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General Principles of management

Pediatric Fractures

Presented by:
Dr. Harjot Singh Gurudatta

Moderator : Dr. Gagan Khanna


Children’s bones are different

Metabolically more active,more vascularity,


aids reduction
Modulus of elasticity better resilience,
size of articular segment underestimated
Reduces tensile strength
comminution
In infants, GP is stronger
than bone
increased diaphyseal
fractures
Provides perfect
remodeling power.
Injury of growth plate
causes deformity
REMODELLING OF BONE IN CHILDREN
Why are children’s fractures different?

• Age related fracture pattern:

– Infants: diaphyseal fractures


– Children: metaphyseal fractures
– Adolescents: epiphyseal injuries
Statistics
• ~ 50% of boys and 25% of girls, expected to have a
fracture during childhood.
• Upper limb # more common with # distal radius
elbow region # viz distal humeral and prox. Radial
being common. Most # in home / school, femur
and pelvic # more with RSA.
• Boys > girls
• Rate increases with age.
• Physeal injuries with age. Mizulta, 1987
General Principles

Failure of union is rare.

Few fractures require operative treatment.

Presence of growth plate presents a challenge to the


surgeon.

Special considerations :

• Pathological fractures and malignancies


• Child abuse(multiple fracture and injuries at different
stages of healing, epiphysio-metaphysis corner injuries)
Centers of Ossification

• 1° ossification center
• Diaphyseal
• 2° ossification centers
• Epiphyseal
• Occur at different stages of
development
• Usually occurs earlier in girls than
boys

source: http://training.seer.cancer.gov
General Principles
Regulation of Epiphyseal Growth
Physis is the primary centre for growth
in most bones. EPIPHYSIS

Four functional zones:

• Reserve zone>> germinal layer for


cartilage cells
• Proliferation zone>>bone length is
created by active growth of cartilage
cells
• Hyprtrophic zone>> Terminally divided
cells ..no active growth, gradually
extending toward metaphysis and to
zone of degeneration
• Provisional calcification>>>
extracellular chondroid gets
impregnated with calcium salt with METAPHYSIS
blood vessels invasing from
metaphysis
Physeal injuries
• Account for ~25% of all
children’s fractures.
• More in boys.
• More in upper limb.
• Most heal well rapidly
with good remodeling.
• Growth may be
affected.
• Physis responds to
compression as well as
distraction(# implants
infection etc)
Salter - Harris Classification
• Type I
– Through physis only
• Type II
– Through physis & metaphysis
• Type III
– Through physis & epiphysis
• Type IV Type VI - Injury to the perichondral structures
Type VII - Isolated injury to the epiphyseal plate
– Through metaphysis, physis &
epiphysis Type VIII - Isolated injury to the metaphysis,
with a potential injury related to endochondral
• Type V ossification
– Crush injury to entire physis Type IX - Injury to the periosteum that may
• Others added later by subsequent interfere with membranous growth
authors(eg Ranga type 6 peripheral
AITKENS , polands, PETERSENS SYSTEM OF
physeal injury)
PHYSEAL INJURIES ARE THERE BUT SALTER
HARRIS REMAINS UNIVERSALLY ACCEPTED.
Described by Robert B. Salter and W. Robert Harris in 1963.
Epiphyseal Injuries
Salter Harris Classification General Treatment
Principles

TYPE 1 AND 2 Closed


reduction &
immobilization
• Type III & IV
• Intra-articular and
physeal step-off needs
anatomic reduction
• ORIF, if necessary
Physeal injuries
• Less than 1% cause physeal bridging affecting
growth.
• Small bridges (<10%) may lyse spontaneously.
• Central bridges more likely to lyse.
• Peripheral bridges more likely to cause deformity
• Avoid injury to physis during fixation.
• Monitor growth over a long period.
• Image suspected physeal bar (CT, MRI)
• Smooth pins should be used for fixation not
threaded ones if they are to cross physes.
Epiphyseal Injuries

Try not to cross the physis, but rather parallel it in the epiphysis or
pin the fracture spike in the metaphysis
Growth Arrest Secondary to Physeal Injury

Complete cessation of longitudinal


growth

• leads to limb length


discrepancy

Partial cessation of longitudinal


growth

• angular deformity, if peripheral


• progressive shortening, if
central
Warn parents about early operative
complications and late
complications, such as bony bridge
formation, angular deformity.
Growth Arrest Lines

Transverse lines of Park- Harris


Lines

Occur after fracture/stress

Result from temporary slowdown


of normal longitudinal growth

Thickened osseous plate in


metaphysis

Should parallel physis


Growth Arrest Lines

Appear 6-12 weeks after fracture

Look for them in follow-up


radiographs after fracture

If parallel physis - no growth


disruption

If angled or point to physis -


suspect bar
Physeal Bar
- Imaging -
• Tomograms/CT
scans
• MRI
• Map bar to
determine
location and
extent
Physeal Bars
- Types -
• I - peripheral,
angular
deformity
• II - central,
tented physis,
shortening
• III -
combined/compl
ete - shortening
Physeal Bar
- Treatment -

Address Assess

• Angular • Growth
deformity remaining
• Limb length • Amount of
discrepancy physis
involved
• Degree of
angular
deformity
• Projected
LLD at
maturity
Physeal Bar Resection
- Indications -
• >2 years remaining growth
• <50% physeal involvement
(cross-sectional)
• Concomitant osteotomy for
>15-20º deformity

• Completion epiphyseodesis
(tethering physis with staple
screw)and contralateral
epiphyseodesis may be
more reliable in older child
• Central bar> peripheral bar
Physeal Bar Resection - Techniques

Direct visualization

Burr/currettes

Interpositional material
(fat, cranioplast) easiest to prevent
reformation
The arrest is removed, leaving in
its place a metaphyseal-epiphyseal
cavity with intact physis
surrounding the area of resection
Torus Fracture
A greenstick fracture is a fracture in a young, soft
bone in which the bone bends and partially
breaks. This is owing in large part to the thick
fiborous periosteum of immature bone
here are three basic forms of greenstick fracture.
In the first a transverse fracture occurs in the
cortex, extends into the midportion of the bone
and becomes oriented along the longitudinal axis
of the bone without disrupting the opposite
cortex.
The second form is a torus or buckling fracture,
caused by impaction , The word torus is derived
from the Latin word 'Tori' meaning swelling or
protuberance.
The third is a bow fracture in which the bone
becomes curved along its longitudinal axis.
Usually pop splint is given!
DIAPHYSEAL FRACTURE

 MORE COMMON IN INFANTS

 Watch for neurovascular insufficiency during convalescence


 Abuse should be considered a possible cause of injury in all young
children with multiple long-bone fractures in association with head
injury

 General principles of fixation essentially remain the same with most


diaphyseal fractures being treated conservatively , displaced fractures
and open fractures requiring internal/external fixation.
Methods of fixation

• Casting - still the


commonest
Methods of fixation

• Casting - still the commonest


• K-wires
– most commonly used
– Metaphyseal fractures
Methods of fixation

• Casting - still the commonest


• K-wires
• most commonly used
• Metaphyseal fractures
• K- wires could be replaced by absorbable
rods
Methods of fixation

• Casting - still the commonest


• K-wires
– most commonly used
– Metaphyseal fractures
• Intramedullary wires, elastic nails
– Very useful
– Diaphyseal fractures
• Screws
Methods of fixation

Casting - still the commonest


K-wires
• most commonly used
• Metaphyseal fractures
Intramedullary wires, elastic nails
• Very useful
• Diaphyseal fractures
Screws
Plates – multiple trauma

more extensive operative exposure


Not load sharing-----removal needed
Newer minimally invasive
percutaneous submuscular plating
Methods of fixation

• Casting - still the commonest


• K-wires
• most commonly used
• Metaphyseal fractures
• Intramedullary wires, elastic nails
• Very useful
• Diaphyseal fractures
• Screws
• Plates – multiple trauma
• IMN - adolescents only (injury to growth)
Methods of fixation

• Casting - still the commonest


• K-wires
• most commonly used
• Metaphyseal fractures
• Intramedullary wires, elastic nails
• Very useful
• Diaphyseal fractures
• Screws
• Plates – multiple trauma
• IMN - adolescents
• Ex-fix – usually in open fractures
Titanium Elastic Nail

The aim of this biological, minimally invasive fracture


treatment is to achieve a level of reduction and
stabilisation that is appropriate to the age of the
child.

The biomechanical principle of the elastically-stable


intramedullary nailing (ESIN) is based on the
symmetrical bracing action of two elastic nails
inserted into the metaphysis, each
of which bears against the inner bone at three points.

This produces the following four biomechanical


properties: flexural stability, axial stability,
translational stability and rotational
stability. All four are essential for achieving optimal
results
INDICATIONS

Age lower limit is 3–4 years


and the upper limit 13–15 years.
Type of fracture
– transverse fractures
– short oblique or Spiral # with cortical suport
– long oblique fractures with cortical support
Fracture site
– femur: diaphyseal
– distal femur: metaphyseal
– femur: subtrochanteric
– lower leg: diaphyseal
– humerus: diaphyseal , subcapital even supracondylar
– radius and ulna: shaft radial neck
– radius: neck
– prophylactic stabilization with juvenile bone cysts
Contraindications
– intraarticular fractures
– complex femoral fractures, particularly
overweight (50–60 kg) and/or age (15–16 years)
Fracture

AP and lateral radiograph Oblique Views, s peciat projections.


CT scans, MRI, etc.

, "
~rticular Growth plate Metaphysis or diaphysis Consider:
.... Remodeling potential

...
End of growth
~---
_
...
...
Age of patient
Growth rate of physis
Plan of joint motion
Position in bone
Displacement
>2mm
Growth remaining

I - Other factors
Deformity visible?
Parents' values
placement SH-1 and SH-2 Special anatomic features
"2 mm
/ I


Unacceptable Acceptable

I " r /
Accept
position
I~=-I Functlonal-
coametlc
reductio
Accept position
ACCEPTABLE REDUCTION

- initial considerations:
growth will not correct rotational deformity
age
distance from physis
amount of deformity
- bayonette apposition
- generally bayonette apposition will require operative reduction
- historically, overriding of a both bones forearm fracture was acceptable if...
- there was no deviation of radius and ulna toward each other;
- there was no encroachment of the interosseous space;
- pt is less than 10 yrs of age;
- in pts < 6 yrs of age:
- upto 15 deg of angulation &<5 deg rotation is acceptable;
- between ages of 6-10 yrs:
- less than 10 deg of angulation should remodel especially if frx is close to distal epiphysis;
- bayonet apposition may be acceptable, although end to end apposition is preferred;
- pts > 12 yrs of age:
- no angulatory or rotational deformity is considered acceptable;
- more aggressive treatment is required, including open reduction and compression plating may be
required;
- Displaced Distal Third Frx:
- angulation up to 20-25 deg during first ten years is OK;
- angulation > 10 deg is unlikely to correct after 10 yrs
Indications for operative fixation

• Open fractures
• Displaced intra articular fractures
( Salter-Harris III-IV )
• fractures with vascular injury
• Compartment syndrome
• Fractures not reduced by closed reduction
( soft tissue interposition, button-holing of
periosteum )
• If reduction could be only maintained in an
abnormal position
Indications for operative fixation
Forearm diaphyseal fracture

Open

Debridement in OR Closed

Angulation 0°-10° Angulation +20°


Angulation 10°-20°
All ages
0-5 years + 5 years

Long arm cast or splint Successful if < 10° Closed reduction

Successful but unstable Unsuccessful

Closed reduction + ESIN Open reduction +ESIN


Humeral diaphyseal fracture

Adolescents &
Older
Older
children
children Infants & younger children

Open Closed
Immobilize in a sling & swath

Debridement in OR Closed reduction

III I & II Surgical indications Midshaft angulation

> 20° < 20°

Closed reduction + ESIN


Immobilize in soft dressing
External fixator
Femoral shaft fracture
Open
Debridement in OR

Infants Younger child Older child Adolescent

Abused Excessive shortening Comminution

Yes No No Yes No Yes

Choice

Hospital Immediate Traction External Reamed


ESIN
& invest. Hip spica Then cast fixator rod
Tibial shaft fracture

Open Closed

Debridement in OR Polytrauma Closed reduction & cast

III I & II Failed Succeed

External fixator Closed reduction + ESIN Consider wedging the cast


Complications
• Ma-lunion is not usually a problem
( except cubitus varus )
• Non-union is hardly seen
( except in the lateral condyle )
• Growth disturbance – epiphyseal dam age
• Vascular – volkmann’s ischemia
• Infection - rare
Complications of Fractures
- Bone -
• Malunion
• Limb length discrepancy
• Physeal arrest
• Nonunion (rare)
• Crossunion
• Osteonecrosis
Complications of Fractures
- Soft Tissue -
• Vascular Injury
• Especially
elbow/knee
• Neurologic Injury
• Usually neuropraxia
• Compartment
Syndrome
• Especially
leg/forearm
• Cast sores/pressure
ulcers
• Cast burns
• Use care with cast
saw
Complications of Fractures
- Cast Syndrome -
• Patient in
spica/body cast
• Acute gastric
distension,
vomiting
• Possibly
mechanical
obstruction of
duodenum by
superior
mesenteric
artery
Location Specific Pediatric Fracture
Complications
Complication Fracture

Cubitus varus Supracondylar humerus fracture

Volkmann’s ischemic contracture Supracondylar humerus fracture

Refracture Femur fracture


Mid-diaphyseal radius/ulna fractures
Overgrowth Femur fracture (especially < 5 years)

Nonunion Lateral humeral condyle fracture

Osteonecrosis Femoral neck fracture


Talus fracture
Progressive valgus Proximal tibia fractures
Supracondylar Fracture of Humerus
Complications
Forearm Fractures
Closed Reduction of Forearm Fractures
Bohler
traction

Open reduction and internal fixation with


plates and screws may be appropriate in the
management of fractures with delayed
presentation or fractures that angulate late in
the course of cast care,when significant
fracture callus makes closed reduction and
percutaneous passage of intramedullary nails
difficult. Tens nail and im nail has improved
results and are preferred in displaced
Closed Reduction of Forearm Fractures
Forearm Fractures
FEMORAL SHAFT FRACTURES

In a baby under 6 months old, a brace


(called a Pavlik Harness) may be able
to hold the broken bone still enough
for successful healing.

traction

Traction before spica casting is


indicated when the fracture is
unstable or
If the shortening of the bones is too
much (more than 3 cm)
In children between 7 months and 5
years old, a spica cast is often
applied.
In general, a spica cast begins at the
chest b/w umbilicus & nipple and
extends all the way down the
fractured leg, with flexion @ 50-90
degrees at knee and hip.

Spica cast management is generally


not used for children with multiple
trauma, head injury, vascular
compromise, floating knee
injuries, significant skin problems, or
multiple fractures. Flexible
intramedullary nails are the
11-15 yrs use of trochanteric entry, predominant treatment for femoral
locked intramedullary nailing for fractures in 5 to 11 year
femoral fractures in the preadolescent olds, although submuscular plating
and adolescent age groups and external fixation have their
place, especially in length-unstable
fractures or fractures in the
proximal and distal third of the
femoral shaft