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Child (Pediatric) Orthopaedics

Pediatric Orthopaedics (Child Orthopaedics) are specialized in traumatic deformities of the spine, bone fractures and extremities in children and young adults. Our clinics are located at the Gleneagles Medical Centre. Our pediatric orthopaedic surgeons are widely recognized both regionally and nationally for innovative surgical treatments, as well as conservative approaches to a wide variety of orthopaedic problems.

Child Orthopaedic

Child Orthopaedic

Among the most-common conditions we treat are:

  • Spinal deformities such as scoliosis, kyphosis, spondylolisthesis, and spinal trauma

  • Pediatric and adolescent sports injuries

  • Foot and hip development problems such as club foot and hip dysplasia

  • Lower extremity deformities such as knock knees, bowleggedness, and rotational problems

  • Upper extremity deformities, whether congenital or developmental

  • Leg length discrepancy

  • Benign and malignant tumors

  • Fractures and other trauma due to Sports

  • Cerebral palsy

  • Limb salvage

  • Radiofrequency ablation of osteoid osteomas

Our pediatric orthopaedic service receives patient inquires and consultations from around the world. Besides our busy operative practice, we are known for recommending non-operative methods or small incision techniques when possible to manage complex pediatric orthopaedic problems.

As a child’s body grows, problems related to specific stages of bone and muscle development may arise. Child Orthopaedics is the medical field concerned with the treatment of musculoskeletal disorders in children from infancy to 18 years of age. Many orthopaedic conditions are unique to a child’s age, and appropriate treatment can often correct problems early in life. Children orthopaedic fields including:

To set an appointment, please call us +65 64712744 or SMS to +65 92357641 (24 Hours Hotline)

Patella Injuries

The patella, or kneecap, is one of three bones, along with the tibia (shin bone) and femur (thigh bone), that make up the knee joint. All of these bones are covered with a layer of cartilage at points where their surfaces come into contact. Furthermore, the patella is wrapped within a tendon. This tendon connects the quadriceps muscle of the thigh to the shin bone (tibia) below the knee joint.

Condromalacia Patella

Condromalacia Patella

The patella is important functionally because it increases the leverage of the knee joint. From a mechanical perspective, the patella allows for an increase of about 30% in strength of extension (kicking) of the leg at the knee joint.

Symptoms of Kneecap Problems

Problems with the kneecap typically cause pain felt directly around the kneecap. Often these symptoms are noticed doing specific activities:

  • Walking stairs (particularly down)
  • Prolonged sitting
  • Kneeling

There are several common problems associated with the kneecap that can cause problems and pain in the knee

Chondromalacia Patellae (Runner’s Knee)
The most common disorder is known as chondromalacia, often called Runner’s Knee. Chondromalacia occurs because of irritation of the cartilage on the undersurface of the kneecap.

Prepatellar Bursitis (Housemaid’s Knee)
Prepatellar bursitis, or Housemaid’s Knee Syndrome, is a condition of swelling and inflammation over the front of the knee. This is commonly seen in patients who kneel for extended periods, such as carpet layers and gardeners.

Patellar Subluxation
Also called an unstable kneecap, patients who experience this painful knee condition have a patella that does not track evenly within its groove on the femur.

Kneecap Dislocation
When the kneecap comes completely out of its groove, the condition is called a patella dislocation. When the kneecap dislocates, it must be put back into its groove.

Treatment of Kneecap Problems

Treatment of these various kneecap conditions depends on the diagnosis, however there are some general guidelines that can be followed. For more information, and for a diagnosis of your knee pain, it is important to see your doctor.

  • Rest
    Resting the injured knee to allow time for inflammation to subside is very important. Cross-training will allow you to keep in shape. When you do return to activity, do so gradually.
  • Physical Therapy
    Physical therapy is very important to balance the strength of the muscles around the knee joint. Most importantly, the quad and hamstring muscle groups should be flexible and balanced.
  • Ice the Injury
    Apply ice to the knee to cool down inflammation in stimulate blood flow to the area. Be careful not to ice too much!
  • Anti-Inflammatory Medications
    Anti-inflammatory medications may help with inflammation and will also help alleviate some of the pain associated with patella conditions.
  • Arthroscopic Surgery
    While surgery is seldom needed because of a kneecap problem, arthroscopy is a treatment option if the problem is not getting any better with conservative treatment.

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Distal Radius Fractures (Broken Wrist)

The radius is the larger of the two bones of the forearm. The end toward the wrist is called the distal end. A fracture of the distal radius occurs when the area of the radius near the wrist breaks.

Distal radius fractures are very common. In fact, the radius is the most commonly broken bone in the arm.

A distal radius fracture almost always occurs about 1 inch from the end of the bone. The break can occur in many different ways, however.

One of the most common distal radius fractures is a Colles fracture, in which the broken fragment of the radius tilts upward. This fracture was first described in 1814 by an Irish surgeon and anatomist, Abraham Colles — hence the name “Colles” fracture.

A Colles fracture occurs when the broken end of the radius tilts upward.
 

Other ways the distal radius can break include:

  • Intra-articular fracture. A fracture that extends into the wrist joint. (“Articular” means “joint.”)
  • Extra-articular fracture. A fracture that does not extend into the joint is called an extra-articular fracture.
  • Open fracture. When a fractured bone breaks the skin, it is called an open fracture. These types of fractures require immediate medical attention because of the risk for infection.
  • Comminuted fracture. When a bone is broken into more than two pieces, it is called a comminuted fracture.

It is important to classify the type of fracture, because some fractures are more difficult to treat than others. Intra-articular fractures, open fractures, comminuted fractures, and displaced fractures (when the broken pieces of bone do not line up straight).are more difficult to treat, for example.

Sometimes, the other bone of the forearm (the ulna) is also broken. This is called a distal ulna fracture.

This illustration shows some of the types of distal radius fractures.
Causes of Distal Radius Fracture:

The most common cause of a distal radius fracture is a fall onto an outstretched arm.

Osteoporosis (a disorder in which bones become very fragile and more likely to break) can make a relatively minor fall result in a broken wrist. Many distal radius fractures in people older than 60 years of age are caused by a fall from a standing position.

A broken wrist can happen even in healthy bones, if the force of the trauma is severe enough. For example, a car accident or a fall off a bike may generate enough force to break a wrist.

Good bone health remains an important prevention option. Wrist guards may help to prevent some fractures, but they will not prevent them all.

Symptoms of Distal Radius Fracture:

A broken wrist usually causes immediate pain, tenderness, bruising, and swelling. In many cases, the wrist hangs in an odd or bent way (deformity).

Doctor Examination:

If the injury is not very painful and the wrist is not deformed, it may be possible to wait until the next day to see a doctor. The wrist may be protected with a splint. An ice pack can be applied to the wrist and the wrist can be elevated until a doctor is able to examine it.

If the injury is very painful, if the wrist is deformed or numb, or the fingers are not pink, it is necessary to go to the emergency room.

To confirm the diagnosis, the doctor will order x-rays of the wrist. X-rays are the most common and widely available diagnostic imaging technique. X-rays can show if the bone is broken and whether there is displacement (a gap between broken bones). They can also show how many pieces of broken bone there are.

(Left) An x-ray of a normal wrist. (Right) The white arrows point to a distal radius fracture.
 

Treatment

Treatment of broken bones follows one basic rule: the broken pieces must be put back into position and prevented from moving out of place until they are healed.

There are many treatment options for a distal radius fracture. The choice depends on many factors, such as the nature of the fracture, your age and activity level, and the surgeon’s personal preferences.

Nonsurgical Treatment

If the broken bone is in a good position, a plaster cast may be applied until the bone heals.

If the position (alignment) of your bone is out of place and likely to limit the future use of your arm, it may be necessary to re-align the broken bone fragments. “Reduction” is the technical term for this process in which the doctor moves the broken pieces into place. When a bone is straightened without having to open the skin (incision), it is called a closed reduction.

After the bone is properly aligned, a splint or cast may be placed on your arm. A splint is usually used for the first few days to allow for a small amount of normal swelling. A cast is usually added a few days to a week or so later, after the swelling goes down. The cast is changed 2 or 3 weeks later as the swelling goes down more, causing the cast to loosen.

Depending on the nature of the fracture, your doctor may closely monitor the healing by taking regular x-rays . If the fracture was reduced or thought to be unstable, x-rays may be taken at weekly intervals for 3 weeks and then at 6 weeks. X-rays may be taken less often if the fracture was not reduced and thought to be stable.

The cast is removed about 6 weeks after the fracture happened. At that point, physical therapy is often started to help improve the motion and function of the injured wrist.

Surgical Treatment

Sometimes, the position of the bone is so much out of place that it cannot be corrected or kept corrected in a cast. This has the potential of interfering with the future functioning of your arm. In this case, surgery may be required.

Procedure. Surgery typically involves making an incision to directly access the broken bones to improve alignment (open reduction).

A plate and screws hold the broken fragments in position while they heal.

Depending on the fracture, there are a number of options for holding the bone in the correct position while it heals:

  • Cast
  • Metal pins (usually stainless steel or titanium)
  • Plate and screws
  • External fixator (a a stabilizing frame outside the body that holds the bones in the proper position so they can heal)
  • Any combination of these techniques

An external fixator.

Open fractures. Surgery is required as soon as possible (within 8 hours after injury) in all open fractures. The exposed soft tissue and bone must be thoroughly cleaned (debrided) and antibiotics may be given to prevent infection. Either external or internal fixation methods will be used to hold the bones in place. If the soft tissues around the fracture are badly damaged, your doctor may apply a temporary external fixator. Internal fixation with plates or screws may be utilized at a second procedure several days later.

Recovery

Because the kinds of distal radius fractures are so varied and the treatment options are so broad, recovery is different for each individual. Talk to your doctor for specific information about your recovery program and return to daily activities.

Pain Management

Most fractures hurt moderately for a few days to a couple of weeks. Many patients find that using ice, elevation (holding their arm up above their heart), and simple, non-prescription medications for pain relief are all that are needed to relieve pain.

Your doctor may recommend combining ibuprofen and acetaminophen to relieve pain and inflammation. The combination of both medications is much more effective than either one alone. If pain is severe, patients may need to take a prescription-strength medication, often a narcotic, for a few days.

Cast and Wound Care

In some cases, original casts will be replaced because swelling has gone down so much that the cast becomes loose. The last cast is usually removed after about 6 weeks.

During healing, casts and splints must be kept dry. A plastic bag over the arm while showering should help. If the cast does become wet, it will not dry very easily. A hair dryer on the cool setting may be helpful.

Most surgical incisions must be kept clean and dry for 5 days or until the sutures (stitches) are removed, whichever occurs later.

Potential Complications

After surgery or casting, it is important that you achieve full motion of your fingers as soon as possible. If you are not able to fully move your fingers within 24 hours due to pain and/or swelling, contact your doctor for evaluation.

Your doctor may loosen your cast or surgical dressing. In some cases, working with a physical or occupational therapist will be required to regain full motion.

Unrelenting pain may be a sign of Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy) which must be treated aggressively with medication or nerve blocks.

Rehabilitation and Return to Activity

Most people do return to all their former activities after a distal radius fracture. The nature of the injury, the kind of treatment received, and the body’s response to the treatment all have an impact, so the answer is different for each individual.

Almost all patients will have some stiffness in the wrist. This will generally lessen in the month or two after the cast is taken off or after surgery, and continue to improve for at least 2 years. If your doctor thinks it is needed, you will start physical therapy within a few days to weeks after surgery, or right after the last cast is taken off.

Most patients will be able to resume light activities, such as swimming or exercising the lower body in the gym, within 1 to 2 months after the cast is removed or within 1 to 2 months after surgery. Vigorous activities, such as skiing or football, may be resumed between 3 and 6 months after the injury.

Long-Term Outcomes

Recovery should be expected to take at least a year.

Some pain with vigorous activities may be expected for the first year. Some residual stiffness or ache is to be expected for 2 years or possibly permanently, especially for high-energy injuries (such as motorcycle crashes), in patients older than 50 years of age, or in patients who have some osteoarthritis. However, the stiffness is usually minor and may not affect the overall function of the arm.

Finally, osteoporosis is a factor in many wrist fractures. It has been suggested that people who have a wrist fracture should be tested for bone weakness, especially if they have other risk factors for osteoporosis. Ask your doctor about osteoporosis testing.

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Patient Guide to Forearm Fracture

Orthopaedic surgeons refer to fractures of the forearm as those fractures that occur in the middle section (shaft) of the forearm bones. Fractures that involve the upper end of the forearm are discussed under elbow fractures. Fractures that involve the lower end are discussed under wrist fractures. The forearm has a complex anatomy to serve its functions – supporting and positioning the hand in space and providing anchorage for muscles that serve hand function. To fully restore these functions after a forearm fracture the bones must heal in the normal anatomical position

What structures are most commonly injured?

There are two bones in the forearm, the ulna which is a straight thin bone which goes from the elbow to the wrist and forms the axis of rotation of the forearm, and the radius. The radius is thin at one end becoming thicker and stronger towards the wrist. It is slightly bowed to allow it to rotate around the ulna when the forearm is rotated.

To demonstrate this place your forearm flat on a table in front of you with the palm up and the back of the little finger touching the table. Now roll the hand over until it is positioned palm down on the table. Note that the little finger and the elbow are still in much the same position while the thumb has moved from outside to inside. When the forearm rotates, the little finger side where the ulna is forms the axis (spindle) around which the rest of the forearm rotates. We can see that the radius is on the outside of the forearm when it is rolled outwards but crosses over the ulna when the forearm is rotated in.

The radius is bowed to allow this movement to occur. If the bowing is not accurately restored after a fracture the forearm will not rotate correctly and this would limit some important functions of the hand.

How do fractures of the forearm commonly happen?

All fractures occur when the limb is subjected to stress outside the normal range. Forearm fractures most commonly occur in three situations – a blow on the forearm, a bending force as in falling on the outstretched hand, or a twisting force where the forearm is over-rotated. Most often these forces cause both bones to break, but a fracture of the ulna alone can occur if you put your arm up to ward off a blow. This isolated fracture of the ulna used to be called the nightstick fracture! Nowadays, the pattern is more common in sports collisions, motor vehicle accidents (MVAs), and falls but it does still occur with violent assault.

Twisting and bending fractures occur with falls, sports accidents, and MVAs. As with all fractures, the damage done to the muscles and tendons is a significant feature of the injury. Open fractures, where the bone comes out through the skin are quite common in the forearm.

Types of Injuries:

An isolated fracture of the ulna used to be called the nightstick fracture! Nowadays, the pattern is more common in sports collisions, motor vehicle accidents (MVAs), and falls but it does still occur with
violent assault.

Twisting and bending fractures occur with falls, sports accidents, and MVAs. As with all fractures, the damage done to the muscles and tendons is a significant feature of the injury. Open fractures, where the bone comes out through the skin are quite common in the forearm.

Symptoms

What symptoms do forearm fractures cause?

Pain and tenderness immediately following an accident are the commonest symptoms of a fractured forearm. The pain is made worse if the forearm is moved or rotated and may be partly relieved by splinting the limb. Deformity of the forearm is common following this type of fracture and there is immediate loss of hand function. You can no longer lift things or grip them with any strength. The forearm is often bruised and swollen. In some severe injuries there may be a wound where the broken bone end has come through the skin. Numbness of the hand is an indication that a nerve to the hand may have been injured at the time of the fracture.

Evaluation

How will my fracture be evaluated?

First aid evaluation consists of inspecting the limb. A fracture would be assumed if the limb is severely painful, if the hand cannot be moved, or the forearm rotated or if the limb is deformed. A sling is usually sufficient splintage for transport to hospital.

In the Emergency Room assessment will include establishing the history and mechanism of injury, looking at the arm (inspection), and palpation (gently feeling it) for tender points . X-ray examination will be undertaken if there is suspicion of fracture of the forearm. In most situations an orthopedic surgeon will be consulted if a forearm fracture is confirmed by x-ray. The orthopedic evaluation will focus on the anatomy of the fracture, the patient’s expectations, and a plan for treatment. There are no special tests usually employed in this situation, other than x-ray.

Treatment

What treatments should I consider?

Nonsurgical Treatment

An isolated fracture of the ulna, also called a nightstick fracture, may be treated in a cast. It is not as important to make the bone absolutely straight so the result of non-operative treatment is often acceptable. The arm is placed in a cast extending from the palm of the hand to above the elbow. This is called a long arm cast. The wrist is held in the neutral position and the elbow at 90 degrees of flexion. It may be painful to put on this cast so an anesthetic may be required for cast application.

Surgery

If the ulna shaft fracture is badly displaced the treatment may be surgery to replace the bone fragments in the correct position and fixation to hold them in place. This has the additional advantage of allowing early movement of the limb.

For reasons described earlier, a fracture of both forearm bones needs to heal with great accuracy. Closed reduction, in which the bone ends are re-aligned without surgery is often not accurate enough. However, in some circumstances a closed reduction is tried. If this is successful the arm will be immobilized in a long arm cast. There is a risk that the fracture will displace in the cast, so frequent follow-up X-rays will be needed.

In the majority of cases, the surgeon will recommend surgery to ensure that the fracture is reduced accurately and fixed with internal fixation. Fixation with plates and screws is a common method although some surgeons recommend the less invasive method of placing a rod into the hollow medullary cavity of the bone, called intramedullary fixation.

Because fixation allows early recovery of movement of the forearm and hand, the long term risk of stiffness and loss of function is reduced. After surgery (internal fixation) a cast is not usually necessary although the limb should not be loaded until the bone is healed. A sling for protection and pain relief is usual practice but unloaded hand, wrist, and elbow movements can be started right away.

Rehabilitation

What happens as I recover?

New bone formation (hard callus) is commonly seen on x-ray bridging across the fracture by six weeks. At this stage the fracture will not easily move out of position. If a cast was used it may be taken off at this stage. The decision to proceed is based on interpretation of the x-rays and assessment of the stage of healing reached.

Physical therapy to regain the normal motion of the forearm, wrist, and hand and to recover strength, endurance and dexterity may be needed. When bridging callus is seen on the x-ray the limb can be gently loaded and the load slowly increased back to normal over the next few weeks.

The healing process reaches 80% of eventual strength by three months post injury and this is normally enough to allow return to normal function and sports. Recent research work has shown that, over the long term, there is a small loss of strength and endurance following open reduction and internal fixation of a forearm fracture and some persistent discomfort, particularly if the fixation is still in place.

Complications

What are the potential complications of this fracture?

Nonunion and malunion are common complications of this fracture but compartment syndrome does occur and has severe consequences.

Compartment Syndrome

The muscles of the forearm move the hand and fingers. When a fracture occurs the bone and muscle bleeds into the closed muscle compartments of the forearm. In some cases this is enough to raise the intra-compartment pressure high enough to stop blood flow to the muscle. As a result the muscle fibers may swell up and die (called necrosis). The swelling increases the pressure to cause a vicious cycle that may end in extensive damage to the muscles of the forearm. This condition is called a compartment syndrome. Untreated, this results in shortening and scarring of the muscles and loss of finger movement. The result is sometimes referred to as a claw hand, because the hand assumes the shape of a claw.

The cardinal sign of compartment syndrome is pain and tenderness of the forearm increased by pressure and by movement of the fingers. Since it is normal for the forearm to hurt after a fracture or after surgery it is often quite difficult to diagnose compartment syndrome.

Doctors and nurses pay a lot of attention to this problem and maintain a high index of suspicion. The treatment for compartment syndrome is immediate surgery to open up the muscle compartments and relieve the pressure. If this is done before any die off of the muscle fibers the outcome is satisfactory although the skin wound may be quite dramatic. Otherwise the outcome depends on the amount of muscle necrosis that has occurred.

Malunion

If the bones of the forearm heal with angulation, shortening, or rotation the fracture is said to be malunited. This is referred to as a malunion. The deformity may be significant enough to prevent full rotation of the forearm or it may be unsightly. Loss of rotation causes a problem with normal hand function so this problem usually requires treatment. The healed fracture is cut and the bone restored to normal length, rotation, and bowing.

Sometimes the extra bone laid down as part of the healing process causes a bony block which interferes with movement of the forearm and it has to be removed. In rare cases the radius actually heals to the ulna (this is called a cross union) and this completely prevents rotation of the forearm. Once the normal shape of the bone has been restored by surgery the fragments are fixed with internal fixation. Early movement to maintain the motion achieved by surgery is recommended.

Closed reduction may not result in anatomical alignment of the bones. Malunion is less common after operative treatment for two reasons. The first is that one aim of surgery is to restore normal alignment of the bones and this aim is usually achieved. The second is that the patient is encouraged to move the forearm once it has been fixed and this reduces the chances of cross-union or the development of a bony block.

Nonunion

nonunion occurs when the healing process does not go on to completion. The first stage of healing results in scar tissue developing in the gap between the bone fragments and this normally turns to bone. If the gap is too big or there is significant movement at the site bone development may not occur and it stays as scar tissue (called soft callus). This failure of healing is also affected by the blood supply of the area and such general medical factors as smoking, diabetes, and alcoholism.

Diagnosis of nonunion is a judgment call by the orthopaedic surgeon. In his/her judgement the fracture will not heal without intervention. The treatment depends on the circumstances but the principle is to do surgery to freshen the bone ends, immobilize them and improve the biological environment by using bone graft to stimulate healing.

Nonunion is more common after nonoperative treatment. It is painful to put stress on an nonunited fracture so treatment is usually continued until healing has been accomplished. The long term consequence of multiple procedures to achieve healing may be scarring and loss of function of the forearm muscles with stiffness.

Painful Hardware

The plates and screws used to immobilize the fracture fragments may be tender. Sometimes they can be felt under the muscle layers and are sore when you rest your arm on a table. Very commonly there is a persistent ache which may be increased by weather changes. The reasons for this symptom are not known but removal of the hardware eliminates the problem.

Surgery to remove the plates and screws is often done once the bones have healed. However, there is a well recognized risk of refracture in the first few weeks after plate removal and patients are advised to be protective of their arm during this period.

Infection

After an open fracture or less commonly after surgery the wound may develop a bacterial infection. This results in increased pain, redness and swelling of the wound area with drainage of pus developing later. Early recognition and treatment of a wound infection may prevent it from becoming established and infecting the bone. Bone infection hinders healing and may be difficult to eliminate.

Treatment requires long term use of antibiotics and surgery to remove all dead and contaminated tissue. The fixation is often left in so that the bone heals more quickly but hardware removal after healing is often required to finally eliminate the infection. With early aggressive treatment of infections the outcome is quite favorable.

Removal of the implants is controversial. The hardware is often uncomfortable and in those cases the patient and surgeon usually agree to removal. However, about 1/10th of these cases have a re-fracture within six weeks of the removal operation. This risk deters some surgeons from removal of the hardware where there are no symptoms. Others believe that the life-time risk of a problem from a retained plate is great enough to warrant removal of plates as a precaution.

Summary

A fracture of the forearm is a serious injury which results from moderate to severe accidents. The goal of treatment is to avoid the complications of malunion and nonunion and restore the best possible function of the limb. Surgery to straighten the bones and fix them in the correct position while they heal is a common way to treat this fracture and the eventual outcome from this treatment is good.

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Arm Fracture in Children

An arm fracture is a crack or break in one or more of the bones in your child’s arm.

Anatomy of the Arm

What causes an arm fracture?

The following are the most common causes of arm fractures:

  • Trauma: A direct hit to your child’s arm may cause a fracture. Car and sports accidents are some examples of trauma that can cause an arm fracture.
  • Fall: The pressure when your child lands on his hands after a fall may cause his arm bone to break.
  • Stress fracture: This is a tiny fracture that happens when your child’s arm muscles become tired from overuse. Stress fractures happen most often during sports when the same motion happens over and over.

What are the different types of arm fractures?

  • Nondisplaced: The bone breaks but the pieces stay in place.
  • Displaced: The bone breaks, and the pieces move out of place.
  • Open fracture: The broken bone breaks through your child’s skin.
  • Salter-Harris fracture: The bone breaks through your child’s growth plate.

What are the signs and symptoms of an arm fracture?

  • Arm and shoulder pain
  • Swollen and bruised arm
  • Abnormal arm position
  • Severe pain when your child moves his arm
  • Weakness or numbness in your child’s arm, hand, or fingers

How is an arm fracture diagnosed?

Your child’s caregiver will ask about his injury and examine him. Your child may need the following tests:

  • X-ray: An x-ray will show the type of fracture your child has.
  • CT scan: This test is also called a CAT scan. An x-ray and computer are used to take pictures of your child’s arm. He may be given dye before the test. Tell caregivers if your child is allergic to iodine or seafood. He may also be allergic to the contrast dye.
  • MRI: This scan uses a powerful magnet and a computer to take pictures of your child’s arm. Your child may be given dye before the test. Tell caregivers if your child is allergic to iodine or seafood. He may also be allergic to the contrast dye. Your child will need to lie still during his test. Never enter the MRI room with any metal objects. This can cause serious injury.
  • Bone scan: This is a test to look at your child’s arm bones. He is given a small, safe amount of dye in an IV. Pictures are taken of his injured arm. The pictures will help caregivers see your child’s arm fracture better.

How is an arm fracture treated?

Treatment will depend on what kind of fracture your child has, and how bad it is. He may need any of the following:

  • Brace, cast, or splint: A brace, cast, or splint will decrease your child’s arm movement and hold the broken bones in place. This will help decrease pain, and prevent further damage to his broken bones.
  • Medicines:
    • Pain medicine: Your child may be given medicine to take away or decrease pain. Do not wait until the pain is severe before you give your child his medicine.
    • Antibiotics: This medicine is given to help prevent or treat an infection caused by bacteria.
  • Physical therapy: A physical therapist can teach your child exercises to help improve movement and decrease pain. Physical therapy can also help improve strength and decrease your child’s risk for loss of function.
  • Surgery: Your child may need debridement before his surgery if he has an open fracture. Debridement is when damaged tissue is removed and the wound is cleaned. Debridement helps prevent infection and improve healing. Your child’s caregiver will use pins, screws, wires, or other materials to hold the bones straight so they can heal. Your child may have pins coming out of his skin.

What are the risks of an arm fracture?

Your child’s arm may not be straight, even after treatment. The nerves in his arm may be damaged, which can make his arm numb or weak. His arm may not heal properly or work as well as it did before your injury. He may have a scar if he has surgery.

When should I seek immediate help for my child?

  • The pain in your child’s injured arm does not get better or gets worse, even after rest and medicine.
  • Your child’s arm, hand, or fingers feel numb.
  • Your child’s arm is swollen, red, and feels warm.
  • You see blood on your child’s splint or cast.

For more information or to schedule for an appointment, please call +65 6471 2744 or Email to: info@boneclinic.com.sg

Fracture of the Finger

If you think a broken (fractured) finger is a minor injury, think again. Without proper treatment a fractured finger can cause major problems. The bones in a normal hand line up precisely. They let you perform many specialized functions, such as grasping a pen or manipulating small objects in your palm. When you fracture a finger bone, it can cause your whole hand to be out of alignment. Without treatment, your broken finger might stay stiff and painful.

Cause

Generally, a fractured finger occurs as the result of an injury to your hand. You can fracture a finger when you slam your fingers in a door or put out your hands to break a fall. You can fracture a finger during a ball game if the ball jams your finger. Carelessness when working with power saws, drills, and other tools can result in a fractured finger.

Symptoms

  • Swelling of the fracture site.
  • Tenderness at the fracture site.
  • Bruising at the fracture site.
  • Inability to move the injured finger in completely.
  • Deformity of the injured finger.

Diagnosis

If you think you fractured your finger, immediately tell your doctor exactly what happened and when it happened. Your doctor must determine not only which bone you fractured, but also how the bone broke. Bones can break in several ways. They can break straight across the bone, in a spiral, into several pieces, or shatter completely.

Your doctor may want to see how your fingers line up when you extend your hand or make a fist. Does any finger overlap its neighbor? Does the injured finger angle in the wrong direction? Does the injured finger look too short? Your doctor may X-ray both of your hands to compare the injured finger on your uninjured finger on your other hand.

Treatment

Nonsurgical Treatment

Your doctor will put your broken bone back into place, usually without surgery. You’ll get a splint or cast to hold your finger straight and protect it from further injury while it heals. Sometimes your doctor may splint the fingers next to the fractured one to provide additional support. Your doctor will tell you how long to wear the splint. Usually a splint on a fractured finger is worn for about three weeks. You may need more X-rays as you heal so your doctor can check the progress of your finger as it heals.

Surgical Treatment

Depending on the type and severity of the fracture, you may need surgery to have pins, screws, or wire put in place to hold your fractured bones together.

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Ankle Fracture

This is a difficult question to answer. The ankle is a complex joint that forms where three bones come together. The bones of the lower leg, the tibia and the fibula, are above the joint, and the talus is below the joint. When a doctor talks about an ankle fracture, he or she is usually talking about a broken bone of the tibia or fibula.The tibia, also called the shin bone, is the larger, weight-bearing bone of the lower leg. Of the weight transferred through the leg, about 90% is carried by the tibia. The fibula is the smaller bone on the outside of the leg. It only carries about 10% of your body weight.

Both the tibia and the fibula wrap around the talus to form the ankle joint. The bony prominences at the ankle are called the medial malleolus (the end of the tibia) and the lateral malleolus (the end of the fibula). The ends of these bones for a cup for the talus to sit within.

The Broken Ankle

When a broken ankle occurs, the injury may be to the end of the tibia (the medial malleolus) or to the fibula (the lateral malleolus), or both. There are many different type of ankle fractures, and attempting to discuss them is the subject of textbooks, not pamphlets like this. The point is, every ankle fracture MUST be treated individually. You must see your doctor and go over the treatment plan with him or her.There are some general treatment principles of ankle fractures that can be explained here. Common symptoms of an ankle fracture include:

  • Pain to touch
  • Swelling
  • Bruising
  • Inability to walk on the leg
  • Deformity around the ankle
If an ankle fracture is suspected you should see your doctor or go to the emergency room. X-rays can be done to determine the extent of the injury. Other injuries may also occur around the ankle joint, including ankle sprains, Achilles tendon ruptures, and other problems that may be confused with a broken ankle. It is important to be properly evaluated so that a treatment plan can be developed.

Once the injury has been determined, a treatment plan is made that is appropriate for the type of ankle fracture. For more information about ankle fracture treatment:

The basic treatments of ankle fractures are described below. Again, anyone with a broken ankle must discuss their individual treatment plan with their doctor, but this outlines some of the basics of ankle fracture treatment:

  • Ice and Elevation
    Swelling is almost universally seen following a broken ankle. An important part of treatment of an ankle fracture is to minimize swelling. Limiting swelling will help control the pain from the ankle fracture and minimize the damage to the surrounding tissues.
  • X-Rays
    Most patients with an ankle fracture are seen in the doctors office or emergency room. The first step is toobtain X-rays to see what the fracture pattern is, how badly displaced the fracture is, and what the condition of the bone looks like. Depending on the appearance of the ankle fracture on X-ray, treatment decisions can be made.
  • Splint
    Splinting an ankle fracture is commonly performed in the emergency room. A splint is often done for a few days, followed by a cast. The splint will allow more room than a cast in case there is continued swelling. If the ankle fracture is not badly displaced, the splint may be put on without moving the broken ankle. If there is displacement, a “reduction” will be performed. After being given anesthesia, the ankle fracture will be re-set to improve the alignment and displacement of the broken bones.
  • Cast
    A cast is usually done after a few days, unless the swelling is minimal and it may be done early after the injury. A cast is made either of plaster or fiberglass. Plaster molds to the skin better, and is preferred if the cast is needed to hold the broken bone in a specific place. If the fracture is not unstable, or if some healing has taken place, a fiberglass cast may be used. The fiberglass is lighter weight and more resilient to wear.
  • Crutches
    Crutches are important, because almost all types of ankle fractures will require some level of immobilization and rest following the injury. Sometime, patients will not be able to place any weight on the ankle for several months, other times within days to weeks. Determining when you can place weight on the broken ankle depends on the type of ankle fracture; this will have to be discussed with your doctor.
  • Surgery
    Surgery is needed for many types of ankle fractures. While not always necessary, surgery for ankle fractures is not uncommon. The need for surgery depends on the appearance of the ankle joint on X-ray and the type of ankle fracture present. Achieving and maintaining alignment of the broken ankle is of utmost importance. Arthritis is common after an ankle fracture, and the best way to reduce the risk of arthritis is to obtain a normal looking ankle joint. If surgery is needed to achieve this goal, your doctor may recommend an operation

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Broken Wrist

A broken wrist is among the most common broken bones. In fact, wrist fractures are the most commonly broken bone in patients under 65 years of age (after that age, hip fracturesbecome the most common broken bone). About 1 of every 6 fractures treated in emergency rooms is a wrist fracture.Usually, when a doctor is describing a wrist fracture, he or she is referring to a fracture of the radius (one of two forearm bones). There are other types of broken bones that occur near the wrist, but a typical wrist fracture generally means the end of the radius bone has been broken. Other bones that can break near the wrist joint include the scaphoid and the ulna.

How is the diagnosis of a wrist fracture made?
A wrist fracture should be suspected when a patient injures their wrist joint and has pain in this area. Common symptoms of a wrist fracture include:

    • Wrist pain
    • Swelling
    • Deformity of the wrist

When a patient comes to the emergency room with wrist pain, and evidence of a possibly broken wrist, an x-ray will be obtained of the injured area. If there is a broken wrist, the x-rays will be carefully reviewed to determine if the fracture is in proper position, and to assess the stability of the bone fragments.What is the usual treatment for a wrist fracture?
Most often, broken wrists can be treated in a cast. The wrist is one area of your body that is very amenable to cast treatment. If the bones are out of proper position, then some light sedation or local anesthesia may be used so your doctor can reset the fracture. This is called ‘reducing’ a wrist fracture, and by performing specific maneuvers, your doctor may be able to realign the broken wrist.

Which wrist fractures need surgery for treatment?
This is a difficult question to answer, and must be addressed on a case by case basis. Even on an individual basis, orthopedists may differ on their opinion of optimal treatment for a given fracture.

Some of the following are important considerations in determining whether or not surgery is necessary for a broken wrist:

  • Age and physical demands of the patient
    If a patient is young and active, every effort will be made to restore the wrist to normal. In some wrist fractures, this may help prevent problems in the years ahead. However, if the patient does not require heavy demands of the wrist, or if the patient is elderly, perfect restoration of the broken bones may not be necessary.
  • Bone quality
    If the bone is thin and weak, meaning the individual has osteoporosis, then surgery may be less beneficial. If plates and screws are used to fix a fracture, the bone quality must be adequate to secure the screws. Surgery is traumatic to the bone, and sometimes the best course of action is to minimize further damage to the bone and treat in a cast.
  • Location of the fracture
    If the fracture involves the cartilage of the wrist joint, then surgery may be more likely. While bone can remodel over time, the cartilage surface of the wrist joint cannot. If the cartilage surfaces are not lined up sufficiently with a reduction (resetting) maneuver, then surgery may be considered.
  • Displacement of the fracture
    If the bones are severely misaligned, then surgery may be performed to properly position the fragments. This is usually attempted without surgery, but it is possible for muscle and tendon to become entrapped and block the resetting. Furthermore, some fractures may be unstable and not stay in position even with a well fit cast. These may need surgery to adequately position the fracture.
  • Adequacy of non-surgical management
    If a fracture is displaced, usually the patient will have an attempted reduction, or repositioning of the broken bone. Sometimes it is difficult to reposition the bones without surgery. Other times, the positioning is satisfactory, but casting may not hold the fracture in that position. Surgery can usually be performed any time in the first two weeks after a fracture to restore the bones to their proper position.

As stated earlier, surgery is not usually needed for a wrist fracture, but it may be considered in some situations. If surgery is performed, there are several options for treatment. Some fractures may be secured with pins to hold the fragments in place. Another option is anexternal fixator, a device that uses pins through the skin and a device outside the skin to pull the fragments into position. Finally, plates and screws may be used to position the fracture properly.

Surgery for Broken Bones

Bone is a living tissue, and when a bone breaks, it can heal itself. However, the bone has to be held in place (immobilised) to make sure it heals in the right position.

This can sometimes be achieved using non-surgical methods, such as a sling or plaster cast. But if this isn’t possible, you may need to have surgery to fix the broken parts of your bone together with a metal plate, rod (also called an intermedullary nail) or pins and a frame (also called external fixators). Plates are fixed to the outside of your bone and hold the broken segments together, whereas rods are inserted inside your bone. Pins pass into your bone through your skin and are fixed outside your body with a frame.

Once your bone has been fixed in place, your body will produce new bone to join the broken parts together.

What are the alternatives?

You may not need surgery if your broken bone can be held in place using non-surgical methods, such as a sling or plaster cast.

Another alternative to surgery is traction. This involves using weights to pull the bones in your leg into place, while they heal. However, this treatment involves a long stay in hospital, and isn’t used very often any more.

Whether or not your surgeon advises surgery depends on a number of factors individual to you, including whether you have any other injuries, the type of fracture, your age and how active you are.

Preparing for surgery for a broken bone

Your surgeon will explain how to prepare for your operation. For example, if you smoke, you will be asked to stop as smoking increases your risk of getting a chest and wound infection, which can slow your recovery. It can also delay fracture healing.

Your surgeon or another healthcare professional will discuss with you what will happen before, during and after your procedure, and any pain you might have. This is your opportunity to understand what will happen, and you can help yourself by preparing questions to ask about the risks, benefits and any alternatives to the procedure. This will help you to be informed, so you can give your consent for the procedure to go ahead, which you may be asked to do by signing a consent form.

Surgery for broken bones is carried out under general anaesthesia. This means you will be asleep during the operation. You will be asked to follow fasting instructions before you have a general anaesthetic. This means not eating or drinking, typically for about six hours beforehand. However, it’s important to follow your surgeon or anaesthetist’s advice.

You may be asked to wear compression stockings and/or have an injection of an anticlotting medicine called heparin to help prevent blood clots forming in the veins in your legs. You will usually be put on an antibiotic drip before surgery. This is to reduce your risk of getting an infection during surgery.

What happens in surgery for a broken bone?

The device used to fix your broken bone will depend on a number of factors. Rods are more commonly used for broken legs and plates and screws for broken arms. Pins and frames tend to be used as a temporary measure for broken legs or if you have severe injury to your leg or arm.

Rods

Your surgeon will first position your arm or leg to line up the broken parts of bone. He or she will then make a small cut to reach your bone. This may be at the top of your arm or leg or in your knee or elbow, depending on which bone you have broken. Your surgeon will then insert the rod down the centre of your arm or leg bone.

Plates and screws

To fix a plate, your surgeon will make a cut through the skin and muscle along the length of your arm or leg. He or she will manoeuvre the broken fragments of bone back into position and then insert the plate so that it is lined up against the length of your bone. The plate will be fixed in place with metal screws.

External fixators

Your surgeon will insert the pins through your skin in your broken arm or leg and fix them together with metal bars. Your surgeon may replace the pins and frame for a plate or rod after two to three weeks.

Your surgeon may use X-rays during the surgery to make sure the plate, rods or pins are positioned correctly. Your surgeon will close your wound with stitches or staples and cover it with a sterile dressing.

What to expect afterwards

Your surgeon or nurse will give you painkillers to help with any discomfort as your anaesthetic wears off.

You may need to keep your arm or leg elevated at first. If you have had surgery for a broken arm, you may be given a sling or splint to keep it supported while it heals. If you have broken your leg, you will be given crutches to use so that you don’t put any weight on your leg. If you have metal pins inserted, you will be told how to keep the insertion points clean.

You will usually be able to go home after one to two days, as long as there are no complications.

You will be started on a rehabilitation programme as soon as possible. A physiotherapist will give you some exercises to do to start getting the movement back in your arm or leg.

Recovering from surgery

If you had surgery for a broken leg, you may be able to start putting some weight on it within a few weeks of your operation, and you may be able to return to work within two weeks if your occupation doesn’t involve any physical work.

It usually takes about six to 10 weeks to make a full recovery from surgery for a broken arm or leg, but this depends on a number of factors, including your age and the type of surgery you have had, so it’s important to follow your surgeon’s advice.

The length of time your dissolvable stitches will take to disappear depends on what type you have. However, they should usually disappear in about three to six months.

Risks

Surgery for broken arms and legs is commonly performed and generally safe. However, in order to make an informed decision and give your consent, you need to be aware of the possible side-effects and the risk of complications.

Side effects

Side-effects are the unwanted but mostly temporary effects you may get after having the procedure.

  • You will feel tired and need to rest as the effects of the anaesthetic wear off.
  • You are likely to have some pain where the nail or plate was inserted. You will be given painkillers, however, tell your surgeon if the pain persists.

Complications

Complications are when problems occur during or after the operation. The possible complications of any operation include an unexpected reaction to the anaesthetic, excessive bleeding or developing a blood clot, usually in a vein in the leg (deep vein thrombosis, or DVT).

  • Your broken bone may not heal (non-union), or heal in the wrong position (mal-union). This is uncommon, but your surgeon will X-ray your bone during your follow-up appointments to check how well it is healing and discuss further treatment options with you if necessary.
  • Damage to a nerve – this may cause some loss of movement or feeling in your arm or leg. This is uncommon and when it does happen, it tends to only be temporary.
  • If you had a rod inserted in your knee for a broken leg, you may continue to have knee pain over the long term. Talk to your surgeon if this happens.
  • Infection. If you develop an infection, your surgeon will give you antibiotics to take or you may be put on an antibiotic drip. If the infection spreads, you may need to have the infected tissue removed.
  • Compartment syndrome – this is when the nerves and blood vessels become compressed, and can lead to tissue death as your leg or arm doesn’t receive enough blood. You may feel extreme pain in the affected limb. If you develop compartment syndrome, you will need to have immediate surgery to relieve the pressure.

The exact risks are specific to you and differ for every person, so we haven’t included statistics here. Ask your surgeon to explain how these risks apply to you.

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New Clinical Practice Guideline For Treating Common Elbow Fractures In Children

The American Academy of Orthopaedic Surgeons (AAOS) Board of Directors has recently approved and released an evidence-based clinical practice guideline (CPG) on “The Treatment of Supracondylar Humerus Fractures.”

Supracondylar humerus fractures are common and likely occur when children are playing, or while climbing trees, jungle gyms and other structures. When young children fall, they tend to hyperextend their arms. As a result they land on a stiff arm, often fracturing the arm, just above the elbow joint.

In addition to the broken bone, the sheer force of this type of fall, may cause “all kinds of consequences. The artery which provides blood to the forearm and hand – runs very close to the elbow, as do the three main nerves of the arm: median, radial and ulnar. As a result, elbow fractures can cause circulation problems, and in 10 to 15 percent of cases, nerve injuries.

This new guideline is the result of a robust review of more than 350 research studies on this topic and includes 14 recommendations on how to stabilize the fracture, remedy circulation problems, and ultimately, ensure the fastest and most comfortable recovery for each child.

Important findings:

  • First, the guideline recommends that surgeons stabilize the fracture with “two or three laterally introduced pins to stabilize the reduction of displaced, misaligned, supracondylar fractures of the humerus.”
  • In addition, the guideline recommends procedures to restore blood flow and circulation if the artery has been stretched, torn or severed. Orthopaedic surgeons know that the first thing to do with an arm without a pulse is to gently realign the arm. Once the fracture is put back into the proper position and established, circulation will likely recover.
  • However, sometimes there is still no pulse in the arm following realignment. This can occur with or without adequate blood flow. The guideline recommends the surgical “exploration” of the blood vessels and nerves in front of the elbow in patients with no wrist pulse, if the hand remains cold and underperfused (without adequate blood flow), to “ensure survival of the tissues in the arm and hand.” In these rare instances, further surgery may be necessary “to prevent rare, but serious, limb threatening and life threatening consequences,” according to the guideline.

The guideline states: “If the hand feels warm, has color from circulation that you can see, and the child can move the muscles of the forearm and demonstrate some motion, then there is evidence that tissues are being nourished despite the absent pulse.” The guideline does not specifically recommend surgery or observation in these cases.

“Ultimately, each physician must evaluate his or her patient’s condition and circumstance and figure out ‘how do I best treat this child.

More about supracondylar humerus fractures

The humerus is the upper arm bone that connects the shoulder to the elbow. A supracondylar fracture of the humerus occurs just above the elbow joint. Treatment may consist of both surgical and nonsurgical options, but depends on the type of fracture and the degree of displacement.