All right. I have 5 o'clock. You are in the room for controversy surrounding pediatric upper extremity fracture care. So if you don't like children, I suggest you leave. No, just kidding. Just making sure you're in the right spot. My name is Josh Abzug from the University of Maryland, and I have an awesome faculty panel with me. Christine Ho from Texas Scottish Rite, Andy Bauer from right here in Boston, and Kevin Little from Cincinnati. And rather than go up and down, up and down, up and down with us starting Proxima, working our way distal, we thought we would each give our own talks. And we'll do two speakers, five mini talks, and then have discussion from the audience, and then do the next two speakers, four more talks, and have discussion in some cases if time allows. So with that said, I will invite Andy Bauer up here to give her talk regarding clavicle fractures, to fix or not. All right, thank you. So these are going to be fast and furious, because we only have about an hour. So I'm going to review the origins of the clavicle controversy in the adolescent population, and then talk to you a little bit about the facts registry, which some of your institutions, if you're at a children's hospital, may be part of. So there were some papers that came out in the more adult population in the mid-2000s, mid to late 2000s, talking about improved outcomes after operative treatment of displaced mid-shaft clavicle fractures. And these were very impactful. And this was during my, so my residency was from 2005 to 2010. This graph is from just at my institution, at Boston Children's Hospital from 1999 to 2010, looking at the volume of operatively treated clavicle fractures. And you can see how, as a resident during this time period, I just thought clavicle should be fixed, right? That was like what we all learned during that time period. And there was a very rapid switch, based on the adult literature, percolating down into the pediatric world. You know, they're fun to fix, and we all started fixing them. But kids are not adults, as you guys know, and what is the evidence for this? And so this kind of consortium of a bunch of different children's hospitals got together to actually try to figure out, what is the evidence? What should we be fixing? Or, you know, is there anything we should be fixing? And so one of their main studies out of this FACTS registry was a hypothesis that, okay, operatively treated clavicle fractures with the most severe patterns in the athletic population, you know, dominant arm of a thrower, whatever, would have superior outcomes to those managed non-operatively. And so that was one of their main, and I say there because I'm not involved in this study, but obviously part of it in data collection, because it happens predominantly at my institution. And so they enrolled patients at eight pediatric centers. The treatment decisions and the follow-up schedule were at the discretion of the treating provider. So if you decided with the family that you wanted to fix the clavicle, then that went into the registry. They had recommended follow-up schedules and imaging. And when they looked at this group of displaced mid-shaft clavicle fractures, they had 137 patients in this more severe group, and they matched the op versus the non-op so that they had no difference in age, sex, hand dominance, fracture shortening, comminution. You know, you can see here, even in the competitive athletes, they had a nice match between operative and non-operative treatment. And the outcomes were really similar. So you know, not a higher rate of nonunion or delayed union or symptomatic malunion in the operative group, but certainly a higher rate of complications from operations, as I think we all know. And then when we look through here at all of the patient satisfaction scores, really no difference at two years patient-reported outcomes. They did have a slightly faster return to sports in the operative group, 10 weeks versus 11 and a half weeks. But at two years, no difference in final reported return to sports or level of performance. And one of the reasons why this may be came out of another study in the FACTS group where they looked at bony remodeling of adolescent displaced clavicle fractures. And so we're all going to talk about remodeling as part of these upper extremity talks, but no one ever really thinks about that with the clavicle. We love to pimp our residents that the clavicle doesn't stop growing until you're 25, but we never think about what that means. And these are some images from this study. So they had, of clavicle fractures that had initial shortening of more than two centimeters, 93% were modeled to less than two centimeters, and 57% were modeled to less than one centimeter. And so maybe this is why not all adolescents are going to follow that same pattern of adults. So based on this happening at my institution, this has been very impactful in my own practice. And I would say for most of my patients, I don't fix the clavicle. They come in. It doesn't matter if you're a football player. It doesn't matter if it's your dominant hand. It doesn't matter if someone measures it as more than two centimeters. It probably doesn't need to be fixed. I would say there are a couple caveats to that in my own practice. So people who just can't get over that initial painful portion of this treatment, like these hurt in the beginning, and some people hurt a lot and feel better when it's fixed in the first couple of days. If they're just constantly calling the office, they're constantly miserable, maybe that's someone who should be fixed. If a slightly earlier return to sports matters, fine, but the study showed a week and a half, right? Does that really matter? Maybe. In Boston, sometimes. And then if there's a concern for delayed union or an open or impending open fracture, okay, those are still probably indications for surgery. But our rate of surgery has dropped dramatically as we've learned more about this through the FACTS registry. So thank you, and then just plugging our book about the congenital hand. Thank you. Am I going to do the other one now? Yes. Okay. Last time I called your name and that it just it worked when we called you Oh, there you go, there you go, you had to call a friend. All right, so another controversy, so hopefully I've solved the last controversy, don't fix the clavicle. For this one, both bone form fractures, plate versus IM nails. So we will talk about acceptable alignment, that's important any time you're thinking about surgery for this because the predominant treatment is non-operative, and then some relative indications for IM nails and plates. So as we all know, pediatric skeleton is different than the adult skeleton. The radial and the ulnar shafts are smaller, there's more trabecular bone in the metathesis, there's a much thicker periosteum, such that a portion of that periosteum is often intact on the compression side of the fracture. This limits the displacement, so it can be good, it can help you obtain and maintain a closed reduction that maybe wouldn't stay in an adult. And then of course, as we all know, there's sagittal and coronal plane remodeling that can be very powerful, especially in younger kids. And so although the topic of this talk is how to fix it, our first choice is not to fix it, but to do a closed reduction and casting with no surgery. And the vast majority of pediatric bone form fractures can be treated that way. When you think about surgery, it's important to think about what's acceptable. And when we say that something is acceptable in pediatrics, I think there's two different ways to think about this. One is what will truly remodel to a normal X-ray versus what will get you a functional outcome. And both of those are different. So when you read about studies from the 50s saying that this is acceptable, it's acceptable for a relatively functional outcome in the 1950s, maybe not acceptable all the way to remodeling to perfect. And I think that's important to distinguish, especially in conversations with patients when you have some funky looking X-rays. So to remodel all the way to normal in a very young patient, you can accept up to 20% mid-shaft angulation. Bayonet apposition is fine, but no rotation because that will not remodel. And as you get older, maybe only 10 degrees of mid-shaft angulation will remodel truly all the way to normal. And again, no rotation. And then there's lots of studies on the results of malunions that say, okay, we can have good functional results, whatever that means, with perhaps slightly more degrees of angulation, probably 30 to 45 degrees of rotation, and again, bayonet apposition. So when we talk about IM nails versus plates, what does the literature have to say? And I find this paper, there's still a role for the experience of a single institution and some of these retrospective studies looking over a longer time period. I think we can still learn from them. So this study looked at 103 IM nails. I personally felt better when I learned that 29% of their IM nails required open reduction to pass them because I think that happens, right? And so maybe one tip is just to know that that's okay and that many of these will need to be opened. Open fractures, not surprisingly, had a longer time to union. And compartment syndrome was a risk, especially if there's an IM nail on the day of injury. So perhaps in a more severe injury, we really need to think, how many times are you going to pass those nails before you open? Or are nails really a better choice than plates where you could do a fasciotomy? Delayed union in this study occurred after IM nails in six patients over 10, but no patients under 10. And the relative chance of a poor or fair outcome increased with age. And the overall complication rate was 14.6%. That's not that low. So this is something that does take, there are some complications and some risk to IM nails. When we look at systematic reviews, they often don't find a difference between nails and plates. And you guys probably all know that. That's why it's part of this talk. So in this systematic review, no statistically significant difference in any of those things below. They did see better cosmesis and a shorter duration of surgery for IM nails. That makes sense. It doesn't take as long to put them in and to close those wounds. And the postoperative radial bow was significantly abnormal after IM nails, but did not affect forearm movement. And again, that makes sense because it's not as rigid or as stable of a fixation. So in my practice, I use IM nails for younger patients. If it's one that I think maybe I can get close, so then it's truly going to be minimally invasive. And particularly if maybe I don't need to stabilize both of the bones. So this is an example of a nine-year-old boy. It seemed like it was open. You can see maybe there's some air in here. But otherwise, very stable fracture. So we took him to the OR because it was open. But otherwise, this would have been something that I would have treated closed. And otherwise, relatively good alignment. And so this patient got an IND and single bone fixation as a relatively minimally invasive way to treat it. In terms of single bone fixation, we know this is acceptable for young patients and if the radius is well aligned. It's not something to start drifting into the 12 to 14-year-old age group, but is a technique in those younger patients. So what about plates? So I would say for my practice, this is for the children who are closer to skeletal maturity, the 14 and 15-year-olds like this kid. If you have to open anyway to get the reduction, you guys are all hand surgeons, it's pretty easy to put the plates in. And if you're not comfortable with IM nails, that's fine. The literature shows in the teenage age group that it doesn't matter. And so if what you have and what you do well are plates, then I think that's fine. An example of that is this 15-year-old left-hand dominant pitcher who broke his left forearm. It was a little rotated, a little displaced, a little angulated, a little proximal. His mom is a physical therapist that I work with. And so he got plates. And he was able to get moving sooner, able to get back training for athletics sooner. And at six months, he has full range of motion and planning to leave the hardware in place. And you can see here, this is very pediatric fixation. There's only five screws in the ulna. But again, to get that anatomic reduction is important in the older kids. And that is it. On to the next. Awesome. Thank you, Andy. I'll ask everyone to hold their questions. I'll run through my three quick ones, and then we can open it up for discussion, if we can figure out how to work this out. Left I can right-click to You just see your prep your presence, it's just your presence just come sit with us All right, so I'm gonna talk to you about proximal humerus fractures to fix or not I Think we are familiar with proximal humerus fractures, but what do you do with this child that presents? You know these account for about 5% of childhood fractures There's tremendous remodeling potential as 80% of longitudinal growth occurs in that proximal humerus region and therefore the vast majority are not operatively managed as I say tremendous remodeling potential here. You can see from this yellow journal article basically normal-looking appearance and And here's another case example after two years of excellent remodeling, but what about that older child? What about the child that maybe not doesn't have a lot of growth left? And there's gonna be impingement potentially decreased range of motion And then they also as Andy alluded to and some you're already talks regarding sports activity Do we need to operate on any of these at all? So when should we really think about this operation? When does it affect well here's what's been written about regarding acceptable? Criteria less than 5 up to 70 degrees of angulation as we get older greater than 12 up to 40 degrees of angulation and less than 50% displacement, I would argue that the majority of us and we can certainly discuss it probably accept higher numbers Even in children over 12 then as what's been listed and published So one of my surgical indications Potentially an adolescent when the greater tuberosity is superior to the articular surface If there's any excessive version and certainly an open fracture Here are your options. You can just try and go to operating room for a closed reduction You can close reduce it and pin it or you can proceed with an open reduction The goal as we all know is to bring the shaft to the head There's no way you're going to bring that head down to the shaft And these are the techniques you can utilize for your closed reduction flexion abduction external rotation Traction with an anterior posterior force and flexion adduction and internal rotation and then traction Here I am attempting To reduce this in the operating room with my flexion adduction internal rotation And in my hands I will say this Never works, maybe once or twice in my career. Have I gotten this to work? So I'd be curious to hear Christine is maybe stronger than I am But this this never works for me. So I feel like if I'm going to operate a room Unfortunately are gonna get an RF They got a delto peck approach. It's not easy to reduce it Even when you open it you often have to put your cob or bone hook and pull really really hard To get that shaft under the head quite often you'll encounter and trap structures your periosteum your long head of your biceps or capsule even and Then typically I'll use a Steinman pins just to stabilize The components I think the important key for me is it doesn't need to be perfect I'm really bringing that shaft down to prevent that impingement primarily up against the acromion I'll show you a picture in a minute You can use some cannulated screws have been written about certainly a plate and screws like an adult or you can use even I am nails So this study looked at I am nailing versus percutaneous pin fixation of pediatric proximal humerus fractures And what they found were pins led to a shorter OR time. You can certainly obviously remove these in the office But there is a fairly high complication rate as you see From superficial pin tract infections hardware migration Etc. I am now is obviously require a second surgery for removal and therefore cost more overall and Then you can have lots of complications associated with these loss of alignment of your fixation as we talked about what the pins pin tract Infections migration you can develop avn of the proximal humerus and you can certainly develop growth arrests, which will lead to a virus deformity So we did seek out via survey to try and find what criteria people utilize To fix these in adolescence and also did not find a clear answer in our study Really? I don't have a clear answer to this date I would consider or if an adolescence high-demand athletes if you have concern for impingement Particularly if the greater tuberosity is superior to your surface, and then I think Steinman pins are your optimal fixation. Thanks I Click on every word maybe it'll work getting faster. Yeah All right, so I'm gonna move a little distal down to the elbow we'll talk about lateral condyle fractures screw versus K wires So I think we all recognize a lateral condyle first second most common pediatric elbow fracture accounting for 10 to 20 percent of pediatric elbow fractures Non-operative care is typically recommended when a displacement is less than two millimeters and this is best assessed on the internal rotation view These children are typically treated in a cast for four to six weeks The first three weeks they are followed weekly to ensure that the displacement does not worsen and if I have any question whatsoever I'll remove that cast obtain repeat radiographs particularly internal bleak to make sure I'm truly assessing the fracture displacement Close reduction and pinning fixation indications involve no significant rotation displacement or lateral translation Displacement greater than that two millimeters with an intact cartilage hinge and you can assess this with an arthrogram has been nicely shown by Jen Weiss RAF obviously there's much greater than two millimeters of displacement without that intact cartilage hinge if there's rotational displacement And if you can't get it closed So here's the arthrogram. Hopefully everyone is familiar with it and I can at least recognize the structures, but there's your fracture line You can see I Utilize a mixture of equal parts of injectable saline and ice of you and you can inject them to a soft spot or more Commonly now I inject a posterior and lecranon fossa to avoid any scuffing of the articular cartilage Then you can range your elbow to disperse your contrast You can assess the integrity of your cartilage hinge as you can see in this picture and then you can Perform this arthrogram for all of your clothes reduction and percutaneous pinning cases Valgus stress will aid in your reduction for a closed technique You can place a K wire in and use it as a joystick and you can advance your K wire and add your additional wires You can place a screw once you have your reduction Here's my setup for a formal open reduction Which is the same for my clothes reduction and pinning the frostbit unit is inverted and utilize as operating table I utilize a sterile tourniquet and young children and then One can also utilize a hand table if that's their preference Typically for the displaced fractures just a three to five centimeter anterolateral incision You really want to get anterior so you can look at the articular surface Once you incise the skin quite often your soft tissue dissection is already done as you see here with minimal dissection needed You typically irrigate and I like to remove all the hematoma and fracture debris that's present And then once you identify your fracture fragment, you're going to sharply incise your periosteum Anteriorly avoid that posterior dissection because your blood supply enters that posterior cortex collateral condyle Avoid any extensive stripping and by doing those two things you decrease your chance of a vascular necrosis And then I utilize an army-navy Across the anterior aspect of the joint just inside the capsule and that allows me visualization Across the entire anterior and distal articular surface Once you reduce your fragment you can hold it with a bone reduction forceps You can utilize your finger K wire as a joystick And again, you can apply that valgus stress and flex to be able to facilitate your reduction But here's becomes the key question. How do we stabilize it? So this has been traditionally the recommendation three K wires One of them is parallel to the joint surface and two are divergent and bicortical in nature This has been shown to be biomechanically the strongest construct The alternative is to utilize a four or four or five cannulated screw The key with this is the screw needs to be placed through the non articular portion of the lateral condyle Your screws should be directed towards the medial metaphysis for bicortical fixation or you can advance it into dense lateral bone on the olecranon Region coracoid olecranon fossa region and then you close your periosteum over your screw Once you fix this fracture, you should assess for stability with a varus stress if you utilize K wires quite often They are buried you can leave them out and pull them at three to four weeks and then put the child back into a long-arm cast Typically, it's four to six weeks of fixation with K wires and follow-up at a week with new radiographs to ensure. There's no loss of reduction So which one should we do screws can lead to greater compression across the fracture site with higher union rates Increased biomechanical stability lower the complication rate. This is obviously more expensive than K wires Most people at least at this day and age are recommending that you take that screw out and there's the potential cost increased cost for that screw removal This study looked at comparison of K wires versus screws and found no major clinical differences However, the K wires did lead to more superficial infections more lateral prominence that bump that we'll see on the lateral side of the elbow and more limitations with elbow extension Gilbert at all also looked at comparison and found that screw fixation led to a shorter time to Union Decreased time in their cast a greater median arc of motion fewer non unions and fewer delayed unions So offer these studies we can conclude that either technique is totally acceptable However, there are better union rates lower complications and better outcomes with regard to range of motion with screw fixation But the need for a second surgery for a removal is obviously another anesthetic and leads to increased costs Thanks First try okay, we're getting better. We're getting better. I love it. Maybe So this is a real short talk just talking about malware fractures, I think it's a big debate Should we splint them in the peds population or should we utilize our K wires? These fractures occur almost exclusively in children due to the attachment of the extensor tendon onto the epiphysis The fragment is actually fairly large typically more than a third of the articular surface is Comprised and the mechanism is the same as a mallet finger an adult force flexion the extended finger and we see it most commonly From sports participation in football and basketball etc. And you see this evolved fracture fragment That's a typically a Salta Harris three or four because the tendon is pulling that fragment proximal and dorsally So should we splint them? Well, let's be less expensive and avoid surgery however We certainly worry about compliance in children an incomplete reduction as this is an articular fracture and this will require somewhat frequent follow-up Surgery with pins or even a plate and screw as Christine's written about Has pros of compliance you can obtain your anatomic alignment But certainly is more expensive than the splint requires anesthesia. And obviously once we start operating we increase our complication rates My indications tend to be very large bony fragments encompassing at least a third of the articular surface But typically half or more if the joint itself is incongruent After you try to put a splint on any Palmer suffix ation of that distal phalanx and sensor lag greater than 30 degrees What I found is not only have the extensor leg But they'll have a large bump That the child and the parent don't like and then if I'm truly concerned that the child is going to be completely non-compliant I'll fix them and then cast over top of my pins So I throw this in really as a debate for us to discuss But the vast majority of bony mallet fractures do have large fragments and Potentially surgery can restore the anatomy and ensure compliance, but we don't have great studies comparing Splinting versus operative intervention for these children. So with that I will end around one And maybe I want to say I don't do plates and screws for mallet fractures. Okay before people start thinking I'm crazy Well, you are crazy, but I know you don't use that technique anymore Never Pins there was a little screw thing hook hook plate thing. I'm a jiggy you did Oh, I see, okay All right anyway Questions, please come up to the mic because I think this is recorded I know it's a little painful potentially, but please walk up right here in the front Maybe why he's walking his way up Andy do you have a tendency to open and plate form fractures that are more proximal? Because you tend to wind up needing to do an open reduction anyway So you wind up putting plates and screws on for more proximal fractures compared to midshaft or any insight into location? If you're like you said if you have to open anyway I find that the amount that I need to open To get my reduction and pass the nail is the same as I would need for a plate And so absolutely and two follow-ups on that does age matter So we know that plates can migrate as the bone kind of reshapes itself as a child grows. Does that play into your decision-making? Particularly in those proximal fractures where you're thinking you may need to open anyway Yeah, but I think that we often see those more proximal fractures in the older kids anyway And so I think that the age and the type of fracture go together so that yes but we just naturally end up seeing more that would be amenable to plating in the older age group and my third and fourth question Sorry, I got a pick on you. You gave the both the talks Just following that all the way through do you start out with nails and if you have to open transition intraoperatively to plates and counsel parents that or do you still Open and proceed with your I am now fixation as your plan a and B if you can't get it closed Yep level for evidence, that's why we're here And so I would say in a younger kid in someone who's under 10 At least I would prefer to use the nails and get them out If I can and so if I can get a close and so I will try the closed reduction first before we prep and see If it's gettable or close to gettable or at least one of them is gettable and then I'll proceed with the nails Or say, okay We'll make a small open incision and pass the nails in the older teenagers are more likely to discuss the pros and cons with the Family beforehand and make a preoperative decision. I would say over age 12 great And I think you kind of just answered my last question when you open to pass your nails and you're following your plan a You're not doing a formal approach and your incision is much smaller just safer You may want to comment on that. I Mean, I think it depends on where you are in the midshaft. You can probably open to pass the nails through a smaller incision I think once you get more proximal, did you say small volar? Did I hear you? Or do you said small? So, all right, that'll be my fifth follow-up and final question I think as you get more proximal you need to make a bigger incision and see what you're doing And so there you may end up just plating I think it does I don't think it matters in the midshaft of the radius where you make your incision if you're just can try to pass the Nails, I've done it bowler dorsal radial. I don't think it matters I will say that the most common reason to do flexible nailing is for an open form fracture It's always the ulna and it's always bowler and it's always a very non anatomic plane that you're dissecting through a lot of FCU And wondering where the artery and nerve is and so one thing I've moved to if I'm struggling trying to get that past Is to just go ahead and just do a traditional incision to really see those and all of a sudden you can you're right there Between FCU and ECU and then you can just go and then you can just drive it right across I mean struggling through that volar incision in a really fat arm. That short is really can be very difficult Kevin anything else to add? No. Good. All right, please Yes Yeah, I think that's a great point. So for the IM nails, we all know that there's about a 10% risk of refracture in the pediatric population after a forearm fracture in the first six months. And so I prefer to wait out that period before I take out my IM nails. Some people take them out very early, like four to six weeks. And I think most of us have moved to a six to nine months kind of thing. So that's my preference for the IM nails is to get through that difficult period of time. For the plates, I think it's controversial. In a younger kid, I'll talk about it with the family and maybe recommend routine hardware removal at six to nine months because of what you're talking about, the stress risers and everything. We know, though, that there's an increased risk of radius fracture removal. And so when we take things out for symptoms, so in a teenager, I would say, I'll take them out because it's symptomatic. I might talk about only taking out the ulnar plate and leaving the radius plate in. I've had cases where we say, oh, let's just take them all out. And then the next football season, they break through where the radial plate was. So I think you can always second guess your choices in that decision. We don't have good data for that. So I would say that because of that problem, if I have a kid who's like, even if they're a teenager, a big teenager, if they're a football player, a wrestler, a gymnast, I tend to like to do flexible nails in the shaft because then I can just take them out. And I don't have to worry about all those holes and stress risers and them having to then lose more time from their sport. So for me, I do take that into consideration when I'm thinking about plates versus flexi nails. So that was gonna be my question to either or all three of you is once you take them out, how much downtime do you want them to have from their sport? Flexi nails, once the wound is healed in two weeks, they'll back. Plates, at least two months. Everyone agree? Based on nothing. Yeah, two weeks to six months, I don't know. And what about retaining flexi nails? So our colleagues in Europe will quite often retain their flexi nails. Any comments on that? I do that in older kids. been forever, if you want, and don't come back. And families like that, because they don't want to come back for the second time. That is not my experience. I find that the families are asking before this hardware even goes in, when the hardware is coming out. And they all seem to want it out. I don't know why, based on nothing. I try to discourage them. Metal poisoning. Well, I was going to say, if you go to the Midwest, maybe they don't want it out. I don't know if I, there is a slight increased risk of non-union with that. I mean, I know that's a low risk to begin with, but I just usually open one side or the other. I don't know. Do you guys? I've never mixed and matched. I would never say never, but I don't tend to do it. That's why I say I never. Because I don't like the way it looks on the x-ray. That's not a very good reason. And I think that the question of retained hardware is a challenge, you know, we don't have, we just don't know. And I think it's hard to, it's hard to plan around what might happen to somebody decades in the future. I will say that on the receiving end of someone, you know, when there's a plate in the mid-shaft and now the kid is, you know, and that was put there 10 years ago and now he's 15, I'm often the one that's gonna be on the receiving end of that. And it's not that hard to take out even. I see lots of heads nodding in a horizontal direction. which I think does happen in the adult world. Well, great. Thank you all. So we're going to move to round two. Kevin's going to come up and talk about medial epicondyle fractures, you are, followed by distal radius fractures. I unfortunately have to catch a flight to avoid any hurricane issues. So thank you. But Christine will take over round two. Great. Thank you. Good luck, Josh. We all have to blame the Hand Society because whenever we have a All right, cool. This is probably the most controversial one that we're going to talk about and you're going to end up not solving any country. So, elbow fracture is super common. So, in medial epicondylosis in particular is somewhere between 11 to 20 percent of all elbow fractures, so it is very common. There are high associations with elbow dislocations, and most commonly in boys as they get older. When you think about the elbow, though, the ossification centers of the elbow, it starts ossifying around 5 to 7 years, and then closes between 15 to 20 years, and then it's not really a physis, right? And the rest are apophysis, right? It's an attachment of muscles and ligaments. And that's how the injury happens, right? Those attachments are pulling off. So typically, this is either a direct blow to the elbow that can whack off this thing, or you can have a fall and have a valgus load that pulls your elbow out and dislocate at the same time. And then you can sometimes do it during sports. Like people I've seen have thrown a baseball too hard and actually popped it off with that stress. So the things I look for on the exam, outside of the history, but looking for the medial elbow, you see a lot of bruising and swelling. You'll see some tenderness around there. You might have some loss of elbow flexion extension, but generally intact supination and pronation. But you do get a pain or tenderness with valgus stress around the elbow. Radiographs, you want to really make sure you get good radiographs. AP is mandatory. Lateral, it's kind of hard to see, but you can kind of get a sense of where it is. Some people recommend this axial view, where you kind of look down and you can see. So there's a good classification scheme looking at these from small avulsion fractures you can see here all the way down to like You know fragments in the joint incarcerated and dislocated, but this is not inclusive any chronic Issues so you know in general the treatment algorithm is controversial It's somewhat not controversial in the various You know minor ones less than five millimeters displacement stable elbow a good range of motion not a lot of swelling They can probably heal not operably. Maybe doesn't even need a cast get them moving quickly because they do get stiff More than 15 millimeters displacement. It's way out of place. It's probably unstable and likely we'll need fixing Or if it's entrapped in the joint and that sort of gray area the 5 to 15 We're like 99% of these fractures show up all right Those are the ones that we always have to go through the whole you know talk with our families So, if you see something like this, you know, elbow dislocation, fractures. set the joint, right? Then you have to get that one out. And if you have to take it out, you might as well fix it at the same time. That's a good indication for fixation. How many of you guys over here have actually closed reduced? it was like really like a satisfying pop when it happened. So anecdotally, I've had friends who have done it. You do this, you do that, and then you like valgus stress and like pop, and it makes a really horrible pediatrician freaking out clunk. But it's cool. All right, so that's where the milking procedure is. So valgus stress, supination, wrist extension, you can actually pull these out. And then you would take them to surgery. And if they're definitely not, if you're still incarcerated, you can't get them out closed, then later. I generally use a cannulated screw. I think a 3-5, 4-5 cannulated screw works really well. I've used headless compression screws sometimes. I've used a tension band. If you have a really small ossific nucleus, I've actually fragmented the piece in half a few times. So I always have a bailout, you know, ready to fix it. You make this nice medial approach. You find the fracture. I've switched to doing this prone. I'm not sure anybody else, do you guys do it prone? It's like a game changer. You do it prone, your arm is like this, and it actually takes all the stress off of it, and it makes it really easy to put it in the right place and reduce it. The trickiest part is getting the x-rays. That's the only thing. And then there are some issues with nerve injuries, obviously, most often ulnar nerve is adjacent to the fracture, but you can get median nerve entrapped in the fracture. You can tickle the radial nerve if you put too generative screw in, and you can get stiffness in hardware removal. For some reason, I didn't do this right, but this is a picture of a kid who had one of the complications that you see. If you have a fracture, it heals incorrectly, and they have some, you know, second fracture down the road. Anyway, so, bottom line is there is no consensus. I think it's, to me, if it's a really minor fracture, you probably can treat it nonoperatively. If it's entrapped in the joint, if it's unstable, and, you know, if it's more than 15 millimeters out of place, you should fix it. You know, Scott Kozen and Dan Zlotilo have taught me that if it's associated with an elbow dislocation or... dislocated elbow, it's probably gonna be unstable. So, uh, yeah, common injuries, you know, complex anatomy in the wrist, especially with the feisies. So your first priority really is to try and treat it closed and then see if it fails that. And then you can try, you know, CRPP if that's not going to work because of fractured location or anatomy or age. Then you can do an open reduction or even down the road a corrective osteotomy. So this is a kid, just an illustrative case, a six-year-old male came to my office with a non-displaced ulcer. It's a two fracture. I want to put a molded cast on, but I got busy and then they put a molded cast on the wrong way. It wasn't me doing it. It was the orthotics. Wow. So he shows up two weeks after the injury with this like improperly molded cast. It's worse, you know, and you really want to fix this now because it's. months, nine months, back to normal. So there's another kid, you know, comes, has a reduced fracture, it's in a cast, comes back. That's what I like to do with these metaphyseal fractures. When you get a little bit more diaphyseal, so metadiaphyseal, it's hard to get. And then the really ones that you want to think about are the shearing fractures. So the mechanism of injury is very helpful. If it's more of a transverse angular fracture, that's... So, if you see these fractures in a logistic radius, I try and do this treatment ladder. I think of remodeling, healing. you know, bad fractures, unstable fractures, metadifficile fractures, or articular surface shearing injuries. So, thank you. And now I think Christine is going to give some talks, and we'll have some cases or... I've only watched you guys do it seven times, but obviously not paying attention. All right. So the pink pulseless supercondylar humerus fracture. So it's pretty obvious if a kid comes in, white pulseless, immediate exploration. But then what do we do if it's pink and pulseless? Watchful waiting? Do we go ahead and explore? So in an attempt to give some guidance, the academy had us do these clinical practice guidelines and it said that there was no reliable evidence, but they recommended emergent closed reduction in patients with decreased perfusion, whatever that means, because they never really defined what does perfusion mean and is perfusion different than flow, which I would say that they are. And then it says again, in absence of reliable evidence, open exploration of the antecubital process should be performed if you have absent wrist pulses and you're under perfuse after reduction pending of displaced supercondylar humerus fractures. And again, no definition of what under perfuse means. And so they could not recommend for or against exploration if you had absent wrist pulses, but a perfused hand. So to me, I was kind of like, okay, well, I don't know what that means. What does that mean? What is perfusion? And is it okay if you have a perfused hand, which means the arm is pink and warm, but you don't have flow, which is the absence of a radial artery. And so I think perfusion and flow are a little bit different and we can debate whether or not it's okay to not have flow, but have perfusion. And I don't think that we know that. So this is the experience that we published out of our institution. We had 54 pulseless supercondylar humerus fractures, all underwent emergent reduction and pinning. Half of them got their palpable pulse restored. Another 20 of them had a Doppler ball pulse restored in a pink hand. Four underwent an immediate vascular procedure. Then of the 20 that had the Doppler ball pulse, one of them deteriorated and required late vascular exploration. So we're really going to look at those five. So obviously we don't have p-values because this is a very small cohort. So the one thing that they all had in common for these patients that required vascular surgery was that they all were non-Doppler ball. And so then patient number five, which was the one that initially was Doppler ball and got sent to the floor, ended up deteriorating at nine hours and ended up being brought back for a thrombosbrachial artery with a saphenous graft bypass, which again goes to show that you might think you're out of the woods, but you just can't send these kids home. You've got to watch them for, I mean, I think at least, you know, I like to watch them for about a day to make sure that every time I go back, it's that Doppler ball artery is very, very consistent and easy to be found. And who knows, maybe these would have been fine if they were pink and warm, but you call vascular surgery and guess what, you get vascular surgery. So just a little bit about nerve injury. Nerve injuries are three times more common when you have a non-palpable pulse in these. So it's just something to keep in mind because we always worry about that masking a compartment syndrome. And so this is my approach. If it's pink, pulseless, and I get a Doppler on the table after pinning, I just splint it with a window. I observe on the floor. I like to watch them for at least 24 hours just to make sure it's very, very consistent because I have had one that was kind of coming and going and coming and going and ended up going back to get explored. If it's pale and white, you can certainly in the OR, you know, undo it, re-pin it, warm the arm up, and hopefully if you re-pin it, it might come to this and you're lucky. And if it doesn't come to this and it's still white, that's a call for vascular and I will go ahead and start doing the open approach for them anteriorly. If it's pink, pulseless, no Doppler, you can warm the arm, you can wait. I usually wait, you know, 10, 15 minutes and we kind of like listen to music and I pull the Doppler out and then I start kind of, if I really can't see it, then I kind of start going up the arm. And if it's like, you know, very, very consistent and it really drops off and I really can't find it distally and it's been a good 10 to 15 minutes. For me, I like to know what's going on and so I will go ahead and open reduce these. The times I've done them, I've found it to either be tented, part of the adventitia is tucked in in the fracture, it's been dragged all sorts of places, and then I release it and I watch and knock on wood hasn't, you know, we've gotten a Doppler pulse back that's been consistent. That said, if you wanted to, oh yeah, if you wait, it might be able to, you can also do this. Then, you know, I have plenty of partners who say this patient has perfusion, they may not have flow, but they will watch those on the floor. And so I think that you kind of have to figure out what your threshold is for being comfortable. For me, if I'm going home and I keep calling up to the APP or the resident who's on call and said, well, how's the Doppler now? Is there a Doppler now? Is I, I can't sleep well, so I'd rather just open. I have plenty of partners who are okay, I think, are more comfortable watching as long as the arm is pink and well perfused, and so I think that you kind of have to decide on your own. In fact, I was talking to Josh about this earlier before he left and he said, if there's not a Doppler, he goes, I don't even pull out the Doppler. If it's pink and warm, I admit and I don't worry about it. So everybody's different. I think you got to figure out your threshold. This is in the handout. The previous slide is not, so if you want to take a picture of it, because I know people really love having the handout be consistent, but this is in the handout, so this is the anterior approach. It's in a yellow journal, ICL, from the academy, and so if you're opening, people ask me, which way do I open? I said, well, it depends what you're opening for. If you're opening to explore the antecubital fossa, the anterior approach is utilitarian. Just make sure you make your proximal incision medial, because that's where you find stuff and if you don't know where it is, you just want to keep going up and up and up and find it where it's normal and then trace it out distally, because that, the bundle can be anywhere. So take-home bullet points, timely reduction and fixation, observe closely. In my thought process, persistent loss of the Doppler signal is highly suspicious for some sort of vascular injury. There may be perfusion, but you don't have flow. Is that okay? There's a study at Carolinas and JBGS that did long-term duplexes on those patients, and some of those patients really had collaterals to beat the band and the hand was living off of that, and I would say in Dallas, I don't think we have a whole lot of dead arms walking around that were not explored. So but then again, 9% of the patients in our cohort underwent vascular repair, so I think that is a consideration for those of you, if you're in a system that you don't have a vascular surgeon or a plastic surgeon or a microsurgeon or someone to call if you're in that situation. I think transferring to a higher level of care is completely appropriate. If you have that ability to do that in your institution, the time to figure that out is not two in the morning, it's, you know, you have to know who are the people that you can call in the middle of the night, because calling service to service in the middle of the night is not great. And then I think you have to see what is your comfort level for a pink pulse-less supracondylar humerus fracture after CRPP, and for me, if I don't get a good dopplable pulse, I personally tend to open, but there are plenty of people who don't. Thanks. All right. All right, so the vast majority of hand fractures in kids are non-operative. Many of them are non-physeal, over half are non-displaced, and the majority of them are closed, so that's good. So if you like to see a lot of things and cast them and just feel global, that's a good practice. But, you know, I think it's important to know and to recognize what the other percentage is that you have to be more aggressive and how to treat those. And so this is the most common, the physeal phalangeal fracture, generally Salter-Harris And the extra octave fracture, the small finger, is typically what's the most common, and they call it that because the finger is so widely abducted, it looks like the kid can reach an extra octave on the piano. And so you want to reduce these. You know, you can flex the MCPs to relax the intrinsics, you can put a little pencil or something in the web space. They used to tell us that you would worry about crushing the digital artery and nerve if you were too aggressive. I have to say I've never seen that. We've got some pretty lunk-headed residents. So after you get these reduced, you want to buddy tape it, you want to check your rotation and angulation, and then you can put them in a cast. Make sure you have one good finger on either side. So for this kid, this is going to necessitate the index and the ring finger, and typically I would go ahead and include the small finger as well because he gets kind of cold and lonely out there by himself. And so I'll do a lot of times all four and leave the thumb out for three to four weeks. And so this is after reduction. You can see everything's lined up well, and you can see all of these condyles are all facing the same direction, so you know your rotation is pretty good. And so this is, you know, checking rotation and angulation. This is the kid that came to see me two months after the initial injury. You can see where that Salter-Harris fracture was, and it doesn't look so bad, but when the kid flexes down, you can see that that ring finger scissors over, and the family really doesn't like that. So this is something that could have been closed-reduced, put in a cast, and the kid would already be on their way back to everything, and this is it now we have to do an extra physio-osteotomy and pin it. So phalangeal neck fractures, you know, my partners who do peds ortho, you know, are like, why do you fix all of these? And I'll tell you why. It's because if you look at this and you flip it upside down, it's like the smallest supracondylar humerus fracture in the world. And I bet every single one of my partners, if this was a supracondylar humerus fracture, it would fix this. And the reason why is because if you don't fix this, you've got this metaphyseal spike that blocks flexion. And a lot of times there would also be angular and rotational deformity as well. You cannot close-reduce these because you cannot control that tiny, tiny, small piece. Certainly if it shows up late, if it's within the first month or so, you can do a percutaneous osteoclasis. But when it's been longer than that, you know, you can do an open reduction and then pin it. There are two case series out there showing that in the young enough child, I believe it was eight and under, these will remodel, but you have to wait and wait and wait and wait. And a lot of the kids still can't flex their fingers all the way down. And so you can pin them like this through each of the recesses, and then it looks like this healed. Personally, I've kind of gone to this with getting it reduced and one down the pike and then a de-rotational one if there's rotational instability. This one seems to be a lot faster, and I don't have to worry about catching the collaterals and having the kid have a flexion contracture. Intercondylar phalangeal fractures, they look really innocent. You know, you get this double density right here, which shows that you've got that malrotation. And so even if it's completely nondisplaced, when I see these, I fix them because it's a lot easier to just put a little towel clip and pin them and hold them than to deal with that late instability when it starts to sag and you've got an incongruent joint surface. And so if you open these again, you know, that blood supply is very tenuous through that collateral recess. And not only, you know, I haven't noticed so much AVN, but certainly these kids do get really stiff. And so this is one that was like a little bit of a nascent malunion. You can see there's red callus there. And so I had to use a little freer, free that up, and then I put two little modular hand screws in there. Diaphysial phalangeal fractures, many of these are not as displaced as that. If they're just a little green stick or a little bit mal-angulated, you can close, reduce these and cast them. The problem is, is when they're off like this, that means that periosteum is completely disrupted and you really don't have a lot of external stability to try to hold that in place. And so obviously, when you get to where they get older, you have less capacity for remodeling. And so if you, you know, have a kid like this and it's completely off and you can't control it, certainly you can splint and buddy tape. And if it is one that's got a mild malunion and you're awaiting remodeling, you have to warn the family. And it always falls in this apex volar deformity. You have to warn the family that they're probably going to get some sort of compensatory deformity. And thumb metacarpal psalter Harris fractures, the vast majority of these are treated non-operatively. I get called all the time being told that they are Bennett's fractures. These are not Bennett's fractures. This is the trapezium. This is the epiphysis. This is not a Bennett's fracture. This is an extra articular fracture. And very rarely, it will be unstable due to the soft tissue and the periosteum interpositioned. And then sometimes you'll get this psalter Harris 3 fracture. So A's and B's right here, this is a right thumb looking on a PA view. Those are treated non-operatively in a cast, even if they're completely displaced because you just get such an amazing amount of remodeling. This is the type C, which we're going to talk about, which necessitates operative intervention. And then this is type D, which is sort of a Bennett's type of fracture where you've got this unstable fracture dislocation. And so that does need to be fixed, treated like a regular intra-articular fracture. So this is that type C, right? And so here, this is the shaft is displaced onerally. And why does it do this? And it's because you've got these really, really strong adductors. And no matter how good your casting technique is, you really can't overcome the adductors because you can't really mold your cast around those adductors to counteract that. And then you've got your abductor pollicis brevis shortening that ray. And so the resident though went ahead and reduced it. It looks very good, but very predictably at one week, it started to drift. And so then we just do a perk pinning, and here we are. A little bit about Seymour's fractures, just because I don't think this is necessarily the target group because most people here are hand surgeons, but this is a very special mallet fracture. It's a Salter-Harris 1 or 2. You always get this deformity because of the pull of the FDP, and then this dorsal metathesis lacerates the nail bed, and it comes in like this in the ER or the urgent care, whoever doesn't realize it's anything big. And they just extend the finger and think that that's fine and send it out. And so this is an open fracture, needs to be treated as such once you take the nail off. That's that metathesis staring right at you with that lacerated germinal matrix. So wash it out, give it antibiotics, reduce the fracture, repair the nail bed. And then the question is if you have that nail plate, you can clean it off and soak it and trim it and stick it in there as a stent, just like this little external splint. And many times these are stable. If they're not stable, then you can consider doing a pin. I would say we see quite a few of these, and I only probably pin one every couple of years. So this is our experience. And again, because it's an open fracture, we found that the timing and quality of treatment matters. If they had acute appropriate treatment, only a very low infection rate. However, if you had delayed treatment, which we defined as over 48 hours, almost 50 percent of them showed up infected to our clinic. And so here's one here that was reduced, put in this cast and a little bit of extension. And here the child is healed with absolutely no deformity and did not need a pin. Thanks. All right. We have 12 minutes. Do you guys want to ask questions or do you want to do cases? I'm prepared for both or either. Yes, question. I love questions. So is this a chronic pain and then suddenly a pop or is this an acute injury? So, you know, I think it depends on how displaced it is. You know, I think when these chronic pain sort of things, it's a question of getting it early. There's probably a stress fracture with a pop and then getting them to rest. I think, you know, dominant arm, you know, it's a discussion. I mean, it's a discussion like it is with anything else that, you know, I've certainly had, you know, I've had some horrendous x-rays. I have one right now on one of my friends, my son's friends, who's a water polo player, but he has full motion and absolutely no valgus instability. But he drifted from 6 millimeters of displacement to now over 10 millimeters of displacement and his x-rays look awful, but he looks great. So, you know, I don't, I think that that's really a discussion with the family as to how aggressive they want to be. I do think that they seem to be less painful when you fix them. I don't know what Andy and Kevin. I fix them any chance I can get. I mean, I think that they, that population is going to put such a high demand on that piece of bone. And I think it's very challenging. In my mind, nonoperative treatment is accepting a nonunion because you need to get them moving sooner in order to get them to not be stiff. And so I think it's really a choice between fixing it and getting it stable and getting it healed and not having it heal. And maybe for a lot of people, it's fine to not have it healed. Like if mine, I would be fine, but I don't pitch. And so I think for those, I would fix it. Is it a nonunion or is it a stable fibrous union? Yeah. Yeah. Right. And that's the real question. Like at some point, you have an apophysis. It's like if it heals, it's always going to have a line there because of the physis until you finally get done growing. So I would say, you know, you mentioned the stiffness. I think the stiffness is a problem whether you fix them or whether you don't fix them. And I think it has to do with how quickly you get them moving. So regardless for me, I try to get them moving like at about 14 days, whether I treat it operatively. Yeah, I mean you can't slow them down right because no matter what they want to get back out there as soon as possible If you're gonna fix them, you're not gonna let him pitch for at least three to four months Yeah, so I try and walk the you know, the non-operative treatment, especially if it's not out of place You know, I've seen those heel they get back They have to do some PT because half the reason they're doing it because they're throwing mechanics are terrible And so you have to actually break it down as to what their underlying problem is and then build them back up again And that's where our sports PTs are amazing Figuring out like how to build up medial elbow strength and then you know Get them to throw correctly and then get them back out and a lot of those will heal But if you don't treat the underlying problem, you're just gonna have recurrent issues So you don't have to fix them all in my experience No, I mean it is nice to throw a screw in there and pat yourself in the back and go home I mean, I just I think it's a discussion like this water polo family, you know, and it was a pop It was an avulsion and that was a you know, that's a discussion and I'm a surgeon want me to fix it I'm happy to fix it. Love to do that surgery And I do like to do it prone and I think if you're in a chronic situation Going prone is key to being able to really get that fragment mobilized because after a couple weeks They're not that easy to mobilize that being said the reason why they have that oftentimes is because they have decreased internal rotation in their shoulder And so to go prone you need full internal rotation So I would just check You know and like when you have them asleep check their shoulder rotation before you turn prone in the baseball players particularly So we had a question like social Q&A part of the app do you have a more Learn from my kids So, so do you have a more granular algorithm for both bone fracture degree angulation for proximal midshaft and distal both bones So how much time do you have? So I would say that okay that 20 degrees 10 degrees 8 years that you know What that's based on that's based on nothing that is based on a yellow journal by Chad Price and Ken You know and Ken was I think a fellow and they just spit out these numbers and we keep repeating it over and over like Mary Beth calls it like the fruitcake that keeps getting past right and it's really not based on on anything There's actually a really good paper by plogue makers from Netherlands and he did these we call a solid charts where he basically Synthesize the literature and asked experts and figured out what the angulation that whatever is and he has like nine different charts for like distal radius and both bone or proximal both bone and you get an idea of like based on age and you know Where it is male female like what their recommendation for angular, you know Acceptable angulation is and so you get this sort of decreasing chart as they get older They have a little bit less, you know So it gives you a little bit of an idea like you can plot it on a chart and that's Something I've brought to our practice to kind of look at this chart and see where people are if we're trying to plan on you know both bone for forearm fracture algorithm, that's kind of what we use instead of like a You know 2010 like it's just and the that doesn't mean like there's a ten-year-old and there's like a ten-year-old What kind of you know, are they 10 going on 5 or 10 going on 20 and that's You know, especially if you're supervising people in satellite clinics and things like that and they say this is a 12 You know, I've got a 12-year-old with 10 degrees of angulation Is he is he 10 or is he 14, you know that really matters? Yeah, check a bone age Yeah, and boys and girls, right? So if it's a girl and they'll postmenarchal that means I've got less than two years of growth remaining and so that those I treat More like an adult and you really want it to be healing anatomically Yeah, good question, though. I still struggle with that in clinics So for me, I like to... I usually see them for four to six months. As long as their growth plates are open, it's much easier than a knee, right, because I can look as long as the kid didn't have a distal ulna-physeal fracture, I can look at that variance and I think you can tell pretty early on how much that variance changes. The distal radius and ulna-physes grow 9 millimeters a year. So that seems really slow in a leg, but that's really fast in an arm and so I can usually tell pretty early on. So what I want to see is that ulna variance has not changed and sometimes you can see that nice Parker-Harris growth, the rest line that's completely parallel to that distal radius. And once I see that, then I tell them that they can be discharged. I do think that there are these very minimally or non-displaced Salter-Harris fractures that happen in the older adolescent and you just put it in a cast and then it's like the physe is like, yeah, I'm tired and then they just shut down and you're like, why did you shut down? This was non-displaced. And so I've had a couple of... I don't know if you guys feel that way. Absolutely. I've had a couple of adolescents that are very prone to shut down quickly. Yeah. So we see them indiscriminately because we have a very large system. We see every single thing that came near to the growth plate back at six months with one of our three hand surgeons. But I think that's probably overkill. And I think the ones you have to be careful about are, we know the threes and fours have a higher risk of growth arrest. And then like Christine said, the kids who are really close to the end of growth. But PASNA funded a large distal radius fracture registry that has... I think, in my experience, the kids who have, like, a fascial fracture with a case. Oh my gosh you have cases. 13 year old male pushed onto the ground by friends at school and it's three or four weeks out. What do you want to do? Yeah. So I look at that as well. So for those of you who don't have a peds ortho background, that first thumb metacarpal physis, it's very conveniently included on wrist x-rays. And so that's a handy way to look. And if it's closed, I, that kid's probably, this kid's probably got less, definitely less than two years, maybe even as little as one year of growth remaining, so. So, yeah, based on that, not a lot of remodeling potential. Yeah, so I will say, we say that very cavalierly, but messed up partial fiseolaris. Okay, and who here wants to wait and watch it remodeled? And there's a 15-year-old that I don't think the x-ray is in here, but that kid remodeled unbelievably. So, yes, so I agree with you. And I went ahead and went in and did that, and there was just such a significant amount of callus. If I remember this case correctly, I couldn't even get it all the way through the back because there was this callus metaphyseal volar lip, so I may have had to go. front and back and then just like Kevin said at the same time I shut down the distal ulna because I didn't want to have to worry about coming back a second time when he Any questions we have 20 seconds 20 seconds All right, well, thank you. Thank you

pediatric upper extremity fracture care

controversies

clavicle fractures

non-operative treatment

lateral condyle fractures

compliance

mallet finger fractures

surgery

hand fractures

elbow fractures

individualized treatment