Upper limb injuries in children. Key points, # & dislocations 7/23/2009 (MIMIC)

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1 Upper limb injuries in children (MIMIC) Key points, # & dislocations Before the age of 16 around 50% of boys & 25% of girls will sustain a # Dislocations are very uncommon Children s bones are less brittle than adult owing to higher collagen bone ratio, therefore incomplete # may occur Epiphyses may bear the brunt of injuries Periosteum in young children is very strong & protects the bone from #, or can limit displacement (toddlers #) 14 year old boy presents having been injured playing rugby. He describes being tackled, being pushed to the ground by another player falling on his right shoulder. He presents with a swelling to the proximal clavicle and SCJ. What injury do you think he may have suffered What complications are you concerned about? What investigation/s does he require? 1

2 Dislocation of sternoclavicular joint Cause: Significant direct force to the shoulder. Blow to anterior shoulder that rotates shoulder backwards & transmits the stress to the joint Anterior dislocation of SCJ much more common 9:1 One of the least dislocated joints in the body Posterior SCJ dislocation est 25% complication rate: pneumothorax, laceration of SVC, occlusion of subclavian artery/vein, disruption of trachea Incidence Higher in young adult males S&S may c/o chest pain & shoulder pain exacerbated by arm movement or in supine position On examination SCJ, conspicuous asymmetry, medial aspect of affected clavicle appears prominent 1 st degree injury, simple sprain, incomplete or stretching of SCJ & Costoclavicular ligament, most common 2 nd degree, clavicle subluxes, only partial tear in CC ligament 3 rd degree, complete rupture of sternoclavicular and costoclavicualr ligaments permits clavicle to completely dislocate from manubrium 2 yr old girl presents with a history of trying to run into the road. Her dad grabbed her arm to stop her. Since then she has refused to use her arm and its hanging by her side. No swelling, bruising or bony tenderness. She cried very time anyone tries to move her arm. What do you think the injury is? Describe the anatomy of the injury Does this child require an x-ray? How will you manage this injury? 2

3 Traction applied to supinated forearm, partial tear of the annular ligament, radial head slips through the tear Reduction through supination or pronation Pulled elbow An 8 year old boy presents having fallen out of a tree, no other injuries. His left elbow is obviously deformed and he is in pain What is this fracture called? What are the complications associated with it? How will you manage his pain? How does this injury need to be managed? Monteggia fracture Angulated proximal ulnar shaft fracture with radial head dislocation Important to get true lateral x-rays so as not to miss radial head dislocation Refer to orthos Neuro-vascular compromise 3

4 The anterior humeral line is drawn along the anterior surface of the distal humerus on a true lateral view. This should intersect the middle third of the capitellum. If distal humerus is displaced backwards, it will intersect more anteriorly or not at all. What is this fracture called? Are any other x-rays required? What is the management of this injury? # of shaft of radius associated with dislocation of distal ulna Galeazzi fracture 4

5 A 7 year old girl presents having fallen on an outstretched hand. She is unable to fully extend her elbow and is in pain Can the SWEET rule be applied to children? Does she need an x-ray? What do you think the injury is most likely to be? What are the potential complications Supracondylar fracture Degree of displacement indicates a relatively high energy injury Most important complication is occlusion or laceration of brachial artery Prolonged ischaemiacompartment syndrome-rapid muscle death Volkmann s ischemic contracture (late muscle fibrosis Neuropraxia of median/radial/ulnar nerves resulting from stretching at the time of injury Most common fracture in the 4-8 yr old age range Any displacement refer to orthos, may require immediate reduction and ORIF 5

6 C- Capitulum, (3 months) R- Radial head, (5 years) I- Internal (medial) epicondyle, (7 years) T- Trochlea, (9 years) O- Olecranon, (11 years) E- External or Lateral epicondyle, (13 years) Good pain relief Summary Careful and gentle examination and careful observation If clinically fractured it is fractured Follow up is always an option 6