UPPER EXTREMITY FRACTURES

Transcription

1 UPPER EXTREMITY FRACTURES Dr. Sumit Kumar Gupta, MD, FRCSC Assistant Professor of Orthopaedics University of Missouri FREQUENCY OF FRACTURES 1

2 FREQUENCY BY SEASON More Common during the summer. Out of school more vigorous and unsupervised physical activities FREQUENCY BY TIME OF DAY 2

3 SPECIFIC FRACTURE TYPES ACTIVITIES ASSOCIATED WITH FRACTURES Playground 90% were upper extremity fractures from a fall off of monkey bars or climbing equipment Change of playground surfaces concrete / dirt / rubber => bark (impact-absorbing) Skateboarding Nature of skateboarding being high speed and extreme maneuvers causes high-energy trauma fractures Roller Skates & In-line Skates Most injuries involve elbow, forearm, wrist, and fingers; < 20% use protective gear 3

4 ACTIVITIES ASSOCIATED WITH FRACTURES Trampoline 1/3 of injuries result from falling off the trampoline Skiing More than half of the injuries occur due to collisions with stationary objects; i.e. trees, poles, stakes Snowboarding Compared to skiers, snowboarders have 2-½ times as many fractures OUTLINE Clavicle Shoulder Humerus shaft Elbow Supracondylar, Lateral condyle, Medial epicondyle, Radial Head/neck, Olecranon Forearm Wrist 4

5 CLAVICLE FRACTURES Birth most common bone broken at delivery 0.4-1% of vaginal births can happen with normal delivery Decreased movement of arm should raise suspicion 1 of 11 clavicle fractures can have associated brachial plexus palsy McBride MT, Hennrikus WL, Mologne TS. Newborn clavicle fractures. Orthopedics Mar;21(3):317-9; discussion Lurie S, Wand S, Golan A, Sadan O. Risk factors for fractured clavicle in the newborn. J Obstet Gynaecol Res Nov;37(11): doi: /j x. Epub 2011 Jul 25. CLAVICLE FRACTURES Rarely need surgery in children Shoulder sling has same outcome as figure of eight, but more comfortable Adolescents may do better with operative fixation if 100% displaced >2cm shortening Open injuries Neurovascular injury Pandya NK, Namdari S, Hosalkar HS. Displaced clavicle fractures in adolescents: facts, controversies, and current trends. J Am Acad Orthop Surg Aug;20(8): doi: /JAAOS

6 CONGENITAL PSEUDARTHROSIS Not painful No callus formation on follow-up xrays Most commonly on right DISTAL CLAVICLE FRACTURES 10% of clavicle fractures Not a true dislocation of the AC joint Fracture through the distal physis Periosteal sleeve is intact 6

7 DISTAL CLAVICLE FRACTURES DISTAL CLAVICLE FRACTURES 7

8 PROXIMAL HUMERUS FRACTURES 80% of humeral growth comes form proximal growth plate Have a high potential to remodel, so can accept a lot of deformity PROXIMAL HUMERUS FRACTURES Extraordinary remodeling potential of the proximal humerus 8

9 PROXIMAL HUMERUS FRACTURE Accept any alignment if 2 yrs growth Sling Sling and Swathe Hanging cast 9

10 HUMERAL SHAFT FRACTURES Excellent healing and remodeling potential If the bones are in the same room it will heal 10

11 HUMERAL SHAFT FRACTURES Treatment: Sling and coaptation splints Hanging arm cast Internal fixation, flexible nails Overgrowth of ~ 1 cm occurs ELBOW FRACTURES Supracondylar fractures (70%) Lateral condylar fractures (15%) Medial epicondylar fractures Radial head/neck fractures Transphyseal Olecranon 11

12 ELBOW FRACTURES Supracondylar fractures (70%) Lateral condylar fractures (15%) Medial epicondylar fractures Radial head/neck fractures Transphyseal Olecranon ELBOW FRACTURES Supracondylar fractures (70%) Lateral condylar fractures (15%) Medial epicondylar fractures Radial head/neck fractures Transphyseal Olecranon 12

13 ELBOW FRACTURES Supracondylar fractures (70%) Lateral condylar fractures (15%) Medial epicondylar fractures Radial head/neck fractures Transphyseal Olecranon ELBOW FRACTURES Supracondylar fractures (70%) Lateral condylar fractures (15%) Medial epicondylar fractures Radial head/neck fractures Transphyseal Olecranon 13

14 ELBOW FRACTURES Supracondylar fractures (70%) Lateral condylar fractures (15%) Medial epicondylar fractures Radial head/neck fractures Transphyseal Olecranon ELBOW FRACTURES Supracondylar fractures (70%) Lateral condylar fractures (15%) Medial epicondylar fractures Radial head/neck fractures Transphyseal Olecranon 14

15 ELBOW FRACTURES 5-10% of all pediatric fractures Knowledge of ossification centers is essential for correct diagnosis SUPRACONDYLAR FRACTURE 70% of all elbow fractures in children Average age: 6 y/o Anatomic predisposition: Ligamentous laxity Metaphyseal remodeling Thin cortex 15

16 MECHANISM Extension injury 97% Flexion injury 3% FAT PAD SIGN Anterior fat pad => means nothing! Posterior fat pad => 76% occult fracture 16

17 CLASSIFICATION Tachdjian s Pediatric Orthopaedics, 4 th Ed. VASCULAR INJURY 0.5-1% incidence Important to document clinical exam Pulses Perfusion Need urgent OR for reduction Tachdjian s Pediatric Orthopaedics, 4 th Ed. 17

18 NERVE INJURY Occurs 7% Anterior Interosseus Nerve Most common Radial nerve Posteromedial displacement Median nerve Posterolateral displacement Ulnar nerve Iatrogenic from pin placement TYPE 1 SUPRACONDYLAR FRACTURE Long arm cast 4-6 weeks Sling is recommended Parents should be instructed on elevation of the extremity to reduce swelling Fingers above the elbow Elbow above the heart 18

19 TYPE 2 AND 3 SUPRACONDYLAR FRACTURES OR for closed reduction and pinning TYPE 2 AND 3 SUPRACONDYLAR FRACTURES OR for closed reduction and pinning 19

20 TYPE 2 AND 3 SUPRACONDYLAR FRACTURES OR for closed reduction and pinning TYPE 2 AND 3 SUPRACONDYLAR FRACTURES 20

21 FLEXION TYPE SUPRACONDYLAR TRANSPHYSEAL FRACTURES Children < 2 years old Diagnosis usually missed Distal humerus being entirely cartilaginous Distinguishing a transphyseal fracture from an elbow dislocation Child abuse 50% of children less than 2 years of age 21

22 LATERAL CONDYLE FRACTURES 2 nd most common elbow fracture LATERAL CONDYLE FRACTURE Most need surgical management Any displacement high rate of non-union when treated with cast Avoid unnecessary dissection especially posterior - AVN 22

23 LATERAL CONDYLE FRACTURE LATERAL CONDYLE FRACTURE NON-UNION 23

24 MEDIAL EPICONDYLE Common in age 9-14 Mechanism Direct trauma Muscle pull from flexor mass Associated with elbow dislocation upto 50% Historically treated non operatively Relative indications for treatment Displacement > 1cm Elbow instability Ulnar nerve symptoms Higher demand patients ELBOW DISLOCATION 24

25 REDUCED ORIF EXCISION OF FRAGMENT AND REDUCTION 25

26 NURSEMAIDS ELBOW Radial head subluxation Common injury in 1-6 years of age Mechanism is usually of longitudinal traction while forearm is pronated and elbow extended NURSEMAIDS ELBOW Anatomy Annular ligament normally passes around radial head The immature radial head is more spherical and smooth (cartilaginous), and can slide out The annulus then gets trapped in the joint Robert E. Kaplan and Kathleen A. Lillis, Recurrent Nursemaid s Elbow (Annular Ligament Displacement) Treatment Via Telephone, PEDIATRICS Vol. 110 No. 1 July 1, 2002 pp

27 NURSEMAIDS ELBOW Presentation Arm held in pronation, elbow partially flexed Unwillingness of child to use that arm Tenderness in antero-lateral elbow No erythema, swelling, warmth, abrasions or ecchymosis NURSEMAIDS ELBOW Supination: Simultaneous supination of the wrist and extension of the elbow (A), followed by flexion of the elbow with the forearm maintained in supination (B). Hyperpronation: Simultaneous pronation of the wrist and extension of the elbow (A), followed by flexion of the elbow with the forearm maintained in pronation (B). Robert E. Kaplan and Kathleen A. Lillis, Recurrent Nursemaid s Elbow (Annular Ligament Displacement) Treatment Via Telephone, PEDIATRICS Vol. 110 No. 1 July 1, 2002 pp

28 FOREARM FRACTURES Common injury Most kids with >2years growth remaining can be treated with closed reduction 28

29 FOREARM FRACTURE Long arm cast safe and effective Bae DS. Pediatric Distal radius and forearm fractures. J hand Surg Am Dec;33(10):

30 WHAT IS THE INJURY? MONTEGGIA FRACTURE 30

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32 DISTAL RADIUS/ULNA FRACTURES Most common fracture in children Majority are managed in cast Commonly a result of a fall on an outstretched hand DISTAL RADIUS/ULNA FRACTURES Well molded cast is key Cast Index x/y Ideally > 0.7 Strongest predictor of loss of reduction Short arm cast is usually sufficient Pin fractures if they redisplace Higher risk of growth plate injury with repeat closed reduction 32

33 TAKE HOME POINTS Clavicle fractures Majority are non-operative Growth and remodeling until 22 years of age Proximal humerus Non operative if > 2 years growth remaining High potential for remodeling Elbow Recognize the anatomy and ossification centers Cannot tolerate any significant deformity Have a low threshold to refer these TAKE HOME POINTS Supracondylar fractures Always assess neurovascular status Anterior interosseus nerve, brachial artery Do not attempt a closed reduction in the ER or clinic Lateral condyle Any displacement needs anatomic open reduction High risk of complications including non union and AVN Medial Epicondyle Can be treated non op for minimally displaced, younger patients or inactive patients 50% associated with elbow dislocations Think of this fracture with significant elbow injury and no fracture seen 33

34 TAKE HOME POINTS Forearm and wrist fracture Always look at the joint above and below pay particular attention to radial head dislocation Most can be managed non operatively Need close follow-up for displaced fractures to ensure reduction is maintained Do not attempt multiple reductions increased incidence of growth arrest Well molded cast is essential to success 34