Transcript Pediatric Upper Extremity Injuries
Review of Orthopaedic Trauma Chapter 29 Pediatric Upper Extremity Injuries
R1 陳彥夫
Scapular Fractures
• • • Incidence: Very rare Mechanism: High energy direct blow Treatment: The same as adult
Clavicle
• • • Incidence: Most frequently fractured bone in childhood Evaluation: PE: pseudoparalysis, crepitation, swelling, point tenderness Imaging: X-ray, stress view, CT Associated injury: neurovascular brachial plexus palsy
• Treatment: immobilizing the shoulder girdle Neonates: bound to thorax Children & adolescents: Figure-8 sling, Velpeau sling • Surgical Indication: open fracture , Severe tenting of the skin , Neurovascular compromise
Sternoclavicular joint
• • • Usually Salter type I or II physeal fracture Ant. Displacement more common Evaluation: PE: lump or depression of chest imaging: 40 ° oblique view CT scan Treatment: Ant.: conservative treatment Post.: traction, towel clip under GA
Acroioclavicular joint
• Classification: Dameron & Rockwood I : mild sprain II: some instability III: gross instability IV: displaced posteriorly V : superior displacement VI: inferior dislocation • Treatment: open reduction is indicated for types III to VI in adolescents
Glenohumeral dislocatons
• • • Incidence: Extremely rare Treatment: similar to adults Recurrence is very common because of ligamentous laxity
Proximal Humerus Fractures
• • • Incidence: Most commonly in adolescents and newborns Mechanism: delivery, a fall on outstretched arm, child abuse Classification: Neer & Horwitz I : displaced ＜ 5mm II : displaced ＜ III: displaced ＜ IV: displaced ＞ 1/3 width 2/3 width 2/3 width
• • Evaluation: PE imaging: proximal epiphysis ossify: 6 months echo maybe helpful Treatment: acceptable reduction guidelines Age < 5 years 5~12 years > 12 years augulation < 70 ° 40~45 ° 40 ° Older adolescents minimal apposition some 50% 50% minimal
• Not exceeds: sling and swath, Velpeau • • Close reduction if exceeds guildline in spica cast in the salute position or via percutaneous pin Open reduction in completely displaced fracture with the biceps tendon interposed or in displaced fracute involving the humeral head articular cartilage
Humeral Shaft Fractures
• • • • • Incidence: < 3 y/o, > 12 y/o Mechanism: vigorous delivery, twisting, direct trauma Evaluation: palpable lump, pseudoparalysis Treatment: infants & children: shoulder immobilizer, sling, hanging arm cast adolescents: closed methods first Complications: overgrowth, malunion, radial nerve injuries
Transphyseal
• • Incidence: Usually occur before age 6 Classification: DeLee, the degree of
ossification of the lateral condylar epiphysis
A: < 1 y/o B: 1 y/o ~ 3 y/o C: 3 y/o ~ 7 y/o A,B: Salter I frx.
• • Evaluation: PE: swallon elbow Imaging: radial capitellar relationship still intact but ossification center is posteriomedial Treatment: reduction in flexion and pronation + long arm cast if unstable: percutaneous pinning
Supracondylar
• • Incidence: Most common in the first decade Classification: a. the direction of sagittal displacement of the distal fragment: ext.: 90%, flex.: 10% b. the degree of displacement I : undisplaced II: displaced but has a hinged posterior cortex III: completely displaced c. the direction of cononal displacement of the distal fragment: med.: 75%, lat.: 25%
• • Evaluation: PE: Puckering of ant. Skin severe displacement with neurologic or vascular injuries Imaging: anterior humeral line, Baumann’s angle, avg 72 ° Associated injuries vascular: brachial a.
neurologic: 7~15% posteromedial: radial n.
Posterolateral: median n.
Flexion angulation: ulnar n.
• Treatment type I: long arm cast for 3~4 weeks type II: splint for 3~5 days, then a cast in a safe amount flexion, if failure, CRPP type III: CRPP (medial pin may damage ulnar n.), open reduction, traction flexion fractures: reduced and stabilized in extension
• Complications neurologic: no improvement in 3 months explore vascular: brachial a. injury, if after reduction, radial pulse(-) arteriogram or CVS compartment syndrome cubitus varus stiffness
Medial Epicondyle
• • • Most commonly between ages 9 & 14 years More in boys, 50% associated elbow dislocation Mechanism: valgus stress, direct blow, sudden flexion-pronation
• • Evaluavalgus stress testtion: PE: : 15 ° flexion Treatment: ORIF is recommend: > 5mm displacement and rotation of 90 ° Absolute: incarceration of the fragment within elbow, ulnar n. dysfunction, elbow instability • D/D: medial condyle fracture – intraartivular, hemarthosis
Lateral Epicondyle
• • • Most often in ages 5 to 10 years Mechanism: valgus stress on the extended elbow with the forearm supinated Classification: Location: Milch type I: Salter IV, stable type II: Salter II, unstable Degree of displacement I: nondisplaced II: <2mm III: >2mm IV: separate completely
• • Treatment: base on displacement type I: casting for 3 to 4 weeks type II: CRPP type III, IV: ORIF Complication: nonunion , physeal arrest, avascular necrosis, delayed union, spur formation, Fishtail deformity, cubitus valgus or varus, myositis ossificans, ulnar nerve palsy
Medial Condyle
• • • Most often in ages 8 to 14 years Mechanism: the same to medial epicondyle Classification: location: Milch location & degree of displacement: Kilfoyle
• • • Evaluation: PE: intraarticular, hemarthrosis Imaging: ossification at age 9 Treatment: nondisplaced: long arm cast for 3 to 4 weeks minimally displaced: CRPP displaced: ORIF Complications: growth disturbance, avascular necrosis, loss of motion, elbow instability
Olecranon
• • more in children with osteogenesis imperfecta Classification: based on mechanism: Wilkins type A: flexion type B: extension valgus: radial neck fracture, avulsion of the medial condyle varus: dislocation of radial head, post. Interosseous nerve injury type C: shear
• Treatment: similar to adult a. undisplaced: cast immobilization in 90 degree of flexion and neutral rotation, ORIF + elbow extension b. displaced: internal fixation
Nursemaid’s Elbow
• • Most common age is 2 to 3 years Mechanism: traction with the elbow extended and the forearm pronated
• Treatment: close reduction elbow is hyperflexed.
feel the characteristic snapping as the ligament is reduced.
Dislocation of Elbow
• • Peak age: 13 years Mechanism: outstretched hand with hyperextension of the elbow, combined with valgus stress • Classification: Wilkins, based on the direction of displacement with respect to the humerus Type I: proximal radioulnar joint intact Type II: proximal radioulnar joint disrupted
• • Treatment: close treatment immobilization for 5 days ~ 3 weeks open treatment medial epicondyle fracture, open injury, brachial a. injury, irreducible dislocation Complication: stiffness, recurrent dislocation, nerve injuries, brachial artery injury
Proximal Radius
• • • Incidence: peak 4 ~ 14 years Mechanism: valgus force on extended elbow, elbow dislocation, fracture dislocation Classification: location: type A: Salter I or II type B: Salter IV type C: total metaphyseal fracture displacement pattern: angulation, translation, complete displacement
• Treatment: angulation<30 ° , translation<5mm: early motion angulation 30~60 ° : close reduction angulation>60 ° or translation>5mm : ORIF if > 10 y/o, angulation <10~15 °
Coronoid Process
• • • • Incidence: 8~9 and 12~14 years Mechanism: elbow dislocation Classification: Regan and Morrey type I: tip of coronoid process type II: <50% of coronoid process type III: >50% of coronoid process Treatment: close treatment in children