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Fracture Management “Oh Snap!”

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Fracture Management “Oh Snap!” Fracture Management “Oh Snap!” Cassidy Foley Davelaar, DO, FAAP, CAQSM Department of Orthopedics and Sports Medicine Assistant Professor University of Central Florida College of Medicine 5th October, 2018 Disclosure . I have no relevant financial relationships with industry to disclose . I will not discuss off label use and/or investigational use in my presentation Importance . A large proportion of orthopedic referrals indicated either a lack of basic textbook knowledge or lack of examination skills and appropriate diagnostic tools . For pediatric residents, skills in recognizing and managing pediatric fractures were suboptimal. Reeder et al. Referral patterns to a pediatric orthopedic clinic: implications for education and practice. Pediatrics. 2004 Mar;113(3 Pt 1):e163-7. Ryan LM et al. Recognition and management of pediatric fractures by pediatric residents. Pediatrics. 2004 Dec;114(6):1530-3. Learning Objectives . Identify STABLE fracture vs UNSTABLE . Identify common fractures by mechanism of injury . Learn the appropriate immobilization for each fracture Kids are not just little Adults . Pediatric skeleton is relatively elastic and rubbery . Growth plates are the area of greatest weakness . Ligaments and tendons are strong relative to bone . Fractures heal quickly; more quickly the younger you are. Pediatric Bone – Anatomy 101 . Epiphysis . Physis . Metaphysis . Diaphysis . Apophysis Pediatric Fracture Classification . Buckle/Torus – compression, does not effect growth plate . Plastic deformation – bowing, no cortical disruption . Greenstick – unicortical tension, cortical disruption . Complete – spiral, oblique, transverse . Physeal – Salter- Harris Classification (l-V) . Apophyseal avulsion Buckle/Torus Fracture . Compression of the periosteum . Typically at the metaphyseal/diaphyseal junction . Open growth plates – Distal radius and ulna buckle fractures Plastic Deformity . Bowing w/o fracture . Often deformed . Requires reduction . Associated w/ fracture – Fibular plastic deformity Greenstick Fracture . Only one cortex is fractured . Incomplete . Typically open growth plates – Distal radius greenstick fracture Complete Fractures . Transverse – perpendicular to shaft . Oblique – across bone @ 45-60º – unstable . Spiral – rotational force Salter- Harris Classification Salter-Harris continued Clues . Kids are not good historians . Mechanism – very low impact, can be any fall . May not be swollen, bruised or deformed . Non-weight bearing/limping child . Knee swelling . Not using the arm, keeping it flexed close to body . Walking on toes or heel Easily missed . Salter-Harris 1 fractures (straight/slipped) . Buckle/Torus fractures . Avulsion fractures . Occult (toddlers fracture and humeral fractures) Fracture mimickers . Causes of limp – legg-calve-perthes, transient synovitis, septic arthritis . Flexed arm, refusing to use – Nursemaids . Pathological fractures – Bone cyst – Tumors . Osteomyelitis – bone pain and fever Pearls for Elbow Fractures . Multiple physes – compare to contralateral side . Look for swelling . Range of motion – Humerus = loss of flexion/extension – Radial head or Olecranon = loss of supination/pronation . Supracondylar fractures in the very young . Radial head fractures in the older child Nursemaids Elbow . Traction injury . No swelling or deformity . Does not improve with time . Child cries and will not use, holds arm flexed close to body . Subluxation of the radial head . Annular ligament slides off the radial head . Occurs from 6 months to 5 years (peak 27 months) . Change in the shape of radial head to “hammer” @ 5-6 yrs Reduction Maneuver . Fully Supinate or Pronate and Flex TREATMENT Nursemaids . Attempt reduction maneuver *ONCE* . Wait 10 minutes If not reduced: . Elbow sling, refer to Orthopedics, *next day* appointment . Multiple attempts can cause trauma to ligament or displace a missed fracture Appearance of Ossification Centers Ossification Centers of the Elbow . C – Capitellum – 2 years . R – Radial head – 4 years . I – Internal / Medial epicondyle – 6 years . T – Trochlea – 8 years . O –Olecranon –10 years . E – External / Lateral condyle – 12 years Elbow Fat Pad . Anterior – can be normal if lying flat against the humerus – abnormal if elevated “sail sign” . Posterior – always abnormal = occult fracture . Indicates hemarthrosis in the setting of appropriate mechanism . Fracture of the distal humerus > proximal radius > ulna Elbow Fat Pads continued Posterior Fat Anterior Fat Pad Pad Occult Fracture Supracondylar Distal Humerus . Physical exam: – Swelling – May appreciate extension Anterior Humeral Line . Should intersect the middle 1/3 of the capitellum in children >5 yrs and touch the capitellum in children <5 yrs Baumanns Angle . Baumanns angle should be 70-50 degrees . Deviation >5-10 degrees should not be accepted . Lateral condyle fractures . Increase carrying angle TREATMENT . Supracondylar fractures cause neural injury 10-15% cases – Recovery from neuropraxia can take up to 6 months – Most common nerve is AIN (can’t make “OK” sign) First: Warm perfused hand without neuro deficits . Type 1 (non-displaced) . Type 2 : Meeting the following criteria – anterior humeral line intersects the capitellum – acceptable Baumann’s angle *GOOD* LONG ARM SPLINT & SLING ~ 90 º elbow flexion . Ortho F/U within 1 week Radial Neck Fracture Forearm Fractures . Most common fracture in pediatrics . FOOSH . May have swelling, bruising, deformity . Tender 1 inch proximal to the radiocarpal joint . Loss of supination/pronation . * Always obtain 2 VIEW (AP/LAT) FOREARM Volar Bruising – Distal radius and ulna buckle fractures – Ulna styloid and distal metaphyseal fracture of the radius TREATMENT Buckle/Torus Fracture . Brace vs Cast . Level 1 evidence splint is as good as a cast for prevention of re-fracture and loss of alignment . No difference in pain . Easier to bath . Better function . No need to return for cast removal . Re-xray Fracture Reduction . Sooner is better . Reduce if obvious deformity . Correct angulation and/or displacement . Older children require more reductions . 3 Factors: – Age to skeletal maturity – Proximity to the physis – Angle of motion @ the jt. Remodeling . 10 year old Salter-Harris ll distal radius TREATMENT Reduced or Unstable Forearm Fracture . LONG ARM SPLINT (SHORT ARM IS INSUFFICIENT) . IMMOBILIZE the ELBOW . Supination of the forearm – Avoid tension across the brachioradialis (avoid pronation) . Sling . Prompt F/U with orthopedics – Younger age – More instability Scaphoid Fractures . Still occur in the skeletally immature . Most frequently fractured carpal bone . 15% of acute wrist injuries . 65% occur at the waist – Proximal 1/3 25% – Distal 1/3 10% . Distal pole & waist most common in kids . Risk AVN is high Scaphoid cont. Physical exam: – Anatomical snuff box tenderness – Scaphoid tubercle tenderness volarly – Pain with resisted pronation Radiographs: – AP/LAT and scaphoid view (30º wrist extension, 20º ulnar deviation) TREATMENT . Stable nondisplaced fracture (majority) . If normal xrays, but positive exam THUMB SPICA CAST IMMOBILIZATION START IMMOBILIZAITION EARLY to avoid nonunion Typical duration > 5 weeks, but reevaluate at 12-21 days Avulsion Fractures - Fingers . Extremely common . Kids heal EXTREMELY quickly . If displaced refer < 1 week . Will heal poorly Jersey Finger . Jersey Finger – 4th finger hyperextended at the DIP – FDP avulsion from the volar base of the distal phalanx – cannot flex the DIP TREATMENT Jersey Finger . Ultrasound has been shown to be the optimal imaging . Wide awake surgery offers optimal intraoperative assessment of the tendon repair . ACUTE diagnosis and prompt SURGICAL referral . 8-12 weeks of recovery Bachoura et al. A review of mallet finger and jersey finger injuries in the athlete. Curr Rev Musculoskelet Med. 2017 Mar;10(1):1-9. Mallet Finger . Mallet Finger – Impact to the distal phalanx of the finger or dorsal laceration – Disrupts terminal extensor tendon attachment (bone or tendon) TREATMENT of Mallet Finger . EXTENSION SPLINTING OF DIP JOINT 6-8 WEEKS . Can move at the PIP . Volar splinting preferred over dorsal . Avoid hyper extension Seymour Fracture . Distal phalangeal physeal fracture with nailbed injury . Middle finger is the most common . Direct trauma or laceration (similar to mallet finger) Exam: – Nail plate lying superficial to the eponychial fold – Open fracture Radiographs: – AP/PA may appear wnl – True lateral necessary TREATMENT Seymour Fracture . Removal of the nail . Irrigation and debridement of the fracture . Percutaneous wire stabilization Phalangeal Neck Fractures . Limited potential to remodel & propensity to re-displace Radiographs: – True lateral will show displacement best Goodell et al Problematic pediatric hand and wrist fractures. JBJS 2016;4(5):e1. TREATMENT Phalangeal Fractures TREATMENT if: – Extraarticular – <10º angulation – <2mm shortening – no rotation 3 weeks of immobilization followed by aggressive motion If not the above criteria: – Percutaneous pinning – Open reduction should be avoided secondary to risk of osteonecrosis of the phalangeal condyles Goodell et al Problematic pediatric hand and wrist fractures. JBJS 2016;4(5):e1. FEMUR . Proximal – SCFE – Apophyseal avulsion – Femoral neck . Shaft – Depending on age concern for abuse . Distal – Supracondylar – Salter-Harris Femoral Neck Fractures . Severe injuries associated with femoral head necrosis . Luckily < 1% of pediatric and adolescent fractures . Poor blood supply makes epiphysis vulnerable to osteonecrosis following femoral
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