Specific injuries

Sternoclavicular joint

Dislocations of this joint are rare in children and most apparent dislocations, even in adults up to the age of about 25, 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; nonunion 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 occasionally 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.

  Acromioclavicular joint

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 conoid and trapeziod ligaments intact. These will heal and remodel with conservative treatment, with a sling for comfort followed by early mobilisation.

Scapular fractures

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 be mobilised as comfort allows.

Fractures of the glenoid are also very uncommon injuries in 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 and Harris fracture of the proximal humerus will occur. In adolescents as in adults, glenohumeral dislocation is 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 recurrent dislocation rate of 70—8 0 per cent reported in the age group 12—16. Approximately 50 per cent of these patients require a stabilisation procedure. Atraumatic dislocations can occur in children with joint laxity or connective tissue disorders.

Proximal humerus

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 and Harris type II in the older child and type I in the younger child. In the younger child, child abuse should be considered, although humeral shaft fractures are more common in child abuse. Salter and 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.

Treatment. Treatment therefore is generally conservative; not only because of the remodelling potential but also because of the malalignment that can be accepted around the shoulder generally. Forty-five degrees of angulation and 50 per cent of displacement can be accepted. In the younger child 70 per cent 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 angulation.

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 often the biceps tendon and this can be achieved through a standard deltopectoral approach. Fracture stabilisation is carried out as described as above.

Metaphyseal fractures

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 hut 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. Nonaccidental injury should always be considered with this injury, particularly in the younger child or with spiral fractures which are due to a twisting force.

Treatment. 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. Nonunion is uncommon in children.

Internal fixation is occasionally required for open frac­tures, associated vascular injuries and the polytrauma 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. 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 per cent of supracondylar fractures are caused by a flexion injury and associated with an anterior deformity.

Radiological diagnosis. 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 lines can be assessed on the injured elbow, as 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 300.

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 300 and can be used to assess the adequacy of reduction of a fracture (Fig 22.29).

 

Classification. 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 (Fig. 22.30).

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 prevent displace­ment and overlap of the fracture fragments.

  Type 3. The fractures are completely displaced with shortening and overlap of the fragments.

Treatment. Type 1 fractures can be treated conservatively in a collar and cuff, with 900 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 unacceptable. Thirty degrees of extension can be accepted due to the 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 straightforward and the posi­tion can be maintained with the elbow at 900. Rarely wires may be required to hold an unstable reduction (Fig. 22.31).

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 genera) anaesthetic traction is applied to the suppinated 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 radio-graphically, 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 he 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 starting point. Alternatively, two wires may he 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 a definitive method of treatment. Traction may be applied using a bone crew inserted into the ulna, or by longitudinal skin traction. Surprisingly, the patient becomes relatively pain free very quickly (Fig. 22.32).

Complications. 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 the 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 nor 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 900 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.

Condylar and epicondylar fractures

Lateral condyle. 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 (see above) (Fig. 22.33).

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 he used.

Complications. Nonunion 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. 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 (Fig. 22.34).

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 intercondylar fractures are rare in children; treatment depends on displacement.

Elbow dislocation

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

These 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.

Treatment. In common with many children’s fractures there is considerable potential for remodelling. Up to 300 of angulation can be accepted, provided there is growth remaining. These injuries can be treated with a simple sling followed by early mobilisatson.

If angulation exceeds 300, 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. These are removed after 2—3 weeks followed by mobilisation.

Olecranon fractures

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.

Aetiology. 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 suppination. Diagnosis is 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.

Treatment. 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 immobilised.

Manipulation under anaesthetic should be considered if angulation of the fracture site exceeds 200. The age of the child and the potential for remodelling should be considered, as correction of up to 100 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.

Complications. 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, take down of the fracture site or osteotomy has to he considered.

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 first-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 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.

Monteggia fracture

This injury, characterised by a dislocation of the radial head at the elbow together with a (usually proximal) ulna fracture, is uncommon in children, accounting for less than 1 per cent 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 obtained (Fig.22.35).

In children this injury can often be managed by manipula­tion and immobilisation in an above-elbow plaster. Follow-up radiographs must be obtained as redisplacement can occur. If a reduction cannot be achieved open reduction and internal fixation is indicated.

Galeazzi fracture

In children this injury is also uncommon and often consists of a 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 a weakness of the perichondral ring. Closed reduction is usually possible with this injury.