Elbow Injuries in Children

Elbow injuries represent a common presentation of children to the emergency department, and approximately 10% of children who sustain a forearm fracture will also have associated injuries to their elbow joint. Having a slightly higher predilection for boys compared with girls, elbow injuries can be seen in any age range. With their propensity for risk-taking behaviors, such as climbing on playground sets and hanging from monkey bars, children 5 to 8 years of age account for the peak incidence of acute elbow fractures and dislocations. Adolescents tend to have lower fracture rates than younger children but often present with chronic overuse injuries. However, sports-related and recreational fractures may also occur in this age group. Although elbow fractures are not as common as other forearm fractures, they must be promptly diagnosed because surgical intervention is often required to prevent poor outcomes.When assessing a child who presents with concern for elbow injury, history and physical examination are the keys to diagnosis. Imaging may be warranted under specific circumstances: if there is an acute trauma to the area such as a fall, a gross deformity or significant swelling or edema, pinpoint pain to palpation, or decreased range of motion, then anteroposterior and lateral radiographs should be obtained. Given the subtle nature of pediatric elbow injuries, the contralateral elbow may also be radiographed for comparison. Proper radiographic evaluation and understanding of the ossification centers of the pediatric elbow are critical for appropriate diagnosis and management.One of the most challenging aspects of diagnosing acute elbow fractures in children is understanding the pediatric ossification centers. The pediatric elbow consists of 6 incompletely ossified areas of cartilage that first appear and then fuse over time. Being familiar with these centers is crucial to differentiating an ossification center from a fracture fragment in children. The mnemonic CRITOE is an aid to remembering the sequence in which they appear and ossify: capitellum, radial head, internal (medial) epicondyle, trochlea, olecranon, and external (lateral) epicondyle (Table, Fig 1). When determining whether there is an elbow fracture, it is important to obtain lateral radiographs to assess for possible joint effusion. An effusion can be recognized by the presence of a posterior fat pad near the distal humerus or if the normal anterior fat pad has been displaced. If an elbow effusion is suspected but no fracture is evident on radiography, then it should be presumed that there is an occult fracture. A patient who is treated for an occult fracture should have a follow-up radiograph in 7 to 10 days to determine whether there is new periosteal growth.Supracondylar fractures are the most common type of elbow fracture in children, accounting for more than 50% of elbow fractures, with a peak incidence between 6 and 8 years of age. Cortical thinning from bone remodeling during this age period makes the supracondylar region prone to fracture. Most supracondylar fractures result from falls onto outstretched hands (so-called FOOSH), which lead to hyperextension of the elbow joint, causing the distal humerus to be posteriorly displaced relative to the humeral shaft. This displacement can be assessed by evaluating the anterior humeral line on a lateral radiograph. Typically, the anterior humeral line passes through the middle third of the capitellum, but with significant displacement, it passes more anteriorly to the capitellum (Fig 2). Although posterior supracondylar fractures may occur from children falling on a flexed elbow, these injuries are much less common. Supracondylar fractures are graded by severity using the Gartland classification system. A type I injury is a nondisplaced fracture that requires immobilization with placement of the affected elbow in a posterior arm splint with the elbow positioned at 90° and follow-up as an outpatient with an orthopedist. Types II and III represent more significant displacement requiring emergency orthopedic evaluation for closed reduction and possible pinning. Because supracondylar fractures pose a high risk of compartment syndrome, evaluation for neurovascular complications is vital.Aside from elbow fractures, dislocations account for a significant portion of elbow injuries. The most common type of dislocation is a radial head subluxation, otherwise known as nursemaid’s elbow. With a peak incidence between 2 and 5 years of age, this injury results from traction on an extended elbow, such as when a child is pulled by the hand. On history, scenarios that should raise suspicion include being pulled by a caretaker, playing with an older sibling, or even self-induced, such as sliding off a bed. The force of the traction leads the annular ligament, which serves as a binder between the ulna and radius, to become entrapped over the radial head. Common presenting symptoms include pain and tenderness over the lateral elbow, with children having a preference to keep their elbow in the flexed and pronated position. Radiographic imaging is not required to make this clinical diagnosis. Treatment includes nonoperative reduction of the radial head by applying gentle pressure over the radial head and either hyperpronating or supinating while flexing the elbow to 90°. Often, a palpable click can be felt if reduction is successful. There is no need to immobilize the child’s arm after reduction, and children should be allowed movement as tolerated. However, it is critical to inform parents of potential reoccurrence, which can happen in up to 30% of patients from a torn annular ligament.With increased participation in youth sports and athletics, chronic elbow injuries have become more prevalent in the pediatric and adolescent populations. Overuse injuries of the elbow are most common in sports that require frequent and recurrent pronation and supination, such as tennis, baseball, and gymnastics. Depending on which side the repetitive forces are being applied, children can develop a spectrum of overuse injuries commonly known as little leaguer’s elbow. Lateral forces applied to the capitellum, such as in pitching a baseball, can lead to avascular necrosis of the developing capitellar ossification center, known as Panner disease, typically seen in younger children, with a peak incidence between 4 and 8 years of age. Radiographs show fragmentation of the capitellum. Treatment consists of rest, review of proper throwing mechanics, as well as gradual return to play. Often, the capitellar ossification resumes normal growth spontaneously without intervention. If young athletes continue to have microtrauma across the lateral radiocapitellar joint, which is prone to damage from a poor blood supply, they can develop ischemia of the capitellum, resulting in stress fractures known as osteochondritis dissecans. With a peak incidence during adolescence, osteochondritis dissecans presents with limited range of motion on pronation and supination, as well as with an effusion. Magnetic resonance imaging is the imaging modality of choice because it is most sensitive in visualizing the chondral surface. Treatment consists of rest, cessation of sporting activity, and rehabilitation with physical therapy. In rare cases, unstable lesions may require surgical intervention.Medial distraction injuries occur when increased valgus stress is placed on the elbow, such as in performing handstands in gymnastics or pitching in baseball. The persistent strain on the elbow leads to a medial epicondyle apophysitis and sometimes even fracture. Common presentation includes pain along the medial epicondyle region, specifically with movement. Patients should be instructed to cease or modify inciting activities, and treatment is focused on RICE (rest, ice, compression, and elevation) therapy. Nonsteroidal anti-inflammatory medications may also be used. The ulnar collateral ligament (UCL), which stabilizes the medial epicondyle region, is prone to tear in older high-achieving athletes with repetitive overuse, such as from pitching. Under rare circumstances, a complete UCL rupture can occur. Symptoms include pain along the medial epicondylar region similar to other medial distraction injuries. Radiographs should be obtained to rule out associated fractures, and magnetic resonance imaging is necessary for evaluation of the ligament. Conservative management for UCL injuries is similar to other medial distraction injuries and includes rest, cessation of the inciting activity, and anti-inflammatory medications. However, surgical treatment (Tommy John surgery) is often required for ligamentous reconstruction.Pediatric elbow injuries are becoming increasingly commonly seen in both the emergency department and primary care settings. It is essential for providers to understand and recognize the 6 ossification centers of the pediatric elbow to appropriately diagnose and manage these children. Orthopedic consultation may be warranted for acute traumatic fractures to prevent poor outcomes. With increased participation in youth sports programs and higher demands placed on athletes, providers should familiarize themselves with chronic overuse injuries and best approaches to regain normal function.If a picture is worth 1,000 words, how many in a whole video? Let me refer you to the Pediatrics in Review issue of July 2008 (e42–e43), where you can find videos illustrating both the pronation and supination techniques for reduction of a nursemaid’s elbow. In the article on ankle injuries in our series on injuries to the extremities of children, I comment on the recent questioning of RICE therapy, particularly the application of ice. For those of you who may not have seen it, let me repeat: the aim of all 4 measures (rest, ice, compression, elevation) is to reduce blood flow to the site of injury with the intent of reducing swelling and pain; and ice, by its numbing effect, does provide at least some analgesia. But several reviews of randomized controlled studies have found that, at best, the evidence for the efficacy of RICE is weak. Furthermore, the body’s inflammatory response, which may actually be an agent of healing, is dampened by the application of cold. This is not to say that RICE should be abandoned, but rather to suggest that we don’t really know what is best. We have been wrong in the past: babies should sleep on their bellies; the introduction of potentially allergenic foods should be delayed. What we need is evidence, not dogma.–Henry M. Adam, MDAssociate Editor, In Brief