Fracture of the proximal end of the clavicle is considered to be a physeal growth plate injury and not a sternoclavicular joint injury, especially if it occurs in patients younger than 25 years of age. The proximal (medial) clavicle epiphysis is the last to fuse (Figure 1).
Diaphyseal fractures in children are common in the middle third of the clavicle (Figure 2). They usually heal with an excellent remodeling ability within one year.
Clavicle birth fracture
Usually the baby is large .Baby may have pseudoparalysis. Treated with sling or simple immobilization. Need to do differential diagnosis between brachial plexus injury and a clavicle fracture. If clavicle fracture, the baby will move the arm early and quickly. (Figure 3)
Congenital pseudoarthrosis is commonly on the right side and could lead to fracture clavicle in the mid-shaft area (Figure 4).The condition is treated conservatively and it is usually asymptomatic. If it is symptomatic and older, treat it with fixation and bone graft.
Proximal humerus fractures
80% of the longitudinal growth of the humerus occurs in the proximal physis. In young children the fractures are treated conservatively with a sling and the patient may get a hanging arm cast. In a young child proximal humerus fractures allow for significant remodeling following the injury of the proximal physis, even if the fracture is badly displaced.In older children, closed reduction and percutaneous pinning maybe needed especially if there is major displacement (Figure 5).
Transepiphyseal separation of the distal humerus: Consider child abuse in these injuries. It is usually confused with elbow dislocation, however in this case the olecranon moves posteriorly and medially and the radiocapitellar line remains the same (Figures 6 and 7). Physeal separation of the distal humerus usually occurs in younger ages. The diagnosis is usually difficult and may be missed. These separations should be highly suspected with elbow injuries before the age of one year.
What are other findings that may be a sign of child abuse?
Look for multiple fractures at different stages of healing, corner fractures, posterior rib fractures or fracture of the femur before they are of walking age.
Lateral condylar fractures
Lateral condylar fractures are most commonly Salter- Harris type VI fractures (Figure 8). Surgery should be done if the fracture is displaced. When surgery is done, it need to be done with a lateral approach and not a posterior approach due to the risk of injury to the blood supply of the capitellum which could cause avascular necrosis. Some people use arthrogram or a percutaneous technique. It is better to open through a lateral approach especially if the fracture is badly displaced (Figure 9).
Complications of lateral condylar fractures:
Nonunion, cubitus valgus, and ulnar nerve symptoms, which takes years to develop. If there is good motion of the elbow but there is pain, then we need to do bone graft and fixation. If there are ulnar symptoms, then you need to release or transpose the ulnar nerve.
Lateral condylar fractures are usually surgical cases.
Medial epicondyle fractures
Little leaguer’s elbow is caused by a pitching motion that places stress on the elbow joint, resulting in avulsion and inflammation of the medial epicondylar apophysis (Figure 10).
Fracture of the medial epicondyle is usually treated conservatively. If there is displacement more than 1 cm, then you need to do surgery. The amount of displacement that requires surgery is controversial.
The medial epicondyle fracture is commonly associated with elbow dislocation (Figure 11). Look for the medial epicondyle on the post reduction x-rays. If the medial epicondyle fragment becomes trapped within the elbow joint, then it needs to be fixed and removed.
Extension type fracture
It is the most common type. The distal fragment displaces posteriorly. Anterior interosseous neurapraxia is the most common nerve palsy, it is usually treated conservatively. The patient cannot do the OK sign or bend the tip of his index finger (Figure 12).
Flexion type fractures
It is rare and occurs due to falling directly on a flexed elbow. The distal fragment is displaced anteriorly (Figure 13). This type of fracture is accompanied with ulnar nerve neurapraxia. Ulnar nerve injury will lead to loss of sensation in the medial one and a half fingers. Later on the patient may also have weakness of the intrinsic hand muscles and clawing (Figure 14).
Treatment of supracondylar fractures is usually by closed reduction and percutaneous pinning. It is important to check the neurovascular status of the extremity and check for a gap in the fracture. The neurovascular bundle may be trapped there. Fixation is usually achieved with 2-3 divergent lateral pins, depending on stability (Figure 15). Medial and lateral pins are better than lateral pins alone (Figure 16).
Proximal ulna fractures
Fracture of the olecranon growth plate can be confused with normal development of the growth plate and vice versa. Look for separation of the metaphyseal fragment (Figure 17). It is usually treated with open reduction and tension band fixation. This may be the initial presentation of osteogenesis imperfect.
Patient will present with pronation and some flexion of the elbow. It is reduced by supination of the forearm and elbow flexion (Figure 18).
Radial head fracture
Radial head fracture maybe associated with compartment syndrome. Conservative treatment is done when there is less than 30 degrees of angulation or 30 degrees of displacement and closed reduction is used if displacement is greater than 30 degrees (Figure 19).
There are two types for this fracture, anterior monteggia fracture, where the radial head is anterior and posterior monteggia fracture, where the radial head is posterior. Closed reduction is done if the proximal ulna is not displaced. Keep the elbow in flexion and the forearm in supination if it is anterior monteggia fracture and keep the elbow in extension if it is posterior monteggia fracture (Figure 20).
Fracture of the distal radius and distal radioulnar joint dislocation (Figure 21). Involvement of the DRUJ can be in the form of a dislocation, subluxation of the joint, or a displaced ulnar physeal injury. Treated with closed anatomic reduction with long arm cast in supination.
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