Case Discussion: Arm Injury

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

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 forearmand 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 • 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 anictericsclerae, 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 adynamicprecordium 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 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 Rule in Rule out n/a • 14, M • Fall, outstretched arm • With right wrist deformity (volar deformation) • X-ray

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

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

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

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

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, ulnarstyloid, 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

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 genuvalgum (knock-knee)

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

35. Pediatric Fractures • Increased risk • 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 Lunatefossae • Sigmoid notch  ulna • Articular cartilage • Radial styloid • I of brachioradialis • O of radial scapholunate, radial lunocapitate ligaments

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

38. Anatomy • Dorsal aspect • 6 dorsal compartments (Wrist and digital extensor tendons) • Extensor carpiulnaris • Extensor digitiminimi • Extensor digitorum • Extensor carpiradialislongus and brevis • Extensor policislongus • Extensor policisbrevis

39. Anatomy

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)

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

42. Fracture Differences: Children vs. Adults • Bone overgrowth • Fractures through diaphysealmetaphysis 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

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

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

47. Frykman’s Classification

48. AO Classification • A:Extraarticularmetaphyseal 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

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

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