Principles of management Pediatric Fractures

1. Principles of managementPediatric Fractures Mohammad Ali Tahririan Fellowship of Pediatric Orthopedics

2. introduction • In Middle East ~60% of population are < 20 yrs. • Fractures account for ~15% of all injuries in children. • Different from adult fractures • Vary in various age groups ( Infants, children, adolescents )

3. Statistics • ~ 50% of boys and 25% of girls, expected to have a fracture during childhood. • Boys > girls • Rate increases with age. Mizulta, 1987

4. Statistics • ~ 50% of boys and 25% of girls, expected to have a fracture during childhood. • Boys > girls • Rate increases with age. • Physeal injuries with age. Mizulta, 1987

5. Statistics Most frequent sites (sample of 923 children, Mizulta, 1987)

6. Why are children’s fractures different? Children have different physiology and anatomy • Growth plate. • Bone. • Cartilage. • Periosteum. • Ligaments. • Age-related • physiology

7. Why are children’s fractures different? Children have different physiology and anatomy • Growth plate: • In infants, GP is stronger than bone increased diaphyseal fractures • Provides perfect remodeling power. • Injury of growth plate causes deformity. • A fracture might lead to overgrowth.

8. Why are children’s fractures different? Children have different physiology and anatomy • Bone: • Increased collagen: bone ratio - lowers modulus of elasticity

9. Why are children’s fractures different? Children have different physiology and anatomy • Bone: • Increased collagen: bone ratio - lowers modulus of elasticity • Increased cancellous bone - reduces tensile strength - reduces tendency of fracture to propagate less comminuted fractures • Bone fails on both tension and compression - commonly seen “buckle” fracture

10. Why are children’s fractures different? Children have different physiology and anatomy • Cartilage: • Increased ratio of cartilage to bone - better resilience - difficult x-ray evaluation - size of articular fragment often under-estimated

11. Why are children’s fractures different? Children have different physiology and anatomy • Periosteum: • Metabolically active • more callus, rapid union, increased remodeling • Thickness and strength • Intact periosteal hinge affects fracture pattern • May aid reduction

12. Why are children’s fractures different? Children have different physiology and anatomy • Age related fracture pattern: • Infants: diaphyseal fractures • Children: metaphyseal fractures • Adolescents: epiphyseal injuries

13. Why are children’s fractures different? Children have different physiology and anatomy • Physiology • Better blood supply rare incidence of delayed and non-union

14. 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.

15. CLASSIFICATION OF PHYSEAL INJURIES

16. Most injuries occur just above area of provisional calcification within the hypertrophic zone. Germinal layer frequently remains intact and attached to the epiphysis Physeal anatomy

17. 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)

18. The power of remodeling • Tremendous power of remodeling • Can accept more angulation and displacement • Rotational mal-alignment ?does not remodel

19. The power of remodeling Factors affecting remodeling potential • Years of remaining growth – most important factor • Position in the bone – the nearer to physis the better • Plane of motion – greatest in sagittal, the frontal, and least for transverse plane • Physeal status – if damaged, less potential for correction • Growth potential of adjacent physis e.g. upper humerus better than lower humerus

20. The power of remodeling Factors affecting remodeling potential • Growth potential of adjacent physis e.g. upper humerus better than lower humerus

21. 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

22. Indications for operative fixation

23. Methods of fixation • Casting - still the commonest

24. Methods of fixation • Casting - still the commonest • K-wires • most commonly used • Metaphyseal fractures

25. Methods of fixation • Casting - still the commonest • K-wires • most commonly used • Metaphyseal fractures • K- wires could be replaced by absorbable rods

26. Methods of fixation • Casting - still the commonest • K-wires • most commonly used • Metaphyseal fractures • K- wires could be replaced by absorbable rods Preoperative immediate 6 months 12 months Hope et al , JBJS 73B(6) ,1991

27. Methods of fixation • Casting - still the commonest • K-wires • most commonly used • Metaphyseal fractures • Intramedullary wires, elastic nails • Very useful • Diaphyseal fractures

28. Methods of fixation • Casting - still the commonest • K-wires • most commonly used • Metaphyseal fractures • Intramedullary wires, elastic nails • Very useful • Diaphyseal fractures • Screws

29. Methods of fixation • Casting - still the commonest • K-wires • most commonly used • Metaphyseal fractures • Intramedullary wires, elastic nails • Very useful • Diaphyseal fractures • Screws

30. 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

31. 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)

32. 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

33. 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 Combination

34. Fixation and stability • Fixation methods provide varying degrees of stability. • Ideal fixation should provide adequate stability and allow normal flexibility. • Often combination methods are best.

35. Complications • Ma-lunion is not usually a problem ( except cubitus varus ) • Non-union is hardly seen ( except in the lateral condyle ) • Growth disturbance – epiphyseal damage • Vascular – volkmann’s ischemia • Infection - rare

36. Beware! Non-accidental injuries

37. Beware! Non-accidental injuries • ?Multiple • At various levels of healing • Unclear history – mismatching with injury • Circumstantial evidence

38. Beware! Non-accidental injuries • Circumstantial evidence • Soft tissue injuries - bruising, burns • Intraabdominal injuries • Intracranial injuries • Delay in seeking treatment

39. Beware! Non-accidental injuries • Specific pattern • Posterior ribs • Skull

40. Beware! Non-accidental injuries • Specific pattern • Corner fractures (traction & rotation)

41. Beware! Non-accidental injuries • Specific pattern • Bucket handle fractures (traction & rotation)

42. Beware! Non-accidental injuries • Specific pattern • Femur shaft fracture • <1 year of age ( 60-70% non accidental) • Transverse fracture • Humeral shaft fracture <3 years of age • Sternal fractures

43. Beware! Malignant tumours • Can present as injury. • History of trauma usual. • 12 y old girl • History of trauma • mild tenderness • Periosteal reaction • 2m later, still tender • Ewings sarcoma

44. summary Children’s bones are different