Global Orthopedics || General Principles of Pediatric Trauma

247R.A. Gosselin et al. (eds.), Global Orthopedics,DOI 10.1007/978-1-4614-1578-7_26, © Springer Science+Business Media New York 2014

Introduction

While image intensifi cation has revolutionized chil-dren’s fracture care in economically developed regions by facilitating minimally invasive tech-niques for reduction and fi xation, such technology is rarely available in resource-challenged environ-ments. However, the majority of fractures and dis-locations in the pediatric population can be managed nonoperatively. To achieve adequate results the sur-geon must have an understanding of the fracture’s remodeling potential, an appreciation for the mech-anism of injury, meticulous casting technique, and close follow-up during early healing to correct minor incongruities and deformities (Fig. 26.1 ).

The most common anesthetic technique for reduction is the hematoma block, performed using the barbotage technique . Approximately half the local anesthetic is injected into the

fracture, and the hematoma is aspirated to restore the initial fl uid volume within the syringe. This process is repeated several times to distribute the anesthetic. After the fi nal aspiration the volume of the hematoma should be unchanged. Ketamine is also useful when available.

A subset of fractures—displaced intra- articular and irreducible fractures—require open surgical treatment and/or fi xation to achieve the best results, recognizing that open approaches increase the risk of infection (Fig. 26.2 ). A prompt diagnosis and early referral are essential if the resources and/or expertise are unavailable locally. Fracture fi xation can usually be done with Kirschner wires or Steinmann pins. Without an image intensifi er, “blind pinning” may be nec-essary, after which alignment and pin placement are assessed with portable radiographs. Open reduction via small incisions can facilitate mini-mally invasive fi xation techniques such as intra-medullary nailing of diaphyseal fractures.

Fracture Healing and Remodeling

The infl ammatory stage of fracture healing begins immediately after the injury and involves hematoma formation around the fracture ends. In the second or reparative phase, random bone is laid down by the endosteum (endochondral) and the periosteum (intramembranous). The last stage involves remod-eling, the extent of which is determined by (1) skel-etal age, (2) the specifi c bone involved, (3) fracture location within the bone, (4) distance of the fracture

D. A. Spiegel , MD (*) Division of Orthopaedic Surgery , Children’s Hospital of Philadelphia, Associate Professor of Orthopaedic Surgery , University of Pennsylvania School of Medicine , Philadelphia , PA, USA

Honorary Consultant in Orthopaedics and Rehabilitation , Hospital and Rehabilitation Centre for Disabled Children , Janagal , Kavre, Nepal e-mail: [email protected]

B. Banskota , MB BS, MRCS, MS Department of Orthopedics , Hospital and Rehabilitation Center for Disabled Children (HRDC) , Janagal, Kavre 6757 , Nepal e-mail: [email protected]

26 General Principles of Pediatric Trauma

David A. Spiegel and Bibek Banskota

mailto:[email protected]

mailto:[email protected]

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from a joint, and (5) whether the angulation occurs in the plane of motion of the neighboring joint.

The remodeling potential is greater when more than 2 years of growth remain and is especially good in children less than 8–10 years of age and in metaphyseal fractures. Seventy-fi ve percent

of remodeling occurs from asymmetric physeal growth, while 25 % is due to a combination of appositional bone growth on the concavity and resorption of bone on the convexity. General guidelines for acceptable alignment are illus-trated in Table 26.1 .

a

c d e

b

Fig. 26.1 ( a , b ) This forearm fracture was treated by a locally made splint. ( c ) In a similar case, the fracture healed in excellent alignment; ( d ) however, the treatment

was complicated by compartment syndrome and a Volkmann’s ischemic contracture. ( e ) Gangrene can com-plicate casting

D.A. Spiegel and B. Banskota

249

a

c

b

Fig. 26.2 ( a ) X-rays of a distal radius and ulna fracture with dislocation of proximal radius (Monteggia variant) was ( b ) initially treated by open reduction and nailing. The patient developed an infection which was ( c ) treated

by irrigation and debridement followed by plating. This was complicated by extensive osteomyelitis, a diffi cult problem to solve


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Table 26.1 General guidelines for acceptable alignment of fractures in children and adolescents

General guidelines for acceptable alignment of common children’s fractures

Lower extremity

Femoral shaft Age (years) Varus/valgus (°) Ant/post-angulation (°) Shortening (mm) Birth–2 30 30 15 2–5 15 20 20 6–10 10 15 15 >11 5 10 10

Tibia and fi bular shaft

≤8 years >8 years Valgus ≤5° ≤5° Varus ≤10° ≤5° Anterior angulation ≤10° ≤5° Posterior angulation ≤5° 0° Shortening 10 mm 5 mm Rotation ≤5° ≤5°

Adapted from Beaty JH, Kasser JR, editors. Rockwood and Wilkins’ fractures in children. 7th ed. Philadelphia: Lippincott, Williams and Wilkins; 2010

Box 26.1 Bone Age Differences

In sub-Saharan Africa it is common to fi nd patients in their late teens or early 20s with epiphyseal fractures. From a study from Malawi, in 85.6 % of 119 patients the skel-etal ages trailed chronological ages by a mean of 20 months [ 1 ]. Anthropological studies from the 1950s showed similar results when comparing East and West African populations to the Western middle class subjects of the commonly used bone atlases. Whether similar differences exist in other populations is unknown.

Physical anthropologists and forensic experts agree that the variations in the rates and times of human maturity are multifac-torial and include genetic and environmen-tal factors. Nutrition contributes to growth and developmental potential, and poor nutrition is commonly associated with stunted growth and delayed development. Chronic low dietary intake usually presents as a slow growth during childhood and adolescence, a late adolescent growth spurt, and a prolonged period of growth [ 2 ]. The specifi c effects of prenatal nutri-tion and the roles of caloric vs. protein mal-nutrition are not well understood.

Environmental stress also infl uences physiological age, but how this occurs is controversial. Chronic diseases may have a role on their own or by the accompanying malnutrition, especially in the young. And all of these factors may affect growth through alterations in the immune system.

Genetic factors affecting skeletal matu-ration are sure to play a role, as populations differ in average skeletal size, degree of sexual dimorphism, and proportions, while the variations within a population can be great.

Not all patients presenting in their late teens or early 20s with epiphyseal frac-tures are short or classically malnourished in appearance. The main points for the orthopedic surgeon are to be aware that physeal fractures occur in this older age group and to take care in planning any pro-cedures dependent on remaining bone growth or giving medical legal statements about age. This latter can be problematic as birth certifi cates are often lacking and knowledge of date of birth vague. At the same time, having an extended growth potential to remodel a fracture can be an advantage.


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Physeal Injuries

Physeal injuries can be due to fractures, infec-tions (osteomyelitis or septic arthritis), tumors, irradiation, vascular insults, and other injuries (thermal, electrical). Physeal fractures are usu-ally classifi ed according to Salter and Harris (Fig. 26.3a ). Peterson has added two additional types, (1) a metaphyseal fracture which extends into the physis (Fig. 26.3b ) and (2) partial loss

of the physis, for example, medial malleolar loss from a lawn mower injury. The most common complication of physeal injuries is growth distur-bance, which results in an angular deformity and/or limb length discrepancy. Growth disturbance is associated with partial or complete physeal arrest, or physeal growth deceleration without full arrest.

The consequences of physeal injuries are more profound for younger children with considerable

I II III IV V

a

b

Fig. 26.3 ( a ) Salter-Harris classifi cation of fractures. Type I fractures extend through the physis, while the Type II pat-terns travel through the physis and then exit through the metaphysis, leaving a metaphyseal component termed the “Thurston-Holland” fragment. Type III fractures extend through the physis and then exit the epiphysis, creating

displacement at both the physis and the joint surface. Type IV fractures extend from the metaphysis, across the physis and epiphysis, exiting in the joint. The rare Type V fracture is a compression injury that is not readily diagnosed on injury fi lms but later presents with growth disturbance. ( b ) A metaphyseal fracture extending into the physis


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growth remaining, high-energy injuries, and in selected physes such as the distal femur, due to its large surface area and undulations. The risk of iatrogenic injury can be reduced by treatment within 7 days after injury, gentle manipulation, and avoiding multiple or repeat reductions.

In the absence of advanced imaging, the diagnosis of growth arrest must be made on plain radiographs, and fi ndings include the loss of the normal physeal contour and asymmetric Harris growth arrest lines (Fig. 26.4 ). While it may be impractical to provide long term follow-up for most patients with physeal fractures, that subset of injuries with the highest risk—Salter-Harris III and IV, high-energy mechanism, late manipulation, or reduction—should be followed closely. It is critical to educate patients and their families about the possibility of growth disturbance, by indicating the possible clinical

features, such as development of an angular deformity and the time over which such changes might occur. For example, rapidly growing physes such as the distal femur might show a disturbance within 2–4 months, while a slower growing physis such as the distal tibia might not show clinical signs until a year or more after the injury. While routine radiographic follow-up within the fi rst few months might identify a growth disturbance before a clinical deformity has occurred, it remains a challenge for many patients to return to a health facility for follow-up. The best option may be to teach families how to evaluate limb lengths and symmetry. Community based rehabilitation workers can be taught to identify complications at an early stage.

If a physeal fracture is malaligned and heal-ing has progressed beyond 7–10 days, several

a b

Fig. 26.4 ( a ) A healed physeal fracture of the medial malleolus with a varus deformity. Note the asymmetric growth arrest line. ( b ) Symmetric growth arrest lines suggest resumption of normal growth


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options exist. If the degree of malalignment is within the expected remodeling potential of that physis and the patient is asymptomatic, obser-vation is the best choice. When alignment is beyond the limits of remodeling and/or the patient’s function is compromised, consider an open realignment and stabilization, recognizing and accepting that a physeal arrest will likely occur. Future plans for maintaining limb lengths within an acceptable range must then be discussed.

The predicted discrepancies after complete physeal arrest are based on the growth potential of the individual physis and the number of years of growth remaining. If a complete growth arrest is diagnosed, an epiphysiodesis of the contralat-eral physes may prevent a limb length discrep-ancy from developing. In younger children, the degree of anticipated discrepancy or the loss of adult height associated with contralateral epi-physiodesis may be unacceptable to the family, and limb lengthening may be the only alternative. For partial growth arrest, both progressive angu-lar deformity and limb length inequality have to be managed, and a number of reconstructive options can be considered. Estimates for the absolute growth in millimeters and percentage growth of each physis have been gathered from the most recent edition of Rockwood and Wilkins’ Fractures in Children and are shown in Table 26.2 .

Management of Neglected Fractures and Dislocations

Fractures and dislocations presenting weeks to months following injury are common and challenging. Treatment decisions are based on symptoms and their impact on the patient’s activities of daily living, the local resources, and the availability of rehabilitation. Outcomes following treatment of neglected fractures and dislocations are often inferior to those for the same injuries presenting acutely, especially when intra- articular and/or physeal. However, utilizing appropriate principles, improvements in symp-toms, and/or function can be expected in most patients.

Fractures with symptomatic malalignment after complete healing require an osteotomy. When fractures present up to 3–4 weeks post- injury, but prior to complete union, osteoclasis can “loosen up” the fracture and facilitate realign-ment. Osteoclasis can be performed by closed manipulation, percutaneous drilling, or by open techniques. Angulation is easier to correct than shortening. Either skeletal traction or an external fi xateur can gradually restore length and align-ment after osteoclasis. An alternative is to per-form an open, acute shortening and realignment.

Neglected intra-articular fractures and joint dislocations are more diffi cult to manage, espe-cially in weight bearing joints, and often require salvage strategies. While much of the available information in the literature focuses on adults, the same principles can be adapted to children and adolescents, taking into account the potential for remodeling and growth.

References

1. Lewis CP, Lavy CBD, Harrison WJ. Delay in skeletal maturity in Malawian children. J Bone Joint Surg Br. 2002;84-B(5):732–4.

2. Fresancho AR. Human adaptation and accommodation. Ann Arbor: University of Michigan Press; 1993. p. 370–2.

Table 26.2 Estimated growth of individual physes as a percentage within each bone and also in millimeters per year

Physis Estimated % of growth

Estimated growth (mm/year)

Proximal humerus 80 7 Distal humerus 20 2 Proximal radius 25 1.8 Distal radius 75 5 Proximal ulna 80 5 Distal ulna 20 1.5 Proximal femur 30 3.5 Distal femur 70 9 Proximal tibia 55 6 Distal tibia 45 3–5 Proximal fi bula 60 6.5 Distal fi bula 40 4.5

From Rathjen KE, Birch JG. Physeal injuries and growth disturbances. In: Beaty JH, Kasser JR, editors. Rockwood and Wilkins’ fractures in children, 7th ed. Philadelphia: Lippincott, Williams and Wilkins; 2010. p. 95


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Suggested Reading

Beaty JH, Kasser JR, editors. Rockwood and Wilkins’ fractures in children. 7th ed. Philadelphia: Lippincott, Williams and Wilkins; 2009.

Gasco J, de Pablos J. Bone remodeling in malunited fractures in children. Is it reliable? J Pediatr Ortho B. 1997;6:126–32.

Peterson HA. Physeal fractures: part 2. Two previously unclassifi ed types. J Pediatr Orthop. 1994;14:431–8.

Wenger DR, Pring ME, editors. Rang’s children’s frac-tures. 3rd ed. Philadelphia: Lipincott Williams and Wilkins; 2005.

Wilkins KE. Principles of fracture remodeling in children. Injury. 2005;36:SA3–11.


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Global Orthopedics || General Principles of Pediatric Trauma