Pediatric Orthopedic Trauma Case Atlas PDF
Preview Pediatric Orthopedic Trauma Case Atlas
> Management of Late Displacement ( 5days) of a Previously Reduced Salter II Distal Radius Fracture Jennifer M. Bauer and Jennifer M. Ty Abstract 1 Brief Clinical History A 12-year-old boy sustained a left Salter-Harris type II distal radius physeal fracture. The fracture underwent A 12-year-old otherwise healthy right-hand dominant boy successful closed reduction but was noted to have dis- fellontohisoutstretchedleftarmaftertrippingwhileplaying placement at 10 days. Given his age and the type of kickball. He was brought immediately to the emergency fracture, remodeling was anticipated, and the fracture room for evaluation. He complained of pain and deformity was not remanipulated at that time due to the increased tohiswrist,aswellastinglingtohisthumb,index,andlong risk of physeal injury with late reduction attempts. The fingers.Onexam,theleftwristhadobviousdorsaldisplace- fracture went on to union with closed treatment and was ment with intact motor function to the hand but decreased noted to have evidence of continued growth and sensationinthedistalmediannervedistribution. remodelingatlastfollow-up,withgoodclinicalandradio- logicoutcomes. 2 Preoperative Clinical Photos Contents and Radiographs 1 BriefClinicalHistory........................................ 1 2 PreoperativeClinicalPhotosandRadiographs........... 1 SeeFig.1. 3 PreoperativeProblemList................................... 1 4 TreatmentStrategy........................................... 1 3 Preoperative Problem List 5 BasicPrinciples............................................... 2 6 ImagesDuringTreatment................................... 2 1. Salter-HarristypeIIdistalradiusfracture 7 TechnicalPearls.............................................. 2 2. Ulnarstyloidfracture 8 OutcomeClinicalPhotosandRadiographs................ 3 3. Ageofpatient,4yearsestimatedgrowthremaining 4. Choiceoffixation/immobilization 9 AvoidingandManagingProblems.......................... 3 5. Mediannerveneuropraxia ReferencesandSuggestedReading............................. 6 4 Treatment Strategy Given the acuity of presentation, 4-year growth potential remaining, and Salter-Harris II fracture pattern, the decision was made to treat with closed reduction and immobilization J.M.Bauer(*)(cid:129)J.M.Ty in the emergency room under conscious sedation. Prompt DepartmentofOrthopedicSurgery,Nemours:AlfredI.duPontHospital reduction is indicated to relieve pressure off the median forChildren,Wilmington,DE,USA e-mail:[email protected];[email protected] nerveatthelevelofthevolarmetaphysealspike. #SpringerInternationalPublishingAG2017 1 C.Iobst,S.L.Frick(eds.),PediatricOrthopedicTraumaCaseAtlas, DOI10.1007/978-3-319-28226-8_44-1 2 J.M.BauerandJ.M.Ty Fig.1 InitialAPandlateral injuryfilmsshowingdisplaced leftdistalradiusSalter-HarrisII fracturewithanassociatedulnar styloidfracture Reductionintheoperatingroomundergeneralanesthesia randomized controlled trials of physeal and distal third withmusclerelaxationandwiththepossibilityofsmoothK- forearm fractures (Webb et al. 2006; Bohm et al. 2006). wire for transphyseal fixation from the styloid was also Thereisnoconsensusontheneedtobivalveorunivalvea considered.Manyauthorsencouragea“gentlereduction”or castorinwhichplanetodoso. onlyoneattemptatareductionmaneuvertopreventinjuryto 4. Closefollow-upforthefirst2weeksisneededtomonitor the growth plate. Types of immobilization include splinting alignment,withatotalimmobilizationtimeof4–6weeks. orcasting,aboveorbelowelbowimmobilization,andplaster of Paris versus fiberglass casting. Each of these options has beenshowntobeeffective. 6 Images During Treatment Afterreduction,thispatient’salignmentwasinitiallyheld inasugar-tongplastermoldtocontrolprono-supination.The SeeFig.2. splint was then overwrapped immediately into a long arm fiberglasscastfordurability. 7 Technical Pearls 1. Longitudinaltractionisusefultohelpavoidphysealinjury 5 Basic Principles on initial reduction. Some favor the use of prereduction finger traction to allow muscles to relax and 1. ThemajorityofdistalradiusphysealfracturesaretypeIor ligamentotaxistoaidthereductionifthechildcantolerate IISalter-Harrisfractures,whichcanbetreatedwithclosed this. reductionifdisplacedandimmobilization.TypeIIIandIV 2. Awell-moldedcastincludestwo-pointpressure precisely fractures of the distal radius are rare but if unable to be placed – 1 volar at the metaphysis, 1 dorsal at the epiph- adequately reduced would warrant open reduction and fixation to align the joint surface. Type V Salter-Harris ysis–alongwithappropriatecastindex. fracturesmayappearbenignatfirstandneednoreduction 3. Physeal injury in distal radius physeal fractures is rare (Houshian et al. 2004), but repeat reduction attempts are butcanbeassociatedwithphysealarrestandthusshould thought to contribute to growth arrest. Compression-type bemanagedexpectantly. injuriesmaybeassociatedwitharrest(Leeetal.1984). 2. Acceptable alignment iscontroversial, but dorsal angula- tion up to 20(cid:1) in patients over 10 years old is widely accepted, given remodeling potential, and up to 30(cid:1) in childrenyoungerthan10. 3. Well-molded short or long arm immobilization has been shown to maintain reduction equally well in several ManagementofLateDisplacement(>5days)ofaPreviouslyReducedSalterIIDistalRadiusFracture 3 Fig.2 APandlateralimmediate postreductionradiographsshow acceptablealignment.Plaster sugar-tongsplintunderfiberglass overwrapisvisible Fig.3 Reductionmaintainedat 4-dayfollow-up,withcomplete resolutionofmedianneuropathy. Thisfollow-upismadewithin 5daystoallowre-manipulationif needed.Whilemostauthorsagree re-manipulationshouldbedone within1week,thereisnospecific evidenceastothiscut-off 2. A physeal crush type V Salter-Harris fracture may be 8 Outcome Clinical Photos initially missed but is at high risk for physeal arrest and and Radiographs shouldbefollowedclosely. 3. Late re-manipulation and multiple manipulation attempts SeeFigs.3,4,5,and6. causeanincreasedrisktothephysis(Leeetal.1984)and shouldbeavoided. 4. Distal radiusphysealfractureshaveexcellentremodeling potentialandclinicalforgiveness,with92%ofthoseover 9 Avoiding and Managing Problems 11yearsoldachievingcompleteremodeling(Houshianet al. 2004). Cannata et al. found that a growth arrest up to 1. Earlyfollow-upafterclosedreductioniskeytoallowfor 1cmwaswelltolerated.(Cannataetal.2003). safe re-manipulation of the fracture if interval loss of 5. Long-term follow-up of distal radius physeal fractures reductionoccurs. ensuresdetectionofphysealarrest,whichisreportedata 4 J.M.BauerandJ.M.Ty Fig.4 (a)Lossofreductionwasnotedat10-dayfollow-upwithfurther attempt was made. The fracture was treated with placement of a new dorsaldisplacement.(b)Alignmentwasconfirmedonlateral-viewin- longarmcastwithagentlemoldtomaintainwhatalignmentremained office fluoroscopy. As it was later than 7 days, no repeat reduction andtoprotectagainstanyfurtherloss Fig.5 Radiographsat4-week follow-up.Alignmentis unchanged,andlongarmcastwas discontinuedtoshortarmcastfor another3weeks rate up to 7% (Lee et al. 1984). If an arrest occurs, ulnar growth remaining, this was successfully treated with an epiphysiodesis, ulnar shortening osteotomy, or radial ulnarepiphysiodesis. lengthening osteotomy may be necessary to avoid ulnar positive variance and subsequent complications, or a physeal bar resection may be performed if anatomically 6. Transientmediannervesensoryneuropraxiamustbedis- possible.Anexampleofaphysealarrestinthesettingofa tinguishedfromacutecarpaltunnelsyndrome,thelatterof close-reduced type II fracture is shown in Fig. 7. As this which is associated with increasing pain and progressive was noted prior todevelopment of significant ulnar posi- sensory deficit, followed by recurrent median nerve tive variance, and there was less than 1 year of expected branchmotorweakness.Acutecarpaltunnelsyndromeis asurgicalurgencyrequiringopennervedecompressionif ManagementofLateDisplacement(>5days)ofaPreviouslyReducedSalterIIDistalRadiusFracture 5 Fig.6 Radiographsat2months(a),7months(b),and12months(c)afterinjuryshowssignificantremodelingwhichisanticipatedtocontinueas thegrowthplateremainsopen.Anulnarstyloidnonunionisnoted 6 J.M.BauerandJ.M.Ty fracturereductiondoesnotreversethesymptoms.Inthese cases, the fracture should be percutaneously pinned to obviatetheneedforasubsequenttightlymoldedcast. 7. Ulnar styloid nonunions are very common and usually asymptomatic. Occasionally, overgrowth can be noted with symptoms of ulnar impingement that responds to excisionandTFCCrepairifneeded. 10 Cross References ▶DistalThirdRadiusFracturesWithanIntactUlna ▶PhysealFractureoftheDistalRadius References and Suggested Reading BohmER,BubbarV,YongHingK,DzusA(2006)Aboveandbelow- the-elbow plaster casts for distal forearm fractures in children. Fig.7 MRIofa15-year-oldmale’swrist,9monthsstatus-posttypeII Arandomizedcontrolledtrial.JBoneJointSurgAm88(1):1–8 Salter-HarrisIIdistalradiusfracture CannataG,DeMaioF,ManciniF,IppolitoE(2003)Physealfracturesof the distal radius and ulna: long-term prognosis. J Orthop Trauma 17(3):172–179 Houshian S, Holst AK, Larsen MS, Torfing T (2004) Remodeling of Salter-Harris type II epiphyseal plate injury of the distal radius. JPediatrOrthop24(5):472–476 Lee BS, Esterhai JL Jr, Das M (1984) Fracture of the distal radial epiphysis:characteristicsandsurgicaltreatmentofprematurepost- traumaticepiphysealclosure.ClinOrthopRelatRes185:90–96 WebbGR,GalpinRD,ArmstrongDG(2006)Comparisonofshortand longarmplastercastsfordisplacedfracturesinthedistalthirdofthe forearminchildren.JBoneJointSurgAm88(1):9–17 Metacarpophalangeal and Interphalangeal Joint Dislocation Felicity G. L. Fishman Abstract 7 TechnicalPearls................................................ 2 A15-year-oldmalesustainedanindexfingerdorsalfrac- 8 OutcomeClinicalPhotosandRadiographs.................. 2 ture dislocation of his metacarpophalangeal (MCP) joint. Multiple closed reduction attempts were made in the 9 AvoidingandManagingProblems............................ 4 emergency room but were ultimately unsuccessful. A 10 Cross-References............................................... 4 simple dislocation can become irreducible if multiple ReferencesandSuggestedReadings............................... 4 attempts at closed reduction are performed via straight traction. The patient was then transferred to a pediatric hospitalforfurthercare.Duetothecomplexnatureofthis 1 Brief Clinical History injury,thepatientwasbroughttotheoperatingroom.An irreducible dorsal dislocation can be approached volarly A 15-year-old right-hand dominant male sustained a right ordorsallydependingonsurgeonpreferenceandconcur- index finger metacarpophalangeal (MCP) joint dislocation rent injuries. The dorsal fracture fragment necessitated a with a metacarpal head fracture while playing football. He dorsalapproachfortheopenreductionandfixation,which was seen outside a hospital emergency department where alsoservedtoavoidthevolarneurovascularbundleinthe multiple attempted closed reductions were unsuccessful. He approach to the MCP joint. The dislocated joint was wastransferredfor furthercare andbroughttotheoperating reduced after releasing the volar plate, which was inter- room for open reduction of his index finger MCP joint and posed. The metacarpal head fracture was then stabilized fixationofhismetacarpalheadfracturewith1.3mmscrews. withtwo1.3mmscrews.Thepatientwasbrieflysplinted postoperatively,andearlyrangeofmotionexerciseswere initiatedwithin2weeksoftheinjury.Thepatientregained 2 Preoperative Clinical Photos functionalmotionwithinafewweeksofhisinjuryandthe and Radiographs fracturehealeduneventfully. SeeFig.1. Contents 1 BriefClinicalHistory.......................................... 1 3 Preoperative Problem List 2 PreoperativeClinicalPhotosandRadiographs............. 1 3 PreoperativeProblemList..................................... 1 1. Dorsal dislocation of index finger metacarpophalangeal 4 TreatmentStrategy............................................. 2 joint 2. Concurrentmetacarpalheadfracture 5 BasicPrinciples................................................. 2 3. Choice of approach for open reduction – dorsal versus 6 ImagesDuringTreatment..................................... 2 volar 4. Choiceoffixationforfracturefragment–screwsversusk wire F.G.L.Fishman(*) DepartmentofOrthopaedicsandRehabilitation,YaleSchoolof Medicine,NewHaven,CT,USA e-mail:Ffi[email protected];felicity.fi[email protected] #SpringerInternationalPublishingAG2017 1 C.Iobst,S.L.Frick(eds.),PediatricOrthopedicTraumaCaseAtlas, DOI10.1007/978-3-319-28226-8_46-1 2 F.G.L.Fishman Fig.1 Radiographsoftherighthand(PA,oblique,andlateralview)demonstratingadislocatedindexfingermetacarpophalangealjointwitha secondmetacarpalheadfracture 4 Treatment Strategy 6 Images During Treatment Closed reduction of metacarpophalangeal joint and inter- SeeFig.2. phalangeal joint dislocations may be attempted with local analgesiabutmayrequiresedationinyoungerchildren.Typ- ically, the wrist is flexed to take tension off of the flexor 7 Technical Pearls tendons and then the middle phalanx (PIP dislocation) or proximal phalanx (MCP dislocation) is translated onto the 1. Not all MCP joint or interphalangeal (IP) joint disloca- proximal phalanx and metacarpal, respectively, while gentle tionsrequireanopenreduction. longitudinal traction is pulled if necessary. In this patient, 2. Closed reduction should consist of wrist flexion to take multipleattemptsatclosedreductionoftheindexfingerMCP tension offtheflexortendons,fingerflexion, gentlepres- fracture dislocation were made without success. The opera- sure directed in the direction opposite of the dislocation. tiveapproachtothedigitcanbedorsalorvolardependingon Do not pull straight traction as this can turn a reducible thesurgeon’spreferenceandconcomitantinjuries.Thedorsal MCPorIPdislocationintoanirreducibledislocation. metacarpal headfracturenecessitated thedorsal approachto 3. AdvantagesofthedorsalapproachtothedislocatedMCP theindexfingerinthiscase. includevisualizationofthevolarplateandincisionwith- outrisktodigitalnerves. 4. Advantages of the volar approach to the dislocated MCP joint include direct visualization of structures typically 5 Basic Principles involved in a dorsal MCP dislocation and direct visuali- zationofthedigitalnerves. 1. Complexdislocationstypicallyrequireopenreduction. 2. VolarapproachtoadorsalMCPjointdislocationprovides direct access to the structures most commonly blocking 8 Outcome Clinical Photos reduction (transverse metacarpal ligament, flexor tendon, and Radiographs volar plate). The digital nerves are in close proximity to thevolarincisionutilizedinthisapproach. SeeFigs.3and4. 3. DorsalapproachforadorsalMCPjointdislocationallows forincisionofthevolarplatetoallowforreductionofthe MCPdislocationwithoutproximitytothedigitalnerves. 4. Concomitantinjuries,suchasfractures,shouldbetreated simultaneously with stable fixation to allow for early motion. MetacarpophalangealandInterphalangealJointDislocation 3 Fig.2 Intraoperativefluoroscopicimagesoftherightindexfingerdemonstratefixationofthesecondmetacarpalheadwith1.3mmscrewsand reductionofthemetacarpophalangealjointdislocation Fig.3 PA(a)andoblique(b) radiographsofrighthand approximately2weeksstatuspost openreductionandfixationofthe secondmetacarpalheadfracture andreductionofindexfinger MCPdislocation Fig.4 Oblique(a)andlateral(b) radiographsofrighthand approximately5monthsstatus postopenreductionofMCPjoint dislocationandfixationof metacarpalheadfracture 4 F.G.L.Fishman 9 Avoiding and Managing Problems 10 Cross-References 1. Donotpullstraighttractionattemptduringclosedreduc- ▶Intra-articularPhalangealFractures tionofMCPorIPdislocation. ▶PhalangealShaftFracture 2. Volar approach – incision through skin only as neuro- ▶ShortArmCast vascularbundlemaybedrapedoverdislocatedmetacarpal orphalanxandlocatedverysuperficially. References and Suggested Readings 3. Reductions may be unstable following reduction and shouldbetakenthrougharangeofmotion. Calfee RP, Sommerkamp TG (2009) Fracture-dislocation about the 4. Early range of motion following stable closed or open fingerjoints.JHandSurgAm34A:1140–1147 reductiontopreventstiffness. Kozin SH, Waters PM (2006) Fractures and dislocations of the hand 5. Premature physeal arrest is a potential complication fol- andcarpusinchildren.In:BeatyJH,KasserJR(eds)Rockwoodand Wilkins’ fractures in children, 6th edn. Lippincott Williams & lowing a IP or MCP joint dislocation in a skeletally Wilkins,Philadelphia,pp257–336 immaturepatient.
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