Paediatric Fracture Paediatric Fracture Research: Evidence That Will Ch Y P tiWill Change Your Practice

Kathy Boutis MD FRCPC MScJune 5, 2011

S k Di lSpeaker Disclosure

I do not have an affiliation (financial or otherwise) with any commercial organization otherwise) with any commercial organization that may have a direct or indirect connection to the content of my presentation.

Learning ObjectivesLearning Objectives

At the end of this session you will be able toAt the end of this session, you will be able to...1. Learn the latest in evidence based emergency

management of common paediatric fracturesmanagement of common paediatric fractures

2. Adapt this evidence into your emergency practice

FracturesFractures

1 Buckle fractures of distal radius1. Buckle fractures of distal radius

2 Mi i ll l t d f t f di t l di2. Minimally angulated fractures of distal radius

3. Ankle

Common FracturesCommon Fractures1. Operative intervention?p

2. Orthopaedic consultation?

3. Immobilization device?

4. Duration of immobilization?

5. Return to sports?

Distal RadiusDistal Radius

Distal Radius – Buckle Distal Radius Buckle 1. Abraham et al. Cochrane Review. 2008.

2. Khan KS et al. Acta Orthop Belg 2007;73:594-7.

3. Oakley E et al. Pediatric Emergency Care 2008;24:65-70.

4 Plint A et al Pediatrics 2006;117(3):691 74. Plint A et al. Pediatrics. 2006;117(3):691-7.

5. Stoffelen D et al. The Journal of Trauma. 1998;44:503-5.

6. West S et al. J Pediatr Orthop 2005;25:322-5.L l I E idLevel I Evidence

Distal Radius – Buckle Distal Radius Buckle

• No indication for operative intervention or No indication for operative intervention or orthopaedic consultation

• Three randomized controlled trials - removable li t d t h t t h i il splint compared to a short arm cast has similar

functional outcomes, higher patient satisfaction– more pain in week 1 in splint group – none of the trials reported re-fracture

Distal Radius – Buckle Distal Radius Buckle

• Removal of splint safely done at home and Removal of splint safely done at home and preferred by caregivers

• Duration of immobilization and return to sports as id d b th ti t’ tguided by the patient’s symptoms

Many faces of the buckle fractureMany faces of the buckle fracture

Distal RadiusDistal Radius

Distal Radius –Mi i ll A l d G i k/TMinimally Angulated Greenstick/TransverseMinimal AngulationMinimal Angulation• Lateral view

A d d t 15 20°• Age dependent: < 15-20°

Distal Radius -Mi i ll A l d G i k/T Minimally Angulated Greenstick/Transverse 1. Al Ansari K et al. CJEM 2007;9:9-15.;

2. Do TT et al. J Pediatr Orthop Part B 2003;12:109-115.

3. Boutis K et al. CMAJ 2010;182:1507-12.

Level I Evidence

Distal Radius –Mi i ll A l d G i k/TMinimally Angulated Greenstick/Transverse• No indication for operative intervention or reduction No indication for operative intervention or reduction

under anaethesia

• No indication for ED orthopaedic consultation if l ti 15 20ºangulation < 15-20º

• Unstable fractures and require fracture clinic follow upp

Distal Radius –Mi i ll A l d G i k/TMinimally Angulated Greenstick/TransverseWhat is the optimal immobilization for the duration of What is the optimal immobilization for the duration of

therapy (i.e. 4-6 weeks)?

• Short or long arm cast?• Short arm cast or splint?

Distal Radius –A l d d R d dAngulated and Reduced

• Below or above elbow cast? Below or above elbow cast?

R d i d t ll d t i l 102• Randomized controlled trial, n = 102• No differences between groups with respect to

complications (angulation, remanipulation)

Level I EvidenceBohm ER et al. J Bone Joint Surg Am. 2006

Distal Radius –Mi i ll A l d G i k/TMinimally Angulated Greenstick/Transverse• Cast or splint?Cast or splint?

Distal Radius –Mi i ll A l d G i k/TMinimally Angulated Greenstick/Transverse• Advantages of the SplintAdvantages of the Splint

P ti t ti (h i t l)• Patient perspective (hygiene, cast removal)• Physician perspective (technical skill)• Health care perspective (added costs)

Distal Radius –Mi i ll A l d G i k/TMinimally Angulated Greenstick/Transverse• 100 children randomized to splint (n= 43) or short 100 children randomized to splint (n= 43) or short

arm cast (n= 49) for 4-6 weeks

• Splint compared to a cast had similar functional hi h ti t ti f ti t ff tirecovery, higher patient satisfaction, cost-effective

Distal Radius –Mi i ll A l d G i k/TMinimally Angulated Greenstick/Transverse• Biggest pitfall to application of splint to this Biggest pitfall to application of splint to this

population is the wrong initial diagnosis

• 100 patients, 4 had to be removed from study– Angulation under-estimated (>20°) – Salter-Harris II fracture

Salter-Harris II Distal RadiusSalter Harris II Distal RadiusA B

AnkleAnkle• Ankle sprain versus Salter-Harris I fracture of Ankle sprain versus Salter Harris I fracture of

distal fibula

• Isolated distal fibular fracture management

Salter-Harris I Distal FibulaSalter Harris I Distal Fibula

A 5 year old boy is playing in the playground and A 5 year old boy is playing in the playground and twists his ankle. He is unable to walk after the injury injury.

O i ti h h t d d lli On examination he has tenderness and swelling maximal over the distal fibula. NVS intact.

Salter-Harris I Distal FibulaSalter Harris I Distal Fibula• Sprains “do not occur in children” – SH1DFSprains do not occur in children SH1DF

• Clinical follow up 50% reclassified to sprains• Clinical follow up – 50% reclassified to sprains

MRI t di i t l 90% l ifi d t • MRI studies – approximately 90% reclassified to sprains / contusions (n=18)

Launay et al. Rev Chir Orthop Rep Appar Mot. 2008.Boutis et al. Injury. 2010.

Isolated Distal Fibular FracturesIsolated Distal Fibular Fractures• Salter-Harris I, II, avulsion Salter Harris I, II, avulsion

• Ankle is a ring like structure bound by ligaments • Ankle is a ring like structure bound by ligaments and bones - stable

• To create instability, it must be broken in two places

• For all of these fractures, ring broken in one place

Low Risk Fractures

A l i f di t l fib l Avulsion of distal fibula Avulsion of distal fibula Avulsion of distal fibula

Salter-Harris I of distal fibula Salter-Harris II of distal fibula

Isolated Distal Fibular FracturesIsolated Distal Fibular Fractures• PEM survey – slightly high riskPEM survey slightly high risk

• Controversial management • Controversial management o tensor, splint / brace, or cast o orthopedicso orthopedics

Boutis. Academic Emergency Medicine. 2010.Cummings. Pediatric Orthopedics. 2006

Isolated Distal Fibular FracturesIsolated Distal Fibular Fractures• 104 children - randomized controlled trial of BKWC (50) 104 children randomized controlled trial of BKWC (50)

versus removable brace (54)

• Brace is superior to BKWC with respect too recovery of physical functiono patient and parental preferences o patient and parental preferences o cost-effectiveness

Level I EvidenceLevel I Evidence

Boutis et al. Pediatrics. 2007.

Isolated Distal Fibular FracturesIsolated Distal Fibular Fractures

• No ED consultation of orthopedics • No ED consultation of orthopedics • Removable posterior slab, brace, tensor are

preferred treatment choices• Duration of immobilization and return to sports • Duration of immobilization and return to sports

guided by patients symptoms• Follow up with primary care physician at one week

SummarySummary

• Buckle distal radius and distal fibular fractures • Buckle distal radius and distal fibular fractures -managed with a focus on symptomatic care

• Salter-Harris I Fractures of distal fibula more likely are sprainsare sprains

• Minimally angulated distal radius fractures can safely be managed with a splint for 4-6 weeks

THANK YOUTHANK YOU

Clinical Decision RulesClinical Decision Rules

12% of ankle injuries have fractures12% of ankle injuries have fractures

Cli i l d i i lClinical decision rules1. OAR - Plint et al, 19992. Low Risk Rules - Boutis et al, 20013 Two Part Malleolar Zone - Dayan et al 20043. Two Part Malleolar Zone Dayan et al, 2004

Ottawa Ankle RulesOttawa Ankle RulesChildrenChildren

Validation in 12 studiesSensitivities 93% - 100%Specificity 13% - 15%p yAnkle x-ray reduction 5% - 16%

Dowling S et al. Acad Emerg Med. 2009.

Low Risk Ankle RulesLow Risk Ankle Rules

Low Risk Ankle RulesLow Risk Ankle RulesDeveloped for children and validatedp

Sensitivity 100% [93.3 -100]y [ ]Specificity* 67.8% [63.8 – 71.1]Ankle x-ray reduction 62.8% y

*Low Risk Injuries – sprains, isolated distal fibular j p ,fractures

Boutis et al. Lancet 2001.Boutis et al. Lancet 2001.

Low Risk Fractures

A l i f di t l fib l Avulsion of distal fibula Avulsion of distal fibula Avulsion of distal fibula

Salter-Harris I of distal fibula Salter-Harris II of distal fibula

Clinical Decision Pediatric Ankle RulesClinical Decision Pediatric Ankle Rules• Prospective Validation and Head-to-Head Comparison Prospective Validation and Head to Head Comparison

of 3 Ankle Rules in a Paediatric Populationo Enrolled 272 children, 0-16 years of ageo Enrolled 272 children, 0 16 years of ageo Compared OAR, LRAR, TPMZ

Gravel et al. Annals of EM. 2009.

Clinical Decision Pediatric Ankle RulesClinical Decision Pediatric Ankle RulesClinical Decision Rule Sensitivity Specificity Proportion of Radiographs y

n=45

p y

n=225

p g p

n=227

OAR 1.00 [0.93-1.00] 0.21 [0.33-0.27] 0.83 [0.79-0.87]

LRAR 0.87** [0.75-0.94] 0.54 [0.47-0.60] 0.44 [0.38-0.50]

TPMZ 0.94 [0.83-0.98] 0.24 [0.19-0.30] 0.94 [0.91–0.96]

**Different outcome “clinically significant” – all radiograph visible fractures

Clinical Decision Pediatric Ankle RulesClinical Decision Pediatric Ankle RulesClinical Decision Rule Sensitivity Specificity Proportion of Radiographs

n=45 n=225 n=227

OAR 1 00 [0 93-1 00] 0 21 [0 33-0 27] 0 83 [0 79-0 87] OAR 1.00 [0.93 1.00] 0.21 [0.33 0.27] 0.83 [0.79 0.87]

LRAR 0.98 0.54 [0.47-0.60] 0.44 [0.38-0.50]

TPMZ 0 96 0 24 [0 19 0 30] 0 94 [0 91 0 96] TPMZ 0.96 0.24 [0.19-0.30] 0.94 [0.91–0.96]

OAR 100% sensitive and would reduce radiography by 7% LRAR 98% sensitive and would reduce radiography by 46%g p y y

Clinical Decision Pediatric Ankle RulesClinical Decision Pediatric Ankle Rules

• Implementation studies for all clinical decision rules Implementation studies for all clinical decision rules are

• Multi-centre implementation study of the Low Risk A kl R l d t b l t d S t b 2011 Ankle Rules due to be completed September 2011