Common Pediatric - PDF Document

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  1. In Office Treatment of Common Pediatric Shoulder Injuries Jeffrey Bechler, MD

  2. Main Objective • Make you Comfortable with Diagnosing and Treating Common Shoulder Injuries/Problems

  3. Objectives 1) Epidemiology of shoulder injuries 2) Pertinent anatomy/terms 3) Physical examination 4) Radiographic evaluation 5) Review of common injuries THE TOP TEN

  4. Epidemiology Nordqvist & Petersson, JSES, • Prospective study of all shoulder injuries in one year in Malmo, Sweden • 248 elderly • 181 adult – 67 clavicle fractures – 60 proximal humeral fractures – 31 shoulder dislocations • 75 children – 65 clavicle fractures – 37 sports related

  5. Epidemiology Increasing incidence of shoulder injuries in children and adolescents • Increased sports participation – Younger age – Increased time/intensity – Higher level of competition – Return to play considerations • Rising popularity of “extreme” sports • Increased awareness

  6. ORTHOPAEDIC TERMINOLOGY • Tendon—connects muscle to bone • Ligament– connects bone to bone • Joint –articulation of two bones • Sprain or Tear – Ligament, Tendon • Strain– Muscle • Fracture=Break=Crack=Chip -- Bone

  7. Fracture=Break=Crack=Broken Pearl

  8. Fracture Terminology • Location—Which bone and where • Displacement – non displaced • Angulation – Angle at the fracture site • Comminution -- How many pieces

  9. TERMINOLOGY

  10. Fracture Description

  11. Salter- Harris Classification

  12. Anatomy Bony anatomy • Proximal humerus • Scapula • Clavicle • Sternum • Thoracic ribs Joints • Glenohumeral joint • Acromioclavicular joint • Sternoclavicular joint

  13. ANATOMY

  14. Physical Examination

  15. ASSESSMENT Inspection Look for Asymmetry

  16. Asymmetry

  17. ASSESSMENT Where does it hurt? • Palpate the structures – Anterior • AC joint, Clavicle, SC joint, Humerus – Posterior • Scapula • Ribs

  18. Physical Exam Palpation S-C JOINT A-C JOINT

  19. Physical Examination “Orthopaedic injuries hurt” Observation • Deformity • Swelling • Ecchymosis • Wounds, skin compromise ROM • 3 Planes • Glenohumeral vs. scapulothoracic Neurovascular evaluation • Axillary nerve • Subclavian/brachial artery

  20. XRAY/MRI • When to order an Xray ? ALWAYS • When to order an MRI? Depends

  21. Radiographic Evaluation Shoulder • AP • Lateral (Y) • Axillary

  22. XRAY REQUEST • AP / Lateral and Axillary views of Right Shoulder and/ or • AP view Right Clavicle • Pearl

  23. MRI or CT Scan Sternoclavicular joint • CXR CT scan

  24. SHOULDER INJURIES IN ADULTS ARE DIFFERENT

  25. Shoulder Problems in Children • Same mechanism of injury • Different “weakest link” • Different treatment

  26. Things you will NOT see in Children • Rotator Cuff Tears • Biceps Tendon Ruptures • Calcific tendonitis • Adhesive Capsulitis ( frozen shoulder) • Osteoarthritis • pearl

  27. Biceps Rupture

  28. Stiff Shoulder

  29. TOP TEN TRAUMATIC • Shoulder Contusion • Fracture of the Clavicle • Fracture of the Humerus • AC Separation– (SC) • Shoulder Dislocation/Subluxation NON TRAUMATIC • Little League Shoulder • Infection/ Bone Cysts • Neck Pain • Overuse instability • Impingement

  30. Traumatic

  31. Contusions (common) • Direct trauma to lateral humerus • Shoulder tender • Difficult to Diagnosis in child - • May lead to myositis ossificans or HO • Goal: protect, maintain ROM, sling for comfort, ice

  32. Fracture of the Clavicle

  33. Clavicle Fractures Presentation • Fall onto lateral aspect of shoulder • Pain, deformity • 10-15% of all Pedi fx • 80% mid shaft • Rare neurovascular compromise, PTX Radiographs • CXR • AP shoulder

  34. Clavicle Fractures Excellent healing potential Treatment • Symptomatic • Reduction not performed • Sling vs. Figure-8 brace • Pain free within 4-6 weeks

  35. Clavicle Fractures Surgical indications • Open fractures • Associated fractures of the shoulder • Vascular compromise • Skin tenting or impending open fracture • Failure to heal

  36. Clavicle Fracture Why is it so common? Only bone that connects the arm to the body. A long tubular bone The “WEAKEST LINK” in the chain in a child.

  37. Humeral Fractures • Shaft • Transverse, treat in sling or brace,10-12 weeks to complete healing • Proximal •Will involve the Growth Plate as the “weakest link” of proximal humerus. • Initial treatment-- Sling, Ice. Ortho

  38. Humeral Fractures • Shaft – Splint, sling, may take several weeks to months, possible nerve injury

  39. Proximal Humerus Growth Plate Fracture

  40. Shoulder Dislocation

  41. Shoulder Dislocation

  42. Acute Dislocations • DIAGNOSIS---Obvious Deformity, flat deltoid, squaring off of shoulder,humeral head in axillla. • OFFICE TREATMENT – Referral to ER for immediate reduction. X-ray. Sling, Ice, Ortho

  43. Acute Subluxations/Dislocations A Spectrum Subluxation – brief, transient translocation or shift, undocumented, spontaneously reduces. Dislocation– Complete dissociation, documented, requiring a reduction Complications are Uncommon, Recurrence rate is high – approaches 90%

  44. Shoulder instability • Physical Therapy • Surgical Repair for Recurrence

  45. AC Separation

  46. Acromioclavicular (AC Joint) Separation

  47. AC joint sprain • “Shoulder separation” • Fall on lateral shoulder • Tender over AC joint • May be prominent (Types I-VI) • Treatment—Xray, Sling, Ice. Ortho

  48. GH Dislocation AC Separation Yes recurrence No recurrence

  49. Dislocation vs. AC Separation Pearl Yes recurrence No recurrence.