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Paediatric Orthopaedic InjuriesPulled elbowDefinition: subluxation of radial headSx: history of being pulled; decr mvmt arm afterExamination: undistressed at rest; no tenderness; clinical diagnosisInvestigation: Xray appears normalMng: if unable to reduce, most will spontaneous reduce in 48hrs; recurrence rate 25-40% Supination/flexion technique: hold arm with thumb on radial head supinate and flex arm Hyperpronation method: hold elbow hyperpronate forearm with other hand; 95% success rateSalter Harris injuries258318024765Epidemiology: 15% long bone fractures in children occur at epiphyseal platePathology: epiphyseal plate is less strong than bone, ligaments and tendonII most common; V may be hard to diagnose; early reduction better; young children have greater growth disturbance; internal fixation across epiphysis incr risk of growth retardationEpidemiology: 15% long bone fractures in children occur at epiphyseal platePathology: epiphyseal plate is less strong than bone, ligaments and tendonII most common; V may be hard to diagnose; early reduction better; young children have greater growth disturbance; internal fixation across epiphysis incr risk of growth retardationI: Separate: through epiphysis , 5-7% reduction easy POP and ortho FU prognosis excellentII: Above: through epiphysis and metaphysis Most common, 75% reduction easy if <48hrs prognosis excellentIII: Low: intra-articular # into epiphysis, 7-10% accurate reduction needed, needs ortho review prognosis goodIV: Thru: intra-articular # into epiphysis and metaphysis, 10% accurate reduction needed, usually open reduction and internal fixation prognosis OKV: Eeek: crush inj to epiphysis; usually of knee / ankle; often joint effusion, significant MOI, <1% POP and ortho FU prognosis poorTorus #1783080139065= buckle #; buckling of periosteum but no # linePOP and ortho FU 1/520= buckle #; buckling of periosteum but no # linePOP and ortho FU 1/52Greenstick #1668780-1691640Cortical disruption and periosteal tearing on convex side of bone, with intact periosteum on concave side0Cortical disruption and periosteal tearing on convex side of bone, with intact periosteum on concave sidePlastric deformities= bowing / bending fractures; no disruption of periosteum / cortex; usually assoc with # elsewhere; needs ortho review for reduction and realignmentPaediatric elbow2545715-5879465 Appears ClosesC apitellum 1-3yrs 14yrsR adial head 3-4yrs 16yrs I nt epicondyle 5-6yrs 15yrsT rochlea 7-9yrs 14yrsO lecranon 9-10yrs 14yrsL at epicondyle 11-12yrs 16yrsXR interpretation:1. Ant humeral line should bisect capitellum in middle 1/3 on lateral; abnormal in supracondylar #, lat condyle2. Angle between line through centre of capitellum and ant humeral line should be 30-45deg3. Radio-capitellar line: Radial head should point towards capitellum on all views; abnormal in lat condyle, radial neck, Monteggia, elbow dislocation4. Baumann angle: angle between physeal line of lat condyle of humerus and line perpendicular to long axis of humeral shaft = 8-28degs; decr angle varus deformity; abnormal in supracondylar #5. Bowing of anterior fat pad6. Any posterior fat pad00 Appears ClosesC apitellum 1-3yrs 14yrsR adial head 3-4yrs 16yrs I nt epicondyle 5-6yrs 15yrsT rochlea 7-9yrs 14yrsO lecranon 9-10yrs 14yrsL at epicondyle 11-12yrs 16yrsXR interpretation:1. Ant humeral line should bisect capitellum in middle 1/3 on lateral; abnormal in supracondylar #, lat condyle2. Angle between line through centre of capitellum and ant humeral line should be 30-45deg3. Radio-capitellar line: Radial head should point towards capitellum on all views; abnormal in lat condyle, radial neck, Monteggia, elbow dislocation4. Baumann angle: angle between physeal line of lat condyle of humerus and line perpendicular to long axis of humeral shaft = 8-28degs; decr angle varus deformity; abnormal in supracondylar #5. Bowing of anterior fat pad6. Any posterior fat padSupra-condylar fracture humerus2354580-1634490Epidemiology: peak incidence 5-8yrs; most common paeds elbow fracture; most common # <8yrs; usually FOOSH (flexion type from fall of flexed elbow, rare)Pathology: distal fragment displaced posteriorly; significantly displaced # are surgical emergency (brachial art, median / radial / ulnar nerve at risk; nerve involvement in 6-16% Volkmann’s ischaemic contracture); risk of cmptmt syndrome00Epidemiology: peak incidence 5-8yrs; most common paeds elbow fracture; most common # <8yrs; usually FOOSH (flexion type from fall of flexed elbow, rare)Pathology: distal fragment displaced posteriorly; significantly displaced # are surgical emergency (brachial art, median / radial / ulnar nerve at risk; nerve involvement in 6-16% Volkmann’s ischaemic contracture); risk of cmptmt syndromeGartland classification: # in distal 1/3 of humerusType I: undisplaced # with evidence of jt effusion; ant and post periosteum intact; prognosis goodType II: displaced, but intact post periosteum; # visible anteriorly, hinging posteriorly; prognosis good IIb: as above + rotation; prognosis bad, need OTType III: displaced ant and post periosteum; no continuity between shaft and distal humerus; can displace postmed, postlat, antlat; prognosis bad, need OTMng: urgent ortho review if NV compromise; immediate ED reduction if cool / pale hand; ortho review if no pulse, but hand otherwise OK; to manipulate – traction at 20deg flexion flexion as far as possible while still retaining radial pulse Type I: wrist-shoulder backslab with elbow flexed 90deg for 4/52; OT preferred in adults as stiffness common, but otherwise not generally recommended; ortho FU within 48hrs Type II and III: need closed / open reduction by ortho Indications for reduction / manipulation: evidence of NV compromise / <50% bony apposition / dorsal angulation >15 deg / lat or medial tilt >10 deg / any rotational deformity / any varus or valgus deformity / compoundEpicondylar fractures of humerus Medial epicondyle (appears at 5-6yrs): 3rd most common paeds elbow #; most common 9-14yrs; 50% assoc with elbow dislocation; risk of medial epicondyle becoming trapped in jt, esp in spontaenously reduced elbow dislocation; needs OT if >1cm of articular surface, or ulnar nerve involvement; needs ortho reviewLateral condyle (appears at 11-12yrs): tend to be unstable; often also involves all of capitellum and ? of trochlea; due to varus stress on extended arm in supination; Milch I = Salter Harris IV; Milch II = Salter Harris II (into jt and lat part of trochlea), most common; OT if displaced, often required; ulnar nerve involvement; needs ortho reviewOther #’sClavicle: OT needed if medial 1/3, displaced lateral 1/3Prox humerus: more common in adolescents; manipulate if >30deg displacementMid humerus: assess radial nerve; uncommon; usually just POPOlecranon (appears at 9-10yrs): from fall on elbow; needs ortho review; OT if displaced >5mm; assoc with radial head/neck #Radial head/neck #: uncommon in children; neck >head; OT if >60deg angulation or >50% displacement; need ortho reviewElbow dislocation: neuro inj in 10%; post most common; ulnar / median nerve injRadial / ulnar shaft: OT if any rotational deformity, >10deg angulation >8yrs, >15-20deg angulation <8yrs; prox shaft injs are more unstableGRIMUR: Galeazzi #: radial shaft # + dislocation of inferior (ie. Distal) radio-ulnar joint Monteggia #: ulnar # + dislocation of radial headHip #: high risk of AVN and growth arrest; dislocations <10yrs can occur with low E traumaFemoral shaft #: peak in late-toddler and mid-teenage years; will not be cause of hypotension in young child# distal femoral physis: popliteal artery and peroneal nerve injTibial / fibula shaft #: OT if >10deg angulationToddler’s #: isolated spiral # of distal tibia; may not be obvious history of trauma; 1/3 most common long bone fracture in children?NAIClavicular # <2yrs, mid-humerus # in small children; femoral shaft # if not yet walkingNotes from: Dunn, TinTinBONES:? remember mnemonic Suspect Harm from Mother or Father? (3 fractures each, 12 types in total)S:? Sternum, scapular, spine or vertebraeH:? Humerus (other than supracondylar), hand (non-ambulating), head (skull fractures – multiple, non-parietal, complex, with associated brain injury)M:? Multiple fractures, metaphyseal corner fractures, metaphyseal bucket handle fracturesF:? Foot (non-ambulating), femur (non-ambulating), fractured ribstone tone ................
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