Transcript ภาพนิ่ง 1

ยงยส จีระธัญญาสกุล
รพ.วชิระภูเก็ต
Developmental Anatomy
Ossification Centers & Physes
• scapular ossification
centers – acromion,
coracoid, glenoid,
medial border
• proximal humeral
physis – tent shaped,
80% of longitudinal
growth
• medial clavicular physis
– last to close 23-25 yrs
Clavicle Fracture
• most common fx in
children
• 50% in <10 yo
• usually midshaft
• almost always heals,
usually clinically
insignificant malunion
• remodels within 1 year
• complications very
uncommon
Clavicle Fracture Patterns
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most in middle
5% distal
< 5% medial
greenstick
common
• beware nutrient
foramen- not a fx
Clavicle Birth Fracture
• large baby
• pseudoparalysis
• simple
immobilization
• if no BP palsy
active movement
should return early
Congenital Pseudarthrosis
of the Clavicle
• right side
• except with
dextrocardia
• if symptomatic in
older child –
excise, tricortical
graft, fixation
Distal Clavicle Fracture
• often intact
periosteum
• usually remodels
• nonoperative tx
Distal Clavicle Fractures- Classification
• similar to adults
• based on amount
& direction of
displacement
Distal Clavicle Injuries
Periosteal Sleeve
Medial Clavicular Injuries
• medial clavicular physis
last to close – 22-24 yo
• clavicle shaft usually
anterior
• may displace
posteriorly
• serendipity view or CT
if suspect
Scapula Fractures
• may be a sign of
significant trauma
• usually nonoperative
treatment
• growth centers may be
confused with fracture
• axillary view often
helpful
coracoid base fracture
Scapula Fractures - Classification
• can have fracture
through common
growth center of
coracoid and
glenoid
Scapula Fractures - Classification
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body
neck
glenoid
acromion
coracoid
intraarticular /
extrarticular
Glenohumeral Dislocations
• rare in children < 12 years old
• high risk of recurrent instability when
initial dislocation occurs in childhood or
adolescence
• anterior, Posterior or Inferior direction
• traumatic or atraumatic etiology
Glenoid Dysplasia
• may predispose to
instability
• may be primary or
secondary (after
brachial plexus
palsy)
Traumatic Shoulder Dislocation
• gentle reduction
• immobilization for
approx 3 weeks
• shoulder rehabilitation
• surgical stabilization
/reconstruction
reserved for recurrent
instability
Atraumatic Instability
• often multiple joint
ligamentous laxity
• multidirectional instability
usually present
• may be voluntary
(discourage)
• rotator cuff strengthening
Proximal Humeral Fracture
• birth injuries
• 0-5 yo
SH I
• 5-11 yo
metaphyseal
• 11-maturity SH II
• others rare (III, IV)
• proximal humeral epiphysis does not
ossify until about age 6 months
• fusion occurs at about age 15 in girls and
17 in boys.
• shape of the physis is conical, with the apex
pointing postermedial
• medial metaphysis is intra-articular
• fractures of the proximal humerus < 5% of
children's fractures
• birth injuries are transphyseal, with the proximal
humeral epiphysis not yet ossified at birth, the
malalignment of the shaft to the glenoid is the
only radiographic finding
Proximal Humeral Physeal Fractures
Neer – Horowitz Classification
• grade I
• grade II
width
• grade III
width
• grade IV
width
< 5 mm
< 1/3 shaft
< 2/3 shaft
> 2/3 shaft
• pull of rotator cuff & subscapularis on proximal
fragment leave it abducted, flexed, and
externally rotated
• pectoralis major pulls the distal fragment into
adduction
• Dameron's acceptable reduction
recommendation of 20 degrees in the older child
is often quoted
• nonoperative treatment is favored for all
fractures
• remodeling potential of proximal humerus is
perhaps the most impressive in the body &
mobility of shoulder surely compensates for
residual deformity at skeletal maturity
• treatment options :
manipulation and immobilization in sling &
swathe
closed reduction and percutaneous pinning
open reduction
no reduction using simply symptomatic
immobilization with arm in sling & swathe
Treatment
• closed treatment for vast majority
• if markedly displaced, attempt closed
reduction and immobilize
• reserve closed reduction and pinning, open
reduction for fractures with significant
displacement (> Neer II) in older adolescents,
recurrent displacement
• reduction with traction, abduction, and
flexion has been described, but with the
generous remodeling potential of this site,
good results are uniform
• proximal humeral fractures primarily are
seen in infancy and adolescents
• fractures prior to adolescence are more
often metaphyseal
• in adolescent, primarily physeal injuries,
the vast majority Type II
J Bone Joint Surg Am. 1969;51:289-297.
THOMAS B. DAMERON, JR. and DONALD B. REIBEL
Proximal Humerus –
Acceptable Alignment
• great remodeling potential – 80% of humeral
length contributed by proximal physis
• shoulder ROM compensatory
• age dependent? – some studies state that even
older adolescents have acceptable functional
outcomes after nonoperative treatment of prox
humerus fxs
Early Healing Noted 3 Weeks
after Closed Reduction in Adolescent
initial film
3 weeks after closed reduction
Metaphyseal Fracture
Remodeling over 6 Months
Pinning Proximal Humerus
• usually don’t need to
• most recent studies quote high complication
rates (pin migration, infection)
• if used leave pins long and bend outside
skin, consider threaded tip pins
• even in older adolescents remodeling
occurs
• few functional deficits
Percutaneous Pinning
may lead to pin migration
Pinning
• bend pins to prevent migration
• threaded tips
Complications of Proximal Humerus Fractures
• malunion with loss of shoulder ROM – rarely
functionally significant
• shortening – up to 3 -4 cm seemingly well
tolerated
• neurologic & vascular compromise less
common than in adults
Humeral Shaft Fractures in Children
• neonates - birth trauma
• birth- 3 yrs - consider possible non-accidental
trauma
• 3-12 yrs - often pathologic fracture through
benign bone tumor or cyst
• >12 yrs - treatment like adults
Birth Fractures
• simple
immobilization
• pseudoparalysis
• little attention to
realignment or
reduction needed
Pathologic Humeral Fracture - UBC
fallen leaf sign & also pseudosubluxation inferiorly
Humeral Shaft Fractures- Treatment
• usually closed
methods
• sling and swathe
• coaptation splint
• fracture bracing
• hanging arm cast
Shoulder ImmobilizationCoaptation Splint
Humeral Shaft Outcomes
• malunion common, but usually little functional
loss
• remodels well
• initial fx shortening may be compensated for
by later overgrowth
• nonunion uncommon
• radial nerve palsy less common, if occurs
usually neuropraxia
Indications for Open Reduction
Shoulder Region Fractures
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open fractures
displaced intraarticular fractures
multiple trauma to facilitate rehabilitation
severe displacement with suspected soft
tissue interposition
Thank You