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New Clinical Practice Guideline For Treating Common Elbow Fractures In Children

The American Academy of Orthopaedic Surgeons (AAOS) Board of Directors has recently approved and released an evidence-based clinical practice guideline (CPG) on “The Treatment of Supracondylar Humerus Fractures.”

Supracondylar humerus fractures are common and likely occur when children are playing, or while climbing trees, jungle gyms and other structures. When young children fall, they tend to hyperextend their arms. As a result they land on a stiff arm, often fracturing the arm, just above the elbow joint.

In addition to the broken bone, the sheer force of this type of fall, may cause “all kinds of consequences. The artery which provides blood to the forearm and hand – runs very close to the elbow, as do the three main nerves of the arm: median, radial and ulnar. As a result, elbow fractures can cause circulation problems, and in 10 to 15 percent of cases, nerve injuries.

This new guideline is the result of a robust review of more than 350 research studies on this topic and includes 14 recommendations on how to stabilize the fracture, remedy circulation problems, and ultimately, ensure the fastest and most comfortable recovery for each child.

Important findings:

  • First, the guideline recommends that surgeons stabilize the fracture with “two or three laterally introduced pins to stabilize the reduction of displaced, misaligned, supracondylar fractures of the humerus.”
  • In addition, the guideline recommends procedures to restore blood flow and circulation if the artery has been stretched, torn or severed. Orthopaedic surgeons know that the first thing to do with an arm without a pulse is to gently realign the arm. Once the fracture is put back into the proper position and established, circulation will likely recover.
  • However, sometimes there is still no pulse in the arm following realignment. This can occur with or without adequate blood flow. The guideline recommends the surgical “exploration” of the blood vessels and nerves in front of the elbow in patients with no wrist pulse, if the hand remains cold and underperfused (without adequate blood flow), to “ensure survival of the tissues in the arm and hand.” In these rare instances, further surgery may be necessary “to prevent rare, but serious, limb threatening and life threatening consequences,” according to the guideline.

The guideline states: “If the hand feels warm, has color from circulation that you can see, and the child can move the muscles of the forearm and demonstrate some motion, then there is evidence that tissues are being nourished despite the absent pulse.” The guideline does not specifically recommend surgery or observation in these cases.

“Ultimately, each physician must evaluate his or her patient’s condition and circumstance and figure out ‘how do I best treat this child.

More about supracondylar humerus fractures

The humerus is the upper arm bone that connects the shoulder to the elbow. A supracondylar fracture of the humerus occurs just above the elbow joint. Treatment may consist of both surgical and nonsurgical options, but depends on the type of fracture and the degree of displacement.

Elbow Fractures in Children

Broken elbows are common injuries in children. Many activities kids participate in make their elbows vulnerable to injury. Furthermore, there are several growth plates (areas of bone that are actively growing) around the elbow joint. These growth plates are susceptible to injury. Children who have elbow injuries should be evaluated by a physician for a fracture.
What causes an elbow fracture in children?
Many activities can cause elbow fractures in children, but jungle gyms are far and away the primary culprit! Kids falling from jungle gyms can injure their elbows as they fall to the ground. Other common activities that cause elbow injuries include gymnastics, football, jumping on beds, and rough play.

When should I have my child see a doctor about an elbow injury?
If you are unsure of the diagnosis it is always safest to have your child seen by their pediatrician or in the emergency room. Signs that should tip you off to a problem include:

  • Inability to straighten or bend the elbow
  • Swelling or discoloration (bruising) around the elbow
  • Pain around the elbow joint
How is an elbow fracture diagnosed?
Your doctor will first evaluate your child’s arm for signs of damage to the nerves and blood vessels around the elbow joint. While damage to these structures are uncommon, it is important to know if there is a problem. Injuries to blood supply of the arm may necessitate early surgical intervention.

X-rays are used to diagnose elbow fractures. In more severe injuries, the fracture will be easily seen on x-ray, but it is not uncommon to have some types of elbow fractures that do not show up on x-ray. The reason is that growth plate fractures may not show up on x-ray like normal broken bones. Therefore, your doctor may request an x-ray of the opposite elbow (your child’s uninjured side) to compare the two for differences. Often the only sign of a broken elbow in a child is swelling seen on x-ray (the so-called ‘fat-pad sign’). In this case, the elbow should be treated as having a break.

What is the treatment of an elbow fracture in a child?
Treatment of elbow fractures depends on several factors including:

    • Location of the fracture
    • Amount of displacement of the fracture
    • Age of the patient
    • Damage to nerves and blood vessels

Some common types of elbow fractures include:

  • Supracondylar Humerus Fracture: The supracondylar fractures are the most common type of elbow fracture. They occur through the growth plate of the humerus (above the elbow joint). The most common cause of these injuries is a fall onto an outstretched arm–often a jungle gym. These injuries most commonly occur in children between the ages of 5 and 7 years old.
  • Condylar Fractures: Condylar fractures also occur just above the elbow joint. When a child sustains a condylar fracture he or she has broken off just one side of the elbow joint.
  • Radial Neck Fractures: Radial neck fractures are uncommon in adults, but often occur in children. The treatment of a radial neck fracture depends on the angulation of the fracture. Treatment may consist of casting, manipulation, or possibly placing pins across the fracture.
  • Radial Head Subluxation: While not a broken bone, a radial head subluxation is a common injury in a young child’s elbow. When a radial head subluxation occurs, the elbow joint slides out of position. These injuries are usually placed back into position quite easily.
  • Olecranon Fractures: Olecranon fractures are injuries to the prominent bone over the back of the elbow. Injuries to this bone can be difficult to differentiate from normal growth plate appearances, so often x-rays of both elbows are obtained for comparison.
  • Splints
    Splinting is the treatment for many elbow fractures, especially those that have minimal displacement (are not out of place). A splint is also commonly used when there is suspicion of an elbow fracture but with normal x-rays.In the case of normal x-rays, a splint will be placed and your child will have new x-rays about a week after injury. The repeat x-rays often show signs of healing of the fracture.

    • Casts
      Casts are often used to treat elbow fractures, but not after the initial injury. More commonly the elbow will be splinted for a week, and a cast may be placed after the swelling has had time to subside.
    • Surgery
      Surgical options include:

      • Pins
        Pins are often used to stabilize the fracture in proper position. The pins are placed by an orthopedic surgery with your child under general anesthesia. The pins hold the fracture in proper position until sufficient healing has taken place, usually about 3 to 6 weeks. A small incision may be necessary to reposition the fracture and to protect the nerves around the elbow joint.
      • Screws
        In older children, sometimes a screw is used to hold the fracture in proper position. Pins are usually used in younger children, but in children who are approaching skeletal maturity a screw may be used instead.

    What are the long term complications of elbow fractures in children?
    Because the fractures are often around the growth plate, there is always a change of injury to the growth plate. This may cause early closure of the growth plate. This is uncommon, and the only way to tell is the growth plate is permanently injured is to watch the child over time.Other potential complications include restriction of motion of the elbow joint, damage to nerves and blood vessels around the elbow, and infection of the pins that are place into the elbow.

    Complications are unusual, but they do occur in a small percentage of patients. Your doctor will follow your child until fracture healing is complete, and then may ask for a follow-up to ensure growth and motion around the elbow is normal. The parent can also monitor the elbow joint and alert the doctor if there is suspicion of a problem after a fracture.

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