PEDIATRIC UPPER EXTREMITY FRACTURE MANAGEMENT JULIA RAWLINGS, MD SPORTS MEDICINE SYMPOSIUM: THE PEDIATRIC ATHLETE 2 MARCH 2018
DISCLOSURE I have nothing to disclose. 2
OBJECTIVES Discuss the diagnosis, management, and outcome of common pediatric upper extremity fractures: Forearm Fractures Supracondylar Fractures Medial Epicondyle Fractures Lateral Condyle Fractures Proximal Humerus Fractures Clavicle Fractures 3
FOREARM FRACTURES 1:100 kids each year Mechanism usually FOOSH Check for neurovascular compromise Open vs. closed Splint in position of comfort for transport Imaging: AP, lateral forearm (includes elbow & wrist) 4
DISTAL RADIUS BUCKLE FRACTURES Pre-formed splint x 3 weeks No follow up is necessary (West, 2005) http://thesgem.com/2013/01/sgem19-bust-a-move; http://www.stltoday.com/lifestyles/health-med- fit/parents-children-prefer-splints-to-casts-and-research-shows-they/article_dee9a65d-0d95-5021-b8f0-5 56c9d695d08c.html
DISTAL RADIUS FRACTURES Most common fracture in pediatrics (28-30%) Metaphysis most frequent site Most do well with closed reduction if needed OR: open, unstable, displaced SH III or IV Above elbow cast or GOOD below elbow cast x 4-6 weeks http://backup.orthobullets.com/pediatrics/4014/distal-radius-fractures--pediatric 6
BOTH BONE MID-SHAFT FOREARM FRACTURES Evaluate x-ray for: Angulation Displacement Bayonet apposition or shortening Rotational deformity Make sure to image wrist and elbow https://www.orthobullets.com/pediatrics/4014/distal-radius-fractures--pediatric; 7
WHAT IS ACCEPTABLE ALIGNMENT? More angulation tolerated near physis Need ~ 2 years of growth remaining 8
REDUCTION AND SPLINTING Sedation generally required in ED (e.g. ketamine, propofol, nitrous oxide) Can consider hematoma block +/- versed Bear et. al (J. Hand Surg Am. 2015) 52 patients w/ distal radius fractures age 5-16y underwent reduction w/ either procedural sedation or hematoma block Overall satisfaction and satisfaction w/ anesthesia similar with 2.2 hr reduction in ED length of stay for hematoma block group 9
REDUCTION AND SPLINTING Periosteum can facilitate or complicate reduction Physis: gentle pushing, minimize attempts to avoid damaging physis Mid-shaft fractures: 1 st : Recreate deformity to unlock periosteum 2 nd : Apply longitudinal traction 3 rd : Correct rotational deformity 4 th : Reduce angulation 10
REDUCTION AND SPLINTING Consider deforming forces on rotation Proximal radius pulled into supination by biceps & supinator Distal radius pulled into pronation by pronator quadratus & brachioradialis Rule of Thumbs: rotate thumb towards apex of fracture 11
REDUCTION AND SPLINTING Sugar tong splint 3-point molding Interosseous molding 90º at elbow 12
INTEROSSEOUS MOLD https://www.rch.org.au/fracture-education/management_principles/management_principles/ 13
FOREARM FRACTURE FOLLOW-UP Total time in cast: ~ 6 weeks Weekly x-rays x 2 At 4 weeks consider moving from AE cast to BE cast Straight ulnar border to avoid a banana cast http://raisingsaints.blogspot.com/2012/04/surprising-it-took-this-long-really.html 14
MONTEGGIA FRACTURES Proximal 1/3 ulnar fracture w/ radial head dislocation https://www.orthobullets.com/trauma/1024/monteggia-fractures 15
GALEAZZI FRACTURES Fracture of distal 1/3 radius with distal ulna dislocation http://hatch.urbanskript.co/galeazzi-fracture/ 16 http://ha tch.urban
ELBOW: OSSIFICATION CENTERS 17
ELBOW Anatomy: Anterior humeral line intersects middle 1/3 of capitellum Long axis of radius aligns w/ capitellum in all views Anterior fat pad can be normal Posterior fat pad never normal 18
ELBOW Anatomy: Anterior humeral line intersects middle 1/3 of capitellum Long axis of radius aligns w/ capitellum in all views Anterior fat pad can be normal Posterior fat pad never normal 19
ELBOW Anatomy: Anterior humeral line intersects middle 1/3 of capitellum Long axis of radius aligns w/ capitellum in all views Anterior fat pad can be normal Posterior fat pad never normal 20
NORMAL NOT NORMAL By James Heilman, MD - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=14633683 21
SUPRACONDYLAR FRACTURES 95-98% extension type Usually FOOSH Most common age is 5-7 years Associated injuries: Radial Nerve Palsy Ulnar Nerve Palsy Anterior Interosseous Nerve Palsy 22
SUPRACONDYLAR FRACTURE TYPE I No or minimal displacement No visible fracture line 23
SUPRACONDYLAR FRACTURE TYPE I Posterior splint w/ elbow at 90 flexion or less x 3-4 weeks If you see a fat pad, treat it like a fracture 24
SUPRACONDYLAR FRACTURE TYPE II Obvious fracture line Posterior cortex intact Varying amounts of displacement Closed reduction with ortho in OR (usually) 25
SUPRACONDYLAR FRACTURE TYPE II Place immediately in posterior splint with <20 flexion or where patient is comfortable 26
SUPRACONDYLAR FRACTURE TYPE III Completely displaced No intact cortex High risk of neurovascular complications Place immediately in posterior splint with <20 flexion Frequent pulse checks Urgent reduction & pinning in OR with ortho 27
MEDIAL EPICONDYLE FRACTURES 5-10% of pediatric elbow fractures (Gottschalk, 2012) Peak incidence: age 9-14 years Last ossification center to fuse at age 15-20 y (Chessare, 1977) Origin of flexor-pronator mass and ulnar collateral ligament (UCL) Mechanism: FOOSH w/ valgus stress to elbow, acute avulsion or overuse injury in throwing athletes https://radiologykey.com/elbow-7/ 28
MEDIAL EPICONDYLE FRACTURES Up to 60% associated w/ elbow dislocation 15-20% of elbow dislocations result in incarceration of medial epicondyle fragment (Gottschalk, 2012) http://www.cmcedmasters.com/ortho-blog/pediatric-elbow-dislocation 29
MEDIAL EPICONDYLE FRACTURES Exam: Pain/swelling over medial epicondyle Consider testing stability with valgus stress Imaging: AP, lateral, consider internal obliques to determine anterior displacement Degrees of displacement difficult to measure 30
MEDIAL EPICONDYLE FRACTURES TREATMENT Non-op: < 5 mm displacement Up to 4 weeks immobilization in AE cast flexed to 90º Usually heals w/ fibrous union Op: > 15 mm or joint entrapment Controversial: 5-15 mm 31
MEDIAL EPICONDYLE FRACTURES TREATMENT Other indications for surgery (Gottschalk, 2012) Gross elbow instability Ulnar nerve damage Overhead athletes or weight-bearing athletes (gymnasts) Fragment in joint Surgery had 92.5% bony union vs. 49.2% non-op group (Kamath, 2009) 32
LATERAL CONDYLE FRACTURES #2 pediatric elbow fracture High risk of non-union, malunion, AVN Mechanism: Avulsion from common extensor complex FOOSH Internal oblique views helpful (fracture is posterolateral) 33
LATERAL CONDYLE FRACTURES TREATMENT Non-op if < 2 mm displacement in all views AE cast 4-6 weeks, elbow at 90º Weekly x-rays x 3 weeks CRPP vs. ORIF http://www.orthobullets.com/pediatrics/4009/lateral-condyle-fracture-- pediatric?expandleftmenu=true 34
PROXIMAL HUMERUS FRACTURES < 5% of pediatric fractures Mechanism: Blunt trauma Indirect trauma Overuse injury in throwers Proximal humerus physis: 80% longitudinal growth in upper arm, so great remodeling potential Imaging: AP, lateral, scapular Y or axillary views 35
PROXIMAL HUMERUS FRACTURES: TREATMENT Acceptable alignment < 10 y.o. = any angulation 10-13 y.o = up to 60º angulation > 13 y.o. = up to 45º angulation & 2/3 displacement Immobilize: sling +/- swathe Sometimes closed reduction attempted Operative for unacceptable angulation or displacement, intra-articular fracture, NV injury, open fracture http://backup.orthobullets.com/pediatrics/4004/proximal-humerus-fracture--pediatric 36
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LITTLE LEAGUE SHOULDER Physis injury of proximal humerus Repeated overhead throwing causes microtrauma High loads of torque May lead to acute SH I fracture Rest & refer to PT for guided throwing program 38
LITTLE LEAGUE ELBOW SH I fracture medial epicondyle Treatment is a period of rest followed by guided throwing program Pitch counts in place to prevent Little League elbow & shoulder vhttps://www.cincinnatichildrens.org/health/l/little-league-shoulde http://orthokids.org/sports-injury-prevention/throwing-injuriesr 39
CLAVICLE FRACTURES 8-15% of pediatric fractures Mechanism: Direct blow to clavicle FOOSH Impact to lateral shoulder Treatment for uncomplicated midshaft fractures: Sling for comfort ROM as pain as allows No high risk activities x 2 months https://eorif.com/pediatric-clavicle-fracture 40
CLAVICLE FRACTURES Hospital for Sick Children in Toronto (Adamich, 2016) 339 skeletally immature patients with mid-shaft clavicle fractures 2 had re-fractures No non-unions No follow up x-rays necessary Majority can be discharged after initial assessment 41
CLAVICLE FRACTURES Surgical indications: Tenting of skin Open fracture NV injury Medial physeal injury https://aneskey.com/chest-and-abdomen/ https://www.orthobullets.com/pediatrics/4123/medial-clavicle-physeal-fractures 42
QUESTIONS??? https://pulptastic.com/cast-designs/ 43
REFERENCES Adamich J, Camp M, Howad A. Do all clavicle fractures in children need to be managed by orthoaedic surgones? Cjem 2016;18(S1):S79. Beck J, Bowen R, Silva M. What s New in Pediatric Medial Epicondyle Fractures? J Pediatr Orthop 2016;0(0):1-5. Calder JD, Solan M, Gidwani S, et al. Management of paediatric clavicle fractures is follow-up necessary?an audit of 346 cases. Ann R Coll Surg Engl. 2002;84:331 333. Chessare JW, Rogers LF, White H, Tachdjian MO: Injuries of the medial epicondylar ossification center of the humerus. AJR Am J Roentgenol 1977;129(1):49-55. Gottschalk, HP et al. Medial Epicondyle Fractures in the Pediatric Population. Journal of the American Academy of Orthopaedic Surgeons. 2012;20(4):223-234. 44
REFERENCES Klatt JB, Aoki SK. The location of the medial humeral epicondyle in children: position based on common radiographic landmarks. J Pediatr Orthop. 2012;32:477 482. Louahem DM, Bourelle S, Buscayret F, et al. Displaced medial epicondyle fractures of the humerus: surgical treatment and results. A report of 139 cases. Arch Orthop Trauma Surg. 2010;130:649 655. Papavasiliou VA. Fracture-separation of the medial epicondylar epiphysis of the elbow joint. Clin Orthop Relat Res. 1982;171: 172 174. Tarallo L, Mugnai R, Fiacchi F, et al. Pediatric medial epicondyle fractures with intra-articular elbow incarceration. J Orthop Traumatol. 2015;16:117 123. West S, Andrews J, Bebbington A, Ennis O, Alderman P. Buckle fractures of the distal radius are safely treated in a soft bandage: a randomized prospective trial of bandage versus plaster cast. J Pediatr Orthop Am 2005;25:322 325. 45