Principles of managementPediatric Fractures

Mamoun KremliRiyadh, Saudi Arabia

Orthokids International SymposiumRiyadh, 2007

بسم الله الرحمن الرحيم

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

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 )

Statistics

• ~ 50% of boys and 25% of girls, expected to have a fracture during childhood.

• Boys > girls• Rate increases with age.

Mizulta, 1987

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

Statistics

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

Why are children’s fractures different?

Children have different physiology and anatomy

• Growth plate.• Bone.• Cartilage.• Periosteum.• Ligaments.• Age-related• physiology

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.

Why are children’s fractures different?

Children have different physiology and anatomy

• Bone:

– Increased collagen: bone ratio - lowers modulus of elasticity

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

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

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

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

Why are children’s fractures different?

Children have different physiology and anatomy

• Physiology

– Better blood supply rare incidence of delayed and non-union

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.

Physeal injuriesClassification: Salter-Harris, Peterson, Ogden

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)

The power of remodeling

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

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

The power of remodeling

Factors affecting remodeling potential

• Growth potential of adjacent physis e.g. upper humerus better than lower

humerus

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

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

• K- wires could be replaced by absorbable rods

Preoperative immediate 6 months 12 months

Hope et al , JBJS 73B(6) ,1991

Methods of fixation

• Casting - still the commonest• K-wires

– most commonly used– Metaphyseal fractures

• Intramedullary wires, elastic nails– Very useful– Diaphyseal fractures

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

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

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

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

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.

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

Beware!

Non-accidental injuries

Beware!

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

Beware!

Non-accidental injuries• Circumstantial evidence

• Soft tissue injuries - bruising, burns• Intraabdominal injuries• Intracranial injuries• Delay in seeking treatment

Beware!

Non-accidental injuries• Specific pattern

– Posterior ribs– Skull

Beware!Non-accidental injuries

• Specific pattern– Corner fractures (traction & rotation)

Beware!Non-accidental injuries

• Specific pattern– Bucket handle fractures (traction & rotation)

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

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

Special considerations

During resuscitation

summaryChildren’s bones are different

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

AO Courses, Riyadh 1-5 May 2005