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

2. 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 )

3. Statistics
~ 50% of boys and 25% of girls, expected to have a fracture during childhood.
Boys > girls
Rate increases with age.
Mizulta, 1987

4. 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

5. (sample of 923 children, Mizulta, 1987)
Statistics
Most frequent sites
(sample of 923 children, Mizulta, 1987)

6. Why are children’s fractures different?
Children have different physiology and anatomy
Growth plate.
Bone.
Cartilage.
Periosteum.
Ligaments.
Age-related
physiology

7. 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.

8. Why are children’s fractures different?
Children have different physiology and anatomy
Bone:
Increased collagen: bone ratio
- lowers modulus of elasticity

9. 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

10. 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

11. 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

12. 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

13. Why are children’s fractures different?
Children have different physiology and anatomy
Physiology
Better blood supply
rare incidence of delayed and non-union

14. 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.

15. CLASSIFICATION OF PHYSEAL INJURIES
Salter-Harris classification of physeal fractures

16. 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

17. 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)

18. The power of remodeling
Tremendous power of remodeling
Can accept more angulation and displacement
Rotational mal-alignment ?does not remodel

19. 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

20. The power of remodeling
Factors affecting remodeling potential
Growth potential of adjacent physis
e.g. upper humerus better than lower humerus

21. 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

22. Indications for operative fixation

23. Methods of fixation
Casting - still the commonest

24. Methods of fixation Casting - still the commonest K-wires
most commonly used
Metaphyseal fractures

25. Methods of fixation Casting - still the commonest K-wires
most commonly used
Metaphyseal fractures
K- wires could be replaced by absorbable rods

26. Methods of fixation Casting - still the commonest K-wires
most commonly used
Metaphyseal fractures
K- wires could be replaced by absorbable rods
Preoperative immediate months months
Hope et al , JBJS 73B(6) ,1991

27. Methods of fixation Casting - still the commonest K-wires
most commonly used
Metaphyseal fractures
Intramedullary wires, elastic nails
Very useful
Diaphyseal fractures

28. Methods of fixation Casting - still the commonest K-wires
most commonly used
Metaphyseal fractures
Intramedullary wires, elastic nails
Very useful
Diaphyseal fractures
Screws

29. Methods of fixation Casting - still the commonest K-wires
most commonly used
Metaphyseal fractures
Intramedullary wires, elastic nails
Very useful
Diaphyseal fractures
Screws

30. 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

31. 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)

32. 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

33. 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

34. 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.

35. 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

36. Non-accidental injuries
Beware!
Non-accidental injuries

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

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

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

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

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

42. 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

43. 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

44. summary
Children’s bones are different