Upper Extremity Injury

Management

Jonathan Pirie MD, Med, FRCPC, FAAP

Learning Objectives

At the end of this session, you will be able to manage common fractures of the: 1.  Humerus 2.  Elbow 3.  Forearm

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Outline

Proximal Humeral #

Mid – Humeral #

Elbow or Mid Forearm #

Distal Forearm (simple #s)

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Proximal Humeral Fractures p  Age patterns:

n  0-5 Salter Harris I n  5-11 Metaphyseal n  >11 SH II

p  Acceptable Angulation n  Pre-teen 50° -70° n  Teen 20° -50° with up

to 50% apposition p  Management ?

n  Immobilization? n  Ortho follow up?

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Proximal Humeral Fractures p Management

n  sling & swathe or collar & cuff n  Good analgesia

p  Maximize OTC analgesics p  Morphine 0.2 mg/kg x 2-3 days

n  f/u with Ortho 5-7 days

How to make a sling!

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Sling & Swathe

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Sling & Swathe

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Velpeau Slings

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Collar & Cuff

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Humeral Shaft Fractures p Carefully assess radial nerve function p  Immediate Ortho referral if:

n  completely displaced, angulated > 30 degree children,

n  10-20 degrees for adolescents, n  radial nerve injury

p Rx: sugar-tong cast

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Sugar Tong

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Supracondylar Fractures

p  Most frequent elbow injury in children p  Mechanism of injury p  X-ray

p  may be subtle p  Complications

p  nerve injury-radial, median, ulnar (10%) p  Volkmann’s ischemia p  cubitus varus

p  Treatment: p  non-displaced: long-arm splint, for moderate swelling

24-hour follow-up p  Displaced (capitellum behind ant. humeral line: ortho

referral

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Lateral Condylar Fracture p  Clinical

n  localized swelling lateral aspect of elbow p  X-ray

n  small metaphyseal fragment on AP and oblique n  Involves physis & articular surface – S.H. type 3 or 4

p  Complications n  non union n  ulnar nerve palsy n  degenerative arthritis n  growth abnormalities

p  Orthopedic referral n  Unstable

Medical Epicondylar Fracture

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Medial Epicondylar Fracture

p Clinical n  localized swelling medial aspect of elbow

p X-ray n  medial epicondyle ossifies 5 - 7 years n  consider X-ray of opposite limb n  incarcerated in joint - “ossific nucleus”

p  Immediate Orthopedic referral n  unstable

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Fractures of Radial Head and Neck p  Mechanism of injury

n  fall on outstretched hand, forearm in supination

p  50 % associated fractures p  Clinical

n  tenderness and ecchymosis over proximal radius n  referred pain to wrist

p  Treatment: above elbow cast (posterior slab) & F/U Ortho

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Supracondylar Fractures

p  Most frequent elbow injury in children p  Peak incidence age 8 years p  Complications

p  nerve injury-radial, median, ulnar (10%) p  Volkmann’s ischemia p  cubitus varus

p  Treatment: p  non-displaced: long-arm splint, for moderate

swelling 24-hour follow-up p  Displaced (capitellum behind ant. humeral line:

ortho referral

Forearm Injuries p  True sprains (ligamentous injuries) are

uncommon with open growth plates p  The most common injuries are:

n  Salter Harris I # n  Soft tissue injuries

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Forearm Fractures p  Taurus (Buckle) #s, “micro” #s, SH I & II

n  Short arm volar slab or splint for 3-6 weeks n  → f/u with FD or Pediatrician

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Forearm Fractures

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Forearm Fractures p  Distal Radius and Ulna #s

n  “Acceptable” angulation: < 5 yrs < 30 degrees 6-10 < 20 11-13 < 15 > 14 < 10

n  Rx: Volar back slab, Benik splint n  Ortho Follow up 1-2 weeks, usually 3-6 weeks of

immobilization

Splint or Cast? p Minimally angulated (<15 degrees), +

<0.5 mm displaced greenstick or transverse #s n  Splint = cast n  Boutis CMAJ 2010

p  Pediatric Fractures with Minimal Intervention n  Boutis PEC 2010

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Benik Splint

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Clinical Deformed

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Bowing Fractures p  Little remodeling, cosmetic & functional deficits

common p  May need reduction p  Orthopedic referral if cosmetically deformed

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Summary

Proximal Humeral # Sling & Swathe or Collar & Cuff

Mid – Humeral # Sugar Tong

Elbow or Mid Forearm # Posterior Long Arm or Sugar Tong

Distal Forearm (simple #s)

Forearm slab or splint