Sports Medicine: Just the Facts

PEDIATRIC FRACTURES

RADIOGRAPHIC EVALUATION

•Physicians evaluating pediatric elbow fractures must
be familiar with normal developmental anatomy as
well as secondary ossification centers about the
elbow.

• It may be helpful to obtain contralateral comparison
  view for comparison because of the confusion
  between ossification centers and fractures.


• The proximal radius should point to the capitellum in
  all views. The long axis of the ulna should line up
  with or be slightly medial to the long axis of the
  humerus on a true anteroposteior(AP) view. The
  anterior humeral line should bisect the capitellum on
  the lateral view. The humeral-capitellar (Baumann’s)
  angle should be within the range of 9–26°of valgus
  (Vitale and Skaggs, 2002).
  •A posterior fat pad sign is always considered to be an
  abnormal radiographic finding, and represents an
  elbow fracture 76% of the time as per a recent prospec-
  tive study (n =45) (Skaggs and Mirzayan, 1999).


• An anterior fat pad sign represents a superficial part of
  anterior fat pad and should be in front of coronoid
  fossa. In normal elbow the anterior fat pad should be
  barely visualized.


• Look for small radiolucent area between bony rim and
  moderate opaque shadows of brachialis.
  •With joint effusion, there will be anterior and superior
  displacement of anterior fat pad (Skaggs and Mirzayan,
  1999).

OSSIFICATION CENTERS OF THE ELBOW

• Capetellum (appears age 1–2)


• Radial Head (appears age 2–4)


• Medial epicondyle (appears age 4–6)
  •Trochlea (appears age 8–11)


• Olecranon (9–11 years)


• Lateral epicondyle (appears age 10–11) (Vitale and
  Skaggs, 2002)
  •A well known, but ribald, mnemonic exists to remem-
  ber this order, but will not be repeated here. (So sue
  me; just remember: you Can’t Resist My Team Of
  Lawyers.)

SUPRACONDYLAR FRACTURES

• Extra-articular supracondylar fractures are extremely
  common in the pediatric population, and represent
  10% of all pediatric fractures. Occur due to fall on

hand or elbow. Extension pattern is far more common

(98%) (Vitale and Skaggs, 2002).

• Performance of a careful neurovascular examination
  is crucial. Any of the neurovascular structures cross-
  ing the elbow joint may be at risk. Radiographs are
  mandatory. The pulseless, poorly perfused hand is a
  true emergency. It is important to rule out vascular
  injury. Vascular injuries are more commonly associ-
  ated with posterolateral displacement, and higher
  grade injuries. The medial spike may tether the
  brachial artery. One must perform frequent rechecks
  of the radial pulse to document its presence as well as
  its quality. An intimal arterial injury may not be ini-
  tially apparent, but may develop over hours.
  Compartment syndromes must be treated emergently,
  and must be carefully watched for (Shaw et al, 1990).


• The anterior interosseus(AI) nerve is most frequently
  injured nerve, most recover spontaneously within
  6 months. The AI nerve can be checked by having the
  patient make an “OK” sign. With posteromedial dis-
  placement, the lateral spike of proximal fragment may
  tether the radial nerve (Ippolito, Caterini, and Scola,
  1986).


• Clinical signs include the “dimple sign” that occurs
  when the fracture ends are caught in the brachialis and
  subcutaneous soft tissues. The olecranon and the two
  epicondyles should form a straight line in the
  extended position, and a triangle when the elbow is
  flexed to 90°. This relationship is unchanged in a
  supracondylar fracture, but is altered by an elbow dis-
  location (Harris, 1992).
  •Treatment is defined by stability of fracture pattern as
  defined by Gartland classification. Type I is nondis-
  placed, type II exhibits anterior gapping, limited rota-
  tional malalignment, and an intact posterior hinge.
  Type III fractures have no cortical continuity and are
  totally unstable. Minimally displaced may be treated
  with splinting, types II and III require reduction most
  require operative intervention to maintain stability
  while in a 90°position of flexion (Harris, 1992).
  •Following reduction, it is crucial to perform a repeat
  neurovascular examination and again check radi-
  ographs.


• Long term sequelae of the supracondylar fracture are
  extremely important and include the following
  (Ippolito, Caterini, and Scola, 1986):
  
  
  1. Cubitus varus is the most common complication
     following supracondylar humerus fracture. It is
     primarily a cosmetic deformity, and does not usu-
     ally create a loss of function. Previously, cubitus
     varus was thought to be created by growth distur-
     bamce, but it is now believed to be due to imper-
     fect fracture reduction. It is extremely important to
     have perfect fracture rotation.
  
  
  
  

294 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE