Elbow Fractures in Children:

Diagnosis and Management

David L. Skaggs, MD

Abstract

Fractures about the elbow are very common in children, but the anatomy of the nonossified cartilage, one often
child’s elbow may make the diagnosis less obvious than in a mature skeleton. must rely on the relationships of
An understanding of the ossification and fusion of the secondary growth centers ossification centers to define the
about the elbow is essential to avoid overlooking these injuries and to optimize injury (Fig. 2). The following ana-
treatment. If plain radiographs are equivocal, an arthrogram of the elbow may tomic relationships should be
clarify the anatomy and diagnosis. Early neurologic and vascular complica- established on all radiographs of
tions are not uncommon and must be recognized before fracture reduction. children’s elbows as part of a trauma
Many late complications, such as malunion, osteonecrosis, and physeal bridg- evaluation:
ing, are largely preventable by correct early diagnosis and treatment. Anatomic (1) The radius should point to
reduction of articular surfaces, restoration of physeal anatomy, and near- the capitellum in all views. If it
anatomic alignment of fracture fragments in the frontal plane are the corner- does not, a lateral condyle fracture,
stones of successful treatment of pediatric elbow fractures. a radial neck fracture, a Monteggia
J Am Acad Orthop Surg 1997;5:303-312 fracture or equivalent, or an elbow
dislocation should be considered.
Normally, the radial neck may be
in as much as 15 degrees of valgus
Elbow fractures in children present order, with those of girls usually a angulation and may be 10 degrees
the practicing orthopaedist with year or two ahead of those of boys. anterior to the radial shaft.
many challenges. The diagnosis The general order of ossification (2) The long axis of the ulna
may be difficult because a large provides landmarks to define the should be in line with and slightly
portion of the elbow is radiolucent anatomy of the largely cartilagi- medial to the long axis of the
in very young children, and the nous elbow during early childhood, humerus on a true anteroposterior
physical examination of an unco- but the actual order of appearance (AP) view. If it is not and if the
operative child with a grossly varies from individual to individ- radial head and capitellum remain
swollen elbow is problematic. ual.1,2 The capitellum appears first, in correct alignment, a transphy-
Furthermore, both acute and long- often by 1 year of age and always seal injury or a displaced supra-
term complications associated with by age 2. The epiphysis of the head
these fractures are notorious. A of the radius and the medial epi-
thorough understanding of the condylar epiphysis appear next, at
Dr. Skaggs is Assistant Professor of Orthopedic
anatomy of the immature elbow, as age 4 or 5. The trochlea and the Surgery, University of Southern California
well as modern techniques of frac- olecranon epiphysis appear next, School of Medicine, Los Angeles, and
ture management, maximizes the at age 8 or 9. The lateral condyle is Attending Surgeon, Division of Orthopedic
chances of a successful outcome. usually last, often appearing at Surgery, Childrens Hospital, Los Angeles.
about age 10 (Fig. 1). The radial
head, the trochlea, and the olecra- Reprint requests: Dr. Skaggs, Childrens
Hospital Los Angeles, 4650 Sunset Boulevard,
Radiographic Anatomy non may appear as multiple ossifi- Mailstop #69, Los Angeles, CA 90027.
cation centers, which should not be
The secondary centers of ossifica- mistaken for a fracture. Copyright 1997 by the American Academy of
tion of the bones about the elbow Because a fracture line in a Orthopaedic Surgeons.
appear in a relatively predictable child’s elbow may travel through

Vol 5, No 6, November/December 1997 303

Elbow Fractures in Children
10 years
4-5 years
8-9 years
1 year
4-5 years
8-9 years
Anteroposterior view
Fig. 1 Secondary ossification centers of the elbow, with range of ages of appearance.
condylar fracture should be consid-
ered. If the radius is no longer
pointing to the capitellum, an
elbow dislocation must be consid-
ered.
(3) The anterior humeral line
bisects the capitellum (Fig. 3, A). If
the center of the capitellum falls
posterior to this line, an extension-
type supracondylar fracture is like-
ly; a transphyseal fracture is possi-
ble, though rare. If the capitellum
is anterior to the line, the less com-
mon flexion-type supracondylar
fracture or a transphyseal fracture
is likely. One must be certain that a
true lateral view of the distal
humerus has been obtained, be-
cause any rotation will make the
capitellum appear posterior rela-
tive to the anterior humeral line.
(4) The humeral capitellar
(Baumann’s) angle (Fig. 3, B) is a
sensitive indicator of varus angula-
tion of the distal humerus and is
primarily useful in assessing the
adequacy of reduction in supra-
condylar and transphyseal frac-
tures (95% of normal elbows have
an angle of 9 to 26 degrees).3 Bau-
mann’s angle is relatively constant
with respect to humeral rotation,
304
1 year
4-5 years
Lateral view
changing only 1.6 degrees for each
10 degrees of humeral rotation,
as long as a true AP view of the
distal humerus has been obtained.4
Angulation of the humerus relative
to the x-ray cassette or angulation
of the x-ray beam relative to the hu-
merus in the sagittal plane marked-
ly decreases the usefulness of this
angle.
Normal Lateral condyle
fracture
Fig. 2 Relationship between the radius and the capitellum and between the midshaft of
the ulna and the midshaft of the humerus in the normal elbow and in the injured elbow, as
visualized on an anteroposterior radiograph.
Journal of the American Academy of Orthopaedic Surgeons
The intracapsular components of
the elbow include the entire radial
head, a portion of the olecranon,
the coronoid process of the ulna,
and the entire articular surface of
the distal humerus. The medial
and lateral epicondyles, as well as a
portion of the radial neck, remain
extra-articular. A lateral radio-
graph of a normal elbow flexed at
90 degrees may show a small ante-
rior fat pad bulging from the shal-
low coronoid fossa. The posterior
fat pad should not be visible, as it
is well contained in the olecranon
fossa. When a posterior fat pad is
visible, an intra-articular injury is
present 90% of the time.5
Comparison radiographs of the
noninjured elbow have not proved
useful in improving accuracy of
diagnosis by orthopaedic surgeons
or residents.6 Arthrography and/
or fluoroscopic imaging is occa-
sionally indicated to establish a
diagnosis when plain radiography
does not suffice. For example,
before ossification of the trochlea
and the medial epicondyle, a lateral
condyle fracture may be difficult to
differentiate from a Salter type II
Elbow Transphyseal
dislocation fracture
 David L. Skaggs, MD

Radial nerve function may be con-

firmed by a thumbs-up sign. The
posterior interosseous nerve should
be carefully assessed in radial neck
fractures.
The sensory examination is
Baumann’s
more difficult, and at times one
angle
must resort to pinching a child in
the ulnar nerve distribution if
placement of a medial pin in the
distal humerus is anticipated. The
presence or absence of a pulse on
palpation or Doppler examination
should be established. The viabili-
ty of the hand can be assessed on
the basis of the temperature and
A B color. Excessive swelling or ecchy-
mosis about the elbow should be
Fig. 3 Anatomic relationships in the elbow. A, A line drawn along the anterior humeral
cortex normally bisects the capitellum. If the center of the capitellum is posterior to this noted, as this is an indication of
line, an extension-type supracondylar fracture is likely; if it is anterior, a flexion-type extensive soft-tissue injury and in-
supracondylar fracture or a transphyseal fracture is likely. B, Baumann’s angle (shown as
creases the risk of compartment syn-
measured on an AP view) is formed by the intersection of the capitellar physis and a line
perpendicular to the humeral axis. drome. Soft-tissue tenting and dim-
pling are also signs of soft-tissue
injury that suggest that reduction
should be performed promptly.
fracture on a plain AP radiograph. Physical Examination The findings on physical exami-
Arthrography is also helpful in nation may aid in diagnosis and
assessing closed reduction of frac- The two most important aspects obviate the need for arthrography
tures involving nonossified carti- of the physical examination are or fluoroscopy under anesthesia.
lage. the neurovascular and soft-tissue The radiographic appearance of a
assessments. The neurologic ex- lateral condyle fracture may be
amination in a child with an in- similar to that of a Salter type II
Vascular Anatomy jured elbow is difficult yet essen- fracture of the distal humerus with
tial, as the rate of neurologic injury a lateral Thurston-Holland frag-
The collateral circulation about the is 10% to 18% for displaced supra- ment. If soft-tissue swelling and
elbow is generally rich. The capi- condylar fractures.7,8 A thorough tenderness are primarily lateral, a
tellum and the lateral portion of preoperative evaluation may pre- lateral condyle fracture is likely.
the trochlea are notable exceptions, vent the uncomfortable situation of Medial swelling suggests the medial
relying on end arteries entering the finding a nerve injury after reduc- periosteal disruption characteristic
posterior portion of the distal tion without knowing the prere- of a Salter type II injury.
humerus near the origin of the duction status. Even young chil-
anconeus.2 Iatrogenic injury to this dren will usually be able to pinch
vascular supply is associated with the examiner’s finger, allowing Lateral Condyle Fractures
osteonecrosis. For this reason, pos- one to palpate contraction of the
terior dissection along the distal first dorsal interosseous muscle Fractures of the lateral condyle are
humerus should be avoided, espe- and confirm ulnar motor function. the second most common fracture
cially in the case of displaced later- The anterior interosseous nerve about the elbow in children, after
al condyle fractures. Some recent should be assessed by observing supracondylar fractures.9 The frac-
articles support a posterior ap- flexion of the thumb interpha- ture pattern is Salter type IV, as the
proach for reduction of supra- langeal joint or the distal interpha- fracture line crosses the metaph-
condylar fractures; however, dis- langeal joint of the index finger. ysis, physis, and epiphysis. The
section should not extend to the This may be observed as the child mechanism of injury is most com-
most distal areas of the condyles. pinches or makes the “O” sign. monly believed to be varus stress

Vol 5, No 6, November/December 1997 305

Elbow Fractures in Children
on an extended elbow with the
forearm in supination.10 This frac-
ture has a well-earned reputation
for complications, which can most
often be avoided by early recogni-
tion and appropriate treatment.
Diagnosis
Swelling and tenderness are
usually limited to the lateral region
of the elbow. Soft-tissue injury is
typically less severe than that seen
in supracondylar fractures, and
acute neurovascular injury is un-
common. Diagnosis may be made
on standard AP and lateral views
of the elbow; however, an oblique
view should be obtained if clinical
suspicion is high, as this is often
the best view for evaluating the
extent of the fracture and its dis-
placement (Fig. 4). A Salter type II
fracture with a lateral metaphyseal
fragment should be ruled out by
physical examination or, if neces-
sary, arthrography.
Classification
The Milch classification is based
on the location of the intra-articular
A B
Fig. 4 Nondisplaced lateral condyle fracture. The AP (A) and lateral (B) radiographs
suggest a lateral condyle fracture. An elevated posterior fat pad (arrowhead) is visible on
the lateral image. The fracture (arrow) is best visualized on an oblique radiograph (C) shot
from anterolateral to posteromedial.
306
extension of the fracture line. In a
Milch type I fracture, the fracture
line is lateral to the trochlea. In a
type II fracture, the fracture line
enters the trochlea, which allows
lateral translation of the ulna and
radius. This classification system is
of limited usefulness, as it does not
affect treatment or predict out-
come.
A classification system based on
displacement and articular congru-
ence tends to be more useful, as it
helps guide treatment. A type I
fracture is one that shows minimal
displacement (<2 mm) and no ar-
ticular involvement; this is often
discernible only on an oblique radio-
graph. A type II fracture is defined
as having an intact articular surface
with moderate (2 to 4 mm) hinged
displacement of the metaphyseal
fragment. A type III fracture is
completely displaced and frequent-
ly rotated. A shortcoming of this
classification system is that it may
be difficult to judge articular sur-
face continuity on a plain radio-
graph; assignment of type II is
inferred on the basis of displace-
C is stable and not at risk for dis-
Journal of the American Academy of Orthopaedic Surgeons
ment of the metaphyseal fragment,
which is confirmed with arthrogra-
phy at surgery.
Treatment
Over the past few decades, the
treatment of lateral condyle frac-
tures has become increasingly
aggressive in an effort to avoid
complications of nonunion and
malunion. Open reduction and
internal fixation is commonly rec-
ommended for all type II and type
III fractures, and some researchers
have suggested percutaneous pin-
ning for type I fractures. More
recently, the pendulum has begun
to swing the other way, with some
authors going so far as to recom-
mend closed treatment for fracture
gaps smaller than 4 mm.11 The fol-
lowing is a treatment protocol that
represents the middle ground
between those extremes.
Nonoperative
Treatment of type I fractures
with cast immobilization is gener-
ally successful. One must be cer-
tain that the fracture is truly type I,
with an oblique radiograph show-
ing less than 2 mm of displacement
(the oblique view often shows
more displacement than the AP or
lateral view). All lateral condyle
fractures being treated nonopera-
tively must be reassessed with AP,
lateral, and oblique views out of
plaster 5 to 7 days after injury to be
certain displacement has not oc-
curred. Increased displacement at
this point is not uncommon and
requires operative treatment. An
investigation of 112 type I fractures
treated with casting suggested that
if the fracture line cannot be fol-
lowed to the epiphysis, the fracture
placement. 12 However, it was
found in that study that when the
fracture line extended into the
epiphysis, 11 (23%) of 47 fractures
displaced.

Operative
In the case of a suspected type
II fracture, arthrography is per-
formed after draping. If the articu-
lar surface is found to be intact,
confirming a type II fracture, per-
cutaneous pinning is performed
with two 0.062-mm Kirschner
wires. The elbow is then brought
through a range of motion, and
fracture stability is assessed with
varus and valgus stress while
viewing the arthrogram. If the
fracture is stable, a long arm cast is
applied. The pins and cast are nor-
mally discontinued after 3 weeks.
Mintzer et al13 reported uniformly
excellent results with percutaneous
pinning of 12 lateral condyle frac-
tures with more than 2 mm of dis-
placement but intact articular sur-
faces.
Type III fractures should be
treated with open reduction and
internal fixation. A lateral inci-
sion is made just anterior to the
lateral condylar ridge and cen-
tered over the fracture. Once
through the superficial fascia, a
traumatic rent is usually seen in
the wrist extensor muscle mass.
The opening in the muscle mass
may be enlarged to visualize the
fracture site and to evacuate
hematoma. Soft-tissue attach-
ments on the posterior portion of
the fracture fragment should not
be detached, as the blood supply
to the lateral trochlea and capitel-
lum enters here. Anatomic reduc-
tion of the articular surface is per-
formed and verified under direct
visualization; use of a head light
is helpful. Dorsiflexion of the
wrist relaxes the wrist extensors
and facilitates reduction. Two
smooth pins are placed percuta-
neously just posterior to the inci-
sion in a parallel or divergent
manner, and fixation stability is
assessed.
Postoperatively, the arm is im-
mobilized with the elbow extended
Vol 5, No 6, November/December 1997
just beyond 90 degrees of flexion to
allow for swelling. Optimal post-
operative immobilization for most
elbow fractures can be achieved by
the use of an anterior and a poste-
rior sterile polyurethane-foam pad
placed directly on the skin, with no
underlying circumferential ban-
daging. Cast padding and then
fiberglass are wrapped circum-
ferentially over the foam. This
method of casting allows for post-
operative swelling and permits
high-quality radiographs. The long
arm cast and pins are usually dis-
continued at 3 weeks, although
they may be continued for 4 or 5
weeks if radiographs suggest slow
healing.
Complications
Nonunion, osteonecrosis, cubi-
tus valgus, and tardy ulnar nerve
palsy are well-described complica-
tions of lateral condyle fractures.
Fractures diagnosed and treated in
a timely fashion with this protocol
should have few complications.
Inadequate treatment and lack of
recognition of loss of reduction are
frequent causes of nonunion or
malunion of lateral condyle frac-
tures.
Traditional teaching suggests
that open reduction should not be
performed on fractures seen later
than 3 weeks after injury, as the
risks of osteonecrosis and a poor
result increase.10 However, Roye et
al 14 reported good results with
open reduction of lateral condyle
fractures in four children 8 weeks
to 14 years after injury. They
stressed the importance of avoid-
ing posterior dissection to maintain
blood supply to the fracture frag-
ment.
Tardy ulnar nerve palsy results
from valgus malalignment and is
usually seen decades after injury.
It may be treated by nerve transpo-
sition and varus osteotomy of the
distal humerus.
David L. Skaggs, MD
Medial Epicondyle
Fractures
Fractures of the medial epicondyle
tend to occur in older children,
between the ages of 10 and 14
years. These fractures are not true
Salter injuries, as the apophysis
rather than the physis is involved.
Simple fractures of the medial epi-
condyle are extra-articular injuries
with limited soft-tissue involve-
ment. A posterior fat pad sign,
gross instability of the elbow, or an
unexpected amount of swelling
should suggest other injuries, such
as an intra-articular medial condyle
fracture or an elbow dislocation.
The most important step in the
evaluation of medial epicondyle
fractures is ruling out concomitant
injury. As many as 50% of these
fractures are associated with elbow
dislocation.15 There is no univer-
sally accepted system for classify-
ing these fractures.
Nonoperative Treatment
There is little controversy about
the recommendation that minimal-
ly displaced fractures may be treat-
ed conservatively. Initially, the
arm should be splinted in 90
degrees of elbow flexion. Active
range-of-motion exercise should
begin within a week of injury. Pro-
tective splinting may be continued
for 3 weeks.
A 35-year follow-up survey of
56 nonreduced displaced fractures
of the medial epicondyle (mean
displacement, 6 mm; range, 1 to 15
mm) confirmed that very good
function and range of motion can
safely be expected in the long term
with treatment by immobilization
alone. 16 The authors reported a
55% rate of pseudarthrosis but
found that the frequency of elbow
symptoms did not differ between
the group of patients with osseous
healing and the group with pseud-
arthrosis. Three patients reported
307
Elbow Fractures in Children
numbness over the ulnar part of
the hand, but all patients had nor-
mal sensibility and strength.
Another study15 compared the
results in 20 children treated non-
operatively and 23 children treated
surgically. The children treated
surgically had radiographic evi-
dence of better reduction and a
higher rate of union than those
treated conservatively, although
they had more minor symptoms.
Most reports in the literature
support nonoperative management
for both nondisplaced and dis-
placed fractures. The literature
does not suggest that there is a
threshold of displacement above
which operative therapy leads to
improved outcome relative to
closed treatment.
Operative Treatment
The only two absolute indica-
tions for operative treatment of
medial epicondyle fractures are
irreducible incarceration of the
medial epicondyle in the joint (Fig.
5) and the rare open fracture. An
incarcerated fragment may occa-
sionally be reduced by opening the
elbow with valgus stress while
extending the wrist to place tension
across the wrist flexors, which have
their origin on the epicondyle. This
maneuver should be performed
gently with the patient under gen-
eral anesthesia. If unsuccessful,
open reduction and internal fixa-
tion while protecting the ulnar
nerve is necessary. For the medial
epicondyle to become trapped
within the joint, an elbow disloca-
tion must have occurred. The
severity of the accompanying soft-
tissue injuries should be considered
by planning for swelling and early
range of motion.
It has been suggested, on largely
theoretical grounds, that medial
epicondyle fractures healing with a
fibrous nonunion can lead to
severe chronic medial instability.17
308
In a review of 20 pediatric elbow
dislocations with a mean of 10 mm
of displacement of the medial epi-
condyle after reduction, ulnar col-
lateral ligament laxity was found in
all 20 children, although only 1 had
any impairment and that was
slight.18 It was concluded that even
severe forms of this injury can be
managed without internal fixation.
One may want to consider opera-
tive repair and fixation of a dis-
placed medial epicondyle fracture
in a child who is expected to make
excessive demands in terms of val-
gus stress on the elbow, such as a
pitcher or a gymnast, although the
benefit of such an approach is cur-
rently unproved.
Olecranon Fractures
Olecranon fractures are less com-
mon than other fractures about the
elbow in children. About one fifth
of all fractures of the olecranon are
associated with another elbow frac-
ture, most often a fracture of the
medial epicondyle. 9 Olecranon
fractures present in a variety of
patterns, and treatment must be
individualized to the pattern.
A B
Fig. 5 Incarcerated medial epicondyle fracture visualized on AP (A) and lateral (B) radio-
graphs, suggesting the elbow has undergone considerable ligamentous disruption.
Journal of the American Academy of Orthopaedic Surgeons
Although fractures of the olecranon
are usually treated closed, an indi-
cation for operative reduction and
fixation is an articular step-off
greater than 2 mm.
In the flexion type of injury, the
posterior portion of the olecranon
fails first in tension, and the frac-
ture line proceeds to the articular
surface. If complete, this fracture is
potentially unstable, as the torn
posterior periosteum cannot func-
tion as a tension band and the pull
of the biceps and triceps further
displaces the fracture. If closed
treatment is chosen, good-quality
radiographs should be obtained at
about 1 week after injury to assess
possible displacement. Traditional
operative technique has involved a
tension band combined with
Kirschner wires. Modifications to
this technique include the use of
absorbable suture as a tension band
and the use of a compression screw
rather than Kirschner wires.
Proximal Radial Fractures
Fractures of the proximal radius in
children tend to involve the me-
taphyseal neck or physis (Salter

type I or II), rather than the head (as
seen in adults). These fractures
commonly occur between the ages
of 8 and 12 years. The most fre-
quent mechanism of injury is a fall
on an outstretched hand with a
valgus moment directing force
through the radius. A valgus injury
may cause an associated medial
epicondyle avulsion or an olecra-
non fracture. Proximal radial frac-
tures are also associated with poste-
rior elbow dislocations, with the
radial head displacing anteriorly if
the fracture occurs during the dislo-
cation and posteriorly if the fracture
occurs during relocation.
Tenderness is often well local-
ized in isolated fractures. Pro-
nation and supination are usually
more painful than elbow flexion
and extension. These findings on
physical examination are often the
key to diagnosing an occult proxi-
mal radial fracture when the sole
radiographic finding is a posterior
fat pad. A subtle radial neck frac-
ture may be present without eleva-
tion of the posterior fat pad, as it
may be extracapsular. Various
classification systems exist, but
these are not particularly useful in
dictating treatment or predicting
outcome. The radial head may
normally display as much as 15
degrees of valgus tilt and may have
bipartite ossification.
Management
The primary goal of treatment is
preservation of motion, specifical-
ly, pronation and supination. The
importance of early motion and
physical therapy should be dis-
cussed with the family at the first
visit to help ensure compliance.
Over the years, a wide range of
“acceptable” angulation and trans-
lation has been proposed. Good
results can be expected in fractures
with less than 30 degrees of angu-
lation and less than 3 mm of trans-
lation. 19,20 It is generally recom-
Vol 5, No 6, November/December 1997
mended that fractures with more
angulation or translation undergo
manipulation under anesthesia.
Open reduction has been recom-
mended for fractures that cannot
be reduced to less than 45 to 60
degrees of angulation.
Dynamic imaging with forearm
rotation precludes the potential of
underestimating the true deformity
on orthogonal films. I believe that
the patient’s range of motion is a
more important criterion for the
acceptability of reduction than the
radiographic appearance, although
support in the literature for this
opinion is lacking. Passive supina-
tion and pronation may be tested
with the patient under general
anesthesia; local anesthesia may be
used for cooperative patients. A
closed or percutaneous reduction
that allows about 60 degrees of
pronation and supination is accept-
able.
Closed Reduction
Most proximal radial fractures
with less than 45 to 60 degrees of
angulation may be adequately
reduced with manipulation with
the patient under general anesthe-
sia. Commonly used is the Patter-
son technique, in which an assis-
tant applies a varus stress to the
extended arm and the surgeon
reduces the radial head by direct
pressure with the thumbs. The arm
should be pronated and supinated
during imaging to ensure that the
direction of maximal displacement
is opposite the surgeon’s thumbs
before attempted reduction.
Another technique is to flex the
elbow to 90 degrees and apply
direct pressure over the radial head
with the thumbs while rotating the
forearm from full supination to
pronation.21 In my experience, this
technique has been effective when
the Patterson technique has failed.
Others have described success-
ful reduction with inflation of a
David L. Skaggs, MD
blood pressure cuff over the frac-
ture site or wrapping of the arm
with an elastic bandage. If passive
pronation and supination are less
than 60 degrees after attempted
closed reduction, percutaneous
reduction may be attempted.
Percutaneous Reduction
If closed reduction fails, percuta-
neous reduction with a Steinmann
pin may be attempted. Success
rates of 83% to 94% have been
reported.22,23 A 2-mm incision is
made lateral and distal to the radial
head, and a 3/16-inch Kirschner
wire is inserted, blunt end first to
prevent sharp injury to the posterior
interosseous nerve. The arm is
pronated to bring the nerve ante-
rior. During visualization with the
image intensifier, the wire is used
to gently push the radial head into
a reduced position22 (Fig. 6). The
arm is then brought through a
range of motion while imaging to
assess stability. Alternatively, the
Kirschner wire may be inserted
directly opposite the fracture,
wedged into the fracture site, and
used as a lever to reduce the radial
head.23 There has been a report of
a single incident of posterior in-
terosseous nerve neurapraxia that
completely recovered and was
attributed to multiple attempts at
closed reduction.22
Open Reduction
Open reduction is indicated for
the minority of fractures in which
less invasive means have failed to
provide a stable reduction allowing
50 to 60 degrees of pronation and
supination. The standard Kocher
approach between the anconeus
and the extensor carpi ulnaris
should be used, holding the arm
pronated to keep the posterior
interosseous nerve anterior to the
operative field. Once reduction has
been achieved, it is usually stable,
as the fracture site has locking
309
Elbow Fractures in Children

A B C

Fig. 6 Percutaneous reduction of a radial neck fracture. A, Prereduction AP film. B, Intraoperative view shows the blunt end of a stout
Kirschner wire pushing the fragment into the reduced position. C, Intraoperative image shows acceptable reduction. The patient had 75
degrees of pronation and supination intraoperatively after reduction.

interdigitations; however, stability
should be assessed under direct
visualization through a full range
of motion of the elbow and fore-
arm. If needed, crossed Kirschner
wires should be inserted obliquely
across the fracture site; trans-
capitellar wires may break and
should be avoided. Excision of the
radial head should be avoided at
all costs in the immature skeleton
as synostosis, cubitus valgus, and
ulnar deviation of the wrist may
develop.
Complications
The most common complica-
tion is loss of pronation and
supination. Most studies report
that fracture angulation and trans-
lation are the most important fac-
tors in predicting long-term
motion. 19,20 Open reduction has
been associated with a greater
loss of motion than closed reduc-
tion.20,24 Selection bias may influ-
ence this association, as more
severe fractures more frequently
require open reduction. However,
it is logical to assume that the
additional soft-tissue trauma and
subsequent scar formation associ-
ated with open reduction may
inhibit motion. Personal experi-
ence suggests that percutaneous
reduction with Kirschner wires is
highly effective in reducing frac-
tures with up to 90 degrees of
angulation and 100% displace-
ment and in maintaining excellent
postoperative range of motion.
Unfortunately, there are no well-
controlled prospective studies
comparing closed, percutaneous,
and open reduction.
Loss of range of motion can be
minimized by early motion. In the
case of fractures not needing reduc-
tion, active motion can be begun
after about 10 to 14 days; in the
case of those requiring reduction,
motion should be postponed for 2
to 3 weeks. Both types of fractures
should be protected with a poste-
rior splint for an additional 2 to 3
weeks. As computer keyboards
become more ubiquitous, prona-
tion may become more important
than supination; for this reason,
casting in mild pronation is recom-
mended. Other complications of
less functional importance are
enlargement of the radial head and
early physeal closure.
Supracondylar Fractures
Otsuka and Kasser7 recently pro-
vided a detailed review of the man-
agement of supracondylar fractures
of the humerus in children. In a
study of 3,350 children, Cheng and
Shen 25 found the supracondylar
fracture to be the most common

310 Journal of the American Academy of Orthopaedic Surgeons


fracture in children under 8 years
of age.
Neurologic injuries and vascular
injuries are not uncommon (report-
ed incidences of 5% to 19%7 and 5%
to 17%8). In the past decade, there
has been an increasing awareness
of injuries to the anterior inter-
osseous nerve associated with this
injury, with one report finding it
the nerve most commonly injured.8
The current recommendation is
to treat type II and type III supra-
condylar fractures with closed
reduction and percutaneous pin-
ning. This treatment has decreased
complications, such as malunion
and compartment syndrome, com-
pared with traction and/or casting.
Transphyseal Fractures of
the Distal Humerus
Although much less common than
supracondylar fractures, transphy-
seal fractures deserve mention
because of their relationship with
child abuse and the pitfalls associ-
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