Upper Limb Trauma - Paediatric Flashcards
Radial Head and Neck Fractures - Pediatric
- Overview
- demographics
a. median age is __to__yrs
b. M:F ?
c. __to__% of all pediatric elbow fractures
d. __% of pediatric fractures overall
- Overview: radial neck fractures in children are a relatively common traumatic injury that usually affects the radial neck (metaphysis) in children 9-10 years of age.
2a. 9-10
2b. 1:1
2c. 5-10%
2d. 1%
Radial Head and Neck Fractures - Pediatric
Pathophysiology
1. mechanism
mechanism
◾usually associated with an extension and valgus loading injury of the elbow
◾elbow dislocation
Radial Head and Neck Fractures - Pediatric
•Associated Conditions [4]
Associated Conditions
- elbow dislocation
- olcecranon fracture
- medial epicondyle fracture
- forearm compartment syndrome
Radial Head and Neck Fractures - Pediatric
ossification centers around the elbow joint
age of ossification is variable but occurs in the following order (C-R-I-T-O-E) at an average age of (years) ◾Capitellum (1 yr.) ◾Radius (3 yr.) ◾Internal or medial epicondyle (5 yr.) ◾Trochlea (7 yr.) ◾Olecranon (9 yr.) ◾External or lateral epicondyle (11 yr.)
Radial Head and Neck Fractures - Pediatric
ossification of radial head
Ossification center of radial head appears between and 3 and 5 years of age
◦may be bipartite
◦radial head fuses with radial shaft between ages of 16 and 18 years
Radial Head and Neck Fractures - Pediatric
Classification systems (2)
- O’Brien
- Judet
(also chambers - rarely used)
Radial Head and Neck Fractures - Pediatric
Classification
- O’Brien Classification
Type 1: 30 degrees
Type 2: 30-60 degrees
Type 3: > 60 degrees
Radial Head and Neck Fractures - Pediatric
Classification
- Judet Classification
Type I: Undisplaced
Type II: < 30 degrees
Type III: 30-60 degrees
Type IVa: 60-80 degrees
Type IVb: More than 80 degrees
Radial Head and Neck Fractures - Pediatric
Treatment: Nonoperative
- immobilization alone
a. indications
b. technique
1a. indications
◾<30 degrees of angulation
◾<3mm translation
1b. technique
◾immobilize in long arm cast or splint without reduction
◾follow-up
- 7 days of immobilization followed by early range of motion
Radial Head and Neck Fractures - Pediatric
Treatment: Nonoperative
- closed reduction and immobilization
a. indications
1a. indications
◾>30 degrees of angulation
◾closed reduction followed by immobilization in long arm cast or splint if an adequate reduction is achieved
Radial Head and Neck Fractures - Pediatric
Treatment: Operative
- closed percutaneous reduction
a. indications
b. Outcomes
1a. indications
◾> 30° of residual angulation following closed reduction
◾3-4 mm of translation
◾< 45° of pronation and supination
1b. outcomes
◾improved outcomes with younger patients, lesser degrees of angulation, and isolated radial neck fractures
Radial Head and Neck Fractures - Pediatric
Treatment: Operative
- open reduction
a. indications
b. Outcomes
1a. indications
◾fracture that cannot be adequately reduced to <45 degrees angulation with closed or percutaneous methods
1b. outcomes
◾open reduction has been associated with a greater loss of motion, increased rates of osteonecrosis and synostosis compared with closed reduction (though this is controversial as higher rates of open reduction are also seen with worse fractures)
Radial Head and Neck Fractures - Pediatric
Closed reduction techniques [4]
Reduction techniques
i. Patterson maneuver
- Ext+Supination+traction + direct pressure over radial head
ii. Israeli (Kaufman) technique
- Pronate+Flex 90+direct pressure
iii. Nehar and Torch technique
- Ext+ Supination + traction + varus force on shaft and pressure over radial head (requires 2 ppl)
iv. elastic bandage technique
- esmarch wrist to upper arm may spontaneous reduce
Radial Head and Neck Fractures - Pediatric
Closed reduction + percutaneous pinning techniques
- K-wire joystick techniques [2]
- Metaizeau technique ?
- K-wire joystick technique
a. push technique
◾blunt end of a large k-wire is pushed against the posterolateral aspect of the proximal fragment
b. lever technique
◾k-wire is placed into the fracture site and levered proximally
(nb: * if unstable after reduction a pin may be placed to maintain reduction)
2 Metaizeau technique ◾involves retrograde insertion of a pin/nail across the fracture site
◾fracture is reduced by rotating the pin/nail
Radial Head and Neck Fractures - Pediatric
Open reduction
- approach
- fixation
- Approach
◾performed with lateral approach (Kocher interval) to radiocapitellar joint
◾pronate to avoid the posterior interosseous nerve (PIN) - Fixation
◾avoid transcapitellar pins
◾internal fixation only used for fractures that are grossly unstable
Radial Head and Neck Fractures - Pediatric
Complications [6]
- Decreased range of motion (loss of pronation more common than supination)
- Radial head overgrowth
- Osteonecrosis
- Nerve injury
(PIN may be injured) - Physeal arrest
- Synostosis
◦most serious complication
◦occurs in cases of open reduction with extensive dissection or delayed treatment
Radial Head and Neck Fractures - Pediatric
Complications
- Radial head overgrowth occurs in __to__% of fractures
- Osteonecrosis occurs in __to__ % of fractures
- Osteonecrosis occurs in up to __% of cases occur with open reduction
- 20-40% of fractures (usually does not affect function)
- 10-20%
- 70%
Radial Head and Neck Fractures - Pediatric
Complications
- Physeal arrest may lead to ?
- Synostosis occurs in cases of ?
- Physeal arrest may lead to cubitus valgus deformity
- Occurs in cases of open reduction with extensive dissection or delayed treatment (most serious complication of radial neck #s)
Distal Clavicle Physeal Fractures
a
Proximal Humerus Fracture - Pediatric
a
Humerus Shaft Fracture - Pediatric
a
Distal Humerus Physeal Separation - Pediatric
a
Supracondylar Fracture - Pediatric
a
Lateral Condyle Fracture - Pediatric
a
Medial Epicondylar Fractures - Pediatric
a
Nursemaid’s Elbow
a
Olecranon Fractures - Pediatric
a
Elbow Dislocation - Pediatric
a
Medial Clavicle Physeal Fracture
- Description
- Also known as ________ ?
- Usually treatment: Op OR Non-op?
- A medial clavicle physeal injury is a rare injury to the medial physis of the clavicle in children.
- Pseudodislocation of the SCJ
- Usually treated conservatively
Medial Clavicle Physeal Fracture
- Epidemiology = common or rare?
- Pathophysiology
a. mechanism (3)
- Epidemiology = rare injury
- Pathophysiology
a. mechanism
- fall onto an outstretched extremity
- direct blow
- child abuse a rare cause
Medial Clavicle Physeal Fracture
Pathophysiology
(b) Pathoanatomy
(c) What de Lee et al. study show?
1b. Pathoanatomy
- considered a childhood equivalent to adult SCJ separation
- physeal sleeve and strong costoclavicular and SC ligs
usually remain intact
however. ..
1c. Series by Lee et al. of 40 patients treated operatively for a posterior sternoclavicular injury 50% were physeal fractures and 50% were actually sternoclavicular dislocations
Can be either anterior displacement
or posterior displacement
Medial Clavicle Physeal Fracture
- Anterior displacement - details
- Posterior dislocation - details / structures at risk
- Anterior displacement
- metaphyseal fragment may be sharp and palpable immediately beneath the skin
clavicular head of the SCM muscle is pulled anteriorly with the bone and spasms
- patient’s head may be tilted towards the affected side - Posterior displacement
- local swelling, tenderness, and depression of the medial end of the clavicle
- innominate artery and vein, internal jugular vein, phrenic and vagus nerves, trachea, and esophagus may be injured with posterior displacement
Medial Clavicle Physeal Fracture
Anatomy :Clavicle ossification
- __a___ bone to ossify in the _b_th week in utero
- central clavicle
a. when is central ossification centre most active - Distal clavicle - growth and ossification age of lateral epiphysis?
- medial clavicle
a. approx __% of clavicular growth occurs at the medial physis
b. does not begin to ossify until __to__ years
c. Age when epiphysis closes?
1a. 1st
1b. 5th week in utero
2a. initial growth (<5 years) occurs from the ossification center in the central portion of the clavicle (intramembranous ossification)
- Distal clavicle: continued growth occurs at the medial and lateral epiphyseal plates
lateral epiphysis does not ossify until age 18 years - Medial clavicle
a. approximately 80%
b. 18 to 20 years
c. last physis to close in the body (20-25yrs)
(NB: sternoclavicular dislocations in teenagers/young adults are usually physeal fracture-dislocations)
Medial Clavicle Physeal Fracture
- Anterior displacement - symptoms/signs
- Posterior dislocation - symptoms/signs
Symptoms (both): (i) pain; (ii) dysfunction
Anterior dislocation (i) deformity with a palpable bump
Posterior dislocations
(i) dyspnea or dysphagia
(ii) tachypnea and stridor
(iii) diminution or absence of distal pulses
(iv) paresthesias or paresis
Medial Clavicle Physeal Fracture
Treatment : Nonoperative
1. Observation: indications (3)
Indications
- most asymptomatic injuries
a. will remodel and do not require intervention as the periosteal sleeve is intact - Anterior displacement
- good functional results treated nonop
- Posterior displacement
- if no injury to mediastinal structures
Medial Clavicle Physeal Fracture
Treatment : Operative
- CR in operative theatre
a. indications (1)
b. contraindications (1)
2a. ORIF : indications (2)
2b. ORIF : Post-op Management (1)
- Closed Reduction
a. indications
i. ) acute posterior displacement with airway, esophageal, or NV compromise
b. contraindications:
i. ) late presenting posterior dislocation
* (note: CR not attempted as medial clavicle may be adherent to vascular structures in the mediastinum)*
2a. ORIF: indications
i. failure of CR with continued symptoms
ii. chronic symptomatic posterior dislocations
2b. Obtain CT to confirm stability
Medial Clavicle Physeal Fracture
Operative : Technique
- Closed reduction in the operating room under anesthesia
a. approach
b. anterior dislocation
i. reduction technique?
ii. if reduction fails ?
c. posterior dislocation
i. reduction technique?
ii. if reduction fails ?
a.) Approach : thoracic surgeon available
b.)Anterior Dislocation
( i.) Reduction
- patient supine with a bolster under shoulders
- longitudinal traction to both upper extremities and gentle posterior pressure to medial metaphyseal fragment applied
- medial fragment may be grasped with a towel clip to help facilitate reduction
( ii.) if unsuccessful, usually treated in a sling
c.) Posterior dislocation
( i.) Reduction
- patient placed supine position with a bolster under shoulders
- longitudinal traction applied to arm with the shoulder aDducted
- a posteriorly directed force is applied to the shoulder while the medial end of the clavicle is grasped with a towel clip and brought anteriorly
(ii.) if reduction fails, proceed to open reduction
Medial Clavicle Physeal Fracture
Treatment : Operative
Open Reduction Internal Fixation
approach
horizontal incision the over superior/medial clavicle
reduction
towel clip to reduce
fixation
sutures from medial clavicle to sternum/medial epiphysis
sutures preferred as may allow for MRI in the future
Medial Clavicle Physeal Fracture
Treatment : ORIF
- approach
- reduction
- fixation
- Approach: horizontal incision the over superior/medial clavicle
- Reduction: towel clip to reduce
- Fixation:
- sutures from medial clavicle to sternum/medial epiphysis
- sutures preferred as may allow for MRI in the future
Medial Clavicle Physeal Fracture
Complications (3 total)
- Long term outcome problem
- Immediate
- Surgical fixation problem
- Persistent instability
(i. ) incidence= rare in children as they have a high propensity to remodel - Laceration of subclavian artery or vein
(i. ) incidence = rare
(ii. ) suggested by rapidly expanding hematoma
(iii. ) thick periosteum usually protective
(iv. )treatment : repair of vessel - Pin migration
(i. ) pin fixation around the clavicle should be avoided
Distal Clavicle Physeal Fractures
- Description
- Epidemiology
a) common OR rare?
b) accounting for __to__% of clavicle fractures in children
- Description
- injury to the distal physis of the clavicle in skeletally immature patients
- most can be treated nonoperatively with sling immobilization - Epidemiology
a. ) rare injury
b. ) 5%-10% of clavicle fractures in children
Distal Clavicle Physeal Fractures
- Pathophysiology: mechanism (3)
- Pathoanatomy
a. childhood equivalent to adult ____
b. periosteum usually ______ with injury
c. clavicle displacement ?
- Pathophysiology: mechanism
i. FOOSH OR fall onto side of the shoulder.
ii. direct blow
iii. child abuse (rare cause) - Pathoanatomy
a. AC separation
b. periosteum usually remains intact with injury
c. clavicle displaces away from physis and periosteal sleeve both of which remain attached to the AC and CC ligaments
Distal Clavicle Physeal Fractures
Anatomy
1. Coracoclavicular (CC) ligaments provide ______stability
- Trapezoid ligaments __cm from ACJ
- Conoid ligaments __cm from ACJ
- Acromioclavicular (AC) ligaments provide ________ stability
- Coracoclavicular (CC) ligaments provide VERTICAL stability
- trapezoid ligaments 2 cm from AC joint
- conoid ligaments 4 cm from AC joint
- Acromioclavicular (AC) ligaments provide HORIZONTAL stability
Distal Clavicle Physeal Fractures
Classification
- eponymous name
- details
- Rockwood’s
Type I: Sprain of the AC ligaments, periosteal tube intact
Type II: Partial disruption of the periosteal tube
Type III: Large split in the periosteal tube with superior displacement
Type IV: Large split in the periosteal tube with posterior displacement of the lateral clavicle through trapezius
Type V: Complete disruption of the periosteal tube with displacement through the deltoid and trapezius
Type VI: Inferior dislocation of the distal clavicle below the coracoid
Distal Clavicle Physeal Fractures
late XR findings ?
intact periosteal sleeve forms a “new” lateral clavicle inferior to the superiorly displaced medial fragment.
Distal Clavicle Physeal Fractures
Treatment : Nonoperative
- indications
Indicated in most cases, especially if periosteum is intact
- a new clavicle will form within the intact periosteal sleeve resulting in a Y shaped clavicle
- the displaced clavicle will typically reabsorb with time and growth
Distal Clavicle Physeal Fractures
Treatment : Operative / Surgical reduction
- Absolute indications (4)
- Relative indications (5)
- absolute indications (rare)
i. open fractures
ii. significant skin compromise
iii. displaced intra-articular extension
iv. a/w NVI requiring surgery - Relative indications
i. severely displaced fractures in older patients with nearly closed physis
ii. displaced and entrapped fragment in trapezius
iii. floating shoulder injuries
iv. some Type III fractures in patients approaching skeletal maturity
v. types IV, V, and VI may need open reduction with repair of periosteal sleeve
Distal Clavicle Physeal Fractures
Complications (3)
- Laceration of subclavian artery or vein
- rare
- suggested by rapidly expanding hematoma
- thick periosteum usually protective
- treatment = vascular repair - Nonunion (rare)
- seen after attempts at open reduction
- treatment = surgical fixation with iliac crest bone grafting - Pin migration
- pin fixation around the clavicle should be avoided
Humerus Shaft Fracture - Pediatric
Overview (Mechanism / Usual Rx)
Overview
- pediatric humeral shaft fractures are usually traumatic in nature, although nonaccidental trauma and pathologic lesions can not be overlooked
- treatment is almost always immobilization due to the high remodeling potential of the pediatric humerus
Humerus Shaft Fracture - Pediatric
Epidemiology
1. incidence: represent
- <10%
- MOI:
(i.) typically associated with trauma
consider (ii) NAI; (iii) pathological #
*(note: consider a pathologic process if # is a result of a low energy mechanism;
may be associated with child abuse if age <3 and fracture pattern is spiral)
3a. neonates: hyper-extension or rotational injury during birth
3b. adolescents :usually direct trauma
pathophysiology
Humerus Shaft Fracture - Pediatric
- Associated conditions
- Prognosis
- Up to ___° of angulation is associated with excellent outcomes due to the large range of motion of the shoulder
- Associated conditions
a. radial nerve palsy (associated with up to 5% of humeral shaft fractures) - Prognosis = excellent
- associated with enormous remodeling potential and rarely requires surgical intervention
- Up to 20° of angulation
Humerus Shaft Fracture - Pediatric
Treatment : Nonoperative
(immobilization in splint or brace)
- indications
- acceptable alignment
a. younger children: < __to__deg angulation
b. older children
< __ deg varus/valgus
< __ deg procurvatum
< __ deg rotation malalignment
< __cm shortening
- Utilized for almost all pediatric humeral shaft fractures (if not pathologic) due to remodeling potential
2a. Acceptable alignment: younger children
< 35-45 deg angulation
2b. Acceptable alignment: Older children
< 20 deg varus/valgus
< 20 deg procurvatum
<15 deg rotation malalignment
< 2cm shortening
Humerus Shaft Fracture - Pediatric
Treatment : Nonoperative
(immobilization in splint or brace)
Techniques (4)
- sling and swathe or cuff and collar in young children
- Coaptation splint or hanging arm cast
- Sarmiento functional brace in older children/adolescents
- ROM exercises can be initiated in 2-3 weeks once pain is controlled
Humerus Shaft Fracture - Pediatric
Operative : ORIF
1. indications (5)
- techniques
i. ______
ii. ______
- indications
i. open fractures
ii. multiply injured patient
iii. ipsilateral forearm fractures (“floating elbow”)
iv. associated shoulder injury
v. unacceptable alignment - techniques
i. flexible intramedullary nail fixation
ii. anterior, anterolateral or posterior approach with 3.5mm or 4.5mm plate fixation
Humerus Shaft Fracture - Pediatric
Complications
1. Radial nerve palsy: occurs in
- Radial nerve Palsy
a. <5%
b. middle and distal 1/3 fractures
c. neuropraxia
d. expected
e. rarely needed - Malunion
rarely produces functional deficits, due to the wide range of motion at the shoulder
up to 20-30° of angulation is associated with excellent outcomes - Delayed union = rare
- may consider U/S bone stimulation - Limb length discrepancy commonly occurs, but rarely causes functional deficits
- Physeal growth arrest
proximal and distal humerus growth plates contributes 80:20 percent to overall humeral length
