1 / 30

Upper Limb Trauma

sulwyn
Download Presentation

Upper Limb Trauma

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    1. Upper Limb Trauma Mr Matthew Barry MS FRCS(Orth) Consultant Orthopaedic Surgeon

    2. Overview Rockwood & Wilkins Fractures in Children 23 topics in Upper Limb section = 1min 18 seconds per topic !

    3. Proximal humerus fracture Uncommon: <5% all fractures Classification Anatomic location Physis Metaphysis Tuberosity Cause Birth injury Fall Direct blow

    4. Birth Injuries Injuries include: Clavicle (95%) Proximal humerus Epiphyseal separation of the distal humerus Femur Analgesia & minimal splintage = rapid union. Almost any position is acceptable

    5. Proximal Humerus fracture Fall onto out-stretched arm or direct trauma Physeal # usually S&H I or II Metaphyseal # Management Proximal humerus has a thick periosteal layer and rapid remodelling for most fractures can be expected. <12 years (approx) conservative Rx with C&C > 12 = nearing skeletal maturity

    6. Proximal Humerus fracture Surgical management Indications: displaced metaphyseal # = off ended (Angulation more acceptable) Displaced physeal fractures Management MUA ? open reduction Percutaneous stabilisation K wires Retrograde elastic nails

    7. Supracondylar fracture Classification Management Timing of surgery The pulseless limb

    8. Supracondylar fracture Flexion Extension (98%) Gartland (1959) I II (A=rotationally stable. B=unstable) III (posteromedial or posterolateral)

    9. Gartland III Supracondylar # Displacement may be: Posteromedial 36% Posterior 27% Posterolateral 37% So what? Posterolateral displacement Brachial artery injury Median nerve injury Posteromedial displacement Radial nerve injury

    10. Supracondylar fracture n=291 Boys 64% Mean age: 6.4 years Neurological symptoms 4% Absent pulse 2% Open # 2%

    11. Supracondylar fracture Clinical features History Examination Defomity pucker sign Distal neurovascular exam

    12. Supracondylar fracture Management Gartland I C&C Gartland II ?C&C ? MUA ? k wires Gartland III MUA + k wires

    13. K wires 2 lateral 3 lateral Crossed ??????????????????

    14. K wires 2 Lateral Avoids ulnar nerve ? less stable -add 3rd wire Crossed ? more stable Ulnar nerve at risk

    15. Ulnar nerve As the elbow is flexed the ulnar nerve moves towards the medial epicondyle So make a small incision and confirm the position of the nerve !

    16. K wires UK review of paed ortho surgeons 93% MUA and wires 84% crossed wires 10% lateral wires Southampton protocol If protocol followed then good result. If not followed then poor result

    17. K wires RCT lateral vs crossed wires Mininder et al JBJS 2007; 89A: 706 2 lateral 6/28= 21% lost reduction Crossed 1/24 = 4% lost reduction

    18. Timing of surgery > 8 hour delay DOES NOT increase rate of open reduction Mehlman et al JBJS 2001; 83A: 323 > 12 hour delay DOES NOT increase rate of open reduction Gupta et al JPO 2004; 24: 245 Quality of reduction NOT affected by > 8 hour delay Carmichael et al. Orthopedics 2006; 29:628 > 8 hour delay DOES increase rate of open reduction Walmsley et al JBJS 2006; 88B :528 Compartment syndrome after 22 hour delay in 11 cases Ramachandran et al JBJS 2008; 90B: 122

    19. Open reduction 22% may require open reduction Mangwani et al. JBJS 2006; 88B: 362-365 Approach Posterior triceps split Lateral / Medial Anterior

    20. The pulseless limb COLD Immediate operation Reduce & k wire Extend arm WARM Emergent operation Reduce & k wire Extend arm

    21. The pulseless limb Angiography - NO! wastes time. Reduction will usually restore the pulse The arterial injury will be at the fracture site Intra-operative doppler may help No pulse but doppler signal = return to ward Pulse oximetry ????

    22. Forearm fracture Epidemiology Management

    23. Epidemiology 3% to 6% all childrens fractures Site 75% distal third 15% mid third 5% prox third 5% Monteggia Age Boys: bimodal Girls: 5-6 years

    24. Management POP ORIF Banjo traction Ex-fix Elastic nail

    25. Forearm - POP Advantages Safe Cheap No scars WORKS! Disadvantages ? joint stiffness Loss of position ~ 5% of fractures require additional stability

    26. Forearm - ORIF Advantages Anatomical reduction Early mobilisation Disadvantages Scars Neuro-vascular injury 2nd GA to remove plate Re-fracture

    27. Forearm Ex-fix Very few reports in literature Not a real option

    28. Forearm Elastic Nail Advantages Excellent stability Early mobilisation Small scars Low re-fracture rate Disadvantages 2nd GA to remove nails Cost

    29. Conclusions Proximal humeral fractures Conservative Rx Supracondylar fractures Gartland III must be K wired Probably OK to leave overnight if NV intact Forearm fractures POP works for most cases Elastic nails

More Related