Management of Fractures in Adolescents

Friday Registrar Presentation

Dr. Stewart Morrison MBBS

Western Health Orthopaedic Department

IntroductionAdolescence✚ Puberty: acceleration phase, peak height velocity, deceleration phase✚ Peak height velocity: Girls 12 years, Boys 14 years✚ Fall between management parameters for adults, and those for children

✚ Quality of Bone .Less mineralised, more vascular, greater callus

.greater energy dissipation, less comminution, quicker healing

✚ Structure of Bone .Physeal Plate

.Closure of Physeal Plate

✚ Psychosocial

Estimation of Maturity✚ Various Methods .Sauvegrain

.Oxford Score

.Greulich’s and Pyle’s Atlas

.Tanner-Whitehouse-III RUS Score

.Sanders modification of TWIIIRUS Score

✚ Biological Staging .Tanner Stages

.Secondary Sexual Characteristics

Classification of Physeal Fractures

✚ Salter-Harris

✚ Perichondral ring of La Croix

✚ Communication✚ Prognosis

ImagingGeneral Principles✚ Joint above, joint below✚ Comparison views

✚ CT✚ MRI

Principles of Treatment: Physeal Fractures

Reduction✚ Traction, gentle manipulation✚ Open preferable to multiple closed attempts✚ No reduction after 7-10 days, unless > 2mm step-off

Fixation✚ Pins, screws should be parallel to the physis✚ Single pass, single smooth K-wire

✚ Resection of periosteum✚ Langenskiöld procedure✚ No reduction after 7-10 days, unless > 2mm step-off

Most heal in 3 weeks.

Growth disturbance monitoring.

Park-Harris Lines

How to succinctly and clearly explain this algorithm to parents?

… when often they only hear the word ‘deformity’

Principles of Treatment: Non-Physeal Fractures✚ Adolescent bone does not have the remodelling capacity of childrens’✚ Weight and specific characteristics need to be taken into account

✚ Displaced diaphyseal fractures – Titanium Elastic Nails

✚ Displaced metaphyseal fractures – Percutaneous Pin Fixation

✚ Supplementation of fixation by splint or cast

✚ Locking plates not usually required

✚ Implant removal

Clavicle✚ First bone to begin ossification, and the last to finish it.

✚ Threshold of > 2 cm of displacement often cited

Operative Considerations

✚ ORIF

✚ Supraclavicular nerve

✚ Neurovascular bundle

✚ Earlier return to full activities (12 vs 16 weeks)

Radial and Ulnar Shafts

✚Studies often convoluted by pediatric participants, and inclusion of metaphyseal fractures✚ More difficult to manage than previously thought

✚ Greenstick✚ Plastic Deformation✚ Complete✚ Comminuted

If a deformity is present in two orthogonal radiographs, the true deformity will be greater than appreciated on either single view

Radial and Ulnar Shafts

Operative Considerations ✚1.5 – 2.0 mm Titanium Elastic Nails (TENS)✚ Closed Reduction closed reduction with percutanous fixation open reduction✚ Reestablish radial bow, eliminate any bowing of ulna✚ Fix radius first✚ Narrowest point of radius is central✚ Narrowest point of ulna is within the distal third✚ Do not cross physes✚ Removal at six months or more

Femoral ShaftPrinciples✚ Timely union✚ No rotational deformity✚ < 2 cm shortening✚ Deformity of < 10-20° (sagittal plane), < 5-10° (coronal plane)

Operative Considerations✚ In adolescents, surgical treatment favoured✚ Elastic intramedullary nails (< 11 yrs, < 49 kg ) .require removal

✚ Rigid nails, plating (> 11 yrs, length ‘unstable’ fractures) .require removal

✚ No randomized trials

✚ External Fixation

Distal Femur✚ High Energy

Metaphyseal Fractures✚ < 10 years; closed reduction + percutaneous cross-pin fixation + long leg cast✚ > 10 years or unstable fracture, consider plating or external fixation

Physeal Fractures✚ SHI + SH II, undisplaced – long leg cast✚ SHI + II, mildly displaced – closed reduction, percutaneous pinning, long leg cast✚ SH II, large metaphyseal fragment – cannulated screws, long leg cast✚ SH III + IV, displaced – cannulated compression screws

✚ All should remain NWB following fixation✚ 50% of distal femoral fractures lead to growth disturbance (SH II highest risk)

Proximal TibiaPhyseal Fractures✚ High energy✚ CT recommended✚ Similar management principles to distal femoral fractures

Metaphyseal Fractures✚ “Cozen Fractures” ✚ Closed reduction, long leg casting✚ Genu valgum is most common complication

Proximal TibiaTibial Spine Fractures✚ Hyperextension of the knee✚ ACL avulsion injury

Tibial Tubercle Fractures✚ Repetitive jumping sports✚ Ogden modification of Watson-Jones Classification✚ Open reduction, internal fixation for II, III, IV✚ V should have periosteal sleeve reattached✚ Genu recuvatum

AnkleConsiderations✚ Fibular physis closes later than the tibial physis (12-14, 15-18 vs. 19-20 yrs)✚ Tibial physis closes in a circular pattern – centre to medial to lateral✚ CT scan recommended

Management✚ SH I or SHII, undisplaced – BK walking cast 3-4 weeks✚ SH I or SHII, displaced – closed reduction, AK cast 3 weeks, then BK 3 weeks✚SH III or SHIV – often require open reduction, internal fixation✚ If periosteal flap not removed, 60% incidence of plate closure✚ No more than 5% of angulation in any plane should be accepted

AnkleTillaux Fracture✚ SHIII of anterolateral distal tibial epiphysis (final area to close) ✚ Internal rotation can provide closed reduction, however often need open reduction

Triplanar Fracture✚ SHIII or SH IV ✚ Appears as SH II on lateral radiograph, SH III on anteroposterior radiograph✚ Younger patient than Tillaux fracture✚ Growth arrest not clinically important✚ Flexion of Knee to 90 degrees, plantar flexion and internal rotation of the foot, with AK cast for 3/52✚ If unsuccessful, proceed to percutaneous or open reduction/fixation

Thank you

Salter RB, Harris WR. Injuries Involving The Epiphyseal Plate. J Bone Joint Surg Am. 1963;45: 587-622.

Khan La, Bradnock Tj, Scott C, Robinson Cm. Fractures Of The Clavicle. J Bone Joint Surg Am. 2009 Feb;91(2):447-60.

Egol Ka Et Al. Management Of Fractures In Adolescents. J Bone Joint Surg. Am. 2010 Dec;92(18) 2947

Zionts Le. Fractures Around The Knee In Children. JAAOS Vol. 10 No. 5 September/October 2002

Alain Diméglio; Yann Philippe Charles; Jean-pierre Daures; Vincenzo De Rosa; Accuracy Of The Sauvegrain Method In Determining Skeletal Age During Puberty. Journal Of Bone And Joint Surgery; Aug 2005; 87, 8; Health & Medical Complete

Momberger N, Stevens P, Smith J, Santora S, Scott S, Anderson J. Intramedullary nailing of femoral fractures in adolescents. J Pediatr Orthop. 2000;20: 482-4.