Supracondylar Fracture of the Humerus in Children

Supracondylar Fracture of the Humerus in Children

The age is between 4-10 years. The injury is caused by a fall onto an outstretched hand. The majority of the fractures are extension type fractures. Type III is a displaced fracture, and it carries a high incidence of neurovascular deficit and compartment syndrome. Compartment syndrome may not develop right away; it may take hours to develop. The physician should not confuse compartment syndrome with the arterial injury. You can have arterial injury and compartment syndrome or compartment syndrome without arterial injury, and in this case, you will need fasciotomy to release the compartment syndrome. The anterior interosseous nerve is involved in the extension type injury. The patient cannot do the OK sign. If you have an extension type injury and you find that the patient has an ulnar nerve palsy after surgery, then it is probably not due to the extension type injury, but rather is due to the medial pin that may have affected the ulnar nerve. In the flexion type injury, the ulnar nerve injury is more common. Based on the Gartland Classification System, a Type I fracture is nondisplaced, a Type I fracture is angulated with an intact posterior cortex, and a Type III fracture is displaced. To treat a Type I fracture, immobilize the patients arm. To treat Type II and Type III fractures, do closed reduction and percutaneous pinning. If you cannot get the alignment correct, then do open reduction. You will place two or three lateral pins. If a medial pin is needed, be careful of the position of the ulnar nerve. Use open incision to introduce the medial pin. Have the elbow in extension, not in flexion, when you place the medial pin because this will relax the ulnar nerve. When you use the pins, do diversion pins. The cross pins configuration, medial and lateral pins, gives the maximum rotatory stability. The crossing should be approximately 2 cm proximal to the fracture. Normally we use two diversion lateral pins and adding a third pin will increase the stiffness in case of medial comminution. Avoid malposition of the fragments because it can lead to malunion and cubitus varus. Very rarely you may have to do corrective osteotomy for the cubitus varus (it is only a cosmetic problem, not a functional problem. If you have a pulseless, pink hand or a pulseless, white hand, then there is decreased perfusion. You will need to do emergency closed reduction and pinning. If closed reduction cannot be done, then you will do open reduction and pinning. After this, if the hand is pink and warm, then you observe. Observe for capillary refill, for temperature, and for color with the elbow in some flexion, but not in hyperflexion. If after the closed reduction and pinning the hand continues to be white and cold, you will do exploration of the artery. A pulseless, white hand from the beginning and you reduced and pinned the fracture, but the hand continues to be white, then you need to explore and repair the artery. You will repair the artery through an anterior approach and you will do fasciotomy after that. Initially, if the circulation was good, but after reduction and fixation you have a pulseless, white hand, then you need to unreduced the fracture fixation. When you have a nerve injury, observe the patient, do not explore the nerve. The recovery will start in about 6-12 weeks and the majority are completed in 4-5 months. Do not explore the nerve in closed fractures. The anterior humeral line should intersect the middle third of the capitellum in children more than 5 years old, and it touches the capitellum in children less than 5 years old. You want to maintain this relationship between the anterior humeral line and the capitellum. You will remove the pin at 3 weeks, you will allow gentle range of motion, you do not need routine physical therapy and the stiffness usually resolves in about 6 months. Do reduction and fixation when the hand is well perfused (pink and warm), then you can wait overnight to do the reduction in the morning. The urgent cases where you cannot wait to do reduction and fixation are the open fractures, the ones with neurovascular deficit, floating elbow, or impending compartment syndrome.

Posterior Labral Tear

Posterior Labral Tear Shoulder Instability

Posterior labral tear could mean posterior instability, which is usually diagnosed by the Jerk test or the Kim test. The lesion is sometimes called a Reverse Bankart Lesion. The lesion is usually seen on the MRI. When there is an avulsion of the posterior inferior labrum, and the lesion is incomplete, concealed, or occult, it is called a Kim lesion. Probing of the posterior labrum is needed to rule out a subtle Kim lesion. Increased glenoid retroversion increases the risk of posterior shoulder instability by 6 times. Flexion, internal rotation and adduction will cause the shoulder to be at risk for posterior shoulder subluxation or dislocation. It is a high risk position. External rotation and abduction will give anterior dislocation and this is really the apprehension test for anterior dislocation or subluxation. Pain or instability with the arm elevated in the scapular plane occurs due to shoulder impingement. Flexion, internal rotation, and adduction will cause the shoulder to be at risk for posterior shoulder subluxation or dislocation. It is a high risk position. External rotation and abduction will give anterior dislocation, and this is really the apprehension test for anterior dislocation or subluxation. Pain or instability with the arm elevated in the scapular plane occurs due to shoulder impingement. Posterior instability of the shoulder can occur in football players, especially in blocking positions such as defensive linemen. It can also occur in weight lifters and other athletes who perform overhead activities. A severe blow to the anterior structures of the arm results in posterior glenohumeral forces with labral detachment at the rim of the glenoid posteriorly. In posterior subluxation, apprehension occurs in pushing heavy objects. With posterior instability, the patient feels instability or a slipping sensation of the shoulder and pain with posteriorly directed force or pressure. This usually occurs during pushing an object at the level of the shoulder (trying to pass a ball, blocking, or bench pressing with heavy weight). During examination, you will find that there is a normal rotator cuff strength, negative sulcus sign, negative anterior apprehension, and full strength in external rotation and internal rotation. There will be no atrophy of the rotator cuff muscles or deltoid muscle. In general, symptoms of posterior instability of the shoulder are usually vague. Rarely the patient complains of true dislocation that needed reduction. Recurrent episodes of subluxation or pain is not uncommon. The Jerk test and the Kim test will be positive. A combined Jerk test and Kim test (positive) has a sensitivity of 97% for the diagnosis of posterior instability of the shoulder. To perform the Jerk test, the patient’s arm is abducted to 90 degrees, fully internally rotated and the elbow is bent. The examiner axially loads the humerus while the arm is moved horizontally across the body. The arm at this point is adducted, and the shoulder will be flexed. Axially loading of the shoulder will be continuously applied at this point. A positive test is indicated by sharp pain in the shoulder with or without a clicking sound. In some cases, the patient may have the sense of instability. The axillary view may show posterior subluxation of the humeral head, glenoid retroversion, or posterior glenoid erosion. MRI is the best study to diagnose the posterior lesion. Arthrogram in addition to MRI will increase the sensitivity for labral pathology. You may find posterior tear of the labrum on the MRI of an asymptomatic thrower, and it does not mean that this is causing the patient’s symptoms. Nonsurgical treatment includes rest, activity modification, or physical therapy (should focus on reconditioning of the rotator cuff and the scapular stabilizers). Surgical treatment is in the form of open or arthroscopic posterior labral repair. In the first few weeks after surgery, protect the repair by avoiding repetitive passive adduction with the shoulder flexed at the shoulder level. You may find a ganglion cyst in addition to the posterior labral tear and that might decrease the external rotation force with the arm to the side due to compression of the nerve to the infraspinatus muscle. In this case, you will treat the condition by decompression or removal of the ganglion cyst and arthroscopic posterior labral tear repair. In addition to the posterior labral tear, the patient may have a Reverse Hill Sachs lesion which could be treated by transfer of the subscapularis tendon and the lesser tuberosity to the lesion. This procedure is usually done for persistent mechanical symptoms. Injury to the posterior branch of the axillary nerve is a complication of surgery. This branch lies within 1mm of the inferior shoulder capsule and the glenoid rim. It can be injured during the procedure from passing sutures into the posterior and inferior labrum. This branch supplies the teres minor muscle and gives sensation to the lateral shoulder. Over tightening of the posterior capsule may lead to anterior subluxation of the shoulder.

Knee Dislocations

Knee Dislocation

Dislocation of the knee is a serious problem.  It should be recognized and managed appropriately early. Knee dislocation is considered an orthopedic emergency. It is important to recognize the dislocation, and do reduction and perform serial neurovascular exam before the reduction and after the reduction. Approximately 50% of knee dislocations spontaneously reduce before formal evaluation. Morbid Obesity can be a risk factor for knee dislocation. Because the joint capsule is torn, knee swelling may not occur with knee dislocation.  The knee dislocation associated with sports injuries have a lower incidence of neurovascular injury than those associated with a high energy mechanism.

There are several types of knee dislocation that are usually described in the literature. There is a classification based on direction of displacement of the tibia and classification system based on the severity of the ligamentous damage was developed by Dr. Schenck. The dislocation of the knee usually involves at least two ligaments. Anterior knee dislocation is caused by hyperextension mechanism that causes failure of the posterior capsule, the PCL and sometimes the ACL. Anterior knee dislocations are the most common types.  Posterior dislocations are seen in dashboard injuries.  The posterior dislocation has the highest rate of vascular injury (about 25%), and sometimes will be a complete tear of the popliteal artery. Lateral dislocation has the highest rate of peroneal nerve injury. Posterolateral dislocation is the most common rotatory dislocation and it is usually irreducible. In rotatory dislocations, the PCL remains intact as the tibia rotates about the femur.  A dimple on the medial side indicates posterolateral dislocation, which means that the dislocation cam be irreducible and the medial femoral condyle button hoes through the joint capsule.

The physical examination and diagnostic studies can direct the treatment in a timely fashion. There could be an obvious deformity. See if there is a dimple sign. You need to check the pulses, get the x-ray, and reduce the knee immediately regardless if there is a pulse or no pulse. When you check the pulses, compare it to the other side. You have to do serial exam of the pulses and the whole idea is to make sure to discover if there is a vascular injury or not, because if there is a vascular injury and there is a delay more than 8 hours in reestablishing the arterial blood flow, that will result in an amputation rate of 85%. The patient may have severe pain, instability, and the exam will be difficult because of guarding and apprehension, but keep focusing on the circulation. Look at the pulses. Look at the x-rays! The patient may have a fracture, such as medical tibial plateau fracture and other intraarticular fractures, the patient may have asymmetry of the joint space, avulsion fractures such as the Segond sign for ACL tear or tibial eminence avulsion fracture.  Look for asymmetry of an irregular joint space on the x-rays. After you reduce, you immobilize, get x-rays, and make sure the dislocation is reduced. Up to 1/3 of knee dislocation have associated injuries that require more urgent attention. Knee dislocation is a high energy injury that will have popliteal artery injury, nerve injury, multiple fractures, head and chest trauma, and compartment syndrome.  The findings of the knee might be subtle, but having knee dislocation makes you think of these conditions and the swelling may not be that significant because the joint capsule is torn. You may have hyperextension of the knee, popliteal ecchymosis, foot drop, or vascular issues, and the patient may also be normal. The knee can be dislocated or be normal. The patient may or not be overweight.

How do you handle a knee dislocation?  You examine the pulses and then you reduce the knee. After you reduce the knee, you examine the pulses and get post reduction A.B.I. (ankle brachial index).  The ankle brachial index (A.B.I.) is very important in the knee dislocation.  The systolic blood pressure measured is divided by that measured at the brachial artery.  A ratio less than 0.9 is considered abnormal and needs further investigation.  Scenario 1:  Good pulses and symmetrical, A.B.I. is more than 0.9, then observe for 24-48 hours with serial neurovascular exam. Scenario 2: After the reduction, if the distal pulses are asymmetrical, or the A.B.I. is less than 0.9, then you will do some kind of a study to see why this is occurring (get a CTA or arteriogram).  Scenario 3: If you have absent distal pulses or clear, hard signs of limb ischemia, do not waste time by doing arteriogram. Take the patient to the operating room, do emergency exploration and then on the table, do arteriogram and the patient will probably need fasciotomy.  You will stabilize the knee with and external fixator.

If the patient has a fracture dislocation, then you will reduce the fracture and get post-reduction CT scan. In general, you will get an MRI before you plan the definitive fixation.  When you try to do a closed reduction and you cannot do the closed reduction, then you have a rotatory dislocation. You should take that patient to the operating room and do the reduction through the anteromedial approach. Make sure that circulation is O.K. before you take the patient to the operating room and make sure you have a vascular surgeon back up.  If the patient has a normal pulse, normal color, and the temperature of the leg and foot is normal for 48 hours, then you can avoid angiography. If the circulation is bad, you are taking the patient to surgery, you will do the external fixator, you will repair the popliteal artery, and you will do the four compartment fasciotomy. Temporary external fixator can be used if the joint is unstable or if there is persistent subluxation or severe soft tissue injury. External fixator should be used on a temporary basis before repair or reconstruction of the ligaments. There is an improved outcome with early treatment less than 3 weeks. Nonoperative treatment of knee dislocation gives and inferior result than operative treatment.

The most important first step to rule out vascular injury, is to examine the pulses and compare to the other side. If you examine the pulses and then you have doubt, and you get the A.B.I. and it is greater than 0.9 then the chance of arterial injury does not exist. Injury to the popliteal artery can occur in up to 40% of cases. The average is 16%. Peroneal palsy occurs in about 25% of knee dislocations, it has a poor prognosis for return of function. Only 50% of patient have return of function. If peroneal palsy persists at the time of definitive reconstruction of the knee injury, then nerve exploration and neurolysis can be done. If no clinical or electrical evidence of nerve continuity exists by 3-4 months, surgical intervention for direct or intercalary nerve repair or tendon transfer of the tibialis posterior tendon to the dorsum of the foot is indicated. Injury to the common peroneal nerve will result in sensory dysfunction at the top of the foot and the patient will not be able to dorsiflex the ankle or the big toe (patient will have foot drop).

The patient with knee dislocation should have a comprehensive examination because of the risk of other serious injuries. The potential for loss of a limb or irreversible damage to the limb is present with any knee dislocation. The prolonged warm ischemia time is a problem in knee dislocation associated with vascular injury with an amputation rate of approximately 20%. Stiffness is a common problem following knee dislocation treatment. 20% of early repair needed manipulation for the knee stiffness.

Subscapularis Muscle Tear

The subscapularis muscle is a large muscle that originates on the anterior surface of the scapula and lies in front of the shoulder. The subscapularis muscle tendon inserts into the lesser tuberosity of the humerus. The subscapularis muscle provides about 50% of the total cuff strength. The subscapularis muscle inserts into the lesser tuberosity of the humerus, while the other rotator cuff muscles have an insertion into the greater tuberosity. The long head of the biceps tendon lies in a groove anteriorly and is held in its position by the transverse humeral ligament. The action of the subscapularis muscle is adduction and internal rotation of the shoulder. The upper and lower subscapular nerves originate from the posterior cord of the brachial plexus. Subscapularis TearThe suprascapular nerve is a different nerve, it innervates the supraspinatus and the infraspinatus muscles. A fall onto an outstretched arm during abduction is usually the mechanism of injury. The presentation is usually anterior shoulder pain following a forcible external rotation injury to the shoulder. Tear of the subscapularis tendon may follow anterior shoulder surgery. There may be an avulsion of the lesser tuberosity of the humerus. Subscapularis tendon tear may be isolated, or it may be associated with other rotator cuff tears. 88% of patients with biceps tendon subluxation are found to have subscapularis tendon tear. Tears can be either acute or chronic. There will be pain in front of the shoulder with weakness of internal rotation and increased passive external rotation. The diagnosis could be difficult and the condition could be missed. The transverse humeral ligament may be torn with complete rupture of the subscapularis tendon, and this may lead to medial dislocation of the biceps tendon from its groove. Lift-off test, bear-hug test, and belly press test all show weakness of internal rotation of the shoulder. When the patient is unable to lift his hand away from the lower back while the shoulder is maximally internally rotated. If you hear that there is a hyper abduction injury after an open repair of the shoulder and an inability to move the dorsum of the hand away from the back, then this is a subscapularis tendon tear. Tears of the subscapularis tendon can be diagnosed with an ultrasound or MRI. The MRI will show detachment of the subscapularis from its insertion into the lesser tuberosity of the humerus. The sagittal MRI will also show you if there is an atrophy of the muscle. If the patient has a total shoulder repair, and the patient fell down and there is an increase in the passive external rotation of the shoulder, the x-ray shows that everything is good, then you will probably need to do ultrasound evaluation of the shoulder to check the integrity of the subscapularis tendon. Arthroscopic identification of a chronic subscapularis tear can be done by the comma sign, which represents avulsion of the superior glenohumeral ligament. Chronic supraspinatus and infraspinatus tear in a young patient, and the tear cannot be repaired, then you will do latissimus dorsi transfer. Both the lift off test and the abdominal compression test needs to show that the patient has a good subscapularis muscle function before you do the latissimus dorsi transfer. Preoperative subscapularis function is necessary for good clinical outcome. In case of posterior dislocation of the shoulder in a young patient, when the humeral head defect is large but less than 50%, you may transfer the subscapularis tendon and the lesser tuberosity into the humeral head defect which is called a reverse Hill-Sachs lesion. Treatment is usually surgery. For a complete acute tear, do open or arthroscopic surgical repair. Biceps tenodesis is needed if there is subluxation of the long head of the biceps. For a chronic subscapularis tendon tear, do pectoralis major muscle transfer. When the subscapularis tear is missed and the tear is chronic, the tendon becomes retracted and atrophic and you will do subcoracoid pectoralis major tendon transfer. It may improve the function and decrease the pain. The subcoracoid position of the transfer allows redirection of the pectoralis major in a direction that is recreating the vector of the subscapularis tendon.