Principles of management Pediatric Fractures

1. Principles of managementPediatric Fractures

2. Objectives • Statistics about fractures in children • How children’s bones are different • Outline principles of management • Point out specific precautions Acknowledgement and recommendation Lynn T Staheli

3. 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 )

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

5. 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

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

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

8. 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.

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

10. 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

11. 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

12. 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

13. 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

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

15. 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.

16. Physeal injuries Classification: Salter-Harris, Peterson, Ogden

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. Special considerations During resuscitation

45. summary Children’s bones are different

46. summary • About 60% of population in ME are children! • Fractures in children are common. • Children’s bones are different • Outline principles of management. • Specific treatment plans (combinations possible) • Specific precautions. • Beware • Non-accidental trauma • Malignant tumors

47. Thank You