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Upper Limb Trauma

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Upper Limb Trauma

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    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

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