deals with all the 6 apophyseal injuries around elbow joint including brief surgical technique also

1. Paediatric elbow :–
apophyseal injuries

2. Apophyseal Injuries

3. COMMON AGE -9 AND 14
M:F = 4 : 1
 during sports -Medial epicondyle
avulsion #s most commonly
affect adolescent baseball
pitchers during periods of rapid
growth, typically between 9 and
14 years of age.
 This is when the growth plate
cartilage is most vulnerable to
injury. One hard pitch can cause
an avulsion fracture. The
forearm muscles anchored to
the elbow at the medial
epicondyle growth plate
contract forcefully during the
pitching motion.
ABOUT 50% ASSOCIATED WITH
ELBOW DISLOCATION
THE APOPHYSEAL FRAGMENT
COULD BECOME ENTRAPPED
WITHIN THE JOINT (15-18%)

4. Signs & symptoms
The main symptom is sudden onset of severe
pain on the inside of the elbow following a
forceful pitch or throw. Some athletes feel or
hear a pop at the time of the injury. There is
usually swelling and some limitation of elbow
motion. Occasionally the ulnar nerve, which
sits next to the medial epicondyle, becomes
irritated after an avulsion fracture, causing
numbness and tingling in the forearm and
fourth and fifth fingers.

5.  As ossification
progresses, parallel
smooth sclerotic
margins develop in
each side of the physis.
 Because it is somewhat
posterior, on a slightly
oblique AP view the
apophysis may be
hidden behind the
distal metaphysis.
The concentric oval nucleus of ossification of
the medial epicondylar apophysis .

6. Elbow ossification centers
Order of Appearance of the individual
ossification
centers is C-R-I-T-O-E: (F/M)
Capitullum 1 yo/2 yo
Radial head 3 yo/4 yo
Medial epicondyle 5 yo/6 yo
Trochlea 7 yo/8 yo
Olecranon 9 yo/10 yo
Lateral epicondyle 11 yo/12 yo

7. The medial epicondyle is a traction apophysis
does not contribute to the distal humerus overall length
In the early ossification process –it is a part of
the entire distal humeral epiphysis
With growth and maturity - becomes
separated arises from the posterior surface of
the medial distal humeral metaphysis

8. Posteromedial location
 ossification center may be difficult to see on
an AP x-ray
 best appreciated on a lateral x-ray
 on AP x-rays, the distal medial metaphyseal
border may overlap the ossific nucleus of the
apophysis - misinterpreted as a fracture

9.  Effusion is associated with
a fracture 70-90% kids
 Risk of occult fracture is
approximately 30%-75%
 Posterior or elevated
anterior fat pad abnormal

10. Soft Tissue Attachments
 The flexor mass, FCR, FCU, FDS, PL and
part of the pronator teres.
 Capsule –
 In younger children, some of the capsule's
origin extends up to the physeal line of
the epicondyle - a fracture line involving
the medial epicondylar apophysis can
enter the joint

11.  In older children and adolescents, as the
epicondyle migrates more proximally, the
capsule is attached only to the medial crista
of the trochlea
Ligamentous Structures
 The ulnar collateral ligament - three separate
bands –anterior, oblique and posterior

12. Acute injuries - Three theories
1. A direct blow, posterior aspect /
posterior medial aspect
2. Avulsion mechanisms,
 Avulsion in elbow extension
(valgus stress)
 Avulsion with elbow flexed
(pure muscle forces) – throwing
base ball, arm wrestling.
conservative treatment good
results.
 Little League Elbow:
medial epicondylar apophysitis
secondary to repeated valgus
stress from throwing;
 medial epicondyle has the
longest exposure to medial
distraction forces because it is
the last ossification center to
close.
 medial epicondylar avulsion
fractures are the most common
elbow injury during adolescence

13. 3. ASSOCIATION WITH ELBOW
DISLOCATION -
 ulnar collateral ligament
provides the avulsion force.
an extreme valgus stress
was applied to the joint, a
vacuum was created within
the joint . The normal
valgus carrying angle tends
to accentuate these
avulsion forces when the
elbow is in extension.
 These associated injuries
like radial neck fractures
with valgus angulation and
greenstick valgus fractures
of the olecranon confirms
the valgus force theory.

14.  fracture of the radial
neck, olecranon, or
coronoid process.
 If the epicondyle
fragment is only
rotated on its axis, the
anterior band of the
ulnar collateral
ligament can become
lax. This laxity can
produce some medial
elbow instability during
extension

15.  Acute injuries
1.Un-displaced -the physeal line
remains intact. swelling and
local tenderness over the medial
epicondyle.
On x-ray, the smoothness of the
physeal line's edge remains
intact. Although there may be
some loss of soft tissue planes
medially on the x-ray,
displacement of the elbow fat
pads may not be present
because the pathology is extra-
articular
 2.Minimally displaced fractures
-a stronger avulsion force- more
soft tissue swelling.
Palpating the fragment may
elicit crepitus .
On x-ray, there is a loss of parallelism
of the smooth sclerotic margins
of the physis .
The radiolucency in the area of the
apophyseal line is usually
increased in width.

16.  3.Displaced fractures
 There may have been an
elbow dislocation that
reduced spontaneously
or by manipulation
 On x-ray, the long axis
of the epicondylar
epiphysis is rotated
medially .The
displacement usually
exceeds 5 mm, but the
fragment remains
proximal to the true
joint surface. This
fragment may contain a
metaphyseal fragment

17.  4.Incarcerated#s(without elbow
dislocation)
 The key clinical finding is a
block to motion, especially
extension
 On x-ray, totally or
partially within the elbow
joint until proven otherwise
.
 Elbow is usually still
found to be
incompletely
reduced. Due to an
impingement of the
fragment within the
joint, a good AP view
may be difficult to
obtain caused by the
inability to extend
the elbow

18.  If the fracture is old and if the
fragment is fused to the coronoid
process, widening of the medial
joint space may be the only clue that
the fragment is lying in the joint.
The epicondylar ossification center
may become fragmented and
mistaken for the fragmented
appearance of the medial crista of
the trochlea. Absence of the
apophyseal center on x-ray may be
further confirmatory evidence that
the fragment is within the joint.
 Comparison x-rays of the opposite
elbow may be necessary to
delineate the true pathology.

19.  Even if the elbow is dislocated,
the fragment can still lie within
the joint and prevent
reduction. Recognition of this
fragment as being within the
joint before a manipulation
points a need for open
reduction.
 An initial manipulation
to extract the fragment
from the elbow joint
may need before a
satisfactory closed
reduction of the elbow

21.  The function of the ulnar
nerve must be carefully
documented
 Valgus Stress Test:
Because the ulnar collateral
ligament's anterior oblique
band may be attached to the
medial epicondylar
apophysis, the elbow may
exhibit some instability after
injury
 This test is performed with
the patient supine and the
arm abducted 90 degrees.
The shoulder and arm are
externally rotated 90 degrees.
The elbow must be flexed at
least 15 degrees to eliminate
the stabilizing force of the
olecranon. If the elbow is
unstable, simple gravity
forces will open the medial
side. A small additional
weight or sedation may be
necessary to acquire an
accurate assessment of the
medial stability with this test.

22.  Slightly displaced or non-
displaced - Widening or
irregularity of the
apophyseal line
 If the fragment is totally
incarcerated - hidden by
the overlying ulnar or
distal humerus - total
absence of the
epicondyle from its
normal position
 If the fracture is only
minimally displaced and
if it is the result of an
avulsion injury, there
may be no effusion
because all the injured
tissues remain extra-
articular.

23.  Most avulsion fractures can
be successfully treated
with cast immobilization
for 4-6 weeks. During this
time ice can be placed on
the elbow for 20-30
minutes every 3-4 hours
while there is pain or
swelling.
 After 4-6 weeks of
immobilization, if X-rays
show the fracture is healing
do physiotherapy . While
most avulsion fractures heal
well with this treatment,
those with a very wide
separation on X-rays may
require surgery. The recovery
time after surgery is similar
that for non-surgical
treatment.

24.  Absolute indication :
Irreducible
incarcerated
fragment
in the elbow joint
 Roberts' Manipulative
Technique
 It involves placing a valgus
stress on the elbow while
supinating the forearm and
simultaneously dorsiflexing
the wrist and fingers to
place the forearm muscles
on stretch; theoretically,
this maneuver should
extract the fragment from
the joint. To be effective,
this procedure should be
carried out within the first
24 hours after injury.

25.  Failure to extract the
fragment by manipulative
techniques 
open extraction and reduction
have been performed with
screw fixation or sutures to
secure the fracture in
position.
 Excision has also been
advocated, especially if the
fragment is comminuted.
 On a long-term basis, intra-
articular retention of the
fragment may not be all that
disabling.
 The epicondyle had fused to the
semilunar surface of the ulna,
producing a large bony
prominence clinically. There was
only minor loss of elbow motion,
with little functional disability.

26.  Relative indication:
 1. Ulnar nerve
dysfunction
 2. Patient with high-
demand upper
extremity function
 A universal finding - a
thick fascial band that
binds the ulnar nerve to
the underlying muscle
 The constriction is
believed to be
responsible for either
the immediate or late
dysfunction of the
ulnar nerve.

27.  medial condylar physis
injuries . This is especially
true if the secondary
ossification centers are
not present
 If there is a significant
hemarthrosis or a
significant piece of
metaphyseal bone
accompanying the
medial epicondylar
fragment, arthrography
or MRI may be indicated
to determine if there is
an intra-articular
component to the
fracture

28. Major
 Failure to recognize incarceration in the elbow
 Ulnar nerve dysfunction
Minor
 Loss of elbow extension
 Myositis ossificans
 Calcification of the collateral ligaments
 Loss of motion
 Cosmetic effects
 Nonunion in the high-performance athlete

29. most common indication for operative
intervention is to ensure a stable elbow in
patients participating in high-demand
activities with their upper extremity
1. A longitudinal incision just anterior to the
medial epicondyle.
2. The fragment is usually displaced
distally and anteriorly
3. The periosteum is removed from the
fracture site, and the clot is extracted by
irrigation. It is important to identify and
protect the ulnar nerve, but a complete
dissection of the nerve is usually unnecessary
4. The elbow is flexed and the forearm is
pronated. A towel clip is used to reduce the #.
5. The fragment is reduced and stabilized
temporarily with one or two small K-wires
6. Final fixation by partially threaded
and over drilled in the epicondylar fragment
to compress it against the metaphysis/a
cannulated 4 mm screw
7. After removal of the K-wires, the elbow is
checked to ensure valgus stability and re-
establishment of a full range of motion.
8. After the surgical incision is closed,
the extremity is placed in a long-arm
cast(bi-valved.)
9. At 5 to 10 days, active motion is
initiated.

30. epicondyle is fragmented
spike washer can be used to secure the
multiple pieces to the metaphysis or
excise the fragments and
reattach the ligament to
the bone and periosteum
at the base of the
epicondylar defect.

31. Preventing medial epipcondyle avulsion
fractures
Lots of pitching puts repetitive stress on the
medial epicondyle growth plate, which can
weaken it and make it more prone to avulsion
fracture.
The best way to prevent medial epicondyle
avulsion fracture is to follow the attached
guidelines for appropriate pitch count limits
and proper rest between pitching
appearances.
DO NOT throw through pain. Pain is a sign of
injury, stress, or overuse. Pushing through
pain will only worsen the injury. Rest is
required to allow time for the injured area to
heal.

32.  a rare injury
 begins to ossify around 10 to 11 years of age
Mechanism of Injury
 In adults - a direct blow
 In children - avulsion forces

33.  If between the origin of
the common extensors
and the extensor carpi
radialis longus - little
displacement.
 If the fracture lines enter
the area of origin of the
extensor carpi radialis
longus - considerable
displacement

34. X-Ray Findings
 The natural separation can be confused with
an avulsion fracture
 The key to determining true separation is
looking beyond the osseous tissues for the
presence of associated soft tissue swelling

35.  Simple immobilization for comfort.
 Surgery – if fragment is incarcerated
within the joint
Complications
 Entrapment of the fragment, either
within the elbow joint or between the
capitullum and the radial head

36.  avulsion forces on the proximal ulna that
occur with the elbow flexed
 occur more often in children with
osteogenesis imperfecta - reason unknown.
 an isolated, displaced fracture of the
olecranon apophysis – consider OI.

37.  Operative treatment - for displaced
fractures. Acceptable displacement
ranges from 3 mm to 5 mm.
 70% of children with OI who sustain an
olecranon apophyseal fracture later have
a fracture of the contralateral olecranon
apophysis

38.  Rarest form of
epiphyseal detachment

39. Ossification of the
olecranon
develops in the
area of the triceps
insertion-9yrs
Bipartite centers
Traction centre-1st
Enveloped by the
triceps insertion
Second smaller-
articular centre

40.  classification  Type1-apophysitis
 Type2-incomplete stress#
 Type3-complete #
 A-pure apophyseal
avulsions
 B-apophyseal-metaphyseal
combination

41. UN DISPLACED INJURIES
 Rest, selective muscle
exercise programme.
 Persistent non union
 Cannulated compression
screw across the apophysis
to stimulate healing
DISPLACED FRACTURES
 Minimal displacement
closed reduction by extension
then long arm
cast/percutaneous pinning
 Complete dis.
 small children K-wire TB
with strong absorbable
sutures. Older  do TB with
steel wire
 Large ossif. centretreated
same like meta #s.

42. SPUR FORMATION
 Overgrowth of epiphysis
 Symptomatic-removed
 Non union
 Apophyseal arrest

43.  Isolated meta #rare
CLASSIFICATION
 Group A-flexion injuries
 Group B- extension injuries
 1. valgus pattern
 2.varus pattern
 Group C-shear injuries

44.  Most common
 Even if the fracture is
severely displaced-
immobilization in
full/partial extension
heal satisfactorily
 Displaced/comminuted
 ORIF
 Fixation devices-
absorbable sutures/axial
screw/TBW with axial K-
wire
 Combination of
screw+fig of eight is best
 If axial wires used the
disadvantage is s/c
prominence

45.  Often in varus the
olecranon angulation
corrected with elbow in
extension ,also reduces
radial head.
 If there is Painful
subluxation of the
radial head present -a
delayed osteotomy of
the proximal
ulna/olecranon.

46.  Distal fragment
displaced anteriorly
with Posterior
periosteum intact
 best reduced in
hyperflexion
 If Periosteum torned
 Fix it with an oblique
screw so that you can
start mobilization
earlier.

47. IRREDUCIBILITY
 Proximal frag. entrapped in
the joint
 Non union/Delayed union
 Compartment syndrome
 Nerve injuries
 Elongation
 Loss of reduction

48. Up to 6 yrs coronoid epiphyseal
1%-2%
Most fractures occur with dislocations of elbow

49.  Type1-avulsion of the
tip of the coronoid
process only
 Type2-a
single/comminuted
fragment <=50%
 Type3->50%
 Type 1 and
2Conservatively with
early motion if no
associated injuries
 With elbow
dislocation- forearm
full supination elbow
100 degrees of flexion.

50.  Large fragment and
marked displacement-
ORIF
 Hentry anterior approach
to the elbow.
 The fragment can be fixed
with a mini fragment screw
or sewn in place through 2
drill holes to the posterior
aspect of the ulna.
COMPLICATIONS
 Large fragment the elbow
may be unstable and prone
to recurrent dislocations.
 Non union with the
production of a free
fragment in the joint
occurs rarely in children.

51. Thank you