OrthoClass - Pediatric Elbow - Dr. S. Lawson

The basics of evaluation for elbow fractures in children are the same as adults - 2 (ideally 3) views, determine if there are any disruptions in the cortex, assess the radiocapitellar and anterior humeral lines (both should bisect the capitellum), and look for signs of hemarthrosis (anterior or lateral fat pads).

Most elbow fractures in children are extension type supracondylar fractures. The Gartland classification system can be used to describe fractures:

1. Type I - minimal to no displacement with no disruption in the cortex
2. Type II - displacement with an interrupted anterior cortex but intact posterior cortex
3. Type III - displaced with disruption of both the anterior and posterior cortex

The elbow is not fully developed until late adolescence. The timing of ossification center development varies from child to child, but girls generally develop slightly earlier than boys. The order of appearance IS reliable - use mnemonic "CRITOE" to remember the order:

• Capitellum
• Radial head
• Internal (medial) epicondyle
• Trochlea
• Olecranon
• External (lateral) epicondyle.

Knowing the order of development can help you determine if that small piece of bone you're seeing is an ossification center or a bone fragment (comparison films of the contralateral elbow may prove helpful as well).
A thorough neurovascular exam is the most important part of your assessment and will help determine management. For a quick motor exam:

• thumbs up checks the radial nerve
• fingers in a "fat five" and crossing the index and middle finger for "good luck" checks the ulnar nerve
• a true "okay sign" (flexion at the DIP of thumb and index finger) checks the median nerve, specifically the anterior interosseous (AIN) branch, which is the most commonly injured in supracondylar fractures

For a quick sensation exam:

• dorsal first webspace tests the radial nerve
• palmar aspect of the index finger tests the median nerve
• palmar aspect of the pinky finger tests the ulnar nerve

Check a radial pulse, and assess color, temperature, and CAP REFILL. Pink and pulseless can be okay; pale and pulseless, however, is not.

If you can't feel a pulse, listen for triphasic or biphasic Doppler flow.

Type I fractures can be splinted in a posterior long arm splint with close Ortho follow-up
Type II fractures can be managed like a type I if there is minimal displacement and swelling and the neurovascular exam is normal - otherwise splint and arrange urgent operative repair
Type III will always require operative repair - emergently if a poor neurovascular exam, urgently if a normal exam
 

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