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2393956978650Supracondylar Fracture of Humerus00Supracondylar Fracture of Humerus15633709204960Pathology00Pathology25742909204960Distal fragment displaced posteriorly; significantly displaced fractures are surgical emergencies (brachial artery, median / radial / ulnar nerve at risk; nerve involvement in 6-16% Volkmann’s ischaemic contracture); risk of compartment syndrome00Distal fragment displaced posteriorly; significantly displaced fractures are surgical emergencies (brachial artery, median / radial / ulnar nerve at risk; nerve involvement in 6-16% Volkmann’s ischaemic contracture); risk of compartment syndrome15652758542655Epi-demiology00Epi-demiology25761958542655Peak incidence 5-8yrs; most common paediatric elbow fracture; most common fracture <8yrs; >95% FOOSH (flexion type, <5%, from fall on flexed elbow, rare, will have volar displacement)00Peak incidence 5-8yrs; most common paediatric elbow fracture; most common fracture <8yrs; >95% FOOSH (flexion type, <5%, from fall on flexed elbow, rare, will have volar displacement)53816256969760003778250697864900156083069786502463803223895X-Ray Interpretation00X-Ray Interpretation15608305494020Fat Pads: anterior displacement in 50% radial head / neck fractures; if posterior present, fracture in >95%Anterior humeral line: should bisect capitellum in middle 1/3 on lateral; abnormal in supracondylar fracture, lateral condyleRadio-capitellar line: line drawn through centre of radial shaft should transect radial head and capitellum; abnormal in lateral condyle, radial neck, Monteggia, elbow dislocationBaumann Angle: angle between physeal line of lateral condyle of humerus and line perpendicular to long axis of humeral shaft = 8-28°; ? angle varus deformity; abnormal in supracondylar fracturesAngle between line through centre of capitellum and anterior humeral line should be 30-45°00Fat Pads: anterior displacement in 50% radial head / neck fractures; if posterior present, fracture in >95%Anterior humeral line: should bisect capitellum in middle 1/3 on lateral; abnormal in supracondylar fracture, lateral condyleRadio-capitellar line: line drawn through centre of radial shaft should transect radial head and capitellum; abnormal in lateral condyle, radial neck, Monteggia, elbow dislocationBaumann Angle: angle between physeal line of lateral condyle of humerus and line perpendicular to long axis of humeral shaft = 8-28°; ? angle varus deformity; abnormal in supracondylar fracturesAngle between line through centre of capitellum and anterior humeral line should be 30-45°40132003223895001857375322389500717551158240002476501157605Paediatric Elbow 00Paediatric Elbow 15614651157605039535101452245C00C42119551452245Capitellum00Capitellum39535102020570I00I42113202020570Internal epicondyle00Internal epicondyle42125902599055Olecranon00Olecranon42119552307590Trochlea00Trochlea39535102599055O00O39535102307590T00T39535102886075L00L42132252886075Lateral epicondyle00Lateral epicondyle42125901739265Radial head00Radial head39535101739265R00R551751514516101-3yrs001-3yrs551815017386303-4yrs003-4yrs551688020199355-6yrs005-6yrs551751523069557-9yrs007-9yrs551815025984209-10yrs009-10yrs5518785288544011-12yrs0011-12yrs55168801158240Appears00Appears6367780145161014yrs0014yrs6368415173863016yrs0016yrs6367145201993515yrs0015yrs6367780230695514yrs0014yrs6368415259842014yrs0014yrs6369050288544016yrs0016yrs63671451158240Closes00Closes246380539750Elbow Fractures00Elbow Fractures 00 00 3105156411595Epicondylar Fracture of Humerus(beware ulnar nerve)00Epicondylar Fracture of Humerus(beware ulnar nerve)27508208146416Lateral condyle: 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 IVMilch II = Salter Harris II (into joint and lateral part of trochlea), most commonOT if displaced, often required; ulnar nerve involvement; needs ortho review00Lateral condyle: 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 IVMilch II = Salter Harris II (into joint and lateral part of trochlea), most commonOT if displaced, often required; ulnar nerve involvement; needs ortho review164973080854550016497306412230045612056412230Medial epicondyle: 3rd most common paediatric elbow fracture; most common 9- 14yrs; 50% associated with elbow dislocation; risk of medial epicondyle becoming trapped in joint, especially in spontaenously reduced elbow dislocation; needs OT if >1cm of articular surface, or ulnar nerve involvement; needs ortho review00Medial epicondyle: 3rd most common paediatric elbow fracture; most common 9- 14yrs; 50% associated with elbow dislocation; risk of medial epicondyle becoming trapped in joint, especially in spontaenously reduced elbow dislocation; needs OT if >1cm of articular surface, or ulnar nerve involvement; needs ortho review3105155078730Intercondylar Fracture of Humerus00Intercondylar Fracture of Humerus31400755078731Most common in adults; classified as T / Y / H depending on segments; associated with severe soft tissue injury00Most common in adults; classified as T / Y / H depending on segments; associated with severe soft tissue injury1649730507872900310515539750Supracondylar Fracture of Humerus00Supracondylar Fracture of Humerus16497304281805Comp-lications00Comp-lications26797004283075Radial (postmed) / median (postlat, especially anterior interosseous nerve which is motor only) / ulnar (less common) nerve (7%); Volkmann ischaemic contracture, compartment syndrome, non / malunion, myositic ossificans; absence of radial pulse initially in children is usually due to vasospasm00Radial (postmed) / median (postlat, especially anterior interosseous nerve which is motor only) / ulnar (less common) nerve (7%); Volkmann ischaemic contracture, compartment syndrome, non / malunion, myositic ossificans; absence of radial pulse initially in children is usually due to vasospasm16497303021330Manage-ment00Manage-ment26797003022600Urgent ortho review: NV compromise (eg. Altered pulse)Immediate ED reduction: cool / pale handManipulation: traction at 20° flexion flexion as far as possible while still retaining radial pulseIndications for manipulation: NV compromise / <50% bony apposition / dorsal angulation >15° / lateral or medial tilt >10° / any rotational deformity / any vagus or valgus deformity / compound fracture 00Urgent ortho review: NV compromise (eg. Altered pulse)Immediate ED reduction: cool / pale handManipulation: traction at 20° flexion flexion as far as possible while still retaining radial pulseIndications for manipulation: NV compromise / <50% bony apposition / dorsal angulation >15° / lateral or medial tilt >10° / any rotational deformity / any vagus or valgus deformity / compound fracture 1649730539750Gartland Classification00Gartland Classification26797002385695III00III30816552385695Displaced anterior and posterior periosteum; no continuity between shaft and distal humerus; can displace postmed, postlat, antlat; prognosis bad, need OT00Displaced anterior and posterior periosteum; no continuity between shaft and distal humerus; can displace postmed, postlat, antlat; prognosis bad, need OT30816552023110As above + rotation; prognosis bad, needs OT00As above + rotation; prognosis bad, needs OT26797002023110IIb00IIb26797001380490II00II30816551379855Displaced (usually posteriorly), but intact posterior periosteum; fracture visible anteriorly, hinging posteriorly; prognosis good; needs closed / open reduction by ortho00Displaced (usually posteriorly), but intact posterior periosteum; fracture visible anteriorly, hinging posteriorly; prognosis good; needs closed / open reduction by ortho2679700539750I00I3081655539750Undisplaced fracture with evidence of joint effusion; antetior and posterior periosteum intact; prognosis good; wrist-to-shoulder backslab with elbow flexed 90° for 4/52; OT preferred in adults as stiffness common, but otherwise not generally recommended; ortho FU within 48hrs00Undisplaced fracture with evidence of joint effusion; antetior and posterior periosteum intact; prognosis good; wrist-to-shoulder backslab with elbow flexed 90° for 4/52; OT preferred in adults as stiffness common, but otherwise not generally recommended; ortho FU within 48hrs310515436880Elbow Dislocation00Elbow Dislocation16129002289810Comp-lications00Comp-lications264287022910801/3 have fracture (eg. Coronoid process, radial head); 15% have medial epicondyle fracture (may become entrapped post-reduction, especially in children); 5-13% have NVI; 8% have brachial artery injury; 15% ulnar nerve injury (usually resolves with conservative treatment); radial and median nerve injury also occur; “terrible triad” = dislcoation + radial head and coronoid fracture001/3 have fracture (eg. Coronoid process, radial head); 15% have medial epicondyle fracture (may become entrapped post-reduction, especially in children); 5-13% have NVI; 8% have brachial artery injury; 15% ulnar nerve injury (usually resolves with conservative treatment); radial and median nerve injury also occur; “terrible triad” = dislcoation + radial head and coronoid fracture16224251437005Manage-ment00Manage-ment26523951438275Reduce with traction, correction of medial / lateral displacement, downward pressure on forearm and flexion with thumbs pushing on olecranon; may fail if radial head fracture; backslab in 90° flexion and sling for 1-2/52; should have FROM post-reduction – concern if locking / clicking Re: # / capsule tear etc…00Reduce with traction, correction of medial / lateral displacement, downward pressure on forearm and flexion with thumbs pushing on olecranon; may fail if radial head fracture; backslab in 90° flexion and sling for 1-2/52; should have FROM post-reduction – concern if locking / clicking Re: # / capsule tear etc…16224254368800296481542862590% postero-lateral; 85% have good functional outcome; 3rd most common large joint dislocationMOI: hyperextension, abduction Incomplete anterior and posterior ligamentous components ruptured Complete anterior, posterior and medial collateral ligaments ruptured0090% postero-lateral; 85% have good functional outcome; 3rd most common large joint dislocationMOI: hyperextension, abduction Incomplete anterior and posterior ligamentous components ruptured Complete anterior, posterior and medial collateral ligaments ruptured ................
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