ORTHOPAEDICS - PAEDIATRICS

ResponseCRITOE - 1,3,5,7,9,11 - This is when the ossification centres appear on Xray - not when they go away (Ages not 100% correct, but good enough for ACEM)
Capitellum - age 1
Radial head - Age 3
Internal (medial) epicondyle - Age 5
Trochlea - Age 7
Olecranon - Age 9
External (lateral) - Age 11

Importance of this - If there is a lateral mal ossification centre in a 6 year old its probably a fracture, not an ossification centre!

ResponseAnterior humeral line - Line extending form anterior edge of humerus should pass through the capitellum with at least ⅓ of the capetellum anterior to it (ie: is in middle ⅓ of capitellum)
Radiocapitellar line - line through the centre of radius should extend so it passes through the centre of the capitellum

ResponseObvious dislocation of the elbow posteriorly and laterally
Lateral view there is small bony fragment above the epiphysis
CRITOE >> displaced fracture of the medial epicondyle (which should be ossified at 5 years) - AP view shows medial epicondyle missing

ResponseNeurovascular compromise - if present will require immediate reduction
Difficulty in relocating in view of displaced medial epicondyle - will need specialist input and likely OT regardless of ED management (OT reduction preferable)
Long term issues - Malunion, non union, poor function, neurovascular impairment

ResponseMedial epicondyle fracture displaced by 5mm
Substantial soft tissue swelling
Small joint effusion
No dislocation
Epiphysis of radial head and capitellum are normal. Not splinted

Management
FYI: <5mm displacement = conservative (long arm 3/52 >> Collar + Cuff 3/52), >15mm displacement = ORIF, in between = ortho’s choice (Usually fix if dominant, >8, or athletes) - RCH

Complications (of this injury)
Non union
Ulnar nerve injury/dysfunction
Joint stiffness, decreased mobility
Elbow dislocation (50%)
Cubitus valgus deformity
Chronic pain
Incarceration of medial epicondyle fragment in elbow joint

ResponseRight elbow
Fracture through radial neck with head displaced >100%
Large anterior and small posterior fat pad
Anterior humeral and radiocapitallar lines intact

Response
Lateral Condylar fracture (NOT Epicondyle) of distal humerus. 1-2mm displacement
Large atnterior + posterior fat pad. Prominant soft tissue swelling laterally
Radiocapitellar and ulnar-trochlear line maintained
Elbow enlocated, no gas to suggest open fracture

ResponseUndisplaced fracture long arm backslab
Early follow up 10 days
Prone to displacement and non union

Displaced fracture >2mm in any view, or neurovascular compromise requires surgical fixation
Ideally in <48 hours. Once displaced fractures consolidate they are hard to move and cause long term problems