management of paediatric upper limb...

Department of O&T PWH CUHK

Management of Paediatric Upper

Limb Fracture

Bobby KW NG Paediatric Orthopaedic Chief,

Department of Orthopaedics & Traumatology,

Prince of Wales Hospital,

Chinese University of Hong Kong,

Shatin, Hong Kong.


Epidemiology of Children Fractures • 1 Distal radius fracture 20.2%

• 2 Supracondylar humeral 17.9%

• 3 Forearm shaft 14.9%

• 4 Tibial Shaft 11.9%

• 5 Fingers & hand 4.9%

• 6 Lateral condyle 4.8%

• 7 Femoral shaft 4.6%

• 8 Ankle 3.1%

• 9 Proximal radius (head & neck) 2.9%

• 10 Humeral shaft 2.8%

• 11 Medial Condyle humeral 2.5%

• 12 Olecranon 1.7%

• 13 Distal radius epiphyseal 1.7%

• 14 Elbow dislocation 0.8%

• 15 Rarities 5.4%

Upper limb #s

account for at

least 71.9% of

all Children

fractures

Review of 6493 fractures JCY Cheng et al JPO 19:344-350 1999


Problems in Treating Children

Fractures – Clinician Anxieties

• Not realising injury- subtle signs

• Not knowing associated complications-e.g.

neurovascular injury, joint dislocations

• Technical - we all learn from our own bitter

experiences

• Too early off cast /late follow up

• Omitted essential management steps


General Notes

• Adequate Explanation of Severity and

potential complications of Injury e.g.

Presence of NVB injury = almost

always Severe. Risks of joint stiffness,

prolonged recovery should be

explained from the outset. Parents tends

to forget- ? natural escape coping

mechanism

• Clear Documentation of Treatment


Common Mistakes

• Failure to take good history- pre-injury status-

mild symptoms- pathological fracture

• Failure to Perform physical examination- by far

most important- most decision making based on

this rather than X-rays- Pull elbow is assessed

better by examination than by X-rays which may

lead to wrong location of injury and more

unnecessary invasive investigations

• Failure to read X-rays systematically

• ALL have implication on treatment strategy


Distal Radius & Galleazzi

Variants


General Principles

• Most fractures – are simple to manage

When acute what ever type: Torus,

Epiphyseal, Greenstick or Displaced-

Treatment mostly standardised

• # Stability - best after anatomical

reduction -what ever type- Respect soft

tissue

• Maintenance of fixation- best when

deforming mechanics is neutralised

Department of O&T PWH CUHK No controversy


Reduction by Price Rule Palm to Apex


Isolated distal radial shaft #


Technical errors


M/10 complete displaced # DR, Tx OR PKWF Long Arm Cast


Revised at 6/52 a very difficult

operation

# displaced between 2/52

to 6/52


Lessons learned • Great parental aggravation when reoperation is

required

• Always warn parents risk of displacement during first few weeks after operation

• Fracture less stable when reduction not anatomical or not neutralised

• Displacement of # after CR/OR + PKWF occurs when swelling subsides

• PKWF Wire movement can occur despite looking good on X-ray

• Close follow up when excessive swelling present

• Change cast earlier e.g. 1/52


Supra-Condylar Humeral #

(SCH)


Pulse-less # & Nerve Palsies


The Pulseless SCH#

Pucker Tenting of skin


Mechanism of Neuro-Vascular

Injury Post-Lat Displacement


SCH# Postero-

Medial

Displacement

Soft Tissue

at Risk

Radial Nerve


No High 5

No Paper


Treatment of Severe Fractures

• Do not hesitate to proceed to open reduction

• Best way to ensure neurovascular structures are protected during reduction

• Best way to ensure anatomical reduction = Best stability

• Approach from side of the “Spike”

• Open both side if necessary- # not stable if not anatomical


Lateral

Left Elbow


T - Condylar Fracture


OR + PKWF


F/2 Elbow injury


ORIF PKWF


Highly active patients

loosening of cast and wires


Forearm Shaft Fractures

Yung SH, Lam CY, Choi KY, Ng KW, Maffulli N, Cheng JCY

Percutaneous intramedullary Kirschner wiring for displaced

diaphyseal forearm fractures in children JBJS B 1998 Vol 80-B No

1 January 1998


Protect for adequate period


Beauty of children fractures- Great Remodelling!


Keeping Cool # at age <10

• Make good assessment

• Allow remodelling to help us


Cast Difficulties in very Young


Great remodelling at yound age


? Ulnar shortening Obtain Comparision views when in doubt


Green Stick # very young age <4 no need for operation Cr LAC


Almost complete remodelling in 6 months


Children’s Curiosities


Wires and sticks in cast, remove when stained or smells


Monteggia Fractures


A common problem in a four

year old- injured elbow-

chubby arm- crying child

Anterior dislocation of the

proximal radio-ulnar joint

Monteggia Type I


Monteggia # diagnosed- what about the nerve!


Note- locked

in neutral ,

the Varus

deformity =

key to

treatment Contralateral

normal- supine

Apex of

the

buckle=

fulcrum


Delayed referral

Always a difficult problem


Patient referred 2 months after injury

Only injury

film

Contralateral normal

PIN Palsy

recovered


Timely treatment always best


Acute Bado II olecranon Greenstick buckle- best Tx

CR + PKWF. Minimal Pin scar- timely treatment


Radial Neck Fractures


Forearm locked at 30 degree pronation


Post MUA Full Pronation Full Supination Neutral Rotation


Fracture Radial Neck

• Associate with Greenstick fracture of

olecranon

• Valgus injury with elbow in extension

– Supination: Anterior

– Pronation: Posterior

– Mid- Sup/Pro: Lateral


Poor Result

• Tibone

– Angulation>30 degree

– Translation > 3mm

• Newman

– Translation > 4mm


Acceptable Angulation

• Depends on age

• 15 degree for elder child

• 30-45 degree for younger child

• Remodeling

– Up to 10 degree of angulation

– up to 40 % of translocation


Close reduction • Patterson:

Extension+Varus+Traction+Supination


Close Reduction Paterson Manoeuvre


Operative Treatments

• Percutaneous Kwire reduction- works well

• Metazean IM pin reduction

• Open reduction

• Surgical intervention ASAP

– <5 days is the maximum limit


Lateral Condyle Fractures


• Best Classified by Jakob as Type I/II/III- just

like Gartland classification for SCH #

• Difficult to distinguish type I( Incomplete #)

from II which had apparently reduced- If in

doubt- clinical stress examination under

Xi-scan or Mini C-arm

• Most important- Union- Takes longer time

• Warn parents of excessive callus

formation


Jakob Type III complete displaced


Easily Missed


Fracture Humerus


M14, Slipped on parallel

bars

Scapular lateral no

dislocation


Post Op X-rays

Callus

already!


Patient reported a

previous injury 1

months ago treated

by bone setter to be

a dislocation-

probable an

impacted fracture at

the metaphyseal

area. Thick

periosteal bone =

infection or fracture


Complex Dislocations- Rare in

Paediatric Orthopaedic

Trauma


History

• M/9 fell off slide at play ground at 1.5metre

• Mechanism of landing unknown

• C/o Severe pain in left elbow

• Elbow locked at deformed position

• Unable to move

• Patient crying, demanding immediate

attention


Cubitus Valgus, forearm

locked in pronation,

medial epicondylar

bruising


Position in Valgus Distal fragment

Pushed medially

Reduction achieved Screening


Difficulties with children

• Acute pain in children is very disturbing and

distressing for both patient, parent and Doctor

• Most Parents are always Anxious, Impulsive

and irritate both child & Doctor

• You only have one chance to look at

elbow quick

• Note the site of swelling, bruising, quickly

check the distal circulation & sensation

you are more than halve way there!


Learning Points

• Approach to Paediatric or anxious

neurotic adult patients- always difficult &

distressing

• Polite self introduction, tell patient your

need to assess the injured part gently and

would try not to move anything at all

• Keep Calm- most difficult- requires

training!


Objectives of Physical

Examination • Where is the swelling?

• Where is the bruising?

• Which way has it deformed?

• Is there distal Neuro-Vascular deficit?

• Which nerve could be injured?

• Movement for Ligamentous stability test or range of motion in acute trauma is both dangerous, inappropriate and unnecessary! Don’t do it. Do it in Theatre at EUA.


Right elbow injury doesn’t look

much! Extremely rare!!


Very Odd looking! Translocation of

Radius and ulnar


Moves well but it is not right! Forearm still

Pronated and olecranon displaced laterally !

Only a severe pronation of the forearm can do this! So

reverse it to achieve reduction


8 Months post injury, full function

management of paediatric upper limb...

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