The document discusses fracture reduction and acceptable deformities in children and adults. It provides guidelines for acceptable angulation, malrotation, and displacement for common fractures based on the patient's age. Remodeling potential is greater in children, allowing for more deformity. Proper reduction aims to restore length, alignment, and joint surface while avoiding unnecessary intervention. Factors like fracture pattern and patient age influence remodeling outcomes.

1. Evaluation of fracture reduction
after conservative management
in children and adults.
By - Dr Mayank Daral
Resident Orthopaedics
Himalayan Hospital
Moderator – Dr Rajesh Maheshwari
Professor and HOD

2. •Reduction -
• is a procedure to restore a fracture or dislocation to
the correct alignment.
•It implies a restoration: re ("back [to initial
position]") + ducere i.e., "bringing back to normal."

3. Principles of Reduction in Diaphyseal
fractures
• Restoration of length
• Mentaining Axial alignment
• Avoiding Rotation
Articular fractures :Principles
• Anatomical reduction and stable fixation of articular
fragements is necessary to restore joint congruity

4. Remodelling
● .It is a balance between bone growth and breakdown. Its
a continous process(For Years)
●
Its more evident after fracture and continues even after
function restoration and radiological union
●
Wolff’s Law-Bone is laid down where needed and resorbed
where not needed.

5. Factors affecting Remodelling
• Age – faster in children .
• Type of bone –flat and cancellous bones >tubular and cortical bones.
• Pattern of fracture –Spiral fractures >oblique fractures >Transverse fracture
>comminuted fractures.
• Type of Reduction –good aposition always preferrable but in children may be
remodelled even in bayonet reduction (side to side contact)
• Closed fractures >Open Fractures

6. In children
• Aim –
• 1.Quick and effective relief of Pain
• 2.Reconstruction of Normal anatomy and Function.
• 3.early mobilization.
• 4.avoidance of unnecessary reductions.
• 5.Avoidance of Late complications.
• 6.to achieve optimum results with Minimum of Invasion.

7. Children’sbonesare different

8. Pediatric
Bone
Lower
Modulu s
Of Elasticit
y
Highly
Porous
Lower
Bending
Strength
Greater
Energy
Absorption
Induces
More Stess
Prevents
Propagation Of
#

9. Physeal injuries
• Account for ~25%of all
children’s fractures.
• More in boys.
• More in upperlimb.
• Most heal well rapidly with
goodremodeling.
• Growth maybe
affected.
• Physisresponds to
compression aswell as
distraction

10. Proximal humerus
• Acceptable deformity –
• ages 1 to 4 years - 70° of angulation with any amount of
displacement.
• ages 5 to 12 years - 40 to 45° of angulation and displacement of one
half the width of the shaft.
• ages 12 years to maturity -15 to 20° of angulation and displacement
less than 30% of the width of shaft

11. • A and B, Radiographs taken of an 8-year-
old boy who sustained a metaphyseal
fracture through the proximal humerus.
• This fracture was treated conservatively.
• C and D,Radiographs taken at 7 weeks
after injury show complete healing of the
fracture..

12. In Adults, (Proximal Humerus)
• Only Undisplaced one part fractures should be conservatively
Managed

13. • Stable proximal humeral fractures through the anatomical neck
• A)AP view B)Y view c)Axillary view.

14. Humeral Shaft
• Acceptable limits
• 20 – 30 Degrees of Varus
• 20 Degrees of anterior Angulation
• 15 Degree of Internal Rotation
• Bayonet apposition with 1-2 cm of shortening is deemed acceptable.

15. • A,B:Radiograph Depicting a Humeral Diaphyseal fracture in a four Day old
infant with Displacement and angulation.

16. • C,D:by 3 months of age ,there is excellent bony healing and early remodelling

17. In Adults
Humeral shaft.
• 20° of anterior (sagittal) angulation ,30 degrees of
varus (coronal ) angulation, and up to 3 cm of bayonet
opposition are acceptable and will not compromise
function or appearance.

18. • A transverse fracture of the middle third of humeral diaphysis .
• B)Six months later the fracture was healed

19. Forearm Fractures- Acceptable deformities
• Angular deformities-correction of 1° per month or 10° per year results
from physeal growth .exponential correction occurs overtime,
therefore increasd correction occurs for greater deformities. The
amount of total correction is location and age dependent, for a patient
in less than 10 years old up to 15° of correction may occur at the wrist.
• Rotational deformities - these do not appreciably correct
• Bayonet apposition -deformity less than equal to 1 cm is acceptable
and will be remodelled if the patient is less than 8 to 10 years old

20. • In children more than 10 years of age no deformity should be accepted
• Plastic deformation- children less than four years or with deformities less
than 20° usually remodel and can be treated with a long arm cast for 4 to
6 weeks until the fracture site is non tender .
• Any plastic deformity should be corrected that
• 1. prevents reduction of a concominant fracture
• 2.prevents full rotation in a child more than four years
• 3 exceeds 20°.

21. A 7year old female with Left both bone complete forearm fracture
• A)AP and Lateral injury radiographs
• B)two month follow up radiograph.

22. • C)two year follow up radiograph shows mild residual deformity.

23. Sagittal plan I
Age (yrs) Boys Girls Frontal plane
4-0 23 15 15
9-11 15 10 5
11-13 10 10 0
>13 5 0 0
Fractures distal end radius and ulna
Angular corrections in degrees

24. • A) anteroposterior view and
lateral view of displaced
Physeal fracture(may 30,2003).
• B )healed malunion one month
after radial physeal fracture
.(June 30)

25. • C) significant
remodelling at five
months after fracture
d) anatomic
remodelling with no
physeal arrest.

26. In Adults.
Distal End Radius
•
• Normal radiographic relationships
• Radial inclination –averages 23° (ranges 13 to 30°)
• radial length averages 11 mm (range 8 – 18 mm)
• Palmar tilt – averages 11 to 12 degrees (range 0 to 28° )
• Acceptable radiographic parameters for a healed Radius in an active health
patient include
• Radial length -within 2 to 3MM of contralateral wrist
• Palmar tilt – 0 degrees
• Intrarticular step off- less than 2 mm
• Radia inclination- less than five degrees loss..!

27. The radiologic limits beyond which correction is recommended
Radiologic measurement Recommended limits
Positive ulnar variance (mm) 2-3
Carpal malalignment None
Dorsal tilt (degrees) Neutral if carpus malaligned.
<10 degrees if carpus aligned
Palmar tilt (degrees) No limit if carpus aligned
Gap or step in joint (mm) 2

28. A)A minimally articular fracture of the distal
Radius
B)despite initial successful manipulation
reduction the fracture has lost position because
of metaphyseal instability but the articular
alighnment is mentained.

29. Femur shaft
• Length
• Ages 2 to 11 years-up to 2 cm overriding is acceptable.
• Ages more than 11 years- up to 1 cm overriding is acceptable
• Angulation-
• Sagittal plane – Up to 30° of recurvatum is acceptable.
• Frontal plane-Up to 10° of Varus /valgus angulation is acceptable.
• Rotation- up to 10° is acceptable. external rotation is better tolerated
than internal rotation.

30. Acceptable angulation
Age (yrs) Varus/Valgus
(Degrees)
Anterior/Posterio
r
(Degrees)
Shortening (mm)
Birth to 2 y 30 30 15
2-5 15 30 20
6-10 10 15 15
11 y to maturity 5 10 10

31. A)This two year old sustainedspiral femoral shaft fracture. B) immediately after reduction
C) six weeks after injury there is anatomical allignment,minimal shortening and good callus formation.

32. • In children acceptable reduction includes 50° apposition of the fracture
ends , less than 1 cm of shortening and less than 5 to 10° angulation in
Sagital plane and Coronal planes with less than 5° of rotation.
• Angular deformity
• Correction of deformity varies by age and gender.
• Girls less than eight years old and boy is less than 10 years old often
experience significant remodelling.
• girls 9 to 12 years old and boys 11 to 12 years old can correct up to 50% of
angulation .
• In adolescents greater than 13 years less than 25% of correction is
expected.
Diaphyseal fractures of tibia and fibula

33. Acceptable alignment of a pediatric diaphyseal tibial fracture
Patient < 8 years >8Years
Valgus 5 degrees 5 degrees
Varus 10 degrees 5 degrees
Angulation anterior 10 degrees 5 degrees
Posterior angulation 5 degrees 0 degrees
Shortening 10 mm 5 mm
Rotation 5 degrees 5 degrees

34. Anteroposterior radiograph of Distal 1/3rd tibia fracture without concominant
fibular fracture in a 10 year old child .
• A)The alignment in coronal plane is acceptable B)a varus angulation developed
within the first 2 weeks after injury.C)A ten degree varus angulation was present
after union.

35. In Adults
Tibia shaft and fibula
Acceptable fracture reduction.
• Less than 5° of varus /valgus angulation is recommended.
• less than 10° of anterior/posterior angulation is recommended.
• less than 10° of rotational deformity is recommended,with external rotation
better tolerated than internal rotation.
• Less than 1 cm off shortening; 5mm of distraction may delay healing 8-12
months.
• more than 50% cortical contact is recommended.
•

37. fracture Age of
patient(yrs)
Angulation
(degree)
Malrotation
(degree)
displacement
Humerus,
proximal
<5 70 - Complete
5-12 40-70 -
>12 40 - 50%
Humerus,
shaft
Any age 20-30(varus) 15 (internal
rotation)
-
Any age 20 (sagittal) - -
Forearm,
shaft
<9 15 45 -
>9 10 30 -
Femur, shaft 0-2 30
(varus/valgus)
30 (sagittal)
- -
3-5 15
(varus/valgus)
20 (sagittal)
- -
6-10 10
(varus/valgus)
15 (sagittal)
- -
>11 5 (varus/valgus)
10 (sagittal)
- -
Tibia, shaft <8 5 (varus/valgus) - -