FRACTURES AND DISLOCATIONS OF THE UPPER LIMB IN CHILDREN
Bony injuries in children are different from adult because their bone is different from adult as they have an epiphysis and they are still growing
Fractures and related childhood injuries you should be aware of the following 1- Epiphyseal injuries 2- Forearm bone fractures 3- Supracondylar fractures 4- Condylar fractures 5-Pulled elbow
What are the difference between pediatric and adult bones
they are different in 1- Higher water content 2- Lower mineral content 3- Greater elasticity 4- Weaker than paediatric ligaments so more fractures fewer sprains
What are the causes of failure of peadiatric bone under load conditions
Compression causes Buckle or torus fractures at metaphysis - diaphysis junction
Bending causes Greenstick fractures and Compression on one side (cortex and periosteum intact) cortex fractured on tension side
Torsion In young children causes diaphyseal spiral fractures eg. tibial fractures in toddlers and in older children causes epiphyseal injuries
Children are not merely small adults. and this is particularly true with fractures and dislocation of the upper limb. Although superficially the injuries may appear to be the same. the pattern and prognosis of the injuries are often very different. Fractures of the proximal humerus in adults are a major problem; they are often complicated by non-union, avascular necrosis and a poor functional outcome. and so the patient may require joint replacement. In children the fracture usually represents an epiphyseal injury and the prognosis is very good. often without treatment, despite significant angulation at the fracture site. Shoulder dislocation, a common adult condition, is very uncommon in children. Apparent dislocations in children are often due to epiphyseal fractures and again may not require treatment. When trying to interpret radiographs. you will need to check the ossification centres visible at each age and their relationship to one another if you are to make an accurate diagnosis
A large part of the body of the scapula is ossified at birth. A secondary ossification centre appears in the coracoid during the first year and and fuses by about the 15 th year the acromion usually develops two ossification centres with all ossification centres fused by about the age of 20 years. These may be confused with fractures on radiographs or predispose to epiphyseal separation. Failure of fusion of the acromion resulting in an os acromiale occurs in about 5% of the population, although there are a number of different reports of the incidence in the literature
The clavicle develops two ossification centres around the fifth to sixth week of fetal life. These fuse within a few weeks of their appearance; failure of this may produce a congenital pseudoarthrosis of the clavicle. A secondary ossification centre appears in the medial end of the clavicle in the late teens. An epiphyseal injury may occur before the appearance of this ossification centre giving the appearance of a sternoclavicular dislocation. This epiphysis fuses by about the age of 25 years. The lateral end occasionally develops a secondary ossification centre at the age of 18-20 years. This is usually small and rapidly fuses to the shaft.
The shaft of the humerus is evident at birth, with the head
appearing by about 6 months. The greater and lesser tuberosities appear around the ages of 2 and 5 years respectively, and fuse by the age of about 6 year) to produce a conical growth plate. In children under the age of 6 years fracture through this growth plate is usually a alter-Hams type I injury, as before the tuberosities fuse the growth plate is more transverse. In the older child a Salter-Harris type II fracture occurs through the conical growth plate. This proximal growth plate accounts for 80% of the humeral growth.
There are six ossification centres around the elbow, and the
usual order of appearance is shown in below together with
the approximate time of appearance. In general, ossification centres appear earlier in females than in males
The shafts of both the radius and ulna are evident at birth.
Ossification centres and the approximate age of appearance
Capitellum by 2 years
Proximal radial epiphysis 4-6 years
Medial epicondyle 5-9 years
Olecranon 8-10 years
Lateral epicondyle 8-13 years
With any childhood injury the possibility of child abuse must always be considered. In general this does not apply to injuries around the shoulder, as most of these injuries occur in those over 5 years old, an age at which child abuse resulting in fractures is uncommon. In the under 5-year-old, a proximal humerus fracture is rarely due to child abuse, although clavicle fractures especially in those under 18 months should be viewed with suspicion. Spiral fractures of the humerus in young children should also be considered as possible non-accidental injuries, although distal humeral fractures and elbow fractures in general are not usually due to child abuse. If. however, the mechanism of injury does not fit the history given or there was a significant delay in presentation, then non-accidental injury should be considered .In a child of any age, an open fracture must be treated by operative debridement and stabilisation of the fracture site. In children, as in adults, polytrauma is a relative indication for surgical treatment.
Summary of Upper arm fractures in children
• Injury patterns are different from adults
• Epiphyseal injuries are common
• The prognosis is good with non-operative treatment even in angulated fractures
• A knowledge of the ossification centres helps the interpretation of radiographs
Fractures which raise the suspicion of non accidental injury in children are
• Fractures in the clavicle of a child under 18 months old
• Spiral fractures of the humerus
• Delay in presentation with any fracture
The risk of at least one fracture up to the age of 16 years in a boy has been reported to be 42%. In girls, the quoted figure is 27%. Of these, fractures of the distal forearm are the most common, accounting for about 20% of the total. Fractures of the clavicle account for 8%, the fourth most common site of fracture In children, with the midshaft of the forearm and the supracondylar region of the humerus both causing about 3% of the fractures. The proximal humerus accounts for 2%, and other fractures around the shoulder account for less than I % of all childhood fractures.
Dislocations of this joint are rare in children and most apparent dislocations, even in adults up to the age of about 25 years,
represent epiphyseal separations. True dislocations and epiphyseal injuries can be manipulated and are often stable. even if unstable fixation of these injuries should be avoided, Internal fixation may damage nearby structures with disastrous results. and wires should be avoided as migration into the chest has been reported. Rapid healing and remodelling will occur. Posterior displacement may be a surgical emergency if vital structures are compromised.
Fractures of the clavicle
Fractures of the medial end of the clavicle are considered above.
Fractures of the shaft of the clavicle account for the majority of clavicle fractures. Many are caused by a fall on the outstretched hand; a bicycle.climbing frame. or bunk bed is commonly involved. Green-stick fractures commonly occur and may be missed on initial radiographs. Temporary rest in a sling for a short period is all that is required for most of these fractures. Displaced fractures of the clavicle are very common but rarely require reduction. In many countries, including many American centres, attempts are made to reduce the displacement with a figure-of-eight bandage to retract the scapula. To be effective this has to be tight, often uncomfortably tight, and needs constant adjustment. A broad arm sling for 2-3 weeks until comfortable is all that is required. Malunion is very common but rarely a functional problem; non-union is very uncommon in children. Relatives can be reassured that the prominent callus will usually resolve over the subsequent months.
Open reduction and fixation with wires or a plate may be required. The indications are similar to those in the adult; open fracture, skin compromise, vascular injury,etc.
Fractures of the lateral end of the clavicle may also be confused with joint dislocations, as discussed below.
Fractures of the shaft of the clavicle In children
• Most caused by a fall
• Splintage to achieve reduction is cruel and unnecessary
• Malunion is common but the bones remodel
• Non-union is rare
True dislocations of this joint are unusual in children. especially in the younger child. The ligaments around the joint are very strong and often the lateral end of the clavicle will fracture. although this may not be apparent on radiographs if unossified. Even with true dislocations the inferior periosteum may be left behind with the cornoid and trapeziod ligaments intact. These will heal and remodel with conservative treatment, with a sling for comfort followed by early mobilisation.
In children, as in adults, fractures of the body of the scapula are uncommon injuries and usually represent direct violence. The significance of this injury is the likely injury to the chest wall and possible pulmonary contusion rather than the scapula fracture itself. These injuries will almost always be treated conservatively with analgesia and a sling for comfort. The arm should mobilised as comfort allows.
Fractures of the glenoid are also very uncommon injuries children.
Dislocation of the glenohumeral joint
Shoulder dislocation in children is unusual except in the adolescent as the ligaments are Stronger than the epiphysis usually a Salter-Harris fracture of the proximal humerus occur. In adolescents, as in adults, glenohumeral dislocation commonly due to a sporting injury and is nearly always an anterior dislocation. Treatment is along adult lines with early closed reduction using standard techniques. The redislocation rate is age related and is higher in the child or adolescent. with a recurred dislocation rate of 70-80% reported in the age group 12-16 years Approximately 50% of these patients require a stabilisation procedure. A traumatic dislocations can occur in children with joint laxity or connective tissue disorders.
Rarer shoulder injuries in children
• Distal clavicle epiphysis subluxes before acromioclavicular joint is damaged
• Scapula injuries may be associated with chest wall injuries and pulmonary contusions
• The proximal humeral epiphysis usually gives before the glenohumerol joint dislocates
Fractures of the proximal humerus usually occur in the older child or adolescent. Not only are accidents more common at this age but the perichondral ring may be weaker just before skeletal maturity. The majority of injuries occurs through the growth plate; Salter-Harris type II in the older child and type in the younger child . In the younger child, child abuse should be considered, although humeral shaft fractures are more common in child abuse. Salter-Harris type III and IV are very uncommon injuries of the proximal humerus.
Fracture displacement is common and is due to the pull of the
pectoralis major attaching to the distal fragment which tends to pull it anteriorly and medially. Although residual shortening is common, the majority of patients will have satisfactory functional results. It has also been reported that manipulation of a displaced fresh fracture did not improve the final outcome when humeral growth or function was assessed.
Proximal humeral fractures In children
• Usually Salter-Harris II epiphyseal plate injuries
• The fracture is best left to remodel
Treatment therefore is generally conservative; not only because of the remodelling potential but also because of the mal alignment that can be accepted around the shoulder generally. Forty-five degrees of angulation and 50% of displacement can be accepted. In the younger child ,70% angulation and any bony contact should heal with good functional results. The fracture is usually treated in a collar and cuff sling, although rarely a hanging cast may be used in the older child with significant shortening or agulation.
If the position is unacceptable closed reduction is attempted .and the fracture held with two or three wires. These wires can be removed after 3 weeks.
Open reduction may occasionally be required for soft-tissue interposition of the biceps tendon and this can be achieved through a standard deltopectoral approach. Fracture stabilisation is carried out as described as above.
This may occur with direct trauma or may occur as a pathological fracture, classically through a unicameral bone cyst.
• displacement is not usually significant; angulation may occur but rarely produces a functional problem. The fractures usually heal rapidly with conservative treatment in a sling. The proximal humerus is the only common site for pathological fractures around the shoulder.
Humeral shaft fractures
These injuries are less common in children than in adults. The fracture is usually transverse or short oblique in pattern, and is due to direct violence; an appropriate history should be available.non-accidental injury should always be considered with this injury, particularly in the younger child or with spiral fractures which are due to a twisting force.
The vast majority of fracture can be treated conservatively with either a simple collar and cuff or a plaster U-slab, Union is usually rapid particularly in the younger child considerable remodelling can occur and so malunion rarely results in a functional problem non union is uncommon in children internal fixation is occasionally required for open fractures associated vascular injuries and the poly trauma patient
Supracondylar fractures of the humerus
This is the most common fracture around the elbow in children and usually occurs in children under the age of 10 years. The injury is usually due to a fall on the outstretched hand with an extended elbow and this results in a hyperextension injury with posterior angulation, with or without posterior displacement of
the distal fracture. Between 1% and 5% of supracondylar fractures are caused by a flexion injury and associated with an anterior deformity,
Displaced fractures are readily diagnosed by plain radiographs but angulated fractures may be difficult to assess. Comparison views of the other elbow can be taken but a number of radiographic line can be assessed on the injured elbow a follows
Capitellum angle. The capitellum is normally angulated and displaced anteriorly to the humeral shaft. In the normal elbow, a line drawn through the centre of the capitellum Joins a line drawn down the humeral shaft at an angle of 30 degree. Anterior humeral line. A line drawn along the anterior cortex should pass through the central portion of the capitellum.
Anterior coronoid line. A line drawn along the coronoid process of the ulna should just pass through the anterior portion of the capitellum.
All of the above lines are drawn on true lateral radiographs. In addition, on a true anteroposterior view. Bauman's angle can be assessed. This is the angle formed between the growth plate of the capitellum and a line perpendicular to the humeral shaft. The normal angle is approximately 30degree and can be used to assess the adequacy of reduction of a fracture .
As noted above, supracondylar fractures can be divided into extension types and the much less common flexion types. Extension types are further subdivided into three types dependent on the angulation and displacement
Type 1 - the fractures are undisplaced but the radiographic lines should be carefully assessed to confirm this .
Type 2 - the fractures are angulated posteriorly, but the posterior periosteum remains intact, and prevents displacement and overlap of the fracture fragments.
Type 3 - the fractures are completely displaced with shortening and overlap of the fragments.
Type 1 fractures can be treated conservatively in a collar and cuff, with 90 degree of flexion at the elbow. This is maintained for 2-3 weeks, with a check radiograph taken after 1 week. As with the initial film, the undisplaced nature of the fracture should be confirmed by plotting the appropriate lines.
Type 2 fractures should be treated by closed reduction if the position is unaccepted thirty degree of extension can be accepted due to remodelling that will occur in the younger child Bauman,s angle should be corrected if there is any varus or valgus deformity as this will not remodel significant rotational deformity is uncommon with this type of fracture reduction is usually straight forward and the position can be maintained with the elbow at 90 degree rarely wires may be required to hold unstable reduction
Type 3 fractures usually require reduction but this is often difficult and the fracture site is commonly unstable after reduction with a significant rotational element under general anaesthetic traction is applied to the supinated forearm the mediolateral displacement of the distal fragment is reduced by direct finger pressure and the carrying angle restored by
comparison with the uninjured side. The extension element of the fracture is the last thing to be corrected by flexing the elbow maximally while applying posterior pressure to the distal fragment. The reduction should. be confirmed radiographically. However, the X-ray source rather than the arm should be
moved to obtain the views. This avoids the risk of fracture displacement if the arm is rotated If the reduction is satisfactory, the position can be maintained, by maximum flexion but this may cause vascular compromise, and, loss of reduction may occur if the elbow extends. It has been recommended by a number of authors that the reduction should be held by two wires. Cross wires through both condyles may be used but care must be taken to avoid an ulnar nerve palsy, as the nerve may be difficult to locate in the swollen elbow. An open technique may be used on the medial side, or the wire may be inserted; through an anterior starring point. Alternatively, two wires may be inserted from the lateral side but biomechanically this is not as strong a fixation.
Failure to obtain a reduction is an indication for open reduction but in the very swollen elbow, traction is a better option. This may be temporary, until the swelling reduces, but can be used as definitive method of treatment. Traction may be applied using bone crew inserted into the ulna, or by longitudinal skin traction Surprisingly, the patient becomes relatively pain free very quickly .
Vascular injury Occlusion of the brachial artery is an uncommon but serious complication. Despite the absence of a radial pulse the arm has a good collateral supply and will not necessarily become ischaemic. Both skin temperature and colour should be assessed, together with Doppler investigation of the pulse
The treatment of vascular compromise is early reduction of fracture under general anaesthetic. If the pulse returns the arm should be monitored carefully. Failure of circulatory return is an indication for exploration of the artery and fracture site,with open reduction and internal fixation with wires. An arteriogram may be obtained but should not be allowed to delay exploration
Neurological injury Transient neurological problems are relatively common after supracondylar fractures. The radial nerve is reported to be the most commonly affected, followed by the median nerve. Treatment is conservative for 3 months initially with good recovery expected.
Volkmann,s ischaemic contracture Flexion contractures of the fingers and wrist are caused by fibrosis of the anterior compartment of the forearm due to a missed compartment syndrome. It can usually be prevented by avoiding immobilisation in excessive flexion of the elbow. If greater than 90 degree of flexion is required to maintain a reduction, the reduction should be held by wires and the elbow extended.
Disproportionate pain in the forearm, particularly on passive extension of the fingers,should be treated by immediate release of all dressings, even if this compromises the reduction. If pain persists fasciotomy is indicated.
Malunion Some degree of malunion is relatively common after supracondylar fracture. A flexion or extension deformity will remodel and observation is indicated. Varus malunion, with a gunstock deformity, is unsightly but is usually not a functional problem. Corrective osteotomies, if necessary,should probably be delayed until skeletal maturity. Valgus deformity may be associated with a tardy ulnar nerve palsy and may require treatment.
Summary of Supracondylar fractures in children
•common after fall on outstretched hand
• Radiograph interpretatioin difficult
• Varus or valgus malunion will not remodel
• Traction is safe early management while the swelling settles
• Brachial artery occlusion requires immediate reduction and close observation
• compartment syndrome must be identified and treated early
Condylar and epicondylar fractures
Lateral condyle fractures
This is a relatively common injury and, after supracondylar fractures, is the second most common elbow fracture in children. It is usually due to a fall on the outstretched hand. Although this injury can occur in younger children the diagnosis is usually apparent on plain radiographs due to the early appearance of the ossification centre of the capitellum
Lateral condyle fractures in children
• Common after fall on outstretched hand
• Early appearance of ossification centre makes diagnosis easy
• Open reduction and internal fixation is needed for displaced fractures
• Non·union may lead to a valgus deformity
Classification Milch has classified this injury based on the location of the articular fracture. A type I fracture either passes through the ossification centre of the capitellum or just passes through the aspect of the trochlea. In either case the majority of the trochlea is intact and the elbow does not dislocate. In type II fractures the fracture line passes at or medial to the trochlear groove and the elbow joint may dislocate if the fracture displaces.
Treatment Undisplaced fractures can be treated by immobilisation for approximately 3 weeks, but check radiographs are required. Most fractures are, however, displaced, and open reduction and internal fixation is required as closed reduction is seldom possible. Anatomical reduction is required and wires or screws can be used.
Complications Non-union occasionally occurs, often as a result of missed fractures or inadequate fixation. This may lead to a valgus deformity and tardy ulnar nerve palsy.Internal fixation and bone grafting can be utilised, either at presentation or at skeletal maturity.
Medial epicondyle fractures
This is the third most common fracture around the elbow and is usually seen in older children. It is due to an avulsion injury and, despite the proximity of the ulnar nerve, it is rarely affected. Diagnosis can usually be made on plain radiographs, although, as with all children's fractures, comparison views of the other side can be taken if there is any doubt .
Treatment Undisplaced fractures can be treated conservatively, with early mobilisation as comfort allows.displaced fractures are usually internally fixed. especially If instability of the elbow is present.
Other elbow fractures
Fractures of the medial condyle. lateral epicondyle and T-intercondylar fractures are rare In children; treatment depends on displacement.
This is an uncommon injury In children. As with adults the elbow usually dislocates posteriorly and radiographs should be studied carefully for associated fractures. Treatment is early reduction instability is rarely a subsequent problem
Proximal radius fractures
The are the fourth most common of the fractures around the elbow in children.They differ from the intra-articular radial head fractures seen in adults as, with children. the injury usually occurs through the epiphysis of the radial neck and the articular surface displaces as a single piece the injury usually results from a fall on the outstretched hand, although it can occur in association with a posterior dislocation of the elbow. This fracture usually occurs after the ossification centre of the proximal radius appears and so the diagnosis is readily made on plain radiographs .
Summary of Proximal radial head fractures In children
• Common after fall on outstretched hand
• The fracture is usually extra-articular
• Remodelling will occur up to 30 degree angulation
In common with many children's fractures, there is considerable potential for remodelling. Up to 30° of angulation can be accepted, provided there is growth remaining. These injuries can be treated with a simple sling followed by early mobilisation.
If angulation exceeds 30 degree, manipulation under anaesthetic is carried out, which can be aided by the use of a percutaneous lever to push the radial head. For irreducible or completely displaced fractures (commonly seen after elbow dislocation) open reduction is carried out. This is usually supplemented by wire fixation, but wires should not be placed across the radiocapitate joint. The wires are removed after 2-3 weeks followed by mobilisation.
These are uncommon injuries and are often minimally displaced. For the occasional injury with Significant displacement, open reaction and tension band wiring along adult lines is recommended.
Fractures of the forearm bones
Fractures of the radius and ulna are the most common fractures in children. The distal third of the bones is most commonly involved and the injury can occur in all age groups after the age of walking. Many injuries are green-stick fractures, often with angulation at the fracture site. Completely displaced fractures do occur and can be difficult to manage by closed means. The combination of a completely displaced distal radius fractures with a green-stick fracture of the distal ulna is also common and can be difficult to control in plaster .
Summary of Forearm fractures In children
• Most common is a green.Stick fracture in the distal third • Manipulation should be considered if angulation greater than 20 degree depending on the age of the child • A completely displaced radius with intact ulna needs open reduction and fixation
• Malunion involving rotation will require osteotomy
In common with many injuries of the upper limb, forearm fractures are usually due to a fall on the outstretched hand. It is believed there is also a rotational element with forced supination. Diagnosis as readily made on plain radiographs, although a fracture line may not always be evident; in this situation the cortical bulge of the torus or buckle fracture can be seen.
Many of these fractures are minimally displaced and can be treated conservatively with 2-4 weeks in plaster, depending on the age of the child. Fractures of the distal sixth of the forearm can be managed in a below-elbow plaster; more proximal fractures require the elbow to be immobilsed.
Manipulation under anaesthetic should be considered if angulation of the fracture site exceeds 20 degree. The age of the child and the potential for remodelling should be considered, as correction of up to 10 degree per year is possible. Although remodelling of an angulation of 30-40 degree is possible in the younger child, parental pressure to correct the obvious deformity may be an indication for manipulation.
Displaced fractures can also be managed by manipulation. as a periosteal hinge often remains intact and can be used to hold the reduction. Failure to reduce the fracture is an indication for open reduction and internal fixation. usually with a plate; small two- to four-hole plates can be used in younger children. Instability of the fracture site after a satisfactory reduction, either at the original operation or at subsequent out-patient review, is an indication of a temporary thin wire to maintain reduction. Thin wires can be safely passed across the distal radial epiphysis, provided care is taken and repeated attempts are avoided. The wire is removed after 2--4 weeks.
One fracture pattern which is notorious for loss of reduction is a completely displaced fracture of the distal radius with an intact or green-stick fracture of the ulna , wiring of the radius at the initial operation should be considered.
Malunion This is relatively common after closed reduction of a displaced fracture. Often by the time the malreduction is diagnosed. the fracture is too sticky to allow remanipulation and the position has to be accepted. For fractures of the distal forearm with volar or dorsal angulation, considerable remodelling, as described above. can occur and the patient can be reassured. For malunions involving a rotation element. particularly with shortening of one bone. the fracture site may need to be taken dawn or an osteotomy performed.
Refracture This is not an uncommon complication and usually occurs in the first few weeks after the plaster is removed.
Although it may be due to inadequate immobilisation, the usual
cause is a return to the original cause of the injury. Although a pathological process should considered it is not usually present and treatment should follow similar lines to a frist-time injury.
Compartment syndrome This is uncommon after a simple forearm fracture and severe pain is usually due to a tight dressing. All patients requiring a general anaesthetic for manipulation should be admitted overnight for observation and the limb elevated Severe pain should be treated by immediate splitting of the plaster and all dressings down to the skin. In the vast majority of cases this will provide immediate relief but a compartment syndrome should be considered if pain persists, particularly in patients with complicated injuries. Compartment syndrome is treated by fasciotomy, irrespective of the age of the child .
This injury. characterized by a dislocation of the radial head at elbow together with a (usually proximal) ulna fracture. is uncommon in children. accounting for less than 1% of all forearm fractures. As in adults it is imperative that the joint above and the joint below a fracture should be visualised radiographically. with the forearm. if a fracture of only one bone is evident. the wrist and elbow joints must be examined and radiographs obtain
In children this injury can often be managed by manipulates and immobilisation in an above-elbow plaster. Follow-up radiographs must be obtained as re-displacement can occur. If a reduction cannot be achieved open reduction and internal fixation indicated.
In children this injury is also uncommon and often consists of distal radius fracture with separation of the distal ulna epiphysis, rather than a true joint disruption. It often occurs in the older child and, as with proximal humeral fractures, may be due to weakness of the perichondral ring. Closed reduction is usually possible with this injury