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Pediatric Long Bone Fractures.pptx
- 1. Pediatric Long BoneFracture (Humerus, Femur, Tibia) Presenter Dr Kaushal Raj Kafle Moderator Asst Prof Dr Sushil Paudel
- 2. Humerus : Anatomy •Three Secondary Ossification Centre • Humeral head, Greater Tuberosity and Lesser tuberosity • Coalesce to single centre by 7 years of age • Closes by 14-22 yrs (earlier in girls)
- 3. Injuries of ProximalHumeral Physis • 80% of humeral growth comes from proximal physis • 3% of all physeal injuries • Common in adolescence • Direct Force: Direct Blow on the postero lateral aspect of Shoulder • Indirect Force : Through humeral shaft as in FOOSH • Birth Trauma • Child Abuse
- 4. Salter and HarrisClassification • Type I SH : Infant and Small Children • Type II SH : Older children and Adolescent • SH Type III/IV and Glenohumeral Dislocation : rare due to the universal ROM at shoulder
- 5. Neer and HorwitzClassification • Grade I : <5mm displacement • Grade II: 5mm-1/3rd of humeral diameter • Grade III : 1/3rd - 2/3rd diameter • Grade IV : >2/3rd diameter displacement • Angulation associated with Grade III and IV
- 6. Clinical Feature • 9-15yrs child • Arm Shortened, Abducted and Extended • Prominence infront of axilla/ distorted axillary fold • Humeral head in position • Swelling and Tenderness
- 7. Xray • AP • AxillaryLateral • Y Scapular view • USG in Neonates and Infants to rule out • Septic Arthritis • Acute Osteomyelitis • Brachial Plexus Injury
- 8. Treatment Neer and HorwitzTreatment Rehabilitation Grade I Symptomatic without reduction Simple Arm sling/ Sling and Swath./Shoulder immobilizer till pain Gentle pendular exercise by 2nd week Over head activities by 4-6 weeks Grade II Grade III < 6yrs Conservative > 6 yrs Controversial Conservative Vs Operative ROM after 2-3 weeks of immbolization Grade IV Closed reduction : traction, abduction, forward flexion, and external rotation of the arm and forearm. Young have Great Remodeling Potential
- 9. • Operative management •Intraarticular • Open • Neurovascular injury • Near Skeletal maturity • Polytrauma patient • Goal : Stabilization of fracture for concurrent management of Adjacent injuries • Approach : Anterior arthrotomy via deltopectoral approach • Screws and Percutaneous pins (2 k wires for 2-3 weeks) • AROM after removal of pins
- 10. Complication • Humeral shortening •Functionally and Cosmetically insignificant • Varus Malalignment • Rarely functional Concern • Rare • Brachial Plexus injury • Axillary artery injury • Valgus malalignment • Osteonecrosis of Humeral head
- 11. Fracture of ProximalMetaphysis and Shaft of Humerus • Proximal Metaphyseal Children> Adolescence • Humeral shaft : 2nd most common birth fracture • Associated with radial nerve injury • High Energy Trauma • Low energy trauma : Rule out pathological Fracture • Forceful muscle Contraction • Unicameral bone cyst and Fibrous dysplaisia
- 12. Diagnosis • Deformity, Swellingand Pain • Radial Nerve Injury : Anaesthesia over the dorsum of the hand (1st and 2nd metacarpal ) • Loss of motor strength of wrist and fingers, thumb extensor and forearm supinator •
- 13. Treatment • Infants andnewborn • 1-3 weeks immbolization • Bandage arm to thorax with modified velpeau bandage or Sling and swathe • Proper skin care • Control in alignment : Not necessary • Palpable callus in 6-8 weeks • Assess Moro Reflex • Follow up assessment for Brachial plexus injury
- 14. • Proximal Humeralmetaphyseal fracture • Symptomatic management • Sling is enough • Shaft : Closed management • Coaptation split • 2-3 weeks : Sling / Hanging Cast / Fracture Brace • Circumduction and Pendular exercises
- 15. Operative management • Openfractures • Polytrauma • EX FIX if extensive soft tissue injury • Intramedullary elastic nails in polytrauma patients for easy nursing care
- 16. Complications • Open andvascular injuries • Radial nerve injury • Non union less common than adult
- 17. Femoral Shaft Fracture •1.6 % of all bony Injuries • Boys : Girls 2.6: 1 • Bimodal Seasonal variation : March and August • Bimodal Distribution • Toddler : Trivial Fall • Adolscent : High Energy Trauma
- 18. Diagnosis • Clear Mechanismof Injury • Deformity, swelling and localized pain • Multiple Trauma/ Head Injury / Non ambulating and Severely disabled child /Patient lacking Sensation (paraplegia /meningomyelocele) • Careful evaluation needed • Swelling and Redness may mimic Infection
- 19. Associated injuries • Waddell’sTraid: Femoral Fracture with Abdominal or Thoracic Injury with Head Injury • High Velocity Automobile Injury • Isolated femoral Fracture: Hypotension is rare • Hematocrit < 30% rarely occurs without Multisystem Injury • Declining Hematocrit SHOULD NOT be contributed to Closed Femoral Fracture Until other sources of blood loss have been eliminated
- 20. Mechanism of Injury •Before Ambulating age • 80% femoral Fracture : ABUSE • Risk Factors of Abuse • History Suspicious for Abuse • Physical or radiological evidence of previous Abuse • Age under 18 months • Transverse Fracture are Better Predictor of Non Accidental Trauma
- 21. • Older Children:Bone Strong to tolerate Forceful blows • High Energy trauma : MVA 90% • Stress Fracture • Adolescent • High Intensity Sports: Football, Basketball or running • Femoral Shaft or Neck Stress Fracture • Child with thigh pain with Unrecognised stress fracture can have displaced SOF # • Extreme Overuse in Non Traditional Sports
- 22. • Pathological Fracture: Rare • Osteogenesis Imperfecta • Generalised Osteopenia : Cerebral Palsy, Myelomeningocele • Neoplasms : Nonossifying Fibroma, Aneursymal Bone Cyst, Unicameral Cyst, Eosinophilic Granulom, Osteosarcome • Subtle Xray Signs : Mixed Lytic Blastic Lesion disrupting trabecular pattern , break in cortex and periosteal reaction
- 23. Imaging • Xray • Includingthe Hip and Knee joint • AP and Lateral View • MRI/Bone scan : Small Buckle Fracture or Stress Fracture • Always Look for Communition or undisplaced Butterfly Fragments, Second fracture, Joint dislocation or pathological features
- 24. Classification • Transverse/ Oblique/Spiral • Communitted /Non Communitted • Open/Closed • Most Common : Closed Simple non communitted >50%
- 25. • Proximal ShaftFracture : Flexed abducted and externally rotated • Midshaft : Less prominent effect , Compensation by adductor and extensor attachement • Distal : Little alteration Most muscles are attached to the same fragment • Supracpndylar: Hyperextension caused by pull of gastrocnemius Short exernal rotators Psoas Abductors
- 26. Treatment • Primary :Age and Fracture Pattern • Secondary: Childs Weight,Assosciated injury, mechanism of Injury, Availabilty of equipment, Surgeons experience • Tertiary: Economic Concern, Post Treatment Care,
- 27. Age Treatment Birth to24 months Pavlik harness (Newborn to 6 month ) Early Spica Cast Traction → spica cast (very rare ) 24 mo-5 years Early Spica Cast Traction → spica cast ExFix (rare) Flexible Intramedullary nail (Rare) 6-11 years Flexible IM nail Traction → spica cast Submuscular plane External fixator 12 years to maturity Trohcanteric Entry IM rod Flexible IM nail Sub Muscular plate Ex Fix (rare)
- 28. Pavlik harness • Proximaland midshaft fracture • Thigh immbolized with soft cotton padding • Hip in moderate flexion and Abduction • Higher pain score compared to immediate hip spica • Average overgrowth 5mm
- 29. Spica Cast • Isolatedfemur # • Children < 5 year • Shortening <2cm • Minimal Swelling in thigh • No other assosciated injuries that prevents cast application • Advantage : Low cost, excellent safety profile, Very high rate of good result, acceptable limb length equality, healing time and motion • Disadvantage: Transportation, Cast intolerance by child, hygiene
- 30. Traction and Spicacast • Rockwood and Wilkins’ fractures in children
- 31. Age Varus/val gus Angulatio n Anterior posterior Angulatio n Shortening (mm) Birth to 24 months 3030 15 24 mo-5 years 15 20 20 6-11 years 10 15 15 12 years to maturity 5 10 10
- 32. Rehabilitation • Spica for4-8 weeks • Infants : 4-6 weeks, toodler (8 weeks ) • After cast removal ask parents to allow weight bearing once the child is comfortable and once the joint stiffness resolves • Physiotherapy : Not recommended. Aggressive ROM apprehends child and delays recovery • Follow up : for 1 year to analyse gait, joint ROM and limb length
- 33. Exfix • Indication • OpenFracture with poor soft tissue coverage • Multiple trauma • Vascular injury requiring immediate revascularization • Failed Non Surgical management • Unstable fracture pattern • Temporarily used to be converted to internal fixation • Advantage : easy to apply , angular rotation correctable in follow ups • Pin tract infection, Increased incidence of non union, delayed union and angular deformity • 5mm overgrowth, Refracture
- 34. ORIF • Plates andScrews • Quick • Anatomical Reduction • Rigid fixation • Early mobilization • Extensive soft tissue stripping • Plate removal • Plate breakage • Overgrowth with anatomical reduction
- 35. Flexible intramedullary nailing •Proximal insertion: avoid GT and Pyriformis • CC or CS configuration • CS and SS better rotational stability than CC • Each nail should be 40% of isthmus • Unstable Fracture: Limb shortening and nail migration
- 36. Rigid intramedullary nail •Indication • Those where Flexible nail is too small • Adolescent kids towards maturity • Advantage • Unstable fracture pattern • Rigid fixation • Rotational stability • Early weight bearing • Minimal angular deformity • Adolscent : AVN injury to medial circumflex artery with nail insertion medial aspect of GT
- 37. Complications • Limb lengthDiscrepancy • Angular Deformity • Rotational deformity • Delayed Union • Non Union • Muscle Weakness • Infection • Neurovascular injury • Compartment Syndrome
- 38. TIBIA FIBULA • TriangularShaped with anterior apex • No muscular attachment in anteromedical surface distal to pesanserinus • Subcutaneous
- 39. Ossification • 3 ossificationforms the tibia • Tibial Diaphysis: 7 months inutero • Proximal Epiphysis : Few months after birth • Distal Epiphysis : 2nd year of life • Fibula • Diaphysis : 8 weeks in utero • Proximal : 4 years • Distal : 2 years • Closure • 16-18 years • 16 years
- 40. Tibia Fibula DiaphysealFracture • 3rd most common • Boys under 10 • Mechanism • Infant and Children <4: Fall from height, fall from standing position, bicycle spoke injury : Spiral or Oblique Fracture • Child > 4: Pedestrian Accident : Comminuted fracture , Open injuries • Child Abuse <5% tibial fracture
- 41. Proximal Tibial MetaphysealFracture • 3-6 years • Non displaced or Green stick fractures • Torsional Stress on medial aspect of leg or direct blow to lateral aspect • Medial Cortex fracture with intact lateral cortex • Fibula may or may not have # or plastic deformation • Xray : Torus, Greenstick and Complete Fracture • Most are undisplaced
- 42. Treatment • Conservative • Reductionunder conscious sedation in valgus deformity • Break the angled Greenstick fracture by bending towards angulation and slightly overcorrect it • Long leg cast with three point fixation • Non weight bearing • Operative • Rare with failed closed reduction • Medial incision over the fracture site , reduction under vision • Suture the torn periosteum and apply cast • CRPP with Crossed K wires and Cast
- 43. Complication Valgus deformity 90% Developsat 6 months and progresses upto 2 year (12-18 mo) Max deformity : 18O , Resolution within 3 year Residual 6O with knee slighlty medial to mechanical axis Counselling Treat only if residual deformity is 15-20O →well-timed medial proximal tibial epiphysiodesis > 20O 3 years after the injury →Varus Osteotomy
- 45. • Bone overgrowth •1cm (max 1.7 cm) • Overall outcome good but some have knee pain • Physeal arrest with crush injuries • Fairly benign early radiographs
- 46. Tibia Fibula DiaphysealFracture • M:F :: 3: 1 • Bimodal incidence: • 3-4 years undisplaced • 15-16 years : • < 6yrs : Oblique or spiral # with minimal displacement • Indirect injury : Fall or twisting injury with leg caught on some object • Toddlers’ Fracture : 1-2 years child with foot being caught on slide while descending down, • Undisplaced and Radiologically inapparent • 6-11 : Simple Transverse # with fibula # direct trauma • Adolscent : High Energy trauma MVA : Behave as adult
- 47. Treatment : Conservative •Conservative • Toddler Fracture : Non displaced Oblique/Spiral Tibia # with intact fibula • Better visualized in Oblique views • Long Leg Cast x 3-4 weeks • Full weight bearing after cast out • Follow up Xray unnecessary • Suspicious case : Long Leg Cast application and 2 week follow up to check for callus
- 48. • Displaced TibialFracture With an Intact Fibula in an Older Child • Tend to angle into varus due to anterolateral muscle pulling distal fragment • Fibula stablises the lateral aspect • Fluoroscopy Guided reduction and molded to maintain 3 point bending forces • Acceptable : 5-10 degree in all plane • Non Weight bearing for 4-6 weeks • Change to short leg walking cast • Recheck weekly for 2-3 week for remanipulation for malalignment • Cast wedging if varus angulation > 5O
- 49. • Displaced TibialFracture With a Fibular Fracture in an Older Child. • Unstable fracture : Difficult to reduce • Acceptable • >50% apposition in • <5-8o angulation in coronal and sagittal plane • Residual varus in coronal plane and posterior angulation • 3 point mold to reduce varus deformity and ankle at 15-20c plantar flexion to prevent posterior angulation • Cast extended to above knee with knee in 30-45c Flexion • Univalve the case, admit, monitor for compartment syndrome • Close monitoring for 2-3 weeks • Convert to fracture boot or below knee cast with callus formation
- 51. Operative Management • RarelyIndicated • Major Indications • Excessive Fracture instability • Loss of reduction • Significant Comminution and Shortening • Displaced Fracture in skeletally mature child
- 52. Options • Flexible intramedullarynail • Fluoroscopy guided entry sparing physis • Lateral and Medial entry with Double C construct • No rotational Control : Long Leg cast • Increased incidence of Compartment syndrome • Functionally excellent outcome with union by 8- 20 weeks • Closed Reduction Percutaneous pin fixation • Young patient with rapid healing
- 53. • External Fixation •Highly unstable Closed Tibial # • 4-6 weeks followed by short leg walking cast for 3-4 week • Open Reduction with Internal Fixation • Routinely not done due to excessive soft tissue stripping • Early mobilization, less angular deformilty compared to Flexible nails • Locking Rigid Intramedullary nail • Child towards Skeletal maturity
- 54. Open Tibial DiaphysealFracture • Rare in children <5% • High energy trauma : Automobile hitting pedestrian, cyclist • Non union and Infection • 8-10yrs Boys • Left leg > Right leg • 58% have associated injuries • 7% Mortality associated with Trauma • Children > 11 behave as adult
- 55. Management • Same asfor adult • Debridement, antibiotics and Splinting • Wound management • Soft tissue management : • VAC • STSG/ FTSG/Flap • Fracture Stabilization • Grade I/ Grade II : Long leg cast with Window • Grossly Contaminated : Ex Fix • Flexible nails
- 56. Indication for amputation •Unreconstructable Vascular Injury • Severe muscle injury with extensive bone loss • Associated nerve injury with no sensation in foot • Mangled Extremity Severity Scoring >7
- 57. Summary • Proximal physealand SOH Fractures in pediatrics can be managed conservatively irrespective of alignment and reduction as it has great remodeling potential • The younger the age more deformity is acceptable in femur fracture • Treatment Modalities in pediatric femur fracture depends on the age and fracture pattern • Proximal tibia fracture will develop valgus deformity irrespective of treatment so counselling is must • Soft tissue status in the shaft of tibia factor determines the outcome in tibia fracture
- 58. References • Tachdjian’s PediatricOrthopaedics 6e • Rockwood and Wilkins’ fractures in children
- 59. Thank you Next presentationon Pediatric Fracture around ankle by Dr suman Maharjan
Editor's Notes
- #41 1st Femur 2nd Both bone #