Elbow fractures in Children - Supracondylar fracture of the humerus

We see a fair number of children's injuries in the hospital, the reason being that the hospital is situated in a residential neighbourhood.

Children frequently fall, and in the process, has the tendency to extend their arms out to protect themselves.
This fact makes injuries involving the upper limbs more frequently seen in the ER (Emergency Room) as compared to the lower limb. The force from the fall, if large enough, can fracture the bone in two common places - the wrist or the elbow.

For the elbow, the forces from the fall travel through the forearm, levers the elbow joint in extension and the bone breaks at the weakest part of the arm - the supracondylar part of the humerus.
This is the so-called supracondylar fracture of the humerus and is the commonest elbow injury seen in children, seen most frequently in the 3 to 8 year old age group. It is also the 2nd most common children's fracture, second only to wrist fractures.

Patients with a suspected supracondylar fracture of the humerus frequently present to the ER with a history of fall, with associated swelling of the elbow and inability to bend the elbow.

*For the parent, if there is a suspicion of an elbow injury or fracture, one should ideally immobilize the limb in a sling prior to bringing to the ER. Besides providing comfort to your child, it limits further movement and displacement (moving out of alignment) of the suspected fracture. Dont know how to do it? look it up here. *

And that was how I met my 7 year old patient in the ER a couple of months ago. He had a nasty fall and was brought to the ER by his parents. His left elbow was deformed and swollen, and painful to the touch.

Swollen left elbow

X rays confirmed my suspicions: a supracondylar fracture of the left humerus.

Now fractures which are minimally displaced, or better yet, undisplaced, can be treated with nothing more than a plaster slab and an armsling. However our patient had what is known as a type III Gartlands fracture, where the fracture ends are totally not in contact with each other. This necessitates an operative reduction (where the surgeon manipulates the fracture ends into place) and fixation with wires.

Fortunately the parents understood the gravity of the situation and agreed for surgery that night. Here are the before and after pics of the X rays:

fracture site (arrowed)

frontal view of the elbow showing the fracture

Fracture reduced (put back) and temporary wires in place. Compare with the first picture

You can see that humpty-dumpty the bone ends has been put back together again.
The wires were removed after a month -   on the x rays below you will note that the fracture is healing well with new bone around the fracture site.

after 2 months

There was still some slight stiffness of the elbow on the last day of treatment which should go away after some physiotherapy. Now our patient is well on his way to playing football again and probably has a nice story to tell his kids later!

- the BomohTulang -

references:


Clinical Practice Guidelines
The Treatment Of Pediatric Supracondylar Humerus Fractures
American Academy of Orthopaedic Surgeons 2011

Current Concepts Review Supracondylar Humeral Fractures in Children
J Bone Joint Surg Am. 2008;90:1121-32

Crossed-pin versus lateral-pin fixation in pediatric supracondylar humeral fractures.
Shamsuddin SA, Penafort R, Sharaf I. Med J Malaysia. 2001; 56(Suppl D):38–44.

Wheeless' Textbook of Orthopaedics (online)

DE QUERVAIN's TENOSYNOVITIS - Pain at the side of the wrist

Wrist pain has multiple causes and can be localized to various areas around the wrist; one of the common ones being pain at the side of the wrist near the base of the thumb. This can be attributed to De Quervains tenosynovitis

De Quervain's tenosynovitis refers to inflammation of tendons together with their enclosing sheath on the side of the wrist at the base of the thumb. These tendons, the extensor pollicis brevis and the abductor pollicis longus tendons, help move the thumb a certain way - to extend and to abduct the thumb (hence their names). On their way to the thumb, the tendons passes through a tunnel (the extensor retinaculum) which helps hold the tendons in place. Much like trigger finger, irritation of the tendon causes the lining (synovium) around the tendon to swell, which makes it difficult for the tendons to move and glide into the tunnel. However, unlike trigger finger, there is no 'catching' sensation - just pain at the side of the wrist during certain positions of the hand.

Patients with De Quervain's frequently complain of pain with certain movements of the wrist, for example when pouring tea from a teapot, using a watering can and lifting the grocery bags during shopping. These particular wrist movements will cause a strain on the said tendons - leading to the wrist pain.

The pain can be replicated by bending your thumb inwards into your palm and making a fist - this is the basis of the eponymous Finkelsteins test. (if you can read Thai, here's a DIY video of the test :P)
Here's a picture of the test - it can be quite painful for the patients to perform so I would proceed slowly if I were to conduct the examination.

Patients are commonly women aged 30 to 50, and frequently mothers of infants. Indeed sometimes when the patients of a child bearing age sees me in the clinic for the problem, my usual interview question would include "have you recently had a baby?" Apparently picking up and carrying of the baby puts the wrist in an awkward position, putting strain to the tendon, and hormonal changes in the tissues further aggravates this situation.

Other conditions that may mimic this would include basal thumb arthritis or the intersection syndrome (most commonly confused with)

Treatment is basically conservative. A period of splinting would help to rest the inflamed tissue; there are smaller splints now which are more comfortable to wear, do ask your therapist about it. Non-steroidal anti-inflammatory medications (NSAIDs), ultrasound therapy and ice all help to relieve the inflammation. These conservative means are all that is needed for the majority of patients

Steroid injection directly into the sheath can be given for more severe cases, although there is a risk of discolouration of the skin at the injection site.

Failed conservative management would necessitate a surgical release of the constricting sheath of the tendon ( the 1st dorsal compartment ). This could be done on an outpatient basis, ideally under general anaesthesia.



- the Bomoh Tulang -

references:

Treatment of de Quervain's disease:role of conservative management.

 Journal of Hand Surgery - British Volume. 26(3):258-60, 2001 Jun.

	Ilyas AM "de Quervain Tenosynovitis of the Wrist" J. Am. Acad. Ortho. Surg., December 2007; 15: 757 - 764.

BOMOH TULANG talks about Back Pain - RAPI magazine

RAPI magazine contacted the Bomoh Tulang the other day, and enquired whether would he be kind enough to write about back pain and prolapsed disc? Well of course I obliged.

The April issue of RAPI mag is already at the newsstands and features a four-page spread on all you need to know about back pain and prolapsed disc. So ladies and gents, if you have any questions about back pain, head over to your nearest newsagent and get your copy now. I'll be signing copies at MPH. ;)

..and no, this is not an April Fool's joke..

  

- the BomohTulang -