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Pediatric Fracture Principles
- 1. Principles of management Pediatric Fractures
- 2. 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
- 3. 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 )
- 4. Statistics • ~ 50% of boys and 25% of girls, expected to have a fracture during childhood. • Boys > girls • Rate increases with age. Mizulta, 1987
- 5. 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
- 6. Statistics Most frequent sites (sample of 923 children, Mizulta, 1987)
- 7. Why are children’s fractures different? Children have different physiology and anatomy • Growth plate. • Bone. • Cartilage. • Periosteum. • Ligaments. • Age-related • physiology
- 8. 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.
- 9. Why are children’s fractures different? Children have different physiology and anatomy • Bone: – Increased collagen: bone ratio - lowers modulus of elasticity
- 10. 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
- 11. 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
- 12. 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
- 13. 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
- 14. Why are children’s fractures different? Children have different physiology and anatomy • Physiology – Better blood supply rare incidence of delayed and non-union
- 15. 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.
- 16. Physeal injuries Classification: Salter-Harris, Peterson, Ogden
- 17. 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)
- 18. The power of remodeling • Tremendous power of remodeling • Can accept more angulation and displacement • Rotational mal-alignment ?does not remodel
- 19. 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
- 20. The power of remodeling Factors affecting remodeling potential • Growth potential of adjacent physis e.g. upper humerus better than lower humerus
- 21. 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
- 22. Indications for operative fixation
- 23. Methods of fixation • Casting - still the commonest
- 24. Methods of fixation • Casting - still the commonest • K-wires – most commonly used – Metaphyseal fractures
- 25. Methods of fixation • Casting - still the commonest • K-wires – most commonly used – Metaphyseal fractures • K- wires could be replaced by absorbable rods
- 26. 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
- 27. Methods of fixation • Casting - still the commonest • K-wires – most commonly used – Metaphyseal fractures • Intramedullary wires, elastic nails – Very useful – Diaphyseal fractures
- 28. Methods of fixation • Casting - still the commonest • K-wires – most commonly used – Metaphyseal fractures • Intramedullary wires, elastic nails – Very useful – Diaphyseal fractures • Screws
- 29. Methods of fixation • Casting - still the commonest • K-wires – most commonly used – Metaphyseal fractures • Intramedullary wires, elastic nails – Very useful – Diaphyseal fractures • Screws
- 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
- 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 only (injury to growth)
- 32. 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
- 33. 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
- 34. 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.
- 35. 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
- 37. Beware! Non-accidental injuries • ?Multiple • At various levels of healing • Unclear history – mismatching with injury • Circumstantial evidence
- 38. Beware! Non-accidental injuries • Circumstantial evidence • Soft tissue injuries - bruising, burns • Intraabdominal injuries • Intracranial injuries • Delay in seeking treatment
- 39. Beware! Non-accidental injuries • Specific pattern – Posterior ribs – Skull
- 40. Beware! Non-accidental injuries • Specific pattern – Corner fractures (traction & rotation)
- 41. Beware! Non-accidental injuries • Specific pattern – Bucket handle fractures (traction & rotation)
- 42. 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
- 43. Beware! Malignant tumours • Can present as injury. • History of trauma usual. • 12y old girl • History of trauma • mild tenderness • Periosteal reaction • 2m later, still tender • Ewings sarcoma
- 45. summary Children’s bones are different
- 46. 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