Fracture in Children 2010

7/23/2019 Fracture in Children 2010

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Fractures In Children

Kitiwan Vipulakorn

Department of Orthopedics

Faculty of Medicine

KKU


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Objectives

2.2//()1//

injury /accident : head & neck injury, fracture,dislocation, body and limb injuries, serious injury,electrical injury, burns, near-drowning & submersion


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Incidence

1.5-2% per year

17.8% in patient presented with

injuries

Peak in 12-15 years old


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Incidence of fractures in long bones

Radius 45.1%

Humerus 18.4%

Tibia 15.1%

Clavicle 13.8%

Femur 7.6%


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Incidence

Physeal injuries 14.7%

Open fractures 2.9%

Multiple fractures 3.6%


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Etiologic factors

Home environment

83% of all injuries / 37% of all fractures

School environment

53% of injuries related to athletic events /20% of all

fractures

Motor vehicle accidents

10% of all injuries / high incidence of femoral shaft

fracture in pedestrian / high incidence of spinal and

pelvic fractures


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Prevention is important


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Prevention is important


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Biological aspects

Anatomical difference

Histological difference

Remaining of growth and

remodeling potentials


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Anatomical differences


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Epiphysealplate or physis

Apophysis

Metaphysis


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Epiphysis

Secondary ossification

center


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Physis / Epiphyseal plate

Rapid , integrated longitudinal and

latitudinal growth


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Metaphysis

Thinner cortex and more porous

Torus of Buckle fracture


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Plastic deformation Incomplete or greenstick fracture


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Periosteum

Thicker , greater osteogenic potentials

Loosely attach to diaphysis and metaphysis

, dense attach to physeal periphery

Affected fracture displacement and

reduction , rate of subperiosteal callus

Effective internal restrain in reduction


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Periosteum


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Apophysis

Epiphysis functioned as attachment of

muscle or ligament : tibial tuberosity ,

greater trochanter , greater tuberosity of

humerus

Tensile responsive structure

Reactive overgrowth :

Osgood-Schlatters lesion


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Biological aspects


Histological difference

Remaining of growth and

remodeling potentials


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Fracture repair


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Fracture healing

Rapid healing

Healing in side to side apposition ( bayonet ) is possible

Spontaneous correction of residual angulation

Younger , fracture site is close to physis, angulation

in plane of joint motion

Fracture may stimulate longitudinal growth by

increasing of blood supply : overgrowth phenomena


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Physeal injuries

Common in injuries at or close to joint in

children


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Salter-Harris classification


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Thurston-Holland fragment or sign


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Articular surface incongruity

Physeal arrest


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Articular surface incongruity

Physeal arrest


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Physeal healing

Through the cell column

Continue increase of cell

number in cell column

Metaphyseal responseincrease bone replacement

in hypertrophic zone

Restore in 3-4 weeks


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Physeal healing

Through the transition of

hypertrophic zone and

primary spongiosa

Fill with hematoma and fibroblastic

tissue

Disorganized cartilage

Metaphyseal vascular invasion

Vascular mediated bone formation


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Physeal healing

Extended across all layer

Fibrous tissue fill gap of physis

and callus at metaphysis

Cell in germinal and hypertrophic

zone expand by divison , maturation

and matrix expansion

In large gap , fibrosis is remaining

and from osseous bridge


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Physeal growth disturbance

Physeal arrest

Central Peripheral Linear


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Physeal arrest

Entire physis :

shortening

Partial physis :angular deformity ,

progressively


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Diagnosis


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Symptoms & Signs

Pain

Swelling

Deformity

Loss of functions

S t & Si


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Symptoms & Signs

swelling

S t & Si


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Symptoms & Signs

Deformity

S t & Si


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Symptoms & Signs

Assessment of neurological signs and vascular

status are important but difficult.

Paper position : radial nerve

Rock position : median nerve

OK position : anterior interosseous nerve

Scissor : ulnar nerve

R di l i l i ti


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Radiological examination

Diaphyseal fractures : one joint above and

one joint below

Physeal fractures : x-ray of the joint ,

normal side may require

Splint is necessary


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Principles of Treatment

Fractures


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Fractures

Rapid and high rate of union

Potential of remodeling

Most fractures treated by non-operative

treatment

Surgical indications : un-accepatable

reduction , specific site ,open fractures ,multiple injuries


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Traction


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Cast


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Reduction or not ?

Immobilization or fixation

Physeal injuries


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Physeal injuries

Salter-Harris type I , II : no or less growth

disturbance : non-operative treatment

Salter-Harris type III , IV : if displaced

surgical treatment is required

Salter-Harris type IV : prevent further

physeal damage : immobilization , decrease

activity or non-weight bearing


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Q & A


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Common Pediatric Fractures



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Radius 45.1%

Humerus 18.4%

Tibia 15.1%

Clavicle 13.8%

Femur 7.6%

F t f di t l t f di & l


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Fracture of distal part of radius & ulna

Most common in forearm fractures

Physeal fracture of radius , ulna

Distal metaphyseal fractureTorus , Greenstick , complete

Galeazzi fracture-dislocation

10-year-old girl fall in outstretched hand. Pain at right wrist


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Physeal injuries of distal radius


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y j

Common associated ulnar fracture

Neurovascular compromised : uncommon , median

nerve

Salter-Harris type II : most common

Treatment : displacement & Salter-Harris type

I ,II : closed reduction , short/long arm cast

Displaced III , IV , irreducible : surgery

A 10-year-old girl fall on outstretched hand. Pain at distal right forearm


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Torus or Buckle fracture


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One cortex

Protected immobilization , relief pain

Heal in 2-4 weeks

Bicortical disruption

Prolong immobilization

Heal in 3-6 weeks

Greenstick Fracture


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Treatment depend on age , degree anddirection of displacement

Displaced should be closed reduction

Acceptable angular correction

Age Saggital :

boy

Saggital :

Girls

Frontal

plane

4-9 20 15 15

9-11 15 10 5

11-13 10 10 0

>13 5 0 0

Complete fracture of distal radius


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p

Closed reduction and

casting or percutaneous

pinning in unstablefracture

A 10-year-old boy fall on outstretched hand. Pain and deformity of right side


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Fracture distal radius and dislocation of

distal radio-ulnar joint

Dorsal / volar

Closed reduction and long arm cast 6-10

weeks

Plastic deformation


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Failure of bending force

Limitation of remodeling in

older child

Angulation > 10 in older > 6

years old : reduction , 3-

points molded

Monteggia fracture-dislocation


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CLASSIFICATION


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Bado's classification Divides into 4 types of true Monteggia lesions

and equivalent lesions

True Monteggia Lesions


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Type I

Anterior dislocation of the radial head with a fracture

of the ulnar diaphysis (mid-shaft)

The most common Monteggia injury in children

70% in most series

True Monteggia Lesions Type II


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Type II

The posterior dislocation of the radial head with an

associated ulnar diaphyseal or metaphyseal fracture

with posterior angulation

Most cases is an adult injury

True Monteggia Lesions Type III


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Type III

Lateral or anterolateral dislocation of the radial head

with a fracture of the ulnar metaphysis

Usually is a greenstick type The second most common (23%)

True Monteggia Lesions

Type IV


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Type IV

Anterior dislocation of the radial head

with fractures of the ulna and radius

The least common (1%)in both children and adults

Monteggia fracture-dislocation


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Closed reduction , long arm cast

Pulled elbow


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Forearm in pronation

Reduced by flexion and supination



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Radius 45.1%

Humerus 18.4%

Tibia 15.1%

Clavicle 13.8%

Femur 7.6%

4-year-old girl fall down. Pain at right elbow


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Supracondylar fracture of humerus


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Fall on outstretched hand in elbowhyperextension

Posterior displacement

Gartlands classification


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Type Ithe anterior cortex isbroken. The posterior cortex

remains intact, and there is

no or minimal angulation of

the distal fragment. Type IIthe anterior cortex is

fractured and the posterior

cortex remains intact.

However, plastic deformationof the posterior cortex, or

greensticking, allows

angulation of the distal

fragment. Type IIIthe distal fragment

is completely displaced

posteriorly.


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Neurovascular injuries


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Malunion : cubitus varus


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A 4-year-old boy fall on outstretched hand. Pain at left elbow


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Lateral condylar of humerus

Ph l i j f di l h


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Physeal injury of distal humerus


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Milch

classification


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Fat pad sign


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Treatment


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Type I : < 2mm displacement : long arm cast 3-5

days and repeat x-ray , continue 3-5 weeks

Type II : 2-4 mm displacement : closed reduction and

percutaneous pinning

Type III : Open reduction and internal fixation


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Nonunion : cubitus valgus


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Physeal arrest


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Q & A


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Q & A

A 10-year-old boy got a car accident. Pain at left thigh ,

could not walk


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Femoral shaft fracture


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High energy trauma

Associated injuries common

Age Treatment

NB- 24months Pavlik harnessImmediate hip spica

Traction and hip spica


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Traction and hip spica

2-5 years Immediate hip spicaTraction and hip spica

External fixation

Flexible IM rod

6-11yTraction and hip spica

Flexible IM rod

Compression plate

External fixation

>12y to maturity Flexible IM rodCompression plate

Locked IM rod

External fixation

Traction


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Bryants tractionBryants traction

Hip spica cast


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Acceptable angulation

Age Varus/valgus Anterior/posterio Shortening (mm)


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g g p

r

g ( )

NB-2years 30 30 15

2-5 years 15 20 20

6-10 years 10 15 15

11yeras to

maturity5 10 10

Flexible intramedullary rod


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Compression plate


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2-year-old boy , limping


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Toddler fracture

Toddler fracture

Long leg cast 3 weeks ( + 2 weeks short leg


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Long leg cast 3 weeks ( + 2 weeks short leg

walking cast)

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Fracture in Children 2010

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