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Average 4.1 of 109 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
Figures A through E are injury radiographs of elbow injuries in children. A child complains of decreased sensation over the small finger acutely after an elbow injury. Which of the following radiographs is consistent with his injury?
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This patient has an ulnar neuropathy. The elbow injury that most likely results in this injury is a flexion-type supracondylar fracture.
Flexion-type supracondylar fractures are uncommon, compared with extension-type fractures. Flexion-type injuries have an increased incidence of ulnar neuropraxia. Extension-type injuries are prone to AIN, PIN, median and radial neuropraxia.
Babal et al. performed a meta-analysis of nerve injuries in supracondylar fractures. They found that nerve injuries occurred in 11% of 5154 fractures. In extension-type injuries, AIN neuropraxia represents 34.1% of associated neurapraxias. In flexion-type injuries, ulnar neuropathy represents 91.3% of associated neurapraxias. Lateral pinning put the median nerve at risk (rate of injury, 2.8%). Medial pinning put the ulnar nerve at risk (rate of injury, 4.1%).
Bashyal et al. retrospectively reviewed 662 fractures that were pinned. The most common complication was pin migration (1.8%). The rate of ulnar nerve injury from blind pin placement was 0.3%, as was the overall rate of ulnar nerve injury (including open ulnar nerve identification prior to placement).
Figures B through E show extension-type supracondylar fracture, lateral condyle, olecranon, and radial neck fractures respectively.
Answer 2: This figure shows a Gartland I minimally displaced extension-type supracondylar fracture. With displaced extension-type fractures, AIN neuropathy is most common.
Answer 3: This figure shows a lateral condyle fracture.
Answer 4: This figure shows a pediatric olecranon fracture.
Answer 5: This figure shows a radial neck fracture.
Babal JC, Mehlman CT, Klein G.
J Pediatr Orthop. 2010 Apr-May;30(3):253-63. PMID: 20357592 (Link to Abstract)
Babal, JPO 2010
Bashyal RK, Chu JY, Schoenecker PL, Dobbs MB, Luhmann SJ, Gordon JE
J Pediatr Orthop. 2009 Oct-Nov;29(7):704-8. PMID: 20104149 (Link to Abstract)
Bashyal, JPO 2009
Please rate question.
Average 4.0 of 17 Ratings
Following successful operative treatment, routine removal of hardware is recommended at 3-4 weeks for which of the following procedures?
Answer 4 shows an example of percutaneous pinning of a pediatric supracondylar fracture. Pin removal is recommended at 3-4 weeks after surgery.
Pediatric supracondylar humerus fractures make up more than half of all pediatric elbow fractures. They typically occur from a fall on an outstretched hand, with extension-type fracture pattern being the most common (95-98%). Treatment options include closed reduction with casting for non-displaced fractures, and closed vs open reduction and pinning for more displaced fractures. Open reduction is rarely required. Following pinning, pin removal is recommended at 3-4 weeks to reduce the risk of pin tract infections, which can extend into the elbow joint.
Green et al. performed a retrospective review on the incidence of ulnar nerve injury with crossed pin placement for pediatric supracondylar humerus fractures using a mini-open technique. They found the rate of iatrogenic ulnar nerve injury to be extremely low and concluded that crossed pin fixation was an appropriate treatment option for unstable supracondylar humerus fractures. However, other studies have found the incidence of ulnar nerve injuries to be higher with medial vs. lateral pins.
Answer 1: Figure A shows an intramedullary nail for a tibia fracture. Tibial nails are not routinely removed.
Answer 2: Figure B shows elastic nails for a both bone forearm fracture. Elastic nails in this setting are taken out no sooner than 4-6 months after surgery.
Answer 3: Figure C shows syndesmotic screws for syndesmotic ligament disruption. Syndesmotic screws can be taken out, but this is not recommended earlier than 3 months.
Answer 5: Figure E shows elastic nails for a femur. Elastic nails in this setting are taken out no sooner than 6-12 months.
Green DW, Widmann RF, Frank JS, Gardner MJ
J Orthop Trauma. 2005 Mar;19(3):158-63. PMID: 15758668 (Link to Abstract)
Green, JOT 2005
Average 4.0 of 12 Ratings
A 7-year-old patient presents with a fracture of her left supracondylar humerus and distal radius as evidenced in Figure A. She is neurovascularly intact and the skin shows no evidence of open wounds. Radiographs of the elbow show a displaced supracondylar fracture. Radiographs of the wrist show an extra-articular distal radius fracture with 25 degrees of dorsal angulation. This injury is most appropriately treated with which of the following?
Closed reduction and casting of the supracondylar humerus fracture and distal radius fracture
Closed reduction and pinning of both the supracondylar humerus fracture and distal radius fracture
Closed reduction and casting of the supracondylar humerus fracture and pinning of distal radius fracture
Open reduction and pinning of both the supracondylar humerus and the distal radius fracture
Closed reduction and pinning of the supracondylar humerus fracture and closed reduction and casting of distal radius fracture
This clinical presentation is consistent with a "floating elbow" with displaced fractures of both the elbow and and wrist. The most appropriate treatment is prompt closed reduction and pinning of both the supracondylar humerus fracture and distal radius fracture.
Displaced floating elbow injuries in the pediatric patient are most appropriately treated with prompt closed reduction and percutaneous pinning of both injuries to prevent the occurrence of compartment syndrome prompted by casting. This combined pinning should occur even if one of the injuries treated in isolation is most appropriately treated with closed reduction and casting as the upper extremity is subject to a large amount of swelling not safe for a circumferential cast.
Ring et al. found that circumferential casting that was required to maintain closed reductions led to compartment syndromes in 20% of patients over a 9 year period of review. There was a 50% complication rate with either compartment syndrome or loss of fracture reduction in the casting group and none in the operative group.
Harrington et al. reviewed pediatric floating elbow injuries over a 7 year period and found that 12 patients were treated successfully with a protocol including aggressive operative management with percutaneous pinning. They found that 10 patients had good or excellent outcomes and the remaining patients had fair outcomes.
Figure A is a clinical photo showing a deformity in both the elbow and wrist.
Answer 1, 3, 4, and 5: None of these would be appropriate due to the risk of compartment syndrome.
Harrington P, Sharif I, Fogarty EE, Dowling FE, Moore DP.
Arch Orthop Trauma Surg. 2000;120(3-4):205-8. PMID: 10738885 (Link to Abstract)
Harrington, AOTS 2000
Ring D, Waters PM, Hotchkiss RN, Kasser JR.
J Pediatr Orthop. 2001 Jul-Aug;21(4):456-9. PMID: 11433156 (Link to Abstract)
Ring, JPO 2001
Average 3.0 of 44 Ratings
Which of the following elbow apophyses is the last to fuse during growth?
External (lateral) epicondyle
Internal (medial) epicondyle
While the external (lateral) epicondyle is the last apophyses to APPEAR on radiographs, this question is asking for which of the apopphyses is the last to FUSE. Therefore, the correct answer is the internal (medial) epicondyle, which is the last to FUSE at around 16 to 19 years. While the order of appearance is discussed more often, it is helpful to know the typical order and age of apophyseal closure when evaluating teenagers (often throwers) with atraumatic elbow pain.
An accepted mnemonic of the order of APPEARANCE of the individual ossification centers of the elbow is C-R-I-T-O-E: Capitellum, Radial head, Internal (medial) epicondyle, Trochlea, Olecranon, External (lateral) epicondyle.
Cheng et al performed a series to re-examine the sequence and pattern of elbow ossification based on a cross-sectional study of 3,154 elbow radiographs in children ranging in age from newborn to 17 years. The sequence of ossification in both boys and girls was found to be the same. The ages at which 50% of the girls were found to have positive radiologic ossification for each of these centers were ages 1, 5, 5, 9, 9, and 10 years, respectively. In boys, with the exception of the capitelum, an average delay of 2 years was found in each of the ossification centers, although the sequence remained similar.
Illustration A shows the different ossification centers. Illustration B shows the age of APPEARANCE and age of FUSION of the different ossification centers. It should be noted that appearance and fusion of the ossification centers do not correlate.
Cheng JC, Wing-Man K, Shen WY, Yurianto H, Xia G, Lau JT, Cheung AY.
J Pediatr Orthop. 1998 Mar-Apr;18(2):161-7. PMID: 9531396 (Link to Abstract)
Cheng, JPO 1998
Average 3.0 of 53 Ratings
A child falls off of the monkey bars at school and sustains the left elbow injury shown in Figure A. What is a disadvantage of the fixation construct shown in Figure B compared to Figure C for this injury pattern?
Less biomechanical stability
Higher incidence of compartment syndrome
Higher chance of osteomyelitis
Higher risk of iatrogenic injury to the ulnar nerve
Higher risk of iatrogenic injury to the anterior interosseous nerve
Crossed (medial and lateral) pin fixation of pediatric supacondylar fractures has been associated with a higher rate of ulnar nerve injury than lateral pinning.
The majority of pediatric supracondylar fractures are treated with closed reduction and percutaneous pinning. This can be done with two lateral pins, or a crossed (medial and lateral) pin technique. The crossed (medial and lateral) pin technique provides a more stable biomechanical configuration for fracture fixation, but has an increased risk of ulnar nerve injury. It is important to note, in the cross pin construct the pins should cross proximal to the fracture. If the pins cross within the fracture site, the construct is less stable. A lateral pin configuration usually provides sufficient stability.
Brauer et al. performed a systematic literature review of medial and lateral entry pinning versus lateral entry pinning for supracondylar fractures of the humerus. Data from 2054 children were identified from 35 studies; 2 randomized trials, 6 cohort studies, and 25 case series. They found with operative fixation using both medial and lateral entry pins, the probability of ulnar nerve injury is 5.04 times higher than with lateral entry pins.
Lyons et al. reviewed 375 supracondylar fractures treated with percutaneous pinning after closed or open reduction. Nineteen developed postoperative ulnar nerve palsies. 17 patients who returned for follow up had complete return of function. Thus, ulnar nerve palsies following percutaneous pinning of the supracondylar fracture typically resolve spontaneously.
Figure A demonstrates a type 3 supracondylar humerus fracture. Figure B and Illustration A shows a cross pin configuration following CRPP of a supracondylar pediatric fracture. Figure C demonstrates a lateral pin configuration. Illustration A shows properly placed cross pins with maintenance of reduction at 4 weeks. Illustration B shows an example of cross pins that were not properly placed with pins crossing near the fracture site, providing poor hold. The anteroposterior distal to proximal pin does not have a satisfactory hold in the proximal fragment. The followup radiographs show minor loss of reduction with malalignment and rotation at the fracture site
Answer 1: Use of lateral entry pins alone demonstrates less stability to torsional loading
Answer 2: Compartment syndrome is usually a complication of the mechanism of injury or excessive reduction attempts rather than the type of fixation
Answer 3: Neither pin pattern has been associated with higher rates of infection, although the most distal pin in lateral entry constructs does usually communicate with the joint
Answer 5: Fractures with apex posterolateral displacement can injure the brachial artery or AIN. Neither pin pattern has shown a higher rate of AIN injury
Brauer CA, Lee BM, Bae DS, Waters PM, Kocher MS.
J Pediatr Orthop. 2007 Mar;27(2):181-6. PMID: 17314643 (Link to Abstract)
Brauer, JPO 2007
Lyons JP, Ashley E, Hoffer MM.
J Pediatr Orthop. 1998 Jan-Feb;18(1):43-5. PMID: 9449100 (Link to Abstract)
Lyons, JPO 1998
Balakumar B, Madhuri V
Indian J Orthop. 2012 Nov;46(6):690-7. PMID: 23325974 (Link to Abstract)
Balakumar, INDJO 2012
Average 3.0 of 13 Ratings
What is the advantage of medial and lateral crossed pins compared to two lateral pins in the treatment of supracondylar humerus fractures?
Greater ultimate clinical arc of elbow motion
Lower revision rate
Lower incidence of ulnar nerve injury
Greater experimental biomechanical stability
More anatomic fracture reduction
Supracondylar fractures of the humerus in children are commonly treated with closed reduction and percutaneous pin fixation. Zionts et al found maximum stability for supracondylar humerus fractures was provided by two crossed pins placed from the medial and lateral condyles in a cadaveric laboratory study. Lee et al also found crossed pins were more stable. No clinical difference has ever been shown between the various pin configurations.
Zionts LE, McKellop HA, Hathaway R.
J Bone Joint Surg Am. 1994 Feb;76(2):253-6. PMID: 8113261 (Link to Abstract)
Zionts, JBJS 1994
Lee SS, Mahar AT, Miesen D, Newton PO
J Pediatr Orthop. 22(4):440-3. PMID: 12131437 (Link to Abstract)
Lee, JPO 2002
Average 3.0 of 17 Ratings
A 7-year-old boy falls off the playground and sustains the injury shown in figure A. What motor deficit is associated with the nerve most commonly injured in this fracture pattern?
Weakness of the flexor digitorum profundus to the index finger
Weakness of the extensor pollicis longus
Weakness of the flexor pollicis longus
Hand intrinsic weakness
The radiograph demonstrates a flexion type supracondylar humerus (SCH) fracture. The ulnar nerve is most commonly injured with this type of fracture, and is manifested with intrinsic hand weakness.
In flexion type supracondylar humerus fractures, the distal fragment is displaced anteriorly. Specifically, the sharp spine of the proximal fragment most commonly injures the ulnar nerve. Extension type SCH fractures are more common than flexion type and are commonly associated with injury to the anterior interosseous nerve (AIN). Weakness of the flexor digitorum profundus to the index finger and flexor pollicis longus would be associated with AIN palsy. Wrist drop would be associated with radial nerve palsy. Weakness of extensor pollicis longus correlates with posterior interosseous nerve palsy. Ulnar nerve palsy would cause hand intrinsic weakness and clawing.
In the meta-analysis by Babal et al, they found that ulnar neuropathy occurred most frequently in flexion-type injuries, representing 91.3% of associated neuropraxias. Conversely, anterior interosseous nerve injury predominated in extension-type fractures, representing 34.1% of associated neuropraxias.
Answer 1 is incorrect as weakness of the flexor digitorum profundus to the index finger would be associated with AIN palsy.
Answer 2 is incorrect as weakness of the extensor pollicis longus correlates with posterior interreous nerve palsy.
Answer 3 is incorrect as wrist drop would be associated with a radial nerve palsy.
Answer 4 is incorrect as weakness of the flexor pollicis longus is associated with an AIN palsy.
Average 4.0 of 70 Ratings
What is the etiology of cubitus varus following a supracondylar humerus fracture in a child?
Overgrowth of the lateral physis
Malreduction of the fracture
Growth arrest of medial physis
Injury to the ulnar nerve
Radial head dislocation
Cubitus varus is typically caused by malreduction of the fracture at the time of fixation; not usually by growth arrest.
The study referenced is a retrospective review of 84 patients with supracondylar fractures of the humerus treated by closed reduction and splinting, traction, or closed reduction and percutaneous pinning (CRPP) to determine the adequacy of the initial reduction and the maintenance of the reduction. Initially, Baumann's angle was adequate and similar in all patients, but the humerocapitellar angle was better with CRPP. Maintenance of reduction in both planes was superior with CRPP, and significantly better clinical results were achieved by CRPP. Nevertheless, there was no functional loss in any patient, and no parent wanted correction of deformity.
France J, Strong M.
J Pediatr Orthop. 1992 Jul-Aug;12(4):494-8. PMID: 1613094 (Link to Abstract)
France, JPO 1992
Average 3.0 of 22 Ratings
A 10-year-old boy sustained the injury shown in figure A while jumping off a trampoline. His hand is pulseless and cold. What is the next step in management?
Loose-fitting splint application and reassess in 1 hour
Emergent closed reduction and pin fixation
Open vascular exploration
Forearm skeletal traction pin
Otsuka and Kasser stated: "Vascular insufficiency at presentation (prevalence, 5%-17%) should be managed initially by rapid reduction and pinning without arteriography."
Copley et al looked at 128 consecutive children with grade III supracondylar humeral fractures. 17 had absent or diminished radial pulses on initial examination. 14 of these 17 children recovered pulse (palpable) after reduction and stabilization of their fractures. The remaining three had persistent absence of radial pulse. Each of these three children were explored immediately and found to have a significant vascular injury requiring repair.
Otsuka NY, Kasser JR.
J Am Acad Orthop Surg. 1997 Jan;5(1):19-26. PMID: 10797204 (Link to Abstract)
Otsuka, JAAOS 1997
Copley LA, Dormans JP, Davidson RS.
J Pediatr Orthop. 1996 Jan-Feb;16(1):99-103. PMID: 8747364 (Link to Abstract)
Copley, JPO 1996
Average 3.0 of 24 Ratings
A 5-year-old boy sustains a type II (Gartland classification) supracondylar fracture which is treated with cast immobilization. Healing results in a mild gunstock deformity. Surgical treatment of this will most likely result in:
improved functional outcome
improved pain relief
improved range of motion
reduce non-union rates
A gunstock deformity, also known as cubitus varus, is the most common complication following a pediatric supracondylar humerus fracture. Cubitus varus typically does not affect range of motion, pain, function or growth. However, cosmetic concerns or recurrent elbow fractures may result. Tardy ulnar nerve palsy may also result, but is not common.
The primary indication for surgical correction of cubitus varus is cosmesis. Surgical treatment may result in neurovascular complications, lateral bone prominence, or failure to maintain correction. In a study by Ippolito et al reviewing the long-term outcome of the treatment of cubitus varus with a supracondylar valgus osteotomy, it was discovered that all but 3 of the 24 patients were satisfied with their clinical and functional outcomes in spite of partial recurrence in almost all patients.
Ippolito E, Moneta MR, D'Arrigo C.
J Bone Joint Surg Am. 1990 Jun;72(5):757-65. PMID: 2355039 (Link to Abstract)
Ippolito, JBJS 1990
Average 3.0 of 19 Ratings
The most common nerve injured in the fracture shown in Figure A innervates all of the following muscles EXCEPT?
flexor digitorum profundus index finger
flexor digitorum profundus middle finger
flexor pollicis longus
extensor pollicis longus
The anterior interosseus nerve (AIN) is the most common nerve injured with extension type pediatric supracondylar fractures as shown in Figure A. The AIN, a branch of the median nerve, is principally a motor nerve and innervates the Flexor Digitorum Profundus Index, Flexor Digitorum Profundus Middle, Flexor Pollicis Longus and Pronator Quadratus. It DOES NOT innervate the Extensor Pollicis Longus, which is innervated by the posterior interosseous nerve, a continuation of the deep branch of the radial nerve. The illustration below shows motor and sensory innervation in the upper extremities.
Dormans JP, Squillante R, Sharf H.
J Hand Surg Am. 1995 Jan;20(1):1-4. PMID: 7722246 (Link to Abstract)
Dormans, JHS 1995
Cramer KE, Green NE, Devito DP.
J Pediatr Orthop. 1993 Jul-Aug;13(4):502-5. PMID: 8370784 (Link to Abstract)
Cramer, JPO 1993
Average 4.0 of 25 Ratings
A 8-year-old boy has a cubitus varus deformity of his left elbow after a supracondylar humerus fracture was treated in a splint. What is the most common cause of this deformity?
Malreduction causing malunion
Medial epicondyle growth arrest
Lateral condyle overgrowth
Medial epicondyle avascular necrosis
Unrecognized compartment syndrome
Supracondylar humerus fractures are the most common elbow fractures in children, accounting for 60-80% of pediatric elbow fractures. While growth disturbance, vascular injury, compartment syndrome and infection are recognized complications of supracondylar fractures and their treatment, none have been associated with the development of cubitus varus (gunstock) deformity. This usually is the result of malunion caused by failure to reduce a collapsed medial column or failure to correct rotation at the fracture site. Current standard treatment for displaced supracondylar humerus fractures is reduction and pinning (closed or open). Cheng et al found an increase in CRPP of supracondylar fractures from 4 to 40% over a 10 year period.
Cheng JC, Ng BK, Ying SY, Lam PK.
J Pediatr Orthop. 1999 May-Jun;19(3):344-50. PMID: 10344317 (Link to Abstract)
Cheng, JPO 1999
Average 4.0 of 21 Ratings
Howard A1, Mulpuri K, Abel MF, Braun S, Bueche M, Epps H, Hosalkar H, Mehlman CT, Scherl S, Goldberg M, Turkelson CM, Wies JL, Boyer K; American Academy of Orthopaedic Surgeons.
J Am Acad Orthop Surg. 2012 Feb;20(2):69-77. PMID: 22553104 (Link to Abstract)
Supracondyar fractures are common and often subtle paediatric elbow fractures. T...
Lateral entry percutaneous pinning of a SCH fx
Educational video describing a patient case of Anterior Interosseous Nerve Injur...
HPI - 7 year old male patient. Presented with history of supracondylar fracture of Left elbow 5 months ago. ORIF was performed and removal of K-wires done after 2 months. Physiotherapy done after surgery, but with little benefit and minimal improvement of ROM.
How can we obtain better elbow motion for this patient?
HPI - Witnessed fall from ladder while at school.
What is your preferred management of this case?
HPI - Child age 8 sustained supracondylar fracture on 20 July 2015, admitted in Hospital and urgently operated. Due to lack of C arm in operation theatre doctor didn't check fracture position and somehow decided not to reoperate later when he confirmed position of fracture by x rays.
How would you treat this patient
HPI - Fall on outstreshed hand 3ms ago
ORIF by k wires
Slap for one and half ms then removal of slap and wires
Physiotherapy till now
How would you treat this patient?
HPI - 6 yr female Rt handed, had closed Lt elbow supracondylar fracture type 3 reduced in ER, 4 days ago,treated second day by open reduction using campell approach due to 2 failed attempts of closed reduction,post reduction xray showed malreduction
Is this reduction accepted or she need revision surgery snd how?
HPI - history of fall on outstretched hand 4 weeks back and took bandages from a bone setter. Now complains of stiffness of elbow
Best line of treatment for this patinet....
HPI - 2years ago fell on out stretched hand, supracondylar left humeral fracture ,treated by above elbow cast for one month
How would you treat this malunion?
HPI - History of fall 2days back resulting in closed supracondylar fracturewith vascular compromise .Gross swelling was present. Radial artery was not palpable. doppler study was not able to pick the pulses.Immediate closed reduction and percutaneous k wire fixation was done .cyanosis was restored and oxygen saturation was about 98 percent .doppler study showed both radial and ulnar pulses to be ok.
Post op x rays were not satisfactory .it has been 2 days post op ,swelling has decreased.
I am not satisfied with my initial closed reduction and percutaneous pinning. What should be the next course of action considering there is gross swelling and vascular compromise?
HPI - A 6-year-old box presents with elbow pain immediately following a fall from bed with an outstretched hand at home.
How would you treat this injury?
HPI - no pain. only cosmetic deformity is concerned for surgical correction
How would you treat this deformity?