Upperlimb fractures in paeds includes supracondylar, lateral condyle, elbow fractures, forearm fractures

1. 1

2. 2

3. 3

4. 4

5. 5

6. 6

7. 7

8. 8

9. 9

10. 10

11. 11

12. 12

13. AO
13

14. 14

15. 15

16. 16

17. 17

18. 18

19. 19

20. 20

21. 21

22. 22

23. • Gently for 10 minutes with 10-15 degree felbow flexion
• The goal is to disengage the humeral shaft from the anterior
muscles and skin, in order to allow accurate reduction of the bony
fragments.
• A palpable soft tissue reduction event will often be felt during the
application of traction.
• The pucker sign, if present, will visibly reduce with successful
traction.
If the muscle is stuck despite
traction, a milking maneuver can
be attempted.
23

24. 24

25. • This must be done before the two
fragments are brought into apposition.
• If the rotation is not correct, the fragments
must be disengaged before another
attempt at correction of the rotation.
• In most cases, the distal fragment requires
external rotation.
25

26. • Thumb is positioned over the olecranon and pushed distally and anteriorly, whilst the elbow is
smoothly flexed.
• If the elbow will not flex fully it is likely that the reduction is incomplete.
• A complete reduction may be felt.
• If a complete reduction can be felt, the arm is fully pronated (in case of a medially displaced
distal fragment) or supinated (in case of laterally displaced distal fragment).
26

27. 27

28. 28

29. 29

30. • Pin entry points are located in the lateral humeral condyle, distal to its maximal width.
• Techniques to assist correct insertion of the pin within the sagittal plane (lateral view) include:
 Identifying the alignment of the humeral shaft when evaluating the reduction and
marking the sagittal alignment on the skin
 Palpation of the humeral head aiming the pin for its center
30

31. 31

32. 32

33. Considered when fractureline is high on the medial side, or unable to stabilize
with lateral wires
**Ulnar nerve can sublux forwards onto, or anterior to, the medial epicondyle
with elbow flexion
• The medial epicondyle is palpated
• A 1 cm longitudinal skin incision is made
directly over the prominence of the medial
epicondyle.
• Blunt dissection is performed, until the medial
epicondyle can be palpated and seen.
• A 2.0 mm drill guide, placed directly onto the
medial epicondyle, is used to establish the
entry point of the K-wire.
33

34. 34

35. Open reduction indication:
• Open fracture
• Failed close reduction
• Vascular or nerve exploration
35

36. Landmark:
• brachioradialis forming lateral border of
supinated forearm
• bicep tendon on the anterior cubital fossa
Lazy S incision from above flexion crease medial side of
the biceps, curve across the front of elbow and curve
towards the medial border of brachioradialis muscle
Internervous plane
• Distally between brachioradialis (radial nerve)
and pronator teres (median nerve)
• Proximally between brachioradialis (radial nerve)
and brachialis muscle (musculocutaneous nerve)
36

37. • In these cases, the sharp proximal fracture end
of the distal humerus pierces most of the deep
structures, such as brachialis muscles, fascia
and the integument. As a result, the exposure
of the vessels is already accomplished in the
majority of cases.
• the neurovascular bundle explored by careful
dissection across the anterior aspect of the
metaphyseal fragment until the bundle is
identified
• Just medial to the biceps tendon, the brachial
artery may be present, with the median nerve
just medial to the artery.
• in a patient presenting with a pulseless, poorly
perfused hand, search for the lacerated ends of
the artery that may have retracted 37

38. 38

39. • The distal fragment can be engaged using a small Hohmann's bone lever, and the
shaft fragment is gently maneuvered into position
• Depending on the fracture anatomy, a small pointed reduction clamp may help to
maintain reduction while K-wires are inserted
39

40. • This procedure is performed with the patient positioned either supine or lateral.
40

41. • Landmark: bony olecranon process at the upper end of ulna (conical and sharp apex)
• Incision: Midline longitudinal incision above elbow and curve laterally at just above
the tip of olecranon, curve medially so it lies over the subcutaneous border of the ulna
• Internervous plane: no true plane
41

42. 42

43. 43

44. 44

45. 45

46. 46

47. >
47

48. 48

49. Fracture line exiting posterior
metaphysis (arrow) typical for lateral
condyle fractures
49

50. 50

51. 51

52. 52

53. •pins are less stiff
•screw may need to be removed if crossing the physis
53

54. 54

55. 55

56. 56

57. 57

58. 58

59. 59

60. • A true lateral radiograph of the elbow joint allows
assessment of the radio-capitellar joint.
• A line drawn along the long axis of shaft of the
radius will bisect the capitellum in all positions of
flexion and extension.
60

61. 61

62. 62

63. 63

64. 64

65. 65

66. Osteology Muscle
Soft tissues
66

67. 67

68. 68

69. 69

70. Angle (0) Malrotation (0) Bayonet Apposition
0-10 years <15 <45 Yes, <1cm shorter
> 10 years <10 <30 No
Approaching
skeletal maturity
(2y growth
remaining)
0 0 No
70

71. 71

72. 72

73. 73

74. 74

75. 75

76. 76

77. Fractures treated late for loss of position may not permit the easy passage of a rod.
In more mature adolescents, there might be a problem in balancing the problems of plating with the
delayed healing that may occur with IM rods.
In these circumstances, open reduction with plate fixation is often the best treatment.
77

78. 78

79. 79

80. 80

81. Coupled relation of rotation and angulation.
A: The radiograph shows deformity with pronation of the
distal fragment and dorsal angulation of the radius. The
ulna has undergone plastic deformation. When a single
bone angulates, it must rotate around the other.
B: Alignment is restored with supination of the distal
fragment. The lateral projections of the elbow and the
wrist are now matched.
Usually mid-diaphyseal occur in tandem with
angulation of incomplete fracture, with cortical
breach of only one side of the bone
Coupled relation of rotation and angulation. This fracture
demonstrates volar angulation. The mechanism of injury was
falling on the outstretched hand. When the fractures of the
radius and ulna are at different levels, angulation cannot occur
without rotation.
Note the AP appearance of the elbow and the lateral projection
of the wrist This deformity is corrected with pronation of the
distal fragment.
81

82. 82

83. 83

84. 84

85. 85

86. 86

87. 87