Various types of fractures in children and genral managemnet strategy

1. General Principles of management
Pediatric Fractures
Presented by:
Dr. Harjot Singh Gurudatta
Moderator : Dr. Gagan Khanna

2. Children’s bones are different
Metabolically more active,more vascularity,
aids reduction
Modulus of elasticity better resilience,
size of articular segment underestimated
Reduces tensile strength
comminution
In infants, GP is stronger
than bone
increased diaphyseal
fractures
Provides perfect
remodeling power.
Injury of growth plate
causes deformity

3. REMODELLING OF BONE IN CHILDREN

4. • Age related fracture pattern:
– Infants: diaphyseal fractures
– Children: metaphyseal fractures
– Adolescents: epiphyseal injuries
Why are children’s fractures different?

5. • ~ 50% of boys and 25% of girls, expected to have a
fracture during childhood.
• Upper limb # more common with # distal radius
elbow region # viz distal humeral and prox. Radial
being common. Most # in home / school, femur
and pelvic # more with RSA.
• Boys > girls
• Rate increases with age.
• Physeal injuries with age. Mizulta, 1987
Statistics

6. General Principles
Failure of union is rare.
Few fractures require operative treatment.
Presence of growth plate presents a challenge to the
surgeon.
Special considerations :
• Pathological fractures and malignancies
• Child abuse(multiple fracture and injuries at different
stages of healing, epiphysio-metaphysis corner injuries)

7. source: http://training.seer.cancer.gov
Centers of Ossification
• 1° ossification center
• Diaphyseal
• 2° ossification centers
• Epiphyseal
• Occur at different stages of
development
• Usually occurs earlier in girls than
boys

8. General Principles
Regulation of Epiphyseal Growth
Physis is the primary centre for growth
in most bones.
Four functional zones:
• Reserve zone>> germinal layer for
cartilage cells
• Proliferation zone>>bone length is
created by active growth of cartilage
cells
• Hyprtrophic zone>> Terminally divided
cells ..no active growth, gradually
extending toward metaphysis and to
zone of degeneration
• Provisional calcification>>>
extracellular chondroid gets
impregnated with calcium salt with
blood vessels invasing from
metaphysis
EPIPHYSIS
METAPHYSIS

9. 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.
• Physis responds to
compression as well as
distraction(# implants
infection etc)

11. • Type I
– Through physis only
• Type II
– Through physis & metaphysis
• Type III
– Through physis & epiphysis
• Type IV
– Through metaphysis, physis &
epiphysis
• Type V
– Crush injury to entire physis
• Others added later by subsequent
authors(eg Ranga type 6 peripheral
physeal injury)
Described by Robert B. Salter and W. Robert Harris in 1963.
Salter - Harris Classification
Type VI - Injury to the perichondral structures
Type VII - Isolated injury to the epiphyseal plate
Type VIII - Isolated injury to the metaphysis,
with a potential injury related to endochondral
ossification
Type IX - Injury to the periosteum that may
interfere with membranous growth
AITKENS , polands, PETERSENS SYSTEM OF
PHYSEAL INJURIES ARE THERE BUT SALTER
HARRIS REMAINS UNIVERSALLY ACCEPTED.

12. Epiphyseal Injuries

13. Salter Harris Classification General Treatment
Principles
TYPE 1 AND 2 Closed
reduction &
immobilization
•Type III & IV
•Intra-articular and
physeal step-off needs
anatomic reduction
•ORIF, if necessary

14. 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)
• Smooth pins should be used for fixation not
threaded ones if they are to cross physes.

15. Epiphyseal Injuries
Try not to cross the physis, but rather parallel it in the epiphysis or
pin the fracture spike in the metaphysis

16. Growth Arrest Secondary to Physeal Injury
Complete cessation of longitudinal
growth
• leads to limb length
discrepancy
Partial cessation of longitudinal
growth
• angular deformity, if peripheral
• progressive shortening, if
central
Warn parents about early operative
complications and late
complications, such as bony bridge
formation, angular deformity.

17. Growth Arrest Lines
Transverse lines of Park- Harris
Lines
Occur after fracture/stress
Result from temporary slowdown
of normal longitudinal growth
Thickened osseous plate in
metaphysis
Should parallel physis

18. Growth Arrest Lines
Appear 6-12 weeks after fracture
Look for them in follow-up
radiographs after fracture
If parallel physis - no growth
disruption
If angled or point to physis -
suspect bar

19. Physeal Bar
- Imaging -
• Tomograms/CT
scans
• MRI
• Map bar to
determine
location and
extent

20. Physeal Bars
- Types -
• I - peripheral,
angular
deformity
• II - central,
tented physis,
shortening
• III -
combined/compl
ete - shortening

21. Physeal Bar
- Treatment -
Address
• Angular
deformity
• Limb length
discrepancy
Assess
• Growth
remaining
• Amount of
physis
involved
• Degree of
angular
deformity
• Projected
LLD at
maturity

22. Physeal Bar Resection
- Indications -
• >2 years remaining growth
• <50% physeal involvement
(cross-sectional)
• Concomitant osteotomy for
>15-20º deformity
• Completion epiphyseodesis
(tethering physis with staple
screw)and contralateral
epiphyseodesis may be
more reliable in older child
• Central bar> peripheral bar

23. Physeal Bar Resection - Techniques
Direct visualization
Burr/currettes
Interpositional material
(fat, cranioplast) easiest to prevent
reformation
The arrest is removed, leaving in
its place a metaphyseal-epiphyseal
cavity with intact physis
surrounding the area of resection

24. A greenstick fracture is a fracture in a young, soft
bone in which the bone bends and partially
breaks. This is owing in large part to the thick
fiborous periosteum of immature bone
here are three basic forms of greenstick fracture.
In the first a transverse fracture occurs in the
cortex, extends into the midportion of the bone
and becomes oriented along the longitudinal axis
of the bone without disrupting the opposite
cortex.
The second form is a torus or buckling fracture,
caused by impaction , The word torus is derived
from the Latin word 'Tori' meaning swelling or
protuberance.
The third is a bow fracture in which the bone
becomes curved along its longitudinal axis.
Usually pop splint is given!
Torus Fracture

25. DIAPHYSEAL FRACTURE
 MORE COMMON IN INFANTS
 Watch for neurovascular insufficiency during convalescence
 Abuse should be considered a possible cause of injury in all young
children with multiple long-bone fractures in association with head
injury
 General principles of fixation essentially remain the same with most
diaphyseal fractures being treated conservatively , displaced fractures
and open fractures requiring internal/external fixation.

26. Methods of fixation
• Casting - still the
commonest

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

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

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

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
more extensive operative exposure
Not load sharing-----removal needed
Newer minimally invasive
percutaneous submuscular plating

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. The aim of this biological, minimally invasive fracture
treatment is to achieve a level of reduction and
stabilisation that is appropriate to the age of the
child.
The biomechanical principle of the elastically-stable
intramedullary nailing (ESIN) is based on the
symmetrical bracing action of two elastic nails
inserted into the metaphysis, each
of which bears against the inner bone at three points.
This produces the following four biomechanical
properties: flexural stability, axial stability,
translational stability and rotational
stability. All four are essential for achieving optimal
results
Titanium Elastic Nail

34. Age lower limit is 3–4 years
and the upper limit 13–15 years.
Type of fracture
– transverse fractures
– short oblique or Spiral # with cortical suport
– long oblique fractures with cortical support
Fracture site
– femur: diaphyseal
– distal femur: metaphyseal
– femur: subtrochanteric
– lower leg: diaphyseal
– humerus: diaphyseal , subcapital even supracondylar
– radius and ulna: shaft radial neck
– radius: neck
– prophylactic stabilization with juvenile bone cysts
Contraindications
– intraarticular fractures
– complex femoral fractures, particularly
overweight (50–60 kg) and/or age (15–16 years)
INDICATIONS

36. - initial considerations:
growth will not correct rotational deformity
age
distance from physis
amount of deformity
- bayonette apposition
- generally bayonette apposition will require operative reduction
- historically, overriding of a both bones forearm fracture was acceptable if...
- there was no deviation of radius and ulna toward each other;
- there was no encroachment of the interosseous space;
- pt is less than 10 yrs of age;
- in pts < 6 yrs of age:
- upto 15 deg of angulation &<5 deg rotation is acceptable;
- between ages of 6-10 yrs:
- less than 10 deg of angulation should remodel especially if frx is close to distal epiphysis;
- bayonet apposition may be acceptable, although end to end apposition is preferred;
- pts > 12 yrs of age:
- no angulatory or rotational deformity is considered acceptable;
- more aggressive treatment is required, including open reduction and compression plating may be
required;
- Displaced Distal Third Frx:
- angulation up to 20-25 deg during first ten years is OK;
- angulation > 10 deg is unlikely to correct after 10 yrs
ACCEPTABLE REDUCTION

37. • 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
Indications for operative fixation

38. Indications for operative fixation

39. Forearm diaphyseal fracture
Open
ClosedDebridement 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

40. Humeral diaphyseal fracture
Adolescents Older children Infants & 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°
III I & II Surgical indications
Adolescents & Older children

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

42. Tibial shaft fracture
Open
Debridement in OR
Closed
III I & II
External fixator Closed reduction + ESIN
Polytrauma
Failed Succeed
Closed reduction & cast
Consider wedging the cast

43. • 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
Complications

44. Complications of Fractures
- Bone -
• Malunion
• Limb length discrepancy
• Physeal arrest
• Nonunion (rare)
• Crossunion
• Osteonecrosis

45. Complications of Fractures
- Soft Tissue -
• Vascular Injury
• Especially
elbow/knee
• Neurologic Injury
• Usually neuropraxia
• Compartment
Syndrome
• Especially
leg/forearm
• Cast sores/pressure
ulcers
• Cast burns
• Use care with cast
saw

46. Complications of Fractures
- Cast Syndrome -
• Patient in
spica/body cast
• Acute gastric
distension,
vomiting
• Possibly
mechanical
obstruction of
duodenum by
superior
mesenteric
artery

47. Location Specific Pediatric Fracture
Complications
Complication Fracture
Cubitus varus Supracondylar humerus fracture
Volkmann’s ischemic contracture Supracondylar humerus fracture
Refracture Femur fracture
Mid-diaphyseal radius/ulna fractures
Overgrowth Femur fracture (especially < 5 years)
Nonunion Lateral humeral condyle fracture
Osteonecrosis Femoral neck fracture
Talus fracture
Progressive valgus Proximal tibia fractures

49. Supracondylar Fracture of Humerus
Complications

50. Forearm Fractures

51. Closed Reduction of Forearm Fractures
Bohler
traction
Open reduction and internal fixation with
plates and screws may be appropriate in the
management of fractures with delayed
presentation or fractures that angulate late in
the course of cast care,when significant
fracture callus makes closed reduction and
percutaneous passage of intramedullary nails
difficult. Tens nail and im nail has improved
results and are preferred in displaced
angulated #

52. Closed Reduction of Forearm Fractures

53. Forearm Fractures

54. FEMORAL SHAFT FRACTURES
In a baby under 6 months old, a brace
(called a Pavlik Harness) may be able
to hold the broken bone still enough
for successful healing.
Traction before spica casting is
indicated when the fracture is
unstable or
If the shortening of the bones is too
much (more than 3 cm)
traction

55. Spica cast management is generally
not used for children with multiple
trauma, head injury, vascular
compromise, floating knee
injuries, significant skin problems, or
multiple fractures. Flexible
intramedullary nails are the
predominant treatment for femoral
fractures in 5 to 11 year
olds, although submuscular plating
and external fixation have their
place, especially in length-unstable
fractures or fractures in the
proximal and distal third of the
femoral shaft
In children between 7 months and 5
years old, a spica cast is often
applied.
In general, a spica cast begins at the
chest b/w umbilicus & nipple and
extends all the way down the
fractured leg, with flexion @ 50-90
degrees at knee and hip.
11-15 yrs use of trochanteric entry,
locked intramedullary nailing for
femoral fractures in the preadolescent
and adolescent age groups