General Principles of management Pediatric Fractures

General Principles of managementPediatric Fractures

Presented by: Dr. Harjot Singh Gurudatta

Moderator : Dr. Gagan Khanna

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Childrens bones are differentMetabolically more active,more vascularity, aids reductionModulus of elasticity better resilience, size of articular segment underestimatedReduces tensile strength comminution

In infants, GP is stronger than bone increased diaphyseal fracturesProvides perfect remodeling power.Injury of growth plate causes deformity

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REMODELLING OF BONE IN CHILDREN

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Age related fracture pattern:

Infants: diaphyseal fracturesChildren: metaphyseal fracturesAdolescents: epiphyseal injuriesWhy are childrens fractures different?

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~ 50% of boys and 25% of girls, expected to have a fracture during childhood.Upper limb # more common with # distal radius elbow region # viz distal humeral and prox. Radial being common. Most # in home / school, femur and pelvic # more with RSA.Boys > girlsRate increases with age.Physeal injuries with age.

Mizulta, 1987

Statistics

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General Principles

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source: http://training.seer.cancer.govCenters of Ossification1 ossification centerDiaphyseal2 ossification centersEpiphysealOccur at different stages of developmentUsually occurs earlier in girls than boys

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General PrinciplesRegulation of Epiphyseal Growth

EPIPHYSISMETAPHYSIS

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Physeal injuriesAccount for ~25% of all childrens fractures.More in boys.More in upper limb.Most heal well rapidly with good remodeling.Growth may be affected.Physis responds to compression as well as distraction(# implants infection etc)

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Type IThrough physis onlyType IIThrough physis & metaphysisType IIIThrough physis & epiphysisType IVThrough metaphysis, physis & epiphysisType VCrush injury to entire physisOthers added later by subsequent authors(eg Ranga type 6 peripheral physeal injury)

Described by Robert B. Salter and W. Robert Harris in 1963.Salter - Harris ClassificationType VI - Injury to the perichondral structuresType VII - Isolated injury to the epiphyseal plateType VIII - Isolated injury to the metaphysis, with a potential injury related to endochondral ossificationType IX - Injury to the periosteum that may interfere with membranous growth

AITKENS , polands, PETERSENS SYSTEM OF PHYSEAL INJURIES ARE THERE BUT SALTER HARRIS REMAINS UNIVERSALLY ACCEPTED.

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Epiphyseal Injuries

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Salter Harris Classification General Treatment Principles

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Physeal injuriesLess than 1% cause physeal bridging affecting growth.Small bridges (2 years remaining growth15-20 deformity

Completion epiphyseodesis (tethering physis with staple screw)and contralateral epiphyseodesis may be more reliable in older childCentral bar> peripheral bar

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Physeal Bar Resection - Techniques

The arrest is removed, leaving in its place a metaphyseal-epiphyseal cavity with intact physis surrounding the area of resection

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Agreenstick fractureis afracturein a young, soft bone in which the bone bends and partially breaks. This is owing in large part to the thick fiborous periosteum of immature bonehere are three basic forms of greenstick fracture.In the first a transverse fracture occurs in the cortex, extends into the midportion of the bone and becomes oriented along the longitudinal axis of the bone without disrupting the opposite cortex.The second form is a torus or buckling fracture, caused by impaction , The word torus is derived from the Latin word 'Tori' meaning swelling or protuberance.The third is a bow fracture in which the bone becomes curved along its longitudinal axis.Usually pop splint is given!Torus Fracture

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DIAPHYSEAL FRACTURE

MORE COMMON IN INFANTS

Watch for neurovascular insufficiency during convalescenceAbuse should be considered a possible cause of injury in all young children with multiple long-bone fractures in association with head injury

General principles of fixation essentially remain the same with most diaphyseal fractures being treated conservatively , displaced fractures and open fractures requiring internal/external fixation.

Methods of fixationCasting - still the commonest

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Casting - still the commonestK-wires most commonly usedMetaphyseal fractures

Methods of fixation

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Methods of fixationCasting - still the commonestK-wiresmost commonly usedMetaphyseal fracturesK- wires could be replaced by absorbable rods

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Casting - still the commonestK-wires most commonly usedMetaphyseal fracturesIntramedullary wires, elastic nailsVery usefulDiaphyseal fracturesScrews

Methods of fixation

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Methods of fixation

more extensive operative exposureNot load sharing-----removal neededNewer minimally invasive percutaneous submuscular plating

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Methods of fixation

Casting - still the commonestK-wiresmost commonly usedMetaphyseal fracturesIntramedullary wires, elastic nailsVery usefulDiaphyseal fracturesScrewsPlates multiple traumaIMN - adolescents only (injury to growth)

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Methods of fixation

Casting - still the commonestK-wiresmost commonly usedMetaphyseal fracturesIntramedullary wires, elastic nailsVery usefulDiaphyseal fracturesScrewsPlates multiple traumaIMN - adolescentsEx-fix usually in open fractures

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The aim of this biological, minimally invasive fracture treatment is to achieve a level of reduction and stabilisation that is appropriate to the age of the child.

The biomechanical principle of the elastically-stable intramedullary nailing (ESIN) is based on the symmetrical bracing action of two elastic nails inserted into the metaphysis, eachof which bears against the inner bone at three points.

This produces the following four biomechanical properties: flexural stability, axial stability, translational stability and rotationalstability. All four are essential for achieving optimal resultsTitanium Elastic Nail

Age lower limit is 34 yearsand the upper limit 1315 years.Type of fracture transverse fractures short oblique or Spiral # with cortical suport long oblique fractures with cortical supportFracture site femur: diaphyseal distal femur: metaphyseal femur: subtrochanteric lower leg: diaphyseal humerus: diaphyseal , subcapital even supracondylar radius and ulna: shaft radial neck radius: neck prophylactic stabilization with juvenile bone cystsContraindications intraarticular fractures complex femoral fractures, particularlyoverweight (5060 kg) and/or age (1516 years)

INDICATIONS

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- initial considerations: growth will not correct rotational deformity age distance from physis amount of deformity - bayonette apposition - generally bayonette apposition will require operative reduction - historically, overriding of a both bones forearm fracture was acceptable if... - there was no deviation of radius and ulna toward each other; - there was no encroachment of the interosseous space; - pt is less than 10 yrs of age; - in pts < 6 yrs of age: - upto 15 deg of angulation & 12 yrs of age: - no angulatory or rotational deformity is considered acceptable; - more aggressive treatment is required, including open reduction and compression plating may be required; - Displaced Distal Third Frx: - angulation up to 20-25 deg during first ten years is OK; - angulation > 10 deg is unlikely to correct after 10 yrs

ACCEPTABLE REDUCTION

Open fracturesDisplaced intra articular fractures( Salter-Harris III-IV )fractures with vascular injuryCompartment syndromeFractures not reduced by closed reduction( soft tissue interposition, button-holing of periosteum )If reduction could be only maintained in an abnormal positionIndications for operative fixation

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Indications for operative fixation

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Forearm diaphyseal fractureOpenClosedDebridement in ORAngulation 0-10Angulation 10-20Angulation +20Closed reductionOpen reduction +ESINUnsuccessful+ 5 yearsAll agesLong arm cast or splint0-5 yearsSuccessful if < 10Successful but unstableClosed reduction + ESIN

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Humeral diaphyseal fractureAdolescents Older childrenInfants & younger childrenDebridement in ORClosed reductionImmobilize in a sling & swathClosedMidshaft angulationClosed reduction + ESINImmobilize in soft dressingExternal fixatorOpen< 20> 20IIII & IISurgical indications

Adolescents & Older children

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Femoral shaft fractureYesDebridement in ORAdolescentExternal fixatorOpenExcessive shorteningAbusedInfantsYounger childOlder childComminutionNoNoYesYesNoReamedrodHospital& invest.ImmediateHip spicaTractionThen castESINChoice

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Tibial shaft fractureOpenDebridement in ORClosedIIII & IIExternal fixatorClosed reduction + ESIN

Polytrauma

FailedSucceedClosed reduction & cast

Consider wedging the cast

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Ma-lunion is not usually a problem ( except cubitus varus )Non-union is hardly seen ( except in the lateral condyle )Growth disturbance epiphyseal damageVascular volkmanns ischemiaInfection - rare

Complications

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Complications of Fractures- Bone -

MalunionLimb length discrepancyPhyseal arrestNonunion (rare)CrossunionOsteonecrosis

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Complications of Fractures- Soft Tissue -Vascular InjuryEspecially elbow/kneeNeurologic InjuryUsually neuropraxiaCompartment SyndromeEspecially leg/forearmCast sores/pressure ulcersCast burnsUse care with cast saw

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Complications of Fractures- Cast Syndrome -Patient in spica/body castAcute gastric distension, vomitingPossibly mechanical obstruction of duodenum by superior mesenteric artery

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Location Specific Pediatric Fracture ComplicationsComplicationFractureCubitus varusSupracondylar humerus fractureVolkmanns ischemic contractureSupracondylar humerus fractureRefractureFemur fractureMid-diaphyseal radius/ulna fracturesOvergrowthFemur fracture (especially < 5 years)NonunionLateral humeral condyle fractureOsteonecrosisFemoral neck fractureTalus fractureProgressive valgusProximal tibia fractures

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Supracondylar Fracture of HumerusComplications

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Forearm Fractures

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Closed Reduction of Forearm Fractures

Bohler traction

Open reduction and internal fixation with plates and screws may be appropriate in the management of fractures with delayed presentation or fractures that angulate late in the course of cast care,when significant fracture callus makes closed reduction and percutaneous passage of intramedullary nails difficult. Tens nail and im nail has improved results and are preferred in displaced angulated #

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Closed Reduction of Forearm Fractures

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Forearm Fractures

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FEMORAL SHAFT FRACTURESIn a baby under 6 months old, a brace (called a Pavlik Harness) may be able to hold the broken bone still enough for successful healing.

Traction before spica casting is indicated when the fracture is unstable orIf the shortening of the bones is too much (more than 3 cm)traction

Spica cast management is generally not used for children with multiple trauma, head injury, vascular compromise, floating knee injuries, significant skin problems, or multiple fractures. Flexible intramedullary nails are the predominant treatment for femoral fractures in 5 to 11 year olds, although submuscular plating and external fixation have their place, especially in length-unstable fractures or fractures in the proximal and distal third of the femoral shaftIn children between 7 months and 5 years old, a spica cast is often applied.In general, a spica cast begins at the chest b/w umbilicus & nipple and extends all the way down the fractured leg, with flexion @ 50-90 degrees at knee and hip.

Spica cast11-15 yrs use of trochanteric entry, locked intramedullary nailing for femoral fractures in the preadolescent and adolescent age groups