Paediatric lower limb fractures.pptxmmmmmk

DISLOCATION OF HIP AND KNEE.pptxnnhhjjjjjj

1. PEDIATRIC LOWER LIMB FRACTURES By Dr. P. Sridev Kumar Chowdary Department of Orthopaedics

2. Paediatric pelvic fractures Usually due to motor vehicle accident Iliac wing and single pelvic ring breaks account for more than 60% injuries Physical examination detects only 70% injuries, hence routine pelvic AP X-ray is recommended for all blunt injury Lateral compression is more common Compared to adults, instability and hemorrhage are less common, but avulsion injuries are more common .

3. Type I

4. L arge superficial hematoma formation beneath the inguinal ligament or in the scrotum Roux's sign:      - a decrease in the distance from the greater trochanter to the pubic spine on the affected side in  lateral compression   fractures Earle's sign:      - a bony prominence or large hematoma as well as tenderness on Per-rectal  examination;

5. Treatment Stable pelvic injuries can be mobilized early . Unstable pelvic injuries may be treated in a Spica cast .

6. Significant pelvic asymmetry should be addressed by surgical method s. (External or internal fixation accordingly). Complications : An improperly reduced pelvis has propensity for complications like scoliosis, apparent limb length inequality, low back ache and abnormal gait. Treatment

7. Proximal Femur fractures Proximal Femur Fractures in the pediatric poplulation are rare fractures caused by high-energy trauma (a fall from a height, a motor vehicle accident, or a fall from a bicycle). O ften associated with polytrauma . Symptoms severe pain in affected hip inability to bear weight
Physical examination: shortened, externally rotated lower extremity

8. Radiology Xrays Hip AP and lateral views Developmental CoxaVara may mimic a hip #. X-ray of uninvolved side helps to rule out this. For type I fracture, an important differential diagnosis is proximal femoral epiphysiolysis , in which the physis separates probably at birt h. MRI is the best imaging modality for a non-displaced or stress fracture of the femoral neck because it provides greater accuracy, earlier diagnosis, and shorter hospital stay, with no exposure to radiation.

9. Treatment Type I: Transepiphyseal fractures Undisplaced : Closed reduction with spica cast. Displaced: Closed reduction with percutaneous pinning.

10. Type II: Transcervical B ecause the fracture is unstable , internal fixation is recommended for all type 2 fractures . Closed reduction maneuver was described in the 1890s by Whitman , who believed that anatomic alignment was mandatory to prevent future deformity. Once reduction is achieved, the fracture should be stabilized with threaded K-wires in a young child and cannulated screws in an older child.

11. Type II: Transcervical

12. Type III : Cervicotrochanteric fracture Non- displaced fractures: - Spica cast can be tried. Internal fixation in older children (> 6yrs age). Displaced fractures: - closed reduction and internal fixation or ORIF in all age groups.

13. Type IV: Pertrochanteric or Intertrochanteric Fractures These fracture t ypically ha ve lowest risk of long-term complications and can be treated with cast immobilization alone in certain patients. Abduction spica for 6 to 12 weeks. Internal fixation advised in unstable and displaced fractures.

14. Points to be considered while treating a paediatric hip fracture Consider hip joint aspiration when a fracture is treated closed so that the tamponade effect is relieved . Avoid compromise of fracture stability/fixation in order to protect the physis ; cross the physis when necessary to achieve stability. Internal fixation options: 0 to 3 yrs age: smooth pins(2/2.4mm)or cannulated screws (3.5/4.0mm) 4 to 8 yrs age:cannulated screws (4/4.5mm) or a paediatric hip-compression screw. > 8 yrs : cannulated screws (6.5/7.3mm) or a hip compression screw Pediatric bone is often denser than adult, hence consider pre-drilling. Consider using an additional hip spica cast in < 8 years

15. Complications A. Avascular necrosis : AVN is the most common and most devastating complication associated with hip fractures in children. Ratliff's Classification of A VN . a) Type I –Diffuse necrosis of femoral head and neck distal to the fracture.  b) Type II- Necrosis confined to the epiphysis.  c) Type III-Necrosis of the femoral neck with sparing of the epiphysis.

16. Treatment: Use of an abduction orthosis Established AVN: Arthrodesis Early AVN: Core decompression and use of vascularised fibular graft have been tried recently. B. Premature physeal closure Mostly due to pins penetrating the physis Can cause femoral shortening , C oxavara , and short femoral neck . C. CoxaVara D. Nonunion : Due to inadequate reduction - Requires a valgus intertrochanteric osteotomy Complications

17. Femoral shaft fractures In children younger than walking age, 80% of these injuries are due to child abuse . Hypotension due to isolated femoral shaft # is rare Waddell's triad : head injury, intraabdominal or intrathoracic trauma, and femoral shaft fracture. This is usually associated with shock.

18. Treatment Protocols AGE Treatment < 6 months Pavlik harness or a posterior splint is used 6 months to 6 years Early Spica cast.
Skeletal traction followed by spica casting may be required From 6 years to 12 years Flexible intramedullary nails placed in a retrograde fashion
Spica casting may be used rarely for the axially stable fractures From 12 years Intramedullary fixation with either flexible or interlocked nails is the treatment of choice.

19. Flexible nailing (Pearls and Pitfalls) Nails are placed in a retrograde fashion Nail size should be 40% of width of femoral canal at isthmus The bone is entered 1.5 to 2 cm proximal to the distal femoral physis Nail diameter calculation : One cm is subtracted from the smallest femoral canal diameter measured on AP and lateral radiographs, and the result divided by 2 . It is less preferred in older children (> 11 years), obese and in long unstable fracture configurations.

20. Fractures in children between 5 and 10 years of age can be stabilized using Retrograde ender nails aiming at 3 point fixation principles

21. Distal femoral fractures often the result of direct trauma with some degree of rotation most commonly a valgus-type force or a hyperextension force Clinically : - pain with inability to bend knee unable to bear weight often in flexed position due to hamstring muscle spasm
Tenderness along the physis in the presence of a knee effusion

22. Diagnosis X-rays: show physeal widening  normal 3-5mm MRI is the diagnostic modality of choice to confirm physeal fracture

23. Treatment Nonoperative : long leg casting  - In nondisplaced fractures for 4-6 weeks C losed reduction and percutaneous fixation followed by casting   Di splaced Salter-Harris I or II fractures some Salter-Harris III or IV injuries if anatomic reduction is achieved . ORIF Salter-Harris III and IV with weight-bearing articular involvement I rreducible SHI and SHII fractures Operative

24. Proximal Tibia physeal fracture R are injuries seen in adolescents that may be associated with vascular injury. Treatment may be non - operative or operative depending on the Salter-Harris classification, stability, and displacement of fracture. Displaced Salter type I or II fractures are treated with percutaneous smooth pins across the physis (type I) or parallel to the physis (metaphysis, type II).

25. Open reduction and internal fixation for displaced Salter-Harris type III and IV.

26. Post Traumatic Tibia Valga (Cozen phenomenon) A transverse impaction fracture or valgus greenstick fracture may leave the lateral cortex intact. These have a tendency toward valgus angulation months after the injury. Hence best treated by reducing/over reducing and maintaining in a long leg cast in extension. If deformity develops , it is best to observe the patient till adolescence as valgus deformity often improves with growth .

27. Surgical treatment should be delayed till adolescence and includes an osteotomy or a well timed medial hemi - epiphysiodesis.

28. Tibial Tubercle Fracture P roximal tibia has two ossification centers   P rimary : proximal tibial physis secondary : tibial tubercle physis or apophysis - insertion of patellar tendon . A tibial tubercle fracture is a break in the bony bump on the upper part of the shin. It occurs when the patellar tendon pulls away a piece of bone.

29. Ogden classification S ubdivides each type into A and B to account for degree of displacement and comminution. Non operative treatment for Type IA Operative treatment for Type IB, II, III - Smooth pins, threaded steinman pins, Tension bands

30. TIBIAL SPINE (INTERCONDYLAR EMINENCE FRACTURES) Meyers and McKeever Classification Type 1:Minimal or no displacement or fragment Rx : long leg cast in 10-15° of knee flexion Type II: Angular elevation of anterior portion with intact posterior hinge Rx : Closed reduction via hyperextension, followed by long leg casting. Open reduction if irreducible Type III: Complete displacement with or without rotation Type IV: Comminuted * Operative treatment for Type III and IV

31. TODDLER FRACTURE A toddler’s fracture, also known as a childhood accidental spiral tibial fracture , is a spiral break in the tibia, or shin bone, of a young child. Common in 9 months and 3 years old, usually caused by a twisting motion to the leg, like falling or stumbling. Treatment :- A long-leg cast for 2 to 3 weeks, conversion to a short-leg walking for an additional 2 to 3 weeks, is usually sufficient.

32. Ankle Fractures V ery common fractures in the pediatric population that are usually caused by direct trauma or a twisting injury. Accounts for 25-40% of all physeal injuries (second most common)
accounts for 5% of all pediatric fractures

33. Dias and Tachdjian Classification Supination-Inversion : Most common mechanism of fracture Stage 1: Salter-Harris 1 or II of the distal fibula Stage II: Salter-Harris III or IV of the medial tibial physis

34. B) Pronation-Eversion-External Rotation Salter-Harris type II fracture distal tibial physis Short oblique distal fibular fracture 4 to 7 cm proximal to the tip. C) Supination Plantar Flexion - Salter-Harris type II fracture of distal tibial physis . Dias and Tachdjian Classification

35. D) Supination-External Rotation Stage 1: Salter-Harris II fracture of the distal tibia Stage II: Spiral fracture of the fibula beginning medially and extending posterosupeiorly . E) Axial Compression : Salter-Harris type V injury to distal tibia Dias and Tachdjian Classification

36. Treatment Lateral Malleolar (Distal Fibula) Fracture : Salter-Harris Type I or II: - Closed reduction and percutaneous pinning. Medial Malleolar - Salter-Harris Type I or II Closed reduction is attempted first Open reduction if closed reduction fails(may have interposed periosteum). Salter-Harris Type III or IV - Open reduction and internal fixation are indicated.

37. Juvenile Tillaux Fractures Salter-Harris type III fracture of the anterolateral tibial epiphysis. External rotation force causes the anterior tibiofibular ligament to avulse the fragment. Occurs in children between the ages of 12 to 14 years; 18-month window where lateral physis remains open.

38. Closed reduction via gentle distraction internal rotation of the foot and direct pressure over the anterolateral tibia. Unstable injuries may require percutaneous pinning with Kirschner wire fixatio n/Screw. Juvenile Tillaux Fractures

39. Triplane Fractures The triplane fracture is so named because the fracture lines occur in three planes : Transverse, coronal, and sagittal. A triplane fracture can occur as two part or three part A 2 part triplane fracture is a type IV Salter harris injury, whereas a 3 part Triplane fracture is a combined type II and type III Salter Harris, in which the type III component is a Tillaux fragment

40. Treatment Nondisplaced fractures may be treated in a long-leg cast. CT scan is essential to determine the degree of displacement. Articular displacement of >2 mm warrants operative fixation, closed reduction and percutaneous pinning or by open reduction and internal fixation.

41. TALAR NECK FRACTURES Operative Treatment Indicated for displaced fractures 5 mm displacement or >5 degree malalignment .

42. Calcaneus fracture Fractures of the calcaneus are rare in children. The usual mechanism is a fall from a height , usually a short distance in younger children and more than 10 feet in adolescents. Treatment is usually non-operative, and outcomes are generally good in a young child. Operative treatment is best used in an adolescent with a displaced intra-articular fracture, with indications the same as in adults.

43. Schmidt and Weiner Classification

44. THANK YOU