fractures of the forearm wrist and hand小儿骨折的前臂手腕和手课件

Pediatric Fractures of the Forearm, Wrist and Hand John A. Heflin, MD Original Author: Amanda Marshall, MD; March 2004 Revised: Steven Frick, MD; August 2006 John A. Heflin, MD; April 2011 Pediatric Forearm Fractures Approximately 40% of childrens long-bone fractures Most from fall to an outstretched hand Ulna susceptible to direct blow “night-stick” fracture Forearm fracture incidence increasing Increased sporting activity Increased body weight Neurologic injury rare (75% of radius and/or ulna fractures Approx 14% in distal physis Pediatric Forearm Fracture Types Plastic Deformation No cortical disruption Stress higher than elastic limit of bone Incomplete “Greenstick” Fractures One cortex intact Include buckle or torus type fractures Complete Fractures No cortex intact Most unstable Goals of Treatment Restore alignment and clinical appearance Limit injury to local soft tissues Prevention of further injury Pain relief Regain functional forearm rotation For ADLs need 50 degrees supination, 50 degrees pronation Pediatric Forearm Primary ossification centers at 8 weeks gestation in both radius and ulna Distal physis provide most (80%) of longitudinal growth Distal epiphyses of radius appears at age 1 Distal epiphyses of distal ulna appears at age 5 Normal forearm rotation: Approx 90 degrees pronation Approx 90 degrees supination Plastic deformation Plastic Deformation of the Forearm Fixed deformation remains when bone stressed beyond elastic limit Most common in forearm May be ulna and/or radius Periosteum remains intact Usually no periosteal callus Deformation can limit pronation/supination Chamay: Jour. Biomechanics 3:263,1970 Plastic Deformation Remodeling not as reliable Reduce when: Obvious clinical deformity Greater than 20 degrees of angulation Prevents reduction of a concomitant fracture Prevents full pronation-supination in a child 4 years Any child older than 8 years Requires considerable force, applied slowly Place in well-molded long arm cast for 4 to 6 weeks Incomplete (Greenstick) Fracture Incomplete (Greenstick) Fractures Minimally displaced fractures: Immobilized in a well-molded long arm cast Unacceptable alignment: Apply pressure to apex of fracture to restore alignment and clinical appearance Slightly overcorrect (5-10 degrees) Completing fracture decreases risk of recurrence of deformity and may facilitate reduction Apex dorsal deformity not well tolerated Complete Fracture Complete Fracture Almost no intrinsic stability to length, linear, or rotational alignment Muscle forces more of a deforming factor Typically has greater soft tissue injury Cruess R:OCNA 4:969,1973 Closed Reduction Method Conscious sedation/Bier block/general anesthesia Traction/counter-traction Reproduce/exaggerate deformity to unlock fragments Reduce/lock fragments using periosteal hinge Correct rotational deformity Closed Reduction Method Optimal forearm immobilization position in rotation: Apex volar: pronation Apex dorsal: supination Maintain cast for 4 to 6 weeks or until radiographic evidence of union Conversion to a short arm cast at 3 to 4 weeks if healing adequate Malreduction of 10 degrees in the middle third can limit rotation by 20 to 30 degrees Excellent Reduction with Well Molded Cast How Much Angulation is too Much? Depends on fracture, location, age, stability Closed reduction should be attempted for any angulation greater than 20 degrees Angulation encroaching on interosseous space may limit rotation Any angulation that is clinically apparent Acceptable Limits Angulation 8 years Overriding (bayonette) apposition acceptable in children 10 years), plates and screws often not removed unless symptomatic Can remove at 6 to 9 months if fracture completely healed Galeazzi Fracture- Radial Shaft Fracture with DRUJ Injury Usually at junction of middle and distal thirds Distal fragment typically angulated towards ulna Closed treatment for most Carefully assess DRUJ post reduction, clinically and radiographically Galeazzi Equivalent Radial shaft fracture with distal ulnar physeal injury instead of DRUJ injury Distal ulnar physeal injuries have a high incidence of growth arrest Galeazzi Fracture Galeazzi Equivalent Distal ulnar epiphysis Previous Injury Following Closed Reduction Distal ulnar epiphysis Pin fixation ulnar epiphysis and ulna to radius pin with above elbow cast Distal Radius Fractures Most common fracture in children 28-30% of all fractures Metaphyseal most frequent 62% of radius fractures Distal radial physis second 14% of radius fractures Simple falls most common mechanism Rapid growth may predispose, with weaker area at metaphysis Distal Radius Fractures Metaphyseal Physeal Salter II most common Torus Greenstick Complete Volar angulation with dorsal displacement most common Differences? Metaphyseal Less compromise of carpal tunnel Less pain Physeal More compromise of the structures in the carpal tunnel More pain Sensory changes Associated Injuries Distal ulnar metaphyseal fracture or ulnar styloid avulsion Distal ulnar physeal injury High incidence of growth disturbance Up to 50% Median or ulnar nerve injury Rare Acute carpal tunnel syndrome Also rare More common in dorsal angulated physeal injuries Ray TD, Tessler RH, Dell PC. Traumatic ulnar physeal arrest after distal forearm fractures in children. J PediatR Orthop 1996; 16( 2): 195-200. Nondisplaced Distal Radius Fractures - Treatment Below elbow immobilization 3 weeks Torus fractures are stable injuries Still need to treat Can treat with a removable forearm splint Displaced Distal Radius Physeal Fractures-Treatment Closed reduction usually not difficult Traction with finger traps (reduce shear) Gentle dorsal push Immobilize Well molded cast / splint above or below elbow (surgeon preference) 3-4 weeks immobilization Physeal Injury Reduction Maneuver Use finger trap for traction Gentle push to complete reduction Majority of correction achieved with traction “Repeated efforts at reduction do nothing more than grate the plate away.” “These injuries unite quickly, so that attempts to correct malposition after a week are liable to do more damage to the plate than good.” Rang, Childrens Fractures 2005. Treatment Recommendations - Reduction Attempts? Treatment Recommendations “For Salter-Harris type I and II injuries in children younger than 10 years of age, angulation of up to 30 can be accepted. In children older than 10 years, up to 15 of angulation is generally acceptable.” Armstrong et al, Skeletal Trauma, 1998. Remodeling Potential - 12 yo Male Presented 10 days after fracture no reduction, splinted in ED and now with early healing no additional reduction At 6 months extensive remodeling of deformity noted Sagittal plane: Apex volar remodels 0.9 degrees per month Coronal Plane: Radial deviation remodels 0.8 degrees per month Thus, 30-350 of residual angulation needs around 5 years to completely remodel Residual Angulation and Complete Remodeling Price CT et al: Malunited forearm fractures in children. J Pediatr Orthop 1990;10: 705-712. Displaced Distal Radius Fractures Care after Closed Reduction Radiograph within one week to check reduction Do not re-manipulate physeal fractures after 5-7 days for fear of further injury to physis Metaphyseal fractures may be re-manipulated for 2-3 weeks if alignment lost Expect significant remodeling of any residual deformity Distal Radius Fractures Potential Complications Growth arrest Unusual after distal radius physeal injury Around 4-5% Malunion Will typically remodel Follow for one year prior to any corrective osteotomy Shortening Usually not a problem Resolves with growth Remodeling at 2 years Growth Arrest following Distal Radius Fracture Injury films Injured and uninjured wrists after premature physeal closure Distal Radius Growth Arrest Relatively rare (approx 4%) Related To: Severity of trauma Amount of displacement Repeated attempts at reduction Re-manipulation or late manipulation Distal Radius Conclusions Most common physeal plate injury (39%) Increased incidence of growth plate abnormalities with 2 or more reductions Distal radius growth arrest rate 4-5% Acceptable alignment: 50% apposition 30 angulation Accept malreduced fractures upon late presentation (over 7 days). Distal Radius Fracture Indications for Operative Treatment Inability to obtain acceptable reduction Open fractures Displaced intra-articular fractures Associated soft tissue injuries Soft tissue interposition Associated fractures (SC humerus) Associated acute carpal tunnel syndrome or compartment syndrome Distal Radius Fixation Options Smooth K-wire fixation usually adequate Avoid physis when possible Some fractures require plate fixation Intra-articular fractures Older pediatric/adolescent patients External fixation for severe soft tissue injury Carpal Injuries in Children Unusual / uncommon in children Scaphoid fracture most common carpal fracture Still less than 1% of all upper extremity fractures Capitate / Lunate / Hamate fractures can occur (rare) Carefully check carpal bones on every wrist film Comparison films of uninjured wrist helpful Acute Distal Radius Metaphyseal Fracture in a 13 year Skateboarder Patient gave history of a fall sustained one year ago with a “bad wrist sprain” Did you note the scaphoid nonunion ? Scaphoid Fractures Not always obvious on plain films Scaphoid Fractures - Treatment Tender snuff box Immobilize until tenderness resolves If still tender at 1-2 weeks Repeat x-ray Confirmed fracture If non-displaced, immobilize in above elbow cast for 6 weeks then short arm cast 4-6 weeks Displaced fracture ORIF 1 mm displacement, 10 degrees angulation Scaphoid Fixation Compression screw fixation is treatment of choice for displaced scaphoid fracture Import to achieve anatomic reduction Hand Fractures Metacarpal and phalangeal fractures If displaced, attempt closed reduction Correct both angulation and rotation Immobilize for 3-4 weeks Indications for ORIF Open fractures Displaced intra-articular fractures Inability to obtain / maintain reduction Phalangeal Fractures (Epidemiology) 43% proximal phalanx Commonly physeal 37% of all physeal fractures Usually SH II (54%) 30% affect small finger 20% affect the thumb Distal Phalangeal Fractures Very common Usually crush injuries Address any associated nail bed injuries If open give appropriate antibiotics, I120:172-184 Fernandez FF et al: Failures and complications in intramedullary nailing of childrens forearm fractures. J Child Orthop 2010; 4(2):159-67 Fischer W. Forearm fractures in childhood (authors transl). Zentralbl Chir 1982;107:138-48. Noonan JK et al: Forearm and Distal Radius Fractures in Children. J Am Acad Orthop S