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115. 2yo refuse to move one arm

visual-inline rebuild2 extracted figuresspeaker notes XML27 study lines4 Q&A

Individual slide images have been cropped from the rendered slide and inserted beside the matching note section. The full slide remains below only for layout/audit.

Clean FRCS notes with inline figures

Type / group	Definition / note
X	ray of skeletally immature patient

•Bilateral elbow

•On the Xray on top the relationship of the proximal ulna and radius are maintained, but the relationship of the humerus and the ulna & radius is disrupted with the later displaced posteromedially

•This is likely a transphyseal fracture of distal humerus (more likely than elbow dislocation as physis is biomechanically the weakest location in distal humerus)

•1. Normal alignment between the proximal radius and the capitellum (radiocapitellar line)

•2. Normal alignment of the proximal radius and ulna with each other

•Vs elbow dislocation: PM displacement in transphyseal injury

•Vs lateral condyle fracture: lateral condyle radial head relationship

•Vs low SCH fracture: wider bone contact in transphyeal, less displacement

•Hyperextension injury (birth injury/ abuse/ trauma, usu <2y)

Anatomy:

•Medial epicondyle involved at young age

•Physis moves distally as one grow, V shaped cleft

•Relationship of radius and capitellum is preserved

•Large fragment, usually less rotation and tilting

•Blood supply good, but medial crista of trochlea blood supply may be disrupted → cubital varus

DeLee classification (this type of fracture almost only < 7y)

Classification / diagram — Fig 2. Classification / diagramtop centre

Type / group	Definition / note
Type A	infant-7m. No lateral condyle ossification center (SH 1)
Type B	7m-3y. Lateral condyle ossified (SH 1, 2)
Type C	3y – 7. large metaphyseal fragment exiting laterally → CR +/- OR + KWF + cast in pronation x 3/52 (+/- arthrogram)

•Highly suspicious of NAI!!

Further Mx:

•MRI

•Management depends on timing of injury, displacement and DeLee type

•Acute undisplaced → CR + Cast in pronation x 3/52

•Acute displaced → CR +/- OR+ KWF + cast in pronation x 3/52

•Late (> 1/52) + displaced → DO NOT manipulate

Direct Q&A

Q1 What diagnostic or radiographic findings support 2yo refuse to move one arm?

•X-ray of skeletally immature patient

•Bilateral elbow

•On the Xray on top the relationship of the proximal ulna and radius are maintained, but the relationship of the humerus and the ulna & radius is disrupted with the later displaced posteromedially

•This is likely a transphyseal fracture of distal humerus (more likely than elbow dislocation as physis is biomechanically the weakest location in distal humerus)

•1. Normal alignment between the proximal radius and the capitellum (radiocapitellar line)

•2. Normal alignment of the proximal radius and ulna with each other

•Vs elbow dislocation: PM displacement in transphyseal injury

•Vs lateral condyle fracture: lateral condyle radial head relationship

•Vs low SCH fracture: wider bone contact in transphyeal, less displacement

•Hyperextension injury (birth injury/ abuse/ trauma, usu <2y)

Q2 What anatomy is relevant to 2yo refuse to move one arm?

Medial epicondyle involved at young age

•Physis moves distally as one grow, V shaped cleft

•Relationship of radius and capitellum is preserved

•Large fragment, usually less rotation and tilting

•Blood supply good, but medial crista of trochlea blood supply may be disrupted → cubital varus

Q3 How is 2yo refuse to move one arm classified here?

•Type A: infant-7m. No lateral condyle ossification center (SH 1)

•Type B: 7m-3y. Lateral condyle ossified (SH 1, 2)

•Type C: 3y – 7. large metaphyseal fragment exiting laterally → CR +/- OR + KWF + cast in pronation x 3/52 (+/- arthrogram)

•Highly suspicious of NAI!!

Q4 How is 2yo refuse to move one arm managed?

•Blood supply good, but medial crista of trochlea blood supply may be disrupted → cubital varus

DeLee classification (this type of fracture almost only < 7y)

Type / group	Definition / note
Type A	infant-7m. No lateral condyle ossification center (SH 1)
Type B	7m-3y. Lateral condyle ossified (SH 1, 2)
Type C	3y – 7. large metaphyseal fragment exiting laterally → CR +/- OR + KWF + cast in pronation x 3/52 (+/- arthrogram)

•Highly suspicious of NAI!!

Further Mx:

•MRI

•Management depends on timing of injury, displacement and DeLee type

•Acute undisplaced → CR + Cast in pronation x 3/52

•Acute displaced → CR +/- OR+ KWF + cast in pronation x 3/52

•Late (> 1/52) + displaced → DO NOT manipulate

Raw speaker-note hierarchy audit

#	lvl	marL	indent	logical	original note line
1	0	None	None	0	X-ray of skeletally immature patient
2	0	None	None	0	Bilateral elbow
3	0	None	None	0	On the Xray on top the relationship of the proximal ulna and radius are maintained, but the relationship of the humerus and the ulna & radius is disrupted with the later displaced posteromedially
4	0	None	None	0	This is likely a transphyseal fracture of distal humerus (more likely than elbow dislocation as physis is biomechanically the weakest location in distal humerus)
5	0	None	None	0	1. Normal alignment between the proximal radius and the capitellum (radiocapitellar line)
6	0	None	None	0	2. Normal alignment of the proximal radius and ulna with each other
7	0	None	None	0	Vs elbow dislocation: PM displacement in transphyseal injury
8	0	None	None	0	Vs lateral condyle fracture: lateral condyle radial head relationship
9	0	None	None	0	Vs low SCH fracture: wider bone contact in transphyeal, less displacement
10	0	None	None	0	Hyperextension injury (birth injury/ abuse/ trauma, usu <2y)
11	0	None	None	0	Anatomy:
12	0	None	None	0	Medial epicondyle involved at young age
13	0	None	None	0	Physis moves distally as one grow, V shaped cleft
14	0	None	None	0	Relationship of radius and capitellum is preserved
15	0	None	None	0	Large fragment, usually less rotation and tilting
16	0	None	None	0	Blood supply good, but medial crista of trochlea blood supply may be disrupted → cubital varus
17	0	None	None	0	DeLee classification (this type of fracture almost only < 7y)
18	1	None	None	1	Type A: infant-7m. No lateral condyle ossification center (SH 1)
19	1	None	None	1	Type B: 7m-3y. Lateral condyle ossified (SH 1, 2)
20	1	None	None	1	Type C: 3y – 7. large metaphyseal fragment exiting laterally → CR +/- OR + KWF + cast in pronation x 3/52 (+/- arthrogram)
21	0	None	None	0	Highly suspicious of NAI!!
22	0	None	None	0	Further Mx:
23	0	None	None	0	MRI
24	0	None	None	0	Management depends on timing of injury, displacement and DeLee type
25	0	None	None	0	Acute undisplaced → CR + Cast in pronation x 3/52
26	0	None	None	0	Acute displaced → CR +/- OR+ KWF + cast in pronation x 3/52
27	0	None	None	0	Late (> 1/52) + displaced → DO NOT manipulate

Improved semantic hierarchy used for the study notes

#	semantic level	section?	rewritten line
1	1		X-ray of skeletally immature patient
2	1		Bilateral elbow
3	1		On the Xray on top the relationship of the proximal ulna and radius are maintained, but the relationship of the humerus and the ulna & radius is disrupted with the later displaced posteromedially
4	1		This is likely a transphyseal fracture of distal humerus (more likely than elbow dislocation as physis is biomechanically the weakest location in distal humerus)
5	1		1. Normal alignment between the proximal radius and the capitellum (radiocapitellar line)
6	1		2. Normal alignment of the proximal radius and ulna with each other
7	1		Vs elbow dislocation: PM displacement in transphyseal injury
8	1		Vs lateral condyle fracture: lateral condyle radial head relationship
9	1		Vs low SCH fracture: wider bone contact in transphyeal, less displacement
10	1		Hyperextension injury (birth injury/ abuse/ trauma, usu <2y)
11	0	yes	Anatomy:
12	1		Medial epicondyle involved at young age
13	1		Physis moves distally as one grow, V shaped cleft
14	1		Relationship of radius and capitellum is preserved
15	1		Large fragment, usually less rotation and tilting
16	1		Blood supply good, but medial crista of trochlea blood supply may be disrupted → cubital varus
17	0	yes	DeLee classification (this type of fracture almost only < 7y)
18	1		Type A: infant-7m. No lateral condyle ossification center (SH 1)
19	1		Type B: 7m-3y. Lateral condyle ossified (SH 1, 2)
20	1		Type C: 3y – 7. large metaphyseal fragment exiting laterally → CR +/- OR + KWF + cast in pronation x 3/52 (+/- arthrogram)
21	1		Highly suspicious of NAI!!
22	0	yes	Further Mx:
23	1		MRI
24	1		Management depends on timing of injury, displacement and DeLee type
25	1		Acute undisplaced → CR + Cast in pronation x 3/52
26	1		Acute displaced → CR +/- OR+ KWF + cast in pronation x 3/52
27	1		Late (> 1/52) + displaced → DO NOT manipulate

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