paediatric injuries around the elbow
supracondylar elbow injuries
pulled elbow in paediatric age r
radiological signs around elbow in supracondylar fracture humerus
Defined as fracture occurring at or proximal to the surgical neck
It is the commonest fracture affecting the shoulder girdle in adults.
Proximal humeral fracture 80% of all humeral fractures.
In pts above the age of 65 years, proximal humeral fractures are the 2nd most frequent upper extremity fractures
ANATOMY -
The proximal humerus is retroverted 35 to 40 degrees relative to the epicondylar axis.
Most common is fall onto outstretched upper extremity from a standing height, in older & osteoporotic woman.
Younger pts present following high energy trauma with significant soft tissue injury.
Less common with excessive shoulder abduction, direct trauma, electric shock and seizures r seizures
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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Supracondylar fractures in children
1.
2. Most common fracture around the
elbow in children (60 percent of
elbow fractures)
Peak age between 5 and 7 years- boys
had a higher incidence
At the peak age for supracondylar
fractures, there is a naturally
occurring hyperextension of the
elbow, which predisposes the distal
humerus to this type of fracture
3. Almost all supracondylar fractures are caused
by accidental trauma rather than abuse
Fall on an outstreched hand with
hyperextension at the elbow with abduction
or adduction,with hand dorsiflexed.
The most commonly associated fractures are
distal radial fractures, but fractures of the
scaphoid and proximal humerus do occur.
Monteggia fractures have also been reported
Asso injury- radial n, meadian n, ulnar n,
brachial artery.
4. 95 percent are extension type injuries, which
produces posterior displacement of the distal
fragment
Fall onto the outstretched hand with the
elbow in full extension
Ligamentous laxity and hyperextension of the
elbow are important mechanical factors
Medial displacement of the distal fragment is
more common than lateral displacement
5. Gartland (1959)
Type 1 non-displaced
Type 2 Angulated/displaced fracture with
intact posterior cortex
Type 3 Complete displacement, with no
contact between fragments
6. Type 1: Non-displaced
• Note the non-
displaced fracture
(Red Arrow)
• Note the posterior
fat pad (Yellow
Arrows)
8. Type 2: Angulated/displaced
fracture with intact posterior
cortex
• In many cases, the type
2 fractures will be
impacted medially,
leading to varus
angulation.
• The varus malposition
must be considered
when reducing these
fractures, applying a
valgus force for
realignment.
10. Suspected in a child with elbow pain or
failure to use the upper extremity after a fall
Type I supracondylar fracture, there may be
distal humeral tenderness, distension or
swelling in the anconeus soft spot (elbow
effusion), restriction of motion, and
evidence of bruising
X-rays may be negative except for a posterior
fat pad sign
11. In type III fractures, gross displacement of the
elbow is evident.
An anterior pucker sign may be present if the
proximal fragment has penetrated the brachialis
and the anterior fascia of the elbow
Careful motor, sensory, and vascular examinations
should be performed in all patients
12. • Nerve injury incidence is high, between 7 and 16 %
(radial, median, and ulnar nerve)
• Anterior interosseous nerve injury is most commonly
injured nerve
• In many cases, assessment of nerve integrity is
limited , because children can not always cooperate
with the exam
13. Supracondylar Humerus Fractures:
Associated Injuries
• 5% have associated
distal radius
fracture
• Physical exam of
distal forearm
• Radiographs if
needed
• If displaced pin
radius also
14. Supracondylar Humerus
Fractures: Associated Injuries
• Vascular injuries are rare, but pulses should
always be assessed before and after
reduction
• In the absence of a radial and/or ulnar
pulse, the fingers may still be well-
perfused, because of the excellent collateral
circulation about the elbow
• Doppler device can be used for assessment
15.
16. Initial management of all patients suspected
of having an elbow injury is splinting in a
comfortable position, generally 20 to 30
degrees of elbow flexion, pending careful
physical examination and x-ray evaluation.
The initial responder should assess the
neurovascular status and other injuries
Tight bandaging or splinting, excessive
flexion or forced extension should be
avoided, as they may compromise vascularity
17. Simple immobilization with a posterior splint
applied at 60 to 90 degrees of elbow flexion
with side supports or a simple collar and cuff
This arrangement allows swelling to occur
and does not put the brachial artery at risk
of compression
Before the splint is applied, it should be
confirmed that the pulse is intact and that
there is good capillary refill
18. If there is any evidence of distal fragment
extension, as judged by lack of intersection of the
anterior humeral line with the capitullum, the
fracture should be reduced and placed in a cast or
treated with percutaneous pinning to secure the
reduction.
The most common cause of cubitus varus
deformity is inadequate treatment of types I and II
fractures.
19. Good stability should be obtained with closed
reduction.
Significant swelling, obliteration of pulse
with flexion, neurovascular injuries,
excessive angulation, and other injuries in
the same extremity are indications for pin
stabilization of most type II fractures
21. If pinning is chosen, two lateral pins through
the distal humeral fragment, engaging the
opposite cortex of the proximal fragment,
are generally sufficient to maintain fracture
alignment
Pins are left protruding through the skin and
are removed at 3 to 4 weeks after fixation,
generally without the need for sedation or
anesthesia.
23. These fractures have a high risk of
neurologic and/or vascular compromise, and
can be associated with a significant amount
of swelling.
Current treatment protocols use
percutaneous pin fixation in almost all cases.
In rare cases, open reduction may be
necessary, especially in cases of vascular
disruption
24. For closed reduction, traction is applied
first, followed by correction of rotational
deformity.
The extension deformity is corrected with
pressure by the surgeon's thumb over the
olecranon and posterior humeral condyles.
25. Traction is applied with the elbow in extension and
the forearm in supination.
The assistant stabilizes the proximal fragment. After
traction has been applied and the length regained,
the fracture is hyperextended to obtain apposition of
the fragments.
While traction is maintained, the varus or valgus
angulation along with the rotation of the distal
fragment is corrected.
Once the length and alignment have been corrected,
the elbow is flexed. Pressure is applied over the
posterior aspect of the olecranon to facilitate
reduction of the distal fragment.
The distal fragment is finally secured to the proximal
fragment by pronating the forearm
29. C-arm Views
• Oblique views with
the C-arm can be
useful to help verify
the reduction
30. Supracondylar Humerus
Fractures
• If pin fixation is used, the pins are
usually bent and cut outside the skin.
• The skin is protected from the pins by
placing felt pad around the pins.
• The arm is immobilized.
• The pins are removed in the clinic 3
weeks later, after radiographs show
periosteal healing.
• In most cases, full recovery of motion
can be expected.
31. Pitfalls of Pin Placement
• Pins Too Close
together
• Instability
• Fracture
displacement
• Get one pin in
lateral and one in
medial column
33. By allowing swelling to decrease and facilitating
closed reduction
In this technique, patients are placed in sidearm or
overhead skin traction for 3 to 5 days until elbow
hyperflexion can be tolerated for closed reduction.
Definitive treatment of the fracture with 14 days of
traction or until healing has occurred historically
has led to a very low incidence of cubitus varus
deformity
Dunlop's traction
Skeletal traction overhead with use of an olecranon
wing nut
34. Type III supracondylar fractures have
significant incidences of brachial artery
injury, vascular insufficiency, and
compartment syndrome
35. About 10% to 20% of patients with type III
present with an absent pulse
emergency management of a patient with a
type III , the arm should be splinted with the
elbow in about 30 degrees of flexion
Perfusion is estimated by color, warmth, and
capillary refill
36. The initial approach to managing a patient
with vascular compromise should be
immediate closed reduction and stabilization
with K-wires.
If an anatomic reduction cannot be obtained
closed, open reduction through an anterior
approach with medial extension allows
evaluation of the brachial artery and removal
of the neurovascular bundle entrapped
within the fracture site or repair of the
brachial artery.
37. increased pressure in a closed fascial space
causes muscle ischemia.
With untreated ischemia, muscle edema
increases, further increasing pressure,
decreasing flow, and leading to muscle
necrosis, fibrosis, and death of involved
muscles.
38. The diagnosis of a compartment syndrome is
based on resistance to passive finger
movement and dramatically increasing pain
after fracture.
The classic five “P” s for the diagnosis of
compartment syndrome
Pain
pallor
pulselessness
paresthesias, and
paralysis
39. fasciotomy if clinical signs of compartment
syndrome are present or if
intracompartmental pressure is greater than
30 mm Hg
contribute to the development of
compartment syndrome are direct muscle
trauma at the time of injury, swelling with
intracompartmental fractures (associated
forearm fracture), decreased arterial inflow,
restricted venous outflow, and elbow
position.
40. AIN appears to be the most commonly
injured , with loss of motor power to the
flexor pollicis longus and the deep flexor to
the index finger
The direction of the fracture's displacement
determines the nerve most likely to be
injured
If the distal fragment is displaced
posteromedially, the radial nerve is more
likely to be injured.
41. if the displacement of the distal fragment is
posterolateral, the neurovascular bundle is
stretched over the proximal fragment, injuring
the median nerve or AIN or both.
In a flexion type of supracondylar fracture,
which is rare, the ulnar nerve is the most likely
nerve to be injured.
if the nerve deficit is present and the fracture is
reducible, open reduction of the fracture and
exploration of the injured nerve are not
indicated.
In most cases, nerve recovery, whether radial,
median, or ulnar, generally occurs at an average
of 2 to 2½ months.
42. Elbow Stiffness
Myositis Ossificans
Nonunion -distal humeral metaphysis is a
well-vascularized area with remarkably rapid
healing, and nonunion is rare
Avascular Necrosis- trochlea after
supracondylar fracture has been reported
43. A decrease in frequency of cubitus varus
deformity after the use of percutaneous pin
fixation
The usual etiology of cubitus varus deformity
is malunion of the distal humeral fragment
rather than growth disturbance
44.
45. As for the treatment of any posttraumatic
malalignment, options include
(a) observation with expected remodeling,
(b) hemiepiphysiodesis and growth alteration
(c) corrective osteotomy- is the only way to
correct a cubitus varus deformity with a high
probability of success
46. 2% of humeral fractures
May not be recognized until reduction is
attempted
Unstable in flexion, whereas extension-type
fractures generally are stable in hyperflexion
A laterally displaced supracondylar fracture
may actually be a flexion-type injury.
47. The mechanism of injury is generally
believed to be a fall directly onto the elbow
The distal fragment is displaced anteriorly
and may migrate proximally in a totally
displaced fracture.
The ulnar nerve is vulnerable in this fracture
pattern
49. Mild angular deformity to complete anterior
displacement
Anterior displacement is often accompanied
by medial or lateral translation
Fracture classification is the same as for
extension-type supracondylar fractures :
type I, nondisplaced fracture
type II, minimally angulated with cortical
contact
type III, totally unstable displaced distal
fracture fragment
50. Type I flexion-type supracondylar fractures
are stable nondisplaced fractures that can
simply be protected in a long-arm cast
If mild angulation, as in a type II fracture,
requires some reduction in extension, the
arm can be immobilized with the elbow fully
extended
51. A problem with type III flexion supracondylar
fractures is that reduction is not easy to
achieve and when achieved, the elbow is
usually in extension, making it quite difficult
to stabilize the distal fragment using pins.
Pinning is generally required for unstable
type II and III flexion supracondylar fractures
Pinning should be performed after closed
reduction with the elbow in mild flexion or
full extension.
53. Open reduction may be required for flexion
type supracondylar fractures.
Open reduction is best performed through
an anteromedial or posterior approach,
rather than an anterior approach, as is used
for extension-type supracondylar fractures
Traction is used very rarely for this type of
fracture
The elbow is generally unstable in increased
flexion, which is a comfortable position for
the patient in traction