orthopaedic fractures in children


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Various types of fractures in children and genral managemnet strategy

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  • orthopaedic fractures in children

    1. 1. General Principles of management Pediatric Fractures Presented by: Dr. Harjot Singh Gurudatta Moderator : Dr. Gagan Khanna
    2. 2. Children’s bones are different Metabolically more active,more vascularity, aids reduction Modulus of elasticity better resilience, size of articular segment underestimated Reduces tensile strength comminution In infants, GP is stronger than bone increased diaphyseal fractures Provides perfect remodeling power. Injury of growth plate causes deformity
    4. 4. • Age related fracture pattern: – Infants: diaphyseal fractures – Children: metaphyseal fractures – Adolescents: epiphyseal injuries Why are children’s fractures different?
    5. 5. • ~ 50% of boys and 25% of girls, expected to have a fracture during childhood. • Upper limb # more common with # distal radius elbow region # viz distal humeral and prox. Radial being common. Most # in home / school, femur and pelvic # more with RSA. • Boys > girls • Rate increases with age. • Physeal injuries with age. Mizulta, 1987 Statistics
    6. 6. General Principles Failure of union is rare. Few fractures require operative treatment. Presence of growth plate presents a challenge to the surgeon. Special considerations : • Pathological fractures and malignancies • Child abuse(multiple fracture and injuries at different stages of healing, epiphysio-metaphysis corner injuries)
    7. 7. source: http://training.seer.cancer.gov Centers of Ossification • 1° ossification center • Diaphyseal • 2° ossification centers • Epiphyseal • Occur at different stages of development • Usually occurs earlier in girls than boys
    8. 8. General Principles Regulation of Epiphyseal Growth Physis is the primary centre for growth in most bones. Four functional zones: • Reserve zone>> germinal layer for cartilage cells • Proliferation zone>>bone length is created by active growth of cartilage cells • Hyprtrophic zone>> Terminally divided cells ..no active growth, gradually extending toward metaphysis and to zone of degeneration • Provisional calcification>>> extracellular chondroid gets impregnated with calcium salt with blood vessels invasing from metaphysis EPIPHYSIS METAPHYSIS
    9. 9. 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. • Physis responds to compression as well as distraction(# implants infection etc)
    10. 10. • Type I – Through physis only • Type II – Through physis & metaphysis • Type III – Through physis & epiphysis • Type IV – Through metaphysis, physis & epiphysis • Type V – Crush injury to entire physis • Others added later by subsequent authors(eg Ranga type 6 peripheral physeal injury) Described by Robert B. Salter and W. Robert Harris in 1963. Salter - Harris Classification Type VI - Injury to the perichondral structures Type VII - Isolated injury to the epiphyseal plate Type VIII - Isolated injury to the metaphysis, with a potential injury related to endochondral ossification Type IX - Injury to the periosteum that may interfere with membranous growth AITKENS , polands, PETERSENS SYSTEM OF PHYSEAL INJURIES ARE THERE BUT SALTER HARRIS REMAINS UNIVERSALLY ACCEPTED.
    11. 11. Epiphyseal Injuries
    12. 12. Salter Harris Classification General Treatment Principles TYPE 1 AND 2 Closed reduction & immobilization •Type III & IV •Intra-articular and physeal step-off needs anatomic reduction •ORIF, if necessary
    13. 13. 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) • Smooth pins should be used for fixation not threaded ones if they are to cross physes.
    14. 14. Epiphyseal Injuries Try not to cross the physis, but rather parallel it in the epiphysis or pin the fracture spike in the metaphysis
    15. 15. Growth Arrest Secondary to Physeal Injury Complete cessation of longitudinal growth • leads to limb length discrepancy Partial cessation of longitudinal growth • angular deformity, if peripheral • progressive shortening, if central Warn parents about early operative complications and late complications, such as bony bridge formation, angular deformity.
    16. 16. Growth Arrest Lines Transverse lines of Park- Harris Lines Occur after fracture/stress Result from temporary slowdown of normal longitudinal growth Thickened osseous plate in metaphysis Should parallel physis
    17. 17. Growth Arrest Lines Appear 6-12 weeks after fracture Look for them in follow-up radiographs after fracture If parallel physis - no growth disruption If angled or point to physis - suspect bar
    18. 18. Physeal Bar - Imaging - • Tomograms/CT scans • MRI • Map bar to determine location and extent
    19. 19. Physeal Bars - Types - • I - peripheral, angular deformity • II - central, tented physis, shortening • III - combined/compl ete - shortening
    20. 20. Physeal Bar - Treatment - Address • Angular deformity • Limb length discrepancy Assess • Growth remaining • Amount of physis involved • Degree of angular deformity • Projected LLD at maturity
    21. 21. Physeal Bar Resection - Indications - • >2 years remaining growth • <50% physeal involvement (cross-sectional) • Concomitant osteotomy for >15-20º deformity • Completion epiphyseodesis (tethering physis with staple screw)and contralateral epiphyseodesis may be more reliable in older child • Central bar> peripheral bar
    22. 22. Physeal Bar Resection - Techniques Direct visualization Burr/currettes Interpositional material (fat, cranioplast) easiest to prevent reformation The arrest is removed, leaving in its place a metaphyseal-epiphyseal cavity with intact physis surrounding the area of resection
    23. 23. A greenstick fracture is a fracture in a young, soft bone in which the bone bends and partially breaks. This is owing in large part to the thick fiborous periosteum of immature bone here are three basic forms of greenstick fracture. In the first a transverse fracture occurs in the cortex, extends into the midportion of the bone and becomes oriented along the longitudinal axis of the bone without disrupting the opposite cortex. The second form is a torus or buckling fracture, caused by impaction , The word torus is derived from the Latin word 'Tori' meaning swelling or protuberance. The third is a bow fracture in which the bone becomes curved along its longitudinal axis. Usually pop splint is given! Torus Fracture
    24. 24. DIAPHYSEAL FRACTURE  MORE COMMON IN INFANTS  Watch for neurovascular insufficiency during convalescence  Abuse should be considered a possible cause of injury in all young children with multiple long-bone fractures in association with head injury  General principles of fixation essentially remain the same with most diaphyseal fractures being treated conservatively , displaced fractures and open fractures requiring internal/external fixation.
    25. 25. Methods of fixation • Casting - still the commonest
    26. 26. • Casting - still the commonest • K-wires – most commonly used – Metaphyseal fractures Methods of fixation
    27. 27. Methods of fixation • Casting - still the commonest • K-wires • most commonly used • Metaphyseal fractures • K- wires could be replaced by absorbable rods
    28. 28. • Casting - still the commonest • K-wires – most commonly used – Metaphyseal fractures • Intramedullary wires, elastic nails – Very useful – Diaphyseal fractures • Screws Methods of fixation
    29. 29. 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 more extensive operative exposure Not load sharing-----removal needed Newer minimally invasive percutaneous submuscular plating
    30. 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 • IMN - adolescents only (injury to growth)
    31. 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 • Ex-fix – usually in open fractures
    32. 32. The aim of this biological, minimally invasive fracture treatment is to achieve a level of reduction and stabilisation that is appropriate to the age of the child. The biomechanical principle of the elastically-stable intramedullary nailing (ESIN) is based on the symmetrical bracing action of two elastic nails inserted into the metaphysis, each of which bears against the inner bone at three points. This produces the following four biomechanical properties: flexural stability, axial stability, translational stability and rotational stability. All four are essential for achieving optimal results Titanium Elastic Nail
    33. 33. Age lower limit is 3–4 years and the upper limit 13–15 years. Type of fracture – transverse fractures – short oblique or Spiral # with cortical suport – long oblique fractures with cortical support Fracture site – femur: diaphyseal – distal femur: metaphyseal – femur: subtrochanteric – lower leg: diaphyseal – humerus: diaphyseal , subcapital even supracondylar – radius and ulna: shaft radial neck – radius: neck – prophylactic stabilization with juvenile bone cysts Contraindications – intraarticular fractures – complex femoral fractures, particularly overweight (50–60 kg) and/or age (15–16 years) INDICATIONS
    34. 34. - initial considerations: growth will not correct rotational deformity age distance from physis amount of deformity - bayonette apposition - generally bayonette apposition will require operative reduction - historically, overriding of a both bones forearm fracture was acceptable if... - there was no deviation of radius and ulna toward each other; - there was no encroachment of the interosseous space; - pt is less than 10 yrs of age; - in pts < 6 yrs of age: - upto 15 deg of angulation &<5 deg rotation is acceptable; - between ages of 6-10 yrs: - less than 10 deg of angulation should remodel especially if frx is close to distal epiphysis; - bayonet apposition may be acceptable, although end to end apposition is preferred; - pts > 12 yrs of age: - no angulatory or rotational deformity is considered acceptable; - more aggressive treatment is required, including open reduction and compression plating may be required; - Displaced Distal Third Frx: - angulation up to 20-25 deg during first ten years is OK; - angulation > 10 deg is unlikely to correct after 10 yrs ACCEPTABLE REDUCTION
    35. 35. • 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
    36. 36. Indications for operative fixation
    37. 37. Forearm diaphyseal fracture Open ClosedDebridement in OR Angulation 0°-10° Angulation 10°-20° Angulation +20° Closed reduction Open reduction +ESIN Unsuccessful + 5 years All ages Long arm cast or splint 0-5 years Successful if < 10° Successful but unstable Closed reduction + ESIN
    38. 38. Humeral diaphyseal fracture Adolescents Older children Infants & younger children Debridement in OR Closed reduction Immobilize in a sling & swath Closed Midshaft angulation Closed reduction + ESIN Immobilize in soft dressing External fixator Open < 20°> 20° III I & II Surgical indications Adolescents & Older children
    39. 39. Femoral shaft fracture Yes Debridement in OR Adolescent External fixator Open Excessive shorteningAbused Infants Younger child Older child Comminution No No Yes YesNo Reamed rod Hospital & invest. Immediate Hip spica Traction Then cast ESIN Choice
    40. 40. Tibial shaft fracture Open Debridement in OR Closed III I & II External fixator Closed reduction + ESIN Polytrauma Failed Succeed Closed reduction & cast Consider wedging the cast
    41. 41. • 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 Complications
    42. 42. Complications of Fractures - Bone - • Malunion • Limb length discrepancy • Physeal arrest • Nonunion (rare) • Crossunion • Osteonecrosis
    43. 43. Complications of Fractures - Soft Tissue - • Vascular Injury • Especially elbow/knee • Neurologic Injury • Usually neuropraxia • Compartment Syndrome • Especially leg/forearm • Cast sores/pressure ulcers • Cast burns • Use care with cast saw
    44. 44. Complications of Fractures - Cast Syndrome - • Patient in spica/body cast • Acute gastric distension, vomiting • Possibly mechanical obstruction of duodenum by superior mesenteric artery
    45. 45. Location Specific Pediatric Fracture Complications Complication Fracture Cubitus varus Supracondylar humerus fracture Volkmann’s ischemic contracture Supracondylar humerus fracture Refracture Femur fracture Mid-diaphyseal radius/ulna fractures Overgrowth Femur fracture (especially < 5 years) Nonunion Lateral humeral condyle fracture Osteonecrosis Femoral neck fracture Talus fracture Progressive valgus Proximal tibia fractures
    46. 46. Supracondylar Fracture of Humerus Complications
    47. 47. Forearm Fractures
    48. 48. Closed Reduction of Forearm Fractures Bohler traction Open reduction and internal fixation with plates and screws may be appropriate in the management of fractures with delayed presentation or fractures that angulate late in the course of cast care,when significant fracture callus makes closed reduction and percutaneous passage of intramedullary nails difficult. Tens nail and im nail has improved results and are preferred in displaced angulated #
    49. 49. Closed Reduction of Forearm Fractures
    50. 50. Forearm Fractures
    51. 51. FEMORAL SHAFT FRACTURES In a baby under 6 months old, a brace (called a Pavlik Harness) may be able to hold the broken bone still enough for successful healing. Traction before spica casting is indicated when the fracture is unstable or If the shortening of the bones is too much (more than 3 cm) traction
    52. 52. Spica cast management is generally not used for children with multiple trauma, head injury, vascular compromise, floating knee injuries, significant skin problems, or multiple fractures. Flexible intramedullary nails are the predominant treatment for femoral fractures in 5 to 11 year olds, although submuscular plating and external fixation have their place, especially in length-unstable fractures or fractures in the proximal and distal third of the femoral shaft In children between 7 months and 5 years old, a spica cast is often applied. In general, a spica cast begins at the chest b/w umbilicus & nipple and extends all the way down the fractured leg, with flexion @ 50-90 degrees at knee and hip. 11-15 yrs use of trochanteric entry, locked intramedullary nailing for femoral fractures in the preadolescent and adolescent age groups