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Paediatric Orthopaedic Trauma Pulled Elbow Salter- Harris Injuries Definition: subluxation of radial head Symptoms: history of being pulled; mvmt arm after Examination: undistressed at rest; no Epidemiology: 15% long bone fractures in children occur at epiphyseal plate Pathology: epiphyseal plate is less strong than bone, ligaments and tendon Early reduction better; young children have greater growth disturbance; Through epiphysis; diagnosis clinical Reduction easy POP and ortho follow up prognosis excellent Management: if unable to reduce, most will spontaneously reduce in 48hrs; recurrence rate 25-40% Supination/flexion technique: hold arm with thumb on radial head supinate and flex arm I SEPARAT E Through epiphysis and metaphysis Reduction easy if <48hrs prognosis excellent II ABOVE Intra-articular fracture into epiphysis Accurate reduction needed, needs ortho R/V prognosis good III LOW Intra-articular fracture into epiphysis and metaphysis Accurate reduction needed; usually open reduction and internal fixation IV THROUGH Crush / axial loading injury to epiphysis; usually of knee / ankle; often joint effusion; significant MOI / tenderness; may be hard to diagnose V EEEEEK!

Paediatric Orthopaedic Trauma Orthopaedic Trauma

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Page 1: Paediatric Orthopaedic Trauma Orthopaedic Trauma

Paediatric Orthopaedic Trauma

Pulled Elbow

Salter-Harris Injuries

Definition: subluxation of radial headSymptoms: history of being pulled; mvmt arm afterExamination: undistressed at rest; no tenderness; clinical diagnosisInvestigation: Xray appears normal

Epidemiology: 15% long bone fractures in children occur at epiphyseal plate

Pathology: epiphyseal plate is less strong than bone, ligaments and tendon

Early reduction better; young children have greater growth disturbance; internal fixation across epiphysis ’s risk of growth retardation

Through epiphysis; diagnosis clinical Reduction easy POP and ortho follow up prognosis excellent

Management: if unable to reduce, most will spontaneously reduce in 48hrs; recurrence rate 25-40% Supination/flexion technique: hold arm with thumb on radial head supinate and flex arm Hyperpronation method: hold elbow hyperpronate forearm with other hand; 95% success rate

I SEPARATE

Through epiphysis and metaphysisReduction easy if <48hrs prognosis excellent MOST COMMON

II ABOVE

Intra-articular fracture into epiphysisAccurate reduction needed, needs ortho R/V prognosis good UNCOMMON

III LOW

Intra-articular fracture into epiphysis and metaphysisAccurate reduction needed; usually open reduction and internal fixation prognosis OK

IV THROUGH

Crush / axial loading injury to epiphysis; usually of knee / ankle; often joint effusion; significant MOI / tenderness; may be hard to diagnosePOP and ortho follow up prognosis poor

V EEEEEK!

Page 2: Paediatric Orthopaedic Trauma Orthopaedic Trauma

Torus FractureBuckle fractureBuckling of periosteum but no fracture linePOP and ortho follow up 1/52

Greenstick Fracture

Cortical disruption and periosteal tearing on convex side of bone with intact periosteum on concave side

Plastic deformities = bowing / bending fractures; no disruption of periosteum / cortex; usually associated with fracture elsewhere; needs ortho review and reduction and realignment

Paediatric Elbow

C apitellum

R adial head

Int epicondyle

Trochlea

Lat epicondyle

Appears Closes

1-3yrs

3-4yrs

5-6yrs

7-9yrs

11-12yrs

14yrs

16yrs

15yrs

14yrs

16yrs

Olecranon 9-10yrs

XR InterpretationAnterior humeral line: should bisect capitellum in middle 1/3 on lateral; abnormal in supracondylar / lateral condyle fractureAngle between line through centre of capitellum and anterior humeral line should be 30-45°

Radio-capitellar line: Radial head should point towards capitellum on all views; abnormal in lateral Condyle / radial neck / Monteggia fractures and elbow dislocationBaumann angle: angle between physeal line of lateral condyle of humerus and line perpendicular to long axis of humeral shaft = 8-28°; angle varus deformity; abnormal in supracondylar fractureBowing of anterior fat padAny posterior fat pad

Supra-condylar Fracture of Humerus

Epidemiology: peak incidence 5-8yrs; most common paediatric elbow fracture; most common fracture <8yrs; usually FOOSH (flexion type from fall of flexed elbow, rare)

Pathology: distal fragment displaced posteriorly; significantly displaced fractures are surgical emergency (brachial artery, median / radial / ulnar nerve at risk; nerve involvement in 6-16% Volkmann’s ischaemic contracture); risk of compartment syndrome

Page 3: Paediatric Orthopaedic Trauma Orthopaedic Trauma

Gartland classification: fracture in distal 1/3 of humerusType I: undisplaced fracture with evidence of joint effusion; anterior and posterior periosteum intact; prognosis goodType II: displaced, but intact post periosteum; fracture visible anteriorly, hinging posteriorly; prognosis good; wrist-shoulder backslab with elbow flexed 90° for 4/52; OT preferred in adults as stiffness common, but otherwise not generally recommended; ortho follow up within 48hrsType IIb: as above + rotation; prognosis bad, need OTType III: displaced anterior and posterior periosteum; no continuity between shaft and distal humerus; can displace postmed, postlat, antlat; prognosis bad, need OT

indications for reduction / manipulation: evidence of NV compromise / <50% bony apposition / dorsal angulation >15° / lateral or medial tilt >10° / any rotational deformity / any varus or valgus deformity / compound

Epicondylar Fractures of

HumerusMedial epicondyle (appears at 5-6yrs): 3rd most common paediatric elbow fracture; most common 9-14yrs; 50% associated with elbow dislocation; risk of medial epicondyle becoming trapped in joint, especially in spontaenously reduced elbow dislocation; needs OT if >1cm of articular surface, or ulnar nerve involvement; needs ortho reviewLateral condyle (appears at 11-12yrs): tend to be unstable; often also involves all of capitellum and ½ of trochlea; due to varus stress on extended arm in supination Milch I = Salter Harris IV Milch II = Salter Harris II (into joint and lateral part of trochlea), most commonOT if displaced, often required; ulnar nerve involvement; needs ortho review

?NAI Clavicular fracture <2 years

Supra-condylar Fracture of Humerus

(cntd)

Urgent ortho review if NV compromise; immediate ED reduction if cool / pale hand; ortho review if no pulse, but hand otherwise OK; to manipulate – traction at 20° flexion flexion as far as possible while still retaining radial pulse

Page 4: Paediatric Orthopaedic Trauma Orthopaedic Trauma

Other Fractures in Paediatrics

Clavicle: OT needed if medial 1/3, displaced lateral 1/3Proximal humerus: more common in adolescents; manipulate if >30° displacementMid humerus: assess radial nerve; uncommon; usually just POPOlecranon (appears at 9-10yrs): from fall on elbow; needs ortho review; OT if displaced >5mm; associated with radial head/neck fractureRadial head/neck fracture: uncommon in children; neck >head; OT if >60° angulation or >50% displacement; need ortho reviewElbow dislocation: neuro injury in 10%; posterior most common; ulnar / median nerve injuryRadial / ulnar shaft: OT if any rotational deformity, >10° angulation >8yrs, >15-20° angulation <8yrs; proximal shaft injuries are more unstableMonteggia fracture: ulnar fracture + dislocation of radial headGaleazzi fracture: radial shaft # + dislocation of distal radio-ulnar jointHip fracture: high risk of AVN and growth arrest; dislocations <10yrs can occur with low energy traumaFemoral shaft fracture: will not be cause of hypotension in young childFracture distal femoral physis: popliteal artery and peroneal nerve injuryTibial / fibula shaft fracture: OT if >10° angulationToddler’s fracture: isolated spiral fracture of distal tibia; may not be obvious history of trauma