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
Fractures
of the lateral end of the clavicle may also be confused with joint dislocations,
as discussed below.
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.
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,
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
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.