Edited by Nattaly Greene, David Evans - 7/1/2021
Descriptors
- Common in children, mostly amongst 9-10 year olds
- Normally occur after fall onto an outstretched arm with an associated valgus force
- Often associated with other injuries including elbow dislocation, olecranon fractures, medial epicondyle fractures, and ulna shaft fractures
- Most are metaphyseal fractures but if they affect the physes the radial head is at high risk of avascular necrosis
Exam Pearls
- Lateral elbow swelling, ecchymosis, pain and limited range of motion
- Assess pronation and supination
- Neurovascular exam focusing on assessment of PIN
- Ensure no forearm compartment syndrome
Workup
Radiographs: Xrays of elbow. AP and lateral of the elbow and radiocapitellar (Greenspan) view - oblique lateral performed by placing the arm on the radiographic table with the elbow flexed at 90 degrees and then thumb pointing upward. Beam is directed 45 degrees proximally.
Things to look out for - Pay close attention for posterior fat pad which should be treated as an occult fracture
Normal angulation 15 degrees of valgus and 5 degrees of apex anterior
Due to the annular ligament stabilizing the distal fragment, translation is often seen at the fracture site
Other imaging: Usually Xrays are sufficient
Other: Normal ossification pattern of elbow and proximal radius is needed for a correct diagnosis
Age of ossification centers: Capitellum (1yr) Radius (3yr) Internal or medial epicondyle (5yr) Trochlea(7yr) Olecranon (9yr) External or lateral epicondyle (11yr)
Radial head 3-5 years - radial head fuses with the radial shaft around 16 years
Management
Need for acute intervention: Fractures with less than 30 degrees of angulation and <2-3 mm translation may be treated closed without need for reduction as long as full pronation and supination is present
Fractures with angulation >30 degrees and translation >3mm (50%) require closed reduction under conscious sedation
Patterson maneuver Hold elbow in extension while applying distal traction and varus stress on a supinated forearm with direct pressure over the radial head
If closed reduction in the emergency room is unsuccessful, then proceed to operating room for percutaneous assisted reduction. Irreducible or unstable fractures treated with open reduction and internal fixation.
Weight-bearing and range of motion: Non weight bearing; immobilization in long arm cast for 7 days followed by early range of motion
Type of immobilization: Long arm bivalved cast with arm in supination
Admission or discharge status: If reducible to within acceptable parameters and adequate ROM, patient may be discharged with follow up in 1 week
Anticoagulation: None
Antibiotics: None
Surgical Indications
Absolute: Open fracture or inability to adequately reduce fracture under conscious sedation