Pediatric Humeral Fracture
Original Editors Ashley Bohanan, Alisha Lopez, Hannah Duncan, Neha Palsule, Brittany Buenteo
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Databases Searched: CINAHL, JOSPT, PubMed, Medline with Full Text, PEDro, Health Reference Center
Keyword Searches: pediatric humeral fractures, pediatric arm fractures, child humeral fractures, pediatric humeral fracture and treatment, management of pediatric humeral fracture
Search Timeline: September 27, 2011 - November 21, 2011
Definition/Description[edit | edit source]
Pediatric humeral fractures can occur in several locations including the proximal humerus, shaft (diaphysis) of the humerus, or the distal humerus. Of these, the supracondylar fracture is the most common[1] followed by lateral humeral condylar fractures.[2]
Proximal humeral fractures mechanism of injury (MOI)
- Fall or a direct hit to the proximal humerus (most common)[1]
Lateral humeral condyle fractures MOI
- A fall onto the hand while in elbow flexion or on the inner posterior part of a flexed elbow, or forceful adduction of the forearm.[2]
- The push-off theory suggested by Milch hypothesized that this fracture is due to a force that is “directed upward and outward along the radius”.[2]
- The pull-off theory proposes that this fracture is an avulsion fracture.[2]
- In a study of pediatric cadaver elbows, Jakob et al stated that this fracture was the consistent result of only adducting the supinated forearm while the elbow was extended.[3] The fracture line began on the lateral part of the condyle, which implies that the condyle was pulled off by the lateral collateral ligament and extensor muscles.[2]
- The most probable cause is a combination of the pull-off and push-off methods.[2]
Supracondylar Fractures MOI
- Hyperextension occurs during a fall onto the outstretched hand (FOOSH) with the elbow in extension, which indirectly puts force on the distal humerus and displaces it posteriorly; this can occur with or without a valgus or varus force. This ‘extension’ type of injury accounts for 95% of the cases.[4]
- Children younger than 3 years usually incur this injury from falling from a height of less than 3 feet (i.e. couch or bed) (Ryan 2010)
- Older children sustain fractures from falls from greater heights off of playground equipment (i.e. swings, monkey bars) (Ryan 2010)
- If the hand is in a supinated position, then a posterolateral displacement occurs.[4]
- If the hand is pronated, then a posteromedial displacement occurs (more common).[4]
- Direct trauma or a fall onto a flexed elbow seldom occurs resulting in a ‘flexion’ type injury (5%) with anterior displacement.[4]
Supracondylar fractures are classified based on how much displacement there is.[1] There are two commonly acknowledged classification systems for extension type supracondylar fractures include Gartland (established in 1959)[1] and the ensuing modification by Wilkins.[5]
Gartland’s Original Classification[5]
- Type I: undisplaced
- Type II: displaced with intact posterior cortex
- Type III: displaced, no cortical contact posteromedial or posterolateral
Modified Classification by Wilkins[5]
- Type 1A: undisplaced fracture
- Type 2A: intact posterior cortex and angulation only
- Type 2B: intact posterior cortex, angulation and rotation
- Type 3A: displaced, no cortical contact, posteromedial
- Type 3B: displaced, no cortical contact, posterolateral
Epidemiology/Etiology[edit | edit source]
Upper extremity fractures are more common in children than those that occur in the lower extremity.[1]
For children and adolescents, proximal humeral fractures are very common.[1] This fracture should be the first diagnosis considered in children between 9 and 15 years of age that sustained a shoulder injury.[1] In addition, this type of fracture can occur during a birth-related injury in newborns.[1]
Humeral shaft (diaphysis) fractures are uncommon in children. If this injury occurs without a major trauma (motor vehicle accident or fall from a height), it should increase the suspicion for a possible non-accidental trauma (child abuse).[1]
Lateral humeral condylar fractures account for 12-20% of all pediatric elbow fractures and occurs mostly in children about 6 years of age.[2]
Medial epicondyle fractures make up 11-20% of all injuries of the elbow in children with 30-55% of cases associated with a dislocation of the elbow.[6]
Pediatric supracondylar fractures make up about 65-75% of all elbow fractures in children.[4] These injuries are serious and if they are not diagnosed and treated quickly and effectively, are linked to significant neurovascular complications and deformity.[4] This fracture has the highest complication rate and is one of the most challenging types of elbow fractures that occur in children.[1]
Supracondylar fractures mostly occur between the ages of 5 and 10 (Ryan 2010) with the peak incidence occurring between 5-8 years of age (after this, dislocations become more frequent).[4] The reason that this injury occurs during this time period is due to greater likelihood of falls, general laxity of the ligaments, and weak bone structure at the supracondylar region.[1] In addition, in children the joint is in a position of hyperextension.[5] Furthermore, the ratio of males to females is 3:2, and the non-dominant side is injured more often.[4]
Complications associated with supracondylar fractures are as follows nerve injuries (7.7%) with the radial nerve most frequently involved (41.2%) followed by the median nerve (36.0%) and ulnar nerve (22.8%), anterior interosseous nerve involvement, true Volkmann’s ischaemic contracture (0.5%)[5], brachial artery injury, malunion, cubitus varus (gunstock deformity), and compartment syndrome.[1]
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References[edit | edit source]
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- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 Hart ES, Grottkau BE, Rebello GN, Albright MB. Broken Bones: Common Pediatric Upper Extremity Fractures – Part II. Orthopaedic Nursing. 2006;25(5):311-323.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Tejwani N, Phillips D, Goldstein RY. Management of Lateral Humeral Condylar Fracture in Children. Journal of the American Academy of Orthopaedic Surgeons. 2011;19:350-358.
- ↑ Jakob R, Fowles JV, Rang M, Kassab MT. Observations concerning fractures of the lateral humeral condyle in children. Journal of Bone and Joint Surgery Br. 1975;57(4):430-436.
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 Lord B, Sarraf KM. Paediatric supracondylar fractures of the humerus: acute assessment and management. British Journal of Hospital Medicine. 2011;72(1):M8-M11.
- ↑ 5.0 5.1 5.2 5.3 5.4 Marquis CP, Cheung G, Dwyer JSM, Emery DFG. Supracondylar fractures of the humerus. Current Orthopaedics. 2008;22(1):62-69.
- ↑ Louahem DM, Bourelle S, Buscayret F, Mazeau P, Kelly P, Dimeglio A, Cottalorda J. Displaced medial epicondyle fractures of the humerus: surgical treatment and results. A report of 139 cases. Archives of Orthopaedic and Trauma Surgery. 2010;130:649-655.
