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PEDIATRIC UPPER EXTREMITY FRACTURE MANAGEMENT

JULIA RAWLINGS, MDSPORTS MEDICINE SYMPOSIUM: THE PEDIATRIC ATHLETE

2 MARCH 2018

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DISCLOSURE

• I have nothing to disclose.

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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

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FOREARM FRACTURES

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• 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)

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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

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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

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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

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WHAT IS ACCEPTABLE ALIGNMENT?

• More angulation tolerated near physis• Need ~ 2 years of growth remaining

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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

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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

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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

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REDUCTION AND SPLINTING

• Sugar tong splint – 3-point molding– Interosseous molding– 90º at elbow

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INTEROSSEOUS MOLD

https://www.rch.org.au/fracture-education/management_principles/Management_Principles/13

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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

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MONTEGGIA FRACTURES

• Proximal 1/3 ulnar fracture w/ radial head dislocation

https://www.orthobullets.com/trauma/1024/monteggia-fractures 15

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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

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ELBOW: OSSIFICATION CENTERS

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ELBOW

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• 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

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ELBOW

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• 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

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ELBOW

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• 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

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By James Heilman, MD - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=14633683

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NORMAL NOT NORMAL

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SUPRACONDYLAR FRACTURES

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• 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

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SUPRACONDYLAR FRACTURE – TYPE I

• No or minimal displacement• No visible fracture line

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SUPRACONDYLAR FRACTURE – TYPE I

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• Posterior splint w/ elbow at 90°flexion or less x 3-4 weeks

• If you see a fat pad, treat it like a fracture

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SUPRACONDYLAR FRACTURE – TYPE II

• Obvious fracture line

• Posterior cortex intact

• Varying amounts of displacement

• Closed reduction with ortho in OR (usually)

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SUPRACONDYLAR FRACTURE – TYPE II

• Place immediately in posterior splint with <20°flexion or where patient is comfortable

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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

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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

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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

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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

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MEDIAL EPICONDYLE FRACTURES TREATMENT

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• 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

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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)

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LATERAL CONDYLE FRACTURES

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• #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)

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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

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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

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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

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LITTLE LEAGUE SHOULDER

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• 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

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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

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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

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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

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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

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QUESTIONS???

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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.

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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.

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