13-­‐02-­‐04  

1  

All Broken Up? Fix, support or let nature take its course:

Pediatric upper extremity fractures

Kathy Boutis MD FRCPC MSc

 

At the end of this session, for upper extremity pediatric fractures, you will be able to…

1. Avoid pitfalls in diagnosis 2. Know ED initial management steps 3. Know the latest evidence for the most common

injuries  

Objectives

Pediatric Fractures •  Pediatric fractures are very common

•  10-25% of all injuries •  Unique and exceptional healing abilities

•  Callous •  Remodelling

Landin LA 1997

Emergency Department Visit

Three weeks later... One year later...

13-­‐02-­‐04  

2  

•  Incomplete physical examination •  It may mean more x-rays

•  Seeing the x-ray before seeing the patient •  Always go back

•  Incomplete or improper views •  Standard views are standard for a reason (e.g. c-spine)

Pitfalls in Pediatric Fracture Diagnosis

•  Negative X-ray = No fracture •  When in doubt – immobilize and refer to clinic

•  Did not compare to the opposite limb •  Over-call and under-call

•  Found a fracture…missed the other more serious fracture

Pitfalls in Pediatric Fracture Diagnosis

CASE 1 Clavicle Bedside ultrasound diagnosis of clavicle fractures

•  100 patients, 43 had clavicle fractures sensitivity 95% (95% CI 83%, 99%) specificity 96% (95% CI 87%, 99%)

•  Advantages of no radiation and length of stay Cross KP et al. Acad Emerg Med. 2010

CASE 2 CASE 2

13-­‐02-­‐04  

3  

Humerus •  Acceptable proximal humeral metaphyseal fracture:

•  Angulation < 45 degrees •  Complete displacement with bayonet apposition

•  Treatment: sling and swath/shoulder immobilizer

•  What about proximal humeral epiphyseal fracture? •  What about mid-shaft humerus fracture?

Radiusap.jpg

CASE 4

Humerus – Suspicion for Abuse?

•  < 15 months •  Mid-shaft •  Spiral/oblique

CASE 5

CASE 5 Elevated Supinator Fat Pad and Proximal Radial Head Fracture

13-­‐02-­‐04  

4  

Proximal Radial Head

•  What are the key physical examination features of this fracture? •  Note an absence of soft-tissue clues on the x-ray

•  How do you distinguish this fracture from a radial

head subluxation?

CASE 6

CASE 6

•  MRI study of 26 children with posterior fat pad in isolation •  six (23%) occult fractures •  bone bruise (73%), muscle tear (4%)       Al-Aubaidi Z 2012

Isolated Posterior Fat Pad

•  POCUS for diagnosis of pediatric elbow fractures • 130 children, 26 sonologists • ED determination of an elevated posterior fat

pad or lipohemarthrosis of the posterior fat pad • sensitivity of 98% and specificity of 70% • diagnose 48 patients but would miss 1 fracture

     

Rabiner Z 2012

Posterior Fat Pad and ED Ultrasound CASE 7

13-­‐02-­‐04  

5  

CASE 7

•  Type 1: Non-displaced (< 2 mm) •  Type 2: Displaced 2A – only anterior cortex # 2B – anterior and posterior cortex # •  Type 3: Displaced with no cortical contact

Supracondylar Fractures

CASE 8 CASE 8

•  Unstable and high risk for complications •  Growth arrest, cubitus valgus, non union, lateral ulnar

nerve palsy

•  Reduction and fixation •  > 2mm displacement; emergent referral

Lateral Condylar Fractures CASE 9  A    B  

13-­‐02-­‐04  

6  

•  Complications – Joint entrapment/elbow dislocations, ulnar neuropathy

•  Emergent Referral •  > 5 mm displacement •  Elbow dislocation •  Ulnar neuropathy

Medial Condylar Fractures CASE 10

CASE 10 CASE 11

CASE 12 CASE 13

13-­‐02-­‐04  

7  

CASE 14

1. Do we treat in a splint versus cast? 2. What is the best venue for follow up?

Distal Radius Buckle Fracture

•  Six randomized controlled trials comparing splint to short arm cast

•  Similar functional outcomes, higher patient satisfaction •  more pain in week 1 in splint group •  none of the trials reported re-fracture

Witney-Lagen 2012; Abraham et al 2008; Khan et al. 2007; Oakley et al. 2008; Plint et al. 2006; West et al. 2005; Stoffelen et al 1998

Distal Radius Buckle – Splint vs. Cast? Many faces of the buckle fracture

A   B   C  

Diagnostic Accuracy A   B   C  

Diagnostic Accuracy A   B   C  

13-­‐02-­‐04  

8  

•  Fracture clinic – single site tertiary care centre cohort –  3 visits, 3 cast changes, 3 x-rays

•  Randomized control trial of splint removal at home versus fracture clinic –  splint safely removed at home and preferred by caregivers

•  Follow up - primary care provider

Bae et al 2012; Symmons et al. 2001

Distal Radius Buckle: Best Venue for Follow Up

CASE 15

Distal Radius – Minimally Angulated Greenstick/Transverse

1. Are these fractures stable? 2. Which angulated fractures need reduction? 3. Immobilization in an above or below elbow cast or

splint?

Distal Radius – Minimally Angulated

•  Two retrospective cohort studies – all cases in a cast

•  Reported further displacement that ranged from 0 to 15 degrees – two cases angulated to 30 degrees – unstable!

•  None required manipulation - normal function and return to

anatomic alignment Al Ansari et al 2007; Do et al. 2003

Minimally Angulated –

Stable/Reduction? •  Randomized controlled trial above versus below elbow

cast, n = 102 •  No differences between groups

–  angulation –  need for re-manipulation –  functional / cosmetic recovery

Bohm et al 2006

Minimally Angulated:

Above vs. Below Elbow Cast

13-­‐02-­‐04  

9  

Minimally Angulated: Splint vs. Cast?

Heresy for displaced and unstable fractures??

•  Randomized to splint or short arm cast 4 weeks (n=100) •  Removable splint at least as effective as the cast with

respect to functional outcomes

•  No differences in degree of further displacement, higher patient satisfaction, and cost-effective

Boutis et al 2010; Goeree et al 2011; Willan et al 2012

Minimally Angulated: Splint vs. Cast?

CASE 16 Summary

•  Avoid pitfalls that increase your chances of error – in real medicine your task is quite different than in this talk

•  Encourage the use of strategies that have been shown to be safe and are more convenient for your patients

•  When in doubt – splint and fracture clinic follow up

THANK YOU