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Distal Humerus Cases OTA RCFC 2.0 Presented by members of POSNA.

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Presentation on theme: "Distal Humerus Cases OTA RCFC 2.0 Presented by members of POSNA."— Presentation transcript:

1 Distal Humerus Cases OTA RCFC 2.0 Presented by members of POSNA

2 Case 1: 5 yo girl fell off the monkey bars. Dx.? Mech.? AIN out. AIN out. Pink, pulseless hand. Pink, pulseless hand.

3 Supracondylar Humerus Fractures 60% of elbow fractures in children under 7. 60% of elbow fractures in children under 7. 96% extension type, from fall on outstretched arm with elbow hperextension. 96% extension type, from fall on outstretched arm with elbow hperextension. 4% flexion type, from fall on olecranon with elbow flexed. 4% flexion type, from fall on olecranon with elbow flexed.

4 Case 1: 5 yo girl fell off the monkey bars. Class.? AIN out. AIN out. Pink, pulseless hand. Pink, pulseless hand.

5 Classification-Gartland Type I: Nondisplaced, +/- posterior fat pad sign. Where is PFPS? Significance? Type I: Nondisplaced, +/- posterior fat pad sign. Where is PFPS? Significance?

6 Posterior Fat Pad Sign PFPS is predictive of occult fracture in 76% of cases. PFPS is predictive of occult fracture in 76% of cases. The fracture is a supracondylar humerus about 50% of the time. The fracture is a supracondylar humerus about 50% of the time. Skaggs & Mirzayan, JBJS, Skaggs & Mirzayan, JBJS, 2001.

7 Classification-Gartland Type II: Angulated with intact posterior cortex. Type II: Angulated with intact posterior cortex.

8 Classification-Gartland Type II: Anterior humeral line anterior to middle of capitellum. Type II: Anterior humeral line anterior to middle of capitellum.

9 Classification-Gartland Type III: Displaced. Type III: Displaced. Usually posteromedially. Usually posteromedially.

10 Classification-Gartland Classification-Gartland Type IV: Multidirectional Unstable. Type IV: Multidirectional Unstable. Leitch, et al., JBJS, Leitch, et al., JBJS, 2006.

11 Classification-Gartland Flexion type. Flexion type.

12 Case 1: 5 yo girl fell off the monkey bars. How do you do a motor exam in a child? AIN out. AIN out. Pink, pulseless hand. Pink, pulseless hand.

13 Quick and Dirty Pediatric NV Exam Rock-Paper-Scissors-OK Rock-Paper-Scissors-OK Rock: Median Nv. Rock: Median Nv. Paper: Radial Nv. Paper: Radial Nv. Scissors: Ulnar Nv. Scissors: Ulnar Nv. OK: AIN. OK: AIN.

14 Neurologic Injury Incidence: ~7%. Incidence: ~7%. Anterior interosseous is most common nerve injured. Anterior interosseous is most common nerve injured. Decreased thumb IP and index DIP flexion. Decreased thumb IP and index DIP flexion.

15 Neurologic Injury: Median Nv. May become entrapped in fracture. May become entrapped in fracture. May mask compartment syndrome, because of associated forearm sensory loss. May mask compartment syndrome, because of associated forearm sensory loss.

16 Neurologic Injury: Ulnar Nv. Ulnar nerve injuries more common in flexion supracondylar fractures. Ulnar nerve injuries more common in flexion supracondylar fractures. Often iatrogenic. Often iatrogenic. Quantification of risk: “Number Needed to Harm” = 28 Quantification of risk: “Number Needed to Harm” = 28 For every 28 pts that have medial/lateral cross pinning vs lateral pins only, one child will sustain an iatrogenic ulnar nv injury. For every 28 pts that have medial/lateral cross pinning vs lateral pins only, one child will sustain an iatrogenic ulnar nv injury. Slobogean, et al., JPO, Slobogean, et al., JPO, 2010.

17 Case 1: 5 yo girl fell off the monkey bars. What else are you worried about? AIN out. AIN out. Pink, pulseless hand. Pink, pulseless hand.

18 Vascular Injury Incidence: ~1% (0.5-5%). Incidence: ~1% (0.5-5%). Maintain high index of suspicion. Maintain high index of suspicion. Perform careful physical exam. Perform careful physical exam.

19 Vascular Injury Indications for exploration: Indications for exploration: Clinically obvious ischemia (white, pulseless hand). Clinically obvious ischemia (white, pulseless hand). Loss of palpable/dopplerable pulse after fracture reduction. Loss of palpable/dopplerable pulse after fracture reduction. Use of arteriography controversial. Use of arteriography controversial. Treatment of “pink, pulseless” hand also controversial. Treatment of “pink, pulseless” hand also controversial.

20 Compartment Syndrome May be difficult to diagnose in kids. May be difficult to diagnose in kids. The Three A’s of compartment syndrome in children: The Three A’s of compartment syndrome in children: Anxiety. Anxiety. Agitation. Agitation. Increasing need for Analgesia. Increasing need for Analgesia. May occur even in open fractures. May occur even in open fractures.

21 Case 1: 5 yo girl fell off the monkey bars. Plan? AIN out. AIN out. Pink, pulseless hand. Pink, pulseless hand.

22 Treatment Gartland I: Casting in situ. Gartland I: Casting in situ. Long arm cast or splint in ° flexion for 3-4 weeks. Long arm cast or splint in ° flexion for 3-4 weeks. Gartland II & III: Closed reduction and percutaneous pinning. Gartland II & III: Closed reduction and percutaneous pinning.

23 Closed Reduction Technique

24 Percutaneous Pinning Crossed pins vs. Lateral: No biomechanical difference in stability if proper technique and pin placement utilized. Crossed pins vs. Lateral: No biomechanical difference in stability if proper technique and pin placement utilized. Skaggs, et al., JBJS, Skaggs, et al., JBJS, Davis, et al., CORR, Davis, et al., CORR, Hamdi, et al., JPO, Hamdi, et al., JPO, Try to make the 2 lateral pins divergent. Try to make the 2 lateral pins divergent. Try not to have pins cross at the fracture site. Try not to have pins cross at the fracture site. Size matters: Pins should be at least the thickness of the cortex. Size matters: Pins should be at least the thickness of the cortex.

25 Closed Reduction/Percutaneous Pinning: 2 Pins

26 Closed Reduction/Percutaneous Pinning: 3 Pins

27

28 Went to OR for CR/PP Had white pulseless hand after reduction. Had white pulseless hand after reduction. Cap refill and weak dopplerable pulse after pinning. Cap refill and weak dopplerable pulse after pinning. Now what? Now what?

29 Vascular Surgery Consult in OR Underwent duplex U/S: Underwent duplex U/S: Did well post op: Did well post op: Pulse returned pod # 2. Pulse returned pod # 2. AIN back at 8 weeks. AIN back at 8 weeks.

30 Can you wait to operate? It depends… Must have a normal N/V exam. Must have a normal N/V exam. Must not have severe swelling. Must not have severe swelling. Must still be considered urgent. Must still be considered urgent. NPO status may be a factor in the decision. NPO status may be a factor in the decision.

31 Complications Ulnar nerve injury. Ulnar nerve injury. Cubitus Varus. Cubitus Varus. Loss of reduction. Loss of reduction. Pin site problems (rare!) Pin site problems (rare!) Most complications can be avoided with attention to detail. Most complications can be avoided with attention to detail.

32 Case 2: 7 yo girl fell off monkey bars. Diagnosis?

33 Lateral Condyle Fractures 17% of elbow fxs. in children. 17% of elbow fxs. in children. Peak incidence: 5-10 years of age. Peak incidence: 5-10 years of age. Mech: Varus stress to extended elbow, with forearm supinated. Mech: Varus stress to extended elbow, with forearm supinated.

34 Lateral Condyle Fractures: PE Lateral swelling and tenderness. Lateral swelling and tenderness. Much less prone to NV injury than SCHFs. Much less prone to NV injury than SCHFs.

35 Case 2: 7 yo girl fell off monkey bars. Classification?

36 Lateral Condyle Fractures: Jakob Classification Stage I: Nondisplaced. Stage I: Nondisplaced. Stage II: Hinged. Stage II: Hinged. Stage III: Rotated. Stage III: Rotated.

37 Case 2: 7 yo girl fell off monkey bars. Treatment?

38 Lateral Condyle Fractures: Treatment Non-displaced fxs. can be treated with cast immobilization at 90° flexion and supination. Non-displaced fxs. can be treated with cast immobilization at 90° flexion and supination. Frequent follow-up and re-imaging is necessary, to watch for late displacement and subsequent need for operative Rx. Frequent follow-up and re-imaging is necessary, to watch for late displacement and subsequent need for operative Rx.

39 Healed uneventfully.

40 Fell off monkey bars again 5 mo later. Class.? Rx.?

41 Lateral Condyle Fractures: Treatment Open reduction and percutaneous pinning for displaced fractures. Open reduction and percutaneous pinning for displaced fractures. It is necessary to visualize the anterior joint line/articular surface prior to fixation. It is necessary to visualize the anterior joint line/articular surface prior to fixation. 2-3 lateral pins: 2-3 lateral pins: Across capitellum to medial epicondyle. Across capitellum to medial epicondyle. At 45° angle to first pin, exiting medially and proximally. At 45° angle to first pin, exiting medially and proximally.

42 Lateral Condyle Fractures: Treatment Arthrogram may be helpful in determining extension into the joint and need for open reduction. Arthrogram may be helpful in determining extension into the joint and need for open reduction.

43 Underwent open reduction and percutaneous pinning. Critique?

44 Procedure/Positioning n Patient supine on radiolucent table. n C-arm comes in perpendicular, from across the table. n Alternatively, hand table with C-arm coming in from the end may be used.

45 Procedure/Approach n Kocher Approach: Slightly curvilinear incision centered over the lateral condyle. Slightly curvilinear incision centered over the lateral condyle. Internervous plane between the extensor carpi ulnaris and the anconeous. Internervous plane between the extensor carpi ulnaris and the anconeous. Stay anterior: avoid posterior stripping in order to preserve trochlear/capitellar blood supply. Stay anterior: avoid posterior stripping in order to preserve trochlear/capitellar blood supply. Open capsule anteriorly and extend distally to radial head. Open capsule anteriorly and extend distally to radial head.

46 Procedure/Reduction & Fixation n Clean fragment ends. n Reduce using dental pick or towel clip. n 2 pins placed percutaneously from posterior to incision: Across capitellum to medial epicondyle. Across capitellum to medial epicondyle. At 45° angle to first pin, exiting medially and proximally. At 45° angle to first pin, exiting medially and proximally. At least 0.062” diameter. At least 0.062” diameter.

47 Procedure/Tools n You must see all the way to the medial side of the joint, to assess reduction at the most medial extent of the fx. Useful tools to facilitate this: Mini-Hohmanns or Chandlers. Mini-Hohmanns or Chandlers. Dental Mirror. Dental Mirror. Head Lamp. Head Lamp.

48 Pearls & Pitfalls n The fracture often performs the approach for you. n The distal fragment may flip…be certain you have the articular cartilage oriented properly. n There is sometimes lateral metaphyseal communition that appears as displacement…it is important to assess reduction at the joint line, not the metaphysis. n Try to reapproximate lateral soft tissues to decrease lateral spur formation.

49 Went on to non-union. Now what?

50 Underwent bone grafting in situ and internal fixation.

51 Lateral Condyle Fractures: Complications Prone to: Prone to: Late displacement. Late displacement. Mal/Nonunion. Mal/Nonunion. Growth disturbance. Growth disturbance. Late deformity. Late deformity. Loss of ROM. Loss of ROM.

52 Healed uneventfully.

53 Removal of hardware 6 mo later.

54 One year later, sustains SCHF on contralateral side. Class.? Rx.?

55 Treated with closed reduction and casting

56 Final f/u SCHF 8 mo post-injury

57 Final f/u lat con about 2 yrs post- injury

58 Did well clinically. With full ROM and no pain bilaterally. Did well clinically. With full ROM and no pain bilaterally.

59 Case 3: 9 yo boy injured L. elbow wrestling, 2 weeks ago. Dx.?

60 Medial Epicondyle Fractures 10% of elbow fractures. 10% of elbow fractures. Peak incidence: 9-15 years of age. Peak incidence: 9-15 years of age. Mech: Fall on extended elbow, with valgus stress. Mech: Fall on extended elbow, with valgus stress.

61 Medial Epicondyle Fractures Avulsion of medial epicondyle from the distal humerus by the wrist flexors. Avulsion of medial epicondyle from the distal humerus by the wrist flexors. Usually a SH I or II. Usually a SH I or II. Can be associated with an elbow dislocation. Can be associated with an elbow dislocation. The medial epicondyle can be entrapped in the joint. The medial epicondyle can be entrapped in the joint.

62 Medial Epicondyle Fractures Reduction maneuver to remove epicondyle from joint: Reduction maneuver to remove epicondyle from joint: valgus stress on elbow. valgus stress on elbow. supination of forearm. supination of forearm. dorsiflexion of wrist and fingers. dorsiflexion of wrist and fingers.

63 He had been seen by an outside MD, who got an MRI. Plan?

64 Medial Epicondyle Fractures Need for reduction/fixation of epicondyle controversial: Need for reduction/fixation of epicondyle controversial: Displacement: >1cm. Displacement: >1cm. Angulation: >45°. Angulation: >45°. Instability: +/- Stress film. Instability: +/- Stress film. Athletic ability/aspirations. Athletic ability/aspirations. Associated with elbow dislocation. Associated with elbow dislocation. ? Risk of tardy ulnar nv. palsy. ? Risk of tardy ulnar nv. palsy.

65 Medial Epicondyle Fractures Reduction can be closed or open. Reduction can be closed or open. Fixation can be percutaneous or open. Fixation can be percutaneous or open. Fixation can be k- wires or a screw. Fixation can be k- wires or a screw.

66 Underwent ORIF. Note how far posterior the medial epicondyle is: screw oriented P to A on lat xray!

67 Questions?


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