1 Common Pediatric Fractures & TraumaProf. Zamzam Dr.Kholoud Al-Zain Ass. Professor and Consultant Pediatric Orthopedic Surgeon F2 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: Provides perfect remodeling power Injury of growth plate causes deformity A fracture might lead to overgrowth

8 Why are Children’s Fractures Different ?Bone: Increased collagen : bone ratio Less brittle deformation

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

10 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

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

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

13 Why are Children’s Fractures Different ?Physiology Better blood supply rare incidence of delayed and non-union

14

15

16 Physis Fractures

17 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

18 Physis Injuries- ClassificationsSalter-Harris Rang’s type VI

19 Salter-Harris Classification

20 Salter-Harris Classification

21 Physis Injuries- ClassificationsSalter-Harris Rang’s type VI Ogden Peterson

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

26 1) Casting  still the commonest

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

32 7) Ex-fix  usually in open #

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 90%  of obstetric # 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 # - Clinical Evaluation:Painful palpable mass along the clavicle Tenderness, crepitus, and ecchymosis May be associated with neurovascular injury Pulmonary status must be assessed.

41 Clavicle # - Radiographic (AP X-ray)

42 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

43 Clavicle # 5% 80% 15%

44 Clavicle # - Allman ClassificationType II  Medial third Type I  Middle third (most common) Type III  Lateral third

45 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

46 Clavicle # - Treatment Newborn: unite in 1 week Up to 2 years:figure-of-eight for 2 weeks Age 2-12 Years: A figure-of-eight or sling for 2-4 weeks

47 Clavicle # - Remodeling

48 Clavicle # - Remodeling

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

51 Humeral Supracondylar Fractures

52 Supracondylar #- Incidences55-75%  of all elbow # M:F 3:2 Age  years Left (non-dominant) side  most frequently #

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

54 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

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

57 Type 1 Anterior Humeral Line Hour-glass appearance

58 Type 2

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

62 Supracondylar #- TreatmentType III: Attempt closed reduction and pinning If fails then open reduction and internal fixation by pinning may be necessary for  unstable #, open #, or # with N.V injury

63 Supracondylar #- Flexion Type 3

64 Supracondylar #-Treatment of Flexion TypeType I: Immobilization in a long arm cast, In near extension, For 2 to 3 weeks Type II: Closed reduction, percutaneous pinning, then splinting Type III: Reduction is often difficult, Most require open reduction and internal fixation with pinning

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

66 Supracondylar #- ComplicationsNeurologic injury (7% to 10%) Most are neurapraxias requiring no treatment Median and anterior interosseous nerves (most common) Vascular injury (0.5%) Direct injury to the brachial artery or secondary to swelling

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

68 Distal Radial Fractures a) Physeal Injuries

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

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

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

72 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

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

74 Distal Radial Physeal #- Treatment Types I & II

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

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

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

78 Distal Radial Fractures b) Metaphyseal Injuries

79 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

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

81 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

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

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

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

85 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

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

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

90 Femoral Shaft #- Clinical EvaluationLook: Pain, Swelling of the thigh, Inability to ambulate, and Variable gross deformity Careful O/E of the overlying soft tissues to rule out the possibility of an open fracture (puncture wound) Feel: Tender # site Careful neurovascular examination is essential

91 Femoral Shaft #- RadiologyAP and lateral views Must include hip, knee joints

92 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

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

94 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)

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

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

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

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

99 Femoral Shaft #- TreatmentOperative Indications: Multiple trauma, including head injury Open fracture Vascular injury Pathologic fracture Uncooperative patient

100

101 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

102 Remember …

103 Remember