Johnny is five. He fell onto his outstretched arm and now is sat in your ED, crying and holding his shoulder adducted. Triage has been ace and given him analgesia so he is adequately comfortable before you examine him.
Joint examinations can be easily remembered by “look, feel, move” and special tests. It’s important that in addition to the joint you’re interested in that you also examine the joint above and below.
Look
Deformity
Swelling
Atrophy: Asymmetry
Wounds
Bruising
Skin tenting (typically clavicular fractures, whereby the bony fragment is causing pressure on the skin and thought to cause skin necrosis, although this is controversial)
A chaperone may be needed to expose the joint adequately in older children.
Feel
Feel for warmth, which could indicate septic arthritis.
Always check the regimental patch for axillary nerve injury and document it.
Move
Assess for range of motion, both active and passive.
Flexion: 180 degrees. Raise arm forward up until they point to the ceiling.
Extension: 45-60 degrees. Stretch the arm out behind them.
ABduction: 150-160 degrees. Put arms out to the side like an aeroplane’s wings and then bring them above their head to point to the ceiling.
ADduction: 30-40 degrees. Put arms out to the side like an aeroplane’s wings and move them in front of their body so they cross over.
External rotation: 90 degrees. Tuck their elbows to their side and swing the hands out.
Internal rotation: 70-90 degrees. Tuck elbows to the side and bring their hands across their tummy.
Scapula winging: Ask the child to push against the wall or your hand. If the scapula wings out this suggests long thoracic nerve pathology.
Some special tests
It is easy to get lost in the number of special tests when examining the shoulder and the trick is to perform those most relevant to the patient in front of you. Many are to test the integrity of the rotator cuff tendons, i.e. Supraspinatus, Infraspinatus, Teres minor and Subscapularis. (SITS)
“Appley Scratch” test: (1)Ask thechild to reach behind their back to touch the inferior border of the opposite scapula (internal rotation and aDDuction) and then (2) reach behind their head to touch the superior angle of the opposite scapula (external rotation an Abduction). A positive test of pain indicates tendinitis of the rotator cuff, usually supraspinatus.
Empty can test: Ask the child to hold their arm raised parallel to the ground and then point their thumbs towards the ground as if they were holding an empty can (this rotates the shoulder in full internal rotation while in abduction). Then push down on the child’s wrist while asking them to resist. A positive test is pain or weakness, suggestive of supraspinatus tear or suprascapular nerve neuropathy.
Lift off test:The child stands and places the back of their hand against their back. Put your hand against theirs, palm to palm, and ask them to push against you. A positive test is pain or weakness, indicating subscapularis muscle pathology.
Scarf test: Ask the child to wrap their arm over the front of their neck reach down over their opposite shoulder towards the scapula (like a scarf). Pain over ACJ when doing this indicates ACJ pathology.
Although the standard approach to limb examination involves a LOOK, FEEL and MOVE (and special tests) structured assessment, in reality, if a young patient has a significant injury, a more pragmatic approach is needed. An X-ray may be warranted before a more thorough exam. This doesn’t mean that you can get away without a documented range of motion exam (even if you explain it is limited by pain) and neurovascular assessment.
Back to Johnny. You noticed a deformity over the middle third of the clavicle, but no skin tenting. He was neurovascularly intact and range of movement only marginally reduced by pain, so you discharged him with a broad arm sling and follow-up (or not) according to your local guidelines.
Selected references
Carson, S., Woolridge, D.P., Colletti, J. and Kilgore, K. (2006) Pediatric upper extremity injuries. Pediatric Clinical North American: 53(1) pp. 41-67
Chambers, P.N., Van Thiel, G.S. and Ferry, S.T. (2015) Clavicle Fracture more than a theoretical risk? A report of 2 Adolescent cases. The American Journal of Orthopedics. 44(10)
McFarland, E.G., Garzon-Muvdi, J., Jia, X., Desai, P. and Petersen, S.A. (2010) Clinical and diagnostic tests for shoulder disorders: a critical review. British Journal of Sports Medicine. 44(5) pp. 328-32.
Cite this article as:
PJ Whooley. Proximal humeral fractures, Don't Forget the Bubbles, 2021. Available at: https://doi.org/10.31440/DFTB.31855
“Slow down!” Joel’s mom shouts at him as he whizzes past on his scooter. Joel turns to answer and doesn’t see the curb which he hits, goes flying and puts out his hand to stop himself. Mom is already running to find him holding his arm.
Proximal humeral fractures are uncommon, accounting for less than 5% of all paediatric fractures. The anatomic characteristics of the proximal humerus can explain the various fracture presentations, complications and outcomes.
Anatomy
Ossification centres
The proximal humeral physis has three ossification centres. Head, lesser tuberosity and greater tuberosity. The capital centres appear at 3 months whereas the two others appear at 1 year of age and fuse between 3 & 5 years to produce tuberosity ossification. By the time the child’s 6, the capital and tuberosity centres fuse into a single proximal epiphyseal centre. At this point it acquires a characteristic ‘tent’ or inverted V shape. This results also in a double contour that can complicate the interpretation of the images. The proximal physis accounts for approximately 80% of the longitudinal growth of the entire bone.
Periosteum
This thick sleeve of periosteum is present along the shaft and limits fracture displacement and promotes healing.
Nerves
The axillary nerve, which supplies the sensory innervation to the regimental badge area, is at potential risk in displaced proximal humeral fractures. However, axillary nerve damage is rare, the majority being only a temporary neuropraxias.
Epidemiology
Proximal humeral fractures show an early modest peak at 10-14 years of age, account for up to 3.5% of all fractures, followed by return to low levels in young adults and then a second increase in later adulthood.
These fractures account for a third of all humeral fractures in neonates and are the second most common birth injury after clavicular fractures. However, they are still rare, occurring in only 0.03 per 1000 births.
The pattern of injury varies with age. Metaphyseal proximal humeral fractures are proportionately higher in pre-pubertal children, compared to a higher proportion of epiphyseal separation in adolescents.
As with any fracture, be aware of the potential of a non-accidental cause. These fractures, can be associated with physical abuse.
Mechanism of Injury
Indirect
Proximal humeral fractures in non-newborns commonly result from a fall backwards onto an outstretched hand with elbow extended and wrist dorsiflexed or a direct blow to the lateral aspect of the shoulder. Pathological fractures can occur as the humerus is a common location of bone cysts and other benign lesions. This might occur with minimal trauma.
Birth injuries
The upper arm can be hyperextended or rotated during delivery, occurring more commonly in infants of diabetic mothers and with shoulder dystocia.
Clinical Evaluation
Newborns
Typically, a newborn with a proximal humeral fracture will hold their arm in extension. Consider these fractures if a history of birth trauma is given. If noted, then infection, clavicle fracture, shoulder dislocation and brachial plexus injuries need to be ruled out. These little ones may be irritable, particularly when the upper limb is moved.
Children and adolescents
As with other upper arm fractures, the typical presentation is with pain, dysfunction, bruising and swelling with a painful range of movement. Displaced fractures result in significant anterior swelling and altered shoulder appearance relative to the contralateral side.
A detailed distal neurovascular examination is needed including evaluation of the radial, ulnar, median, axillary and musculoskeletal nerves. Be particularly vigilant for any axillary nerve deficit with decreased sensation over the regimental badge area and loss of the deltoid muscle function (shoulder ABDuction).
Radiology
Proximal humeral fractures are identified on routine AP and axillary views of the humerus. If there is clinical concern of a dislocation then dedicated shoulder views should also be taken. If there is tenderness over the physis and no obvious fracture, a suspicion of a Salter Harris (SH) I fracture can be made. Imaging the contralateral humerus may be helpful to determine if there is any widening of the physis.
Patterns of fracture
There are two variations of proximal humeral fractures: metaphyseal and epiphyseal separation.
Metaphyseal fractures (70%) usually occur at the surgical neck, although can also occur at the metaphyseal-diaphyseal junction, typically a transverse or short oblique fracture. These fractures typically occur in 5-12 year olds.
Epiphyseal fractures (30%) occur in the under 5s and over 12s. The type of epiphyseal fracture depends on skeletal maturity.
SH I fractures are less common and can be seen at all ages before growth-plate closure, most commonly in <5 year olds.
SH II fractures are the most common type, chiefly in adolescents over the age of 12.
SH III & IV fractures are exceedingly rare.
A metaphyseal fracture at the surgical neck of the humerus
Epiphyseal Salter Harris II fracture of the proximal humerus in a 6 year old
Pathological fractures
40% of pathological fractures involve the proximal humerus. The leading cause is a unicameral bone cyst, as this lesion develops in the proximal humerus in 51% of cases. Other causes are aneurysmal bone cysts, non-ossifying fibromas, fibrous dysplasia and bone malignancies.
Displacement
If a proximal humeral fracture displaces, it usually does so in a varus direction, with the humeral head moving medially and posterior to the shaft. This occurs due to pectoralis major traction pulling the distal segment medially, while the rotator cuff and deltoid pull the proximal component superiorly in a tendency towards flexion and external rotation. Displacement is often absent or minimal in 40% of metaphyseal fractures, but is more common in epiphyseal injuries, occurring in up to 85%.
Proximal humerus fracture in an 11 year old with varus deformity
Classification
The Neer-Horowitz classification is the most frequently used classification system for this type of fracture. It divides the proximal humerus into 4 parts, classifying fracture by the degree of displacement as well as the fracture line, consisting of:
Humeral head
Greater tuberosity
Lesser tuberosity
Humeral shaft
One-part fractures involve 1 – 4 undisplaced parts (<1cm AND <45 degrees)
Two-part fractures account for 20% of proximal humeral fractures, involving 2 – 4 parts, 1 of which is displaced (i.e. >1cm OR >45 degrees)
Surgical neck – most common
Greater tuberosity – often seen with anterior shoulder dislocation. A lower threshold for displacement (>5 mm) has been proposed.
Anatomical neck
Lesser tuberosity
Three-part fractures account for 5% of proximal humeral fractures and involve 3 – 4 parts, 2 of which are displaced (i.e. > 1cm OR > 45 degrees)
Greater tuberosity and shaft displaced with respect to lesser tuberosity and articular surface which remain together.
Lesser tuberosity and shaft are displaced with respect to the greater tuberosity and articular surface which remain together.
Four-part fractures are uncommon, occurring in less than 1% of proximal humeral fractures. They involve more than 4 parts, 3 of which are displaced (i.e. >1 cm OR > 45 degrees with respect to the 4th). Four-part fractures require operative reduction.
Management
Initial treatment
Displaced fractures can be very painful so ensure pain is addressed with adequate analgesia.
The aim of immobilisation is to keep the elbow by the side, flexed to 90 degrees with the forearm against the torso. A simple sling is sufficient plus / minus a swathe for younger ages. Straps and adhesive tape can be used as described by Durrajer. Other options include a shoulder immobiliser or a U-shaped coaptation splint.
Neurovascular status must be checked before and after immobilisation.
Orthopaedic consultation should be obtained if there is:
associated shoulder dislocation
intra-articular (SH IV) fracture
completely displaced fracture in a child over 12 years.
associated neurovascular compromise
open fracture (rare)
evidence of compartment syndrome
Definitive Treatment
Newborns usually have SH I fractures, which have an excellent prognosis. A sling and a swathe is sufficient for up to 4 weeks. The primary role of follow up is to ensure there is no brachial plexus injury.
Children and adolescents with minimally displaced fractures are usually managed with a sling or shoulder immobiliser. Gentle pendulum exercise is started between weeks 2 to 4 post injury and active range of movement at 4 to 6 weeks. We would expect near to normal function by 2 months.
Significantly displaced fractures in children 12 and under should be treated with a U-slab, sling and swathe.
Acceptable angulation
< 5 years – any degree is allowed as proximal humeral fractures in young children have excellent remodelling potential.
5 to 12 years – 40 to 70 degrees of angulation is acceptable
>12 years – up to 40 degrees of angulation or 2/3 displacement.
Operative
Fractures in which immobilisation would result in unacceptable alignment are managed with closed reduction +/- fixation. Open reduction and internal fixation (ORIF) is indicated if acceptable reduction is not possible due to soft tissue interposition. Most commonly this is caused by the long head of biceps tendon, but can also be caused by the joint capsule, infolded periosteum and deltoid muscle. ORIF is also indicated in open fractures, compound fractures and intra-articular displacement of the fracture.
Complications
Complicated are rare in children, but when do occur are more common in older children, with shortening of the humerus due to physeal damage. This usually has no functional affect. Radiographic malunion can occur but rarely has any functional affect.
Non accidental injury
And finally, as with any fracture, it is imperative that a mechanism inconsistent with an injury or fracture in an otherwise healthy child should prompt escalation and involve the child protection team.
Joel’s x-ray shows a proximal humeral fracture through the surgical neck, with 20 degrees of angulation. He’s placed in a shoulder immobiliser and followed-up in fracture clinic, where he’s advised to start gentle pendulum exercises after a couple of weeks. Two months later he’s back on his scooter, helmet on, flying down the pavement without a care in the world.
References
LA. Landin. Epidemiology of the children’s fractures. J Pediatric Orthop B. 1997;6(2):79
E.J. Ortiz, M.H. Isler, J.E. Navia, R. Canosa, Pathologic fractures in children. Clin Orthop Relat Res, 432 (2005), pp. 116-126
MW Shrader et al, Proximal humerus and humeral shaft fractures in children. Hand Clin 2007;23(4);431
Six-year-old Rosie was running in from the back yard when she just tripped over the skateboard that her mum had told her to tidy up. She landed directly onto her left arm. She was brought to the ED and it was noted she was unable to extend her left wrist and she had pins and needles over the back of her hand.
Humeral shaft fractures are uncommon, accounting for less than 10% of paediatric fractures. Children have a great ability to remodel and heal with little or no deformity despite significant displacement and angulation therefore most of these fractures can be managed with simple immobilization.
Anatomy
The thick periosteal sleeve of the humerus limits the displacement of humeral fractures and promotes excellent healing. The main anatomical feature that is important to remember is the radial nerve, which curves around the back of the mid humerus and is at risk of injury. That said, injuries of the radial nerve secondary to humeral fractures are rarely associated with long-term deficits with the majority being temporary neuropraxia.
Mechanism of injury
Neonates – hyper extension or rotation as they pass through the birth canal. The typical fracture is a transverse midshaft fracture.
Pathological fracture – suggested when a midshaft humeral fracture occurs after only minimal trauma. The humerus is a common site for bone cysts and other benign lesions. These occur most commonly in children 3-12 years of age.
Non accidental injury – Is the mechanism inconsistent with the injury or is there a fracture in a healthy child younger than 3 years? This should raise concern for child abuse. These fractures can be transverse fractures from a direct blow or an oblique or spiral fracture caused by traction with humeral twisting.
Evaluation
These injuries often present with mid arm pain and swelling. If a humeral fracture is present with no visible deformity, it is typically minimally displaced.
Determine if there is any distal neurovascular compromise (check out the elbow examination post for some top tips on neurovascular assessment in upper limb injuries). Vascular injuries are extremely rare but midshaft fractures are associated with radial nerveinjuries in 5% of fractures. This will be evident with paraesthesia / numbness in the dorsum of the hand between the 1st and 2nd metacarpal and motor deficit with reduced thumb and wrist extension and reduced forearm supination.
Radiology
Typical Anterior-posterior (AP) and lateral views are sufficient. A prominent vascular groove in the distal humerus is commonly seen on plain film and should not be confused with a fracture line.
There are four key descriptors of humeral fractures:
Anatomical location: proximal, middle or distal third
Fracture pattern: spiral, short oblique, transverse or comminuted
Degree of displacement and angulation
Presence of soft tissue damage: is the fracture open or closed?
Analgesia and immobilisation
Give early analgesia. These are sore and children often require opiate analgesia such as intranasal fentanyl or diamorphine, which are safe to give if there is no facial trauma or signs of head injury present.
Immobilization in a sling and swathe or shoulder immobilizer enhances patient comfort and reduces the chance of further fracture displacement. Be sure to check for and document any neurovascular deficit pre and post immobilization.
Infants – sling and a swathe for 4 weeks is sufficient regardless of the degree of displacement.
Older children – In incomplete fractures then a sling and swathe, a collar and cuff sling or a shoulder immobiliser can be used.
Complete and moderately displaced fractures are better managed in a hanging U-slab. This uses gravity to decrease the deformity by relaxing the muscles and also improves the child’s comfort. Provided there is no radial nerve injury, the fracture can be reduced under procedural sedation to improve clinical alignment. After reduction, the child is placed in a U-slab or coaptation splint for 2 weeks. In the fracture clinic, they will then be reassessed and braced in a functional clamshell brace until approximately 4 weeks.
Hanging U-slab
Refer for orthopaedic assessment in ED if there are any of the following features present:
Compound fracture with neurovascular compromise
Open fracture
100% displacement
Fracture with clinical deformity
Angulation more than 20° in children and 10° in adolescents
Compartment syndrome (rare in midshaft humeral fractures)
Operative management involves open reduction and internal fixation. It is indicated in many of the above but also the multiply injured patient to aid in early ambulation including concomitant forearm fractures resulting in a “floating elbow”.
‘Floating elbow’ in a child with concomitant humeral and forearm fractures. Image from Orthobullets.com
Outcomes
Malunion is common, but there’s usually little functional loss. These remodel well.
Initial fracture shortening may be compensated for by later overgrowth
Nonunion is uncommon
Radial nerve palsy is less common, and when occurs, is usually a temporary neuropraxia
Rosie was brought to theatre for an open reduction of her left midshaft humerus fracture. The radial nerve was trapped in the fracture line but not severed. After a few weeks of physio Rosie has regained full movement of her wrist and hand and she loves the fact that she has a scar on her arm. Skateboards have been banned from the house…
References
JC. Cheng, JY. Shen. Limb fracture pattern in different pediatric age groups: a study of 3,350 children. J Orthop Trauma. 1993;7(1):15
S. Carson, DP. Woolridge, J. Colletti, K. Kilgore, Pediatric upper extremity injuries. Pediatr Clin North Am. 2006 Feb;53(1):41-67, v.
Figure 3 – Case courtesy of Dr Hani Salam, <ahref=”https://radiopaedia.org/”>Radiopaedia.org</a>. From the case <ahref=”https://radiopaedia.org/cases/13537″>rID: 13537</a>
Cite this article as:
PJ Whooley and James Foley. Shoulder x-ray interpretation, Don't Forget the Bubbles, 2020. Available at: https://doi.org/10.31440/DFTB.29653
Don’t be bamboozled by a paediatric shoulder x-ray. Use an ABCD approach and pick up some tips and tricks in our step-by-step guide.
A – An adequate x-ray
Is it the right patient and do you have the 2 views you want to see? The typical views are AP (external rotation) and the scapular Y view. (Not sure why then thisx meme may help). Occasionally an axillary view is added to assess for dislocations and glenohumeral instability.
AP view
Lateral view
Y view
B – Bones
Go through the bones one at a time. Follow the cortex of every bone in each view. Look for a disruption or a buckle in the cortex or any fracture fragments. They should all be smooth.
The clavicle is a good bone to start with – it is by far the most common paediatric shoulder injury. Midshaft fractures account for 80% of clavicle fractures. Make sure there are no distal or medial fractures as they can often be subtle.
Move onto the proximal humerus – check the epiphysis and metaphysis. A normal humeral head looks like a walking stick on the AP view. The most common fracture of the humerus is a metaphyseal fracture. Metaphyseal fractures occur in ages 5-12 and Salter-Harris fractures outside of this range.
Don’t forget the scapula, seen best on the Y view. Management is conservative but a fracture here indicates a significant trauma.
Like the paediatric elbow, the paediatric shoulder has ossification centres, so x-ray appearances differ depending on the age of the child.
At birth, the humeral diaphysis, mid position of clavicle and the body of the scapula are ossified – the rest are essentially cartilage.
The proximal humerus has three ossification centres:
Look carefully for the following two – if they appear early they may be the only sign of an avulsion fracture:
The sub-coracoid ossificiation centre appears between 8 to 10 years and completely fuses between 16 and 17 years of age, forming the upper third of the glenoid articular surface . If it appears before the age of 8, this may indicate an avulsion (pulled by the long head of biceps at its attachment to the superior glenoid).
The inferior glenoid ossification centre, appears at the lower two-thirds of the glenoid articular surface. It grows and fuses to form a horseshoe shaped epiphysis that combines with glenoid rim and sub-coracoid ossification centre. This appears between 14 and 15 years (although sometimes as young as 11 years), with complete fusion by 17 to 18 years. It can be difficult to view on standard radiographs but sometimes it can be seen on the Grashey (AP oblique) view
A top tip: If you are unsure whether what you are seeing is an avulsion fracture or a simple ossification centre, then press directly on the patient where the fragment is. If this isn’t painful then it is highly likely to be an ossification centre and not an avulsion. Range of movement is another great give-away – it is quite hard to have an avulsion fracture and intact range of movement! If in doubt, speak to a friendly radiologist (in hours) or be conservative and place in an arm sling and bring back to clinic (out of hours) for re-assessment (when the x-ray will have been reported).
Don’t forget the other bones that don’t make up the shoulder. Have a look for rib fractures, and if you see old healing rib fractures then consider non accidental injury.
C – Connections & Connective Tissue
Are all the bits connected to where they should be? Ask yourself a few questions when you’re looking at the different joints.
Glenohumeral joint:
Do the articular surfaces of the humerus and glenoid have 2 parallel lines with an even joint space?
Does the humeral head sit evenly on the glenoid in all views?
Does the humeral head sit adjacent to the glenoid on the AP view? Does it sit over the glenoid on the Y view? If the answers to these questions are no, and instead the humeral head is lying under the coracoid process, this indicates an anterior shoulder dislocation
Anterior Shoulder Dislocation (AP and Y views).The humeral head is located beneath the coracoid on the AP view and no longer located centrally on the Y view. In addition there is flattening of the humeral head suggesting a Hill Sachs lesion (more on this in the upcoming shoulder dislocation post)
Has the humeral head lost its characteristic walking stick appearance on the AP view? Does it instead look rounder, like a light bulb? If the answer to these questions is yes, this suggests a posterior shoulder dislocation.
Is there a joint effusion or lipohaemarthorsis present? This could indicate an intra-articular fracture of the glenoid or the humeral head.
Does the bottom of the acromion lines up with the bottom of the distal clavicle? If there’s a step, think clavicle fracture or physeal injury
Normal alignment of the AC joint
Is there widening of the acromioclavicular joint (normal is 5-8mm) or coracoclavicular distance (normal is 10-13mm)? A widened AC joint > 8mm suggests an AC ligament rupture. If the coracoclavicular (CC) distance is >13 mm consider CC ligament rupture. If you’re unsure, get weighted views of both AC or CC joints to compare each side (literally with the child holding weights in each hand to stress the joints).
AP view of shoulder
D – Don’t forget the other tissues
Always look around the area to look for foreign bodies or subcutaneous emphysema indicating a pneumothorax or pneumomediastinum. If there are, then a dedicated chest x-ray should be performed.
And finally, although the above may seem complicated, realistically common things are common.
Clavicle Fractures. By far the most common. 80% are mid-shaft and occur following a fall onto the outstretched hand or shoulder or direct trauma from a seatbelt or during sport.
Proximal humeral fractures. These occur in older children.
Anterior shoulder dislocation. Usually in older children playing sports. Falls result in forced ABDuction, external rotation, and extension. Account for 95% of shoulder dislocations.
Don’t miss
Acromioclavicular Joint injuries – widening or step at acromioclavicular joint and/or increased coraco-clavicular distance.
JS. Zember, ZS Rosenberg, S. Kwong, SP. Kothary, MA. Bedoya. Normal Skeletal Maturation and Imaging Pitfalls in the Pediatric Shoulder. Radiographics. 2015 Jul-Aug;35(4):1108-22
Cite this article as:
Lisa Dunlop. Lateral condylar fractures of the humerus, Don't Forget the Bubbles, 2020. Available at: https://doi.org/10.31440/DFTB.21030
Six-year-old William was playing hopscotch in the playground but fell, landing on his left outstretched hand. Afterwards, he complained of left elbow pain and was taken to the local Emergency Department. He was told that he had a lateral condylar fracture of the humerus…
Epidemiology
This is a relatively common fracture in the paediatric population and occurs mainly in children below the age of 7 years old, with a mean age of 6. It accounts for approximately 10-20% of paediatric elbow fractures and is the second most common intra-articular fracture.
History
The most common aetiology for this fracture is a fall onto an outstretched hand. The patient will complain of pain to the lateral aspect of the elbow. The level of pain may be low in minimally displaced fractures.
Examination
Have a look at our post on elbow examination for tips on how to do a full assessment of a child’s elbow.
Inspection of the joint will reveal an elbow with swelling to the lateral aspect. There is usually minimal deformity. Bruising may indicate a brachioradialis tear and therefore likely instability. Tenderness is usually limited to the lateral aspect and crepitus may be palpated on movement. Wrist flexion and extension may reproduce the pain.
It is important to carefully examine the joint below and above the injured area. Don’t forget to examine the rest of the child for other injuries.
Remember to be suspicious of non-accidental injury in cases where there are inconsistencies in the history and injury type.
Investigations
AP and lateral x-rays of the elbow are required. Oblique views can be valuable if no fracture is seen on lateral or AP views but clinical suspicion remains. This is where your knowledge of the ossification centres comes into play (for detail on this see CRITOE). The ossification centres appear on x-rays in the order: Capitellum, Radial head, Internal epicondyle, Trochlea, Olecranon and the External epicondyle, also known as the lateral condyle. The lateral epicondyle appears at the age of 8-12 years old and fuses at age 12-14 years old.
The paediatric elbow is largely cartilaginous. Lateral condylar fractures often only affect the cartilaginous part of the humerus. As cartilage is not radiopaque, the true extent of the fracture is often not fully understood when looking at the x-ray.
The presence of anterior and posterior fat pads may often be the only indication that a fracture is present.
The most commonly associated fracture is the ipsilateral elbow dislocation (usually posterolaterally) and ipsilateral humeral fractures (most commonly the olecranon). Ensure you obtain radiographs for other suspected fractures.
Lateral condyle fractures can be classified depending on their x-ray appearances.
Classification
There are several different classification methods. The most common classifications as below.
Milch Classification
Type 1
The fracture line is lateral to the trochlear groove… not into the humero-ulnar joint
Type 2
The fracture line is medial to the trochlear groove and is, therefore, a fracture-dislocation and unstable.
Milch Classification
Jakob Classification
Stage 1
<2mm displacement, which indicates intact cartilaginous hinge
Stage 2
2-4mm of displacement
Stage 3
>4mm displacement with rotation of the fragment
Jakob Classification
Immediate treatment in the ED
Provide immediate adequate analgesia to the child prior to any examination or investigation.
If the fracture is open, conservatively manage the wound, consider tetanus status and antibiotics.
Keep the child nil by mouth as they may need urgent surgery.
Treatment following imaging
Treatment depends on the degree of displacement of the fracture.
Due to the high complication rate of these fractures, all lateral condylar fractures should be referred for to the on-call orthopaedic team while in the Emergency Department.
Jakob classification
Treatment option
Follow up
Stage 1 (<2mm of displacement)
Conservative management with immobilisation with above elbow cast to 90 degrees.
Weekly imaging in fracture clinic with the cast in place for 4-6 weeks.
Stage 2 and 3 (> 2mm with or without rotation)
These all must go to theatre and have closed reduction with percutaneous pinning or open reduction with screw fixation.
3-6 weeks in above-elbow cast and orthopaedic follow up.
Areas of controversy
Serial radiographs are often recommended in the management of conservative management minimally or undisplaced lateral condylar fractures. A systematic review by Tan et al 2018 found that serial X-rays have no clinical significance. However, if the 1 week up x-ray is not satisfactory, this should be followed up appropriately under the patient’s treating orthopaedic team.
Potential complications
This type of fracture is associated with a high rate of complications, which usually develop later, during the healing process.
The reduction must be accurate. If there is malunion, the fragment does not adequately unite or the epiphyseal plate is damaged then complications may occur:
Stiffness is the most common complication, usually fully resolving by 48 weeks.
Delayed union occurs if the fracture has not healed after 6 weeks. This usually occurs if the fracture visible at 2 weeks.
Non-union is more likely when delayed union occurs.
Cubitus valgus deformity occurs with lateral physeal growth arrest.
Delayed “tardy ulnar palsy” may develop as the child grows and the ulnar nerve is stretched across the elbow with valgus deformity.
Avascular necrosis may develop 1-3 years after the fracture.
Lateral condylar fractures of the humerus can present with minimal pain or deformity and can be missed (16.6% misdiagnosed as presented by Tan et al 20181). Due to the high rate of complication, it is important that we do not miss these fractures.
William was found to have an isolated Jakob stage 3 type lateral condylar fracture and was taken to theatre that evening. Open reduction was required, and internal screw fixation secured the fragment. His cast was removed 4 weeks after and his joint mobility continues to improve.
References
Bowden G, McNally MA, Thomas RYW, Gibson A. 2013. Oxford Handbook of Orthopaedics and Trauma, Oxford Medical Publications. Page 564-5
