Upper Extremity Fractures & Lawn Mower Injury Prevention 7/16/2012. Viewing Time. Faculty Disclosure. Target Audience. Speaker Faculty Disclosure

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1 Viewing Time This presentation will take approximately one hour to complete. Target Audience This program is designed for primary care physicians. Other health care professionals working with patients and their families may also find this program of interest. Faculty Disclosure It is the policy of Children s Hospitals and Clinics of Minnesota to ensure balance, independence, objectivity, and scientific rigor in all its educational programs. Our faculty have been asked to disclose to our program audience any real or apparent conflicts of interest related to the content of their presentations. They have also been requested to let you know when any products mentioned in their presentations are not labeled for the use under discussion or are still under investigation. 3 Speaker Faculty Disclosure Jennifer C. Laine, MD has disclosed no actual or apparent conflict of interest in relation to this educational activity. During this educational activity Dr. Laine will not be discussing the off-label use of any commercial or investigational product not approved for any purpose by the FDA. Upper Extremity Fractures & Lawn Mower Injury Prevention Pediatric Grand Rounds: July 12, 2012 Jennifer C. Laine, MD Orthopedic Surgeon Gillette Children s Specialty Healthcare Children s Hospitals and Clinics of Minnesota 5 1

2 Upper Extremity Fractures & Lawn Mower Injury Prevention Pediatric Grand Rounds: July 12, 2012 A lecture on the evaluation, treatment and management of pediatric upper extremity fractures. Includes a discussion of lawnmower safety for children. Program Objectives Upon completion of this program, participants should be able to: Overview of unique aspects of the pediatric skeleton with respect to injury, healing and remodeling. Review of the initial assessment of a patient with upper extremity injury history, physical exam, imaging. Review initial management of pediatric upper extremity injuries; when to splint, when to follow-up with orthopaedics and when surgery is indicated. Discuss pitfalls associated with managing the injured child. Disclaimer Children s Hospitals and Clinics of Minnesota accepts no responsibility for the materials presented through these Grand Rounds seminars. Each professional presenter assumes all responsibility for maintaining confidentiality or obtaining authorization, in accordance with all applicable laws. Accreditation Children s Hospitals and Clinics of Minnesota is accredited by the Minnesota Medical Association to provide continuing medical education for physicians. Children s Hospitals and Clinics of Minnesota designates this educational activity for a maximum of 1 AMA Category 1 Credit TM toward the AMA Physician s Recognition Award. Each Physician should only claim credit for the actual time he/she spent in the activity. Retention of CME Records It is the policy of Children s Medical Education program that we cannot offer to retain CME records for physicians attending or viewing the online CME activity. The Minnesota Medical Association designates that physicians are responsible for maintaining their own CME records. Receiving CME Credit To receive CME credit, you must view the entire program. When the program is completed, click the Post Test button on the interface to access the Post Test. You must successfully pass the Post Test to receive CME credit. 2

3 Disclosures Pediatric Upper Extremity Fractures: Diagnosis and Initial Management No Disclosures Jennifer C. Laine, MD Pediatric Grand Rounds at Children s - MN July 12, 2012 Objectives Overview of unique aspects of the pediatric skeleton with respect to injury and healing Review of the initial assessment of a patient with upper extremity injury History, physical exam, imaging Review initial management of pediatric upper extremity injuries When to splint When to follow-up with orthopaedics When surgery is indicated Pitfalls associated with managing the injured child Provide an awareness of lawnmower injuries and prevention Outline Epidemiology Pediatric Injury Overview Specific Injuries Clavicle Shoulder Humerus Elbow Forearm Wrist Cooper, et al. JBMR

4 Pediatric Skeleton Children are not simply small adults Though some adults are simply large children Pediatric Skeleton Less dense and more porous Periosteum is very thick Presence of growth plates (physes) Ends of long bones are nonossified cartilage The Pediatric Skeleton Comminuted fractures are uncommon The Pediatric Skeleton Comminuted fractures are uncommon Large pores in the immature cortex can prevent propagation (greenstick) Large pores in the immature cortex can prevent propagation (greenstick) Fail with tension or compression (buckle fracture Fail with tension or compression (buckle fracture Images: radiologyassistant.com; Images: radiologyassistant.com; Anatomy of the Pediatric Skeleton Anatomic Differences Growth Plates Most obvious difference is the presence of growth plates and thick periosteum Growth plate injuries may lead to significant growth disturbances Missed diagnoses Reduction of the growth plate injury must be precise Image: davidlnelsonmd.com 4

5 Anatomic Differences Periosteum Periosteum has greater bone forming potential Helps to maintain alignment of simple fractures Reduces the amount of displacement of fractures Can aid in the reduction of fractures Remodeling Remodeling may make reduction accuracy somewhat less important than in an adult Intra-articular fractures must be anatomically reduced and will not remodel Image: Remodeling Years of growth remaining Location vs. physis Growth potential of physis Plane of motion Evaluation History: Mechanism, velocity, timing Hand dominance? Exam: Look at whole child Deformity? Spontaneous movement? Remove splints, bandages Squeeze each extremity Range every major joint in all extremities Point of maximal tenderness Capillary refill, pulses Pain with passive stretch Staheli L. Fundamentals of Pediatric Orthopedics, 2008 Point of Maximal Tenderness Clavicle Shoulder Length of humerus Medial and lateral epicondyle Posterior distal humerus Olecranon Radial head Length of radius and ulna Snuffbox tenderness (scaphoid) Evaluation Upper Extremity Thumbs-up Posterior Interosseous Nerve (PIN radial) A-OK Anterior Interosseous Nerve (AIN median) Spread or cross fingers Ulnar Image: mountnittany.org Image: childbehaviorsolution.blogspot.com, danceswithchaos.wordpress.com 5

6 Evaluation Upper Extremity Sensory Exam: Axillary Radial Median Ulnar Imaging Plain Radiographs Orthogonal views; obliques Image joint above/below Contralateral imaging MRI: rare Image: healthhype.com Incidence Upper extremity fractures account for up to 75% of all childhood fractures Clavicle Fracture Obstetrical injury: 0.5% ~90% of obstetrical fractures 8-15% of all pediatric fractures Fall onto shoulder Usually midshaft (80%) Image: shoulderdistociainfo.com, shoulderdoc.co.uk Clavicle Fractures Skin tenting? Neurologically intact? AP clavicle Cephalad-directed view Medial Clavicle/SC Joint: serendipity view Lateral Clavicle: axillary lateral Clavicle Fractures Treatment Supportive; sling No reduction attempt No sports 6-8 weeks Bump will remodel Image: Tachdjian s Pediatric Orthopaedics 2008 panoramapeds.com 6

7 Clavicle Fracture Operative Indications? Uncommon Skin tenting Neurologic compromise Multiple injuries (floating shoulder) Older Adolescent? Grey zone Earlier follow-up Proximal Humerus Fractures <5% of all pediatric fractures Enormous healing and remodeling potential Birth injury: Physeal injury/separation Child (5-12): metaphyseal Adolescent (13-16): physeal Cary, et al. JPO 2011 Image: Tachdjian s Pediatric Orthopaedics 2008; jbjs.org Proximal Humerus Fractures Mechanism Direct: blow to shoulder Indirect: fall on outstretched arm Sports, MVA Presentation Pain, swelling, ecchymosis Internally rotated Associated: dislocation, brachial plexus injury, PTX, rib fxs Image: concordortho.com; autoaccidentlawyeroregon.com Proximal Humerus Fractures AP Axillary Lateral (Scapulary Y) (CT) Image: orthobullets.com Proximal Humerus Fractures <11yo no reduction needed Good results regardless of displacement >11yo grossly displaced fractures need reduction Traction, abduction, flexion, ER Goal: <50% displacement, 20 degrees angulation High rate re-displacement Barriers Rockwood and Wilkins 2006 Image: courtesy of M. Diab, MD Proximal Humerus Fractures Immobilization Sling and swathe Shoulder immobilizer Hanging arm cast Shoulder spica Rockwood and Wilkins 2006 Image: creativecastingconcepts.com, allegromedical.com 7

8 Humeral Shaft Fractures <10% of pediatric humerus fractures 2-5% pediatric fractures <3yo >12yo 10yoM Fall from tree 10 days after cast One month after injury Rockwood and Wilkins 2006 Image: wheelessonline.com Humeral Shaft Fracture <3yo: Spiral twisting injury Transverse direct blow Abuse 61% of all new fxs in child abuse Accidental > abuse Humeral Shaft Fracture >12yo: Transverse fractures Direct blow Fall PVA GSW Pathologic fracture through cyst Sports Direct blow Throwing stress injury Humeral Shaft Fracture Young child: pseudoparalysis Older child: pain, swelling, refusal to move extremity Supported with contra hand, held to body Neurologic exam Radial Nerve Vascular exam Imaging: orthogonal views humerus Shoulder/elbow Image: e-radiography.net Humeral Shaft Fracture: Alignment Not Weightbearing Shoulder compensation Beatty: <5yo: 70 degrees, complete displacement 5-12: degrees >12yo: 40 degrees and 50% apposition Clinical appearance >> XR alignment Beatty AAOS Instr Course Lecture 1992 Rockwood and Wilkins

9 Treatment Infant: ACE wrap swathe Coaptation splint Hanging arm cast Functional bracing 6mo M 2 weeks after fall 30 degrees varus 12mo M Image: steinergraphics.com; creativecastingconcepts.com, swissorthoma.ch Incidence 8-9% of all pediatric fractures occur about the elbow THE ELBOW Image: Tachdjian s Pediatric Orthopaedics 2008;jbjs.org Distal humerus 86.4% 69% supracondylar 17% lateral condyle 14% medial epicondyle 1% T-condylar Challenges in Diagnosis Difficult physical exam Pediatric elbow ossification centers Different fracture types than in adult Work-up Mechanism Careful assessment of: Soft tissues Neurologic status Vascular status pulses, capillary refill, warmth Don t forget radial neck, wrist! Image ENTIRE extremity Multiple fractures common Images: orange44.blogspot.com, wheelessonline.com, jbjs.org 9

10 Radiographic Anatomy Ossification Centers Radiographic Anatomy Ossification Centers 5moM 3+8M 6+7M 10+7M Skaggs, D. JAAOS 1997 Radiographic Anatomy Radiographic Anatomy Image: emedicine.medscape.com Radiographic Anatomy Radius should point at capitellum in every view! Radius should point at capitellum in every view! Image: Tachdjian s Pediatric Orthopaedics Skaggs, D. JAAOS

11 Transphyseal Fracture Difficult to recognize <4yo; esp. <18mos Shear force muffled crepitus Non-accidental trauma! Supracondylar Humerus Fracture Most common elbow fracture - 60% Age 1-7 years; peak 5-7 Thin supracondylar region - 1mm thick Extension type 96% Flexion type 4% Image: Rockwood and Wilkins 2006 Mechanism Fall on outstretched hand, elbow extended Most have hyperextensible elbows Directs force to anatomically weak olecranan fossa Associated Injuries Nerve % Radial 45% Median 32% - AIN Ulnar 23% - usually flexion type Image: Rockwood and Wilkins 2006 Image: Tachdjian s Pedaitric Orthopaedics; jbjs.org Associated Injuries Vascular 1% Brachialis muscle protects brachial artery Tethering, spasm, tear, entrapment Classification Gartland Classification Type I Nondisplaced Type II Angulated, one cortex intact Type III Displaced Image: courtesy M. Diab, MD; Rowell PJW. Injury

12 TYPE I Type I X-ray findings may be minimal Fracture line may not be visible Tenderness on exam, posterior fat pad Immobilization Posterior long-arm splint in 90degrees Follow-up with ortho in few days Ensure alignment Type II Type II Most can be reduced simply by flexing elbow Controversial Most are now treated surgically Closed reduction and percutaneous pinning Long arm splint 5yoM Fall from monkey bars Call ortho or have ortho follow-up in 1-2 days Type III Type III More commonly associated with neurovascular injury, compartment syndrome Most treated with closed reduction, pinning Open reduction rarely required 6yoM Fall from Monkey Bars Splint elbow as it lies degrees flexion Do not wrap tightly Check neurovascular exam before and after! Ortho Consult 12

13 Lateral Condylar Fracture 17% elbow fractures Ages 5-10 Varus stress to extended elbow Spectrum from nondisplaced fractures without articular surface disruption to displaced intraarticular fractures 3yoM Fall from bike Lateral Condylar Fracture Nondisplaced - rare. Beware! May be treated with immobilization Displaced - open reduction Complications Nonunion Permanent loss of motion Cubitus valgus Tardy ulnar nerve palsy Internal Oblique View 3yoM Fall from playground Consult ortho Follow-up 1-2 days Image: Rockwood and Wilkins 2006 Treatment: Open reduction, pinning Monteggia Fractures Proximal 1/3 ulnar fracture, dislocated radial head 0.4% all pediatric forearm fractures Peak incidence age 4-10 years 11-20% nerve palsies - PIN most common 13

14 Diagnosis Anterior 70% AP/Lat x-rays including wrist and elbow Line through radial head must pass through center of capitellum Plastic deformation of ulna Lateral 24% Radial N injury Image: emedicine.medscape.com Forearm Fractures 45% of all childhood fractures 62% upper limb fractures 81% occur in those > 5 yea 75-84% distal third 15-18% middle third THE FOREARM Forearm Fractures Most treated closed Goal of treatment is to align extremity longitudinally and rotationally Requires understanding of: Mechanism of injury Anatomy Deforming forces Remodeling ability Forearm Shaft Fractures 3.4% all childhood, 18% forearm fractures Peak - latter part first decade More complex than distal fractures Require a more aggressive approach Angulation results in loss of rotation 14

15 Forearm Shaft Fractures Angulation post reduction frequent X-ray weekly for at least 3 weeks Remanipulation is possible up to 4 weeks Forearm Shaft Fractures Angulation post reduction frequent X-ray weekly for at least 3 weeks Remanipulation is possible up to 4 weeks Careful cast molding essential 3 point, interosseous mold, straight ulnar border Consider extension casting in small children Proximal fractures 3 point mold Immobilization 8-10 weeks common Forearm Fractures Rotation is lost most often 60% lose > 20 degrees Rarely does this result in functional deficit 85% treated with closed reduction have satisfactory results Role of Open Reduction Irreducible or unstable reduction Age 10 or older Segmental or open fractures Associated elbow, humeral,vascular injury Refracture Plate vs. Intramedullary fixation Image: Tachdjian s Pediatric Orthopaedics; jbjs.org 11yoF Fall from monkey bars 15

16 Distal Radius/Ulna Fractures 21% all pediatric fractures Occur ages 2-14, peak 9-10 girls, 3-14 boys Low energy injury Spectrum of injury from buckle to displaced physeal or metaphyseal fractures Remodeling Potential Age Degree of angulation Is angulation in plane of motion? Metaphyseal fractures have a greater capacity to remodel Most correction occurs in the distal physis Larsen - up to 28 degrees of correction can occur at the distal physis in those < 11 Bayonet apposition acceptable in < age 8-10 Management If uncomfortable with reductions ortho consult If comfortable closed reduction Sugartong splint to immobilize wrist and elbow If not too swollen, can use LAC Ortho follow-up within the week to ensure reduction has been maintained Distal Radius Physeal Fx Most common physeal fracture: 28-46% 75% occur between years Salter-Harris Type 2: 58-75% Hyperextension injury - dorsal displacement Image: radiologytutorial.com 16

17 Distal Radial Physeal Fracture Reduce displaced fractures promptly Some SH 2 are difficult to reduce - accept 50% apposition if angulation corrected Remanipulation difficult after 10 days Single reduction - physeal arrest rare Premature physeal arrest occurs in 27% undergoing 2 or more reduction attempts Distal Radial Physeal Fracture Heal rapidly - 3 to 4 weeks Long arm cast Three-point moulding, not excessive flexion Open reduction rarely necessary Image: accessem.com Buckle Fractures (= Torus) Compression fx at metaphyseal-diaphyseal junction Torus fracture = Buckle fracture Torus = Ring at column base If uncertain: re-xray 1 week Brief casting 2-3 weeks needed Small children require a long arm cast simply to keep the cast on Torus fracture = Buckle fracture Torus = Ring at column base Management Well-molded splint or long arm cast Heal well 17

18 Summary Pediatric skeletal anatomy leads to unique injuries Injuries can be easily missed without the proper work-up Most injuries do well with non-operative management Any fracture that might need surgery: consult ortho or at least follow-up in first few days Any fracture that has been reduced or might displace follow-up within one week Please do not hesitate to call us with questions or consults! Lawnmower Related Injuries 100% Preventable Jennifer C. Laine, MD Gillette Children s Specialty Healthcare Image: pediatricsnow.com Thebrownwall.blogspot.com The Stats The Stats US Consumer Product Safety Commission (2003): 60 million lawnmowers in use in 2003; 9.5 million riding mowers US Consumer Product Safety Commission (2007): 210,000 people treated in doctors offices, emergency departments and clinics for lawnmower injuries 16,000 children Lau ST. Pediatric Surg Int 2006 AAOS 2012 (US CPSC) 18

19 The Stats The Stats ~75 deaths per year due to lawnmowers 1 in 5 is a young child From , the number of lawn mower related injuries per year increased by 18% Lau ST. Pediatric Surg Int 2006 Lau ST. Pediatric Surg Int 2006 The Stats The Stats ~3/4 boys Average age: ~7-11 years old bimodal Loder RT. Journal Pediatric Orthopaedics 1997 Lau ST. Pediatric Surg Int 2006 Vollman D and Smith G. Pediatrics 2006 Vollman D and Smith GA. Pediatrics 2006 The Setting The Season 89% in own yard 72% walking up to mower 50% injured while mower in reverse 78% injured by the usual operator of the mower Farley FA, et al. Journal Pediatric Orthopaedics 1996 Volman D and Smith GA. Pediatrics

20 The Injuries Projectiles Image: cartoonstock.com Volman D and Smith GA. Pediatrics 2006 Projectiles Most common mechanism for injury 80% of foreign body injuries are to eyeball/face or lower extremities Kinetic energy is three times the power of a magnum Amputations Momentum at the tip of a blade could launch a 1.2lb object at a speed of 232mph Costilla V and Bishai DM. Annals of Emergency Medicine 2006 Loder RT, et al.. Journal Pediatric Orthopaedics 1997 Ourfreedomproducts.com Image: offthemark.com Amputations Lawnmower was #1 cause of traumatic amputation (21.6%) 83% of foot and ankle amputations Average age: 4.6y 69% were <5yo Riding Mowers Mean length of stay: 12.5 days Mean total procedures per extremity: 4.8 Mean charge: $21,777 (1996) Image: cartoonstock.com 20

21 Riding Mowers Riding Mowers US Consumer Product Safety Commission Survey: 2.6 injuries per year per 1000 ride-on mowers 3x injury rate versus walk-behind power mowers 55% of households with riding mowers and children under 10 allow their children to ride on mowers 9% of injured operators are 14 or younger Rate of injury for 5-14yo more than twice that for 15-65yo 8% of deaths related to ride-on mowers involve passengers (6yo) and bystanders (4yo) Lau ST. Pediatric Surg Int 2006 Smith G. Pediatrics 2001 Psychologic Effects Unique psychosocial circumstances Parent is usually the operator! Survey: Half of children altered goals and plans for future Majority reported moderate regular pain 56% of parent survey profiles showed defensive response denial or underreporting psych symptoms Prevention Farley FA, et al. Journal Pediatric Orthopaedics 1996 Prevention 16yo riding AAP Recommendations Children indoors 12yo walking Pick up the yard before mowing No passengers Sturdy shoes Education No mowing in reverse 21

22 So this year we finally broke that stronghold of fear and invited our children to ride on our mower. The smiles on their faces tell the story of growing up enjoying all things in life. The joy of independence. Of trying new things and growing in confidence. Aswewalk.wordpress.com How can we best educate our patients and families regarding these preventable injuries?? Thank You Special Thanks to Stephen Sundberg, MD Mark Dahl, MD Richard Andersen, MD Mickey Starr John Crampton Lee Kanten Question We ve been told that Ibuprofen hinders the bone remodeling process, but it helps control swelling and pain. What do you think about the use of Ibuprofen on kids with fractures? Thank you for viewing this presentation! To receive CME credit, please click the Post Test button on the interface, and complete the post test 22