1. Management of Fractures in Adolescents
Friday Registrar Presentation
Dr. Stewart Morrison MBBS
Western Health Orthopaedic Department

2. Introduction Adolescence
Puberty: acceleration phase, peak height velocity, deceleration phase
Peak height velocity: Girls 12 years, Boys 14 years
Fall between management parameters for adults, and those for children
Quality of Bone .Less mineralised, more vascular, greater callus
.greater energy dissipation, less comminution, quicker healing
Structure of Bone .Physeal Plate
.Closure of Physeal Plate
Psychosocial
Physeal fractures occur where dislocations and ligamentous injuries would occur in adults: Tib spine, Tillaux fracture, tib tuberosity avulsion
Iatrogenic injury to physis

3. Estimation of Maturity
Various Methods .Sauvegrain
.Oxford Score
.Greulich’s and Pyle’s Atlas
.Tanner-Whitehouse-III RUS Score
.Sanders modification of TWIIIRUS Score
Biological Staging .Tanner Stages
.Secondary Sexual Characteristics
Chrono age does not equal bone age
Sanders modification – if the physes of distal phalanges are wide open, skel immaturl, if partially closed, is at peak, of closed, reached peak height velocity

7. Classification of Physeal Fractures
Salter-Harris
Perichondral ring of La Croix
Communication
Prognosis
based on the mechanism of inj ury and the relationship of the fracture line to the growing cells of the epiphyseal plate. The classification is also correlated with the prognosis concerning disturbance of growth.
Salter harris V is a retrospective diagnosis

8. Imaging General Principles Joint above, joint below Comparison viewsCT
MRI
Chrono age does not equal bone age
Sanders modification – if the physes of distal phalanges are wide open, skel immaturl, if partially closed, is at peak, of closed, reached peak height velocity

9. Principles of Treatment: Physeal Fractures
Reduction
Traction, gentle manipulation
Open preferable to multiple closed attempts
No reduction after 7-10 days, unless > 2mm step-off
Fixation
Pins, screws should be parallel to the physis
Single pass, single smooth K-wire
Resection of periosteum
Langenskiöld procedure
Langenskold – free fat interpositional graft Mo
Most heal in 3 weeks.
Growth disturbance monitoring.

10. Park-Harris Lines

11. How to succinctly and clearly explain this algorithm to parents?
… when often they only hear the word ‘deformity’

12. Principles of Treatment: Non-Physeal Fractures
Adolescent bone does not have the remodelling capacity of childrens’
Weight and specific characteristics need to be taken into account
Displaced diaphyseal fractures – Titanium Elastic Nails
Displaced metaphyseal fractures – Percutaneous Pin Fixation
Supplementation of fixation by splint or cast
Locking plates not usually required
Implant removal
Langenskold – free fat interpositional graft Mo

15. Clavicle First bone to begin ossification, and the last to finish it.
Threshold of > 2 cm of displacement often cited
Operative Considerations
ORIF
Supraclavicular nerve
Neurovascular bundle
Earlier return to full activities (12 vs 16 weeks)
Aiding the regeration of tissue with poor healing potential
Been used since the 1980s for wound healing, ortho for augementation of bone grafting, no definite evidence that it improves bone healing
Released cytokines bind to transmemebraine receptors on the surface of the local or circulating cells, and induce intracellular signaling. This results in production of proteins responsible for cellular chemotaxis, matrix synthesis, and proliferation

16. Radial and Ulnar Shafts
Studies often convoluted by pediatric participants, and inclusion of metaphyseal fractures
More difficult to manage than previously thought
Greenstick
Plastic Deformation
Complete
Comminuted
If a deformity is present in two orthogonal radiographs, the true deformity will be greater than appreciated on either single view
Aiding the regeration of tissue with poor healing potential
Been used since the 1980s for wound healing, ortho for augementation of bone grafting, no definite evidence that it improves bone healing
Released cytokines bind to transmemebraine receptors on the surface of the local or circulating cells, and induce intracellular signaling. This results in production of proteins responsible for cellular chemotaxis, matrix synthesis, and proliferation

17. Radial and Ulnar Shafts
Operative Considerations
1.5 – 2.0 mm Titanium Elastic Nails (TENS)
Closed Reduction  closed reduction with percutanous fixation  open reduction
Reestablish radial bow, eliminate any bowing of ulna
Fix radius first
Narrowest point of radius is central
Narrowest point of ulna is within the distal third
Do not cross physes
Removal at six months or more
Aiding the regeration of tissue with poor healing potential
Been used since the 1980s for wound healing, ortho for augementation of bone grafting, no definite evidence that it improves bone healing
Released cytokines bind to transmemebraine receptors on the surface of the local or circulating cells, and induce intracellular signaling. This results in production of proteins responsible for cellular chemotaxis, matrix synthesis, and proliferation

18. Femoral Shaft Principles Timely union No rotational deformity
< 2 cm shortening
Deformity of < 10-20° (sagittal plane), < 5-10° (coronal plane)
Operative Considerations
In adolescents, surgical treatment favoured
Elastic intramedullary nails (< 11 yrs, < 49 kg ) .require removal
Rigid nails, plating (> 11 yrs, length ‘unstable’ fractures) .require removal
No randomized trials
External Fixation
TENS – two nails of same diameter, width of each to be 40% of canal at narrowest point
PIRIFORMIS entry point only if physis closed, or AVN
Ex fix – soft tissue, trauma, severe shortening.
Patients and families, cosmetic appearance, scars, infection

19. Distal Femur High Energy Metaphyseal Fractures
< 10 years; closed reduction + percutaneous cross-pin fixation + long leg cast
> 10 years or unstable fracture, consider plating or external fixation
Physeal Fractures
SHI + SH II, undisplaced – long leg cast
SHI + II, mildly displaced – closed reduction, percutaneous pinning, long leg cast
SH II, large metaphyseal fragment – cannulated screws, long leg cast
SH III + IV, displaced – cannulated compression screws
All should remain NWB following fixation
50% of distal femoral fractures lead to growth disturbance (SH II highest risk)
Aiding the regeration of tissue with poor healing potential
Been used since the 1980s for wound healing, ortho for augementation of bone grafting, no definite evidence that it improves bone healing
Released cytokines bind to transmemebraine receptors on the surface of the local or circulating cells, and induce intracellular signaling. This results in production of proteins responsible for cellular chemotaxis, matrix synthesis, and proliferation

20. Proximal Tibia Physeal Fractures High energy CT recommended
Similar management principles to distal femoral fractures
Metaphyseal Fractures
“Cozen Fractures”
Closed reduction, long leg casting
Genu valgum is most common complication
Aiding the regeration of tissue with poor healing potential
Been used since the 1980s for wound healing, ortho for augementation of bone grafting, no definite evidence that it improves bone healing
Released cytokines bind to transmemebraine receptors on the surface of the local or circulating cells, and induce intracellular signaling. This results in production of proteins responsible for cellular chemotaxis, matrix synthesis, and proliferation

21. Proximal Tibia Tibial Spine Fractures Hyperextension of the knee
ACL avulsion injury
Tibial Tubercle Fractures
Repetitive jumping sports
Ogden modification of Watson-Jones Classification
Open reduction, internal fixation for II, III, IV
V should have periosteal sleeve reattached
Genu recuvatum
Aiding the regeration of tissue with poor healing potential
Been used since the 1980s for wound healing, ortho for augementation of bone grafting, no definite evidence that it improves bone healing
Released cytokines bind to transmemebraine receptors on the surface of the local or circulating cells, and induce intracellular signaling. This results in production of proteins responsible for cellular chemotaxis, matrix synthesis, and proliferation

22. Ankle
Considerations
Fibular physis closes later than the tibial physis (12-14, vs yrs)
Tibial physis closes in a circular pattern – centre to medial to lateral
CT scan recommended
Management
SH I or SHII, undisplaced – BK walking cast 3-4 weeks
SH I or SHII, displaced – closed reduction, AK cast 3 weeks, then BK 3 weeks
SH III or SHIV – often require open reduction, internal fixation
If periosteal flap not removed, 60% incidence of plate closure
No more than 5% of angulation in any plane should be accepted
Aiding the regeration of tissue with poor healing potential
Been used since the 1980s for wound healing, ortho for augementation of bone grafting, no definite evidence that it improves bone healing
Released cytokines bind to transmemebraine receptors on the surface of the local or circulating cells, and induce intracellular signaling. This results in production of proteins responsible for cellular chemotaxis, matrix synthesis, and proliferation

23. Ankle Tillaux Fracture
SHIII of anterolateral distal tibial epiphysis (final area to close)
Internal rotation can provide closed reduction, however often need open reduction
Triplanar Fracture
SHIII or SH IV
Appears as SH II on lateral radiograph, SH III on anteroposterior radiograph
Younger patient than Tillaux fracture
Growth arrest not clinically important
Flexion of Knee to 90 degrees, plantar flexion and internal rotation of the foot, with AK cast for 3/52
If unsuccessful, proceed to percutaneous or open reduction/fixation
Aiding the regeration of tissue with poor healing potential
Been used since the 1980s for wound healing, ortho for augementation of bone grafting, no definite evidence that it improves bone healing
Released cytokines bind to transmemebraine receptors on the surface of the local or circulating cells, and induce intracellular signaling. This results in production of proteins responsible for cellular chemotaxis, matrix synthesis, and proliferation

24. Thank you
Salter RB, Harris WR. Injuries Involving The Epiphyseal Plate. J Bone Joint Surg Am. 1963;45: Khan La, Bradnock Tj, Scott C, Robinson Cm. Fractures Of The Clavicle. J Bone Joint Surg Am Feb;91(2): Egol Ka Et Al. Management Of Fractures In Adolescents. J Bone Joint Surg. Am Dec;92(18) 2947 Zionts Le. Fractures Around The Knee In Children. JAAOS Vol. 10 No. 5 September/October 2002 Alain Diméglio; Yann Philippe Charles; Jean-pierre Daures; Vincenzo De Rosa; Accuracy Of The Sauvegrain Method In Determining Skeletal Age During Puberty. Journal Of Bone And Joint Surgery; Aug 2005; 87, 8; Health & Medical Complete Momberger N, Stevens P, Smith J, Santora S, Scott S, Anderson J. Intramedullary nailing of femoral fractures in adolescents. J Pediatr Orthop. 2000;20: