Trombino – kids fractures – 3.23.10
Key concepts: What makes kids Fx special!
Know the concepts: remodeling, growth plate fx, etc.
Don’t need to know most of the individual Fx
What makes fractures different in the immature skeleton?
More common
More often with minimal trauma
Physeal disruptions 15%
May lead to growth disturbance
Physis constantly undergoes change with growth
1
Salter Classification: this matters cuz it changes the prognosis
for the pt.
I: goes right through the growth plate
II: little piece of bone
III & IV: need to fix cuz in joint
V: axial loading compression Fx (rare) compress growth
plate
I & II: do better.
Patterns of Injury to Growing Bone
Diaphyseal
Epicondylar
Metaphyseal
Subcapital
Physeal
Supracondylar
Epiphyseal
Transcondylar
Articular
Intercondylar
Pattern of Fracture
Longitudinal
Spiral
Impacted
Comminuted
Bowing
Greenstick
Torus
Pathologic
Stress
Tours fracture: unilat cortex Fx, stable. Green stick is where one
side breaks & the other bends.
Postnatal Growth of Human Limbs
-Knowledge of percentage growth contribution each
physis important
-67% of growth of legs from physis around knee
-80% of growth of arm from proximal humerus and
distal radial physis
Physeal Anatomy
Reserve zone (higher chance of growth disturbance)
Zone of Columns
Hypertrophic zone (larger)
Calcified cartilage zone (larger and most common place
of growth)
Primary spongiosa
Formation of Long Bones
Primary ossification center
Secondary ossification
Perichondral ring
Physeal Injury: Epidemiology
-Males greater than females
-Only 15% fractures actually involve growth plate
-Physeal plate weakest in adolescents
-Male physis open longer
-Distal physis more involved except proximal humerus
Treatment for Physeal Fractures
Simple immobilization
Closed reduction
Percutaneous fixation (pinning w/o threads so it
doesn’t close the growth plate)
Internal fixation
Treatment of physeal fractures
Repeated attempts at closed reduction should be
avoided
Displaced fractures often need to be reduced
Unstable fractures may need fixation
Salter III and IV require anatomic reductionintraarticular (need to be perfect)
Complications
Physeal arrest- close follow-up needed for 1-2 years
Articular injury
Below: pt has salter Fx of distal radius. L radius stopped
growing = bad.
Plastic Deformation = bowing!
Unique to children’s bones
Bowing may be substantial
Reduction difficult
Required experienced hands
Intact Periosteal Sleeve
-periostium is really thick so you may not see it on Xray
Aid to reduction
Remember position when reducing fractures
Remodeling: want to grow straight, don’t want to over Tx kids
Propensity of long bones to return to anatomic position
with growth
Osteoclasts and osteoblasts active
Remodeling helps
-Children with 2 or more years of predicted growth
-Fractures near the bone ends e.g.. Distal femur,
Distal radius
-Deformity in the plane of motion of the joint
-Translation or bayonet position without
shortening will remodel (a little overlap)
Trombino – kids fractures – 3.23.10
Closed reduction if displaced- pinned
Open reduction
Bone deposited at convexity
Complications
Neuropraxia 5-9%
Radial
Anterior interosseous
Vascular injury: brachial artery (surgical emergency)
Remodeling doesn’t necessarily help
-Displaced intraarticular fractures (salter IV & V)
-Malrotated fractures
-Fractures with angulation out of the plane of motion
General Principles of Fracture Care (skipped)
Determine and Describe injury
Displacement
Angulation
Shortening
Opposition
Open
Closed
Immobilization
Splint to immobilize joint above and below
If fracture is to be reduced
Appropriate anesthesia
Reverse mechanism of injury
Gentleness important in physeal fractures
SPECIFIC UPPER EXTREMITY FRACTURES
Proximal Humerus Fractures
Salter I common in neonates
Metaphyseal fractures- most common in 5-10 yearsbenign treatment
Adolescent- usually Salter I or II- closed reduction and
pinning
cubitus varus – will not remodel this. Did not use pins.
Lateral Condyle fracture of the Humerus
Salter fracture of the distal humerus
Localized soft tissue swelling
Often delayed diagnosis
metaphyseal Fx in humerus. R is a yr later = huge remodeling.
Good!
Shoulder Joint
Broad range of motion
Proximal humeral physis
Large growth potential
Expect remodeling
Supracondylar Humerus Fractures (common!)
Classification
Type I – nondisplaced
Type II- distal fragment extended
Type III- marked displaced
Falling on outstretched hand.
Treatment
Immobilization
Fx into articular surface, fix cuz in joint.
Lateral condyle fracture Treatment
Nondisplaced- closed
Displaced- greater than 3mm open reduction
Displaced- less than 3 mm percutaneous pinning
Follow-up is key in peds Fx!!!
Forearm fractures (skipped a lot of)
Motion of the forearm
Flexion
Extension
Pronation- 50-80 degrees
Supination- 80-120 degrees
Forearm fractures Treatment
Nondisplaced- long arm cast
Displaced – reduction and casting
Occasional fixation
Bayoneting is acceptable (overlap on setting)
Take longer to heal cuz farther from epiphysis
2
Trombino – kids fractures – 3.23.10
Guidelines for acceptable reduction
Age less than 9
May accept
Complete displacement
15 degree angulation in AP plane
45 degrees in lateral plane
Age greater than 9
10 degrees angulation
Some bayonet if no shortening
Describing Fx
-distal is in good alignment to prox. Bowar apex angulations.
3
external fixator traction from the outside, good on big wounds,
not as common.
Distal Femoral Physeal Fractures
-BAD Fx to get!
Occur from valgus stress
Most frequent in adolescents
Watch for growth arrest
Distal radius fractures
Metaphyseal and Salter Fractures
Often occur from fall on outstretched hand
May accept up to 20-40 degrees dorsal/volar angulation
in children less than 10
May accept small amount of angulation in children older
than 10
Radioulnar angulation not accepted as well
Lower Extremity Fractures
Femur Fractures
Mechanism: lots of energy
Falls\
MVA
Pedestrian MVA
Traditional treatment
Immediate spica cast
Traction
Femur Fracture: Immediate Spica Cast
Lower energy trauma
Younger children
Initial shortening less than 2 cm.
Traction and Spica casting
10 day to 3 week traction
Less well tolerated in the older children
Clear Operative Indications
Multiple trauma
Head Injury
Open fracture
Vascular injury
Pathologic fracture
External fixation
Flexible IM nailing
Plating
Proximal Tibial Physis Fracture
-High incidence of vascular injury
-unstable
Fx looks straight L image, but grows crocked. Asym growth after
Fx heals.
Tibial eminence injury
Common bicycle injury
Epiphyseal and articular fracture
Treatment
Type I- immobilization
Type II- reduction in extension
Type III- open reduction, internal fixation with
arthroscopy
elevate up fragment where ACL inserts. Need to fix so they don’t
get a loose joint.
Patellar Sleeve Fracture
Unique to children
Difficult to make diagnosis
Cartilagenous portion on patella avulses
Trombino – kids fractures – 3.23.10
Requires open reduction
Big huge swollen knee, will fill in w/bone  long patella
 weak quad. Fix with sutures.
4
-Malrotated fractures
-Fractures with angulation out of the plane of motion
6. When placing a splint is should immobilize the joint ____________
& _____________ the injury.
7. Describe the mechanism of injury in a nursemaid’s elbow.
What is the prognosis?
Ankle Fractures: Teenager!
Teens: growth plates get weak as you get older, this
closes earlier
Often physeal
Triplane fractures
Tillaux fractures
Common in adolescents
May require reduction and fixation
Answers:
1. D
2. B
3. Prognosis = I & II Fix = III & IV, axial loading injury = V
Nursemaids elbow
-radial head sublexation (it slips out of annular
ligament). A lot of kids ligaments are lax. Longitudinal
traction (not a fall)
Mechanism longitudinal traction
Responds to simple manipulation
Occasionally requires immobilization if recurrent
X-ray are normal
-once reduced = normal
if you don’t have a good Hx don’t pull on people’s elbows until
you know for sure.
Questions:
1. All of the following fractures are unique to pediatrics EXCEPT?
A. Bowing
B. Greenstick
C. Torus
D. Spiral
2. In this fracture one cortex breaks and the other bends (use the
answers to #1)
3. Which Salter classifications have the best prognosis? Which
ones do you need to fix because they are in the joint space?
Which one is from an axial loading compression?
4. What is unique to children’s bones, a substantial defect,
difficult to reduce, and requires experienced hands to treat?
5. What helps in all of these situations?
-Children with 2 or more years of predicted growth
-Fractures near the bone ends e.g.. Distal femur, Distal
radius
-Deformity in the plane of motion of the joint
-Translation or bayonet position without shortening
will remodel (a little overlap)
But doesn’t help in these situations?
-Displaced intraarticular fractures (salter IV & V)
4.
5.
6.
7.
Bowing/plastic deformation.
Remodeling
Above and below
Mechanism longitudinal traction, once it is reduced the
kids are fine.