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Background: Incarcerated medial epicondyle fractures in association with elbow trauma are rare and an absolute indication for intervention. Because of the infrequent nature, outcomes following this injury are not well documented. We studied a large cohort of these injuries to determine factors associated with functional outcomes. It was hypothesized that a greater duration between initial presentation and time of surgery would lead to poorer outcomes., Methods: A total of 32 patients aged 18 and under who underwent surgical treatment for an incarcerated medical epicondyle fracture at a level-1 pediatric trauma center from 2003 to 2015 were identified. All patients had a confirmed diagnosis of an incarcerated medial epicondyle at surgery. Medical records and radiographs were reviewed to determine the patient demographics, mechanism of injury, preoperative neurological symptoms, time of primary presentation, time of elbow reduction, and time to surgical intervention. Postoperative outcomes, including pain, range of motion, and ulnar nerve symptoms, were also collected. The Roberts outcome score was determined for each subject., Results: A radiographically confirmed elbow dislocation was identified in 25 subjects. The mean age at injury was 13.2 years (range, 7.3 to 17.8 y). Initial presentation was at a referring institution in 30 patients (94%). First closed reduction attempt of the ulnohumeral joint occurred in the emergency room in 24 subjects (75%); of these 7 subjects (22%) had a first reduction attempted in the emergency room at our institution, 2 patients experienced first elbow reduction during surgical intervention. The median time from first presentation to surgery was 21.9 hours (interquartile range, 15 to 40). Fourteen subjects displayed preoperative ulnar nerve symptoms. Of these, 9 subsequently reported postoperative ulnar nerve symptoms. There was no effect of time to surgical intervention on the Roberts outcome scores at follow-up, nerve symptoms, symptomatic hardware, or need for second surgery to remove hardware. There were 16 subjects with excellent outcomes, 13 with good outcomes, 3 with fair outcomes, and 0 with poor outcomes (based on the Roberts criteria)., Conclusions: Incarcerated medial epicondyle fractures are commonly associated with ulnar nerve symptoms; however, they are not associated with a significant rate of other complications. There was no increased risk of complications in subjects who had a longer duration between initial presentation and surgery. This suggests that, while the presence of an incarcerated medial epicondyle fracture is certainly an indication for timely operative intervention; the injury in isolation does not need to be considered emergent. Other factors including neurovascular status and ability to achieve joint reduction may still necessitate emergency operative care., Level of Evidence: Level IV-therapeutic study, case series.

Background: The supra-condylar humeral fractures are commonest fractures at the elbow in children and represent a third of all limb fractures in children under the age of 7 years. These fractures are associated with neurological deficit and any of the three long nerves of upper arm can be involved in these fractures. This study was conducted to determine the frequency of median nerve injury in children aged 2-11 years presenting with closed supracondylar fracture of humerus., Methods: This descriptive cross-sectional study was conducted at the department of orthopaedics and trauma, Ayub Teaching Hospital Abbottabad from July 2016 to June 2018. One hundred and seventy-one patients with supracondylar fracture of humerus were enrolled. They were treated as per department protocols and the outcome in terms of neurological damage was noted for each study participant., Results: The frequency of neurological damage was 21.05% with median nerve affected most commonly (13.45%). A statistically strong association was found between damage to median nerve and type of fracture, arm involvement and sex of patients (p<0.05) while no statistically significant association with age was obtained., Conclusion: Neurological damage is a common complication of supracondylar humeral fractures with median nerve being the most commonly affected nerve in these fractures.

Background: Supracondylar humeral fractures (SCHF) are the most common elbow fractures in children. The epidemiology of these injuries in the United States is described., Methods: The Nationwide Emergency Department Sample database was queried for all children (age, below 18 y) with SCHF treated in the emergency department (ED) from 2006 to 2011, and weighted estimates were extracted., Results: A total of 63,348 ED visits for SCHF were identified. The weighted estimate of ED visits remained stable over the study period, ranging from 60.3 to 71.8 per 100,000 children annually. There was no significant difference in fracture rate (52% male) by sex. The mean age of closed injury was 5.5±3.1 years, with 53.6% of fractures occurring in children 3 to 6 years. Open injuries accounted for 1.0% of fractures. Children with open injuries were significantly older (mean, 9.1±4.4 y; P<0.0001) and more often male (OR, 1.43; P<0.001). Neurovascular injury occurred in significantly older children (mean, 7.6±3.1 y; P<0.0001) and was documented in 11.4% of open fractures and 3.6% of operative fractures. Although the South had the greatest number of total SCHF-related ED visits, children in the West had significantly more SCHF-related ED visits per 100,000 children annually (77.9) than all other regions (P<0.05). Average fracture rates were approximately 60% higher in April to September than October to March (P<0.001). Mean total charges for patients treated and discharged from the ED were $2965, compared with $17,865 in children admitted for surgery (P<0.05). Mean charges were significantly higher in the West compared with all other regions (P<0.0001)., Conclusions: The incidence of pediatric SCHF-related ED visits remained stable from 2006 to 2011 and occurred most frequently in children aged 3 to 6 years. Open injuries are rare and are more likely to occur in older boys. There are significant differences in the injury rates and charges across geographic regions, identifying opportunities for injury prevention, cost reduction, and value improvement. The indications for operative management should be clearly delineated given the high cost of surgical treatment., Level of Evidence: Therapeutic Level IV.

Introduction: Lateral condyle fractures are a common pediatric elbow injury. Nonunion is a known complication of this injury but its incidence and causative risk factors are unknown. Further, a clear and consistent definition of nonunion for pediatric lateral condyle fractures does not exist. The purpose of this study is to determine the rate of nonunion, the risk factors associated with it and to provide a clear definition., Methods: A retrospective chart review of all pediatric lateral condyle fractures treated at an urban, tertiary pediatric care center between 2001 and 2014. Data collected included demographics, Weiss classification, type of treatment, follow-up, time from injury to surgery and complications. For patients with nonunions, additional treatments and final range of motion were also recorded. A nonunion was defined as lack of callus with fragment migration by 8 weeks after initiation of treatment., Results: A total of 530 patients were identified of which 500 were available for review. There were 7/500 (1.4%) nonunions in the cohort. Nonunion occurred in 1.4% (2/140) of type I fractures, 0% (0 /178) of type II fractures, and 3% (5/168) of type III fractures. The only significant risk factor for nonunion was the presence of a type III fracture (P=0.05). Five patients with nonunion underwent revision surgery with a partially threaded cannulated cancellous screw. All of these patients went on to union. Four of the 5 patients had their screws removed after union., Conclusion: Nonunion after pediatric lateral condyle fracture is rare and is defined by lack of any callus with fragment migration at 8 weeks. The only significant risk factor for nonunion development was the presence of a type III fracture. Revision surgery with a partially threaded screw achieved union in all cases., Level of Evidence: Level IV-retrospective case review.

Background: Low-trauma fractures (also called osteoporotic fragility fractures or fall-induced fractures) of older adults are a serious public health problem. However, very little population-based information is available on the nationwide numbers, incidences, and especially secular trends of elderly people's low-trauma fractures of the distal humerus., Methods: We assessed the current trends in the number and incidence of these fractures in 60-year-old or older women in Finland by taking into account all women who were admitted to Finnish hospitals for primary treatment of such fracture in 1970-2014., Results: The annual number of low-trauma distal humeral fractures among Finnish women 60 years of age or older rose over fivefold between 1970 and 1998 (from 42 to 224 fractures), but thereafter, the number decreased down to 198 fractures in 2014. The age-adjusted incidence (per 100,000 persons) of these fractures also increased in 1970-1998 (from 12 to 35) but decreased thereafter to 23 in 2014. The finding was similar in the age-specific patient groups (60-69, 70-79, and 80+): The incidence rose from 1970 till 1998 and decreased thereafter., Conclusions: The steep rise in the rate of low-trauma distal humeral fractures in 60-year-old or older Finnish women from 1970 till late 1990s has been followed by a clearly declining fracture rate. The exact reasons for this secular change are unknown, but a cohort effect toward improved functional ability among elderly women, as well as measures to prevent falls and alleviate fall severity, could partly explain the phenomenon.

Purpose: While performing CT examinations of the elbow, we frequently observed a previously undescribed fracture fragment of the supinator crest of the ulna. According to the anatomy of the lateral collateral ligament complex, this fracture might be an avulsion fracture of the annular ligament and/or the lateral ulnar collateral ligament. The aim of this study was to further characterize these fragments and document their associated injuries., Methods: Retrospective evaluation of CT scans of the elbow was performed. Conventional X-ray and CT diagnoses were used to systematically document any associated injuries., Results: A total of 152 CT scans were evaluated. The fragment in question was discovered in 17 patients (11.2%). The average age of the patients was 40 years (±14.9; 9-71 years). The fragment size varied between a few millimetres and 2.4 cm. Multifragmented fractures were observed. In 82.3% of the cases, associated radial head fractures were diagnosed. In 29.4%, a coronoid process fracture was present. Distal humerus fractures were found in 23.5%. Instability in the medial collateral ligament and an Osborne-Cotterill lesion were found in 11.8% of the patients, respectively., Conclusions: In a significant percentage of the population, a previously undescribed fracture fragment of the supinator crest of the ulna could be detected. The most frequently occurring associated injuries were fractures of the radial head, the coronoid process, and the distal humerus. The aetiology of these lesions is unknown; however, bony avulsion of the annular or the lateral ulnar collateral ligament seems to be the most likely cause. If this fragment is to be diagnosed by CT, the possibility of lateral or posterolateral instability should be considered.

Heterotopic ossification is a common complication of Orthopaedic Trauma Association (OTA) type C distal humerus fractures and ulnohumeral fracture dislocations. The purpose of this study was to precisely define the incidence of heterotopic ossification following major elbow trauma and to identify risk factors for the development of clinically significant heterotopic ossification and for surgical excision of elbow heterotopic ossification.Current Procedural Terminology codes identified 156 patients who underwent operative intervention for a distal humerus fracture or an ulnohumeral fracture dislocation at 2 Level I trauma centers over 6 years. The incidence of elbow heterotopic ossification was recorded at >90 days following the definitive procedure. Risk factors for the development of class 3 or 4 heterotopic ossification and for surgical excision of heterotopic ossification were evaluated using separate multivariable logistic regression analyses. Brooker class 3 or 4 heterotopic ossification occurred following 18 (14%) of 125 distal humerus fractures, 15 (22%) of 69 OTA type C distal humerus fractures, and 11 (35%) of 31 ulnohumeral fracture dislocations. Surgical excision of heterotopic ossification was performed after 12 (10%) of 125 distal humerus fractures, 10 (14%) of 69 OTA type C distal humerus fractures, and 8 (26%) of 31 ulnohumeral fracture dislocations. Sustaining a severe elbow injury (P<.05) or a delay of fixation (P=.05) was found to be independent risk factors for Brooker class 3 or 4 heterotopic ossification. Severe elbow injury (P<.05) and male sex (P<.05) were associated with operative excision of heterotopic ossification., (Copyright 2012, SLACK Incorporated.)

Distal humeral fractures in adults are relatively uncommon injuries that require operative intervention in the majority of cases. Dual plate fixation, with placement of a separate strong plate on each column and orientation of the plates either at 90° or 180° to each other, is indicated for all adult fractures involving both columns of the distal part of the humerus. Acute total elbow arthroplasty is the preferred treatment for elderly patients with a displaced, comminuted, intra-articular distal humeral fracture that is not amenable to stable internal fixation. Displaced coronal shear fractures of the distal humeral articular surface require operative fixation, most typically via a lateral approach., (© 2011 by the Journal of Bone and Joint Surgery, Incorporated)

Flexion-type supracondylar humerus fractures remain an uncommon variant of the common extension-type injury. They are often thought to be more difficult injuries, more probable to require open reduction, and have neurovascular complications. We reviewed the 10-year history of flexion-type supracondylar elbow fractures treated at 1 institution and compared these cases with those of an extension-type cohort collected during a similar period. The patients in the flexion-type group (mean age, 7.5 years) were significantly older than those in the extension-type group (mean age, 5.8 years). The fractures in flexion-type group were also more probable to require open reduction (31%) than those in the extension-type group (10%). There was no difference in the incidence of preoperative nerve symptoms; however, the flexion-type group had a significantly increased incidence rate of ulnar nerve symptoms (19% vs 3% in the extension-type group) and need for ulnar nerve decompression. The flexion-type variant should be recognized preoperatively, and the potential pitfalls involved with the treatment of these injuries appreciated.

Fractures of the distal humeral articular surface which do not involve the medial and lateral columns are often more extensive than is apparent from plain radiographs. This retrospective study describes the epidemiology of this injury using modern classification systems and compares pre-operative radiography with operative findings. The study group included 79 patients with a mean age of 47 years (13 to 91). The annual incidence was 1.5 per 100,000 population, and was highest in women over the age of 60. The majority of the fractures (59; 75%) were sustained in falls from standing height. Young males tended to sustain more high-energy injuries with more complex fracture patterns. In 24% of cases (19) there was a concomitant radial head fracture. Classification from plain radiographs often underestimates the true extent of the injury and computed tomography may be of benefit in pre-operative planning, especially in those over 60 years of age.

A change in the locations where children are treated for supracondylar fractures of the humerus has occurred during the past 13 years. Pediatric orthopaedic surgeons at specialist centers are seeing an increased number of such fractures. In New England, the number of supracondylar fractures of the humerus treated by closed reduction and percutaneous pinning has remained relatively constant between 1991 and 1999 with a range of 276 to 346 fractures per year, averaging 320 per year. In 1991, 63% of patients were treated by general orthopaedic surgeons in a nonspecialist setting. By 1999, 68% of the fractures were treated at centers with pediatric orthopaedic specialists available whereas only 32% were treated in a general orthopaedic setting. Associated with this change is a decreased length of stay from 2.2 (+/- 0.6) days in nonspecialist centers to 1.4 (+/- 0.4) days average in specialist centers.

Background: Supracondylar fracture of humerus is the most common fracture in first decade of life. There are various treatment modalities for this fracture i.e closed reduction and casting, open reduction and internal fixation and percutaneous pinning. Study was conducted to know the outcome of Percutaneous Pinning in the management of displaced supracondylar fracture of humerus in children., Methods: This study was conducted at orthopedic unit of Khyber Teaching Hospital Peshawar from January 1996 to December 2000. Twenty children of 3-12 years age with displaced supracondylar fracture (Gartland type II & III) of humerus were included. Outcome measures were according to Flynn criteria i.e loss of elbow motion & carrying angle., Results: The children presenting were 14 male (70%) and 6 females (30%). The involved side was left in fifteen(75%) and right in five(25%) of patients. Nineteen patients (95%) had extension type & one patient (5%) had flexion type of fracture. Gartland type II were six (30%) & type III were fourteen (70%). Our result showed excellent outcome in thirteen (65%), good outcome in four (20 %) and poor outcome in three (15 %) patients., Conclusion: Percutaneous pinning is safe, cost effective, time saving and provides greater skeletal stability with excellent results.

Summary: Flexion-type supracondylar elbow fractures are uncommon in children. Minimally displaced fractures were treated in plaster cast in 7 children, and 22 children with a displaced fracture were treated by closed reduction and percutaneous pinning. Results after an average follow-up of 6.3 years showed that the treatment of choice yielded excellent or good results in 86.2% of the patients. All patients were satisfied with the end result and had normal use of their elbow.

We present a study of the pattern of elbow fractures in children under 15 years of age, during a 5-year period, with special reference to supracondylar humerus fractures. The incidence was 308/100 000 per year; 58% of the children had a fracture in the supracondylar area of the humerus. There were 355 elbow fractures, and there were 164 boys (46%) and 191 girls (54%). The mean age for the entire group was 7.9 years (for boys, 7.2 years; for girls, 8.5 years). Of 209 supracondylar fractures (including 5 combination fractures), 134 were type I, 40 were type II, and 35 were type III (as classified by Gartland). Associated temporary nerve injuries involving the median, radial, and ulnar nerves were seen in 15 patients with type III supracondylar fractures. Associated brachial artery injuries were seen in 6 patients, 5 of whom had type III fractures.

Normal Baumann angles in 98 children aged 2 to 13 years and abnormal Baumann angles in 71 children with supracondylar humeral fractures were evaluated. In healthy children, Baumann angles ranged from 64 degrees to 80 degrees (72.4 degrees +/- 4.6 degrees) in boys and from 65 degrees to 81 degrees (72.9 degrees +/- 5.9 degrees) in girls. A significant negative relation (P < 0.01) between Baumann angle and carrying angle was noted, but there were no significant differences in Baumann angles between boys and girls (P > 0.05) and no significant correlation of Baumann angle with increasing age (P > 0.05). In patients with fractures, the Baumann angle measured after immediate reduction correlated well with the carrying angle measured after union or at final follow-up (P < 0.01). This angle measured after reduction may be used to predict the final carrying angle so that cubitus varus deformity can be effectively prevented.

The radiographs of 589 elbow fractures in children under the age of 16 years were reviewed. The most common fractures were: supracondylar fracture of the humerus -55 per cent, fracture of the radial neck -14 per cent, and fracture of the lateral humeral condyle -12 per cent. One fifth of all fractures of the olecranon were associated with another elbow fracture; most often a fracture of the medial epicondyle. The average annual incidence of elbow fractures in the age group studied was 12 per 10.000 (10.0-14.7) without a significant change of the incidence between 1950 and 1979. Supracondylar and lateral condylar fracture of the humerus and fracture of the olecranon occurred more often in boys. Fractures of the lateral humeral condyle were more often caused by higher energy levels than the other fracture groups.