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Common Hand injuries by age groups
  • < 8 yo
  • 9-12 yo
  • Teenagers
  • < 8 yo = distal phalanx fx
  • 9-12 yo = P1 small finger
  • Teenagers = neck small MC
Indications for CRPP of distal radius fx
1. floating elbow (ipsalateral upracondylar fx)
2. displaced DR fx with intact ulna
2 randomized trials have shown equal results for SAC or LAC with distal 1/3rd BB forearm fxs
Risk of physeal arrest with physeal fx of distal radius and ulna
  • radius = 5-7%
  • Ulna = 50%
OKU 9 with no citation
Ossification order of carpus
  • Cathys - capitate (3/2 mo)
  • Highwire - hamate (4/3 mo)
  • Tricks - triquetrum (2/1.5yr)
  • Lacked - lunate (4/2.5yr)
  • Several - Scaphoid (5.5/4yr)
  • Trapeze - trapezium (6/4yr)
  • Talent - trapezoid (6/4yr)
  • Points - pisiform (11/9.5yr)
  1. Galeazzi fx
  2. Galeazzi equivalent
  1. radial shaft fx with associated DRUJ injury
  2. radial shaft with ulna SH I or II
immoblize in supination for stability of DRUJ
Most common carpus bone fx in peds?
Scaphoid: often ND, tx with longarm thumb spica 6-8 weeks, displaced fxs >10 yo consider ORIF
surgical indications for radial neck fx (peds)
  1. >30 degrees residual deformity
  2. >3-4mm translation
  3. <45 degrees sup/pronation
Peds forearm criteria(angles)
  • <10 = upto 15 degrees
  • >10 = upto 10 degrees and no bayonet apposition
peds forearm refracture rate
5-10% risk
Peds prox humerus fxs (clssification)
Neer & Horwitz
  • Grade I - <5mm displaced
  • Grade II - <1/3rd humeral diameter
  • Grade III - <2/3rd displaced
  • Grade IV - >2/3rds displaced
Tx prox humerus fx (Neer & Horwitz)
Grade I and II - Non-op
Grade III & IV - consider CR

CR = obtained by 90 abduction & 90 ext rotation

block reduction: long head biceps, capsule, or periosteum
Most common nerve injured with supracondylar humerus fracture
AIN
Nerve injury in supracondylar fx:
  1. posterolateral displacement
  2. posteromedial displacement
  3. medial pin/ rare iatrogenic
  1. median
  2. radial
  3. ulnar (3-8% risk of injury w/ medial pin)
Residual deformities of malreduced supracondylar fractures
  1. cubitus varus (gunstock) deformity: mostly cosmetic with little functional difficulty: decreaed risk with CRPP
  2. Recurvatum - assoc with Type II & III closed tx and casting
Type I lateral condyle fractures .. 2-10% displace significantly to require reduction and pinning
Lateral condyle fractures (classification)
Milch - rarely used
  • I - fx through capitellum ossification center (SH IV)
  • II - fx medial to capitelum (SH II)
Tx based:
  • I - <2mm displacement
  • II - 2-4mm displaced
  • III - >4mm displaced ..often rotated
Reduction maneuver for encarcerated medial epicondyle
supination, valgus stress, wrist & finger extension
Type of proximal humerus fx based on age:
  1. young children
  2. 5-11 yrs old
  3. >11 yo
  1. SH I
  2. Metaphyseal
  3. SH II
Neonate proximal humerus injury
generally Type I
difficult to visualize with single AP film ok
posteriorly diplaced epiphysis = vanishing epiphysis sign
most do well without formal manipulation
acceptable reduction measurements for pediatric proximal humerus fractures
  1. <5yr
  2. 5-12
  3. >12yr
  1. 70 degrees & 100% displaced
  2. 40-70 degrees angulation, no displacement recommendation
  3. 40 degrees and 50% displaced
Anatomic location of brachial plexus & subclavian artery to clavicle.
junction of medial 2/3rds & lateral 1/3rd
  • 80% of clavicle growth from medial physis
  • medial epiphysis completes ossification @ 23-25
stabilizing ligaments of SC joint
  • intra-articular disc ligament
  • A&P capsular ligaments - anterior stronger than posterior - attach to epiphysis - physis is extra-articular
  • interclavicular ligament
  • costoclavicular ligament (rhomboid)
Classification for lateral clavicle fxs (peds)
glenopolar angle
Radial Neck Fxs:
  • post dislocations
  • medial epicondyle fxs
  • 8-12yrs old
Acceptable displacement of radial neck fxs -- 'Rule of 3's'
Non-op
  • <30 degree angulation
  • <3mm displacement
  • 1/3rd of radial head involvement
Monteggia Fractures:
  • ulna fx w/ radial head dislocation
  • Outcomes based on re-establishment of ulnar length/alignment
  • List Bado Classification
Bado
  • I - ant radial head & ulna apex
  • II - post radial had & ulna apex
  • III - lateral dislocation w/ ulna fx
  • IV - ant dislocation w/ fx of both rad & ulna
Forearm rotational deforming forces based on location of fx:
Prox 1/3rd: supinated by supinator & biceps

Distal 1/3rd: pronated by PQ & BR
Rate of radius remodeling (distal & midshaft)
Distal: 0.9 degree/month or 10 degree/yr

Mid: 4.4 degrees per year
Acceptable reduction based on remodeling (midshaft):
  • <8 yo
  • >8 yo
  • <8 yo - 20 midshaft angulation, bayonet, no rotation
  • >8 yo - 10 angulation, no rotation
Acceptable reduction based on function (midshaft):
  • 10-15 angulation
  • 30-45 rotation
  • bayonet apposition
Acceptable distal radius reductions:
  • <12 yo
  • >12 yo
  • < 12 yo = 20-25 degrees sagital angulation, 50% translation
  • >12 yo = 10 degrees sagital and coronal
Distal radius metaphyseal fxs w/ pt over 10yrs old, angulation >30 degrees or complete displacement = 39% loss of reduction
Base of thumb metacarpal fxs - tolerate 30 degrees of angulation, tx with thumb spica
seymours's fracture
  • physeal fx of distal phalanx with nail bed laceration
  • often incarceration of germinal matrix
  • remove nail, I&D, repair nail bed, and reduce fx
Pediatric gamekeepers
SH III of thumb P1, recommend ORIF
Phalangeal neck fxs
  • door jam injury
  • middle > proximal phalanx
  • border digits most often
  • little remodeling potential
  • attempt CRPP w/ displaced
  • Type I - ND
  • Type II - dsplaced w/ bony contact
  • Type III - no bony contact
PRUJ - most stable in supination do to tightening of quadrate ligament and interosseous memebrane are tight and there is also the most bondy contact b/t radius and ulna
interosseous membrane
  • most taut in neutral to 30 degrees supination
  • oblique fibers from prox rad to distal ulnar
  • starts 1cm distal to radial tuberosity and ends @ DRUJ
acceptable alignment of prox 1/3rd radius and ulna fxs
less than ten degrees displacement
hand position if proximal radius fx is distal to biceps insertion -- ulna distal to insertion of triceps
cast in supination to match the deformign forces of the supinator, biceps & brachialis  --  mild extension to match extension deformity of ulna from triceps
risk of physeal arrest with FX
  • distal radius
  • distal ulna
radius = 3-5%
ulna = 20-50%
location of insertion of the FDP and extensor tendons on the distal phalanx?
  • FDP - metaphysis
  • Extensors - epiphysis
age of appearance for secondary ossification (@ base) centers in MC & phalanges
MC - 3yo
Prox phalanx - 3yo
Middle phalanx - 4yo
Dist phalanx - 5yo
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