1. Case Discussion: Arm Injury
ASMPH 2012, Group 7
19 March 2011
Department of Orthopedics
The Medical City

2. Objectives To present a case of pediatric trauma
To apply the following concepts to a case:
History taking and physical examination
Staging and classification of fractures
To present the anatomy of the forearm and related common fractures in the pediatric age group
Overview of diagnostic and therapeutic modalities in orthopedic trauma

3. Case Presentation
Patient History

4. General Data TO 14 year old male Lives in Palau Right-handed
Informant: Patient, good reliability
Chief Complaint: Wrist Injury

5. History of Present Illness
Fall
2nd floor of house ~ 20ft
hitting R hand, fully extended
on sandy surface
(+) loss of consciousness for a few seconds
(+) deformity on R wrist
(–) break in skin
(–) bruising
8 days PTA

6. History of Present Illness
Consult at local hospital X-ray revealed fracture of the distal radius Given Tramadol Discharged (no ortho) (-) Change in sensorium (-) Nausea, vomiting, seizure (-) numbing of R hand
8 days PTA
Admission

7. Review of Systems General: no weight loss,
Cutaneous: no lesion, no pruritus
HEENT: with occasional headaches
no redness
no aural/nasal discharge
no neck masses
no sore throat
Cardiovascular: no easy fatigability, fainting spells, no palpitation
Respiratory: no cough, colds
Abdominal: no change in bowel movement
Genitourinary: no change in urination
Endocrine: no polyuria, polydypsia, no heat/cold intolerance
Hematopoietic: no easy bruisability, or bleeding

8. Past Medical History
No asthma, hypertension, diabetes, allergies, heart disease, bone diseases
No maintenance medications
No previous surgeries
Does not recall previous immunizations
Hospitalized > 5 years ago 2o AGE

9. Family History Diabetes Mellitus, Heart Disease
No hypertension, asthma, cancer, stroke, or allergies

10. Personal/Social History
1st year high school student
Lives with his family in a 2 story house in Palau
Denies smoking, alcohol drinking, and drug abuse

11. Case Presentation
Physical Exam

12. Physical Exam General Survey Vital Signs
Awake, active, and not in cardiorespiratory distress
Vital Signs
Febrile at 37.5oC
RR 20 bpm
HR 71 bpm
Height:168cm weight:59kg BMI: 20.9

13. Physical Exam Skin Dirty skin No rashes, hemorrhages, scars Moist
CRT 1-2 seconds

14. Physical Exam
Head no lesions Eyes anicteric sclerae, slightly pale palpebral conjunctiva pupils 2-3mm Ears no discharge, tenderness Nose septum midline, moist mucosa Throat mouth and tongue moist no TPC

15. Physical Exam
Neck no cervical lymphadonapathy supple Chest adynamic precordium no heaves, thrills, or lifts, PMI at 5th ICS MCL regular rate, normal rhythm no murmurs Lungs symmetrical chest expansion, no retractions clear breath sounds

16. Physical Exam
Abdomen flat, no scars, no lesions normoactive bowel sounds tympanitic on all quadrants soft nontender no masses, no organomegally

17. Physical Exam
Right upper extremity Shoulder and Elbow no deformity, no asymmetry no discoloration, no lesions no tenderness, no swelling no limitation of movement full ROM

18. Physical Exam Tenderness around the wrist
Right upper extremity Volarly deformed distal forearm Bluish discoloration on the anterior wrist No lesions
Tenderness around the wrist
Soft tissue swelling of the anterior wrist
Wrist ROM limitation due to pain
intact radial, median, and ulnar nerves (motor and sensory)
Positive Allen’s sign
ROM limitation due to pain

19. Diagnostic Test

20. Salient Features Subjective 14 year old male R-handed 8 days PTA
Fall from 20ft on sand
Right arm extended
(+) R wrist deformity
(–) break in skin
(–) bruising
(–) R hand numbness
Immobilized with short posterior arm splint
Objective
Right upper extremity
posteriorly deformed distal forearm
bluish discoloration on the anterior wrist
(–) external lesions noted
X-ray
Dorsally displaced fracture of the distal radius, right

21. Colles’ fracture 14, M Fall, outstretched arm
Rule in
Rule out
14, M
Fall, outstretched arm
With right wrist deformity (volar deformation)
X-ray
n/a

22. Smith’s fracture 14, M Fall, extended arm With wrist deformity
Rule in
Rule out
14, M
Fall, extended arm
With wrist deformity
Volar deformation of distal forearm
X-rays

23. Scaphoid fracture 14, M Fall With outstretched forearm
Rule in
Rule out
14, M
Fall
With outstretched forearm
Without pain at snuffbox
X-rays

24. Galeazzi fracture-dislocation
Rule in
Rule out
14,M
Fall
Outstretched arm
With deformity of the wrist area
Volar deformation of the distal forearm
X-rays

25. Monteggia fracture-dislocation
Rule in
Rule out
14,M
Fall
Outstretched arm
*With deformity of the wrist area
No deformity of the elbow, with no limitation of movement at the elbow
X-rays

26. Pre-Operative Diagnosis
Fracture, closed, complete, transverse, displaced, distal radius, Right

27. Procedure Done
Closed reduction, percutaneous pinning, application of long arm cast, Right

28. Post-Operative
Fracture, closed, complete, transverse, displaced, ulnar styloid, Right
Distal radius and ulna styloid fracture, Right
s/p Closed reduction, percutaneous pinning, application of long arm cast, Right

29. Post-Operative

30. Case Discussion

31. Common Pediatric Fractures
Upper Extremities

32. Guidelines for Pediatric Orthopedics
Bones tend to remodel itself
Process is faster in children
In deformities near end of bones, and
In deformities in plane of motion of nearest joint
Skeletal deformities worsen as abnormal growth continues
Can tolerate long-term immobilization better
Guidelines for Pediatric Ortho
Bones tend to remodel itself toward the adult configuration
Process is faster, in deformities near end of bones, and in deformities in plane of motion of nearest joint
Skeletal deformities worsen as abnormal growth continues
E.g. permanent damage to growth plate
Faster in rapidly growing areas (e.g. knee)
Exaggerated in children
Children can tolerate long-term immobilization beter than adults and tend to recover soft tissue mobility spontaneously following most injuries
Fracture healing is usually more rapid and predictable in the actively growing skeleton
Joint surfaces in children are generally more tolerant of irregularity.
Although degenerative arthritic changes may follow childhood injury
Often an asymptomatic interval of many decades before process becomes clinically evident
Many so-called deformities, such as metatarsus adductus, internal tibial torsion, and genu valgum (knock-knee), are actually physiologic variations that correct spontaneously with growth

33. Guidelines for Pediatric Orthopedics
Tend to recover soft tissue mobility spontaneously
Fracture healing is more rapid and predictable
Joint surfaces are more tolerant of irregularity
Physiologic variations correct spontaneously with growth
E.g. metatarsus adductus, internal tibial torsion, and genu valgum (knock-knee)
Guidelines for Pediatric Ortho
Bones tend to remodel itself toward the adult configuration
Process is faster, in deformities near end of bones, and in deformities in plane of motion of nearest joint
Skeletal deformities worsen as abnormal growth continues
E.g. permanent damage to growth plate
Faster in rapidly growing areas (e.g. knee)
Exaggerated in children
Children can tolerate long-term immobilization beter than adults and tend to recover soft tissue mobility spontaneously following most injuries
Fracture healing is usually more rapid and predictable in the actively growing skeleton
Joint surfaces in children are generally more tolerant of irregularity.
Although degenerative arthritic changes may follow childhood injury
Often an asymptomatic interval of many decades before process becomes clinically evident
Many so-called deformities, such as metatarsus adductus, internal tibial torsion, and genu valgum (knock-knee), are actually physiologic variations that correct spontaneously with growth

34. Pediatric Fractures Forearm fractures are most common – 40%
Distal aspect of ulna and radius (more common)
Non-dominant arm
Most common Mechanism of injury  Direct FALL with wrist and hand Extended
Physeal fractures (>50%) in distal radial have associated ulnar fractures

35. Pediatric Fractures Increased risk Symptoms Overweight children
Boys:Girls = 2:1
Ages 2-10 years group susceptible to fall
Symptoms
Pain in distal forearm
Tenderness over fracture site
Limited motion of forearm, wrist and hand

36. Anatomy The distal radius has 3 articular components
Scaphoid and Lunate fossae
Sigmoid notch  ulna
Articular cartilage
Radial styloid
I of brachioradialis
O of radial scapholunate, radial lunocapitate ligaments
Articular components of the distal radius. L = lunate articular surface; N = sigmoid notch; S = scaphoid articular surface.
Condyloid synovial joint of the wrist – formed by the articular surfaces of the radius, ulna, scaphoid, lunate and triquetral

37. Anatomy Physis Epiphysis Growth plate Facilitates remodelling
Can cause deformity
Epiphysis
Cartilagenous
Radiolucent

38. Anatomy
Dorsal aspect
6 dorsal compartments (Wrist and digital extensor tendons)
Extensor carpi ulnaris
Extensor digiti minimi
Extensor digitorum
Extensor carpi radialis longus and brevis
Extensor policis longus
Extensor policis brevis
A: Dorsal section of the wrist, showing the six dorsal compartments of the extensor tendons.

39. Anatomy
B: Cross section of the wrist, showing the tendons, arteries, and nerves

40. Fracture Differences: Children vs. Adults
Growth disturbance
Shortening, angular deformity
Bone remodeling
Open physis
Angular deformity is realigned by asymmetrical growth of physis
The closer to physis, greater potential for spontaneous correction
Remodeling is faster in plane of joint motion
UE: fastest growth in upper and lower ends (e.g. proximal humerus, distal radius, ulna)
LE: fastest growth in middle (e.g. distal femur, proximal tibia, fibula)
Growth disturbance
Shortening, angular deformity
Bone remodeling
Open physis
Angular deformity is realigned by asymmetrical growth of physis
The younger the child and the closer the fracture site to physis, greater potential for spontaneous correction
Remodeling is faster in plane of joint motion
UE: fastest growth in upper and lower ends (e.g. proximal humerus, distal radius, ulna)
LE: fastest growth in middle (e.g. distal femur, proximal tibia, fibula)
Periosteum is thicker and remains intact on the side of bone toward which the distal fragment is displaced
Periosteal hinges facilitate reduction
Disrupting the hinge increases difficulty in maintaining reduction

41. Fracture Differences: Children vs. Adults
Bone remodeling
Periosteum is thicker and remains intact on the side of bone where the distal fragment is displaced
Periosteal hinges facilitate reduction
Disruption increases difficulty in maintaining reduction
Elasticity
Torus, greenstick
Growth disturbance
Shortening, angular deformity
Bone remodeling
Open physis
Angular deformity is realigned by asymmetrical growth of physis
The younger the child and the closer the fracture site to physis, greater potential for spontaneous correction
Remodeling is faster in plane of joint motion
UE: fastest growth in upper and lower ends (e.g. proximal humerus, distal radius, ulna)
LE: fastest growth in middle (e.g. distal femur, proximal tibia, fibula)
Periosteum is thicker and remains intact on the side of bone toward which the distal fragment is displaced
Periosteal hinges facilitate reduction
Disrupting the hinge increases difficulty in maintaining reduction

42. Fracture Differences: Children vs. Adults
Bone overgrowth
Fractures through diaphyseal metaphysis of a long bone stimulates longitudinal growth (increased blood supply to physis and epiphysis)
Rapid rate of healing
Thickened periosteum + Abundant blood supply
Younger child, more rapid union
Nonunion
Usually does not occur because of thick periosteum
Elasticity
More elastic (torus, greenstick)
Bone overgrowth
Fractures through diaphyseal metaphysis of a long bone stimulates longitudinal growth (increased blood supply to physis and epiphysis)
Rate of healing
Rapid due to thickened periosteum and abundant blood supply
Younger child, more rapid union
Nonunion
Usually does not occur because of thick periosteum

43. Distal Forearm Fractures
General Classification
Physeal fractures
Distal radius
Distal ulna
Distal metaphyseal (radius or ulna)
Torus
Greenstick
Complete fractures
Galeazzi fracture-dislocations
Dorsal displaced
Volar displaced

44. Physeal fractures

45. Salter-Harris Classification
I – Complete fracture through growth plate
II – Fracture through growth plate with extension to metaphysis
III – Fracture through growth plate with extension to epiphysis
IV – Fracture through epiphysis, growth plate, and metaphysis
V – Impaction fracture with collapse of growth plate A

46. Distal Fractures
A – Greenstick fracture: Transverse crack that retains its continuity
B – Torus fracture: Small buckle or impaction of one cortex with a slight bend on the opposite cortex.
C – Plastic deformation: Change in the natural shape of a bone without a detectable fracture line
Softer bone in children can lead to unique fracture behavior (in addition to the fracture patterns seen in adults). A: Greenstick fracture; B: torus fracture; C: plastic deformation

47. Frykman’s Classification
Frykman’s Classification of distal radius fracture
Classifies it according to:
The presence or absence of an ulnar-styloid fracture, and
Whether fracture lines are
extra-articular,
intra-articular involving the radio-carpal joint
Intraarticular involving distal radioulnar joint, or
Intrarticular involving both radiocarpal and distal radioulnar joint

48. AO Classification A: Extraarticular metaphyseal fracture
A1: Isolated fracture of distal ulna
A2: Simple radial fracture
A3: Radial fracture w/ metaphyseal impaction.
B: Intraarticular rim fracture
B1: Fracture of radial styloid
B2: Dorsal rim fracture
B3: Volar rim fracture
C: Complex intraarticular fracture
C1: Radiocarpal joint congruity preserved, metaphysis fractured
C2: Articular displacement
C3: Diaphyseal-metaphyseal involvement
Injury of the distal radioulnar joint is possible in any of these fractures:
A: Extraarticular metaphyseal fracture. Junction of the metaphysis and diaphysis is identified by the "square" or T method (greatest width on frontal plane of distal forearm; illustrated in
A1: Isolated fracture of distal ulna
A2: Simple radial fracture
A3: Radial fracture w/ metaphyseal impaction.
B: Intraarticular rim fracture (preserving the continuity of the epiphysis and metaphysis)
B1: Fracture of radial styloid
B2: Dorsal rim fracture (dorsal Barton's fracture)
B3: Volar rim fracture (reverse Barton's 5 Goyrand-Smith type 2, Letenneur).
C: Complex intraarticular fracture (disrupting the continuity of the epiphysis and metaphysis)
C1: Radiocarpal joint congruity preserved, metaphysis fractured
C2: Articular displacement
C3: Diaphyseal-metaphyseal involvement. It should be considered that injury of the distal radioulnar joint is possible in any of these fractures

49. Mason Classification of Radial Head Fractures
Type I – Non-displaced;
Type II – Displaced, usually involving a single large fragment;
Type III – Comminuted;
Type IV – Associated with an elbow dislocation
Treatment
Type I fractures – Non-operative treatment with early motion can generally produce a good outcome.
Type II fractures – Controversial
Nonsurgical treatment
With near normal motion, <2 mm step-off and without associated injury:
Open reduction and internal fixation can be performed with pins, articular screws, or Herbert screws
With associated injuries (may compromise elbow stability) or fractures with a mechanical block to full motion,.
Implants
should be placed into the nonarticular safe zone to avoid impingement on the sigmoid fossa of the ulna. The safe zone corresponds to the lateral 100° arc with the forearm in neutral rotation.
The result of ORIF is less predictable when there is more than one fragment in Type II fractures, and limitation of forearm rotation not attributable to implant prominence can be expected.
Type III fractures
Early excision with immediate motion with no associated elbow instability, coronoid fracture, wrist pain, or distal radio-ulnar joint injury
If with any 3 of above, then current literature recommends placement of a metallic radial head prosthesis

50. Colles’ Fracture Distal metaphysis of radius “Silver fork deformity”
Volar angulation
Dorsal displacement
Loss of radial inclination
Radial shortening

51. Smith’s Fracture Reverse Colles’ Fracture
Dorsally angulated distal radius fracture
Hand and wrist displaced volarly with respect to the forearm

52. Barton’s Fracture Intra-articular fracture dislocation
Carpus and a rim of the distal radius are displaced together

53. Chauffer’s fracture
Radial styloid fracture

54. Dislocation of Radiocarpal Joint
Carpal-ligamentous injury or fracture

55. Nightstick Fracture
Isolated Ulnar Fracture
Result from a direct blow

56. Monteggia Fracture
Injury involving fracture of proximal 1/3 of ulna w/ anterior dislocation of radial head
Classification
Type 1: fracture of ulnar diaphysis w/ anterior angulation and anterior dislocation of radial head (60%)
Type 2: Fracture of ulnar diaphysis w/ posterior angulation, posterior or posterolateral dislocation of radial head (15%)
Type 3: Fracture of ulnar metaphysis w/ lateral or anterolateral dislocation of radial head (20%)
Type 4: Fracture of ulna and radius at proximal 1/3 w/ anterior dislocation of radial head (5%)
Type 1 > Type 3 > Type 2
Radial N &/or posterior interosseus N injury

57. Galeazzi Fracture Fracture anywhere along length of radius
W/ or w/o ulnar fracture
W/ injury to distal radioulnar joint (DRUJ)
Styloid fractures
Radial shortening >5mm
DRUJ dislocation

58. Trauma Assessment

59. Trauma Assessment Primary survey (ABCDE) Resuscitation
Secondary survey
Definitive care

60. Orthopedic Examination
History
General examination
Neurologic examination
Muscle examination

62. Diagnostics
Imaging studies

63. Management “Clearing” the cervical spine Early total care
Damage control orthopedics (?)
Soft-tissue injuries and traumatic arthrotomies
Open trauma – flaps and soft-tissue coverage

64. Complications Acute respiratory distress syndrome Atelectasis
Pulmonary embolism and DVT
Compartment syndrome
Heterotopic bone formation

65. Common Fractures in Children

66. Case Discussion: Arm Injury
ASMPH 2012, Group 7
19 March 2011
Department of Orthopedics
The Medical City