Interesting case

Ext. สทิธกิรปภาวนิ 5402161

Patient profile เด็กชายไทย อายุ 6 ปี

Chief Complaint

ตกต้นไทรแขนซา้ยบวมผิดรูป 1 ชม.ก่อนมาโรงพยาบาล

Intial management Airway with c spine protection Breathing Circulation Disability Exposure and environment control

Secondary survey ไมแ่พย้าแพอ้าหาร ไมม่โีรคประจำาตัว ไมใ่ชย้าใดเป็นประจำา NPO time 8 ชม.ก่อนมาโรงพยาบาล

Event 1ชม. ก่อนมาโรงพยาบาลตกจากต้นไทร จากนัน้

ปวดแขนขา้งซา้ยทันที และ แขนซา้ยผิดรูป ไมย่อม ขยบัขอ้ศอกแขนและขอ้มอื ไมส่ลบ ไมม่หีวั

กระแทกพื้น ไมป่วดหวั ไมค่ล่ืนไส้

Physical Examination (แรกรบั)

V/S- BT 37.4 C, BP 139/55 mmHg, PR 106/min, RR 20/min O2 sat 97% room air

GA- alert Skin:no rash HEENT no wound at face and scalp Heart-normal s1 s2 Lungs-symmetrical chest wall movement,

no use accessory muscle,good air entry,no adventicious sound

Abdomen-no distension, soft,not tender

extremitiesS shape deformities,swelling,ecchymosis 3 cm,marked tenderness at distal humerus of left arm,loss of isosceles triangle,range of motion limited due to pain,no wound, no fat globue

S shape deformities

S shape deformities

S shape deformities

neurovascular Radial pulse 2+ Ulnar pulse 2+ Capillary refill < 2 sec OK sign intact Great sign intact Bye-bye sign intact

Problem list

Acute left elbow pain and deformities

History of trauma at left elbow

DDx Closed Supracondylar fracture of

left the humerus Closed Lateral condyla fracture of

left the humerus Subluxation of the radial head of left

elbow

Immobilization Temporary splint(woody splint) or

Long posterior arm slap Go to x-ray

investigation Flim elbow true AP,Lat

Preoperative Diagnosis Closed Totally displace

Supracondylar fracture of left the humerus (GARTLAND 3)

Refer Definitive treatment Close reduction in OR with internal

fixation by K-wire percutaneous crossed pinning

Apply posterior long arm slab in slightly flexion and arm sling

Postoperative Diagnosis Closed Totally displace

Supracondylar fracture of left the humerus (GARTLAND 4 )

Post op care Elevation/swelling control Pain control Observe compartment syndrome and

neurovascular complication Remove pin and slab at 4

week/clinical union

SUPRACONDYLAR FRACTURES OF

HUMERUS

Distal Humerus Anatomy

Medial epicondyle proximal to trochlea –

Lateral epicondyle proximal to capitellum –

Radial fossa – accommodates margin of radial head during flexion

Coronoid fossa – accepts coronoid process of ulna during flexion

Supracondylar Fractures of Humerus

It is # which involves the lower end of the humerus usually involving the thin portion of the humerus through

Olecranon fossa orJust above the fossa orMetaphysis

Most common elbow injuries in children.

Makes up approximately 60% of elbow injuries.

Becomes uncommon as the age increases.

General considerations Incidence of supracondylar #:

a) Age : peak age : 5-7 yrs

Average age : 6.7 yrs

b) Sex : Boys > Girls (Earlier)

Boys = Girls (Latest Trends)

c) Side : Left > Right ( Non dominant >

dominant )d) Nerve injuries : 7% - Median>

Radial > Ulnare) Vascular injuries : 1%f) Open injuries : < 1%

g) Cause of # Fall from height 70% ----- children > 3 yrsFall from bed children < 3 yrsNon accidental injury ( Child abuse) children < 15

months

h) Associated #s Distal radius > Scaphoid > Proximal

humerus > Monteggia

i) Clinical typesExtension type: 98%Flexion type : 2%

Mechanism of injury For Extension

type of SC # humerus

Fall on outstretched hand

Elbow hyper extended

Fore arm – pronated or

supinated

Mechanism of injury

For Flexion type of SC # humerus

Fall directly on the elbow rather than out stretched hand

Radiographic anatomy of distal Humerus

What are the radiographic views:Antero posteriorLateralObliqueAxial ( jones view )

What to look for in

AP View----- Baumann`s angle

Radiographic Anatomy

Baumann’s angle is formed by a line perpendicular to the axis of the humerus, and a line that goes through the superior part of physis of the capitellum.

There is a wide range of normal for this value, and it can vary with rotation of the radiograph.

The Baumann angle is good measurement of any deviation of distal humerus`s angulation

In this case, the medial impaction and varus position alters the Bauman’s angle.

Radiograph Anatomy/Landmarks

Anterior Humeral Line:

This is drawn along the anterior humeral cortex.

It should pass through the junction of anterior & middle 3rd of the capitellum.

Radiograph Anatomy/Landmarks

The capitellum is angulated anteriorly about 30 degrees.

The appearance of the distal humerus is similar to a hockey stick.

30

Radiograph Anatomy/Landmarks

The physis of the capitellum is usually wider posteriorly,

compared to the anterior portion of the physis Wider

Anatomical classification of SC #

Radiographic Classification of SC #s

Based on X- Ray appreance # displacement Gartland described 3 types:

Type – I : Undisplaced

Type – II : Displaced (posterior cortex intact)

Type –III : Displaced ( no cortical contact)

Posteromedial Posterolateral

Type 1: Non-displaced

Note the non- displaced fracture (Red Arrow)

Note the posterior fat pad (Yellow Arrows)

Type 2: Angulated/Displaced Fracture with Intact Posterior

Cortex

Type 3: Complete Displacement, with No Contact between

Fragments

Clinical signs & Symptoms

In most cases, children will not move the elbow if a fracture is present, although this may not be the case for non-displaced fractures.

Swelling about elbow is a constant feature, develop within first few hrs.

S shaped deformity

Distal humeral tenderness

Anterior plucker sign +ve

S-shaped configuration of UL

Physical Examination Neurologic exam is essential, as nerve injuries are

common. In most cases, full recovery can be expected

Neuro-motor exam may be limited by the childs ability to cooperate because of age, pain, or fear.

Thumb extension– EPL (radial – PIN branch)

Thumb flexion – FPL (median – AIN branch)

Cross fingers - Adductors (ulnar)

Nerve injury incidence is high, between 7 and 16 % (median, radial and ulnar nerve)

Anterior interosseous nerve is most commonly injured nerve

In many cases, assessment of nerve integrity is limited , because children can not always cooperate with the exam

Carefully document pre manipulation exam, as post manipulation neurologic deficits can alter decision making

Physical Examination

Vascular injuries are rare, but pulses should always be assessed before and after reduction

In the absence of a radial and/or ulnar pulse, the fingers may still be well-perfused,

because of the excellent collateral circulation about the elbow

Doppler device can be used for assessment

Physical Examination

Physical Examination

Thorough documentation of all findings is important. A simple record of “neurovascular status is intact” is unacceptable.

Individual assessment and recording of motor, sensory, and vascular function is essential

Always palpate the arm and forearm for signs of compartment syndrome.

Treatment General principles:

Splinting elbow in comfortable position

20-30degrees of flexion of elbow, pending

Careful physical examination & X-ray evaluation.

Tight bandaging/ excessive flexion or excessive extension should be avoided

Associated life threatening complications ( if any)

to be attended first.

Simple posterior long arm splint for 3-7days.

Elbow 60-90o flexion & Forearm neutral position.

Check X-ray after 3-7 days to document any displacement or lack of it.

Splint converted to long arm cast if no displacement.

If displacement noticed # reduction done & cast applied or pinning done.

Treatment of type – I #

Duration of immobilisation 3-4wks.

No need for any physiotheraphy ( Generally )

Outcome: Predictablly excellent if alignment is maintained during early healing.

Hence type – I #s requires careful

treatment & follow up.

Treatment of type – II # Good stability obtained after closed reduction.

Once satisfactory reduction achieved further management is same as type – I.

If medial column collapse present then skeletal stabilisation with 2 lateral pins is advocated.

Recent trends led to SELECTIVE PINNING for type – II #s

SELECTIVE PINNING Closed reduction is done Splinting in flexion Non movable cuff & collar sling Early careful X-ray follow up

If # displacement /angulation noticed pin stabilisation is

done .

Treatment of type – III # Treatment involves management of

skeletal injuries & associated soft tissue injuries (if any).

Treatment of skeletal injury:Reduction either closed or open Stabilisation either with pins or

cast

Technique of reduction (closed)

Traction – to restore length & alignment. Milking maneuver -- if length & alignment

not restored by traction

Correction of medial/ lateral displacements. Correction of rotational deformities. Correction of posterior displacement by --

flexion reduction maneuver

Elbow held in hyper flexion. Fore arm held in pronation – if distal fragment

is postero medially displaced,

Fore arm held in supination -- if distal fragment is postero laterally displaced.

Indications for open reduction

Open reduction is indicated to obtain alignment if closed reduction is unsuccessful as with the following,

Button holing of the proximal fragment through the anterior soft tissues ,

Interposition of the biceps ,

Interposition of the neurovascular structures .

An open reduction is also indicated if there is an open fracture ,that requires irrigation and debridement .

Complications Immediate : a) neurological b) vascular Early : a) compartment syndrome b) volkmann`s ischemia Late : a) mal union : cubitus varus / cubitus

valgus b) volkmann`s ischemic contracture c) myositis ossificans d) elbow stiffness