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