Approaches to Pediatric Fractures Of the foot and ankle Dan Preece MS IV CSPM Class 2009

Pediatric Fractures Accident: the leading cause of death for pts under 14 years of age. Half of all emergency room admissions are for children. In a 10 year study of 700 pediatric fractures only 6% involved the foot and ankle with injury to the distal tibia and fibula being the most common types. Pediatric fractures are usually the result of major trauma (MVA, gunshot, lawn mower, falls etc.) because of the flexibility of the pediatric foot and its ability to adapt and recover from abnormally large forces. Gumann G. Fractures of the foot and ankle. Philadelphia, PA: Elsevier; 2004. Pg 335-336.

Pediatric Fractures The physis (if present) of long bones is the weakest biomechanical link . Physeal disruption will usually result before ligamentous injury. Physeal disruption that leads to the creation of a physeal bar can result in limb length discrepancy and angular deformities of the shaft of long bones. Gumann G. Fractures of the Foot and Ankle. Philadelphia, PA: Elsevier; 2004. Pg 335-336.

Fractures Unique To Pediatrics Green Stick Fracture (radius) www.legacyhealth.org

Fractures Unique To Pediatrics Torus/Buckle Fracture www.legacyhealth.org

Fractures Unique To Pediatrics Cancellous Fracture: Immature bone is subject to compressive forces that crush trabeculae. This deformity is difficult to diagnose because little cortical disruption can be appreciated on x-ray. Bilateral views may help with identification.

Fractures Unique To Pediatrics Plastic Deformation (Bowing): A bow in a long bone that does not spontaneously recover. Bowing will be noted on x-ray with no cortical defects/breaks. Source: Contemporary Pediatrics By: Robert L Hatch, M. Patrice. Eiff, MD Originally published: November 1, 2003

Salter-Harris Classification The Salter-Harris classification method helps to describe fracture lines from an anatomical but not a mechanism of action stand point. Useful when planning fixation approach.

Classification: Anatomical description http://www.e-radiography.net

Classification: Anatomical description http://www.e-radiography.net

Classification: Anatomical description http://www.e-radiography.net

Classification: Anatomical description http://www.e-radiography.net

Classification: Anatomical description http://www.e-radiography.net

Classification: Anatomical description *Due to avulsion or contusion. http://www.e-radiography.net

Salter-Harris Tx and Prognosis Types I & II – Closed reduction possible Types III & IV Congruity of articular surfaces essential Usually require ORIF Accurate reduction more important than I & II Types I, II & III consolidate quickly Type V / VI – prognosis poor

Dias and Tachdjian Classification The Dias-Tachdjian combines both the concepts of Lauge-Hansen (mechanism of action) and Salter-Harris (anatomical description) to describe pediatric fractures of the foot and ankle. The supination-inversion mechanism is the most common type encountered. Gumann G. Fractures of the foot and ankle. Philadelphia, PA: Elsevier; 2004. Pg 335-336.

Dias and Tachdjian Classification

Dias and Tachdjian Classification

Dias and Tachdjian Classification

Dias and Tachdjian Classification

Dias and Tachdjian Classification *Fracture resulting from external rotational forces.

Dias and Tachdjian Classification *May be associated with a high fibular fracture due to external rotation forces.

Closed Reduction of Pediatric Fractures Closed Reduction is usually sufficient for the majority of pediatric fractures. The Dias and Tachdjian Classification system is used to facilitate closed reduction. Define the mechanism of injury. Increase the deformity. Apply distractive forces Reverse the direction of the original deforming force. The foot and ankle should be immobilized in the opposite position of that of the position/mechanism of injury. Gumann G. Fractures of the foot and ankle. Philadelphia, PA: Elsevier; 2004. Pg 335-371.

Guidelines for ORIF of Pediatric Fractures In certain cases, such as those requiring anatomic realignment of the physis or articular surface, there are clear indications for surgical management. Surgical management is used to: maintain optimal alignment allow early ROM facilitate mobilization of children Flynn JM, Skaggs DL. The surgical management of pediatric fractures of the lower extremity. Instructional Course Lectures: 2003;52:647-59

Pediatric ORIF Golden Rules: Never cause compression across the physis (unless the goal is to close the physis). Only smooth hardware should cross the physis (smooth K-wire and Steinman pins). No threaded screws, wires or pins. Removal of hardware once fracture healing has been achieved to avoid further complications as pt continues to grow. Pediatric pts heal very fast, don’t delay corrective procedures (fixate within 7-10 days). Often pediatric pts will be very far along the healing process of bone at the 4th week.

Supination-inversion (adduction) Fixation A. Burns DPM. Podiatric Trauma Lecture Series. Spring 2008 CSPM.

Supination-inversion (adduction) Fixation A. Burns DPM. Podiatric Trauma Lecture Series. Spring 2008 CSPM.

Pronation-Eversion-External Rotation Fixation A. Burns DPM. Podiatric Trauma Lecture Series. Spring 2008 CSPM.

Complications with Pediatric Fractures Compartment syndrome Growth arrest Angular deformities Avascular necrosis Limb length discrepancy

Harris Growth Arrest Lines (Park’s Lines) Following trauma, growth may cease temporarily but mineral deposition continues creating lines visible on x-ray. Park’s lines may eventually reabsorb. Don’t confuse with a fracture/stress fracture later on. → Banks AS, Downey MS, Martin DE, Miller SJ, eds. McGlamry's Comprehensive Textbook of Foot and Ankle Surgery. 3rd edition. Philadelphia, PA: Lippincott, Williams &Wilkins; 2001. Pg 1957-1991.

“Fish Tail” Deformity Disruption of physis can result in central tethering and a fish tail appearance at the physis. Recommendations are to follow the pt radiographically following injury for 1-3 years or even until skeletal maturity to monitor the possible occurrence and plan correction (if needed) of this complication. → Banks AS, Downey MS, Martin DE, Miller SJ, eds. McGlamry's Comprehensive Textbook of Foot and Ankle Surgery. 3rd edition. Philadelphia, PA: Lippincott, Williams &Wilkins; 2001. Pg 1957-1991.

Growth Arrest Resection is called for if a bar has developed across 30-50% of the physis. Langenskjold A. Surgical treatment of partial closure of the growth plate. J Pediatric Orthopedics. 1981;1:3-11. If less than 40% of physis has developed a bar, resection with interposition of adipose tissue or methyl methacrylate should be attempted. If the osseous bridge is greater than 50% of the physis then a supramalleolar opening wedge should be used to correct deformity. Gumann G. Fractures of the foot and ankle. Philadelphia, PA: Elsevier; 2004. Pg 335-367.

New Approaches Kubiak et al. in 2005 performed a retrospective review looking at the differences in results of the treatment of pediatric tibia fractures (in the proximal 2/3 of the tibia) with external fixation versus flexible nails. They reviewed 31 patients who required operative treatment for tibia fractures. Sixteen were treated with flexible nails and 15 with external fixation. Major findings in this study included a significantly shorter time to union for the patients in the flexible nail group (7 vs. 18 weeks), and a significantly higher rate of bone-related complications in the group treated with external fixation. **Flexible IM nail fixation is not indicated for fractures needing fixation across the physis. Kubiak EN, Egol KA, Scher D, et al. Operative treatment of tibial fractures in children: are elastic nails an improvement over external fixation? J Bone Joint Surgery Am 2005; 87A:1761–1768.

Sources: Banks AS, Downey MS, Martin DE, Miller SJ, eds. McGlamry's Comprehensive Textbook of Foot and Ankle Surgery. 3rd edition. Philadelphia, PA: Lippincott, Williams &Wilkins; 2001. Pg 1957-1991. Burns A. DPM. Podiatric Trauma Lecture Series given at CSPM. Spring 2008. Flynn JM, Skaggs DL. The surgical management of pediatric fractures of the lower extremity. Instructional Course Lectures: 2003;52:647-59. Gumann G. Fractures of the foot and ankle. Philadelphia, PA: Elsevier; 2004. Pg 335-367. Langenskjold A. Surgical treatment of partial closure of the growth plate. J Pediatric Orthopedics. 1981;1:3-11. Kubiak EN, Egol KA, Scher D, et al. Operative treatment of tibial fractures in children: are elastic nails an improvement over external fixation? J Bone Joint Surgery 2005; 87A:1761–1768. www.legacyhealth.org www.e-radiography.net

New Theme for SLC VA Podiatry: Mark 9:45   "If thy foot offend thee, cut it off."