Pediatric Floating Elbows: What Is All the Fuss About? A Multicenter Perspective

Saturday, October 21, 2023

9:45 AM – 9:51 AM PST

Location: 4B

Presenting Author(s)

Benton E. Heyworth, MD

Attending Orthopedic Surgeon
Boston Children's Hospital
Boston, Massachusetts, United States

Disclosure(s): Allosource, Inc.: Grant or Research Support, or I am listed as the PI (Ongoing); Arthrex, Inc.: Consultant (Ongoing); Imagen, Inc.: Stock Shareholder (excluding mutual funds) (Ongoing); Kairos Surgical: Consultant (Ongoing); Vericel, Inc.: Grant or Research Support, or I am listed as the PI (Ongoing)

Corresponding Author(s)

Keith Baldwin, MD, MSPT

Children's Hospital of Philadelphia
Philadelphia, Pennsylvania, United States

Disclosure(s): Pfizer: Stock Shareholder (excluding mutual funds) (Ongoing)

Co-Author(s)

JZ

Jenny Zheng, BS

Children's Hospital of Philadelphia
JH

Jaclyn Hill, MD

Texas Children's Hospital
JS

Julia Sanders, MD

Children's Hospital Colorado
BS

Benjamin Shore, MD, MPH (he/him/his)

Associate Professor Pediatric Orthopaedic Surgery
Boston Children's Hospital
Needham, Massachusetts, United States
AB

Allan Beebe, MD

Nationwide Children's Hospital
JS

Jonathan Schoenecker, MD, PhD
TB

Todd Blumberg, MD

Seattle Children's Hospital
YL

Ying Li, MD

C.S. Mott Children's Hospital
AR

Anthony Riccio, MD

Texas Scottish Rite Hospital
IS

Ishaan Swarup, MD

UCSF Benioff Children's Hospital
Rachel Y. Goldstein, MD

Associate Professor of Orthopaedic Surgery
Children's Hospital of Los Angeles
JD

Jaime R. Denning, MD

Cincinnati Children's Hospital
KR

Kathleen Rickert, MD

Rady Children's Hospital
JL

Jill Larson, MD

Lurie Children's Hospital
DS

David D. Spence, MD

Group Author(s)

GC

Group CORTICES

Purpose: Floating elbow injuries are defined as ipsilateral concomitant fractures of the distal humerus and radius and/or ulna. Although pediatric orthopaedic dogma suggests a high risk of acute compartment syndrome (ACS) and other adverse outcomes, a recent systematic review suggests otherwise. We aimed to assess treatment paradigms and outcomes of pediatric floating elbow injuries and identify a true rate of associated ACS.

Methods: A multicenter retrospective database was created to review patients under the age of 18 years who presented from May 2014 to April 2019 with floating elbow injuries, defined as a distal third humerus fracture and concomitant radius and/or ulna fracture. Patient demographics, injury characteristics, treatment course, and outcomes were evaluated. A severity subclassification was developed based on fracture displacement (Figure 1).

Results: 454 patients were evaluated across 15 institutions (1A: 67, 1B: 92, 2A: 65, 2B: 230). Median age at time of injury was 6.8 years (interquartile range [IQR]: 5.6-8.1 years), and the cohort was 51% male. Median length of follow-up was 2.5 months (IQR: 1.9-4.4 months). 13 patients (2.9%) presented without a palpable pulse or Doppler signal, all of whom had displaced humeral fractures (P = 0.006). 84 patients (18.5%) presented with nerve injuries, which were more common in Class 3 fractures (P <0.001), and only 14 (3.1%) had persistent nerve injuries at final follow-up (P = 0.029). Displacement largely dictated whether the distal injury was treated with fixation (1A: 16, 1B: 55, 2A: 24, 2B: 175; P<0.001) or immobilization. Open reduction rate of the proximal fracture was 7.7% overall. There was 1 case (0.2%) of compartment syndrome, involving displaced proximal and distal fractures. Most patients returned to activities with no-to-few modifications (1A: 94%, 1B: 90%, 2A: 95%, 2B: 88%). Following Flynn’s criteria, early outcomes were excellent or good in 315 patients (69%), fair for 101 patients (22%), and poor for 32 patients (7%). Outcomes did not differ significantly by injury severity subclassification (P = 0.055).

Conclusion: This multicenter study of a large cohort of pediatric floating elbow injuries demonstrates a low rate of ACS (0.2%). Closed treatment of the distal fracture is common for nondisplaced fractures. Rates of nerve and vascular injury correlated with injury severity and were comparable to those of isolated component injuries.

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