Complex pediatric elbow injury: an uncommon case

Management of Lateral Condyle Humeral Fracture Associated With Elbow Dislocation in Children. A Retrospective International Multicenter Cohort Study

OBJECTIVES

Lateral humeral condyle fractures account for 12% to 17% of all distal humerus fractures in children, and usually occur as an isolated injury or are associated with radial neck and/or proximal ulna fractures. The presentation with a concomitant dislocation of the elbow is rare. Therefore, literature on young patients with this uncommon combination is sparse and mostly limited to case reports and small case series. The aim of the present study is to identify the best treatment strategy for this injury, recognize potential risk factors for the development of complications, and identify predictors of outcome.

METHODS

This is a multicenter retrospective review of electronic and written medical records for skeletally immature patients who were diagnosed with a lateral condyle fracture of the humerus associated with elbow dislocation (ED). Data recorded included patient demographics, fracture classification, direction of the dislocation, treatment strategy, time to union, elbow range of motion, complications, and additional procedures. The modified Flynn criteria were used to determine the outcomes.

RESULTS

We identified 23 patients who presented to 3 institutions with a concomitant lateral humeral condyle fractures and an ED. The mean age at the time of injury was 8.7 years (range: 6 to 13 y). The median time from injury to surgery was 1 day (interquartile range: 0.5, minimum to maximum: 0 to 29 d). The median follow-up was 24 weeks (interquartile range: 16, minimum to maximum: 4 to 120 wk). The injury occurred more commonly in males (79%) with Weiss type 3 fractures. The direction of the dislocation was posterior or posteromedial in most cases. Open reduction through a modified Kocher lateral approach and fixation with either Kirschner wires (N = 12) or cannulated screws (N = 9) was the preferred method of treatment. Eight patients (34.8%) developed complications, including persistent elbow stiffness (N = 5), elbow instability (N = 1), and avascular necrosis (N = 2). There were no cases of delayed union, nonunion, malunion, heterotopic ossification, neurological injury, or hardware failure. Patients treated with casting or Kirschner wire fixation had a significantly increased rate of elbow stiffness compared with screw fixation (50%, 25%, and 11%, respectively, P = 0.015). According to Flynn's criteria, 65% of the patients had good or excellent outcomes, and 35% had poor.

CONCLUSION

The findings of this study demonstrate a higher than previously described rate of complications in children with lateral condyle humerus fracture associated with ED, including persistent elbow stiffness, avascular necrosis, and chronic elbow instability, leading to unsatisfactory clinical outcomes in over one-third of the cases. Our findings suggest that the internal fixation with screws, combined with a shorter postoperative immobilization period (2 wk) may lead to improved clinical outcomes.

LEVEL OF EVIDENCE

Level III-therapeutic, case series.

Extra-Articular Corrective Osteotomy for Malunion of Intra-Articular Fracture of the Elbow in a Child: A Case Report

Introduction

Malunion of intra-articular fracture of the elbow in children is uncommon and may be difficult to treat. Intra-articular corrective osteotomies are still not commonly performed in children, and the main reason is the concern regarding the risk of osteonecrosis. We present a case of extra-articular corrective osteotomy for malunion after open reduction and internal fixation for fracture dislocation of the elbow.

Case Report

An 8-year-old boy was injured by a fall and he underwent an operation the day after the injury with diagnosis of lateral condyle fracture of the right humerus. He was referred to our department 4 months after the operation due to restricted range of motion. His elbow exhibited cubitus varus, and range of motion was 80° of flexion, -30° of extension, 55° of pronation, and 85° of supination. Plain radiographs showed malunion, a Baumann angle of 3°, and a tilting angle of 5°. We diagnosed this injury not as lateral condyle fracture but as posterolateral dislocation with Milch type 1 lateral condyle fracture associated with osteochondral flap fracture of the coronoid process with computed tomography images at the time of injury. Because the patient was only 8 years old, we decided to perform an extra-articular corrective osteotomy to encourage bone remodeling and improve the flexion range of motion. After the operation, the range of motion improved as 130° of flexion, -30o of extension, 85o of pronation, and 90° of supination 4 years after the operation. Plain radiographs showed that the epiphysis of the capitellum was closed, and the trochlea presented a fishtail deformity.

Conclusion

We obtained relatively good outcomes with extra-articular corrective osteotomy, and long-term follow-up is necessary. Especially in the elbow, the injury itself may cause fishtail deformity due to avascular necrosis of the trochlea, and if an additional osteotomy is performed, the risk increases. Although there is concern about the occurrence of secondary osteoarthritis, we expect that the intra-articular deformity would be remodeled due to the patient's young age if normal elbow movement could be obtained.

Complex Fracture-Dislocations of the Elbow in the Pediatric Population

BACKGROUND

Complex fracture-dislocations of the elbow, including terrible triad of the elbow, are serious injuries with guarded outcomes in adults. Although described extensively in adults, little is known about similar complex fracture-dislocations of the elbow in the pediatric population. The purpose of this study was to describe patterns of elbow dislocations with associated fractures in children and report the outcomes of these injuries.

METHODS

This was a retrospective review of patients who presented to a level I trauma center from 2007 to 2019 with an elbow dislocation and at least 2 associated fractures. Demographic data, fracture locations, and treatment modality were recorded. Operative reports and radiographs were reviewed to determine clinical outcomes and complications.

RESULTS

A total of 26 patients (mean age, 9.8 y) were identified. The majority of patients sustained an elbow dislocation and a medial epicondyle fracture (n=16). The most common third fractures involved the lateral condyle (n=8) or radial neck (n=7). At mean 6.03±3.11 months follow-up, 3 patients lacked ≥10 degrees of extension, and 2 patients lacked ≥15 degrees of flexion. Most patients had a Flynn score of "excellent" (n=20, 76.9%) or "good" (n=2, 7.7%). One patient with significant residual stiffness (>30 degrees flexion contracture) eventually underwent open contracture release.

CONCLUSIONS

The most common complex elbow fracture-dislocation pattern in this series was an elbow dislocation with fracture of the medial epicondyle and lateral condyle or radial neck. In contrast to adult terrible triad injuries, most patients had a favorable clinical outcome, with nearly 80% excellent results and a low rate of complications.

LEVEL OF EVIDENCE

Therapeutic Level IV-case series.

[Fracture of the medial and lateral epicondyle associated with elbow dislocation in children (about a case)]

La luxation du coude est une lésion relativement rare chez l’enfant. Elle représente 3 a 6% des traumatismes du coude, On constate souvent des fractures associées à cette luxation, ce sont le plus souvent des fractures de l’épicondyle médial, l’association d’une fracture de l’épicondyle latéral et médial à la fois à une luxation reste exceptionnelle. Nous rapportons le cas d’un enfant âgé de 13 ans victime d’un traumatisme du coude gauche par un mécanisme indirect. L’examen locomoteur a objectivé un coude gauche tuméfié, déformé avec une impotence fonctionnelle totale. La radiographie a mis en évidence une luxation posteroexterne du coude associée à une fracture de l’épicondyle latéral et de l’épicondyle médial qui se trouve incarcéré en intra articulaire. La prise en charge a consisté en une réduction de la luxation sous anesthésie, avec un contrôle scopique objectivant une bonne réduction, une fracture de l’épicondyle latéral jugée stade 1 selon la classification de Lagrange et Rigault après réduction et une fracture de l’épicondyle médial stade 2 selon la classification de Watson-Jones, d’où la décision d’opérer cette dernière, avec un abord postéromédial du coude. Le contrôle radiologique post opératoire immédiat et à distance jugé satisfaisant avec une ablation de l’attelle faite à 3 semaines, et une ablation de matériel d’ostéosynthèse faite à 6 semaines, une rééducation du coude était prescrite, avec un bon résultat clinique.

Posteromedial elbow dislocation with lateral humeral condylar fracture in children: Three case reports and a literature review

RATIONALE

Posteromedial dislocations of the elbow with lateral humeral condylar fractures (LCFs) are uncommon, and only isolated cases have been reported in the English-language literature. Because of the complex radiolucent cartilaginous structures and late-appearing ossification centers, radiological diagnosis of elbow dislocations with LCF in children is challenging.

PATIENT CONCERNS

We report three children with posteromedial elbow dislocation: two patients with Milch type I and one patient with Milch type II LCF.

DIAGNOSES

In our report, radiographs showed only a small bone fragment, and arthrography or computed tomography were helpful diagnostic aids in cases 1 and 3. In contrast, the patient in case 2 was initially misdiagnosed as having an epiphyseal separation of the distal humerus, and open reduction and internal fixation through the posterior approach revealed Milch type II LCF.

INTERVENTIONS

In case 1 and 3, Milch type I LCFs, open reduction and internal fixation was performed through the posterolateral approach. On the other hand, in case 2, Milch type II LCF, open reduction and internal fixation was performed through the posterior approach.

OUTCOMES

Poor reduction of Milch type I LCFs resulted in incongruity of the articular surface and poor cosmetic results in two patients. In case 2, Milch type II LCF, plain radiographs showed adequate healing without elbow deformity and the clinical result was excellent.

LESSONS

Because LCFs are intra-articular fractures, anatomical reduction is crucial for satisfactory outcomes. We promote awareness of this injury, especially posteromedial dislocation with Milch type I LCF. Preoperative evaluation is helpful for achieving satisfactory outcomes, and open reduction and internal fixation through an anterolateral approach might be most appropriate for Milch type I LCFs.

Concurrent Lateral Condyle Mass Fracture With Olecranon Fracture: A Case Report and Brief Review of Literature

INTRODUCTION

There is very limited literature describing the association of lateral condyle mass (LCM) fracture of the distal humerus associated concurrently with olecranon fracture. Herein, a case is reported of a displaced LCM fracture with displaced olecranon fracture, due to complex trauma while getting out of a vehicle, which was managed by open reduction and internal fixation.

CASE PRESENTATION

A 4.5- year- old boy suffered severe pain and swelling around his right elbow due to trauma which he suffered while trying to get out of a vehicle which was in motion. Plain radiographs of the anteroposterior, lateral, and oblique views showed a displaced lateral mass fracture associated with a displaced olecranon fracture. Open reduction and internal fixation was carried out and near normal function was achieved.

CONCLUSIONS

In view of the paucity of literature and rare incidence of this injury, this case report highlights the need to be aware of other injuries which can occur in association with LCM fractures in children.

Pediatric open elbow dislocation without fracture: A case report

INTRODUCTION

Elbow dislocations in children are rare injuries. These injuries are often in the form of complex injuries that is accompanied by the median nerve damage and medial epicondyle fracture in the pediatric age group. Open elbow dislocation without fracture in the pediatric age group has been reported very rarely in the literature.

PRESENTATION OF CASE

The purpose of this study is to present an 8-year-old patient who has open elbow dislocation without fracture accompanying with brachial artery injury. In the clinical examination of the patient, there was an open wound in the transverse antecubital region. After repair of brachial artery injury, open reduction was performed under general anesthesia. In the postoperative clinical examination at 6 months, left elbow flexion was 140°, extension was full and there were no deficit in the supination and pronation of the forearm.

DISCUSSION

Elbow dislocation without fracture in pediatric patients is a very rare injury. Usually the trauma mechanism of elbow dislocation is falling on outstretched hand with elbow in approximately 30° of flexion. However our patient had fallen on outstretched hand with elbow in full extension. Although this type of trauma mechanism is typical for supracondylar humerus fractures in pediatric age group, in our patient an open posterior elbow dislocation without fracture had occurred.

CONCLUSION

Pediatric elbow dislocations are rare injuries and the management of these injuries can be technically demanding due to concurrent neurovascular injuries. An open dislocation without fracture is very rare and it should be treated with immediate intervention, an effective teamwork and good rehabilitation.

[Posteromedial dislocation of the elbow with lateral condyle and coronoid process fractures: a case report]

We report the occurrence of a rare injury in a teenager not yet described in the literature: the association of posteromedial elbow dislocation, lateral condyle and coronoid process fractures. The treatment required fixation of lateral condyle and coronoid process thanks to lateral and medial approaches and capsular fixation. This lesion is unstable, such as the terrible triad described in adults. It requires external and anterior stabilization of the elbow. The management of such injuries of the elbow is complex. It must consider both bone and ligament instability, and risk of injury to growth plates.

Occult posterolateral rotatory dislocation of the elbow with olecranon fracture in a child: a case report

Introduction

Acute posterolateral rotator elbow dislocation in a child is rare and can be easily misdiagnosed due to immaturity of the epiphysis. This is the first case of occult posterolateral rotator elbow dislocation in combination with an olecranon fracture. We report our experience with this case, which was not diagnosed correctly by plain radiographs.

Case presentation

An 11-year-old Asian boy suffered severe pain and swelling of his right elbow after his outstretched arm hit a car dashboard in a motor vehicle accident. Plain radiographs showed only a minimally displaced olecranon fracture and a tiny lateral epicondylar avulsion fracture. However, stress radiographs under general anesthesia revealed severe posterolateral rotatory instability. During surgery, we found that the cartilaginous lateral epicondylar apophysis was much larger than the epicondylar fragment on the radiographs. After the lateral epicondylar osteochondral fragment and lateral collateral ligament complex were fixed, the instability disappeared.

Conclusion

Our experience with this case shows that it is important to check for instability with pediatric elbow fractures, because a tiny avulsion fracture was able to cause severe posterolateral rotatory instability in a child.

Tomographic index as auxiliary criteria for surgery indication in fracture dislocation of acetabulum posterior wall

There are situations which the tomographic exam is done on the affected hip or situations where the contralateral hip presents abnormalities that make it impossible to compare. In this study we aimed to evaluate a tomographic index that does not require comparison between the both hips. Twenty two patients with unilateral acetabular fracture dislocation with fracture of posterior wall were studied. We established the relationship between the remaining posterior wall and the femoral head diameter (head/wall index-H/W index). We evaluated 45 two-dimensional computed tomography scan in normal hips and established the H/W index. In 45 normal hips we simulated a posterior wall fracture with involvement of 25% and 30% of the posterior wall and calculated the H/W index. We divided into five groups with five different H/W index (fractured group with non surgical treatment; fractured group; normal group; normal group with simulated fracture of 25% and; 30% of the posterior wall). 2.4 was the lowest limit of confidence interval of the group with 25% of the posterior wall fracture. When we analyzed the confidence interval of the 30% fracture group the upper limit of the confidence interval was 2.7, close to the lower limit of the surgical group that was 2.9. Thus, we suggest the 2.4 the H/W index limit as an auxiliary criteria to indicate whether or not to operate. H/W index is helpful to decide whether or not surgery indication in the fracture dislocation of the posterior wall of the acetabulum.

Outcome of lateral humeral condylar mass fractures in children associated with elbow dislocation or olecranon fracture

Of 2,502 elbow/humeral injuries treated at our department between 1990 and 2005, we identified a cohort of 20 lateral condylar mass (LCM) fractures of the humerus in children associated with elbow dislocation (n = 12; mean age 8.2 years) or with olecranon fracture (n = 8; mean age 4.1 years). Eight patients with undisplaced fracture pattern were treated conservatively yielding a satisfactory outcome. Good to excellent results were obtained in the majority (85%). Overall, the result was poor in three patients (15%; 25% of the operated cohort) due to terminal 20-30 degrees loss of extension. There was no obvious difference in the outcome between the isolated displaced LCM fractures described in the literature and this cohort. Testing of elbow stability by examination under anaesthesia is stressed. Undisplaced fracture patterns need to be closely observed. Parents should be warned about the likelihood of some degree of unfavourable outcome in the displaced LCM fractures with associated elbow injuries.