bolintiam, cruz, dela cruz, lu, que, rivera, sioco, tai, valera, veloso together as one
TRANSCRIPT
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B O L I N T I A M , C R U Z , D E L A C R U Z , L U , Q U E , R I V E R A , S I O C O , T A I , V A L E R A , V E L O S O
TOGETHER AS ONE
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IDENTIFYING DATA
• ML• 15 F• Mandaluyong City• RC• Student• Right handed
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CHIEF COMPLAINT
“Hindi maigalaw mabuti ang kaliwang braso” (limitation of movement of the left arm)
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HPI
14 months PTA
(October 2011)
• Playing on top of a rolling drum
• Fell with an outstretched left arm
• (+) limp L arm
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HPI
14 months PTA
(October 2011)
• (+) swelling, gross deformity
• (-) open wound• (-) numbness and
other sensory deficits
• “Hilot” for two months
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HPI
12 months PTA
• No improvement of symptoms
• Limitation of flexion of elbow to only about 30deg
• Sought consult in POC• X rays were
done
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XRAY
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XRAY
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XRAY
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XRAY
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XRAY
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ELBOW X RAY (AP)
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ELBOW X RAY (OBLIQUE)
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ELBOW X RAY (LATERAL)
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HPI
12 months PTA
• No improvement of symptoms
• Limitation of flexion of elbow to only about 30deg
• Sought consult in POC• Xray
• Advised to follow-up after 6 months
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HPI
6 months PTA
• On follow-up:• Advised surgery• Referred to another
institution• Deferred
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HPI
1 month PTA
• Patient sought consult with attending physician and was advised surgery• Referred to DM
ADMISSION
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PAST MEDICAL HISTORY
• No asthma, lung, heart, kidney, liver and other congenital diseases• No previous hospitalizations• No previous surgeries• No allergies to food and medications
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IMMUNIZATION
• DPT x 3• OPV x 3• Hep B x3• BCG• Measles
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DEVELOPMENTAL HISTORY
• At par with age• Cognition, motor, verbal
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FUNCTIONAL HISTORY (ACTIVITIES OF DAILY LIVING )
Prior to accident
• Bathing• Dressing• Grooming• Oral care• Toileting• Transferring• Eating
After accident
• Difficulty in • Bathing• Dressing• Grooming• Eating
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FUNCTIONAL HISTORY (INSTRUMENTAL ACTIVITIES OF DAILY LIVING)
Prior to accident
• Shopping• Food preparation• Housekeeping• Laundry• Transportation• Finances
After accident
• Difficulty in• Food preparation• Housekeeping• Laundry
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FAMILY HISTORY
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FAMILY HISTORY
• (+) Diabetes- father of patient, osteoporosis- grandmother of patient• (-) Hypertension, Dyslipidemia, Stroke, MI,
Cardiac Problems, Renal Problems, Cancer, Asthma
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PERSONAL AND SOCIAL HISTORY
• Non-smoker• Non-alcoholic beverage• No illicit drug use
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PERSONAL AND SOCIAL HISTORY (HEADSSS)
• Home• Close to family
• Education• Incoming 1st year high
school student• Forced to stop school
this year
• Activities• Loves to watch TV
• Diet• 3 meals: rice and meat
• Suicide• None
• Sex• None
• Substance• None
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REVIEW OF SYSTEMS
• General: (-) fever, weight loss, loss of appetite• Musculoskeletal/Derma: No skin lesions or
changes• HEENT: (-) history of head injury. (-) BOV, tinnitus,
epistaxis, (-)dysphagia or enlarged lymph nodes• Respiratory: (-) cough or colds, wheezing,
hemoptysis• Gastrointestinal: (-) abdominal pain, changes in
bowel habits, diarrhea, or constipation• Genitourinary: (-) dysuria or hematuria,
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PHYSICAL EXAM
• Awake, alert, coherent• Vitals: • 42 kg, 142; BMI 18.2 Normal• BP 100/60• HR 86• RR 19 • Temp 36.4• Not in pain (0)
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PHYSICAL EXAMINATION
GENERAL APPEARANCE
Alert, coherent, cooperative, medium-build
VITAL SIGNS BP: 100/60 Temp: 36.4 VAS: 0/10HR: 86 RR: 19Wt: 42g Ht: 152 cm BMI: 26.06
SKIN AND HAIR
warm, good skin turgor, (-) no thinning of hair
EYES Pink palpebral conjunctiva, Anicteric sclerae, EBRTL, (-) lid lag
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PHYSICAL EXAMINATION
MOUTH (-) Lesions in the buccal mucosa, (-) TPC, (-) enlargement of the tongue
NECK (-) CLAD, non-enlarged thyroid, (-) thyroid nodule
CHEST No intercostal retractions, No use of accessory muscles, equal chest expansion, Clear breath sounds, (-) rales and wheezes
CARDIOVASCULAR
Adynamic precordium, no heaves thrills and lifts. Normal rate and regular rhythm, Good S1 and S2 sounds, no murmurs, full and equal pulses on all extremities
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PHYSICAL EXAMINATION
ABDOMEN No lesions, NABS, tympanitic upon percussion, no organomegaly, (-)tenderness
GU (-) CVA tenderness
Extremities (+) gross deformity of the Left arm(+) limitation of movement• Maximum flexion: 30
degrees• Extension: 0 degrees• Slight limitation on
pronation and supination
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SALIENT FEATURES
Subjective Objective
- 15/F- CC: LOM, left arm- History of left arm trauma- Swelling and gross deformity- No consult done- Manipulation through regular
“paghihilot”
- Gross deformity of the left arm- Limitation of movement
• Maximum flexion: 30 degrees
• Extension: 0 degrees• Slight limitation on
pronation and supination- X Ray findings
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DIFFERENTIALS
• Extension fracture of the supracondylar humerus
Rule In Rule Out
Previous hx of significant fall on an outstretched hand
Majority of supracondylar fracture of the humerus are extension type (97-99%)
Swollen elbow that patient is hesitant to move
Elbow becomes angulated
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DIFFERENTIALS
• Flexion fracture of the supracondylar humerus
Rule In Rule Out
Hx of left arm trauma Usually a result of falling onto a flexed elbow
(+) swelling
(+) limitation of movement
(+) gross deformity of the left arm
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DIFFERENTIALS
• Elbow Joint Dislocation (Posterior)
Rule In Rule Out
Hx of fall on an extended arm
On palpation, the olecranon is displaced from the plane of the epicondyles
(+) swelling
(+) limitation of movement
(+) gross deformity of the left arm
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DIFFERENTIALS
• Juvenile Idiopathic (Rheumatoid) Arthritis
Rule In Rule Out
15/F Hx of fall on an extended arm
(+) swelling Morning stiffness
(+) limitation of movement
Usually polyarticular
(+) gross deformity of the left arm
Usually presents with other systemic manifestations
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DIFFERENTIALS
• Malignancy: Osteosarcoma
Rule In Rule Out
Usually develops during rapid growth that occur in adolescence average age is 15
Runs in families
Boys and girls have similar incidence
Tends to occur in shin, thigh and upper arm
Most common malignant bone tumor in children
Present with bone fracture, bone pain
Presents with LOM, limping, tenderness, swelling, redness
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WORKING IMPRESSION
Malunion of the left elbow probably secondary to neglected supracondylar humerus fracture
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ANATOMY OF THE ELBOW
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HUMERUS
• Capitulum (lateral) radial head• Trochlea (medial) trochlear notch of the ulna• Anterior Coronoid fossa receives coronoid
process of ulna during full flexion• Posterior Olecranon fossa receives olecranon of
ulna during extension• Radial fossa receives edge of head of radius
during full flexion
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ULNA
• Stabilizing bone• Located medially, longer• Articulation between ulna and humerus flexion,
extension (with minimal abduction and adduction during pronation - supination)• Tapers at the end to form the ulnar head and the
styloid process• Doesn’t reach and participate in joint action
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RADIUS
• Head of the radius and capitulum flexion and extension of the elbow
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MUSCLES
Muscle Proximal attachment
Distal attachment
Action
Biceps brachii Short head: tip of coracoid process of scapulaLong Head: Supraglenoid tubercle of scapula
Tuberosity of radius and fascia of forearm
Supinates forearmFlexes forearmShort head: resists shoulder dislocation
Coracobrachialis Tip of coracoid process of scapula
Middle third of medial surface of humerus
Helps flex and adduct armResists shoulder dislocation
Brachialis Distal half of anterior surface of humerus
Coronoid process and tuberosity ulna
Flexes forearm in all positions
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MUSCLES
Muscle Proximal Attachement
Distal Attachment
Muscle Action
Triceps brachii Long head: infraglenoid tubercle of scapulaLateral head: posterior surface of humerus, superior to radial grooveMedial head: posterior surface of humerus, inferior to radial groove
Proximal end of olecranon of ulna and fascia of forearm
Main forearm extensorLong head – resists humeral dislocationImportant during adduction
Anconeus Lateral epicondyle of humerus
Lateral surface of olecranon and superior part of the posteriior surface of ulna
Assists triceps in forearm extensionStabilize elbow joint
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SUPRACONDYLAR HUMERUS FRACTURES
• Fractures of the distal humerus just above the epicondyles• Typically remains extra articular• 55% to 75% of all elbow fractures• Peak incidence 5 to 8 years, after which
dislocations become more frequent• The left, or nondominant side, is most frequently
injured
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SUPRACONDYLAR FRACTURES
• In 5 – 8 year olds, bone remodeling causes a decreased anteroposterior diameter in the supracondylar region, making this area susceptible to injury
• Ligamentous laxity in this age range increased likelihood of hyperextension injury
• The anterior capsule is thickened and stronger than the posterior capsule. • In extension: the fibers of the anterior capsule are taut, serving as a
fulcrum by which the olecranon becomes firmly engaged in the olecranon fossa
• With extreme force: hyperextension may cause the olecranon process to impinge on the superior olecranon fossa and supracondylar region
• The periosteal hinge remains intact on the side of the displacement
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MECHANISM OF INJURY
• Extension type • Hyperextension occurs during fall onto an outstretched
hand with or without varus/valgus force• Hand is pronated posteromedial displacement
*More common*Possible radial nerve injury
• Hand is supinated posterolateral displacement *Possible median nerve and vascular compromise
• Flexion type: Caused by direct trauma or a fall onto a flexed elbow
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• Typical presentation: swollen, tender elbow with painful range of motion
• S-shaped angulation at the elbow: a complete (Type III) fracture results in two points of angulation to give it an S shape.
• Pucker sign• Dimpling of the skin anteriorly secondary to penetration of the
proximal fragment into the brachialis muscle• Means reduction of the fracture may be difficult with simple
manipulation
• Evaluate integrity of the median, radial, and ulnar nerves plus their terminal branches
• Can be occult on radiographs with only a positive fat pad sign
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Lateral radiograph with positive fat pad sign in a patient with a nondisplaced fracture of the radial headAnterior lucency (arrow) elevated anterior fat Posterior lucency (arrowhead) elevated posterior fat pad
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SUPRACONDYLAR FRACTURES
Type I: NondisplacedType II: Displaced with intact posterior
cortex; may be angulated or rotated
Type III: Complete displacement; posteromedial or posterolateral
Gartland Classification based on the degree of displacement
EXTENSION TYPE (98%)
FLEXION TYPE (2%)
Type I: NondisplacedType II: Displaced with intact anterior
cortexType III: Complete displacement; usually
anterolateral
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GARTLAND - EXTENSION TYPE
type I (undisplaced), II (displaced with an intact posterior cortex), and III (displaced with no cortical contact)
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TREATMENT – EXTENSION TYPE
Type I: Immobilization in a long arm cast or splint at 60 to 90 degrees of flexion is indicated for 2 to 3 weeks.
Type II: This is usually reducible by closed methods followed by casting; it may require pinning if unstable (crossed pins versus two lateral pins) or if reduction cannot be maintained without excessive flexion that may place neurovascular structures at risk.
Type III: Attempt closed reduction and pinning; traction (olecranon skeletal traction) may be needed for comminuted fractures with marked soft tissue swelling or damage.Open reduction and internal fixation may be necessary for rotationally unstable fractures, open fractures, and those with neurovascular injury (crossed pins versus two lateral pins).
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TREATMENT – FLEXION TYPE
Type I: Immobilization in a long arm cast in near extension is indicated for 2 to 3 weeks.
Type II: Closed reduction is followed by percutaneous pinning with two lateral pins or crossed pins.
Type III: Reduction is often difficult; most require open reduction and internal fixation with crossed pins.
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BONE HEALING
• Primary• Cortex attempts to heal without callus formation• Occurs when fx is anatomically reduced, the blood supply
is preserved, and the fracture is rigidly stabilized
• Secondary• Formation of callus • Involves participation of the periosteum and external soft
tissues
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4 STAGES OF FRACTURE HEALING
1. Hematoma formation (inflammation) and angiogenesis.
2. Cartilage formation with subsequent calcification3. Cartilage removal and bone formation4. Bone remodeling
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STAGE 1 - HEMATOMA FORMATION AND ANGIOGENESIS
• < 1 week after a fracture• Transforming growth factor beta (TGF-) and
platelet derived-growth factor (PDGF) are released from platelets at the fracture site• Osteogenic cells and inflammatory cells
ensheathe the fracture and differentiate into chondrocytes or osteoblasts.
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STAGE 2 - CARTILAGE FORMATION WITH SUBSEQUENT CALCIFICATION
• ~ 1 to 3 weeks after fracture• Radiologic evidence of mineral formation signals
the onset of this phase. • consisting of calcified cartilage, woven bone
made from cartilage, and woven bone formed directly.• Woven bone replaces cartilage in callus by active
transport of minerals and their precipitation from a supersaturated solution
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STAGE 3 - CARTILAGE REMOVAL AND BONE FORMATION
• ~ 1 to 3 months after fracture• woven-bone mineralized callus replaced by
lamellar bone arranged in osteonal systems • 3 characteristics:– It forms only under conditions of mechanical stability;– It has the ability to replace fibrous or muscle tissue; and– It forms within the confines of the bone defect
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STAGE 4 – BONE REMODELLING
• Can be around several years• meticulously coordinated removal of bone from
one site and deposition in another.• Two lines of cells, osteoclasts and osteoblasts, are
responsible for this process• Osteoclasts – resorption• Osteoblast - accretion
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MALUNION
• Described to be a fractured bone that did not heal in an anatomic position• Bone may have: • Angulated• Rotated out of position• Overrided another bone
• Causes shortening of the limb
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• Shortening is better tolerated in the upper limb• >1 inch poorly tolerated in the lower limb• Causes:• Inadequate immobilization• Misalignment• Premature removal of an immobilizer
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• Surgical Indication: • Pain• Impaired normal function
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NON-UNION
• Healing by fibroblastic response instead of bone formation• Caused by:• Overdistraction• Excessive motion • Inadequate immobilization
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MALUNION VS. NON-UNION
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MANAGEMENT
• Traditional management- relied the intact posterior periosteum to maintain the stability of a closed reduction. • no longer recommended because the forced
flexion required to maintain stability of the fracture leads to excessive pressure in the antecubital fossa and increases the risk of compartment syndrome.
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• anatomical closed reduction of the fracture then hold it in position with two or three pins introduced from the lateral side of the distal fragment. • splinted in 45 degrees of flexion, a safe position
for the swelling and circulation. • pins can be removed in three to four weeks, with
resumption of full activities a month later.
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• Laterally introduced pins are preferred to crossed pins because there is a 2% to 6% risk of iatrogenic ulnar nerve injury.
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• Crossed pinning of a supracondylar fracture. Both columns are pinned and the fracture is stable
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OSTEOTOMY
• surgical operation whereby a bone is cut to shorten, lengthen, or change its alignment. Can be used to straighten a bone that has healed crookedly following a fracture.
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• Immobilization in a long arm cast (or posterior splint for swelling) with the elbow flexed to 90 degrees and the forearm in neutral for 2 to 3 weeks postoperatively, at which time the cast may be discontinued and the pins removed• The patient should then be maintained in a sling
with range-of-motion exercises and restricted activity for an additional 4 to 6 weeks
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COMPLICATIONS OF SUPRACONDYLAR FRACTURES
• Vascular Injury• Forearm compartment syndrome resulting in
Volkmann’s ischemic conracture• Nerve Injury• Cubitus varus deformity
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COMPLICATIONS: VASCULAR INJURY
• Absence of radial pulse (10-20 %)• Most common with Type II and II SFs• Brachial artery – most freq. injured in
posterolaterally displaced fractures
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COMPLICATIONS: VOLKMANN ISCHEMIC CONTRACTURE
• Vascular injury and swelling lead to the dev’t of compartment syndrome (w/in 12-24 hours)• Ischemia and Infarction can progress to
Volkmann’s Ischemic Fracture• Fixed flexion of the elbow• Pronation of the forearm• Flexion of at the wrist• Joint extension of the MTC-Phalangeal Joint
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COMPLICATIONS: NEUROLOGIC DEFICIT
• Freq. 10-20 %, and increases with Type III SFs to 49%• Median Nerve Injury – Posterolateral distal fracture
fragment displacement w/ medial mov’t of the proximal fx fragment
• Radial Nerve Injury – Lateral proximal fracture fragment displacement
• Ulnar nerve Injury – Flexion type supracondylar fractures
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COMPLICATIONS: CUBITUS VARUS DEFORMITY
• Angular deformity or ‘gunstock’ deformtiy – long term complication• Remodeling and correction of fracture angulation
is limited for children with SFs
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PROGNOSIS OF PATIENTS WITH SFS
• Long term outcome and function• very good if the fracture is appropriately diagnosed and
treated
• Many of the associated complications• Self-limited• Amenable to functional repair w/ surgical intervention
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• Weiss JM, Kay RM, Waters P, Yang S, Skaggs DL. Distal humerus osteotomy for supracondylar fracture malunion in children: a study of perioperative complications. Am J Orthop (Belle Mead NJ). 2010 Jan;39(1):22-5.
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SPECIAL CHARACTERISTICS OF PEDIATRIC BONES
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ANATOMY
• Less dense and more porouso More vascular channelso More water and cellular content, less mineral contento Higher collagen to bone ratio
• Periosteum o Stronger, thicker and more fibrous o Loosely attached and easily elevated with trauma
(especially diaphysis)o More firmly attached in metaphyseal-epiphyseal region
helps stabilize the growth plate allowing more active bone growth
o Thickens and is continuous with physis at perichondreal ring (ring of Lacroix) Additional resistance to shear force
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ANATOMY
• Physis (Growth plate) unique cartilaginous structureo Thickness depends on ageo Weaker than bone in torsion, shear and bending
predisposes children to injuryo Facilitates remodelling o Can possibly cause deformity
• Ligaments functionally stronger than bone in children
o More injuries result in fractures rather than sprains
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ANATOMY
• Blood supply o In growing bone rich metaphyseal
circulation with fine capillary loops ending at the physis
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BIOMECHANICS
• More elastic and weaker Injury at lower energy trauma (compression, torsion, bending forces)
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PHYSIOLOGY
• More rapid bone healing / metabolismo Increased blood flowo Increased cellular activityo More active periosteum
• High remodeling potential especially near the growth plate