Diaphyseal fractures in children Mohamed M. Zamzam Associate Professor & Consultant Pediatric Orthopedic Surgeon KKUH, Riyadh, Saudi Arabia

Objectives To recall specific considerations of diaphyseal fractures in children To be aware of common possible complications To identify the treatment of choice in each particular situation among a big list of management options To create an algorithm as a guide for managing long bone shaft fractures in pediatric population Diaphyseal Fractures in Children

General Principles About 15% of injuries in children are skeletal Out of all skeletal injuries in children –Radial shaft fractures 6.4 % –Tibial shaft fractures 6.2 % –Femoral shaft fractures 2.1 % –Proximal & shaft humerus fractures 1.4 % Diaphyseal Fractures in Children

Specific Problems Premature complete physeal closure Progressive limb length discrepancy Nonunion Open reduction and internal fixation Diaphyseal Fractures in Children

General management Cast Internal fixation External fixation Diaphyseal Fractures in Children

General management Cast Internal fixation External fixation Diaphyseal Fractures in Children

General management Cast Internal fixation External fixation Diaphyseal Fractures in Children

General management Indications for surgery Head injury Multiple injuries Adolescence Failure of conservative means Severe soft-tissue injury Neurological disorder Malunion and delayed union Diaphyseal Fractures in Children

Elastic stable intramedullary nailing (ESIN) The principle 2 elastic nails Maximum curve Orientation The size Good knowledge of the technique Diaphyseal Fractures in Children

Elastic stable intramedullary nailing (ESIN) Advantages No need for postoperative cast Primary bone union Avoidance of growth plate injury Minimum invasive surgery Excellent functional and cosmetic results Diaphyseal Fractures in Children

Elastic stable intramedullary nailing (ESIN) Complications Nonunion ?? Osteomyelitis (rate is 2%) Overgrowth ( <10 mm before age of 10 years) Cortical perforation Re-fractures ? Skin irritation Diaphyseal Fractures in Children

Forearm The distal radial epiphyseal plate realigned well in children below 10 years Radioulnar angulation usually associated with loss of motion The risk of refracture Diaphyseal Fractures in Children

Forearm Treatment options Closed reduction + cast AO plates Intramedullary fixation Diaphyseal Fractures in Children

Forearm Closed intramedullary nailing Internal fixation of the radius only The radius has the more complicated function Better alignment of the ulnar fracture Diaphyseal Fractures in Children

Forearm diaphyseal fracture Open Closed Debridement in OR

Forearm diaphyseal fracture Open Closed Debridement in OR Angulation 0°-10° Angulation 10°-20° Angulation +20°

Forearm diaphyseal fracture Open Closed Debridement in OR Angulation 0°-10° Angulation 10°-20° Angulation +20° Closed reduction + 5 years All ages Long arm cast or splint 0-5 years Successful if < 10°

Forearm diaphyseal fracture Open Closed Debridement in OR Angulation 0°-10° Angulation 10°-20° Angulation +20° Closed reduction Open reduction +ESIN Unsuccessful + 5 years All ages Long arm cast or splint 0-5 years Successful if < 10° Successful but unstable Closed reduction + ESIN

Humerus Incidence is related to the cause and age group Classified according to –Fracture pattern –Location –Tissues damaged Diaphyseal Fractures in Children

Humerus Priority is given to conservative treatment Osteosynthesis (10%) External fixation Diaphyseal Fractures in Children

Humerus potential operative indications Open fractures Multiple trauma Bilateral injuries Compartment syndromes Pathological fracture Significant nerve injuries Inadequate closed reduction Diaphyseal Fractures in Children

Humeral diaphyseal fracture Adolescents & Older childrenInfants & younger children Immobilize in a sling & swath ClosedOpen

Humeral diaphyseal fracture Adolescents Older childrenInfants & younger children Debridement in OR Immobilize in a sling & swath Closed Closed reduction + ESIN External fixator Open IIII & II Adolescents & Older children

Humeral diaphyseal fracture Adolescents Older childrenInfants & younger children Debridement in OR Closed reduction Immobilize in a sling & swath Closed Midshaft angulation Closed reduction + ESIN Immobilize in soft dressing External fixator Open < 20°> 20° IIII & IISurgical indications Adolescents & Older children

Femur Stress fracture Pulmonary complications Growth disturbances resulting in 1. accelerated growth 2. retarded growth 3. axial deformities 4. rotational deformities Spontaneous correction Diaphyseal Fractures in Children

Femur Stress fracture Pulmonary complications Growth disturbances resulting in 1. accelerated growth 2. retarded growth 3. axial deformities 4. rotational deformities Spontaneous correction Diaphyseal Fractures in Children

Femur Stress fracture Pulmonary complications Growth disturbances resulting in 1. accelerated growth 2. retarded growth 3. axial deformities 4. rotational deformities Spontaneous correction Diaphyseal Fractures in Children

Femur Stress fracture Pulmonary complications Growth disturbances resulting in 1. accelerated growth 2. retarded growth 3. axial deformities 4. rotational deformities Spontaneous correction Diaphyseal Fractures in Children

Femur Adequately managed non-operatively Operative approach 2-5 years post-injury non-debilitating pain Strict adherence to a surgical technique Diaphyseal Fractures in Children

Femur Treatment options Immediate hip spica Delayed hip spica Plate osteosynthesis Conventional IMN Stainless steel K-wires Titanium elastic nailing External fixation Diaphyseal Fractures in Children

Femur The optimal method Economic reasons Parents’ decision years (no man's land) Diaphyseal Fractures in Children

Femur Conservative mode Low risk of overgrowth Rotational malalignment of up to 20 degrees corrects during growth Economically, cheap Diaphyseal Fractures in Children

Femur Narrow low-contact DCP Minimal exposure Percutaneous screw placement Stable mode of fixation Biologic healing potential Early patient mobilization Diaphyseal Fractures in Children

Femur Rigid intramedullary nail In older children and adolescents Placement through the lateral aspect of GT 1. Safe technique 2. Effective 3. Well tolerated Growth arrest of the greater trochanter Hip function Diaphyseal Fractures in Children

Femur ESIN simple procedure Minimal blood loss Short operative time K-wires # Titanium 2 to 14 years # Ender nails Diaphyseal Fractures in Children

Femur External fixation Simple and elegant Risk of refracture Length of hospital stay Time to union Wire site infection Diaphyseal Fractures in Children

Femoral shaft fracture Debridement in OR Adolescent Open InfantsYounger childOlder child

Femoral shaft fracture Yes Debridement in OR Adolescent Open Abused InfantsYounger childOlder child No Hospital & invest. Immediate Hip spica

Femoral shaft fracture Yes Debridement in OR Adolescent Open Excessive shorteningAbused InfantsYounger childOlder child No Yes Hospital & invest. Immediate Hip spica Traction Then cast ESIN Choice

Femoral shaft fracture Yes Debridement in OR Adolescent External fixator Open Excessive shorteningAbused InfantsYounger childOlder child Comminution No Yes No Hospital & invest. Immediate Hip spica Traction Then cast ESIN Choice

Femoral shaft fracture Yes Debridement in OR Adolescent External fixator Open Excessive shorteningAbused InfantsYounger childOlder child Comminution No Yes No Reamed rod Hospital & invest. Immediate Hip spica Traction Then cast ESIN Choice

Tibia Special considerations Child abuse Isolated tibial fractures Open fractures Pathological fractures Stress fractures Diaphyseal Fractures in Children

Tibia Special considerations Child abuse Isolated tibial fractures Open fractures Pathological fractures Stress fractures Diaphyseal Fractures in Children

Tibia Special considerations Child abuse Isolated tibial fractures Open fractures Pathological fractures Stress fractures Diaphyseal Fractures in Children

Tibia Special considerations Child abuse Isolated tibial fractures Open fractures Pathological fractures Stress fractures Diaphyseal Fractures in Children

Tibia Special considerations Child abuse Isolated tibial fractures Open fractures Pathological fractures Stress fractures Diaphyseal Fractures in Children

Tibia Specific problems Delayed unions Nonunion Malunion Compartment syndromes Diaphyseal Fractures in Children

Tibia Specific problems Delayed unions Nonunion Malunion Compartment syndromes Diaphyseal Fractures in Children

Tibia Specific problems Delayed unions Nonunion Malunion Compartment syndromes Diaphyseal Fractures in Children

Tibia Specific problems Delayed unions Nonunion Malunion Compartment syndromes Diaphyseal Fractures in Children

Tibia Treatment is based on: patient age concomitant injuries fracture pattern surgeon experience Diaphyseal Fractures in Children

Tibia Treatment options Closed reduction and casting External fixation Internal fixation ESIN Diaphyseal Fractures in Children

Tibia Treatment of sequelae after union: Physeal closure Leg-length discrepancy Progressive valgus deformity Diaphyseal Fractures in Children

Tibia Treatment of sequelae after union: Physeal closure Leg-length discrepancy Progressive valgus deformity Diaphyseal Fractures in Children

Tibia Treatment of sequelae after union: Physeal closure Leg-length discrepancy Progressive valgus deformity Diaphyseal Fractures in Children

Tibial shaft fracture Open Debridement in OR Closed IIII & II External fixatorClosed reduction + ESIN Polytrauma

Tibial shaft fracture Open Debridement in OR Closed IIII & II External fixatorClosed reduction + ESIN Polytrauma

Tibial shaft fracture Open Debridement in OR Closed IIII & II External fixatorClosed reduction + ESIN Polytrauma FailedSucceed Closed reduction & cast Consider wedging the cast

Summary Non surgical treatment is the treatment of choice in most diaphyseal fractures in children If surgery is indicated, ESIN is the best option Special attention is directed to –Open fractures –Child abuse –Pathological fractures Always, consider the high healing power of children Diaphyseal Fractures in Children

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