Paeds Trauma (Complete) Flashcards
What children are at greatest risk of child abuse?
[Clin Orthop Relat Res (2011) 469:790–797] [JAAOS 2000;8:10-20]
- First-born children, unplanned children, premature infants, stepchildren, and handicapped children
- Single-parent homes, drug abusing parents, parents who were themselves abused, unemployed parents, and families of lower socioeconomic status
When present, which fracture has the highest probability of abuse?
[Clin Orthop Relat Res (2011) 469:790–797]
Rib fractures (70% chance of abuse)
What percentage of femur fractures in children less than 3 (and less than 1) are due to child abuse?
[Clin Orthop Relat Res (2011) 469:790–797]
- Less than 3 = 12-13%
- Less than 1 = 30%
What are the orthopedic manifestations of child abuse?
[JAAOS 2000;8:10-20]
- Long bone fractures in nonambulatory child
- Multiple fractures in various stages of healing
* Occurs in 70% of abused children less than 1 year of age and more than 50% of all abused children - Rib fractures (posterior and posterolateral)
- Transphyseal fracture of the distal humerus
- Metaphyseal ‘corner fracture’ or ‘bucket handle fracture’
- Vertebral compression fractures
- Spinous process avulsions
What are nonorthopedic manifestations of child abuse?
[JAAOS 2000;8:10-20]
- Bruises
- Suggestive locations include perineum, buttock, genitalia, trunk, back of legs, back of head
- Multiple and in different stages of healing
- Skull fractures
* Suggestive types include multiple, crossing suture lines, depressed, bilateral, skull base - Retinal hemorrhages
- Subdural hematoma
- Visceral injury
What age is the typical presentation for a transphyseal distal humerus fracture?
[JAAOS 2016;24:e39-e44]
<3
What are three common mechanisms of injury for a transphyseal distal humerus fracture?
[JAAOS 2016;24:e39-e44]
- Birth injury
- Nonaccidental trauma
- FOOSH
What are the radiographic features of transphyseal distal humerus fracture?
[JAAOS 2016;24:e39-e44]
- Key – forearm is not aligned with the humeral shaft
- If capitellum present it will be aligned with the radial shaft
- Most common direction is posteromedial displacement of the forearm
What is the management of transphyseal distal humerus fractures?
[JAAOS 2016;24:e39-e44]
CRPP with arthrogram
- Arthrogram is performed and direction of displacement is confirmed
- Closed reduction is performed similar to supracondylar fractures
- 2-3 lateral pins – divergent, engaging opposite cortex and wide spread
- Pins removed at 3 weeks
What is the most common complication of a transphyseal distal humerus fracture?
[JAAOS 2016;24:e39-e44]
Cubitus varus
What percentage of growth does the proximal humerus growth plate contribute to longitudinal growth?
[JAAOS 2015;23:77-86]
80%
What is the most common proximal humerus fracture angulation?
[JAAOS 2015;23:77-86]
Apex anterior
- Hinges on the thicker intact posteromedial periosteum
What is Little League Shoulder?
[JAAOS 2015;23:77-86]
- Fracture of the proximal humeral growth plate as a result of overthrowing
- Imaging will reveal widening of the proximal humeral growth plate and, in more advanced cases, fragmentation, sclerosis, and even cyst formation
What is the most common classification of pediatric proximal humerus fractures?
[JAAOS 2015;23:77-86]
Neer and Horwitz Classification
- Grade I - <5mm displacement
- Grade II - <1/3 of the shaft width
- Grade III - 2/3 of the shaft width
- Grade IV - >2/3 of the shaft width
What is the management of pediatric proximal humerus fractures?
[JAAOS 2015;23:77-86]
- Nonoperative
- Birth fractures
- Grade I and II
- Operative
- Grade I and II with open fractures, vascular injury or polytrauma
- Grade III and IV
- Controversial
- Generally, surgical indications include:
- Age >11
- Neuromuscular disorders
- Nerve palsies
- Anticipated deformity after fracture healing
- e.Irreducible fracture dislocation
- No consensus on acceptable angulation
- Generally, surgical indications include:
- Controversial
What are blocks to closed reduction of proximal humerus fractures?
[JAAOS 2015;23:77-86]
- LHB tendon
- Capsule
- Periosteum
What is the closed reduction maneuver for proximal humerus fractures?
[Orthobullets]
- Longitudinal traction
- Abduction to 90°
- ER
What are the surgical options for proximal humerus fractures?
[JAAOS 2015;23:77-86]
CRPP – 2-3 lateral pins
What is the most common age range for supracondylar humerus fractures?
[JAAOS 2012;20:69-77]
5-7
What extremity is most commonly affected in SCHF?
[JAAOS 2012;20:69-77]
Left or nondominant
What percentage pf SCHF are extension type?
[JAAOS 2015;23:e72-e80]
95%
What is the most common associated fracture with a supracondylar humerus fracture?
[JAAOS 2012;20:69-77]
Ipsilateral distal radius
A supracondylar humerus fracture with an ipsilateral forearm fracture places a patient at increased risk for what complication?
[JAAOS 2012;20:69-77]
Compartment syndrome
What is the most common nerve injury associated with an extension type supracondylar fracture?
[JAAOS 2012;20:69-77] [JAAOS 2015;23:e72-e80]
- Extension type
- Anterior interosseous nerve
- Followed by median, radial and ulnar
- Flexion type
* Ulnar nerve - Posterolateral displacement
* Median and anterior interosseous nerve - Posteromedial displacement
* Radial nerve
In the absence of a distal radial pulse, what are clinical indicators of sufficient perfusion?
[JAAOS 2012;20:69-77]
- Normal capillary refill
- Temperature
- Color (typically described as pink)
What are the 3 categories of vascular status following a supracondylar humerus fracture?
[JAAOS 2012;20:69-77]
- Normal
- Pulseless with a pink hand (perfused)
- Dysvascular (pulseless with a white hand)
The presence of which fat pad sign is indicative of an occult SCHF?
[JAAOS 2012;20:69-77]
Posterior fat pad
The anterior humeral line intersects what portion of the capitellum?
[JAAOS 2012;20:69-77]
- >4 years of age = middle 1/3
- <4 years of age = may lie in anterior 1/3
What is the classification of supracondylar humerus fractures?
[JAAOS 2012;20:69-77][CORR 201;473(2) 738–741]
Gartland classification (describes extension type)
- .Type I - nondisplaced
- Type II - displaced with intact posterior hinge
- Type IIA – no rotation or translation
- .Type IIB – rotation or translation
- Type III - complete displacement
- Type IV - unstable in flexion and extension (complete disruption of periosteal hinge)
- Medial comminution – collapse of medial column with resulting loss of Baumann’s angle
What is Baumann’s angle?
[Orthobullets]
- Angle formed between a line parallel to the longitudinal axis of the humeral shaft and a line along the lateral condylar physis as viewed on the AP image
- Normal = 70-75 (compare to contralateral side)
- Deviation >5-10 should not be accepted
What is the management of supracondylar fractures based on Gartland classification?
[JAAOS 2012;20:69-77]
- Type I
- Nonoperative
- Long arm cast 90° elbow flexion for 3-4 weeks
- Type II
- Nonoperative
- Type IIA – controversial, some authors treat these nonoperative with closed reduction, casting and close followup (consider if minimal swelling)
- Operative
- Type IIB – CRPP
- Type III
- Type IIB – CRPP
- Operative
- CRPP, long arm splinting with elbow at 60-80°, pins removed at 3-4 weeks
- Type IV
- Operative
- CRPP
What are blocks to closed reduction of supracondylar fractures?
[JAAOS 2015;23:e72-e80]
- Brachialis muscle interposition
- Button-holing of metaphyseal spike through brachialis
- Brachial artery
- Nerve
- Periosteum
- Joint capsule
What is the technique for closed reduction of an extension type supracondylar fracture?
[CORR course]
- Elbow extension, longitudinal traction, correct varus/valgus and medial/lateral translation and rotation, flex elbow with thumb pressure over olecranon to correct sagittal alignment
- Consider milking brachialis if distal humerus buttonholed through
What is the technique for closed reduction of a flexion type supracondylar humerus fracture?
- “push-pull technique” [Journal of Pediatric Orthopaedics B 2016, 25:412–416]
* With elbow at 45 correct coronal plane deformity (varus/valgus/translation), flex elbow to 90 with towel under apex of deformity apply a posterior directed force along the axis of the forearm, slight over correction can be corrected with a pull along the axis of the forearm - Traditionally done in extension
What are the complications associated with operative treatment of supracondylar fracture?
[JAAOS 2012;20:69-77]
- Pin migration
- Pin tract infection
- Osteomyelitis/septic arthritis
- Malunion
- Compartment syndrome
- Ulnar nerve injury
What are indications for emergent management of supracondylar humerus fractures?
[JAAOS 2012;20:69-77]
- Open fracture
- Dysvascular limb
- Skin puckering
- Floating elbow
- Median nerve palsy
- Evolving compartment syndrome
- Young age (unreliable exam)
- Cognitive disability (unreliable exam)
What is the timing of surgical intervention for Type III supracondylar humerus fractures?
[JAAOS 2012;20:69-77]
- Safe to delay 12-18 hours
- Arm is splinted in 20-40° of flexion, neurovascular checks
- Nurse q2h, no sedating analgesics
What is the incidence of ulnar nerve injury with medial pin placement?
[JAAOS 2012;20:69-77]
10%
What is the recommended pin placement in management of supracondylar fractures?
[JAAOS 2012;20:69-77]
- Adequate number of lateral pins
* In general, Type II – 2 pins, Type III – 3 pins - As far apart as possible
- Pins should be divergent
- Pins should not converge or cross at fracture site
- Pins should engage both the medial and lateral columns
- Consider a medial pin if fracture remains unstable or in presence of comminution
What is the technique for medial pin placement in SCHF?
[JAAOS 2012;20:69-77]
- Small incision over medial epicondyle
- Elbow in extension (prevents ulnar nerve from subluxing anterior)
- Identify and protect ulnar nerve
What are the indications for a medial pin in SCHF?
[CORR course]
- Reverse obliquity
- Very distal fractures
- Very young
What are technical errors in lateral pin placement that can lead to loss of reduction of a SCHF?
[JAAOS 2012;20:69-77]
- Failure to engage both fragments with at least two pins
- Failure to achieve bicortical fixation with at least two pins
- Failure to achieve ≥2 mm of pin separation at the fracture site
What is the management of the pulseless hand in the setting of a supracondylar humerus fractures?
[JAAOS 2012;20:69-77]
- In the presence of adequate perfusion (pink)
- Reduce fracture and pin
- If adequate perfusion remains – admit for observation with elbow in approx. 45° flexion
- In the presence of pulseless extremity and inadequate perfusion (white)
- Reduce the fracture and pin
- If remains dysvascular – explore artery and monitor for compartment syndrome (consider fasciotomy)
- If adequate perfusion - admit for observation with elbow in approx. 45° flexion
What neurological injury is associated with injury to the brachial artery in SCHF?
[JBJS 2015;97:937-43]
Median nerve
In a SCHF, if an open exploration is performed and there is still inadequate distal perfusion despite the brachial artery being in continuity and decompressed, what can be attempted relieve vasospasm?
[JBJS 2015;97:937-43]
- Increase ambient temperature
- Apply topical lidocaine or papaverine
- Stellate ganglion block
What are the indications for open reduction of supracondylar fractures?
[JAAOS 2015;23:e72-e80]
- Failed closed reduction
- Open fracture
- Compartment syndrome
- Neurologic and/or vascular injury requiring open exploration
What approaches are used for management of open reduction of supracondylar fractures?
[JAAOS 2015;23:e72-e80]
“go to the metaphyseal spike”- [CORR course]
- Anterior approach = extension type
- Transverse or ‘lazy S’ over flexion crease of antecubital fossa
- If releasing blocks to reduction – stay lateral to biceps tendon to avoid neurovascular structures
- If exploring neurovascular bundle – identify proximal to fracture site
- Lateral approach = posteromedial displacement
* Plane between BR and triceps - Medial approach = posterolateral displacement and flexion type
What are the disadvantages of the posterior approach to opening a SCHF?
[JAAOS 2015;23:e72-e80]
- Increased elbow stiffness
- Difficult access to interposed anterior structures
- Risk of trochlear osteonecrosis
- Less cosmetic
What are the complications associated with supracondylar humerus fractures?
[JAAOS 2012;20:69-77]
- Cubitus varus
- Can lead to cosmetic concerns and tardy posterolateral rotatory instability b
- No effect on elbow ROM
- Correctional osteotomy should be considered if significant varus present
- Performed at >1 year
- Lateral closing wedge osteotomy with pin fixation
- What is the Skaggs osteotomy? [J Child Orthop. 2011 Aug; 5(4): 305–312]
- Interlocking lateral wedge osteotomy with lateral pin fixation
- Corrects cubitus varus and extension
- Enhanced stability and less lateral prominence than closing wedge
- Compartment syndrome
What is the typical age in which a lateral humeral condylar fracture occurs?
[J Am Acad Orthop Surg 2011;19:350-358]
Typically 6 years of age
What radiographic view best demonstrates a lateral condyle fracture?
[J Am Acad Orthop Surg 2011;19:350-358]
Internal oblique view (fragment often lies posterolateral)
What is the role of an arthrogram in the management of a lateral condyle humerus fracture?
[J Am Acad Orthop Surg 2011;19:350-358]
- Limited diagnostic value as it is performed in the OR with patient under sedation
- Useful for intra-operative assessment
How is an arthrogram administered in the context of distal humerus lateral condyle fracture?
[J Am Acad Orthop Surg 2011;19:350-358]
Traditionally performed via the lateral soft spot, which is a triangle formed by the radial head, olecranon, and lateral column of the humerus.
- This area may be distorted in patients with lateral condylar fracture
- Alternatively, the needle may be placed directly into the posterior surface of the olecranon fossa.
How are lateral condyle fractures classified?
[J Am Acad Orthop Surg 2011;19:350-358]
- Milch classification (historical)
- Type I – fracture line that courses lateral to the trochlea and into the capitulotrochlear groove
- Elbow is stable as the trochlea is intact
- Type II – fracture line that extends into the apex of the trochlea
- Elbow is unstable as the trochlea is disrupted
- Jakob classification (based on fracture fragment displacement)
- Type I – nondisplaced, intact articular surface
- Type II – fracture is complete extending through the articular surface, may be moderately displaced
- Type III – complete displacement and fragment rotation, loss of relationship between capitellum and radius
- WEISS Classification (based on displacement and articular cartilage)
- Based on fracture displacement and articular congruity
- TYPE I
- Fracture is displaced < 2 mm
- TYPE II
- Fracture displaced ≥2mm with intact articular cartilage, as demonstrated by arthrogram (i.e. articular hinge)
- TYPE III
- Fracture displaced ≥2mm and the articular surface is not intact (i.e. no hinge)
- TYPE I
What are the indications for nonop vs. operative management in lateral condyle humerus fractures?
[J Am Acad Orthop Surg 2011;19:350-358]
- Nonoperative indications
- Type I, nondisplaced
- Fractures with an intact cartilage hinge that has been confirmed on MRI
- ≤2 mm displacement on all radiographic views
- Operative indications
- >2mm displacement
- 2-4mm = CRPP
- >4mm = ORIF
- Nonunion
Operative options for lateral condyle humerus fracture?
- CRPP
- Weiss Type II (2-4mm displacement, intact articular cartilage)
- Technique
- Closed reduction performed with forearm supinated, elbow extended, varus stress to elbow followed by fragment manipulation anteromedially
- Two parallel or slightly divergent K-wires plus a transverse pin to control rotation
- Open reduction
- Weiss and Jakob Type III (articular cartilage disruption, displaced >4mm, fragment malrotation)
- Technique
- Kocher interval (anconeus and ECU)
- Avoid posterior and distal dissection (risk of fragment AVN)
- Anatomic reduction under direct visualization with fluoro confirmation
- Fixation
- K-wire OR Partially threaded screw
What complications are associated with lateral condylar fractures +/- surgical management?
[J Am Acad Orthop Surg 2011;19:350-358]
- Lateral spur
- Nonunion (due to synovial fluid, pull of common extensor origin, poor metaphyseal circulation to distal fragment)
* More common with nonoperative treatment - Cubitus varus (20%)
* More common in nondisplaced and minimally displaced fractures - Cubitus valgus (10%)
- Tardy ulnar nerve palsy
- Progressive ulnar nerve paralysis developing late (average 22 years post injury)
- Manage with anterior ulnar nerve transposition
- Fishtail deformity
* Deepening of the trochlear groove, no clinical significance - Growth disturbance
* Minimal and involved medial aspect of the condyle (little effect on length or deviation)