There are several fractures that occur around the elbow. Most of them occur when a child falls from a height, like the monkey bars. Unfortunately, many fractures that occur near the elbow require surgery because of one of two reasons:
- The fracture pieces are very separated from each other and would heal poorly if left in this position.
- The fracture crosses into the elbow joint and the bones need to be aligned as perfectly as possible to prevent future arthritis.
Injuries around the elbow are frequent in children, and can involve any of three bones. These are the humerus, which is the upper arm bone, or the radius or ulna, which are the two bones of the forearm. In young children, the elbow joint is largely cartilage, which can make injuries difficult to detect on x-ray. The elbow has a number of growth centers that may be injured in various fractures. These growth centers ossify, or turn to bone, as a child grows and matures, which can make the elbow x-rays of children of different ages look very different, and can further complicate proper diagnosis of elbow injuries. Below is a normal xray of a 9 year old boy demonstrating the three bones that make up the elbow joint.
ACUTE ELBOW INJURIES
SUPRACONDYLAR HUMERUS FRACTURES:
Supracondylar humerus fractures are one of the most common fractures in children, and account for over half of the fractures around the elbow alone. It is an injury that Children’s Orthopedics of Atlanta treats every day. It is most common in children ages 5-7, but it is not uncommon outside this range. It occurs in equally in boys and girls. The break, or fracture, occurs just above the elbow joint, through the humerus. When a child places her hand out in front out in front of her to break her fall, she does so with the elbow joint locked straight. At that moment, the top part of the ulna bone (known as the olecranon) is forced into the thin olecranon fossa of the humerus, causing the bone to break. During the ages of 5-7, the olecranon fossa is very thin, and thus more likely to break.
Many of these fractures are minimally displaced, meaning that the bones are not too far separated from each other. If that is the case, often times, your clinician (doctor or PA/NP) will recommend cast treatment for several weeks. However, if the bones are separated from each other and appear crooked on x-rays, than most likely you're COA surgeon will recommend surgery in order to help align the bones and then maintain the alignment.
Most of the time, your doctor will not need to make any incisions to align (aka "reduce") the bones back in place. However, to ensure that the bones do not move once they are aligned, your surgeon will place 2-3 sterile metal pins through the skin, inside the bone, and across the fracture to hold it in place. Those pins stay outside the skin but are protected underneath the cast. Those pins are removed after approximately 3-4 weeks in the office.
Removing the pins in the office is not painful, but some children become very frightened by either the removal of the cast or pulling of the pins. We recommend that you bring a distraction for your child – headphones with music, a tablet or phone, or a favorite toy or game are often very helpful.
Once the pins are removed, your child will either be placed back in a cast for a few weeks, or more likely, will be allowed to start moving his arm.
The majority of the time, there are no long-term consequences of having one of these elbow fractures. Some children may be a little stiffer on the fractured side versus the non-fractured side, and occasionally, the bone does not heal in the exact position as it was placed during surgery.
Below is an example of an 8 year old girl who fell and suffered a supracondylar humerus fracture. The bone was severely displaced, and thus surgery was recommended to align the bones. The x-ray on the left represent her injury films. The middle radiograph is 3 weeks after the surgery in which the cast, and then the pins, were removed in the office. The final radiograph was 4 weeks later, or 7 weeks from the injury showing the bone completely healed. She no longer needed any additional follow-up as she was pain free and had no stiffness.
LATERAL CONDYLE FRACTURES:
Lateral Condyle fractures are a common type of elbow injury in children. They account for 17-20% of elbow fractures in children, and usually occur between 5-10 years of age. They most commonly are due to a fall on an outstretched hand. In a lateral condyle fracture, the outside edge of the elbow joint is broken, and the outside of the elbow is typically painful and swollen. Lateral condyle fractures frequently involve both the growth plate as well as the elbow joint surface, and frequently require surgery to heal properly.
For surgery, usually an incision is made on the outside of the elbow and the fractured pieces are put back in place under direct visualization. After the pieces are aligned properly, 2-3 pins are placed to keep the pieces in place. A cast is then applied over the pins, and the cast and pins remain in place for 3-4 weeks. After that time, the cast is removed and the pins are pulled out in the office. Below are some x-rays of a lateral condyle fracture at injury and at the time of surgery.
MEDIAL EPICONDYLE FRACTURES:
Medial Epicondyle fractures are another common type of elbow fracture seen in children. The inside portion of the elbow is injured, frequently due to a fall on an outstretched hand. Medial epicondyle fractures are also frequently associated with elbow dislocations. Sometimes, the fragment of bone can get trapped inside the elbow joint when the injury occurs with an elbow dislocation.
Medial epicondyle fractures sometimes require surgery. Reasons for needing surgery for this fracture include fragment entrapment in the joint, elbow instability, and significant displacement of the fragment. If surgery is required, the fragment is repositioned and fixed with a screw or a pin. If no surgery is required, usually only a period of immobilization is required - typically 4-6 weeks.
Elbow dislocations account for about 3-6% of pediatric elbow injuries. The injury occurs when the joint between the ulna and humerus comes out of place, and most commonly occurs due to a fall on an outstretched hand. It occurs in males about three times as often as in females, and most commonly occurs in children 10-15 years old. It is extremely rare in children younger than 3. About half the time, the medial epicondyle is also fractured when the elbow dislocates. If there are no fractures associated with the dislocation, then the joint is put back in place with the child under sedation, and the elbow is immobilized for around a week. If there is a fracture in addition to the dislocation, then surgery may be required depending on the fracture.
The biggest obstacle after an elbow dislocation is regaining range of motion. Elbow dislocations associated with broken bones, especially in the adolescent, are at highest risk of developing stiffness later. Depending on the age of your child, and the severity of injury, your clinician may recommend physical therapy to help your child regain all of his motion. Physical therapy can range from weeks to months. It is very rare for the elbow to dislocate again once it has been placed back in its socket.
RADIAL HEAD AND NECK FRACTURES:
Radial neck fractures account for about 1-5% elbow injuries in children. They usually occur in children around 9-10 years old, and occur equally as often in boys and girls. The top of the radius, on the outside of the elbow, fractures just below the elbow joint, and often is significantly displaced. When this occurs, the top of the radius needs to get put back into place. Usually this can be done in the emergency room with the child under sedation, however sometimes the radius can’t be realigned without surgery. If the radius can be successfully realigned, the elbow is immobilized for around a week, and then the child can begin moving the elbow. If surgery is required, then the elbow may me immobilized for slightly longer.
Nursemaid’s Elbow is a common elbow injury seen in young children, usually around 2-5 years old. The injury is usually caused by sudden pull on the child’s arm. After the injury the child usually carries the arm with the elbow slightly bend with the palm down, and does not want to move the arm. The injury occurs when the radial head is pulled out of joint with the humerus, and one of the ligaments around the elbow becomes entrapped around it. This can occur due to the laxity of ligaments in young children. The injury is usually easily corrected by simple maneuver that your doctor can perform. The child usually begins using the elbow normally within a few minutes after correction, and no cast, splint, or further treatment is required.
ELBOW PAIN/CHRONIC INJURIES
LITTLE LEAGUE ELBOW:
Ulnar collateral ligament injuries in children are part of a spectrum of elbow injuries in children who play throwing sports. It is often called “Little Leaguer’s Elbow” because of its strong association with very active baseball players, usually pitchers. The injury occurs from repetitive stress on the inside of the elbow, and can range anywhere from injuries to the ligament on the inside of the elbow to fractures of the bone on the inside of the elbow. Younger children tend to be injured at a part of the bone call the apophysis, while older children tend to have injuries to the ligament.
The first sign is pain on the inside of the elbow with throwing, and if the child continues to throw, the pain will worsen and throwing speed, accuracy and distance will begin to decrease. The treatment is to stop throwing for a period, usually several weeks, followed by a gradual return to throwing. Limiting the number of innings pitched per week as well as making sure proper pitching mechanics are used are crucial to both prevention and treatment of this problem. In some cases when the injury to the bone or ligament is severe, surgery is required for the injury to heal.
OCD (OSTEOCHONDRITIS DISSECANS) OF THE ELBOW:
OCD lesions, or Osteochondritis Dissecans lesions of the elbow typically occur in active children after 10 years of age, however on occasion it can occur in younger children. Children with this disorder most commonly heavily participate in throwing sports and gymnastics. The first symptom is activity related elbow pain in the dominant arm; the pain may be just on the outside of the elbow or the entire elbow may hurt. Later symptoms may include catching, locking, a grinding sensation, and loss of motion.
The injury occurs from repetitive stress on the capitellum, which is on the outside of the elbow on the upper arm bone. If the activity continues, the pain will progress and the injury will become worse. The treatment is stopping activity for 3-6 weeks followed by a slow, gradual return to activity over a period of another 6-12 weeks. This is effective up to 90% of the time; in cases that do not respond to this treatment or are very severe, surgery may be needed.