جراحة العظام / علاج العظام في الاردن / افضل دكتور عظام في الاردن / افضل اخصائي عظام في الاردن / استشاري عظام/افضل استشاري عظام في الاردن /جراحة عظام / /عمليات تطويل العظام في الاردن / اطباء العظام في الاردن / دكتور طب عظام في الاردن / الاطباء في الاردن / خلع ورك / عمليات اليزاروف في الاردن /علاج الكسور /خلع الولادة / تركيب المفصل / اوجاع العظام /افضل طبيب عظام اطفال في الاردن / استشاري اطفال عظام في الاردن / /علاج خلع الكتف / علاج التواء الكاحل / التواء الكاحل / علاج الام العظام / علاج هشاشة العظام / ارقام اطباء عظام في الاردن / مشاكل العظام والمفاصل /مستشار جراحة العظام والمفاصل والكسور/مستشار جراحة عظام الأطفال. الكوع ، المرفق ، الاطفال ، كسور الاطفال

1. Freih Odeh Abu Hassan
F.R.C.S.(Eng.),F.R.C.S.(Tr.&Orth)
Professor Of Orthopaedics
University Of Jordan
Pearls and Pitfalls

2. 1= High rate of complications
2= Results of non operative R/ are not always good.
3= > skeletally immature ( 5-10 y)
4=The child’s elbow is well
vascularized  # healing very
quickly.
Different from many other pediatric injuries!!!

3. C
O
R
I

4. They enter the post. portion of the lat condyle lat. to the origin of the capsule & proximal to the articular cartilage, they are end vessels

5. 1- Normal Elbow
Radiographic parameters
64-81

6. 2- Check med.& lat. Column for
translation or comminution

7. 3-The humeral–ulnar angle is the most accurate in determining the true
carrying angle of the elbow.

8. 4-Pseudofracture
The O.C of the trochlea may be
irregular, producing a fragmented
appearance

9. 5-Oblique view

10. Direction of displacement
-=Post.medial # - 75%
=Post.lateral # - 25%
Post.lateral # are more associated with NV injury.

11. Principles of treatment
1-Avoid catastrophes
e.g Vascular lesion, C. synd.
2-Minimize embarrassment
e.g Cubitus varus,
Iatrogenic N injury

12. Emergency Room R/

13. 1-Simple splint in the same
position then x-ray
2-In limb ischaemia align #
3-Avoid flexion
4- Record pulse & sensation

14. 1A- Long arm splintremove 1w 
X-ray Splint for 2 w
1B (med.column collapse) CR+cast
=Avoid elbow flexion > 90°
=Insist on elevation
=Missed inj.
=Med.column collapse
Type I fracture

16. Med.column collapse
1B

17. =CR and Percut. Pins ,why ?
=Long-arm cast for 3 w
= 77% do well without pins
Type II fractures
Hyperflexion

18. Type II , medial impaction.

19. CR and percut. pins
(Cross-wires)

20. =CR + Percut. Pins + 3 w cast
Medial and lateral cross-pin technique is the gold standard, but it places the ulnar nerve at risk.
Type III fractures

22. Traction in extended
elbow and forearm
supination
1

23. Correct varus or
valgus and rotation
2

24. Elbow flexion +
pressure on
olecranon then
forearm pronation
3

26. 4

27. Post med
Med Pin insertion
5

29. 30-40 degree

32. 1-Compound #
2-Arterial inj
3-Compartment synd.
4-Absent pulse after MUA
5-Irreducible #

33. Irreducible #

34. 1-Arterial injury (5–12%)
A pulseless but pink hand can be observed.
Decrease flexion
2-C.Syndrome
3-Nerve Palsy

35. A pulseless white hand after CR and pinning  open exploration with a vascular surgeon.
The anteromedial approach provides good exposure for the vascular repair and OR.

36. Nerve injuries
Loss of sensation & sweating
= 5–19% always neurapraxias.
= 3–6 months to resolve .
=The anterior interosseous N

38. AIN palsy

39. 1=VIC due to immobilization in hyperflexion
2=Malunion
=Due to rotation  “gunstock”
deformity (cubitus varus).
=Inadequate correction of medial
collapse.
= Wait 2years then correct

41. after repeated MUA
3-M.Ossificans

44. Associated with
-Vascular inj.
-VIC
-OPEN #
CR or OR + Pins

46. = Be aware of the
*Fracture patterns,
*Relevant anatomy - blood supply
*Risk of nonunion,
*Postop. follow-up in order to assess
potential deformity and neurologic
sequelae.

47. Diagnosis
AP + Lat. + Oblique view
Milch Type I
Travels from the metaphysis of the distal humerus through the distal lateral epiph. and through the trochleocapitellar groove.

48. Milch Type II
Travels from the distal lateral humeral metaphysis above the epiphysis and exits through the trochlea.

49. S-IV
S-II
I
II

50. DISPLACEMENT: (Rutherford(

51. Stage I
Posterior splint vs. long arm cast
CLOSE FOLLOW-UP
because of high incidence of late
displacement and eventual nonmalunion .

52. Stage II/III
CR + percut. pins if reducible closed.
If not, ORIF + percut. pins
Post-operative Management
Long arm cast at 90 degrees until
radiographic healing
Polyglycolic acid pins

53. =Exposure bet. Brachio R + Triceps.
= Avoid post. dissection of the
fragment to preserve the vascular
supply.
=Careful elevation of the ant. capsule
and dissection to the medial extent
of the fracture fragment.

54. Stage I
4w

55. Stage II

56. After 7days

57. Stage III

59. Cubitus Varus
Secondary to malunion
or capitellar overgrowth

62. Non Union

63. AVN due to extensive dissection

65. Not involve the joint surface or growth cartilage.
The medial epicondyle is a postero- medial structure that serves as the origin of the flexor–pronator muscle mass + medial collateral lig. complex

66. = Associated injuries:
*Elbow dislocation - 50%
*Ulnar neurapraxia.

67. Non-surgical R/ of isolated medial epicondyle # with 5 –15 mm displacement yielded results similar to those obtained with ORIF
Farsetti P, etal
JBJS-A 2001.

68. Operative R/ of med. epicondyle #
= < 10 y old  ORIF (K-wire) and
remove at 3 w.
= In older children  single partially threaded cannulated screw
Early motion is strongly suggested

69. Fracture - dislocation

72. =1%
= Dislocation of the radial head and
ulnar fracture ( proximal 1/3 )

73. Ulnar bow sign
Normal
Type I Monteggia

76. Type I - Anterior dislocation,
Type II- Posterior dislocations.
Type III -Lateral dislocation.
Type IV Radial + Ulnar #
+ radial head dislocation

77. The most reliable method to recognize Monteggia fracture

78. “Monteggia equivalents.”
1= Ulnar plastic deformation -17%
2= Pulled elbow syndrome
3=Both–bone forearm fractures
4=Isolated radial neck fractures
5=Dislocation of the elbow with an ulnar diaphyseal fracture

79. 8-17% of Monteggia # have a neurapraxia of the PIN
Recovery of nerve function takes several days to 2 months after injury

80. The goal of treatment
= Correct the ulnar deformity
= Restoring ulnar length and realigning
the radiocapitellar joint.
=Reduction of the ulnar fracture often
reduces the radial head .
=It is essential to confirm maintenance
of reduction.

81. OR is necessary for unstable fractures
or when closed treatment fails.
Internal fixation of the ulna with an IM Kirshner wire may allow reduction of the radial head.
This method is better than plate fixation

82. The Kocher (posterolateral) approach
is often utilized for open reduction of the radial head.

85. Missed injury
= Limited elbow ROM
=Arthrosis,
=Nerve complications
Ulnar osteotomy + OR of the radial head and reconstruction of the annular ligament.

86. Open surgical treatment
44% obtained a functional arc of motion of 30° to 130°.