Management of Fractures in Adolescents

1. Management of Fractures in Adolescents Friday Registrar Presentation Dr. Stewart Morrison MBBS Western Health Orthopaedic Department

2. Introduction Adolescence • Puberty: acceleration phase, peak height velocity, deceleration phase • Peak height velocity: Girls 12 years, Boys 14 years • Fall between management parameters for adults, and those for children • Quality of Bone .Less mineralised, more vascular, greater callus .greater energy dissipation, less comminution, quicker healing • Structure of Bone .Physeal Plate .Closure of Physeal Plate • Psychosocial

3. Estimation of Maturity • Various Methods .Sauvegrain .Oxford Score .Greulich’s and Pyle’s Atlas .Tanner-Whitehouse-III RUS Score .Sanders modification of TWIIIRUS Score • Biological Staging .Tanner Stages .Secondary Sexual Characteristics

7. Classification of Physeal Fractures • Salter-Harris • Perichondral ring of La Croix • Communication • Prognosis

8. Imaging General Principles • Joint above, joint below • Comparison views • CT • MRI

9. Principles of Treatment: Physeal Fractures Reduction • Traction, gentle manipulation • Open preferable to multiple closed attempts • No reduction after 7-10 days, unless > 2mm step-off Fixation • Pins, screws should be parallel to the physis • Single pass, single smooth K-wire • Resection of periosteum • Langenskiöld procedure • No reduction after 7-10 days, unless > 2mm step-off Most heal in 3 weeks. Growth disturbance monitoring.

10. Park-Harris Lines

11. How to succinctly and clearly explain this algorithm to parents? … when often they only hear the word ‘deformity’

12. Principles of Treatment: Non-Physeal Fractures • Adolescent bone does not have the remodelling capacity of childrens’ • Weight and specific characteristics need to be taken into account • Displaced diaphyseal fractures – Titanium Elastic Nails • Displaced metaphyseal fractures – Percutaneous Pin Fixation • Supplementation of fixation by splint or cast • Locking plates not usually required • Implant removal

15. Clavicle • First bone to begin ossification, and the last to finish it. • Threshold of > 2 cm of displacement often cited Operative Considerations • ORIF • Supraclavicular nerve • Neurovascular bundle • Earlier return to full activities (12 vs 16 weeks)

16. Radial and Ulnar Shafts • Studies often convoluted by pediatric participants, and inclusion of metaphyseal fractures • More difficult to manage than previously thought • Greenstick • Plastic Deformation • Complete • Comminuted • If a deformity is present in two orthogonal radiographs, the true deformity will be greater than appreciated on either single view

17. Radial and Ulnar Shafts • Operative Considerations • 1.5 – 2.0 mm Titanium Elastic Nails (TENS) • Closed Reduction closed reduction with percutanous fixation  open reduction • Reestablish radial bow, eliminate any bowing of ulna • Fix radius first • Narrowest point of radius is central • Narrowest point of ulna is within the distal third • Do not cross physes • Removal at six months or more

18. Femoral Shaft Principles • Timely union • No rotational deformity • < 2 cm shortening • Deformity of < 10-20° (sagittal plane), < 5-10° (coronal plane) Operative Considerations • In adolescents, surgical treatment favoured • Elastic intramedullary nails (< 11 yrs, < 49 kg ) .require removal • Rigid nails, plating (> 11 yrs, length ‘unstable’ fractures) .require removal • No randomized trials • External Fixation

19. Distal Femur • High Energy Metaphyseal Fractures • < 10 years; closed reduction + percutaneous cross-pin fixation + long leg cast • > 10 years or unstable fracture, consider plating or external fixation • Physeal Fractures • SHI + SH II, undisplaced – long leg cast • SHI + II, mildly displaced – closed reduction, percutaneous pinning, long leg cast • SH II, large metaphyseal fragment – cannulated screws, long leg cast • SH III + IV, displaced – cannulated compression screws • All should remain NWB following fixation • 50% of distal femoral fractures lead to growth disturbance (SH II highest risk)

20. Proximal Tibia • Physeal Fractures • High energy • CT recommended • Similar management principles to distal femoral fractures • Metaphyseal Fractures • “Cozen Fractures” • Closed reduction, long leg casting • Genu valgum is most common complication

21. Proximal Tibia Tibial Spine Fractures • Hyperextension of the knee • ACL avulsion injury • Tibial Tubercle Fractures • Repetitive jumping sports • Ogden modification of Watson-Jones Classification • Open reduction, internal fixation for II, III, IV • V should have periosteal sleeve reattached • Genu recuvatum

22. Ankle Considerations • Fibular physis closes later than the tibial physis (12-14, 15-18 vs. 19-20 yrs) • Tibial physis closes in a circular pattern – centre to medial to lateral • CT scan recommended • Management • SH I or SHII, undisplaced – BK walking cast 3-4 weeks • SH I or SHII, displaced – closed reduction, AK cast 3 weeks, then BK 3 weeks • SH III or SHIV – often require open reduction, internal fixation • If periosteal flap not removed, 60% incidence of plate closure • No more than 5% of angulation in any plane should be accepted

23. Ankle Tillaux Fracture • SHIII of anterolateral distal tibial epiphysis (final area to close) • Internal rotation can provide closed reduction, however often need open reduction • Triplanar Fracture • SHIII or SH IV • Appears as SH II on lateral radiograph, SH III on anteroposterior radiograph • Younger patient than Tillaux fracture • Growth arrest not clinically important • Flexion of Knee to 90 degrees, plantar flexion and internal rotation of the foot, with AK cast for 3/52 • If unsuccessful, proceed to percutaneous or open reduction/fixation

24. Thank you Salter RB, Harris WR. Injuries Involving The Epiphyseal Plate. J Bone Joint Surg Am. 1963;45: 587-622. Khan La, Bradnock Tj, Scott C, Robinson Cm. Fractures Of The Clavicle. J Bone Joint Surg Am. 2009 Feb;91(2):447-60. Egol Ka Et Al. Management Of Fractures In Adolescents. J Bone Joint Surg. Am. 2010 Dec;92(18) 2947 Zionts Le. Fractures Around The Knee In Children. JAAOS Vol. 10 No. 5 September/October 2002 Alain Diméglio; Yann Philippe Charles; Jean-pierre Daures; Vincenzo De Rosa; Accuracy Of The Sauvegrain Method In Determining Skeletal Age During Puberty. Journal Of Bone And Joint Surgery; Aug 2005; 87, 8; Health & Medical Complete Momberger N, Stevens P, Smith J, Santora S, Scott S, Anderson J. Intramedullary nailing of femoral fractures in adolescents. J Pediatr Orthop. 2000;20: 482-4.