Traumatologie Pediatrica - General

8/9/2019 Traumatologie Pediatrica - General

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Anatomy Unique to Skeletally

Immature Bones• Anatomy

– Epiphysis

– Physis – etaphysis

– !iaphysis

• Physis " #ro$th plate


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Anatomy Unique to Skeletally

Immature Bones• Periosteum

– Thicker

– ore osteo#enic – Attached firmly at

periphery of physes

• Bone

– ore porous

– ore ductile


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Periosteum

• %steo#enic

• ore readily ele&ated from

diaphysis and metaphysis

than in adults

• %ften intact on the conca&e

'compression( side of the

in)ury

– %ften helpful as a hin#e for

reduction – Promotes rapid healin#

• Periosteal ne$ *one

contri*utes to remodelin#

Fro#: %he &lose" %reat#ent o'

Fractures, John &harle(


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Physeal Anatomy

• +ross , secondary

centers of ossification

• -istolo#ic .ones• /ascular anatomy


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0enters of %ssification

• 12 ossification center

– !iaphyseal

• 32 ossification centers – Epiphyseal

– %ccur at different

sta#es of de&elopment

– Usually occurs earlier

in #irls than *oys

source: htt):**training+seer+cancer+gov


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Physeal Anatomy

• 4eser&e .one

– atri5 production

• Proliferati&e .one – 0ellular proliferation

– 6on#itudinal #ro$th

• -ypertrophic .one

– su*di&ided into• aturation

• !e#eneration

• Pro&isional calcification

ith )er#ission 'ro# M+ -hert, MD

McMaster .niversit(, /a#ilton, Ontario

Epiphyseal side

Metaphyseal side


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4adio#raphic E&aluation of the

In)ured 0hild• At least 3 ortho#onal

&ie$s

• Include )oint a*o&e and

*elo$ fracture

• Understand normal

ossification patterns

•0omparison radio#raphsrarely needed7 *ut can *e

useful in some situations


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Special Ima#in#

• E&aluate intra,articular

in&ol&ement

– Tomo#rams7 0T scan7 4I7

arthro#ram

• Identify fracture throu#h

nonossified area

– Arthro#ram7 4I

• Identify occult 'or stress(

fractures

– Bone scan7 4I

• Assess &ascularity 'contro&ersial(

– Bone scan7 4I


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Fractures common only in

skeletally immature• Physeal in)uries

– 8$eak link9 " physis7

especially to$ard endof #ro$th

• Buckle or Torus

Fracture

• Plastic !eformation

• +reenstick Fracture


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Buckle or Torus Fracture

• 0ompression failure

• Sta*le

• Usually atmetaphyseal :

diaphyseal )unction


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Plastic !eformation

• The non,re&ersi*le

deformation after elastic

limit surpassed 'yield

stren#th(

• 0aused predominantly *y

slip at microcracks

• Permanent deformity can

result

– These do not remodel $ell

• Forearm7 fi*ula common


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+reenstick Fractures

• Bendin# mechanism

• Failure on tension side

• Incomplete fracture7 plastic deformation on

compression side

• ay need to completefracture to reali#n


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Salter , -arris 0lassification

• Type I

– Throu#h physis only

• Type II

– Throu#h physis ; metaphysis

• Type III

– Throu#h physis ; epiphysis

• Type I/

– Throu#h metaphysis7 physis ;

epiphysis

• Type / – 0rush in)ury to entire physis

• %thers added later *y su*sequent

authors

Descri$e" $( o$ert + Salter an" + o$ert /arris in 1!+


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Salter -arris 0lassification

+eneral Treatment Principles• Type I ; Type II

– 0losed reduction ;

immo*ili.ation – E5ceptions

• Pro5imal femur

• !istal femur


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Salter -arris 0lassification

+eneral Treatment Principles• Type III ; I/

– Intra,articular and

physeal step,off needsanatomic reduction

– %4IF7 if necessary


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Physeal Fractures

• Traditionally *elie&ed to occur primarily throu#h

.one of hypertrophy

• 4ecent studies sho$ fractures often tra&erse morethan one .one

• +ro$th distur*ance:arrest potentially related to

– 6ocation of fracture $ithin physeal .ones

– !isruption of &ascularity

Jara#illo et al, a"iolog(, 2000+Johnson et al, 3et Surg, 2004+

Klein#an Marks, A# J oentgenol, 1!+


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Treatment Principles

• >hen possi*le7 restore?

– 6en#th7 ali#nment ; rotation

• aintain residual an#ulation as small as possi*le usin# closed treatment methods

– molded casts7 cast chan#es7 cast $ed#in#7 etc<

• !isplaced intra,articular fractures $ill notremodel

– anatomic reduction mandatory


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0losed ethods• Achie&e adequate pain control and rela5ation

– Anesthesia

• 6ocal• 4e#ional

• +eneral

– 0onscious sedation 'often com*ination of dru#s(

• Propofol

• @etamine

• Ben.odia.epines

• =arcotics


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0losed ethods• /ast ma)ority of pediatric fractures treated

*y closed methods<

– E5ceptions , open fractures7 intra,articularfractures7 multi,trauma

• Attempt to restore ali#nment 'do not al$ays

rely on remodelin#(• +entle reduction of physeal in)uries

'adequate rela5ation7 traction(


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0losed ethods• >ell molded casts:splints

– Use ,point fi5ation principle

• 0onsider immo*ili.ation method on day of in)ury that

$ill last throu#h entire course of treatment – 6imit splint or cast chan#es

• 0onsider likelihood of post,reduction s$ellin# – 0ast splittin# or splint

• If fracture is unsta*le7 repeat radio#raphs at $eeklyinter&als to document maintenance of accepta*le

position until early *one healin#


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E5cellent reduction maintained $ith

thin7 $ell,molded cast:splint


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Fi*er#lass cast applied $ith proper technique

and split:spread is e5cellent $ay to safely

immo*ili.e lim*7 maintain reduction andaccommodate s$ellin#


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6oss of 4eduction

• etaphyseal:diaphyseal fractures can *e

remanipulated $ith appropriateanesthesia:anal#esia up to $eeks after

in)ury

• In #eneral7 do not remanipulate physealfractures after ,C days

– increased risk of physeal dama#e


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%pen ethods• 4espect and protect physis

• Adequate &isuali.ation

– resect periosteum7 metaphyseal *one7 if needed

• @eep fi5ation in metaphysis : epiphysis if

possi*le $hen much #ro$th potential

remains

– Use smooth @,$ires if need to cross physis


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%4IF Salter I/

!istal Ti*ia

5 6ote e)i)h(seal*#eta)h(seal 7ires to track )osto)erative gro7th


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0omplications of Fractures

, Bone ,• alunion

• 6im* len#th

discrepancy• Physeal arrest

• =onunion 'rare(

• 0rossunion• %steonecrosis


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, Soft Tissue ,• /ascular In)ury – Especially el*o$:knee

• =eurolo#ic In)ury

– Usually neuropra5ia

• 0ompartment Syndrome

– Especially le#:forearm

• 0ast sores:pressure ulcers

• 0ast *urns

– Use care $ith cast sa$


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, 0ast Syndrome ,• Patient in spica:*ody

cast

• Acute #astricdistension7 &omitin#

• Possi*ly mechanical

o*struction of

duodenum *y superior

mesenteric artery


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6ocation Specific Pediatric

Fracture 0omplicationsComplication Fracture

0u*itus &arus Supracondylar humerus fracture

/olkmannDs ischemic contracture Supracondylar humerus fracture

4efracture Femur fractureid,diaphyseal radius:ulna fractures

%&er#ro$th Femur fracture 'especially years(

=onunion 6ateral humeral condyle fracture

%steonecrosis Femoral neck fractureTalus fracture

Pro#ressi&e &al#us Pro5imal ti*ia fractures


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4emodelin# of 0hildrenDs

Fractures• %ccurs *y physeal ;

periosteal #ro$th

chan#es• +reater in youn#er

children

• +reater if near a

rapidly #ro$in#

physis


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Immo*ili.ation Time

• In #eneral7 physeal in)uries heal in half the

time it takes for nonphyseal fracture in thesame re#ion

• -ealin# time dependent on fracture

location7 displacement• Stiffness from immo*ili.ation rare7 thus err

to$ards more time in cast if in dou*t


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4emodelin# of 0hildrenDs

Fractures• =ot as relia*le for?

– idshaft an#ulation

– %lder children

– 6ar#e an#ulation '3G,GH(

• >ill not remodel for?

– 4otational deformity

– Intraarticular deformity


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4emodelin# more likely if?

• 3 years or more

#ro$th remainin#

• Fractures near endof *one

• An#ulation in plane

of mo&ement ofad)acent )oint

10 7eeks )ost8in9ur(1 7eek )ost8in9ur(


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-ealin# Salter I !istal Ti*ia Fracture


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+ro$th Arrest Secondary to

Physeal In)ury• 0omplete cessation of

lon#itudinal #ro$th

– leads to lim* len#th

discrepancy

• Partial cessation of

lon#itudinal #ro$th

– an#ular deformity7 if peripheral

– pro#ressi&e shortenin#7

if central


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Physes Suscepti*le to

+ro$th Arrest• 6ar#e cross sectional

area

• 6ar#e #ro$th potential• 0omple5 #eometric

anatomy

• !istal femur distal

ti*ia7 pro5imal ti*ia

distal radius


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+ro$th Arrest 6ines

• Trans&erse lines of Park,

-arris 6ines

• %ccur after fracture:stress• 4esult from temporary

slo$do$n of normal

lon#itudinal #ro$th

• Thickened osseous plate in

metaphysis

• Should parallel physis


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+ro$th Arrest 6ines

• Appear ,13 $eeks

after fracture

• 6ook for them infollo$,up radio#raphs

after fracture

• If parallel physis , no

#ro$th disruption• If an#led or point to

physis , suspect *ar


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Physeal Bar

, Ima#in# ,• Scano#ram :

%rthoroent#eno#ram

• Tomo#rams:0T scans• 4I

• ap *ar to determine

location and e5tent


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Physeal Bar

, Treatment ,• Address

– An#ular deformity

– 6im* len#th discrepancy

• Assess

– +ro$th remainin#

– Amount of physis in&ol&ed

– !e#ree of an#ular

deformity – Pro)ected 66! at maturity


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Physeal Bar 4esection

, Indications ,• 3 years remainin# #ro$th

• GJ physeal in&ol&ement 'cross,sectional(

• 0oncomitant osteotomy for 1,3GH

deformity

• 0ompletion epiphyseodesis and contralateral

epiphyseodesis may *e more relia*le in olderchild


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Physeal Bar 4esection ,

Techniques• !irect &isuali.ation

• Burr:currettes

• Interpositional material'fat7 cranioplast( to

pre&ent reformation

• >ire markers to

document future

#ro$th


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Epiphysis or ApophysisK

• Epiphysis , forces are

compressi&e on physeal

plate

• Apophysis , forces are

tensile

• -istolo#ically distinct

– Apophysis has less proliferatin# cartila#e and

more fi*rocolla#en to

help resist tensile forces


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Apophyseal In)uries

• Ti*ial tu*ercle

• edial Epicondyle

– %ften associated $ithdislocation

• ay *e preceded *y

chronic

in)ury:reparati&e processes


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Patholo#ic Fractures

• !ia#nostic $orkup

important

– 6ocal *one lesion – +enerali.ed *one

$eakness

• Pro#nosis dependent

on *iolo#y of lesion• %ften need sur#ery


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ol(ostotic Fi$rous D(s)lasia


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%pen Fractures

Principles• I/ anti*iotics7 tetanus

prophyla5is

• Emer#ent irri#ation ;de*ridement

– Ideally $ithin ,L

hours of in)ury

• Skeletal sta*ili.ation

• Soft tissue co&era#e


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0hronic %steomyelitis follo$in#

%pen Femur Fracture

• E5tremely rare in children

• Serial de*ridement

• Follo$ed *y simultaneous

*one #raft and soft tissue

co&era#e

Monsivais, J South Ortho) Assoc, 1!+


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6a$nmo$er In)uries• 0ommon cause of open

fractures ; amputations in

children

• ost are

– A rider or *ystander 'CGJ(

– Under years old 'CLJ(

• -i#h complication rate

– Infection

– +ro$th arrest

– Amputation

• GJ poor results

o"er, JJS8A#, 2004


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6a$nmo$er In)uries – often 4esult

in Amputations


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%&eruse In)uries

• ore common aschildren andadolescents participate

in hi#h le&el athletics

• Soccer7 dance7 *ase*all7 #ymnastics

•Ask a*out trainin#re#imens

• echanical pain

Fe#oral stress 'racture

/e(7orth, &urr O)in e"iatr, 200


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%&eruse In)uries

• !ia#nosis – -istory:E5am

– Serial radio#raphs

– Bone scan – 0T:4I

• Treatment – A*stinence from

sport:acti&ity

– 0ast if child is o&erly acti&e – Spica:Fi5ation for all

femoral neck stress f5s

Fe#oral stress 'racture

/e(7orth, &urr O)in e"iatr, 200


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Femoral Shaft Stress Fracture in

13 year old ale 4unner


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etal 4emo&al in 0hildren

• 0ontro&ersial

• -istorically recommended

if si#nificant #ro$th

remainin#

• Indications e&ol&in#

• Intramedullary de&ices

and plates :scre$s around

hip still remo&ed *y many

in youn# patients

Ki#, =n9ur( 200>+eterson, J e"iatr Ortho), 200>+


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Summary

• Pediatric musculoskeletal in)uries are

relati&ely common

• +eneral orthopaedic sur#eons can treatma)ority of fractures

• 4emem*er pediatric musculoskeletal

differences• ost fractures heal7 re#ardless of treatment


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Summary

• ost important factors?

– Patient a#e

– echanism of in)ury

– Associated in)uries

• +ood results – possi*le $ith all types treatment

• Trend for more in&asi&e treatment

• ust use #ood clinical )ud#ment and #oodtechnique to #et #ood results


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Bi*lio#raphy• Salter 47 -arris >4? In)uries In&ol&in# the Epiphyseal Plate< N Bone Noint Sur#

Am< 1OM?LC,33<

• Naramillo !7 @ammen B7 Shapiro F? 0artila#inous path of physeal fracture,

separations? e&aluation $ith 4 ima#in#,,an e5perimental study $ith

histolo#ic correlation in ra**its< 4adiolo#y 3GGG31?GM,11<

• Nohnson N7 Nohnson A7 Eurell N? -istolo#ical appearance of naturally occurrin#

canine physeal fractures< /et Sur# 1OOM3?L1,<

• @leinman ; arks? A re#ional approach to the classic metaphyseal lesion in

a*used infants? the pro5imal humerus. Am N 4oent#enol 1OO1C?1OO,MG<

• onsi&ais N? Effecti&e mana#ement of osteomyelitis after #rade III open

fractures< N South %rthop Assoc 1OO?G,<


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Bi*lio#raphy• 6oder 4? !emo#raphics of tramatic amputations in children< Implications for

pre&ention strate#ies< N Bone Noint Sur# Am 3GGML?O3,L<

• -ey$orth B ; +reen !? 6o$er e5tremity stress fractures in pediatric and adolescent

athletes< 0urr %pin Pediatr 3GGL3G?L,1<

• @im >7 et al? The remo&al of forearm plates in children< In)ury 3GG?1M3C,G

• Peterson -? etallic implant remo&al in children< N Pediatr %rthop 3GG3?1GC,1<

• >en#er !7 Prin# ; 4and ? 4an#Ds 0hildrenDs Fractures7 rd ed< Philadelphia?

6ippincott >illiams ; >ilkins7 3GG<

• 4ock$ood 0 ; >ilkins @? Fractures in 0hildren7 Cth ed< Philadelphia? 6ippincott

>illiams ; >ilkins7 3GGO<

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Traumatologie Pediatrica - General