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DISTAL HUMERUS FRACTURE PEDIATRIC

Introduction

Fracture Nomenclature for Pediatric Distal Humerus fractures

Hand Surgery Resource’s Diagnostic Guides describe fractures by the anatomical name of the fractured bone and then characterize the fracture by the Acronym:

In addition, anatomically named fractures are often also identified by specific eponyms or other special features.

For the Pediatric Distal Humerus Fractures, the historical and specifically named fractures include no fracture eponyms.

The elbow is the most frequent site of fracture in the pediatric population, and most of these injuries involve the distal humerus. Most pediatric distal humerus fractures are classified as either supracondylar—the most common type—lateral condyle, or medial epicondyle fractures. Pediatric supracondylar and other distal humerus fractures typically result from a fall on an outstretched hand and are seen most frequently in children between the ages of 5–10. Concomitant distal radius fractures may also occur with supracondylar fractures, and there is a risk for neurovascular complications in all pediatric distal humerus fracture patterns. Conservative treatment with splint and/or cast immobilization is generally recommended for nondisplaced and minimally displaced fractures, while surgery is often required for displaced fractures and those that fail conservative management.1-3

Definitions

  • A pediatric distal humerus fracture is a disruption of the mechanical integrity of the pediatric distal humerus.
  • A pediatric distal humerus fracture produces a discontinuity in the distal humeral contours that can be complete or incomplete.
  • A pediatric distal humerus fracture is caused by a direct force that exceeds the breaking point of the bone.

Hand Surgery Resource’s Fracture Description and Characterization Acronym

SPORADIC

S – Stability; P – Pattern; O – Open; R – Rotation; A – Angulation; D – Displacement; I – Intra-articular; C – Closed

S - Stability (stable or unstable)

  • Universally accepted definitions of clinical fracture stability are not well defined in the literature.4-6
  • Stable: fracture fragment pattern is generally nondisplaced or minimally displaced. It does not require reduction, and the fracture fragments’ alignment is maintained by with simple splinting or casting. However, most definitions define a stable fracture as one that will maintain anatomical alignment after a simple closed reduction and splinting. Some authors add that stable fractures remain aligned, even when adjacent joints are put to a partial range of motion (ROM).
  • Unstable: will not remain anatomically or nearly anatomically aligned after a successful closed reduction and immobilization. Typical unstable pediatric distal humerus fractures have significant deformity with comminution, displacement, angulation, and/or shortening.

P - Pattern2,3,7

  • The three most common distal humerus fracture types in pediatric patients are supracondylar fractures, lateral condyle fractures, and medial epicondyle fractures.3
  • Supracondylar fractures
    • Most common of all pediatric distal humerus fractures
    • Occur just above the lateral condyle and medial epicondyle
    • Typically diagnosed according to the modified Gartland classification system:
      • Type I
        • Nondisplaced and minimally displaced (<2 mm) fractures
        • Associated with an intact anterior humeral line
        • Very stable due to periosteum staying intact circumferentially
      • Type II
        • Fractures displaced >2 mm with an intact posterior hinge
          • Type IIA: fractures that are extended but with no rotational abnormality or fragment translation
          • Type IIB: fractures with an extension deformity and some degree of rotational displacement or fragment translation
      • Type III
        • Displaced fractures with no meaningful cortical contact
        • Involve some extension in the sagittal plane and rotation in the frontal and/or transverse planes
        • Periosteum is significantly torn, and concomitant soft-tissue and neurovascular injuries are common
      • Type IV
        • Fractures that are unstable in both flexion and extension due to complete loss of a periosteal hinge
  • Lateral condyle fractures
    • Second most common fracture type in pediatric patients
    • Typically follow a Salter-Harris IV fracture pattern, meaning the fracture transects the metaphysis, physis, and epiphysis of the lateral condyle
    • Typically, diagnosed according to the Milch classification system
      • Milch I: fracture line traverses laterally to the to the trochlear groove and the elbow is stable (less common)
      • Milch II: fracture passes through the trochlear groove and the elbow is unstable (more common)
  • Medical epicondyle fractures
    • Third most common fracture type in pediatric patients
    • Extra-articular fractures involving the medial epicondyle apophysis
    • No routinely used classification system for diagnoses

O - Open

  • Open: a wound connects the external environment to the fracture site. The wound provides a pathway for bacteria to reach and infect the fracture site. As a result, there is always a risk for chronic osteomyelitis. Therefore, open fractures of the pediatric distal humerus require antibiotics with surgical irrigation and wound debridement.4,8,9

R - Rotation

  • Pediatric distal humerus fracture deformity can be caused by proximal rotation of the fracture fragment in relation to the distal fracture fragment.
  • Degree of malrotation of the fracture fragments can be used to describe the fracture deformity.

A - Angulation (fracture fragments in relationship to one another)

  • Angulation is measured in degrees after identifying the direction of the apex of the angulation.
  • Straight: no angulatory deformity
  • Angulated: bent at the fracture site

D - Displacement (Contour)

  • Displaced: disrupted cortical contours
  • Nondisplaced: ≥1 fracture lines defining one or several fracture fragments; however, the external cortical contours are not significantly disrupted

I - Intra-articular involvement

  • Intra-articular fractures are those that enter a joint with ≥1 of their fracture lines.
  • Pediatric distal humerus fractures can have fragment involvement at the radiocapitellar or ulnohumeral joints.
  • If a fracture line enters a joint but does not displace the articular surface of the joint, then it is unlikely that this fracture will predispose to post-traumatic osteoarthritis. If the articular surface is separated or there is a step-off in the articular surface, then the congruity of the joint will be compromised, and the risk of post-traumatic osteoarthritis increases significantly.

C - Closed

  • Closed: no associated wounds; the external environment has no connection to the fracture site or any of the fracture fragments.4-6

Related Anatomy10-14

  • The elbow is a hinge-type synovial joint comprised of the radius, ulna, and humerus, and formed by three articulations: the ulnohumeral joint, radiocapitellar joint, and proximal radioulnar joint (PRUJ).
  • The ulnohumeral joint is the articulation of the olecranon process of the ulna and the medial condyle of the humerus. It allows for flexion and extension of the elbow. It is a hinge joint in which the trochlea serves as the center of the hinge and is supported by medial and lateral columns. The pediatric distal humerus has a triangular shape in the coronal plane formed by these columns and is linked by the articular segment.
    • The pediatric distal humerus also features three depressions—the coronoid, radial, and olecranon fossae—which accommodate the forearm bones during flexion or extension at the elbow.
  • The radiocapitellar joint is the articulation of the radial head with the capitellum of the humerus, which is a convex, rounded surface that covers the anterior and inferior surfaces of the lateral condyle. The lateral condyle is the outer bony prominence of the elbow. It is essential to elbow longitudinal and valgus stability and has an integral relationship with the lateral collateral ligament (LCL).
  • The key ligaments of the elbow include the LCL (which extends from the lateral epicondyle and blends with the annular ligament of the radius), the MCL (which originates from the medial epicondyle and attaches to the coronoid process and olecranon of the ulna), and the annular ligament (which encircles the radial head and stabilizes the PRUJ and radiocapitellar joint).
  • The key tendons of the elbow include the tendons associated with the biceps, triceps, extensor carpi radialis brevis (ECRB), and extensor carpi radialis longus (ECRL) muscles.

Incidence

  • Supracondylar fractures are the most common type of fracture overall in children under 7 years of age and the most common type of elbow fracture in all children.1,3
    • These fractures account for about 15% of all pediatric fractures, approximately 30% of all pediatric limb fractures, and about 50–70% of all pediatric elbow fractures.1,3
    • Approximately 96–98% of pediatric supracondylar humerus fractures are extension-type fractures.1
    • The peak incidence of supracondylar fractures in pediatrics is between ages 5 to 7.2
  • Lateral condyle fractures are the second most common type of elbow fracture in children and account for 15–20% of all pediatric elbow fractures.3
  • Medical epicondyle fractures typically occur in early adolescence (9–14 years of age) and are seen more often in boys secondary to injuries sustained in sports like football, baseball, and gymnastics.3

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ICD-10 Codes

  • DISTAL HUMERUS FRACTURE - PEDIATRIC

    Diagnostic Guide Name

    DISTAL HUMERUS FRACTURE - PEDIATRIC

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    DISTAL HUMERUS FRACTURE - PEDIATRIC    
    AVULSION FRACTURE MEDIAL CONDYLE    
    - DISPLACED S42.442_S42.441_ 
    - NONDISPLACED S42.445_S42.444_ 
    TRANSCONDYLAR    
    - DISPLACED S42.472_S42.471_ 
    - NONDISPLACED S42.475_S42.474_ 
    AVULSION FRACTURE LATERAL CONDYLE    
    - DISPLACED S42.432_S42.431_ 
    - NONDISPLACED S42.435_S42.434_ 
    SIMPLE SUPRACONDYLAR FRACTURE WITH/WITHOUT INTERCONDYLAR FRACTURE    
    - DISPLACED S42.412_S42.411_ 
    - NONDISPLACED S42.415_S42.414_ 
    COMMINUTED SUPRACONDYLAR FRACTURE WITH/WITHOUT INTERCONDYLAR FRACTURE    
    - DISPLACED S42.422_S42.421_ 
    - NONDISPLACED S42.425_S42.424_ 
    OTHER FRACTURE OF LOWER HUMERUS    
    - DISPLACED S42.492_S42.491_ 
    - NONDISPLACED S42.495_S42.494_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S42
     Closed FracturesOpen Type I or II or OtherOpen Type IIIA, IIIB, or IIIC
    Initial EncounterABC
    Subsequent Routine HealingDEF
    Subsequent Delayed HealingGHJ
    Subsequent NonunionKMN
    Subsequent MalunionPQR
    SequelaSSS

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Symptoms
History of trauma
Fracture pain
Fracture deformity
Swelling, ecchymosis & tenderness
Abrasion
Typical History

A typical patient is a 6-year-old girl who was learning how to rollerblade without wearing elbow pads. The girl was going downhill on her rollerblades at a moderate speed when she lost her balance and fell forward. She landed on her right outstretched hand with her elbow in full extension with significant force, and the impact resulted in a supracondylar fracture of the distal humerus. Soon thereafter, the girl noticed that her elbow had become tender, swollen, and painful, and she had difficulty flexing and extending it. After her father noticed the extent of his daughter’s injury, he took her to the emergency department to be evaluated.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • When treating closed pediatric distal humerus fractures, the treating surgeon has 4 basic goals:4,9
    1. An elbow with a normal appearance. The X-ray may not need to be perfect, but the elbow should have no obvious deformity (ie, the elbow looks normal!)
    2. Avoid elbow stiffness by maintaining a normal functional ROM (ie, the elbow works!)
    3. The elbow is not painful (ie, the elbow does not hurt!)
    4. Congruent joint surface with none-to-minimal joint surface irregularities (ie, the elbow does not develop early post-traumatic arthritis!)
  • One additional goal is mandatory for open fractures:
    1. Fracture care should minimize the risk for infection and osteomyelitis.
Conservative
  • Nonoperative treatment is typically recommended for all nondisplaced and minimally displaced pediatric distal humerus fractures (e.g., Type I supracondylar fractures).3,7 This approach consists of immobilization with a long arm posterior splint with forearm in a neutral position and the elbow at 60–90° of flexion. After swelling is under control, patients are usually switched to a cast, which is left in place for about 3–4 weeks and monitored intermittently with radiography to ensure fracture healing is taking place.
  • Displaced pediatric distal humerus fractures that require surgery may also undergo initial splint immobilization with the elbow in a comfortable position of approximately 20–40° of flexion before surgical intervention.
Operative
  • Surgical treatment of pediatric distal humerus fractures must always be an individualized therapeutic decision.3,7,15,17 However, surgical pediatric distal humerus fracture care is most frequently recommended when:
    1. Closed reduction fails or the simple splint or cast immobilization does not maintain the reduction. For these irreducible or unstable fractures, operative treatment is recommended to achieve the 4 treatment goals of fracture care.
    2. There is a significantly displaced pediatric distal humerus fracture involving the radiocapitellar or ulnohumeral joint.
    3. Open pediatric distal humerus fractures. These injuries require surgical care in the form of irrigation and debridement to prevent chronic infection.
  • The two most frequently utilized surgical procedures for pediatric distal humerus fractures are closed reduction and percutaneous pinning (CRPP) and open reduction and internal fixation (ORIF).
  • CRPP
    • Most common surgical procedure for pediatric distal humerus fractures; recommended initially for all moderately-to-severely displaced fractures that are not open.
    • Involves the repositioning of displaced bone fragments with two—or three, for severely displaced fractures—metal pins placed laterally. The fracture is first reduced in the frontal plane, and then with the elbow flexed and the olecranon pushed anteriorly, the sagittal deformity is corrected.
  • ORIF
    • Indicated for the following cases: when CRPP fails, open fractures, and limbs with vascular insufficiency, which may indicate an entrapped brachial artery.
    • The direct anterior approach is recommended for patients with neurovascular compromise because it allows for direct visualization of the brachial artery and median nerve in addition to the fracture fragments.
    • The posterior approach is not typically recommended due to the association with loss of motion and the risk of osteonecrosis, which can occur when the posterior end of the arterial supply to the trochlea is disrupted.

Post-treatment Management

  • The care and precautions related to immobilization devices for the pediatric distal humerus fracture must be carefully reviewed with the patient. Patients should be educated regarding care and precautions. Patients should know that pain, especially increasing pain, numbness, tingling, skin irritation, splint loosening, or excessive tightness are red flags and should be reported to the surgeon or his team.
  • Pain should be managed with properly fitting splints and casts, reassurance, elevation, ice in the initial post-fracture period, and mild pain medications. Patients should be encouraged to discontinue pain medication as soon as possible. Opioid use should be kept to a minimum.
  • Joints that are splinted for closed stable fractures are usually immobilized.
  • Fractures that require internal fixation can usually be mobilized after 4 weeks.
  • Therapist-guided, gentle active ROM exercises for the hand, wrist, and shoulder should begin immediately after surgery. Active ROM exercises for the elbow should begin 7–10 days post-surgically if there are no wound issues. Strengthening exercises may begin after there is radiographic evidence that the fracture has healed, which typically occurs around 8–12 weeks after surgery.17,18
Complications
  • Neuropraxia
    • Most common complication in pediatric supracondylar fractures; usually involves the interosseous nerve.1
  • Cubitus varus
    • Common in supracondylar fractures managed with either casting or pinning.
  • Compartment syndrome
    • Rare, but may be severe.2
  • Stiffness
  • Aseptic necrosis
  • Avascular necrosis
  • Malunion
  • Loss of elbow ROM
  • Heterotopic ossification
  • Hardware failure
  • Non-union
  • Post-traumatic arthritis
Outcomes
  • In one study of 34 patients with supracondylar fractures that underwent ORIF through an anterior approach, only 6% had an unsatisfactory loss of motion.19
    • Similarly, in a study of 65 patients with supracondylar fractures that underwent ORIF through either a medial or lateral approach, 78% of patients had an excellent or good outcome, and loss of motion only occurred in four cases.20
  • Another study compared CRPP to ORIF in 28 children with displaced supracondylar fractures, and no between-group differences were identified in assessments of neurovascular injury, ROM, infection rate, or union rate.21
  • Additional research has shown that pediatric patients can often rapidly recover elbow ROM after undergoing treatment for supracondylar fractures, although recovery is usually slower for older patients and those with more severe fracture patterns.22
Key Educational Points
  • Although modern techniques have improved outcomes in pediatric distal humerus fractures, several controversies remain, such as the urgency of operative treatment, the configuration of pin placement, whether Type II supracondylar fractures should be treated surgically or conservatively, and how to manage dysvascular limbs.7
  • ORIF was once associated with elbow stiffness, myositis ossificans, significant scarring, and iatrogenic neurovascular injury, but the rate of complications following this procedure has decreased in recent times.7
  • Skin puckering during this examination may occur with these fractures in children.7
  • The neurovascular exam should include sensory and motor function assessments of the median, radial, ulnar, and interosseous nerves for signs of damage.15
  • Clinicians should be suspicious of the possibility of compartment syndrome, which includes the following signs: considerable swelling and/or ecchymosis, anterior skin puckering, and an absent pulse.7
  • A true anteroposterior (AP) view of the distal humerus and a true lateral radiograph of the elbow are typically recommended initially.7 Oblique views of the elbow and comparison radiographs of the contralateral elbow are not routinely needed, but may help to identify minimally displaced fractures.2 For fractures that are not visible on radiography, the presence of the posterior fat pad on lateral radiographs strongly suggests the presence of an occult elbow fracture.2
  • Computerized tomography (CT) scanning may be needed for fractures that cannot be visualized on plain radiography.16
References

Cited Articles

  1. Babal JC, Mehlman CT, Klein G. Nerve injuries associated with pediatric supracondylar humeral fractures: a meta-analysis. J Pediatr Orthop 2010;30(3):253-263. PMID: 20357592
  2. Abzug JM, Herman MJ. Management of supracondylar humerus fractures in children: current concepts. J Am Acad Orthop Surg 2012;20(2):69-77. PMID: 22302444
  3. Saeed W, Waseem M. Elbow Fractures Overview. In: StatPearls. Treasure Island (FL) 2021. PMID: 28723005
  4. Cheah AE, Yao J. Hand Fractures: Indications, the Tried and True and New Innovations. J Hand Surg Am 2016;41(6):712-722. PMID: 27113910
  5. Nesbitt KS, Failla JM, Les C. Assessment of instability factors in adult distal radius fractures. J Hand Surg Am 2004;29(6):1128-1138. PMID: 15576227
  6. Walenkamp MM, Vos LM, Strackee SD, Goslings JC, Schep NW. The Unstable Distal Radius Fracture-How Do We Define It? A Systematic Review. J Wrist Surg 2015;4(4):307-316. PMID: 26649263
  7. Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J Bone Joint Surg Am 2008;90(5):1121-1132. PMID: 18451407
  8. Ketonis C, Dwyer J, Ilyas AM. Timing of Debridement and Infection Rates in Open Fractures of the Hand: A Systematic Review. Hand (N Y) 2017;12(2):119-126. PMID: 28344521
  9. Meals C, Meals R. Hand fractures: a review of current treatment strategies. J Hand Surg Am 2013;38(5):1021-1031. PMID: 23618458
  10. Fernandez, DL and Jupiter, JB. Fractures of the Distal Radius: A Practical Approch to Management. Second ed. New York: Springer Science+Business Media New York; 2002.
  11. Zumstein MA, Hasan AP, McGuire DT, Eng K, Bain GI. Distal radius attachments of the radiocarpal ligaments: an anatomical study. J Wrist Surg 2013;2(4):346-350. PMID: 24436840
  12. Burkhart KJ, Wegmann K, Muller LP, Gohlke FE. Fractures of the Radial Head. Hand Clin 2015;31(4):533-546. PMID: 26498543
  13. van Riet RP, van den Bekerom MPJ, Tongel AV, Spross C, Barco R, et al. Radial head fractures. Shoulder & Elbow 2020;12(3):212–223. PMID: 32565923
  14. Beazley JC, Baraza N, Jordan R, Modi CS. Distal Humeral Fractures-Current Concepts. Open Orthop J 2017;11:1353-1363. PMID: 29290875
  15. Crean TE, Nallamothu SV. Distal Humerus Fractures. In: StatPearls. Treasure Island (FL) 2021. PMID: 30285369
  16. Caviglia H, Garrido CP, Palazzi FF, Meana NV. Pediatric fractures of the humerus. Clin Orthop Relat Res 2005(432):49-56. PMID: 15738803
  17. Galano GJ, Ahmad CS, Levine WN. Current treatment strategies for bicolumnar distal humerus fractures. J Am Acad Orthop Surg 2010;18(1):20-30. PMID: 20044489
  18. Lauder A, Richard MJ. Management of distal humerus fractures. Eur J Orthop Surg Traumatol 2020;30(5):745-762. PMID: 31965305
  19. Fleuriau-Chateau P, McIntyre W, Letts M. An analysis of open reduction of irreducible supracondylar fractures of the humerus in children. Can J Surg 1998;41(2):112-118. PMID: 9575993
  20. Reitman RD, Waters P, Millis M. Open reduction and internal fixation for supracondylar humerus fractures in children. J Pediatr Orthop 2001;21(2):157-161. PMID: 11242241
  21. Kaewpornsawan K. Comparison between closed reduction with percutaneous pinning and open reduction with pinning in children with closed totally displaced supracondylar humeral fractures: a randomized controlled trial. J Pediatr Orthop B 2001;10(2):131-137. PMID: 11360779
  22. Spencer HT, Wong M, Fong YJ, Penman A, Silva M. Prospective longitudinal evaluation of elbow motion following pediatric supracondylar humeral fractures. J Bone Joint Surg Am 2010;92(4):904-910. PMID: 20360514
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