Diaphyseal fractures in children

Mohamed M. ZamzamAssociate Professor & Consultant Pediatric

Orthopedic Surgeon

KKUH, Riyadh, Saudi Arabia

Objectives

• To recall specific considerations of diaphyseal fractures in children

• To be aware of common possible complications

• To identify the treatment of choice in each particular situation among a big list of management options

• To create an algorithm as a guide for managing long bone shaft fractures in pediatric population

Diaphyseal Fractures in Children

General Principles

• About 15% of injuries in children are skeletal

• Out of all skeletal injuries in children – Radial shaft fractures 6.4 %

– Tibial shaft fractures 6.2 %

– Femoral shaft fractures 2.1 %

– Proximal & shaft humerus fractures 1.4 %

Diaphyseal Fractures in Children

Specific Problems

• Premature complete physeal closure

• Progressive limb length discrepancy

• Nonunion

• Open reduction and internal fixation

Diaphyseal Fractures in Children

General management

• Cast• Internal fixation• External fixation

Diaphyseal Fractures in Children

General management

• Cast• Internal fixation• External fixation

Diaphyseal Fractures in Children

General management

• Cast• Internal fixation• External fixation

Diaphyseal Fractures in Children

General management

Indications for surgery • Head injury

• Multiple injuries

• Adolescence

• Failure of conservative means

• Severe soft-tissue injury

• Neurological disorder

• Malunion and delayed union

Diaphyseal Fractures in Children

Elastic stable intramedullary nailing (ESIN)

The principle • 2 elastic nails

• Maximum curve

• Orientation

• The size

• Good knowledge of the technique

Diaphyseal Fractures in Children

Elastic stable intramedullary nailing (ESIN)

Advantages • No need for postoperative cast

• Primary bone union

• Avoidance of growth plate injury

• Minimum invasive surgery

• Excellent functional and cosmetic results

Diaphyseal Fractures in Children

Elastic stable intramedullary nailing (ESIN)

Complications• Nonunion ??

• Osteomyelitis (rate is 2%)

• Overgrowth ( <10 mm before age of 10 years)

• Cortical perforation

• Re-fractures ?

• Skin irritation

Diaphyseal Fractures in Children

Forearm

• The distal radial epiphyseal plate realigned well in children below 10 years

• Radioulnar angulation usually associated with loss of motion

• The risk of refracture

Diaphyseal Fractures in Children

Forearm

Treatment options• Closed reduction + cast

• AO plates

• Intramedullary fixation

Diaphyseal Fractures in Children

Forearm

Closed intramedullary nailing

• Specific anatomic considerations

• The isthmus of radius and ulna is narrow (range = 3-6 mm)

• Optimum entry points

Diaphyseal Fractures in Children