Introduction Epidemiology incidence uncommon fracture in children in the US, accounts for <5% of all pediatric fractures peak age between 5-10 year old Pathophysiology mechanism fall onto outstretched arm with elbow in flexion (most common) triceps and brachialis tensioning causes a transverse olecranon fracture elbow in extension varus/valgus bending forces through the olecranon causes longitudinal fracture lines varus may lead to associated radial head dislocation valgus may lead to an associated fracture of the radial neck direct trauma (least common) shear force creates anterior tension failure with anterior displacement of the distal fracture and intact posterior periosteum location metaphyseal (most common) physeal epiphyseal (apophyseal) intra-articular extra-articular Associated conditions osteogenesis imperfecta olecranon avulsion fractures are highly suspicious for osteogenesis imperfecta Anatomy Ossification centers of elbow age of ossification/appearance and age of fusion are two independent events that must be differentiated olecranon apophysis ossifies/appears at age 9 years fuses at age ~ 15 -17 years Ossification center Years at ossification (appear on xray) (1) Years at fusion (appear on xray) (1) Capitellum 1 12-14* Radius 3 14-16 Internal (medial) epicondyle 5 16-18 Trochlea 7 12-14* Olecranon 9 15-17 External (lateral) epicondyle 11 12-14* (1) +/- one year, varies between boys and girl. C-R-I-T-O-E to remember age of ossification. CTE-R-O-I to remember age of fusion (capitellum, trochlea and external (lateral) epicondyle fuse together at puberty. Together they fuse to the distal humerus between the ages of 14-16 years old) Olecranon ossification fusion of the epiphysis to the metaphysis of the olecranon occurs from anterior to posterior average age of closure is between the ages of 15-17 years old partial closure may be mistaken for olecranon fracture Presentation History acute fall onto outstretched arm or direct elbow trauma Symptoms pain swelling of posterior elbow inability to extend elbow Physical exam inspection swelling and deformity contusion or abrasion over elbow may be suggestive of direct trauma palpation crepitus defect detected between fracture fragments gapping may suggest a disruption in the posterior periosteum, which makes the fracture more unstable movement lack of active elbow extension Imaging Radiographs recommended views AP and lateral elbow xrays findings fracture configuration (transverse, oblique, longitudinal) intra-articular displacement high suspicion for associated fracture (radial neck, lateral condyle, distal radius, etc.) proximal physis is oblique (green line) which differentiates it from a fracture (red line) secondary ossification center (patella cubiti) does not represent a fracture Treatment Nonoperative NSAIDS, rest, immobilization with avoidance of elbow resistance exercises indications stress fractures in repetitive motion athletes apophysitis outcomes monitor until there is clinical improvement convert to casting if needed long arm splint or casting indications minimally displaced fractures duration 3-4 weeks total repeat imaging at 7 days to ensure no significant displacement Operative ORIF indications displaced fractures unstable fractures with loss of posterior periosteum comminution techniques tension band wiring AO technique with axial K-wires congruent articular surface consider early range of motion post-operatively high rate of removal of hardware tension band suturing use absorbable sutures (e.g. Number 1 polydioxanone (PDS) suture or fiberwire) may combine with oblique cortical lag screw with PDS with metaphyseal fractures plate and screws considered with comminuted fractures with partially fused ossification centers axial screw +/- tension wiring Complications Nonunion Delayed Union Compartment syndrome Ulnar nerve neurapraxia due to pseudarthrosis with inadequate fixation Loss of Reduction Elbow stiffness <table style="width: 100%; background-color: #ffffff; border: 0px solid #f4f4f4;" border="0" cellspacing="0"> <tbody> <tr> <td style="color: #000000; font-family: Arial, Helvetica, sans-serif; font-size: medium;" bgcolor="#f4f4f4"><span style="font-size: medium; font-weight: bold;">Introduction</span></td> </tr> <tr> <td> <ul style="font-size: medium;"> <li>Epidemiology <ul> <li>incidence <ul> <li><span style="font-size: medium; color: #0000cc;">uncommon fracture</span><span style="font-size: medium;"> in children </span></li> <li>in the US, accounts for <5% of all pediatric fractures</li> <li>peak age between 5-10 year old</li> </ul> </li> </ul> </li> <li>Pathophysiology <ul> <li>mechanism <ul> <li><span style="color: #0000cc;">fall onto outstretched arm</span> with <ul> <li><span style="color: #0000cc;">elbow in flexion</span> <ul> <li>will lead to triceps tensioning causing an olecranon avulsion fracture</li> </ul> </li> <li><span style="color: #0000cc;">elbow in extension</span> <ul> <li> can lead to varus/valgus bending forces through the olecranon causing oblique fracture lines</li> </ul> </li> </ul> </li> <li>direct trauma (least common)</li> </ul> </li> <li>location <ul style="font-size: medium;"> <li><span style="color: #0000cc;">metaphyseal (most common)</span></li> </ul> <ul style="font-size: medium;"> <li>physeal </li> </ul> <ul> <li>epiphyseal (apophyseal) <ul> <li>intra-articular</li> <li>extra-articular</li> </ul> </li> </ul> </li> </ul> </li> <li>Associated conditions <ul> <li><span style="color: #0000cc;">osteogenesis imperfecta</span> <ul> <li>olecranon avulsion fractures are highly suspicious for osteogenesis imperfecta <a title="question" href="#47"><img style="border-style: none; margin: 0px; padding: 0px; color: #333333; font-size: 12px;" src="/images/question.png" alt="" /></a></li> </ul> </li> </ul> </li> </ul> </td> </tr> <tr> <td style="background-color: #f4f4f4;">Anatomy</td> </tr> <tr> <td> <ul style="font-size: medium;"> <li>Ossification centers of elbow <ul> <li>age of ossification/appearance and <span style="color: #0000cc;">age of fusion</span> are two independent events that must be differentiated <a href="https://upload.orthobullets.com/question/3490/images/ossifcation%20of%20the%20elbow.jpg"><img style="border-style: none; margin: 0px; padding: 0px; color: #333333; font-size: 12px;" src="/images/pencil.jpg" alt="" /></a><span style="color: #333333;"> <a href="https://upload.orthobullets.com/question/3490/images/elbow%20ossification%20and%20fusion.jpg"><img style="border-style: none; margin: 0px; padding: 0px; color: #333333;" src="/images/pencil.jpg" alt="" /></a> <a style="text-decoration-line: none; color: #22229c; font-size: 12px; margin-right: 5px;" title="AP left elbow showing ossification centers " href="https://upload.orthobullets.com/topic/4010/images/cropped%20critol.jpg"><img style="border-style: none; margin: 0px; padding: 0px;" src="/images/camera.gif" alt="" /></a><a style="text-decoration-line: none; color: #22229c; font-size: 12px; margin-right: 5px;" title="Olecranon ossification center" href="https://upload.orthobullets.com/topic/4010/images/cropped%20critol-2.jpg"><img style="border-style: none; margin: 0px; padding: 0px;" src="/images/camera.gif" alt="" /> </a></span></li> <li><span>olecranon apophysis</span> <ul> <li><span>ossifies/appears at age 9 years</span></li> <li><span>fuses at age ~ 15 -17 years</span></li> </ul> </li> </ul> </li> </ul> </td> </tr> <tr> <td style="text-align: center;"><table style="width: 663px;" border="1" cellspacing="0" align="center" bordercolor="#dfeafb"> <tbody> <tr> <td style="font-size: medium;" width="34%" bgcolor="#dfeafb"><div style="font-size: small; text-align: center;"><em><strong>Ossification center</strong></em></div></td> <td style="font-size: medium;" width="36%" bgcolor="#dfeafb"><div style="font-size: small; text-align: center;"><em><strong>Years at ossification</strong> (appear on xray)</em><span style="font-size: 10px;"> (1)</span></div></td> <td style="background-color: #dfeafb; text-align: center;"><em style="font-size: small;"><strong>Years at fusion</strong> (appear on xray)</em><span style="font-size: 10px;"> (1)</span></td> </tr> <tr> <td style="font-size: medium; padding-left: 30px;"><span style="font-size: small;"><span style="color: #0000cc;"><span style="color: #000000;">C</span></span>apitellum</span></td> <td style="font-size: medium;"><div style="text-align: center;"><span style="font-size: small;">1</span></div></td> <td style="text-align: center;"><span style="font-size: small;">12-14*</span></td> </tr> <tr> <td style="font-size: medium; padding-left: 30px;"><span style="font-size: small;"><span style="color: #0000cc;"><span style="color: #000000;">R</span></span>adius</span></td> <td style="font-size: medium;"><div style="text-align: center;"><span style="font-size: small;">3</span></div></td> <td style="text-align: center;"><span style="font-size: small;">14-16<br /> </span></td> </tr> <tr> <td style="font-size: medium; padding-left: 30px;"><span style="font-size: small;"><span style="color: #0000cc;"><span style="color: #000000;">I</span><span style="color: #000000;">nternal (m</span></span>edial) epicondyle</span></td> <td style="font-size: medium;"><div style="text-align: center;"><span style="font-size: small;">5</span></div></td> <td style="text-align: center;"><span style="font-size: small;"><span style="color: #0000cc;">16-18</span></span></td> </tr> <tr> <td style="font-size: medium; padding-left: 30px;"><span style="font-size: small;"><span style="color: #0000cc;"><span style="color: #000000;">T</span></span>rochlea</span></td> <td style="font-size: medium;"><div style="text-align: center;"><span style="font-size: small;">7</span></div></td> <td style="text-align: center;"><span style="font-size: small;">12-14*<br /> </span></td> </tr> <tr> <td style="font-size: medium; padding-left: 30px;"><span style="font-size: small;"><span style="color: #000000;">O</span>lecranon</span></td> <td style="font-size: medium;"><div style="text-align: center;"><span style="font-size: small;">9</span></div></td> <td style="text-align: center;"><span style="font-size: small;">15-17<br /> </span></td> </tr> <tr> <td style="font-size: medium; padding-left: 30px;"><span style="font-size: small;">External (lateral) epicondyle</span></td> <td style="font-size: medium;"><div style="text-align: center;"><span style="font-size: small;">11</span></div></td> <td style="text-align: center;"><span style="font-size: small;">12-14*</span></td> </tr> <tr> <td style="font-size: medium; padding-left: 30px;" colspan="3" height="22"><p style="font-size: medium;"><span style="font-size: x-small;">(1) +/- one year, varies between boys and girl. <br /> <span style="color: #0000cc;"><span style="color: #000000;">C-R-I-T-O-E to remember age of ossification. <br /> </span></span><span style="color: #000000;">CTE-R-O-I to remember age of fusion (capitellum, trochlea and external (lateral) epicondyle fuse together at puberty. Together they fuse to the distal humerus between the ages of 14-16 years old)</span></span></p></td> </tr> </tbody> </table></td> </tr> <tr> <td> </td> </tr> <tr> <td style="background-color: #f4f4f4;"><strong>Anatomy</strong></td> </tr> <tr> <td> <table style="border: 0px solid #f4f4f4; width: 704px;" border="0" cellspacing="0"> <tbody> <tr> <td> <ul style="font-size: medium;"> <li>Ossification centers of elbow <ul> <li><span style="font-size: medium;"><span style="color: #0000cc;">age of ossification/appearance</span> and <span style="color: #0000cc;">age of fusion</span> are two independent events that must be differentiated <a href="https://upload.orthobullets.com/question/3490/images/ossifcation%20of%20the%20elbow.jpg"><img style="border-style: none; margin: 0px; padding: 0px; color: #333333; font-size: 12px;" src="/images/pencil.jpg" alt="" /></a><span style="color: #333333;"> <a href="https://upload.orthobullets.com/question/3490/images/elbow%20ossification%20and%20fusion.jpg"><img style="border-style: none; margin: 0px; padding: 0px; color: #333333;" src="/images/pencil.jpg" alt="" /></a> <a style="text-decoration: none; color: #22229c; font-size: 12px; margin-right: 5px;" title="AP left elbow showing ossification centers " href="https://upload.orthobullets.com/topic/4010/images/cropped%20critol.jpg"><img style="border-style: none; margin: 0px; padding: 0px;" src="/images/camera.gif" alt="" /></a><a style="text-decoration: none; color: #22229c; font-size: 12px; margin-right: 5px;" title="Olecranon ossification center" href="https://upload.orthobullets.com/topic/4010/images/cropped%20critol-2.jpg"><img style="border-style: none; margin: 0px; padding: 0px;" src="/images/camera.gif" alt="" /> </a></span> </span> <ul> <li><span style="font-size: medium;">olecranon apophysis </span> <ul> <li><span style="font-size: medium;">ossifies/appears at age 9 years</span></li> <li><span style="font-size: medium;">fuses at age ~ 15 -17 years</span></li> </ul> </li> </ul> </li> </ul> </li> </ul> </td> </tr> <tr> <td style="font-size: medium;" valign="top"><ul> <li><span style="color: #0000cc; font-size: 16px;">Olecranon ossification</span> <ul> <li><span style="font-size: 16px;">fusion of the epiphysis to the metaphysis of the olecranon occurs from anterior to posterior</span></li> <li><span style="font-size: 16px;">average age of closure is between the ages of 15-17 years old</span></li> <li><span style="color: #0000cc;">partial closure may be mistaken for olecranon fractur</span><span style="color: #0000cc;">e </span></li> </ul> </li> </ul> </td> </tr> </tbody> </table> </td> </tr> <tr> <td style="background-color: #f4f4f4;"><strong>Presentation</strong></td> </tr> <tr> <td> <ul> <li><span style="font-size: medium;">History </span> <ul> <li><span style="font-size: medium;">acute fall onto outstretched arm or direct elbow trauma</span></li> </ul> </li> <li><span style="font-size: medium;">Symptoms </span> <ul> <li><span style="font-size: medium;">pain</span></li> <li><span style="font-size: medium;">swelling of posterior elbow</span></li> <li><span style="font-size: medium;">inability to extend elbow</span></li> </ul> </li> <li><span style="font-size: medium;">Physical exam </span> <ul> <li><span style="font-size: medium;">inspection </span> <ul> <li><span style="font-size: medium;">swelling and deformity</span></li> <li><span style="font-size: medium;">contusion or abrasion over elbow may be suggestive of direct trauma</span></li> </ul> </li> <li><span style="font-size: medium;">palpation </span> <ul> <li><span style="font-size: medium;">crepitus</span></li> <li><span style="font-size: medium;">defect detected between fracture fragments</span></li> <li><span style="font-size: medium;">gapping may suggest a disruption in the posterior periosteum, which makes the fracture more unstable</span></li> </ul> </li> <li><span style="font-size: medium;">movement </span> <ul> <li><span style="font-size: medium;"><span style="color: #0000cc;">lack of active elbow extension</span> </span></li> </ul> </li> </ul> </li> </ul> </td> </tr> <tr> <td style="background-color: #f4f4f4;"><strong>Imaging</strong></td> </tr> <tr> <td> <ul> <li><span style="font-size: medium;">Radiographs </span> <ul> <li><span style="font-size: medium;">recommended views </span> <ul> <li><span style="font-size: medium;">AP and lateral xrays that should always be obtained on evaluation</span></li> </ul> </li> </ul> <ul style="font-size: medium;"> <li>findings <ul> <li><span style="font-size: medium;">fracture configuration (transverse, oblique, longitudinal)</span></li> <li><span style="font-size: medium;">intra-articular displacement </span></li> <li><span style="font-size: medium;">associated fracture (radial neck, medial/lateral condyle, distal radius, etc.)</span></li> </ul> </li> </ul> </li> </ul> </td> </tr> <tr> <td style="color: #000000; font-family: Arial, Helvetica, sans-serif; font-size: medium;" bgcolor="#f4f4f4"><span style="font-size: medium; font-weight: bold;">Treatment</span></td> </tr> <tr> <td style="color: #000000; font-family: Arial, Helvetica, sans-serif; font-size: medium;" valign="top"> <ul style="font-size: medium;"> <li style="color: #000000; font-size: medium; font-family: Arial, Helvetica, sans-serif;">Nonoperative <ul> <li style="color: #000000; font-size: medium;"><span style="font-size: medium;"><span style="color: #0000cc;"><strong><strong style="font-size: medium;"><span style="color: #0606bd;">NSAIDS, rest, immobilization with </span></strong>avoidance of elbow resistance exercises</strong></span> </span> <ul> <li style="color: #000000; font-family: Arial, Helvetica, sans-serif; font-size: medium;"><span style="font-size: medium;">indications </span> <ul style="color: #000000; font-family: Arial, Helvetica, sans-serif; font-size: medium;"> <li><span style="font-size: medium;">partial stress fractures</span></li> </ul> </li> <li><span style="font-size: medium;">outcomes</span> <ul style="color: #000000; font-family: Arial, Helvetica, sans-serif; font-size: medium;"> <li><span style="font-size: medium;">monitor until there is clinical improvement</span></li> <li><span style="font-size: medium;">convert to casting if needed</span></li> </ul> </li> </ul> </li> <li><span style="font-size: medium;"><span style="color: #0000cc;"><strong>long arm splint or casting </strong></span> </span> <ul style="font-family: Arial, Helvetica, sans-serif;"> <li><span style="font-size: medium;">indications </span> <ul style="color: #000000; font-family: Arial, Helvetica, sans-serif; font-size: medium;"> <li><span style="font-size: medium;">minimally displaced fractures</span></li> <li><span style="font-size: medium;">integrity of posterior olecranon periosteum maintained </span></li> </ul> </li> <li><span style="font-size: medium;">duration</span> <ul style="color: #000000; font-family: Arial, Helvetica, sans-serif; font-size: medium;"> <li><span style="font-size: medium;">3-4 weeks total</span></li> <li><span style="font-size: medium;">repeat imaging at 7-10 days to ensure no significant displacement</span></li> </ul> </li> </ul> </li> </ul> </li> <li style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: medium;">Operative </span> <ul> <li><span style="font-size: medium;"><strong style="font-size: medium;"><span style="color: #0000cc;">ORIF</span></strong> </span> <ul> <li><span style="font-size: medium;">indications </span> <ul> <li><span style="font-size: medium;"><span style="color: #0000cc;">displaced fractures</span></span></li> </ul> </li> <li style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: medium;">techniques </span> <ul> <li><span style="font-size: medium;">tension band wiring </span> <ul style="font-family: Arial, Helvetica, sans-serif;"> <li><span style="font-size: medium;">AO technique with axial K-wires</span></li> <li><span style="font-size: medium;">congruent articular surface</span></li> <li>consider early range of motion post-operatively</li> </ul> </li> <li style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: medium;">tension band suturing </span> <ul> <li><span style="font-size: medium;">use absorbable sutures (e.g. Number 1 polydioxanone (PDS) suture)</span></li> <li>may combine with oblique cortical lag screw with PDS with metaphyseal fractures</li> </ul> </li> <li style="font-family: Arial, Helvetica, sans-serif;">plate and screws <ul> <li>considered with comminuted fractures with partially fused ossification centers</li> </ul> </li> </ul> </li> </ul> </li> </ul> </li> </ul> </td> </tr> <tr> <td style="background-color: #f4f4f4;"><strong>Complications</strong></td> </tr> <tr> <td> <ul> <li><span style="color: #0000cc;">Nonunion</span></li> <li><span style="color: #0000cc;">Delayed Union</span></li> <li><span style="color: #0000cc;">Compartment syndrome</span></li> <li><span style="color: #0000cc;">Ulnar nerve neurapraxia</span> due to pseudarthrosis with inadequate fixation</li> <li><span style="color: #0000cc;">Loss of Reduction</span></li> <li><span style="color: #0000cc;">Elbow stiffness</span></li> </ul> </td> </tr> </tbody> </table>
QUESTIONS 1 of 3 1 2 3 Previous Next (SBQ10PE.88.1) A 5-year-old girl presents to the emergency room after a fall off a playground with right elbow pain. She refuses to move her arm due to the pain but is neurovascularly intact distally. Radiographs are shown in Figures A and B. What is the best next step in treatment? Tested Concept QID: 9114 FIGURES: A B Type & Select Correct Answer 1 NSAIDs, rest, and immobilization with avoidance of elbow resistance exercises 5% (73/1334) 2 Splint/cast immobilization 46% (616/1334) 3 Elastic stable intrameduallary nailing (ESIN) 2% (28/1334) 4 Open reduction internal fixation (ORIF) using a tension band construct 32% (431/1334) 5 Open reduction internal fixation (ORIF) using a plate and screws 13% (180/1334) L 5 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ05.10) The injury pattern seen in Figure A following minimal trauma is consider to be highly suspicious of which of the following conditions? Tested Concept QID: 47 FIGURES: A Type & Select Correct Answer 1 Osteogenesis imperfecta 71% (3539/4980) 2 Neurofibromatosis 2% (75/4980) 3 Osteosarcoma 0% (17/4980) 4 Non-accidental injury 24% (1212/4980) 5 Aneurysmal bone cyst 2% (111/4980) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept