Principles of management
Pediatric Fractures
Objectives
• Statistics about fractures in children
• How children’s bones are different
• Outline principles of management
• Point out specific precautions
Acknowledgement and recommendation
Lynn T Staheli
introduction
• In Middle East ~60% of population are < 20 yrs.
• Fractures account for ~15% of all injuries in children.
• Different from adult fractures
• Vary in various age groups
( Infants, children, adolescents )
Statistics
• ~ 50% of boys and 25% of girls, expected to have a
fracture during childhood.
• Boys > girls
• Rate increases with age.
Mizulta, 1987
Statistics
• ~ 50% of boys and 25% of girls, expected to have a
fracture during childhood.
• Boys > girls
• Rate increases with age.
• Physeal injuries with age.
Mizulta, 1987
Statistics
Most frequent sites
(sample of 923 children, Mizulta, 1987)
Why are children’s fractures different?
Children have different physiology and anatomy
• Growth plate.
• Bone.
• Cartilage.
• Periosteum.
• Ligaments.
• Age-related
• physiology
Why are children’s fractures different?
Children have different physiology and anatomy
• Growth plate:
– In infants, GP is stronger than bone
increased diaphyseal fractures
– Provides perfect remodeling power.
– Injury of growth plate causes deformity.
– A fracture might lead to overgrowth.
Why are children’s fractures different?
Children have different physiology and anatomy
• Bone:
– Increased collagen: bone ratio
- lowers modulus of elasticity
Why are children’s fractures different?
Children have different physiology and anatomy
• Bone:
– Increased collagen: bone ratio
- lowers modulus of elasticity
– Increased cancellous bone
- reduces tensile strength
- reduces tendency of fracture to propagate
less comminuted fractures
– Bone fails on both tension and compression
- commonly seen “buckle” fracture
Why are children’s fractures different?
Children have different physiology and anatomy
• Cartilage:
– Increased ratio of cartilage to bone
- better resilience
- difficult x-ray evaluation
- size of articular fragment often under-estimated
Why are children’s fractures different?
Children have different physiology and anatomy
• Periosteum:
– Metabolically active
• more callus, rapid union, increased remodeling
– Thickness and strength
• Intact periosteal hinge affects fracture pattern
• May aid reduction
Why are children’s fractures different?
Children have different physiology and anatomy
• Age related fracture pattern:
– Infants: diaphyseal fractures
– Children: metaphyseal fractures
– Adolescents: epiphyseal injuries
Why are children’s fractures different?
Children have different physiology and anatomy
• Physiology
– Better blood supply
rare incidence of delayed and non-union
Physeal injuries
• Account for ~25% of all children’s fractures.
• More in boys.
• More in upper limb.
• Most heal well rapidly with good remodeling.
• Growth may be affected.
Physeal injuries
Classification: Salter-Harris, Peterson, Ogden
Physeal injuries
• Less than 1% cause physeal bridging affecting
growth.
– Small bridges (<10%) may lyse spontaneously.
– Central bridges more likely to lyse.
– Peripheral bridges more likely to cause deformity
– Avoid injury to physis during fixation.
– Monitor growth over a long period.
– Image suspected physeal bar (CT, MRI)
The power of remodeling
• Tremendous power of remodeling
• Can accept more angulation and displacement
• Rotational mal-alignment ?does not remodel
The power of remodeling
Factors affecting remodeling potential
• Years of remaining growth – most important factor
• Position in the bone – the nearer to physis the better
• Plane of motion –
greatest in sagittal, the frontal, and least for transverse plane
• Physeal status – if damaged, less potential for correction
• Growth potential of adjacent physis
e.g. upper humerus better than lower humerus
The power of remodeling
Factors affecting remodeling potential
• Growth potential of adjacent physis
e.g. upper humerus better than lower humerus
Indications for operative fixation
• Open fractures
• Displaced intra articular fractures
( Salter-Harris III-IV )
• fractures with vascular injury
• ? Compartment syndrome
• Fractures not reduced by closed reduction
( soft tissue interposition, button-holing of periosteum )
• If reduction could be only maintained in an abnormal
position
Indications for operative fixation
Methods of fixation
• Casting - still the commonest
Methods of fixation
• Casting - still the commonest
• K-wires
– most commonly used
– Metaphyseal fractures
Methods of fixation
• Casting - still the commonest
• K-wires
– most commonly used
– Metaphyseal fractures
• K- wires could be replaced by absorbable rods
Methods of fixation
• Casting - still the commonest
• K-wires
– most commonly used
– Metaphyseal fractures
• K- wires could be replaced by absorbable rods
Preoperative immediate 6 months 12 months
Hope et al , JBJS 73B(6) ,1991
Methods of fixation
• Casting - still the commonest
• K-wires
– most commonly used
– Metaphyseal fractures
• Intramedullary wires, elastic nails
– Very useful
– Diaphyseal fractures
Methods of fixation
• Casting - still the commonest
• K-wires
– most commonly used
– Metaphyseal fractures
• Intramedullary wires, elastic nails
– Very useful
– Diaphyseal fractures
• Screws
Methods of fixation
• Casting - still the commonest
• K-wires
– most commonly used
– Metaphyseal fractures
• Intramedullary wires, elastic nails
– Very useful
– Diaphyseal fractures
• Screws
Methods of fixation
• Casting - still the commonest
• K-wires
– most commonly used
– Metaphyseal fractures
• Intramedullary wires, elastic nails
– Very useful
– Diaphyseal fractures
• Screws
• Plates – multiple trauma
Methods of fixation
• Casting - still the commonest
• K-wires
– most commonly used
– Metaphyseal fractures
• Intramedullary wires, elastic nails
– Very useful
– Diaphyseal fractures
• Screws
• Plates – multiple trauma
• IMN - adolescents only (injury to growth)
Methods of fixation
• Casting - still the commonest
• K-wires
– most commonly used
– Metaphyseal fractures
• Intramedullary wires, elastic nails
– Very useful
– Diaphyseal fractures
• Screws
• Plates – multiple trauma
• IMN - adolescents
• Ex-fix – usually in open fractures
Methods of fixation
• Casting - still the commonest
• K-wires
– most commonly used
– Metaphyseal fractures
• Intramedullary wires, elastic nails
– Very useful
– Diaphyseal fractures
• Screws
• Plates – multiple trauma
• IMN - adolescents i o n
a t
• Ex-fix bi n
o m
C
Fixation and stability
• Fixation methods provide
varying degrees of
stability.
• Ideal fixation should
provide adequate stability
and allow normal flexibility.
• Often combination methods
are best.
Complications
• Ma-lunion is not usually a problem
( except cubitus varus )
• Non-union is hardly seen
( except in the lateral condyle )
• Growth disturbance – epiphyseal damage
• Vascular – volkmann’s ischemia
• Infection - rare
Beware!
Non-accidental injuries
Beware!
Non-accidental injuries
• ?Multiple
• At various levels of healing
• Unclear history – mismatching with injury
• Circumstantial evidence
Beware!
Non-accidental injuries
• Circumstantial evidence
• Soft tissue injuries - bruising, burns
• Intraabdominal injuries
• Intracranial injuries
• Delay in seeking treatment
Beware!
Non-accidental injuries
• Specific pattern
– Posterior ribs
– Skull
Beware!
Non-accidental injuries
• Specific pattern
– Corner fractures (traction & rotation)
Beware!
Non-accidental injuries
• Specific pattern
– Bucket handle fractures (traction & rotation)
Beware!
Non-accidental injuries
• Specific pattern
– Femur shaft fracture
• <1 year of age ( 60-70% non accidental)
• Transverse fracture
– Humeral shaft fracture <3 years of age
– Sternal fractures
Beware!
Malignant tumours
• Can present as injury.
• History of trauma usual.
•12 y old girl
• History of trauma
• mild tenderness
• Periosteal reaction
• 2m later, still tender
• Ewings sarcoma
Special considerations
During resuscitation
summary
Children’s bones are different
summary
• About 60% of population in ME are children!
• Fractures in children are common.
• Children’s bones are different
• Outline principles of management.
• Specific treatment plans (combinations possible)
• Specific precautions.
• Beware
– Non-accidental trauma
– Malignant tumors
