Download - Common Fractures Of Upper Limb

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Dr. Sumit Kumar Gupta, MD, FRCSCAssistant Professor of Orthopaedics

University of Missouri

UPPER EXTREMITY FRACTURES

FREQUENCY OF FRACTURES

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FREQUENCY BY SEASON

More Common during the summer.

Out of school – more vigorous and

unsupervised physical activities

FREQUENCY BY TIME OF DAY

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SPECIFIC FRACTURE TYPES

ACTIVITIES ASSOCIATED WITH FRACTURES• Playground

• 90% were upper extremity fractures from a fall off of monkey bars or climbing equipment

• Change of playground surfaces• concrete / dirt / rubber => bark (impact-absorbing)

• Skateboarding• Nature of skateboarding being high speed and extreme maneuvers

causes high-energy trauma fractures• Roller Skates & In-line Skates

• Most injuries involve elbow, forearm, wrist, and fingers; < 20% use protective gear

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ACTIVITIES ASSOCIATED WITH FRACTURES• Trampoline

• 1/3 of injuries result from falling off the trampoline• Skiing

• More than half of the injuries occur due to collisions with stationary objects; i.e. trees, poles, stakes

• Snowboarding• Compared to skiers, snowboarders have 2-½ times as many fractures

OUTLINE• Clavicle• Shoulder• Humerus – shaft• Elbow

• Supracondylar, Lateral condyle, Medial epicondyle, Radial Head/neck, Olecranon

• Forearm• Wrist

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CLAVICLE FRACTURES• Birth – most common bone broken at delivery

• 0.4-1% of vaginal births – can happen with normal delivery

• Decreased movement of arm should raise suspicion

• 1 of 11 clavicle fractures can have associated brachial plexus palsy

McBride MT, Hennrikus WL, Mologne TS. Newborn clavicle fractures. Orthopedics. 1998 Mar;21(3):317-9; discussion 319-20.Lurie S, Wand S, Golan A, Sadan O. Risk factors for fractured clavicle in the newborn. J Obstet Gynaecol Res. 2011 Nov;37(11):1572-4. doi: 10.1111/j.1447-0756.2011.01576.x. Epub 2011 Jul 25.

CLAVICLE FRACTURES• Rarely need surgery in children

• Shoulder sling has same outcome as figure of eight, but more comfortable

• Adolescents may do better with operative fixation if

• 100% displaced

• >2cm shortening

• Open injuries

• Neurovascular injury

Pandya NK, Namdari S, Hosalkar HS. Displaced clavicle fractures in adolescents: facts, controversies, and current trends. J Am Acad Orthop Surg. 2012 Aug;20(8):498-505. doi: 10.5435/JAAOS-20-08-498.

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CONGENITAL PSEUDARTHROSIS• Not painful

• No callus formation on follow-up xrays

• Most commonly on right

DISTAL CLAVICLE FRACTURES• 10% of clavicle fractures• Not a true dislocation of the AC joint• Fracture through the distal physis• Periosteal sleeve is intact

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DISTAL CLAVICLE FRACTURES

DISTAL CLAVICLE FRACTURES

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PROXIMAL HUMERUS FRACTURES• 80% of humeral growth comes form proximal

growth plate

• Have a high potential to remodel, so can accept a lot of deformity

PROXIMAL HUMERUS FRACTURES

Extraordinary remodeling

potential of the proximal humerus

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PROXIMAL HUMERUS FRACTURE• Accept any alignment if ≥ 2 yrs growth

• Sling• Sling and Swathe• Hanging cast

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HUMERAL SHAFT FRACTURES• Excellent healing and remodeling potential• “If the bones are in the same room it will heal”

http://www.rch.org.au/clinicalguide/guideline_index/fractures/Humeral_shaft_fractures_Emergency_Department/

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HUMERAL SHAFT FRACTURES• Treatment:

• Sling and coaptation splints• Hanging arm cast• Internal fixation, flexible nails

• Overgrowth of ~ 1 cm occurs

ELBOW FRACTURES• Supracondylar fractures (70%)

• Lateral condylar fractures (15%)

• Medial epicondylar fractures

• Radial head/neck fractures

• Transphyseal

• Olecranon

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• Transphyseal

• Olecranon





• Transphyseal

• Olecranon

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• Transphyseal

• Olecranon





• Transphyseal

• Olecranon

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• Transphyseal

• Olecranon





• Transphyseal

• Olecranon

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ELBOW FRACTURES• 5-10% of all pediatric fractures

• Knowledge of ossification centers is essential for correct diagnosis

SUPRACONDYLAR FRACTURE• 70% of all elbow fractures in children

• Average age: 6 y/o

• Anatomic predisposition:

• Ligamentous laxity

• Metaphyseal “remodeling”

• Thin cortex

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MECHANISM• Extension injury – 97%

• Flexion injury – 3%

FAT PAD SIGN• Anterior fat pad => means nothing!

• Posterior fat pad => 76% occult fracture

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CLASSIFICATION

Tachdjian’s Pediatric Orthopaedics, 4th Ed.

VASCULAR INJURY• 0.5-1% incidence

• Important to document clinical exam

• Pulses

• Perfusion

• Need urgent OR for reduction

Tachdjian’s Pediatric Orthopaedics, 4th Ed.

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NERVE INJURY• Occurs 7%

• Anterior Interosseus Nerve

• Most common

• Radial nerve

• Posteromedial displacement

• Median nerve

• Posterolateral displacement

• Ulnar nerve

• Iatrogenic from pin placement

TYPE 1 SUPRACONDYLAR FRACTURE• Long arm cast

• 4-6 weeks

• Sling is recommended• Parents should be instructed on elevation of the extremity to reduce

swelling • Fingers above the elbow• Elbow above the heart

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TYPE 2 AND 3 SUPRACONDYLAR FRACTURES• OR for closed reduction and pinning


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TYPE 2 AND 3 SUPRACONDYLAR FRACTURES

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FLEXION TYPE SUPRACONDYLAR

TRANSPHYSEAL FRACTURES• Children < 2 years old• Diagnosis usually missed

• Distal humerus being entirely cartilaginous • Distinguishing a transphyseal fracture from an elbow dislocation

• Child abuse • 50% of children less than 2 years of age

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LATERAL CONDYLE FRACTURES• 2nd most common elbow fracture

LATERAL CONDYLE FRACTURE• Most need surgical management

• Any displacement – high rate of non-union when treated with cast

• Avoid unnecessary dissection especially posterior - AVN

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LATERAL CONDYLE FRACTURE

LATERAL CONDYLE FRACTURE – NON-UNION

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MEDIAL EPICONDYLE• Common in age 9-14• Mechanism

• Direct trauma• Muscle pull from flexor mass• Associated with elbow dislocation – upto 50%

• Historically treated non operatively• Relative indications for treatment

• Displacement > 1cm• Elbow instability• Ulnar nerve symptoms• Higher demand patients

ELBOW DISLOCATION

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REDUCED

ORIF – EXCISION OF FRAGMENT AND REDUCTION

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NURSEMAIDS ELBOW• Radial head subluxation

• Common injury in 1-6 years of age

• Mechanism is usually of longitudinal traction while forearm is pronated and elbow extended

NURSEMAIDS ELBOW• Anatomy

• Annular ligament normally passes around radial head

• The immature radial head is more spherical and smooth (cartilaginous), and can slide out

• The annulus then gets trapped in the joint

Robert E. Kaplan and Kathleen A. Lillis, Recurrent Nursemaid’s Elbow (Annular Ligament Displacement) Treatment Via Telephone, PEDIATRICS Vol. 110 No. 1 July 1, 2002 pp. 171 -174

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NURSEMAIDS ELBOW• Presentation

• Arm held in pronation, elbow partially flexed

• Unwillingness of child to use that arm

• Tenderness in antero-lateral elbow

• No erythema, swelling, warmth, abrasions or ecchymosis

NURSEMAIDS ELBOWSupination: Simultaneous supination of the wrist and extension of the elbow (A),

followed by flexion of the elbow with the forearm maintained in

supination (B).

Hyperpronation: Simultaneous pronation of the wrist and extension of the elbow (A),

followed by flexion of the elbow with the forearm maintained in

pronation (B).Robert E. Kaplan and Kathleen A. Lillis, Recurrent Nursemaid’s Elbow (Annular Ligament Displacement) Treatment Via Telephone, PEDIATRICS Vol. 110 No. 1 July 1, 2002 pp. 171 -174

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FOREARM FRACTURES• Common injury

• Most kids with >2years growth remaining can be treated with closed reduction

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FOREARM FRACTURE• Long arm cast – safe and effective

Bae DS. Pediatric Distal radius and forearm fractures. J hand Surg Am. 2008 Dec;33(10):1911-23

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WHAT IS THE INJURY?

MONTEGGIA FRACTURE

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DISTAL RADIUS/ULNA FRACTURES

• Most common fracture in children

• Majority are managed in cast

• Commonly a result of a fall on an outstretched hand

DISTAL RADIUS/ULNA FRACTURES• Well molded cast is key

• Cast Index

• x/y

• Ideally > 0.7

• Strongest predictor of loss of reduction

• Short arm cast is usually sufficient

• Pin fractures if they redisplace

• Higher risk of growth plate injury with repeat closed reduction

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TAKE HOME POINTS• Clavicle fractures

• Majority are non-operative

• Growth and remodeling until 22 years of age

• Proximal humerus

• Non operative if > 2 years growth remaining

• High potential for remodeling

• Elbow

• Recognize the anatomy and ossification centers

• Cannot tolerate any significant deformity

• Have a low threshold to refer these

TAKE HOME POINTS • Supracondylar fractures

• Always assess neurovascular status – Anterior interosseus nerve, brachial artery

• Do not attempt a closed reduction in the ER or clinic

• Lateral condyle

• Any displacement needs anatomic open reduction

• High risk of complications including non union and AVN

• Medial Epicondyle

• Can be treated non op for minimally displaced, younger patients or inactive patients

• 50% associated with elbow dislocations

• Think of this fracture with significant elbow injury and no fracture seen

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TAKE HOME POINTS• Forearm and wrist fracture

• Always look at the joint above and below – pay particular attention to radial head dislocation

• Most can be managed non operatively

• Need close follow-up for displaced fractures to ensure reduction is maintained

• Do not attempt multiple reductions – increased incidence of growth arrest

• Well molded cast is essential to success