1. Surgical fixation of fractures in children Alwyn Abraham CONSULTANT IN TRAUMA (ADULT & CHILDREN) & ELECTIVE CHILDREN’S ORTHOPAEDIC SURGERY Leicester Royal Infirmary

2. Overview 1.Properties of paediatric bone are different. 2.The pattern of fractures are different in children 3.What are the common children’s injuries that require stabilisation?

3. Summary Have a low threshold to K-wire displaced distal metaphyseal fractures Radius shaft fractures: ESIN Femoral fractures – spica or ESIN Tibial fractures – cast/ ESIN/ bone transport for severe injuries.

4. Bony anatomy in children Plastic Deformation A result of the different composition of paediatric bone Energy absorbed prior to fracture Affects reduction.

5. Bony anatomy in children Remodelling potential Related to site Related to age Related to severity of deformity Related to plane of deformity Phenomenon of overgrowth

6. Pattern of injuries in children Epidemiology of children’s fractures Worlock P & Stower M. Fracture patterns in Nottingham Children. J.Paed.Orth;1986 6(6):656-660 Calendar year 1981 in age < 12 years 826 patients with 923#s (pop 102841)‏ Injuries and causes and in –0-18 mths –18-60 mths –> 5yrs of age

7. Pattern of injuries in children Worlock P & Stower M. Fracture patterns in Nottingham Children. J.Paed.Orth;1986 6(6):656-660

8. Pattern of injuries in children Worlock P & Stower M. Fracture patterns in Nottingham Children. J.Paed.Orth;1986 6(6):656-660

9. Pattern of injuries in children Worlock P & Stower M. Fracture patterns in Nottingham Children. J.Paed.Orth;1986 6(6):656-660

10. Wrist fractures in children Wrist fractures

11. Interventions for treating metaphyseal distal radius fractures in children A Cochrane Systematic Review and Meta analysis (in press)‏ Alwyn Abraham * Helen Handoll § & Tahir Khan † * Consultant Orthopaedic Surgeon, University Hospital of Leicester § University of Teesside † Consultant Orthopaedic Surgeon, Manchester Children’s Hospitals

12. Wrist fractures in children Synopsis use removable splint for buckle fractures after an MUA use a below elbow cast after an MUA use a K wire

13. Wrist fractures in children Search strategy Cochrane Bone Joint and Muscle Trauma Group Specialised Register (to Jan 2008), Cochrane Central Register of Controlled Trials (The Cochrane Library Jan 2008)‏ MEDLINE (1966 to Jan 2008)‏ MEDLINE pending (accessed Jan 2008)‏ EMBASE (1988 to Jan 2008)‏ CINAHL (1982 to Jan 2008)‏ reference lists of articles. Only English language studies were reviewed.

14. Wrist fractures in children Subject-specific strategy 1. Ulna Fractures/ or Radius Fractures/ 2. (distal or metaphys$ or epiphys$ or torus or wrist).tw. 3. and/1-2 4. Wrist Injuries/ or Forearm Injuries/ 5. fracture$.tw. 6. and/4-5 7. (ulna$1 or radius or radial or forearm$1 or wrist$1).tw. 8. and/2,5,7 9. or/3,6,8 10. exp Pediatrics/ 11. Infant, Newborn/ 12. Infant/ 13. exp Child/ 14. Adolescent/ not exp Adult/ 15. (paediatr$ or pediatr$ or neonate$ or bab$3 or infant$ or child$ or teenage$ or adolescen$).tw. 16. or/10-15 17. and/9,16

15. 12 th May, 2007 Wrist fractures in children 15 Wrist fractures requiring surgical stabilisation MUA and above elbow cast vs. MUA K-wire Gibbons 1994, McLauchlan 2002, Miller 2005

16. Radius shaft fractures in children Radius shaft fractures

17. Interventions for treating radius shaft fractures in children A Cochrane Systematic Review and Meta analysis (in progress)‏ Alwyn Abraham * Sujit Kumar § & Sameena Choudhary † * Consultant Orthopaedic Surgeon, University Hospital of Leicester § SpR Orthopaedics, London † SpR Orthopaedics, Birmingham

18. Radius shaft fractures in children Deformity remodelling depends on : Age 8-10 Severity >10º Plastic deformity Radius shaft fractures

19. Radius shaft literature Zionts JPO 2005castsn-=258-15Deformity 10 deg FROM Bhaskar JBJSBr 2001 ORIF single vs. both N=12 vs. 20Ave = 11No major complications Houshian injury 2005 Single bone ESINN=206-15No complications up to 20mths Fernandez Injury 2005 ORIF vs. ESINN=19 vs. 452 re-operations each group Lacombes 2005ESINN=121>85 re-operations Jubel JPOB 2005ESINN=51No major complications Myers 2004Single bone ESIN=254-15No major complications Radius shaft fractures

20. ESIN minor complications Superficial Radial nerve injury Prominent nail Open reduction Keloid/ hypertrophic scars Radius shaft fractures

21. Femoral shaft fractures in children Femoral fractures Selection based on Age bodyweight Fracture configuration

22. Femoral shaft fractures in preschool children

23. N=72 1.5-5.9 yrs 9/72 nail adjustment Early weight bearing in all

24. Body weight Femoral fractures

25. Body weight Femoral fractures

26. N=39 25 short fractures vs. 15 long fractures Re-operation rate 2/24 vs. 6/15

28. Femoral fractures

35. Tibial fractures in children

37. 5 yr period 16#s in 14 patients Ave age 10yrs 4 mths 3 open fractures Union 8 wks (15 wks for open #s)‏

38. Tibial fractures

43. Recap 1.Properties of paediatric bone are different. 2.The pattern of fractures are different in children 3.What are the common children’s injuries that require stabilisation? 4.The techniques used are a bit different in children

44. Summary Have a low threshold to K-wire displaced distal metaphyseal fractures Radius shaft fractures: ESIN for displaced/ angulated fractures Femoral fractures – spica or ESIN Tibial fractures – cast/ ESIN/ bone transport for severe injuries. Tibial fractures