Journal of Orthopaedic Diseases and Traumatology

EDITORIAL
Year
: 2021  |  Volume : 4  |  Issue : 1  |  Page : 1--2

Pediatric elbow injuries – Challenges in management


Mazhar Abbas, Yasir Salam Siddiqui 
 Department of Orthopaedic Surgery, Faculty of Medicine, AMU, Aligarh, Uttar Pradesh, India

Correspondence Address:
Mazhar Abbas
Department of Orthopaedic Surgery, Faculty of Medicine, AMU, Aligarh. UP.202002
India




How to cite this article:
Abbas M, Siddiqui YS. Pediatric elbow injuries – Challenges in management.J Orthop Dis Traumatol 2021;4:1-2


How to cite this URL:
Abbas M, Siddiqui YS. Pediatric elbow injuries – Challenges in management. J Orthop Dis Traumatol [serial online] 2021 [cited 2021 Oct 21 ];4:1-2
Available from: https://www.jodt.org/text.asp?2021/4/1/1/305742


Full Text



In skeletally mature patients, the identification and characterization of elbo injuries is quite straightforard. Hoever, elbo injuries in children are challenging to an average orthopedic surgeon, especially the radiological features and their subsequent diagnosis and management. These injuries are frequently missed oing to the lack of ossification of elbo epiphyses and the large cartilaginous fractured fragment often appearing innocuous radiologically.[1],[2],[3] Hence, there are some difficulties in diagnosis and management of pediatric elbo injuries. The orthopedician should essentially anticipate it to avoid failure of detecting the correct injury pattern and its optimal treatment.

Kasser J., Peter M. Waters, and Beaty J. grouped these pediatric elbo injuries as TRASH lesions because of their difficult characterization and propensity to miss on initial radiology.[1],[2] TRASH stands for “The Radiographic Appearance Seemed Harmless”. These lesions are predominantly osteochondral injuries in children less than 10 years of age, often associated ith unrecognized, spontaneously reduced elbo dislocations.[1],[4],[5] TRASH lesions include unossified medial condyle fractures, unossified transphyseal distal humerus separation, entrapped medial epicondyle fractures, complex osteochondral elbo fracture–dislocations, osteochondral fractures ith joint incongruity, radial head compression fractures ith radiocapitellar subluxation, Monteggia fracture–dislocations, and lateral condyle avulsion shear fractures.[1],[2],[3] Inability to diagnose such injury has potentially overhelming consequences on the function and stability of the elbo.

Such injuries are generally seen in children under 10 years of age folloing high-energy impact to the elbo. Precise description of such elbo injuries is of utmost significance to plan the optimum treatment beforehand. A mismatch beteen the clinical presentation and radiological evaluation of the injury should raise a suspicion of TRASH lesion in the mind of orthopedic surgeon. Substantial block to elbo range of motion and/or a greater amount of selling than ould be expected for the innocent fracture seen on initial radiographs deserves further evaluation by additional imaging modalities. MRI, ultrasound, and CT scans are the choices for better delineation of the injury, ith their merits and demerits of one modality over the other.[1],[2],[6],[7] USG is economical, readily available, and requires no sedation but requires the expertise of the musculoskeletal radiologist. It can determine the fractured fragment size, donor site, and joint congruency. CT scans oing to the lack of ossification around the elbo in younger children are of limited utility and may expose the child to unnecessary high radiation. Hoever, for older children, it can be of great value. MRI provides excellent visualization of the fractured fragments including their size, orientation, and joint involvement. Hoever, it is expensive, not readily available, and often requires sedation. Finally, intraoperative arthrograms can be useful in ascertaining the size and location of a fragment.[1],[3] Hoever, as it is done intraoperatively, preoperative planning can be challenging. The parallel study of the plain radiographs of the opposite uninjured elbo cannot be overemphasized. Closely comparing the bilateral elbo radiographs might reveal an abnormal bony fragment or a joint malalignment. In any particular patient, some or all of these modalities may be necessary to make an accurate diagnosis. Hence, the challenge of prompt diagnosis can be overhelmed by high index of suspicion and early additional imaging techniques.

Most of these injuries are displaced and unstable requiring anatomical reduction and internal fixation ith or ithout soft-tissue repair for further stability.[1] Fixation of these fragments can be challenging. One should be ready ith multiple fixation options and depending on the fracture geometry, various fixation options ranging from K-ires, headless compression scres, mini plates and scres, to bio-absorbable fixation techniques[1],[3] can be exploited. As these fragments are small and intra-articular, the chosen surgical approach should allo the best visualization of reduction of the fragment and placement of fixation device. Rigid internal fixation is desirable to permit early motion exercises for better remodeling and prevention of elbo stiffness.[1],[3] Sometimes, a severely deformed osteochondral fragment may not be reduced to the donor site. Shaving don and shaping of the fragment may be required to prevent mechanical block to elbo motion and instability. The primary goal in management of pediatric elbo injuries is to provide a smooth gliding joint. If a smooth articular surface cannot be attained due to fragmentation, the fragment should safely be excised to avoid blocks to motion.[3]

Parents should be informed about the risks of potential complications including nonunion, avascular necrosis (AVN), elbo stiffness, and groth disturbances leading to deformities. Understanding the complexity of these fractures and the challenges associated ith their treatment is an absolute necessity.[1],[3] These injuries hen diagnosed late, missed completely, or treated improperly can result in long-term complications. Moreover, surgical reconstruction of the late presenting malunion is also difficult.

Similar to elbo TRASH lesions, some injuries in the pediatric loer extremity are often unnoticed or underappreciated. Such lesions do have serious long-term consequences if managed inappropriately. These injuries include traumatic hip dislocations ith intra-articular pathology, greater trochanteric avulsion fractures, patellar sleeve fractures, minimally displaced proximal tibial metaphyseal fractures, and minimally displaced Salter–Harris III and IV fractures of the medial malleolus.[8] Making the correct diagnosis and executing appropriate treatment, including adequate follo-up, is vital.

To conclude, pediatric elbo injuries are among the most challenging musculoskeletal conditions to the orthopedic surgeon. They are quite often missed or misdiagnosed because of their subtle nature. Large cartilaginous areas and various epiphyseal ossification centers make the interpretation of radiographs demanding. The challenge of prompt diagnosis can be overhelmed by high index of suspicion and early utilization of additional imaging techniques. Most of these injuries are unstable requiring restoration of normal anatomy, preferably ith open reduction and rigid fixation to allo early motion exercises. Even after early recognition and optimal treatment, complications do occur. Hence, long-term clinicoradiological follo-up is obligatory for detection of nonunion, AVN, and premature physeal closure.

References

1Waters PM, Beaty J, Kasser J. Elbo “TRASH” (The radiographic appearance seemed harmless) lesions. J Pediatr Orthop 2010;30 Supp 2:S77-81.
2Keser S, Demirel N, Bayar A, Ege A. The coexistence of fractures of the capitellum and the radial head: A rare case. Acta Orthop Traumatol Turc 2007;41:69-73.
3Luker K, Frick SL. TRASH (The Radiographic Appearance Seemed Harmless) Lesions About the Elbo. In Book: Pediatric Orthopedic Trauma Case Atlas. Springer, Cham, Sitzerland; 2020.
4Sodl JF, Ricchetti ET, Huffman GR. Acute osteochondral shear fracture of the capitellum in a telve-year-old patient. A case report. J Bone Joint Surg Am 2008;90:629-33.
5Song KS, Jeon SH. Osteochondral flap fracture of the olecranon ith dislocation of the elbo in a child: A case report. J Orthop Trauma 2003;17:229-31.
6Fritz RC. MR imaging of osteochondral and articular lesions. Magn Reson Imaging Clin N Am 1997;5:579-602.
7Lazar RD, Waters PM, Jaramillo D. The use of ultrasonography in the diagnosis of occult fracture of the radial neck. A case report. J Bone Joint Surg Am 1998;80:1361-4.
8Holmes S. “TRASH” lesions of the pediatric loer extremity. JPOSNA 2019;1:1-11.