# Pediatric fracture and it's complication

It discuss about the most common cause for pediatric fracture

1. Pediatric fractures Woublem Zewde ,Orthopedic Surgeon at BLH, Lecture for medical students Jan.2017

2. Learning outcome Describe the unique anatomic, physiologic & biomehanical features of pediatric skeleton Describe fracture patterns Discuss the management of common fracture R emodeling List complication of pediatric fractures

3. Pediatric fractures-Introduction Fractures represent the most common & significant injury in children. 40% of boys & 30% of girls sustain at least one fracture by age 16. 20% children who present with an injury have a fracture Sprains do not occur. Dislocations are rare. The fracture is usually a single bone. Multiple & open fractures are not common.

4. A natomic feature: G rowth plate Longitudinal growth Has five zones Weaker than tendons/ lig . Bloodless Increased osteogenic potential

5. Physis / Histology

6. Growth plate/ Physis Is a cartilaginous disc situated bt metaphysis & epiphysis. It is responsible for longitudinal growth through endochondral ossification. It is weaker than the tendons,ligaments or joint capsules. Growth plate injuries account for 30% of skeletal trauma in children.

7. Growth plate…. It has 5 distinct zones The plane of injury occurs through the hypertrophic zone. The hypertrophic zone is bloodless ,so an epiphyseal fracture does not produce much swelling. Has a high osteogenic potential. The germinal layer remains attached with the epiphysis.

8. Contribution of physis to the longitudinal growth Proximal Distal Humerus 80% 20% Radius 25% 75% Ulna 80% 20% Femur 30% 70% Tibia 55% 45% fibula 60% 40%

9. P eriosteum Is much thicker ,stronger and readily torn in a child than in an adult. It maintains reduction of the fracture fragments It prevents excessive displacement. It produces callus more quickly & in greater amount than in adults.

10. Biomechanical features Bones in children are softer & more pliable due to the more porous cortex than in adults. A child can sustain a fall of much greater magnitude than an adult without breaking any bone.

11. Causes Trauma : low energy (commonest ) : high energy eg . Femur fracture Pathological : O steomyelites : Unicameral bone cyst : O steogenesis imperfecta : Rickets Stress Child abuse is a frequent cause in children under 3yrs of age.

12. Classification Buckle /Torus fracture : young children / metaphysis Plastic deformation : the bone is bent without a fracture.Occurs in ulna & fibula Green stick fracture : the bone breaks at one cortex & bends at the other cortex. Complete fractures occur in femur/ humerus /tibia Overriding ( bayonette ) position is OK Communited fractures & open fracture are associated with sever trauma.

13. Buckle /torus fracture Metaphyseal Young children Stable fracture Heals within 3 wk

14. Plastic Deformation Significant curvature that produces clinical deformity should be corrected Greater than 20 degrees, older than 8 years – reduce deformity General anesthesia Considerable force, slowly applied over a padded fulcrum

15. Green stick Clavicle Fractures Greenstick common

16. Complete Forearm Fracture

17. Growth plate #/Salter Harris classification Type 1: epiphysis is separated from the metaphysis at the hypertrophic zone. If the periosteum is torn displacement occurs Often missed initially ( Dx -sprain) X-rays appear normal except for the soft tissue swelling over physis ( later appears wide because of healing) Diagnosis is clinical by eliciting tenderness at the joint

18. Growth plate … Type 2 : the commonest, the epiphysis is displaced with metaphseal fragment . ( Thurston Holland ) Type 3: intra-articular Type 4: involves the epiphysis , physis & metaphysis Type 5: is a crush injury to part or whole plate.(Rare)

19. Fracture healing Fractures heal quickly (3 – 6 wk ) *Blood supply * Stability * Increased osteoblastic activity The skeletal system has the ability to remodel after fracture healing is complete.

20. Remodeling potential Children have great remodeling potential because of the remaining growth . Realignment will occur over months in response to normal stresses placed upon the bone.

21. F actors that affect remodeling…. *Age *Distance from the fracture *Amount of angulation *Direction of deformity *Proximity of deformity * Tendency to overgrow ( femoral shaft fracture)

22. Principles of management of Salter- Harris fracture Reduction should be gentle and early Avoid repeated attempts at closed reduction Avoid late remanipulation > 5days, consider remodeling potential SH 1 & 2 generally CR and casting depending on stability ( OR infrequently indicated ) SH 3 & 4 generally need open reduction and fixation

23. Principles….. Most important, consider extended follow- up Follow for growth arrest / shortening or angular deformity Expect significant remodeling of any residual deformity

24. Type 1

25. Type 1

26. Type 2

27. Salter 3 Injury- CRIF

28. Salter 4 Distal Tibia Fracture Fixation avoids physis

29. Treatment of femoral shaft fracture Traction - skin /skeletal Avoid physis if pins are used Hip spica Open reduction & internal fixation intramedullary nails

30. Current Technique – Above knee cast (thigh and leg) first. Hip and knee- 40-45 flexion, foot out. Can include opposite thigh if desired. Unilateral spica cast effective for low energy fractures- see H. Epps, J Pediatr Orthop 2006

31. Femoral Remodeling after Fracture Will not correct significant rotational malunion , varsus & valgus Overgrowth 1-1.5 cm may occur, especially in younger children treated nonoperatively Angular deformity will remodel significantly in children <5 years old, less reliably in 5-10 year old, and is unlikely to be substantial in children >10 years old

32. Distal Femoral Physeal Fractures direct blow mechanism Salter I or II common check neurologic / vascular status Growth arrest will result if not stabilized with pins

33. Distal Radius Fractures Most commonly fractured bone in children Metaphyseal most frequent, distal radial physeal second Simple falls most common mechanism Accept malreduced fractures upon late presentation (over 7 days). Imperfect reductions in young children <5yrs of metaphyseal fractures are accepted

34. Displaced Distal Radius Fractures- Treatment (46%) Closed reduction usually not difficult Traction , recreate deformity and reduce using intact periosteal hinge Immobilize Well molded cast / splint, above or below elbow surgeon preference 3-4 weeks immobilization Acceptable alignment : 50% apposition 30 ° angulation

35. Excellent Reduction with Well Molded Cast

36. Precautions after cast application Never use circular cast after fresh fracture Apply splints,gutter etc. Instruct parents to have close observation If the cast becomes tight If movement of the fingers /toes is painful Swelling/color change/numbness If pain has increased

37. Open Metadiaphyseal Fractures- I&D, Pinning

38. 16 Year old with Rotational Malunion- in older patients operative treatment preferred to maintain functional forearm rotation

39. Shoulder Immobilization- Coaptation Splint –U slab with a collar & cuff sling

40. Remodeling over 6 Months

41. Metaphyseal Fxs -Remodeling…

42. 2dary centers of ossification C- 1 R- 3 I- 5 T- 7 O-9 L-11

43. Elbow Fractures in Children: Radiograph Anatomy/Landmarks Bauman ’ s angle is formed by a line perpendicular to the axis of the humerus , and a line that goes through the physis of the capitellum . In this case, the medial impaction and varus position reduces Bauman ’ s angle.

44. Elbow Fractures in Children: Radiograph Anatomy/Landmarks Anterior Humeral Line: This is drawn along the anterior humeral cortex. It should pass through the middle of the capitellum.

45. Elbow Fractures in Children: Radiograph Anatomy/Landmarks The capitellum is angulated anteriorly about 30 o 30

46. Elbow Fractures in Children: Radiograph Anatomy/Landmarks Radiocapitellar line – should intersect the capitellum

47. Supracondylar fracture of the humerus Most common fracture of the elbow in children (65%) pediatric trauma Occurs between 4- 10 yrs of age Occurs from fall on outstretched hand (FOOSH)

48. Types Depending on the direction of the distal fragment: Extension (98 %)= medial (75%) = lateral (25%) Flexion (2%)

49. Extension type: Classification Gartland 1959 Type 1 : Nondisplaced Type 2: Angulated /displaced with intact posterior cortex Type 3: Complete displacement with no contact between fragments

50. Type 1: Non-displaced Note the non- displaced fracture Note the posterior fat pad

51. Type 2: displaced/angulated /intact posterior cortex

52. Type 2: Angulated/displaced fracture with intact posterior cortex In many cases, the type 2 fractures will be impacted medially, leading to varus angulation. The varus malposition must be considered when reducing these fractures, applying a valgus force for realignment.

53. Type 3: Complete displacement

54. Type 3 Supracondylar Fracture posteriomedial displacement

55. Associated injuries Nerve injury ( 7-14%) Anterior interosseous nerve (commonest) Radial nerve brachial muscle Brachial artery U lnar nerve

56. Clinical features – Look ,Feel & Move Pain Swelling Numbness Inability to use the hand Deformity Eccymosis Brachialis sign Puckered skin S-configuration Tenderness Feel radial pulse Check for capillary refill of the fingers, color &warmth of the hand Sensory & motor examination

57. Physical examination * Vascular status: presence of radial pulse : color & warmth of the hand : capillary refill *Radial nerve : extension of the wrist ,fingers & thumb *Medial nerve: flexion of the fingers * A nterior interosseous nerve: flexion of DIP & IP of index & thumb *Ulnar nerve: abduction /adduction of the fingers

58. Supracondylar Asessment /medial nerve injury

59. Pink pulseless hand=tethering or entrapment of both vessel /nerve at the fracture site Type 3 supracondylar fracture, with absent ulnar and radial pulses, but fingers had capillary refill less than 2 seconds. Rx= exploration

60. Initial evaluation Evaluate the position of the elbow & the degree of swelling (obvious deformity + considerable swelling = fracture Evaluate the vascular status Evaluation of neurologic function of the hand Signs & symptoms of compartment syndrome *Splint the elbow in 20 o before x-rays are taken

61. Compartment syndrome Pain – most important, pain out of proportion to the injury (child becoming more and more restless /needing more analgesia ) Most reliable signs are pain on passive stretching and pain on palpation of the involved compartment ( tense swelling) Other features like pallor, pulselessness , paralysis, paraesthesia etc. appear very late and we should not wait for these things.

62. Supracondylar Humerus Fractures: Treatment *Type 1: I mmobilization for 3 -4 wks , at 90 o of flexion. If there is significant swelling, do not flex to 90 degrees until the swelling subsides. *Type 2: Close reduction & Pecutaneous pinning under fluoroscopy for angulation >30 o *Current treatment protocols use percutaneous pin fixation in almost all cases.

63. Dunlop Overhead Traction

64. Lee et al. – JPO 2002

65. Treatment of supracondylar fracture at BLH (Type 3) Patients usually present with significant swelling & obvious deformity Admitted to wards for lateral arm traction Open reduction & internal fixation (5 days) 2 parallel K-wires are used to fix the fracture & the elbow immobilized with long arm cast Pins are removed after 4 wks Follow-up for one year

66. C omplication *Compartment syndrome * Volkmanns ischemic contracture * Malunion / cubitus varus (gunstock ) Vascular injury Loss of reduction Restricted movement Myositis ossificans (heterotopic bone formation) Neurovascular injury with pin placement

67. Forearm Fasciotomy Volar-Henry approach Include a carpal tunnel release Release lacertus fibrosus and fascia Protect median nerve, brachial artery and tendons after release

68. Volkman’s ischemic contracture

69. Medial Impaction Fracture Cubitus varus 2 years later

70. Supracondylar fracture-Flexion Type

71. Supracondylar fracture/Flexion type Rare 2% Distal fragment is anteriorly flexed Ulnar nerve injury is common OR & IF -Reduce with extension

72. Lateral Condyle Fracture 2 nd most common fracture, representing (15 %) of elbow trauma in children Usually occurs from FOOSH + Varus force Injury ( capitellum & trochlea )

73. Type 1: AP Lat Oblique

74. Type 2 Fragment is significantly displaced & rotated

75. Lateral condyle #/ Classification It is an intra-articular fracture (type IV Salter-Harris fracture ) Classification : Type 1 – Undisplaced <2mm displacement & articular surface is intact *Oblique x-ray is necessary to identify the fracture :Type 2- Displaced ,the articular surface is disrupted ,the fragment is rotated

76. Clinical features Mild swelling & tenderness on the lateral aspect of the elbow D eformity & bony prominence on the lateral aspect of elbow Neurovascular injury is rare

77. Treatment Type 1: P osterior splint (2wks) ,elbow 90 degree followed by long arm cast for 4-6 wks Type 2: open reduction & internal fixation to achieve anatomic reduction Pins are removed after 4 wks

78. Lateral Condyle Fractures: Complications Non-union Growth arrest Progressive cubitus valgus Ulnar neuropathy

79. Medial Epicondyle Fracture Represents 5-10 % of pediatric elbow fractures Occurs with valgus stress to the elbow, which avulses the medial epicondyle Frequently associated with an elbow dislocation (50% ) Long term studies – favor nonoperative Rx Absolute indication is entrapped fragment after dislocation with incongruent elbow joint

80. Medial epicondyle fracture + elbow dislocation

81. Medial Epicondyle Fracture: Elbow dislocation with medial epicondyle avulsion, treated with ORIF.

82. Pathological fracture Differential diagnosis Chronic osteomyelites Neoplasm Osteogenesis imperfecta Rickets

83. Unicameral bone cyst

84. 3 yo Osteogenesis Imperfecta - multiple fxs Lt femur

85. Child abuse 80% of femoral shaft fractures in children < 3yr are caused by child abuse Multiple fractures at different stages of healing Bruises,scars History is not realiable

86. P hysiotherapy Encourage active exercise Passive exercise(elbow joint) is contraindicated. The full range of elbow motion is slow to return. Physiotherapy does not increase the speed of recovery.

87. Thank-you