1 Common Pediatric Fractures & TraumaProf. Zamzam Dr.Kholoud Al-Zain Ass. Professor and Consultant Pediatric Orthopedic Surgeon F1 Dec 2016

2 Objectives Introduction to Ped. # & traumaDifference between Ped. & adult Fractures of the physis  Salter-Harris classification Indications of operative treatment Methods of treatment of Ped # & trauma Common Ped #: U.L  clavicle, s.c, distal radius L.L  femur shaft

3 Pediatric Fractures

4 Introduction Fractures account for ~15% of all injuries in childrenDifferent from adult fractures Vary in various age groups (infants, children, adolescents )

5 Statistics Boys > girls Rate increases with age Mizulta, 1987

6 Difference Between A Child & Adult’s Fractures & Trauma

7 Why are Children’s Fractures Different ?Children have different physiology and anatomy Growth plate Bone Cartilage Periosteum Ligaments Physiology  age Anatomy  blood supply

8 Why are Children’s Fractures Different ?Growth plate: Provides perfect remodeling power Injury of growth plate causes deformity A fracture might lead to overgrowth

9 Why are Children’s Fractures Different ?Bone:  (collagen : bone) ratio Less brittle deformation

10 Why are Children’s Fractures Different ?Cartilage: Difficult X-ray evaluation Size of articular fragment often under-estimated

11 Why are Children’s Fractures Different ?Periosteum: Metabolically active More callus Rapid union Increased remodeling Thickness and strength Intact periosteal hinge affects fracture pattern May aid reduction

12 Why are Children’s Fractures Different ?Ligaments: Are functionally stronger than bone. Therefore, a higher proportion of injuries that produce sprains in adults result in fractures in children.

13 Why are Children’s Fractures Different ?Age related fracture pattern: Infants  diaphyseal fractures Children  metaphyseal fractures Adolescents  epiphyseal injuries

14 Why are Children’s Fractures Different ?Physiology Better blood supply  incidence  delayed and non-union

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17 Physis Fractures

18 Physis Injuries Account for ~25% of all children’s # More in boysMore in upper limb Most heal well, rapidly, with good remodeling Growth may be affected

19 Physis Injuries- ClassificationsSalter-Harris Classification

20 Salter-Harris Classification

21 Salter-Harris Classification

22 Physis Injuries- ComplicationsLess than 1% cause physeal bridging  affecting growth (varus, valgus, or even L.L.I) Keep in mind: Small bridges (<10%)  may lyse spontaneously Central bridges  more likely to lyse Peripheral bridges  more likely to cause deformity Take care with: Avoid injury to physis during fixation Monitor growth over a long period Image suspected physeal bar (MRI, CT)

23 Indications of Operative Treatment

24 General Management Indications for surgery Open fracturesSevere soft-tissue injury Fractures with vascular injury ? Compartment syndrome Multiple injuries/# Displaced intra articular fractures (Salter-Harris III-IV ) Failure of conservative means (irreducible or unstable #’s) Malunion and delayed union Adolescence Head injury Neurological disorder

25 Methods of Treatment of Pediatric Fractures & Trauma (7)

27 2) K-wires Most commonly used internal fixation (I.F)Usually used in  metaphyseal fractures

28 3) Intramedullary wires (Elastic nails)

29 4) Screws

30 5) Plates  specially in multiple trauma

31 6) I.M.N  only in adolescents (>12y)

33 Methods of Fixation Combination

34 Common Pediatric Fractures

35 Common Pediatric FracturesUpper limb: Clavicle Humeral supracondylar Distal Radius Lower Limbs: Femur shaft (diaphysis)

36 Clavicle Fractures

37 Clavicle # - Incidents 8-15%  of all pediatric # 0.5%  of normal SVD1.6%  of breech deliveries 80%  of clavicle # occur in the shaft The periosteal sleeve always remains in the anatomic position  therefore, remodeling is ensured

38 Clavicle # - Mechanism InjuryIndirect  fall onto an outstretched hand Direct: The most common mechanism Has highest incidence of injury to the underlying: N.V &, Pulmonary structures Birth injury

39 Clavicle # - ExaminationLook  Ecchymosis Feel: Tender # site As a palpable mass along the clavicle (as in displaced #) Crepitus (when lung is compromised) Special tests  Must assesse for any: N.V injury Pulmonary injury

40 Clavicle # - Radiographic (AP X-ray)

41 Clavicle # - Reading XR Location: Open or closed  see air on XR(medial, middle, lateral) ⅓  commonest middle ⅓ Or junction of ⅓’s  commonest middle/lateral ⅓ Open or closed  see air on XR Displacement  % Fracture type: Segmental Comminuted Greenstick

42 Clavicle # 5% 80% 15%

44 Clavicle # - Treatment Newborn (< 28 days): 1m – 2y: 2 – 12y:No orthotics Unite in 1w 1m – 2y: Figure-of-eight For 2w 2 – 12y: Figure-of-eight or sling For 2-4 weeks

45 Clavicle # - Remodeling

46 Clavicle # - Remodeling

47 Clavicle # - Treatment Indications of operative treatment:Open #’s, or Neurovascular compromise

48 Clavicle # - Complications (rare)From the #: Malunion Nonunion Secondary from healing: Neurovascular compromise Pulmonary injury In the wound: Bad healed scar Dehiscence Infection

49 Humeral Supracondylar Fractures

51 Supracondylar #- Mechanism of InjuryIndirect: Extension type >95% Direct: Flexion type < 3% Need pic’s

52 Supracondylar #- Clinical EvaluationLook: Swollen S-shaped angulation Pucker sign (dimpling of the skin anteriorly) May have burses Feel: Tender elbow Move: Painful & can’t really move it Neurovascular examination

53 Supracondylar #- Gartland ClassificationType III Complete displacement (extension type) may be: Posteromedial (75%), or Posterolateral (25%)

54 Supracondylar #- Gartland ClassificationType III Complete displacement (extension type) may be: Posteromedial (75%), or Posterolateral (25%)

55 Type 1 Anterior Humeral Line Hour-glass appearance

56 Type 2

57 Type 3

59 Supracondylar #- TreatmentType I: Immobilization in a long arm (cast, or splint), At (60° – 90°) of flexion, For 2-3 weeks Type II: Closed reduction, followed by casting, or Percutaneous pinning (if: unstable or sever swelling), then splinting

62 Supracondylar #- ComplicationsNeurologic injury (7% to 10%): Median and anterior interosseous nerves (most common) Most are neurapraxias Requiring no treatment Ulnar nerve  iatrogenic Vascular injury (0.5%): Direct injury to the brachial artery, or Secondary to swelling

63 Supracondylar #- ComplicationsLoss of motion (stiffness) Myositis ossificans Angular deformity (cubitus varus) Compartment syndrome

64 Distal Radial Fractures a) Physeal Injuries

65 Distal Radial Physeal #- “S.H” Type I

66 Distal Radial Physeal #- “S.H” Type II

67 Distal Radial Physeal #- “S.H” Type III

68 Distal Radial Physeal #- Treatment Types I & IIClosed reduction, Followed by long arm cast, with the forearm pronated We can accept deformity: 50% apposition, With no  angulation or rotation

69 Distal Radial Physeal #- Treatment Types I & IIGrowth arrest can occur in 25%  with repeated manipulations Open reduction is indicated Irreducible # Open #

70 Distal Radial Physeal #- Treatment Types I & II

71 Distal Radial Physeal #- Treatment Types IIIAnatomic reduction is necessary ORIF with smooth pins or screws

72 Distal Radial Physeal #- Treatment Types IV & VRare injuries Need ORIF

73 Distal Radial Physeal #- ComplicationsPhyseal arrest Shortening Angular deformity Ulnar styloid nonunion Carpal tunnel syndrome

74 Distal Radial Fractures b) Metaphyseal Injuries

75 Classification Depending on the biomechanical pattern:Torus (only one cortex is involved) Incomplete (greenstick) Complete We need to also describe: Direction of displacement, & Involvement of the ulna

76 Distal Radius Metaphyseal InjuriesTorus fracture Stable Immobilized for pain relief Bicortical injuries should be treated in a long arm cast

77 Distal Radius Metaphyseal InjuriesIncomplete (greenstick) Greater ability to remodel in the sagittal plane Closed reduction and above elbow cast with supinated forearm to relax the brachioradialis muscle

78 Distal Radius Metaphyseal InjuriesComplete fracture Closed reduction Well molded long arm cast for 3-4 weeks

79 Distal Radius Metaphyseal InjuriesComplete fracture Indications for percutaneous pinning without open reduction loss of reduction Excessive swelling Multiple manipulations Associated with floating elbow

80 Distal Radius Metaphyseal InjuriesComplete fracture Indications for ORIF: Irreducible fracture Open fracture Compartment syndrome

81 Distal Radius Meta. Injuries- ComplicationsMalunion Residual angulation may result in loss of forearm rotation Nonunion Rare Refracture With early return to activity (before 6 w) Growth disturbance Overgrowth or undergrowth Neurovascular injuries With extreme positions of immobilization

82 Femoral Shaft Fractures

83 Femoral Shaft # 1.6%  of all pediatric # M > F Age:(2 – 4) years years old Mid-adolescence Adolescence  >90% due to RTA

84 Femoral Shaft # In children younger than walking age:80% of these injuries are caused by child abuse This decreases to 30% in toddlers

85 Femoral Shaft #- Mechanism of InjuryDirect trauma: RTA, Fall, or Child abuse Indirect trauma: Rotational injury Pathologic #: Osteogenesis imperfecta, Nonossifying fibroma, Bone cysts, and Tumors

88 Femoral Shaft #- ClassificationDescriptive Open or closed Level of fracture: (proximal, middle, distal) ⅓ Fracture pattern: transverse, oblique, spiral, butterfly fragment, comminution Displacement Angulation Anatomic Neck Subtrochanteric Shaft Supracondylar

89 Femoral Shaft #- TreatmentLess than 6m: Pavlik Harness, Traction then hip spica casting

90 Femoral Shaft #- Treatment6m – 6y: C.R and immediate hip spica casting (>95%) Traction followed by hip spica casting (if there is difficulty to maintain length and acceptable alignment)

91 Femoral Shaft #- Treatment6 – 12y: Flexible I.M.N Bridge Plating External Fixation

92 Femoral Shaft #- Treatment6 – 12y: Flexible IMN Bridge Plating External Fixation

93 Femoral Shaft #- Treatment6 – 12y: Flexible IMN Bridge Plating External Fixation: Multiple injuries Open fracture Comminuted # Unstable patient

94 Femoral Shaft #- Treatment12y to skeletal maturity: Intramedullary fixation with either: Flexible nails, or Interlocked I.M nail

95 Femoral Shaft #- ComplicationsMalunion Remodeling will not correct rotational deformities Nonunion (Rare) Muscle weakness Leg length discrepancy Secondary to shortening or overgrowth Overgrowth of 1.5 to 2.0 cm is common in 2-10 year of age Osteonecrosis with antegrade IMN <16 year

96 Remember …

97 Remember Difference between adult and pediatric fracturesGrowth plate fractures Methods of treatment of pediatric fractures and there indications The importance of growth plates and periosteum in remodeling Growth plat fractures classifications, treatments, and complications Know the common pediatric fracture’s: mechanism of injury, evaluations, treatments, and complications Pediatric fractures have great remodeling potentials A good number of cases can be treated conservatively Operative fixations aids in avoiding complications