Principles of management Pediatric Fractures Mohammad Ali Tahririan Fellowship of Pediatric Orthopedics

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

(sample of 923 children, 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.

CLASSIFICATION OF PHYSEAL INJURIES Salter-Harris classification of physeal fractures

Physeal anatomy Most injuries occur just above area of provisional calcification within the hypertrophic zone. Germinal layer frequently remains intact and attached to the epiphysis physis is connected to the epiphysis and metaphysis by the zone of Ranvier and the perichondral ring of LaCroix zone of Ranvier is a wedge-shaped group of germinal cells, continuous with the physis, contributes to latitudinal, or circumferential, growth of the physis; consists of three cell, Osteoblasts form the bony portion of the perichondral ring at the metaphysis; chondrocytes contribute to latitudinal growth; and fibroblasts circumscribe the zone and anchor it to perichondrium above and below physis. The perichondral ring of LaCroix is a fibrous structure that is continuous with the fibroblasts of the zone of Ranvier and the periosteum of the metaphysis, provides strong mechanical support for the bone–cartilage junction of the physis

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 Combination 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 Combination

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

Non-accidental injuries Beware! Non-accidental injuries

Non-accidental injuries Beware! Non-accidental injuries ?Multiple At various levels of healing Unclear history – mismatching with injury Circumstantial evidence

Non-accidental injuries Beware! Non-accidental injuries Circumstantial evidence Soft tissue injuries - bruising, burns Intraabdominal injuries Intracranial injuries Delay in seeking treatment

Non-accidental injuries Beware! Non-accidental injuries Specific pattern Posterior ribs Skull

Non-accidental injuries Beware! Non-accidental injuries Specific pattern Corner fractures (traction & rotation)

Non-accidental injuries Beware! Non-accidental injuries Specific pattern Bucket handle fractures (traction & rotation)

Non-accidental injuries 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

summary Children’s bones are different