Cori Cross, MD (Host): Welcome to Peds Cast, a podcast brought to you by Children's of Alabama. I'm your host, Dr. Cori Cross. Today, we'll be discussing elbow injuries, and we are joined by Dr. Kevin Williams, who's an Assistant professor in the Division of Orthopedic Surgery at Children's of Alabama. Dr. Williams, thank you for being here with us today.

Kevin A. Williams, MD: Thank you So much for having me. I appreciate the time.

Host: So, let's start with a brief overview of children's elbow fractures. How common are they and what are the main causes of the injury?

Kevin A. Williams, MD: Children break their elbows relatively routinely. We see these types of injuries all the time, both when we are taking call in the hospital itself and then also in our clinic practice as well. Our literature suggests that elbow fractures account for about 10% of all childhood fractures and only wrist and forearm fractures are a little bit more common injuries in the arm, which account for about 40% of all pediatric breaks.

Host: And how are children breaking their elbow?

Kevin A. Williams, MD: Well, there are lots of different opportunities for kids to have breaks, especially of their upper extremities or arms. And most commonly, children are breaking their elbows the same way that they break their forearms and wrists when they're falling onto an outstretched hand that they've placed out to basically protect themselves or catch themselves. The force transmits through that wrist, forearm, and then sometimes up into the elbow. And then depending on the position of the elbow, there are some weak spots around the elbow that can break in several different locations.

A couple of examples of kids falling onto their arms occur on the playground when they're jumping off a swing or falling from the monkey bars. And then, like a lot of elbow injuries can also occur in activities, in sports such as gymnastics, skateboarding, football, roller skating, things like that.

Host: So, it sounds like elbow fractures are common, not just in smaller toddler age children, but as children grow and they're playing, like you said, football. They still have an increased risk for these fractures because of the activities they're involved in.

Kevin A. Williams, MD: That's true, and depending on the age, there are different locations within the elbow that can break. And so, we have to treat each one of these fractures uniquely, depending on the age of the child. And then, the capacity for the bone to essentially heal and then remodel itself back to a normal position, which is one of the reasons why these are so important, is because in terms of your elbow, there's a high chance of having a continued deformity if we don't put this back into place and hold it there effectively. And so, it's very important for us to treat these either operatively if they're fairly displaced or angulated, to make sure that the elbow functions properly in the future.

Host: That makes sense. And just to back up for a second, why don't you tell us about the different types of fractures that there are, and like you mentioned, some are non-displaced, and therefore non-operative, right?

Kevin A. Williams, MD: That's correct. And so based on the different types of fracture and also how displaced or angulated they are is the basis for how we treat these. And so if they're non-displaced in areas that will generally heal very well. We try to treat these without surgery and with some type of immobilization, such as a cast, a brace or a splint. But if they are in a location which seems fairly displaced and could confound our eventual return back to function, that's when we begin to think about putting these back into place, either operatively or in the emergency room, and then sometimes holding them there with either a cast or occasionally even internal fixation, such as metal wires, pins, screws, or plates.

Host: And that makes sense because the elbow is such an important joint, we have to make sure that it continues to function for the life of the individual. So, tell us, Dr. Williams, you've been studying elbow fractures in children for quite a while. What exactly do your studies address and why is there a need for these studies?

Kevin A. Williams, MD: Yes, we have. And our most recent study was over the time period of about a year, and we looked at the amount of a certain type of fracture, which is a fracture right above the elbow joint at the end of the humerus bone called a supracondylar humerus fracture. Now, the importance of this fracture is that in this location, the bone does not grow as much as other locations, for example, near the shoulder or by the wrist. And so, it's imperative that we have these bones put back into place exactly where they were or else they could grow aberrantly with some type of angulation, again cause some dysfunction in the future and potentially even have nerve or muscular implications as well.

And so, looking at these fractures, we looked at our particular experience at Children's of Alabama. And we end up treating about one of these operatively every other day. And so, we had about 170 fractures in the time period of a year. And we looked at basically the demographics behind the fracture, where they come from and how we treated them. And we found that less than about 30% to 40% of our elbow fractures are actually first seen at Children's of Alabama. Most of them come from around Alabama, Mississippi, or even Georgia, so around from around the region and have been seen at different hospitals prior to being transported to our hospital.

And then, we're currently looking at the different ways that these kids are transported. Sometimes it's via ambulance or emergency services because the status of their elbow fracture could be portending towards some nerve injuries or severe swelling. Or sometimes we have them transported via private vehicle. And when that occurs, it's generally a faster process that does save a decent amount of time, but sometimes they show up and are not quite ready for surgery. And so, we're looking at how to streamline that process because sometimes we have to wait quite a while before being able to treat these fractures with surgery in the time that we want to,

Host: And I think you're hinting upon that, that the timing is important, how long it takes to set the bone matters, correct?

Kevin A. Williams, MD: Right, exactly. Because the longer that these sit displaced, sometimes they can lead to increasing swelling and things, even like compartment syndrome when the swelling overcomes the body's ability to continue to pump the appropriate amount of blood to and fro into the muscles and the structures distally. And then also, in the instance of a nerve or a blood vessel injury, us being able to address that sooner rather than later.

Host: Got it. And you're also doing studies on non-displaced fractures as well, correct?

Kevin A. Williams, MD: We are. We are looking at the importance of continuing to obtain additional x-rays on fractures that haven't moved initially. And we actually found that we don't really change our treatment of these fractures if we're getting x-rays. And so thus, we're going to try to contribute to the literature that we don't necessarily need to obtain additional x-rays. And that could save a lot of money for both the healthcare institution as well as the families, and it looks like it's about $700 per patient of savings.

Host: Wow. And radiation as well.

Kevin A. Williams, MD: Yeah. Yeah, exactly. That's a good point too.

Host: Well, that's really interesting. Now, the interventions you're doing are going to be locally at Children's of Alabama, or are you partnering with any other hospitals?

Kevin A. Williams, MD: We've started most of these studies locally, but are certainly open to interinstitutional additional studies to contribute to the literature. Because when we finally do branch out and try to look at the outcomes of these fractures and how these kids are doing based on our treatment methods, we'd like to compare to different institutions as well to give our readers an idea of what the best care is and at what point in the process of contributing to this care we make certain decisions to give the best healthcare possible to these children.

Host: That makes sense. And you're really talking about why it's so important to do these evaluations and to do these studies, because you want to have the best practices and you want to know what those are. So, that makes a lot of sense. Is there anything else in summary that you'd like to share with our listeners today?

Kevin A. Williams, MD: Well, I think that it's important to know when to refer to either the ER or an orthopedic physician when a child has an elbow fracture. And so, things to look out for or to see, if there's a fall into an outstretched hand, look for swelling, noticeable deformity, or inability to move the arm correctly. And occasionally, one could also have difficulties moving particular fingers of the wrist. And so, if that's the case, I think it's important to make sure that these children are seen as quickly as possible so we can give the care necessary. And then, obviously, this is really important to us and this is how we treat these children and then also contribute to our research abilities to provide the best, most up-to-date care for every child we see.

Just so we can closely study each different fracture pattern and know the details behind the fracture itself and to be able to allow us to figure out the right treatment path, either non-operative or operative. And so, we really pay a lot of attention to these elbow fractures and appreciate everyone that is out there helping us take care of them.

Host: And Dr. Williams, so as a parent or as a physician, if you get a phone call of a child who falls on an outstretched arm and they already have the pain and the swelling that sort of makes it sound indicative of a fracture, should they forego coming to the pediatrician's office and go directly to the ER because they're going to save time and be hooked up with an orthopedist faster that way?

Kevin A. Williams, MD: It's a good question. And obviously, each situation is relatively unique. But if you notice increasing swelling, increasing pain to the point where it's difficult to actually make the child comfortable, then sometimes it is prudent to be able to bypass the pediatrician or the urgent care and just go straight to the emergency room.

And obviously,, it's a somewhat difficult situation, because the emergency rooms these days have very high wait times. But if there's a deformity of an elbow that has some type of concomitant loss of sensation, or if the swelling has increased enough where the child can't be comfortable, you'll usually be able to bypass the ER wait room to be able to get an x-ray to make sure treatment is given in an expedient manner.

Host: That makes sense. Well, thank you so much for sharing your expertise with us today. This has been a very interesting conversation. Really appreciate you being here.

Kevin A. Williams, MD: Thank you so much for having me. I appreciate it.

Host: If you would like more information or to refer patients to Children's of Alabama, visit www.childrensal.org. That concludes this episode of Children's of Alabama Peds Cast. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for other topics that might be of interest to you. Please remember to subscribe, rate, and review this podcast. I'm your host, Dr. Cori Cross. Thanks for listening to this episode of Children's of Alabama Peds Cast. I'm your host, Dr. Cori Cross.