B O L I N T I A M , C R U Z , D E L A C R U Z , L U , Q U E , R I V E R A , S I O C O , T A I , V A L E R A , V E L O S O

TOGETHER AS ONE

IDENTIFYING DATA

• ML• 15 F• Mandaluyong City• RC• Student• Right handed

CHIEF COMPLAINT

“Hindi maigalaw mabuti ang kaliwang braso” (limitation of movement of the left arm)

HPI

14 months PTA

(October 2011)

• Playing on top of a rolling drum

• Fell with an outstretched left arm

• (+) limp L arm

HPI

14 months PTA

(October 2011)

• (+) swelling, gross deformity

• (-) open wound• (-) numbness and

other sensory deficits

• “Hilot” for two months

HPI

12 months PTA

• No improvement of symptoms

• Limitation of flexion of elbow to only about 30deg

• Sought consult in POC• X rays were

done

XRAY

XRAY

XRAY

XRAY

XRAY

ELBOW X RAY (AP)

ELBOW X RAY (OBLIQUE)

ELBOW X RAY (LATERAL)

HPI

12 months PTA

• No improvement of symptoms

• Limitation of flexion of elbow to only about 30deg

• Sought consult in POC• Xray

• Advised to follow-up after 6 months

HPI

6 months PTA

• On follow-up:• Advised surgery• Referred to another

institution• Deferred

HPI

1 month PTA

• Patient sought consult with attending physician and was advised surgery• Referred to DM

ADMISSION

PAST MEDICAL HISTORY

• No asthma, lung, heart, kidney, liver and other congenital diseases• No previous hospitalizations• No previous surgeries• No allergies to food and medications

IMMUNIZATION

• DPT x 3• OPV x 3• Hep B x3• BCG• Measles

DEVELOPMENTAL HISTORY

• At par with age• Cognition, motor, verbal

FUNCTIONAL HISTORY (ACTIVITIES OF DAILY LIVING )

Prior to accident

• Bathing• Dressing• Grooming• Oral care• Toileting• Transferring• Eating

After accident

• Difficulty in • Bathing• Dressing• Grooming• Eating

FUNCTIONAL HISTORY (INSTRUMENTAL ACTIVITIES OF DAILY LIVING)

Prior to accident

• Shopping• Food preparation• Housekeeping• Laundry• Transportation• Finances

After accident

• Difficulty in• Food preparation• Housekeeping• Laundry

FAMILY HISTORY

FAMILY HISTORY

• (+) Diabetes- father of patient, osteoporosis- grandmother of patient• (-) Hypertension, Dyslipidemia, Stroke, MI,

Cardiac Problems, Renal Problems, Cancer, Asthma

PERSONAL AND SOCIAL HISTORY

• Non-smoker• Non-alcoholic beverage• No illicit drug use

PERSONAL AND SOCIAL HISTORY (HEADSSS)

• Home• Close to family

• Education• Incoming 1st year high

school student• Forced to stop school

this year

• Activities• Loves to watch TV

• Diet• 3 meals: rice and meat

• Suicide• None

• Sex• None

• Substance• None

REVIEW OF SYSTEMS

• General: (-) fever, weight loss, loss of appetite• Musculoskeletal/Derma: No skin lesions or

changes• HEENT: (-) history of head injury. (-) BOV, tinnitus,

epistaxis, (-)dysphagia or enlarged lymph nodes• Respiratory: (-) cough or colds, wheezing,

hemoptysis• Gastrointestinal: (-) abdominal pain, changes in

bowel habits, diarrhea, or constipation• Genitourinary: (-) dysuria or hematuria,

PHYSICAL EXAM

• Awake, alert, coherent• Vitals: • 42 kg, 142; BMI 18.2 Normal• BP 100/60• HR 86• RR 19 • Temp 36.4• Not in pain (0)

PHYSICAL EXAMINATION

GENERAL APPEARANCE

Alert, coherent, cooperative, medium-build

VITAL SIGNS BP: 100/60 Temp: 36.4 VAS: 0/10HR: 86 RR: 19Wt: 42g Ht: 152 cm BMI: 26.06

SKIN AND HAIR

warm, good skin turgor, (-) no thinning of hair

EYES Pink palpebral conjunctiva, Anicteric sclerae, EBRTL, (-) lid lag

PHYSICAL EXAMINATION

MOUTH (-) Lesions in the buccal mucosa, (-) TPC, (-) enlargement of the tongue

NECK (-) CLAD, non-enlarged thyroid, (-) thyroid nodule

CHEST No intercostal retractions, No use of accessory muscles, equal chest expansion, Clear breath sounds, (-) rales and wheezes

CARDIOVASCULAR

Adynamic precordium, no heaves thrills and lifts. Normal rate and regular rhythm, Good S1 and S2 sounds, no murmurs, full and equal pulses on all extremities

PHYSICAL EXAMINATION

ABDOMEN No lesions, NABS, tympanitic upon percussion, no organomegaly, (-)tenderness

GU (-) CVA tenderness

Extremities (+) gross deformity of the Left arm(+) limitation of movement• Maximum flexion: 30

degrees• Extension: 0 degrees• Slight limitation on

pronation and supination

SALIENT FEATURES

Subjective Objective

- 15/F- CC: LOM, left arm- History of left arm trauma- Swelling and gross deformity- No consult done- Manipulation through regular

“paghihilot”

- Gross deformity of the left arm- Limitation of movement

• Maximum flexion: 30 degrees

• Extension: 0 degrees• Slight limitation on

pronation and supination- X Ray findings

DIFFERENTIALS

• Extension fracture of the supracondylar humerus

Rule In Rule Out

Previous hx of significant fall on an outstretched hand

Majority of supracondylar fracture of the humerus are extension type (97-99%)

Swollen elbow that patient is hesitant to move

Elbow becomes angulated

DIFFERENTIALS

• Flexion fracture of the supracondylar humerus

Rule In Rule Out

Hx of left arm trauma Usually a result of falling onto a flexed elbow

(+) swelling

(+) limitation of movement

(+) gross deformity of the left arm

DIFFERENTIALS

• Elbow Joint Dislocation (Posterior)

Rule In Rule Out

Hx of fall on an extended arm

On palpation, the olecranon is displaced from the plane of the epicondyles

(+) swelling

(+) limitation of movement

(+) gross deformity of the left arm

DIFFERENTIALS

• Juvenile Idiopathic (Rheumatoid) Arthritis

Rule In Rule Out

15/F Hx of fall on an extended arm

(+) swelling Morning stiffness

(+) limitation of movement

Usually polyarticular

(+) gross deformity of the left arm

Usually presents with other systemic manifestations

DIFFERENTIALS

• Malignancy: Osteosarcoma

Rule In Rule Out

Usually develops during rapid growth that occur in adolescence average age is 15

Runs in families

Boys and girls have similar incidence

Tends to occur in shin, thigh and upper arm

Most common malignant bone tumor in children

Present with bone fracture, bone pain

Presents with LOM, limping, tenderness, swelling, redness

WORKING IMPRESSION

Malunion of the left elbow probably secondary to neglected supracondylar humerus fracture

ANATOMY OF THE ELBOW

HUMERUS

• Capitulum (lateral) radial head• Trochlea (medial) trochlear notch of the ulna• Anterior Coronoid fossa receives coronoid

process of ulna during full flexion• Posterior Olecranon fossa receives olecranon of

ulna during extension• Radial fossa receives edge of head of radius

during full flexion

ULNA

• Stabilizing bone• Located medially, longer• Articulation between ulna and humerus flexion,

extension (with minimal abduction and adduction during pronation - supination)• Tapers at the end to form the ulnar head and the

styloid process• Doesn’t reach and participate in joint action

RADIUS

• Head of the radius and capitulum flexion and extension of the elbow

MUSCLES

Muscle Proximal attachment

Distal attachment

Action

Biceps brachii Short head: tip of coracoid process of scapulaLong Head: Supraglenoid tubercle of scapula

Tuberosity of radius and fascia of forearm

Supinates forearmFlexes forearmShort head: resists shoulder dislocation

Coracobrachialis Tip of coracoid process of scapula

Middle third of medial surface of humerus

Helps flex and adduct armResists shoulder dislocation

Brachialis Distal half of anterior surface of humerus

Coronoid process and tuberosity ulna

Flexes forearm in all positions

MUSCLES

Muscle Proximal Attachement

Distal Attachment

Muscle Action

Triceps brachii Long head: infraglenoid tubercle of scapulaLateral head: posterior surface of humerus, superior to radial grooveMedial head: posterior surface of humerus, inferior to radial groove

Proximal end of olecranon of ulna and fascia of forearm

Main forearm extensorLong head – resists humeral dislocationImportant during adduction

Anconeus Lateral epicondyle of humerus

Lateral surface of olecranon and superior part of the posteriior surface of ulna

Assists triceps in forearm extensionStabilize elbow joint

SUPRACONDYLAR HUMERUS FRACTURES

• Fractures of the distal humerus just above the epicondyles• Typically remains extra articular• 55% to 75% of all elbow fractures• Peak incidence 5 to 8 years, after which

dislocations become more frequent• The left, or nondominant side, is most frequently

injured

SUPRACONDYLAR FRACTURES

• In 5 – 8 year olds, bone remodeling causes a decreased anteroposterior diameter in the supracondylar region, making this area susceptible to injury

• Ligamentous laxity in this age range increased likelihood of hyperextension injury

• The anterior capsule is thickened and stronger than the posterior capsule. • In extension: the fibers of the anterior capsule are taut, serving as a

fulcrum by which the olecranon becomes firmly engaged in the olecranon fossa

• With extreme force: hyperextension may cause the olecranon process to impinge on the superior olecranon fossa and supracondylar region

• The periosteal hinge remains intact on the side of the displacement

MECHANISM OF INJURY

• Extension type • Hyperextension occurs during fall onto an outstretched

hand with or without varus/valgus force• Hand is pronated posteromedial displacement

*More common*Possible radial nerve injury

• Hand is supinated posterolateral displacement *Possible median nerve and vascular compromise

• Flexion type: Caused by direct trauma or a fall onto a flexed elbow

• Typical presentation: swollen, tender elbow with painful range of motion

• S-shaped angulation at the elbow: a complete (Type III) fracture results in two points of angulation to give it an S shape.

• Pucker sign• Dimpling of the skin anteriorly secondary to penetration of the

proximal fragment into the brachialis muscle• Means reduction of the fracture may be difficult with simple

manipulation

• Evaluate integrity of the median, radial, and ulnar nerves plus their terminal branches

• Can be occult on radiographs with only a positive fat pad sign

Lateral radiograph with positive fat pad sign in a patient with a nondisplaced fracture of the radial headAnterior lucency (arrow) elevated anterior fat Posterior lucency (arrowhead) elevated posterior fat pad

SUPRACONDYLAR FRACTURES

Type I: NondisplacedType II: Displaced with intact posterior

cortex; may be angulated or rotated

Type III: Complete displacement; posteromedial or posterolateral

Gartland Classification based on the degree of displacement

EXTENSION TYPE (98%)

FLEXION TYPE (2%)

Type I: NondisplacedType II: Displaced with intact anterior

cortexType III: Complete displacement; usually

anterolateral

GARTLAND - EXTENSION TYPE

type I (undisplaced), II (displaced with an intact posterior cortex), and III (displaced with no cortical contact)

TREATMENT – EXTENSION TYPE

Type I: Immobilization in a long arm cast or splint at 60 to 90 degrees of flexion is indicated for 2 to 3 weeks.

Type II: This is usually reducible by closed methods followed by casting; it may require pinning if unstable (crossed pins versus two lateral pins) or if reduction cannot be maintained without excessive flexion that may place neurovascular structures at risk.

Type III: Attempt closed reduction and pinning; traction (olecranon skeletal traction) may be needed for comminuted fractures with marked soft tissue swelling or damage.Open reduction and internal fixation may be necessary for rotationally unstable fractures, open fractures, and those with neurovascular injury (crossed pins versus two lateral pins).

TREATMENT – FLEXION TYPE

Type I: Immobilization in a long arm cast in near extension is indicated for 2 to 3 weeks.

Type II: Closed reduction is followed by percutaneous pinning with two lateral pins or crossed pins.

Type III: Reduction is often difficult; most require open reduction and internal fixation with crossed pins.

BONE HEALING

• Primary• Cortex attempts to heal without callus formation• Occurs when fx is anatomically reduced, the blood supply

is preserved, and the fracture is rigidly stabilized

• Secondary• Formation of callus • Involves participation of the periosteum and external soft

tissues

4 STAGES OF FRACTURE HEALING

1. Hematoma formation (inflammation) and angiogenesis.

2. Cartilage formation with subsequent calcification3. Cartilage removal and bone formation4. Bone remodeling

STAGE 1 - HEMATOMA FORMATION AND ANGIOGENESIS

• < 1 week after a fracture• Transforming growth factor beta (TGF-) and

platelet derived-growth factor (PDGF) are released from platelets at the fracture site• Osteogenic cells and inflammatory cells

ensheathe the fracture and differentiate into chondrocytes or osteoblasts.

STAGE 2 - CARTILAGE FORMATION WITH SUBSEQUENT CALCIFICATION

• ~ 1 to 3 weeks after fracture• Radiologic evidence of mineral formation signals

the onset of this phase. • consisting of calcified cartilage, woven bone

made from cartilage, and woven bone formed directly.• Woven bone replaces cartilage in callus by active

transport of minerals and their precipitation from a supersaturated solution

STAGE 3 - CARTILAGE REMOVAL AND BONE FORMATION

• ~ 1 to 3 months after fracture• woven-bone mineralized callus replaced by

lamellar bone arranged in osteonal systems • 3 characteristics:– It forms only under conditions of mechanical stability;– It has the ability to replace fibrous or muscle tissue; and– It forms within the confines of the bone defect

STAGE 4 – BONE REMODELLING

• Can be around several years• meticulously coordinated removal of bone from

one site and deposition in another.• Two lines of cells, osteoclasts and osteoblasts, are

responsible for this process• Osteoclasts – resorption• Osteoblast - accretion

MALUNION

• Described to be a fractured bone that did not heal in an anatomic position• Bone may have: • Angulated• Rotated out of position• Overrided another bone

• Causes shortening of the limb

• Shortening is better tolerated in the upper limb• >1 inch poorly tolerated in the lower limb• Causes:• Inadequate immobilization• Misalignment• Premature removal of an immobilizer

• Surgical Indication: • Pain• Impaired normal function

NON-UNION

• Healing by fibroblastic response instead of bone formation• Caused by:• Overdistraction• Excessive motion • Inadequate immobilization

MALUNION VS. NON-UNION

MANAGEMENT

• Traditional management- relied the intact posterior periosteum to maintain the stability of a closed reduction.  • no longer recommended because the forced

flexion required to maintain stability of the fracture leads to excessive pressure in the antecubital fossa and increases the risk of compartment syndrome.

• anatomical closed reduction of the fracture then hold it in position with two or three pins introduced from the lateral side of the distal fragment.  • splinted in 45 degrees of flexion, a safe position

for the swelling and circulation.  • pins can be removed in three to four weeks, with

resumption of full activities a month later.

• Laterally introduced pins are preferred to crossed pins because there is a 2% to 6% risk of iatrogenic ulnar nerve injury. 

• Crossed pinning of a supracondylar fracture.  Both columns are pinned and the fracture is stable

OSTEOTOMY

•  surgical operation whereby a bone is cut to shorten, lengthen, or change its alignment. Can be used to straighten a bone that has healed crookedly following a fracture.

• Immobilization in a long arm cast (or posterior splint for swelling) with the elbow flexed to 90 degrees and the forearm in neutral for 2 to 3 weeks postoperatively, at which time the cast may be discontinued and the pins removed• The patient should then be maintained in a sling

with range-of-motion exercises and restricted activity for an additional 4 to 6 weeks

COMPLICATIONS OF SUPRACONDYLAR FRACTURES

• Vascular Injury• Forearm compartment syndrome resulting in

Volkmann’s ischemic conracture• Nerve Injury• Cubitus varus deformity

COMPLICATIONS: VASCULAR INJURY

• Absence of radial pulse (10-20 %)• Most common with Type II and II SFs• Brachial artery – most freq. injured in

posterolaterally displaced fractures

COMPLICATIONS: VOLKMANN ISCHEMIC CONTRACTURE

• Vascular injury and swelling lead to the dev’t of compartment syndrome (w/in 12-24 hours)• Ischemia and Infarction can progress to

Volkmann’s Ischemic Fracture• Fixed flexion of the elbow• Pronation of the forearm• Flexion of at the wrist• Joint extension of the MTC-Phalangeal Joint

COMPLICATIONS: NEUROLOGIC DEFICIT

• Freq. 10-20 %, and increases with Type III SFs to 49%• Median Nerve Injury – Posterolateral distal fracture

fragment displacement w/ medial mov’t of the proximal fx fragment

• Radial Nerve Injury – Lateral proximal fracture fragment displacement

• Ulnar nerve Injury – Flexion type supracondylar fractures

COMPLICATIONS: CUBITUS VARUS DEFORMITY

• Angular deformity or ‘gunstock’ deformtiy – long term complication• Remodeling and correction of fracture angulation

is limited for children with SFs

PROGNOSIS OF PATIENTS WITH SFS

• Long term outcome and function• very good if the fracture is appropriately diagnosed and

treated

• Many of the associated complications• Self-limited• Amenable to functional repair w/ surgical intervention

• Weiss JM, Kay RM, Waters P, Yang S, Skaggs DL. Distal humerus osteotomy for supracondylar fracture malunion in children: a study of perioperative complications. Am J Orthop (Belle Mead NJ). 2010 Jan;39(1):22-5.

SPECIAL CHARACTERISTICS OF PEDIATRIC BONES

ANATOMY

• Less dense and more porouso More vascular channelso More water and cellular content, less mineral contento Higher collagen to bone ratio

• Periosteum o Stronger, thicker and more fibrous o Loosely attached and easily elevated with trauma

(especially diaphysis)o More firmly attached in metaphyseal-epiphyseal region

helps stabilize the growth plate allowing more active bone growth

o Thickens and is continuous with physis at perichondreal ring (ring of Lacroix) Additional resistance to shear force

ANATOMY

• Physis (Growth plate) unique cartilaginous structureo Thickness depends on ageo Weaker than bone in torsion, shear and bending

predisposes children to injuryo Facilitates remodelling o Can possibly cause deformity

• Ligaments functionally stronger than bone in children

o More injuries result in fractures rather than sprains

ANATOMY

• Blood supply o In growing bone rich metaphyseal

circulation with fine capillary loops ending at the physis

BIOMECHANICS

• More elastic and weaker Injury at lower energy trauma (compression, torsion, bending forces)

PHYSIOLOGY

• More rapid bone healing / metabolismo Increased blood flowo Increased cellular activityo More active periosteum

• High remodeling potential especially near the growth plate