Pediatric Elbow Dislocation in Children


Pe Elbow Dislocation in Children

There are five conditions connected to elbow dislocations in children: pediatric elbow dislocation, pulled elbow (nursemaid’s elbow), congenital dislocation of the radial head, monteggia fracture, and transepiphyseal separation of the distal humerus. dislA pediatric elbow dislocation by itself occurs in older children between 10-15 years old. It is rare before the age of 3, and it is not a very common injury. The elbow dislocation is usually posterolateral.There is no relationship between the radial head and the capitellum, but you maintain the relationship between the radius and the ulna, so it is an elbow dislocation and not a Monteggia. The treatment of the pediatric elbow dislocation is closed reduction and early range of motion. This condition may have an associated medial epicondyle fracture.  Check if the medial epicondyle fracture is entrapped in the joint or not. The joint will appear incongruous. This fragment may be hard to detect especially if there is a spontaneous reduction of the elbow by itself. After reduction, if the fragment is still in the joint or if there is substantial fragment displacement, this is an indication for surgery (ORIF). Pulled elbow, or nursemaid’s elbow, is a common injury in young children between the ages of 2-3 years old. When pulling the child’s arm, the child goes in one direction and the parent goes in another direction, causing the annular ligament to become torn and trapped inside the joint and the radial head may be sublexed. This is not an elbow dislocation. It is a pulled elbow where the child refuses to move the elbow and the position of the arm of the child will be slightly flexed but pronated. When you get the x-rays, the x-rays are negative. It can be treated by reduction. elbowIt should be reduced by full supination of the arm followed by flexion and there will be no need for immobilization of the arm, let the child use the arm. In order to test if the elbow is reduced, you should give the child a piece of chocolate or candy. If the child can bend the elbow (flex the elbow) so he can have the piece of chocolate in his mouth, then that elbow is reduced. Congenital dislocation of the radial head is usually bilateral, and you can’t reduce it. There will be no significant history of trauma and the capitellum looks hypoplastic. You will find that there is posterior dislocation of the radial head, and the radius is bowed and shortened. You should check for other anomalies and if the condition is symptomatic, you will do radial head resection in adulthood. Monteggia fracture is a proximal 1/3 ulnar fracture and radial head dislocation or subluxation. The condition may be difficult to diagnose, and if the diagnosis is delayed, then the treatment will be complicated, and there will be more complications. Make sure that there is not a posterior interosseous nerve injury. The diagnosis is difficult because the fracture of the ulna may not be very apparent, but you have to look at the radial head position in relationship to the capitellum. The most common type of Monteggia dislocation is anterior dislocation of the radial head (check the relationship of the radial head and the capitellum. In Monteggia fracture, the radial head is the one that is dislocated and not the elbow. The relationship between the radial head and the ulna is also interrupted. If you do not get anatomic alignment of the ulna, the radial head may continue to sublex, and the ulna will heal in a bad position with the radial head dislocated. This condition will need osteotomy of the ulna and open reduction of the radial head. Differentiating pediatric elbow dislocation from transepipyseal separation of the distal humerus can be difficult. Because there is no clearly visible ossific centers at the distal humerus at the younger age, this condition can be misdiagnosed as an elbow dislocation. In pediatric elbow dislocation, the olecranon moves posteriorly and laterally. Pediatric elbow dislocation does not occur in children at 1 or 2 years old. Transepiphyseal separation of the distal humerus usually occurs in a younger age group than an elbow dislocation. The distal fragment goes medially. In transepiphyseal separation, you will find that the radiocapitellar line remains the same. When you have this condition of transepiphyseal separation of the distal humerus, consider child abuse, look for other signs of abuse.

Quadrangular or Quadrilateral Space Syndrome


Quadrangular syndrome is compression of the posterior humeral circumflex artery and or the axillary nerve within the quadrangular space. Compression of the structures within this space may lead to pain and paresthesia. There may also be weakness of the deltoid and teres minor muscles. This syndrome is usually caused by trauma, fractures, dislocation, tumors, or hematoma. It may also occur due to sports requiring overhead throwing activities. The area of the quadrilateral space decreases in size when the arm is abducted. This may lead to compression of the structures in the quadrangular space as the teres major and minor muscles come together.

quad space

Quadrangular or Quadrilateral Space Syndrome presents itself as paresthesia and hyperthesias around the shoulder and upper arm. Deltoid atrophy is another clinical sign. Tenderness will be discovered over the quadrilateral space. An MRI arteriogram (MRA) will show the status of the artery and the condition of the muscles (atrophy of the deltoid or teres minor). Additionally, it may show cysts, ganglia, or tumors. An arteriogram can also be used and may show compression of the posterior humeral circumflex artery.


Treatment typically consists of physical therapy and cortisteroid injections. Surgical compression of the nerve may be considered after failure of conservative treatment methods for six months. The posterior approach will be used.

AVN of the Femoral Head- Causes, Trauma to the Hip

AVNAvascular necrosis (AVN), or osteonecrosis, is death of a segment of bone due to disruption of the blood supply. Extraosseous or intraosseous interruption of the venous or arterial blood flow. AVN may be caused due to fractures of the femoral neck or dislocations of the hip, or due to mechanical disruption of blood vessels. Trauma to the deep branch of the Medial Femoral Circumflex Artery may occur with antegrade rod placement during piriformis entry in children. Posterior dislocation of the femoral head should be reduced in an expedited way to decrease the risk of thrombosis of the vessels which supply the femoral head. Osteonecrosis develops in about 2-20% of hips that are reduced within 6 hours. The risk of osteonecrosis will increase with delay in reduction of the hip. Osteonecrosis appears within two years after the injury. It is evident within one year in most patients.

acute femoral neck fracture

With a Pipken fracture, the patient should be informed about the complications of AVN preoperatively. Fixation failure is associated with osteonecrosis or nonunion. The effect of the anterior approach on osteonecrosis is not known. Stress fractures should be pinned before displacement occurs. Displacement will have a bad result. Osteonecrosis can be clinically significant when followed by lateral segmental collapse. The more vertical the fracture line, the greater the chance of AVN occurring. In acetabular fracture fixation, during intraoperative dissection for acetabular fracture reduction and fixation, avoid injury to the ascending branch of the Medial Femoral Circumflex Artery (MFCA). Fractures of the hip in children are associated with a high rate of osteonecrosis.



Hip Dislocation- Sciatic Nerve Injury

Dislocation of the hip is a serious condition that may have significant complications. Pure hip dislocation with or without fracture of the acetabulum or femoral head can cause complications. The worse complication associated with dislocation of the hip is avascular necrosis, due to damage to the blood supply. AVN is death of a segment of the bone in the femoral head. Avascular necrosis may occur if the avndislocation is not reduced in a reasonable period of time. Emergency reduction of dislocations is needed in less than 8 hours of injury. Although x-ray is helpful, a CT scan clearly outlines the bony injury. Other complications associated with dislocation of the hip is injury to the sciatic nerve and arthritis of the hip joint. Injury to the sciatic nerve occurs in about 10-20% of the cases involving posterior dislocation. The sciatic nerve starts in the lower back and runs through the buttock and lower limb. In the lower thigh, just above the back of the knee, the sciatic nerve divides into two nerves, the tibial and peroneal nerves, which innervate different parts of the lower leg. The common peroneal nerve then travels anterior, around the fibular neck, dividing into superficial and deep peroneal nerves. The deep peroneal nerve dives innervation to the tibialis anterior muscle of the lower leg which is responsible for dorsiflexion of the ankle.

tibial common nerve

When injury occurs to the sciatic nerve due to posterior hip dislocation, the common peroneal nerve is usually affected, causing weakness in dorsiflexion of the ankle and loss of toe extension can also occur. Injury to the sciatic nerve usually involves the common peroneal nerve. Injury can occur in carrying degrees of severity and can be missed. Movement of the toes may appear as dorsiflexion; however, this really is the result of plantarflexion. Documenting the injury is important to avoid medical legal problems. Injury to the sciatic nerve typically occurs from the dislocation and not from the reduction. The longer the wait for reduction of the dislocation, the more the patient is predisposed to sciatic nerve injury. The length of time a hip remains dislocated influences the incidence and severity of major sciatic nerve injury. The patient may require an anti-foot drop splint.

foot drop

Peroneal nerve injury/foot drop is treated with physical therapy and waiting. EMG and other nerve studies may be used to assess the condition of the muscles. This condition may take a long time for recovery, usually a partial recovery of the nerve is achieved in a majority of cases. If no recovery is achieved, a surgeon should explore the nerve for repair, graft, or tendon transfer. Sciatic nerve palsy could occur from surgery due to retractors or from traction, usually in posterior hip surgery. Preoperative partial injury of the nerve could deteriorate after surgery. Preoperative documentation of the nerve injury is important.