Pediatric Elbow Fracture

Etiology: Trauma
Imaging Radiograph:
— 60% are supracondylar, 15% are lateral epicondyle, 10% are medial epicondyle, radial neck, occult
— Elbow ossification (CRITOE 1,5,7,10,10,11) – Capitellum – 1 year, Radial head – 5 years, Internal (medial) epicondyle – 7 years, Trochlea – 10 years, Olecranon – 10 years, External (lateral) epicondyle – 11 years
— Anterior humeral line through anterior cortex of humerus bisects middle third of capitellum on lateral view
— Radial capitellar line parallel to and bisecting radial head and neck should bisect capitellum on all views, this is useful in diagnosing radial head dislocation
— Anterior fat pad may be seen normally but should not be elevated, posterior fat pad should never be seen
DDX: Nursemaid elbow is subluxation or dislocation of radial head treated with manual reduction often during positioning for radiograph
Complications:
Treatment:
Clinical: If fat pad elevation is present but fracture is not seen, treat as occult fracture and followup in 2 weeks

Supracondylar elbow fracture

Etiology: 95% are due to fall on outstretched hand hyperextension
Imaging Radiograph:
— Fracture line is above the condyles
— Joint effusion almost always present
— Elevation of anterior or posterior fat pads
— Gartland Type I is minimally displaced fracture, Gartland Type II is displaced distal fracture with intact posterior cortex, Gartland Type III has complete fracture fragment displacement
DDX:
Complications: Malunion resulting in cubitus varus or fishtail deformity due to avascular necrosis of central portion of distal humeral physis and lateral trochlea
Treatment:
Clinical:
— Most common elbow fracture type in children
— Seen in 3-10 years old

Lateral epicondyle elbow fracture

Etiology:
— Varus stress causes avulsion of common extensor tendon or lateral collateral ligament
— Fall on outstretched hand causes axial load and impingement of radial head
Imaging Radiograph:
— Often subtle
— Typically Salter Harris Type IV fracture and epiphyseal component may not be visible
— Type 1 has less than 2 millimeters displacement, Type 2 has greater than 2 millimeters displacement, Type 3 has complete avulsion of fracture fragment
DDX:
Complications:
Treatment: Require internal fixation if greater than 2 millimeters distraction
Clinical:
— Second most common elbow fracture in children
— Seen in 3-10 years old

Medial epicondyle elbow fracture

Etiology:
— Acute valgus stress with flexor-pronator muscle contraction
— Chronic valgus overuse
— Fall on outstretched hand
— Arm wrestling,
Imaging Radiograph:
— Physeal widening and epicondylar rotation
— Up to 50% associated with elbow dislocation
DDX:
Complications:
— Medial epicondyle entrapment in elbow joint due to a posterior elbow dislocation in 1/3 to 1/2 of medial epicondyle fractures resulting in an absent ossification center so make sure to use CRITOE to find absent ossification center when trochlea is ossified
— Ulnar collateral ligament is rarely ruptured
Treatment: Requires internal fixation if greater than 5 millimeters distration
Clinical:
— Third most common elbow fracture in children
— Seen in 7-15 years old
— Most common acute fracture seen in adolescent throwing athlete

Radial head / neck elbow fracture

Etiology: Compression of radial head against capitellum on valgus force
Imaging Radiograph: Radial neck fracture in children, radial head fracture in adults
DDX:
Complications:
Treatment:
Clinical:

Olecranon elbow fracture

Occult elbow fracture

Etiology:
Imaging Radiograph: Fat pad elevation is present and fracture is not seen
DDX:
Complications:
Treatment: If fat pad elevation is present and fracture is not seen treat as occult fracture and followup in 2 weeks
Clinical:

Epiphyseal separation elbow fracture

Etiology: Birth injury or accidental trauma or abuse
Imaging Radiograph:
— Fracture through physis separates epiphysis from metaphysis
— Can look like posterior elbow dislocation on radiographs
DDX:
Complications:
Treatment:
Clinical:
— In first few years of life
— Epiphyseal separation more common in neonates and toddlers than traumatic joint dislocation

Elbow dislocation

Etiology: Trauma
Imaging Radiograph:
— Look for intra-articular fragments in an elbow dislocation
— Coronoid process fractures are commonly associated with elbow dislocation
Imaging CT: Can be helpful
Note: In elbow dislocation in children always look for medial epicondyle to make sure it is not entrapped in elbow joint
DDX:
Complications: Posterior elbow dislocation associated with brachial artery injury
Treatment:
Clinical: