Elbow Fractures In Children: Current Treatment and Management of Complications

 Video Presentation

Overview

Introduction: Stephen W. Burke MD, Chairman, HSS Pediatric Service: I would like to welcome everybody this morning to the Leon Root Visiting Professorship Lecture. It gives me a great deal of pleasure to introduce this year's speaker, Dr. James Beaty. In addition to being Professor of Orthopaedic Surgery at the University of Tennessee, he is the Chief-of-Staff at the Campbell Clinic. He is director of the Board of Directors of the American Board of Orthopedic Surgery, Chairman of the Program Committee of American Orthopaedic Association, President and past President of the Middle American Orthopaedic Association, as well as holding virtually every other office imaginable in the Pediatric Orthopaedic Society of North America. He is co-editor of what is probably the definitive book on children's fractures. He is active in the American Academy of Orthopaedic Surgery and Instructional Course lectures, and Associate Editor of the Journal of Bone and Joint Surgery. He is truly a giant in the field of pediatric orthopaedics as well as being a superb lecturer. It gives me great pleasure to introduce him to you this morning.

Dr. Beaty: It is an honor to be here to deliver the Leon Root Lecture. Leon Root is a gentleman, he is a distinguished pediatric orthopaedist and his contributions in osteogenesis imperfecta and cerebral palsy have been incorporated into the practice of pediatric orthopaedics. It gives me great honor to be here on your behalf, Leon.

I would like to discuss what is new in pediatric elbow fractures, provide information for the residents and discuss some new techniques and approaches that we weren't using ten years ago.

For the orthopaedic residents this is the famous CRITO eponym, which reminds us that the ossification enters in the elbow and occurs over a ten year timetable. That is very important to remember as you are analyzing the Emergency Room x-rays. Also we are going to talk about applied anatomy. That is age of ossification. Whenever you see an elevated anterior fat pad that is abnormal and you should never see a posterior fat pad. We will discuss the anatomy of the elbow as we continue.

First of all, let's discuss making diagnosis. In the Emergency Room setting it important to always include oblique x-rays with AP films. But, small children, what doing now we didn't do ten years ago utilizing arthrography and especially MRI some articular injuries you can't see by plain x-ray. CT is really not that except in certain circumstances, example when loose bodies present. The stress views are very helpful for suspected lateral condyles.

The transepiphyseal separations in a child younger than three looks like an elbow dislocation. But remember the lateral condyle of the radial head of the olecranon all move as one unit so that is a trans-physeal injury rather than a true dislocation. Unlike the thinking in the old literature, we now believe that these injuries should be reduced; pinned and treated like supracondylar fractures. They are not going to remodel with time.

Supracondylar fractures are the most common elbow injury we see. They are a major source of anxiety and present problems for some of us. I will try to give you a good treatment algorithm and solutions to these problems, but will also talk about pitfalls in treatment. Supracondylar fractures comprise 70% of all elbow fractures in children. This classification system has stood the test of time: type 1 is nondisplaced as you see here, type 2 and 3 are displaced with or without some cortical contact.

Now for the residents who are here in the audience, what is the difference in these two fractures? I am going to try to convince you that this injury should be treated ultimately as if it were a type 3 with complete displacement. One take-home message is to reduce and pin these minimally displaced injuries. Why is that true with the type 2 fracture? Because you often see varus or valgus malalignment which often occurs with medial comminution as you see here. What is new here is to treat these as a type 3 fracture and manipulate and pin them. This is not going to remodel in the coronal plane over time. So the first take-home message is reduce and pin the type 2's, and treat them as a type 3 fracture. Manipulation by correcting the varus or valgus alignment, varus in this case, and then percutaneous pin fixation. In this patient, these are two lateral pins, but I would have no qualms about a third medial pin for this particular case.

Now for the type 3 fractures, which are the most severely displaced fractures, what are treatment options? Closed reduction and splinting is really not utilized anymore, too many risks of vascular injury and unacceptable deformity. Traction, either skin or skeletal, is rarely utilized but there are certain occasions where it is appropriate.

Look at this extremely comminuted fracture with the humeral extension. There are some fractures that are either take down or treat like a severe T-condylar or supracondylar and treated with skeletal traction. Rarely will I do this, but in this case I did. Open reduction and internal fixation is advisable for irreducible fractures and vascular injuries; closed reduction and percutaneous pinning has become the treatment of choice for most of us when the fracture is reducible and in the absence of vascular injury.

What have I learned in the past 20 years about this technique? Obviously, under general anesthesia we use the image, which is very helpful in learning how to do this. We use small K-wires in children less than six and 564th of an inch K-wires in children six and older. Mercer Ring described the reduction technique many years ago, traction, correction of medial or lateral displacement, flexion of the elbow, and then assessment of your reduction and pinning.

What are some surgical tips for this particular problem? Well, I like to use the receptacle end of the image intensifier as my operating table and I will actually place the flexed elbow on that so that I can hold it fully flexed, maintained in flexion, and then by internal and external rotation, I can obtain a lateral. Pin position can be assessed with the image intensifier and postoperative I have gone to placing the kids in some degree of extension more than flexion at about 45 degrees because they have a difficult time regaining all of their extension and it is probably better to place them in 45 rather than 90.

Now here is a question for all of us. What is the story with lateral versus crossed pins and supracondylar fractures? Laboratory studies showing that this is a more stable construct and this has proven true in clinical practice. What is the risk of late displacement, what is the risk of getting an angular deformity, and what about iatrogenic nerve injury? There is no question in the lab that this is the strongest construct. This is probably second, this is third, and this is very last when you look at constructs.

This is the ideal cross pinning with the pin in the medial epicondyle up through the lateral column for the lateral pin. Some fractures are just more amenable to two lateral pins than they are a medial plus a lateral pin. So I will tell you in my practice, I think that cross pinning is still the standard goal, but I am treating more and more cases with two lateral pins alone in the fractures that are not grossly unstable. I find that in clinical practice it turns out okay but in the presence of more displacement and more instability, I will use cross pinning.

Here are a couple of pitfalls that I have seen.First of all, incorrect diagnosis. This is truly a lateral condyle fracture not a supracondylar fracture with some very poor pins, small pins and incorrect diagnosis. What about loss of fixation? Well, if you look critically, obviously this pin from a lateral portal insertion really crosses into the medial epicondyle region. This one crossed through the medial epicondyle as well. So I am going to show you what happens in loss of fixation and how to deal with it depending on what the outcome might be.

Now what is the indication for open reduction? Well, with irreducible fractures, with open fractures, or vascular injuries, these are known techniques. What's new I think, is that 10 to 15 years ago, a lot of people were still using either a lateral or medial lateral approach and what has really changed in the past fifteen years in particular, is that we are doing an anterior curvilinear approach. The fracture has already been dissected, the spike of the humerus has already dissected through the antecubital fossa structures and there is no reason to approach this medially or laterally. Just go straight anteriorly curving toward the side of the spike of the metaphysis. So we will do an open reduction through the anterior approach and then percutaneously pin it after we have reduced it under direct visualization.

What is the story about the risk of loss of motion? One of the papers that came out of this institution with Andy's influence showed that open reduction did not necessarily yield any long-term problems with motion and I think that is a good thing to remember. In our practice, about 10% of the cases that we see we simply can't reduce because the reduction is unacceptable and we have no problem with approaching a poor reduction anteriorly.

Now another complication with supracondylar fractures is the pulseless hand. This occurs about 10% of the time with the supracondylar fractures but interestingly enough less than 1% of these cases require surgical treatment. Naturally this is an emergency when the hand is nonviable. Some of us think that with earlier treatment, with reduction and pinning and even from the old era of avoidance of extreme flexion, there is no question that some of this probably has led to not having to operate on so many brachial arteries.

That being said, when you see a patient with this particular problem, even though the incidence is low, we must distinguish between the patient who has absent pulses but a pink viable hand--this is a common clinical scenario--versus absent pulses in a pale and nonviable hand. The latter is obviously an orthopedic emergency. Is an arteriogram necessary in this case? Probably not. I don't think there is a reason to go by the Radiology Department and obtain an arteriogram. If you want to do one, then do a single shot on the operating table. Unless you have a more proximal ipsilateral injury of the humerus or the shoulder, it is unlikely that you need an arteriogram.

If this is an isolated injury in the supracondylar fracture you know where the problem is. So in the Operating Room, you can actually do an anterior approach to reduce the fracture under direct visualization, percutaneously pin it, and then explore the artery if necessary with either repair or vein grafting.

I have given this talk a number of times and have said that in our institution we probably have only had between a half dozen to ten patients in the past 20 years that required brachial artery exploration, but when it was necessary because there wasn't enough lateral circulation, I have been happy that I have done it.

Counter to that, some of the more recent literature implies that some of the brachial arteries that have been repaired re-occlude within a short period of time. The pros and cons of that probably can be debated by all of us but in the emergent situation it is obviously the right thing to do.

Here is the approach-typically these are posterolaterally displaced injuries with brachial artery injury. This particular case demonstrates just an intimal tear that clotted off in the brachial artery itself, with excision of the clot and repair of the artery. Certainly vein grafting is appropriate if necessary.

The other complications with supracondylar fractures include cubitus varus. This is interestingly not only a cosmetic issue, but has been a medical-legal problem for a number of years. We find that most patients who come to our institution do so because they want an elective osteotomy to correct it. We are using lateral closing wedge and screw fixation and what is new with this problem is that this is not an acute management of a fracture, this is a reconstructive surgery. You want to approach it differently than you would if you are managing an acute fracture. So, it should be a reconstructive osteotomy done not in the diaphysis, though within 4 cm of the joint, and this should be rigidly fixed, not like an acute fracture with pin fixation or screw fixation.

Here is one of my very happy patients. You can see preoperatively on your right, if you notice very carefully he has an obvious cubitus varus on the left. By the way, what did that come from? It came from a type 2 supracondylar fracture that drifted into varus and was treated closed. So again, that is one that should be manipulated and pinned.

Preoperative planning for this treatment I think is very critical and the easiest way to do this is simply to x-ray the opposite elbow and look to see exactly what the humeral olecranon and the humeral ulnar angle is and plot out a wedge that can be performed just proximal to the coronoid and olecranon fossa.

The shoulder makes up for a tremendous amount of rotation so I don't think that you have to rotate through your osteotomy site. If you want to add some flexion or extension to make up for any carrying angle on the lateral view, that is appropriate. But this is a closing wedge osteotomy that Paul Derose and his colleagues described quite nicely with a little bit of off-set to correct width problems in the distal humerus. Here he is just as happy postoperatively as he was preoperatively, as you can see. But again note that the osteotomy has been performed just proximal to the olecranon and coronoid fossa. This is in very good metaphyseal bone, not trying to extend up into the diaphysis of the humerus, and again screw fixation-treating the problem reconstructively, not like an acute injury.

Neurologic problems occur in about 7% of supracondylar fractures. The median nerve if you include the anterior interosseus branch is certainly the most common with 40%. The radial nerve at 35% and the ulnar nerve at 25%. We are fortunate that most of these will resolve over time. It is appropriate I think in rare circumstances to consider nerve exploration at somewhere in the 6 to 12 month mark if the nerve injury is not resolving.

In my practice, I have had two patients that I saw for consultation with the median nerve trapped in the fracture site, that we have extracted. Several patients with ulnar nerve injuries that probably involved the pinning, that did not resolve over a year's time, underwent neurolysis in that area, which is occasionally important to do in the treatment of a late neurologic problem.

The flexion supracondylar fracture fortunately only comprises about 2% of the supracondylar fractures that we see. This can be an extremely difficult closed reduction. About once a quarter, I will get a phone call from an orthopaedic surgeon who is in the Operating Room and the story is always the same, it's "I've got a supracondylar fracture and something is not right". The message there is either it is a flexion injury that the orthopaedic surgeon is trying to treat like an extension injury or occasionally it is a P-condylar that just hasn't been recognized.

Now you can tell here the condyles have been displaced anteriorly, the shaft of the humerus. This is a very difficult closed reduction. It's sometimes necessary to try an extension. Sometimes this fragment is so mobile that you can actually displace it posteriorly and then reduce it like an extension type injury, but it may require an open reduction. You obviously should avoid excessive flexion because, as I will show you in a moment, you don't always regain extension if you heal with excessive flexion of that fragment.

If you are going to have to do an open reduction of this injury which way should it be approached? Probably posteriorly, because the soft tissue dissection. Again it has been done for you here and all of your anterior structures are intact, so approach that posteriorly to correct it.

Here is another example, this happened to involve the head of our Operating Room in our children's hospital. Her daughter had a very low flexion supracondylar. This particular fracture required open reduction again through the posterior approach.

Earlier I showed you some complications including late displacement or late presentation of a fracture. What should we do in these circumstances? Once you are past the four to five day mark, if the closed reduction can be done it does become more difficult as new bone forms. And there have been a number of articles reporting an increased instance of myositis ossificans with open reduction.

Some of the international literature have shown open reductions performed at two to three weeks with only a small increase in the risk of myositis, but it certainly is a potential problem. What are the options in this case? Well one is to treat it with observation and elect to do an osteotomy at a later date. This certainly would be appropriate in this case where you are 70% of the way healed and have a tremendous amount of callous and new bone formed. I wouldn't want to take that down late.

What does it matter because of the potential remodeling of the distal humerus? Well as I mentioned to you earlier, I do not believe that there is really any significant coronal plane remodeling. I don't think the carrying angle of the distal humerus really models. On the lateral view, anecdotally, you can probably have about 30 degrees of tilt posteriorly of the distal condyles and not have a cubitus rectus, but loss of about 30 degrees of flexion. I personally think that there is some remodeling in the sagittal plane.

I can't tell you that scientifically, I can only tell you anecdotally from following my patients, but I pay just as much attention to the reduction of this injury in the lateral plane as I do the anterior carrying angle and I encourage you to do the same. In this particular case, I followed the patient along. She had a slight increase in cubitus valgus but was very happy cosmetically with the elbow and did not require any type of late osteotomy.

Finally in supracondylar fractures, myositis does occur. As you see here this is a rather large myositis, not at the elbow joint, but up underneath the brachialis and biceps muscle in the humerus. It has been reported after multiple attempts at closed reduction; it is fairly rare after an early open reduction. After closed reduction, typically myositis begins to resolve in the 18 to 24 month time frame and, as you know, with all fractures around the elbow, particularly in children you don't have to avoid any aggressive passive range of motion program postoperatively.

The truth be known, there are not many six year olds that cooperate with physical therapy anyway. So I think that you can expect them to gradually regain their motion after most well treated fractures. I am going to move very quickly through some other elbow fractures, and what I would like to do particularly for the residents in the audience, is to offer you two or three pieces of information that will apply to the treatment of these fractures and how you will manage them in your future practice as well.

Lateral condyle injuries comprise about 15% of all elbow fractures. This is Kay Wupon's classification that has pretty much stood the test of time with type 1's having about 2 mm or less of displacement in the metaphysis, type 2 injuries having about 2 to 4 mm of displacement and type 3s having complete displacement and rotation as you see here.

If you are like me the classification systems are helpful if they have some direct clinical application. In this particular classification there is a fallacy that should be pointed out, and that is that you cannot see the trochlea in the 6 and 7-year-old child. Why not? Because it hasn't ossified yet and it's not going to until the kids are in the 8 to 10-year-old age range. So that is the limit with lateral condyle fractures particularly with minimal displacement, as we'll see.

Well what is new with the lateral condyle world? In the old literature I think there was a general consensus that the nondisplaced fracture as you see here on the lateral view--a very small posterolateral Thurston-Holland fragment-casting and following to union even with weekly or every-other-week x-rays was indicated. There is a school of thought now that percutaneous pin fixation for the nondisplaced or minimally displaced fracture is appropriate. I don't have an argument with that. I would argue that 95 to 96% of the completely nondisplaced fractures heal with the mobilization. The late displacement rate is only about 4 to 5%. If you are trying to avoid late displacement of this fracture and if you are going to follow that child in your office, you need to have good x-rays done at about a week to ten day intervals and probably taken with the bivalved cast removed rather than x-raying through the cast.

If you do get late displacement and/or nonunion, I am going to show you in a few moments how to deal with that by a modified late open reduction. What is happening with the type 2 injuries where you have this 2 to 4 mm displacement in the metaphyseal part? We feel that if they are stable by arthrography and in our institution we are doing a lot of MRI for this 2 to 4 mm range injury because with MRI you can see the trochlea. MRI is being recommended for displacement in the 2 to 4 mm range because of the question about extension into the articular surface. Then I think you should proceed with open reduction and internal fixation. There is no reason to try to manage that nonoperatively and push that curve that far.

There is one problem with this injury, sometimes if this displacement is in the 3, 4, 5, 6 mm range and you are trying to percutaneously pin it, you may get union, but interestingly enough you get a change in the curing angle of your elbow. You get a little bit of the cubitus varus deformity that the families are not really happy with.

Closed treatment of this type fracture-with displacement in the 6, 7, 8 mm range-is very inappropriate. Even if you are fortunate enough to get a union, you basically have an interarticular malunion with loss of motion and a very poor result. So I think that in the 30's our forefathers said this is one of the fractures of necessity requiring treatment and I think that is still true to this day.

For the displaced fracture, just a few surgical tips, straight forward lateral approach, the brachioradialis triceps interval, it is important to leave the soft tissues attached to the lateral condyle, that is the blood supply of the lateral condyles and no stripping of any of the posterior attachments. Use two smooth K-wires, you can bury these beneath the skin if you want to. You can actually take the kids out in 10 days or two weeks and let them begin to move a little bit and then possibly remove the pins at the three to four week mark.

Just a note that these pins look parallel on the AP view. On the lateral view, or at least on one view, these should be slightly divergent and not perfectly parallel.

Now what about some complications and problems with these injuries? Well, we do still see nonunions with lateral condyle fractures and are probably just not recognizing the initial injury and treating it surgically. There has been a great deal of discussion about the difference between a nonunion that is in good position versus a nonunion that is in a poor position.

Now what we mean by a good position is if the lateral condylar fragment has displaced less than 1 cm from the joint surface and there is certainly no change in the carrying angle of the elbow, if the lateral condylar physis is open and growing normally, and if you have a large metaphyseal fragment this is a candidate for a reconstruction of the elbow by late open reduction and internal fixation and bone grafting.

For the residents who are here, let me point out that the distal humeral physis only contributes 20% of the growth of the distal humerus or to the entire growth of the humerus, so even if the physis is not normal in these kids that are late grammar-school-age, that is still not necessarily a contraindication to reconstruction.

What is new about operating on this compared to 10 to 15 years ago? Now this is a reconstructive procedure and again all you are trying to do is gain the union of the metaphyseal fragment of the lateral condyle with metaphysis of the distal humerus. With late nonunions like this you are not going to restore the articular congruity perfectly. As a matter of fact, trying to do that may even lead to some stiffness of the elbow joint or you may denude the blood supply of the lateral condyle, so I would encourage you to treat this as an extraarticular reconstruction, not as an interarticular procedure.

What about our follow-up of this patient? This heart-shaped or fish-tail shaped anomaly which you see is very common after lateral condyle fractures that have undergone acute treatment. Very typically they will develop some growth disturbance where the fracture crossed the physis of the distal humerus. It is interesting radiographically, but it means nothing clinically and it is not a problem for the patient.

Now what about the lateral condyle which is in poor position, that is very much displaced, with a small or nonexistent metaphyseal fragment? This is really cubitus valgus, somewhat of a cosmetic problem as you see here. We do see nerve palsies anywhere from the grammar school years well into adult life from an old nonunion of the lateral condyle and certainly anterior transposition is appropriate.

Under rare circumstances in the adult who complains of instability or pain there is nothing wrong with fusing this fragment to the metaphysis late or even with osteotomy. What about avascular necrosis with lateral condyle fractures as a complication? Well as you see here, this is after open reduction and internal fixation, about 10 months later, the ossific nucleus looks very avascular. You wonder and worry about what is going to happen to that at the time.

We collected about ten kids who developed avascular necrosis (for a paper that we will publish next year) and interestingly enough when they develop avascular necrosis of the lateral condyle it behaves like Legg-Perthes disease. Over time it simply reossifies and fills back in with good solid bone and surprisingly, the kids that we follow, the dozen or so that we have, have really not had any long-term problems. Now I don't know how that is going to hold up into adult life with congruity and symptoms, but so far, with at least intermediate follow-up, these patients have not been symptomatic.

Lastly with lateral condyle fractures, let's discuss the natural history of nonunions. Years ago, if you had a nonunion like this, the argument was leave them alone. You might make them worse with surgery; let them proceed, and if they develop a tardy nerve injury, then you can transpose the nerve. But as you notice, the natural history of the nonunion is really poor, particularly when you have a large fragment that significantly displaces into the articular surface. And as you follow this child over time, they ultimately develop a very progressive cubitus valgus deformity and this was the case, he did present with a tardy nerve palsy.

So another take-home message from this morning is to initiate aggressive treatment for lateral condyle fractures. The natural history of nonunions is poor enough. These fractures should be reconstructed in my experience and not left alone to the natural history.

Now lastly, let me just cover a few fractures around the elbow that are fairly common and a few things that we have learned in the past few years. Medial epicondyles. Nothing much has really changed in this area. We still are treating the minimally displaced fractures closed. Fractures that are displaced more than about 1 cm with stress testing often have instability medially, and there is no problem with surgical treatment for such cases.

The type 3 fractures with complete displacement, as I will show you, can be treated by open reduction and screw fixation. The pitfalls for the medial epicondyle fracture are as follows. They do occur quite frequently. With elbow dislocation in children, up to 50% will have an associated fracture in either medial epicondyle, lateral condyle or radial head and neck. We do see cases of entrapment in the joint after closed reduction. Rarely do you see ulnar nerve injuries and I am going to show you a medial condyle fracture in just a moment.

Here is a case of a teenager that had an elbow dislocation. After reduction you can obviously see the fragment of the medial epicondyle entrapped in the joint. We should have a nice eponym like Schintin's line for the incongruity that you see at the articular surface of the elbow. This fragment is simply extracted and fixed back with screw fixation in the adolescent patient.

One of the tips here of course is that when you have an elbow dislocation in the child and an associated fracture that you operate and treat the problem early. And you need to fix the fracture so that you can begin motion within ten days or two weeks, not at 6 or 8 weeks down the line. You are simply going to lose motion by delaying.

You want to be aware of the medial condyle fracture. This is a rare injury that we see in children. Instead of being an epicondylar injury, a true condylar injury requires a very high index of suspicion. Why? Because of nonossification medially. These can be diagnosed easily by MRI or arthrography and surgical treatment should be undertaken for displaced medial condylar injuries.

Here is an example of an older teenager that has a split fracture simply isolated to the medial condyle itself. These are nicely treated with either pin or screw fixation and again provides early motion. What about the other side of the elbow? Remember that the term pediatric fractures should include the teenage patient and that we see injuries in the teenager just as we do in the adult.

Very rarely, we do see capitellar fractures in teenagers, isolated to the articular surface and not involving the metaphysic. Just as in the adult, we would do an open reduction through a lateral approach and percutaneous fixation, typically cannulated screw fixation as you see here, for the isolated capitellar fracture.

Lastly, I am going to briefly cover two problematic fractures that we see rarely in kids. I will try to show you a couple of surgical tips in managing these problems. What about radial head and neck fractures such as the one you see here? What is acceptable? We will talk about some guidelines. I am going to describe a technique of percutaneous manipulation of this injury and also techniques of fixation and show you some problem cases.

In radial neck fractures when we are describing the anatomy we talk about angulation of the radial head in relation to the radial neck. We also discuss translation. That is simply displacement in the coronal plane of the fracture and typically speaking, a lot of these fractures will be displaced or translated laterally or anteriorly and will also have significant angulation.

This injury can occur with a valgus force injury of the elbow and it also can occur with an elbow dislocation as you see depicted below. I think in the past years these techniques have all been described as closed manipulation and reduction. Percutaneous manipulation has been gaining popularity in the last ten years. This is a good algorithm. I think if your angulation is in the 45 to 60 degree range this is probably not going to remodel to your satisfaction and this number could even be dropped down to 30 degrees in the older child and I don't think we would disagree with that.

Displacement greater than 50% causes a problem because of the effect of the radial head. You begin to lose some pronation and supination. A technique of reduction as described by pronating the forearm in a varus stress injury is the Patterson technique. I think it may work for minimally displaced fractures, but not necessarily for the more severely displaced.

If you have to proceed with open reduction then you want to use some very small oblique K-wire fixation, which I will show you, and to avoid a transcapitellar pin if at all possible. What is really new with this injury is our reluctance to operate on it, quite frankly. We have tried to do everything possible not to do open reductions of radial head and neck fractures because often times we just don't get the clinical result that we want even if we realign the radial head and neck.

So two techniques have evolved in the past five to ten years. The first one was percutaneous manipulation by taking the blunt end of the Steinmann pin and under fluoroscopic control, manipulating the metaphyseal fragment of the radial neck injury and radial head injury to push it back up onto the radial neck itself. This can also be done by the Metazo technique by inserting a rod in the forearm and doing it retrograde, that is much like a tonsillectomy. You don't necessarily want to do that in a retrograde approach. I think this is a much more direct approach.

Now what about displacement after elbow dislocation? This is a typical example where you have an elbow dislocation in a 12 to 13 year old and you can see that the radial head was displaced off of the radial neck. This is the radial head here and with reduction of the elbow you have 100% displacement of the radial head. This is a case that I have shown over the years with great fun because one of my partners told me he had done a great job of reducing this fracture and I am going to want to show this case and publish it in any textbook. He was right about that because when he reduced the radial head, here is the articular surface over here and here is the metaphysis, so the fragment is inverted 180 degrees, so he simply did an open reduction and reduced the fracture.

Let me point out that in fixing these, if you have to do this openly, here are a couple of surgical tips. One is to use the lateral approach. Obviously you want to try to match it up as anatomically as much as you possibly can because obviously that is not going to remodel and you are not going to get any sudden increase in supination and pronation with remodeling. When you fix this fracture, if you have to fix it, then use a very small smooth K-wire fixation. Start at the articular margin of the radial head and just extend into the neck of the radius.

If you have an associated ulnar injury, particularly an associated olecranon injury, do not put your fixation across toward the olecranon fracture. The instance of synostosis is so high with that injury, it should really be avoided at all costs. This is obviously a candidate that is not right for percutaneous manipulation. When you are displaced anteriorly you just don't have the ability to do that safely, so open reduction is appropriate for this injury.

Is there remodeling of radial neck fractures? I think to some degree we see a lot of avascular changes because of the tenuous blood supply of the radial head anyway and you will see this kind of picture after open reduction. But interestingly enough, as you would expect in children, you do get some nice healing and remodeling. We have seen some cases of AVN and we have seen some growth disturbances, but fortunately because of the low amount of growth in this physis it is generally not a huge problem.

This is a pitfall for diagnosing this problem. We see some small peripheral radial head injuries that present with isolated subluxation of the radial head and as I will show you in just a moment, this may be a Monteggia variant as much as anything. But you must look very carefully for a small displacement injuries of the radial head that can sublux late.

Lastly, I would like to discuss the Monteggia injury. The Beto classification has pretty much held up over time, but type 1's are the most common with anterior displacement of the radial head, type 2's posterior are less common and type 3's reduce it frequently and type 4's have anterior dislocation of the radial head, but also an associated radial shaft fracture.

What is new in the Monteggia world is that we have recognized over the past ten to fifteen years that there probably should be an eponym for the Monteggia equivalent. We are seeing so many injuries that don't fit any of the classification patterns, but they are basically Monteggia equivalents as you see here, ulnar shaft fracture injury distally, also radial neck fracture with displacement through the neck injury itself, sometimes with or without olecranon fractures. But there are numerous fracture patterns that fit the Monteggia equivalent and I encourage you to look for with a high index of suspicion when you see an isolated elbow injury, obviously evaluating the forearm and vice-versa.

In children the classic treatment has been by closed reduction. We can stabilize the ulna fracture and reduce the radial head in a congruous manner and simply casting in a stable position for four to six weeks. Many textbooks point out the importance of a concentric reduction of the radial head on all views. And as you see here, I think that is important to look at in both the AP and lateral views.

Here is a good example of a child that I saw a few years ago and treated in the Emergency Room, who came back to my office. You can see that the radial head was displaced anteriorly. There is plastic deformation of the ulna which should be straight essentially on the lateral view. This child should now be taken back and remanipulated with closed reduction and concentric alignment of the radial head and neck to the lateral condyle.

The type 3 injury is a particular problem because a number of these will be associated with olecranon injuries or greenstick fractures of the proximal ulna. This is very difficult to manipulate and in a lot of these cases I find that we have to do an open reduction of the ulna. Even though it seems stable it is really not aligned and often times it takes open reduction of that injury to be able to reduce the radial head.

If the radial head is irreducible because soft tissue is interposed, you need to think about two things. Number one, is the ulnar fracture stable, that is, is it out to length and straight? And is there interposed soft tissue and ligament, etc, between the radial head and the lateral condyle? This injury as I pointed out earlier, may require open reduction of the fracture; most likely it will and then if there is interposed soft tissue it can be extracted. But the failures of closed reduction are more common after the type 1 anterior, and interestingly enough, even more common after the type 3 laterals.

What's new in Monteggia's is that I find myself fixing this injury more than I did ten or fifteen years ago. If the ulna is unstable, there is no point in horsing around with cast management. Fix the ulna. In the adolescent, as you see here, this is fixed with plate fixation. In the younger child with a shaft injury I treat with intramedullary rodding of the forearm to maintain the arm and straighten out the length. Be aggressive with the ulnar fracture if it is causing problems with this injury. Don't try to manage this strictly with casting alone.

Finally regarding complications with this injury, it is really missing the radial head dislocation or the late Monteggia lesion. There are two options here. One is benign neglect and excise the radial head at skeletal maturity if the kid is symptomatic. A number of authors have shown that to relieve symptoms. They may gain a little bit of motion, but not very much.

The other option, which we prefer, is late reconstruction by ulnar lengthening angulation osteotomy and reduction of the radial head. Obviously, experience, particularly experience in elbow surgery is required do this well. Here is an example of a late Monteggia reconstruction. Again, simply late displacement of the radial head, lengthening angulation osteotomy done here, fixation has been removed with reduction of the radial head.

Is it necessary to reconstruct the annular ligament? I think it should be done, 3 to 6 months post injury, if gross instability and masses of fibrous tissue are present in that region and particularly in Monteggia's. It is not necessary in every case.

So I would like to thank you for the gracious invitation to come visit. It is a real honor to be here to honor Leon Root. I have admired him from afar for many, many years. I thank you all for your hospitality and it has been pleasure being with you.

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posted 11/1/2002