General Principles of management
Pediatric Fractures
Presented by:
Dr. Harjot Singh Gurudatta
Moderator : Dr. Gagan Khanna
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
REMODELLING OF BONE IN CHILDREN
Why are children’s fractures different?
• Age related fracture pattern:
– Infants: diaphyseal fractures
– Children: metaphyseal fractures
– Adolescents: epiphyseal injuries
Statistics
• ~ 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
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)
Centers of Ossification
• 1° ossification center
• Diaphyseal
• 2° ossification centers
• Epiphyseal
• Occur at different stages of
development
• Usually occurs earlier in girls than
boys
source: [Link]
General Principles
Regulation of Epiphyseal Growth
Physis is the primary centre for growth
in most bones. EPIPHYSIS
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 METAPHYSIS
blood vessels invasing from
metaphysis
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)
Salter - Harris Classification
• Type I
– Through physis only
• Type II
– Through physis & metaphysis
• Type III
– Through physis & epiphysis
• Type IV Type VI - Injury to the perichondral structures
Type VII - Isolated injury to the epiphyseal plate
– Through metaphysis, physis &
epiphysis Type VIII - Isolated injury to the metaphysis,
with a potential injury related to endochondral
• Type V ossification
– Crush injury to entire physis Type IX - Injury to the periosteum that may
• Others added later by subsequent interfere with membranous growth
authors(eg Ranga type 6 peripheral
AITKENS , polands, PETERSENS SYSTEM OF
physeal injury)
PHYSEAL INJURIES ARE THERE BUT SALTER
HARRIS REMAINS UNIVERSALLY ACCEPTED.
Described by Robert B. Salter and W. Robert Harris in 1963.
Epiphyseal Injuries
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
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.
Epiphyseal Injuries
Try not to cross the physis, but rather parallel it in the epiphysis or
pin the fracture spike in the metaphysis
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.
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
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
Physeal Bar
- Imaging -
• Tomograms/CT
scans
• MRI
• Map bar to
determine
location and
extent
Physeal Bars
- Types -
• I - peripheral,
angular
deformity
• II - central,
tented physis,
shortening
• III -
combined/compl
ete - shortening
Physeal Bar
- Treatment -
Address Assess
• Angular • Growth
deformity remaining
• Limb length • Amount of
discrepancy physis
involved
• Degree of
angular
deformity
• Projected
LLD at
maturity
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
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
Torus Fracture
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!
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.
Methods of fixation
• Casting - still the
commonest
Methods of fixation
• Casting - still the commonest
• K-wires
– most commonly used
– Metaphyseal fractures
Methods of fixation
• Casting - still the commonest
• K-wires
• most commonly used
• Metaphyseal fractures
• K- wires could be replaced by absorbable
rods
Methods of fixation
• Casting - still the commonest
• K-wires
– most commonly used
– Metaphyseal fractures
• Intramedullary wires, elastic nails
– Very useful
– Diaphyseal fractures
• Screws
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
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)
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
Titanium Elastic Nail
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
INDICATIONS
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)
Fracture
AP and lateral radiograph Oblique Views, s peciat projections.
CT scans, MRI, etc.
, "
~rticular Growth plate Metaphysis or diaphysis Consider:
.... Remodeling potential
...
End of growth
~---
_
...
...
Age of patient
Growth rate of physis
Plan of joint motion
Position in bone
Displacement
>2mm
Growth remaining
I - Other factors
Deformity visible?
Parents' values
placement SH-1 and SH-2 Special anatomic features
"2 mm
/ I
•
Unacceptable Acceptable
I " r /
Accept
position
I~=-I Functlonal-
coametlc
reductio
Accept position
ACCEPTABLE REDUCTION
- 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
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
Indications for operative fixation
Forearm diaphyseal fracture
Open
Debridement in OR Closed
Angulation 0°-10° Angulation +20°
Angulation 10°-20°
All ages
0-5 years + 5 years
Long arm cast or splint Successful if < 10° Closed reduction
Successful but unstable Unsuccessful
Closed reduction + ESIN Open reduction +ESIN
Humeral diaphyseal fracture
Adolescents &
Older
Older
children
children Infants & younger children
Open Closed
Immobilize in a sling & swath
Debridement in OR Closed reduction
III I & II Surgical indications Midshaft angulation
> 20° < 20°
Closed reduction + ESIN
Immobilize in soft dressing
External fixator
Femoral shaft fracture
Open
Debridement in OR
Infants Younger child Older child Adolescent
Abused Excessive shortening Comminution
Yes No No Yes No Yes
Choice
Hospital Immediate Traction External Reamed
ESIN
& invest. Hip spica Then cast fixator rod
Tibial shaft fracture
Open Closed
Debridement in OR Polytrauma Closed reduction & cast
III I & II Failed Succeed
External fixator Closed reduction + ESIN Consider wedging the cast
Complications
• Ma-lunion is not usually a problem
( except cubitus varus )
• Non-union is hardly seen
( except in the lateral condyle )
• Growth disturbance – epiphyseal dam age
• Vascular – volkmann’s ischemia
• Infection - rare
Complications of Fractures
- Bone -
• Malunion
• Limb length discrepancy
• Physeal arrest
• Nonunion (rare)
• Crossunion
• Osteonecrosis
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
Complications of Fractures
- Cast Syndrome -
• Patient in
spica/body cast
• Acute gastric
distension,
vomiting
• Possibly
mechanical
obstruction of
duodenum by
superior
mesenteric
artery
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
Supracondylar Fracture of Humerus
Complications
Forearm Fractures
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
Closed Reduction of Forearm Fractures
Forearm Fractures
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
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)
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.
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
11-15 yrs use of trochanteric entry, predominant treatment for femoral
locked intramedullary nailing for fractures in 5 to 11 year
femoral fractures in the preadolescent olds, although submuscular plating
and adolescent age groups and external fixation have their
place, especially in length-unstable
fractures or fractures in the
proximal and distal third of the
femoral shaft
