Dr. Anisuddin Bhatti Paediatric Orthopaedic Surgeon DR. Ziauddin University Karachi presented talk on Paediatric fractures principles of treatment at AKU karachi on August 2023 in Orthopaedic Review course. Acknowledged for some text material & photo taken from Published literature.

1. May 2023Trama Cors

2. Principles,
Pearls &
pitfalls
Paediatric
Fractures
Anisuddin Bhatti
Dr. Ziauddin University Hospital Clifton
President (Past) POSP & POA Pakistan
Focal Person Ponseti International, Pakistan
Founding Director, PORP registry

3. Agenda
• Epidemiology
• How R they different.?
o Pathoanatomy
o Fracture Healing
o Remodeling
o Growth palate Injuries

4. EPIDEMIOLOGY: Age
• Paediatric Fractures amounts to 20% of Paediatric
Trauma.
• At least 1/3 Paediatric population suffer a fracture
before 12 years of age.
• The risk for fracture increases with age.
• Boys are much more likely to sustain a fracture
than girls: 62% vs 38% of all frx
• Peak incidence in male < 14 years
• Peak incidence in Female < 14 years
Cooper etal Bone Mineral 2004 (19)

5. EPIDEMIOLOGY: Locations
•Femoral Shaft fractures
have bimodal peak, at the
age 2 & 17 years.
• The most common,
locations of fractures
in children are in the
upper extremities.
•
Cooper etal Bone Mineral 2004 (19)

6. EPIDEMIOLOGY: Sports Activities
• Paediatric Frx amounts to
25% of all childhood Sports
injuries.
• Forearm fractures have
been strongly associated
with trampoline and
monkey bar use.
“Trauma from either playing events or sports
injuries accounts for the majority of fractures.”

7. EPIDEMIOLOGY: Sports Activities
• Risk of fractures
requiring reduction
is 4 times higher
with fall from
height vs a fall
while playing on
level ground
equipments.

8. Children's bones are
different from adult's
Different in respect of
• Anatomy
• Physiology
• Healing
• Remodeling
• Complications

9. Patho-Anatomical differences
1. Absorb more energy before breaking.
2. Thick Periosteum.
3. Physis & Epiphysis
Hence Paediatric bones behave differently than adults in terms of:
o Fracture location
o Fracture pattern
o Fracture Healing & Remodeling
“Hence Pediatric frxs are treated differently and more often Non-
Operatively”.
Blount WP 1955 & ST Canale 1990

10. Thick Periosteum
Thick periosteum is due to presence
of thick, very vascular and
biologically active fibro-cellular
sheath i.e. the CAMBIUM
The Cambium consist of osteo-progenitor flat &
spindle shaped cells, which are capable of
differentiating into osteoblasts and bone
formation, in response to various stimulations….
Wolf law

11. Thick Periosteum: Growth & Healing
CAMBIUM is responsible for:
• Appositional growth,
• healing of fractures
• remodeling, faster than
adult.

12. Thick periosteum: Stability & Plasticity
Thick Periosteum impart:
o Some stability to a fracture.
o More plasticity to bone. [meaning it can bend a
lot before it breaks, never return o normal -
bowing].

13. Thick periosteum: Frx Reduction
The periosteum mostly, remain intact on
concave side, that:
o preserves some bone tissue continuity across
the fracture – the greenstick fracture
o provide advantage to reduce the fractures
with greater ease.
o reduce the chances of displacement and/or
angulation.
o Lowers the incidence of open fractures.

14. Thick periosteum: Complete Reformation
• In open frxs with complete loss of bone
segment, the intact periosteal sleeve
reasonably helps in:
o complete reformation of the missing
bone…
o Complete reformation never happen in
adults.

15. Growth Plate: Physis
Hypertrophic zone is most cellular, most weak
all the physeal fractures occur through this zone

16. Physis: Structure
Physis is divided
into four main
zones
1. Reserve
2. Proliferative
3. Hypertrophic
4. Provisional
calcification
Hypertrophic zone is most cellular, all the
physeal fractures occur through this zone

17. Physis: Hypertrophic zone
• Growth Plate itself and
Hypertrophic zone in
particular, is the weakest
points in children Skeleton.
• A site of many Paediatric
fractures
• leads to a unique pattern of
frx, which is not seen in
adult

18. Growth Plate (Physis)
Growth Plate is responsible for:
o LONGITUDINAL GROWTH
o REMODELING.
• It allows the fractured bones to Remodel to
correct their own shape to straighten itself out
over time… that insignificantly happen in
adults.
• The Growth plate must be persevered in as
nearly normal to avoid possible growth arrest
and angular deformities…. A dilemma

19. GROWTH PLATE: Osseous Bridge
The Physeal fractures do not heal by classic
callus formation but in few cases instead of
primary healing it heals with a callus leading to
formation of a OSSEOUS BRIDGE between
secondary ossification centre & metaphysis
(Primary Ossific centre)
As a result an angular deformity &/or growth
arrest may develop very soon.

20. GROWTH PLATE: Deformity
The angular deformities & growth arrest may
also occur when:
• Physeal fracture surfaces are not re-apposed
properly
• Vascular supply to the growing cartilage is
permanently interrupted.

21. FRACTURE HEALING CAPACITY
Children's bones have an amazing capacity to heal.
Younger the child the more true the fact:
• In infants, a fracture of the mid shaft of the
femur will heal easily in a hip spica.
•
• In adults, the rate of non-union of femur
fractures is quite high even after surgery.
Blount WP 1955, Canale ST 1990

22. REMODELING : Wolf Law
Remodeling is a continuous process throughout
life, in which damaged bone is:
• repaired, homeostasis is maintained,
• “bone is reinforced in the lines of increased
stress”.
• Post fracture the bones shapes to straighten
itself out over time

23. REMODELING: Wolf & Hueter’s Law
The capability remodeling depends:
• not only on the mechanisms of bone
remodeling - Wolff 's law
but
• also on re-orientation of the physis by
asymmetrical growth following fracture
- Hueter–Volkmann law or Delpech 's law.

24. REMODELING: Alignment Acceptance
• Due to amazing remodeling capacity of
fractured bones we accept some fracture
alignments [but not rotational misalignment]
in children that we cannot accept in adults.
• Whereas; in adults we always strive to align a
fracture perfectly
• We have a little more leverage in the child.

25. Remodeling: Blount’s Rules 1955
Blount’s rules regarding Remodeling and
prognosis are based on 3 Factors:
(1) Age of child
(2) Location of fracture
(3) Degree of angulation

26. Blount’s Rules 1955: Age
A. Greater angulation is acceptable when child is
young and deformity is near the end of bone.
B. Good remodeling is anticipated if a child
has > 2 years of growing left
C. Reduction must be almost perfect if child is near
maturity or if fracture is near middle of the bone

27. Blount’s Rules 1955 - Plan of Motion
(D) Spontaneous correction of on angular deformity
is greatest when angulation is in plane of motion
of nearby hinged joint.
(E) Angulations with its apex towards Flexor aspect
of a joint will usually result in little deformity

28. Blount’s Rules1955
Functional Restoration & Rotational deformity
(F) Angulations in any other direction (other
than plane of motion) will probably persist
at least to some extent
(G) The rotational misalignment never correct,
leads to permanent deformity.
(H) Function often return to normal unless
fracture occur near end of growth period.

29. Blount’s Rules - Summary
Remodeling Potential
• Awareness of the remodeling potential of a
particular fracture significantly assist in the
decision making process while managing a
paediatric fracture.
• Remodelling is best, closer to the physis
• Most remodelling of a fracture is complete by
two years
• Anticipate remodeling if child has > 2 years of
growing left

30. Blount’s Rules - Summary
Remodeling Potential
• Mild angulation deformities often correct
themselves
o 20 degrees coronal angulation (ref. Femur)
o 30 degrees sagittal angulation (ref. Femur)
• Translation <50% do remodel (ref. Femur)
• Shortening < 15mm may get corrected over time
• Rotational deformities require reduction (don’t
remodel)
“Deformities in two planes do not remodel as
competently as those in single plane”. Shannak 1988

31. Remodeling: Humerus frx
The remodeling in proximal Humerus fractures in
children is sufficiently better than femur, the
However, acceptable angulations and
displacement do vary with the patients age.
1.In a child younger than 5 year of age , as much
age 70% displacement can be accepted.
2. In a child 5 to 12 years of age, the maximum
acceptable angulations is 40 to 70 degree.

32. Remodeling: Humerus frx.
3.As much as 40 degree of angulation and 50%
fracture displacement are tolerated in children
older than 12 years of age.
4.In distal Humerus fractures translation of 30 %
& angulation of <15 in varus or valgus is
acceptable due to good remodeling potential.
5.Whereas, Rotational malalignment can not be
expected to remodel for more than few
degrees

33. Paediatric Fracture Patterns
The factors that leads to unique fracture pattern
& treatment modalities:
• Low bone mineral density,
• Developing growth plates
• Proportionally stronger ligaments and
tendons,
• Increased bone flexibility and Plasticity

34. Paediatric Fracture Patterns
 Avulsion type fractures.
 Plastic deformation.
 Buckle Fractures
 Torus frx
 Green Stick Fractures
 Toddlers’ factures
 Growth Plate Injuries
 Non trauma-Physeal
injuries
 SUFE / SCFE
To
be
discussed
by
next
speakers

35. Paediatric
Bone
parts
must be
Saved
Rather to
Salvage
• Significant growth potential
• Overwhelming Remodeling capacity
• Good compensatory leg length deficiency

36. Reconstruction & Replacement with
Spare parts
Allah Almighty! has given us number of spare parts
in our body to reconstruct articular condylar defects
in Mature (adults) skeleton, example:
• Reconstruction of distal radius with fibular head,
femoral condylar with patellar graft
• With armamentarium to replace the lost condyles
with metal or plastics e.g. Silastic replacement of
Radial head / metatarsal heads. you can change
femoral head & replace Talus

37. Reconstruction & Replacement with
Spare parts
• However, despite having enormous potential to
remodel, children bones are devoid of facility to
recover the complete loss of articular condyle once
removed & replaced either with available spare part or
with a metal or plastic piece.
• He has given you wisdom, not to excise radial head,
femoral head or any condyles etc despite the fact they
are severely broken & may lead to AVN & early OA……
they contain a magic disc … that may grow slowly &
restore lost piece to some extent.

38. L. Staheli, MD
Health Education Low-cost Publications

39. Remodeling in Children
Remodelling of proximal femoral physeal fracture in an infant
Note the remodelling of the completely displaced femoral head (red arrows)
throughout childhood (yellow arrow). Normal appearance is shown at age 15
years (orange arrow).

40. Remodeling in Children
Remodelling of the humerus
This 8 year old boy shows a complete loss of apposition (red arrow). Note
the remodelling over the next 2 years (yellow arrow

41. Remodeling in Children
Remodelling of the
forearm
This fracture (red arrow)
could not be reduced by
manipulation and was left
with side-to-side alignment.
Remodelling corrects the
deformity in 18 months
(yellow arrow).

42. Remodeling in Children
Remodelling of femoral shaft fracture
This segmental fracture in an 8 year-old girl was managed in traction
and in a cast (red arrow). Note the filling in of the periosteal sheath at 6
months (yellow arrow) and restoration of normal femoral shape at age
13 years (orange arrow).

43. Remodeling in Children
Remodelling of the humerus
This 8-year-old boy shows a
complete loss of apposition (red
arrow). Note the remodelling
over the next 2 years (yellow
arrow).

44. Remodeling in Children
Remodelling of side-
to-side apposition
This 8-year-old child
sustained this fracture,
which was aligned but
not reduced (red
arrow). Over a period
of 2 years, tibia
remodelling resulted in
a good outcome
(yellow arrow).).

45. Remodeling in Adolescent
Limited remodelling in adolescent
This transverse fracture of the mid shaft of the femur (red arrow) in a 15
year-old boy healed but showed limited remodelling (yellow arrow) due to
the limited remaining growth over the next 2 years (yellow arrow).
Poster created by L. Staheli, MD
Contribution: upper left – Edison Forlin,
Curitiba, Brazil
For copies of this poster or booklet and
other publications
See our web site at: global-help.org
Health Education Low-cost
Publications