Upper Extremity Injury Management. Jonathan Pirie MD, Med, FRCPC, FAAP

Transcription

1 Upper Extremity Injury Management Jonathan Pirie MD, Med, FRCPC, FAAP

2 Learning Objectives At the end of this session, you will be able to manage common fractures of the: 1. Humerus 2. Elbow 3. Forearm

3 Outline Proximal Humeral # Mid Humeral # Elbow or Mid Forearm # Distal Forearm (simple #s) 3

4 Proximal Humeral Fractures p Age patterns: n 0-5 Salter Harris I n 5-11 Metaphyseal n >11 SH II p Acceptable Angulation n Pre-teen n Teen with up to 50% apposition p Management? n Immobilization? n Ortho follow up? 4

5 Proximal Humeral Fractures p Management n sling & swathe or collar & cuff n Good analgesia p Maximize OTC analgesics p Morphine 0.2 mg/kg x 2-3 days n f/u with Ortho 5-7 days 5

6 How to make a sling! 6

7 Sling & Swathe 7

8 Sling & Swathe 8

9 Velpeau Slings 9

10 Collar & Cuff 10

11 Humeral Shaft Fractures p Carefully assess radial nerve function p Immediate Ortho referral if: n completely displaced, angulated > 30 degree children, n degrees for adolescents, n radial nerve injury p Rx: sugar-tong cast 11

12 Sugar Tong 12

13 Supracondylar Fractures p p p p p Most frequent elbow injury in children Mechanism of injury X-ray p may be subtle Complications p nerve injury-radial, median, ulnar (10%) p Volkmann s ischemia p cubitus varus Treatment: p non-displaced: long-arm splint, for moderate swelling 24-hour follow-up p Displaced (capitellum behind ant. humeral line: ortho referral 13

14

15

16

17

18 Lateral Condylar Fracture p Clinical n localized swelling lateral aspect of elbow p X-ray n small metaphyseal fragment on AP and oblique n Involves physis & articular surface S.H. type 3 or 4 p Complications n non union n ulnar nerve palsy n degenerative arthritis n growth abnormalities p Orthopedic referral n Unstable 18

19 Medical Epicondylar Fracture

20 Medial Epicondylar Fracture p Clinical n localized swelling medial aspect of elbow p X-ray n medial epicondyle ossifies 5-7 years n consider X-ray of opposite limb n incarcerated in joint - ossific nucleus p Immediate Orthopedic referral n unstable 20

21

22

23 Fractures of Radial Head and Neck p Mechanism of injury n fall on outstretched hand, forearm in supination p 50 % associated fractures p Clinical n tenderness and ecchymosis over proximal radius n referred pain to wrist p Treatment: above elbow cast (posterior slab) & F/ U Ortho 23

24 Supracondylar Fractures p Most frequent elbow injury in children p Peak incidence age 8 years p Complications p nerve injury-radial, median, ulnar (10%) p Volkmann s ischemia p cubitus varus p Treatment: p non-displaced: long-arm splint, for moderate swelling 24-hour follow-up p Displaced (capitellum behind ant. humeral line: ortho referral 24

25 Forearm Injuries p True sprains (ligamentous injuries) are uncommon with open growth plates p The most common injuries are: n Salter Harris I # n Soft tissue injuries 25

26 Forearm Fractures p Taurus (Buckle) #s, micro #s, SH I & II n Short arm volar slab or splint for 3-6 weeks n f/u with FD or Pediatrician 26

27 Forearm Fractures 27

28 Forearm Fractures p Distal Radius and Ulna #s n Acceptable angulation: < 5 yrs < 30 degrees 6-10 < < 15 > 14 < 10 n Rx: Volar back slab, Benik splint n Ortho Follow up 1-2 weeks, usually 3-6 weeks of immobilization 28

29 Splint or Cast? p Minimally angulated (<15 degrees), + <0.5 mm displaced greenstick or transverse #s n Splint = cast n Boutis CMAJ 2010 p Pediatric Fractures with Minimal Intervention n Boutis PEC

30 Benik Splint 30

31 Clinical Deformed 31

32 Bowing Fractures p Little remodeling, cosmetic & functional deficits common p May need reduction p Orthopedic referral if cosmetically deformed 32

33 Summary Proximal Humeral # Mid Humeral # Sling & Swathe or Collar & Cuff Sugar Tong Elbow or Mid Forearm # Distal Forearm (simple #s) Posterior Long Arm or Sugar Tong Forearm slab or splint 33