© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
PEDIATRIC UPPER EXTREMITY FRACTURE MANAGEMENT
JULIA RAWLINGS, MDSPORTS MEDICINE SYMPOSIUM: THE PEDIATRIC ATHLETE
2 MARCH 2018
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
DISCLOSURE
• I have nothing to disclose.
2
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
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
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
FOREARM FRACTURES
4
• 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)
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
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-b8f0-56c9d695d08c.html
5
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
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
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
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
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
WHAT IS ACCEPTABLE ALIGNMENT?
• More angulation tolerated near physis• Need ~ 2 years of growth remaining
8
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
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
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
REDUCTION AND SPLINTING
• Periosteum can facilitate or complicate reduction
• Physis: gentle pushing, minimize attempts to avoid damaging physis
• Mid-shaft fractures:– 1st: Recreate deformity to unlock periosteum– 2nd: Apply longitudinal traction– 3rd: Correct rotational deformity– 4th: Reduce angulation
10
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
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
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
REDUCTION AND SPLINTING
• Sugar tong splint – 3-point molding– Interosseous molding– 90º at elbow
12
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
INTEROSSEOUS MOLD
https://www.rch.org.au/fracture-education/management_principles/Management_Principles/13
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
FOREARM FRACTURE FOLLOW-UP
http://raisingsaints.blogspot.com/2012/04/surprising-it-took-this-long-really.html 14
• 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
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
MONTEGGIA FRACTURES
• Proximal 1/3 ulnar fracture w/ radial head dislocation
https://www.orthobullets.com/trauma/1024/monteggia-fractures 15
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
GALEAZZI FRACTURES
h t t p : / / h at c h . u r b a ns k r i p t . c o
http://hatch.urbanskript.co/galeazzi-fracture/ 16
• Fracture of distal 1/3 radius with distal ulna dislocation
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
ELBOW: OSSIFICATION CENTERS
17
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
ELBOW
18
• 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 nevernormal
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
ELBOW
19
• 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 nevernormal
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
ELBOW
20
• 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 nevernormal
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
By James Heilman, MD - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=14633683
21
NORMAL NOT NORMAL
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
SUPRACONDYLAR FRACTURES
22
• 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
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
SUPRACONDYLAR FRACTURE – TYPE I
• No or minimal displacement• No visible fracture line
23
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
SUPRACONDYLAR FRACTURE – TYPE I
24
• Posterior splint w/ elbow at 90°flexion or less x 3-4 weeks
• If you see a fat pad, treat it like a fracture
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
SUPRACONDYLAR FRACTURE – TYPE II
• Obvious fracture line
• Posterior cortex intact
• Varying amounts of displacement
• Closed reduction with ortho in OR (usually)
25
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
SUPRACONDYLAR FRACTURE – TYPE II
• Place immediately in posterior splint with <20°flexion or where patient is comfortable
26
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
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
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
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
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
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
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
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
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
MEDIAL EPICONDYLE FRACTURES TREATMENT
31
• 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
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
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
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
LATERAL CONDYLE FRACTURES
33
• #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)
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
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
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
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
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
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--pediatric36
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
37
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
LITTLE LEAGUE SHOULDER
38
• 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
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
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-shouldehttp://orthokids.org/Sports-Injury-Prevention/Throwing-Injuriesr
39
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
CLAVICLE FRACTURES
• 8-15% of pediatric fractures• Mechanism:
– Direct blow to clavicle– FOOSH– Impact to lateral shoulder
• Treatment for uncomplicated mid-shaft fractures: – Sling for comfort– ROM as pain as allows– No high risk activities x 2 months
https://eorif.com/pediatric-clavicle-fracture 40
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
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
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
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
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
QUESTIONS???
https://pulptastic.com/cast-designs/ 43
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
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 paediatricclavicle 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 Roentgenol1977;129(1):49-55.
• Gottschalk, HP et al. Medial Epicondyle Fractures in the Pediatric Population. Journal of the American Academy of OrthopaedicSurgeons. 2012;20(4):223-234.
44
© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
REFERENCES
• Klatt JB, Aoki SK. The location of the medial humeral epicondyle in children: position based on common radiographic landmarks. J PediatrOrthop. 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 epicondylarepiphysis 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