicondyle is superimposed over the olecranon ( arrow ). C, A CT scan obtained 5 weeks after injury demonstrates an entrapped osteocartilaginous fragment in the medial joint line. ant, Anterior; H, humerus; med, medial.

Several authors have advocated an AP valgus stress radiograph for the assessment of stability after medial epicondyle fracture. This radiograph is obtained with the patient supine, the arm abducted 90 degrees, the shoulder externally rotated 90 degrees, and the elbow flexed at least 15 degrees to eliminate the stabilizing force of the olecranon. In this position gravity will create widening on the medial side of an unstable elbow. Because sedation is generally required, we have found this radiograph to be of little clinical use.

Treatment

Displaced Fractures

Treatment of displaced (>5 mm) medial epicondyle fractures is more controversial. Although a number of studies have reported superior results with closed treatment, these series all included a few patients in whom symptomatic nonunion developed. Accepted operative indications include open fractures, gross elbow instability, and fragments incarcerated in the joint. Some have reported excellent results with open reduction and internal fixation of medial epicondyle fractures. However, there have also been reports of stiffness and nonunion after operative treatment. Farsetti and co-workers reviewed 42 patients at an average follow-up of 45 years and found that closed management produced good results in all patients, despite failure of the epicondyle to unite. Those treated by open reduction had mostly good results, whereas those who underwent excision of the epicondyle did poorly. Their study strongly supported closed management of this injury. Woods and Tullos have expressed concern that symptomatic treatment of displaced fractures in a high-demand, overhead athlete may lead to symptomatic valgus instability because of functional lengthening of the ulnar collateral ligament. Because such late instability can be difficult to treat, they advocated open reduction and internal fixation of medial epicondyle fractures in serious overhead athletes. Unfortunately, it is often difficult to predict whether a young patient with a displaced medial epicondyle fracture will develop into an overhead athlete.

We have had good results with operative and conservative treatment of displaced medial epicondyle fractures. We treat these injuries on an individual basis after a thorough discussion with the parents. Although some have described closed reduction and percutaneous pinning for displaced fractures, we favor open reduction to ensure that the ulnar nerve is not damaged. Open reduction is performed through a medial longitudinal skin incision. The ulnar nerve is identified, dissected free, and retracted posteriorly. The fractured medial epicondyle is identified and is anatomically repositioned with a towel clip. We favor fixation with a partially threaded screw, often using a cannulated system to achieve temporary fixation ( Fig. 33-84 ). Care must be taken in young patients to prevent comminution of the predominantly cartilaginous distal fragment during fixation. After open reduction we immobilize the elbow in flexion for 1 to 3 weeks, after which active range-of-motion exercises are initiated. We occasionally splint the wrist for an additional 3 to 4 weeks after cast removal to prevent active contraction of the flexor muscle mass, which might displace the distal fragment.

A, Displaced medial epicondyle fracture in a 14-year-old Little League pitcher. The injury was sustained during pitching. B, Anteroposterior radiograph obtained after open reduction and fixation of the medial epicondyle fragment.

Complications

Complications from medial epicondyle fractures include stiffness, ulnar neuritis, missed incarceration, radial nerve injury, and symptomatic nonunion. Stiffness is the most common complication and is best prevented by avoiding prolonged immobilization. It is important to remember that the soft tissue injury is usually much more significant than the radiographic abnormality. We favor a brief period of immobilization (no more than 3 weeks), followed by early active range-of-motion exercises. Aggressive physical or occupational therapy should be avoided in the early (initial 6 weeks) phase because it has been shown to lead to increased stiffness. The incidence of ulnar nerve dysfunction varies from 10% to 16%. If the fragment is entrapped in the joint, the incidence of ulnar nerve dysfunction may be as high as 50%.

Traditionally, surgical treatment of late-identified entrapped fragments has been avoided. However, recent studies have shown good results with late extraction of incarcerated fragments. Fowles and associates reported improved range of motion (80% normal), decreased pain, and improved ulnar nerve symptoms in six patients treated by surgical extraction an average of 14 weeks after injury. Somewhat surprisingly, there are also long-term follow-up reports showing good results with persistently retained fragments.

Symptomatic nonunion in a high-performance athlete is difficult to treat. Wilkins and associates reported the case of a high-performance adolescent baseball pitcher who had to stop pitching after nonoperative management of a medial epicondyle fracture. We have had some success in establishing union in symptomatic patients. Our approach is to stabilize the fragment with in situ fixation and a local bone graft. We do not attempt to mobilize the fragment and reduce it anatomically. Others have advocated simple excision of the symptomatic nonunion with reattachment of the ulnar collateral ligament. We do not have experience with this technique and prefer an initial attempt at establishing union.

Anatomy

The anatomic constraints to posterior dislocation include the anterior capsule, the coronoid process (which resists posterior displacement of the ulna), and the collateral ligaments. During posterior elbow dislocation the momentum of the body applied to the lower end of the humerus tears the joint capsule anteriorly. The relatively small coronoid is unable to prevent proximal and posterior displacement of the ulna. The collateral ligaments are stretched or ruptured. The radius and ulna, being firmly bound by the annular ligament and interosseous membrane, are displaced together. The coronoid becomes locked in the olecranon fossa by contraction of the biceps and triceps. In posterolateral dislocations, the biceps tendon serves as a fulcrum about which the distal fragment (the forearm) rotates laterally. The normal cubitus valgus of the elbow also promotes lateral displacement. If only one collateral ligament is torn, one of the forearm bones will dislocate while the other undergoes rotatory subluxation.

With posterior and posterior lateral dislocations, the ulnar collateral ligament and medial epicondyle may be avulsed. After reduction, the medial epicondyle may remain incarcerated within the joint (see discussion under Medial Epicondyle Fractures ). With posteromedial dislocation, fracture of the lateral condyle may occur. Injury to the radial head or neck is another frequent finding with posterior elbow dislocations.

The neurovascular anatomy of the arm plays an important role in the potential complications that may develop after elbow dislocations (see Fig. 33-33 ). As with supracondylar fractures, the brachial artery and median nerve lie anterior to the humerus and may be injured when stretched over the displaced proximal fragment. The ulnar nerve lies immediately posterior to the medial epicondyle and is particularly at risk with dislocations associated with medial epicondyle fractures. ^‡k

‡k References .

Mechanism of Injury

Elbow dislocations are usually the result of a fall on an outstretched arm. The direction of displacement varies according to the direction of the force. The most frequent elbow dislocation is posterior or posterolateral and is usually the result of a fall with the forearm supinated and the elbow extended or partially flexed ( Fig. 33-85 ). Though less common, anterior, medial, lateral, and divergent dislocations can occur. Anterior dislocations are caused by a direct blow to or fall on the olecranon process. Medial or lateral dislocations usually result from direct trauma, violent twisting of the forearm, or falls on the hand. In divergent dislocations, which are extremely rare, the radius and ulna are dissociated from each other proximally and dislocated from the humerus. ^§k

Elbow dislocations are generally the result of a fall onto a supinated forearm with the elbow in flexion or extension.

§k References .

Diagnosis

Immediately after the injury, the patient has a painful and swollen elbow that is held in flexion. Attempts at motion are painful and restricted. From the anterior view the forearm appears to be shortened, whereas from the posterior view the upper part of the arm appears to be decreased in length. The distal humerus creates a fullness within the antecubital fossa.

The differential diagnosis includes transphyseal fractures, supracondylar fractures, Milch type II lateral condylar fractures, and Monteggia fractures (see Fig. 33-40 ). Very rare entities include divergent dislocations (distal humerus inserted between the proximal radius and ulna), and convergent dislocation (posterior dislocation of the elbow with proximal radioulnar translocation).

An accurate diagnosis can be made by assessing good-quality AP and lateral radiographs. The relationship of the radius to the ulna should be analyzed to rule out a divergent dislocation. Radiographs should also be scrutinized to identify any associated fractures, with particular attention to the medial epicondyle, coronoid process, proximal radius, and lateral condyle. Elbow dislocations are classified according to the displacement of the distal fragment.

Treatment

Thorough examination of the skin and assessment of the vascular and neurologic status of the extremity are imperative because neurovascular injuries are not uncommon. ^‖k

‖k References .

Technique for closed reduction of posterior elbow dislocation. A, The elbow is hyperextended to disengage the coronoid from the olecranon fossa. B, Traction is applied to restore length and correct the carrying angle. C, The elbow is then reduced with posterior displacement of the distal end of the humerus and flexion of the elbow.

Anterior dislocation is a very rare injury. Linscheid and Wheeler reported two cases of anterior dislocation out of 110 elbow dislocations. Anterior dislocations are associated with extensive soft tissue damage and often fracture of the olecranon or the proximal ulna. Reduction is accomplished by longitudinal traction with the elbow in flexion and firm pressure applied distally and posteriorly on the forearm as the elbow is gradually extended. Reduction of the rare medial or lateral dislocation of the elbow follows the principles outlined for the treatment of posterior dislocation, that is, traction, correction of coronal plane deformity, and flexion.

After successful closed reduction, good-quality radiographs must be obtained, including a perfect lateral view to ensure that there are no entrapped intraarticular fragments. We immobilize the extremity in a posterior splint. Because compartment syndrome has been reported after elbow dislocation, we recommend admission to the hospital for overnight observation after reduction. The splint is continued for 1 to 2 weeks. Once the splint is removed, active range of motion is encouraged. We reassess the range of motion 6 to 8 weeks after injury. If there is significant stiffness at this time, formal physical or occupational therapy can be initiated. We avoid earlier (<6 weeks after injury) passive range of motion because it has been associated with increased stiffness. Aggressive range-of-motion exercises are never indicated.

When associated with a fracture, the dislocation should be reduced and the fracture reassessed and managed appropriately according to findings on the postreduction radiographs. Late-identified dislocations generally require open reduction.

Complications

Stiffness is the most common complication after elbow dislocation. Other complications include vascular injury, peripheral nerve injury, myositis ossificans, and recurrent dislocation. ^¶k

¶k References .

Both heterotopic bone formation and myositis ossificans have been reported after elbow dislocation. Limited amounts of heterotopic bone commonly form along the course of the collateral ligaments. Myositis ossificans may occur within the brachialis muscle. A delay in the initial reduction and vigorous passive stretching exercises after cast removal have been reported to lead to myositis ossificans. Rest, gentle active range-of-motion exercises, and antiinflammatory medications such as indomethacin (Indocin) or naproxen (Naprosyn) are recommended during the active phase of myositis ossificans. Myositis may spontaneously resolve over time (see Fig. 33-68 ).

Vascular injury is uncommon with elbow dislocation. It is usually seen with open injuries. ^#k

#k References .

References .

Median nerve injury may occur in one of three ways ( Fig. 33-87 ). ^†l

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