Management of Fractures in
Adolescents
Friday Registrar Presentation
Dr. Stewart Morrison MBBS
Western Health Orthopaedic Department
Introduction
Adolescence
✚ Puberty: acceleration phase, peak height velocity, deceleration phase
✚ Peak height velocity: Girls 12 years, Boys 14 years
✚ Fall between management parameters for adults, and those for children
✚ Quality of Bone
.Less mineralised, more vascular, greater callus
.greater energy dissipation, less comminution, quicker healing
✚ Structure of Bone
.Physeal Plate
.Closure of Physeal Plate
✚ Psychosocial
Estimation of Maturity
✚ Various Methods
.Sauvegrain
.Oxford Score
.Greulich’s and Pyle’s Atlas
.Tanner-Whitehouse-III RUS Score
.Sanders modification of TWIIIRUS Score
✚ Biological Staging
.Tanner Stages
.Secondary Sexual Characteristics
Classification of Physeal Fractures
✚ Salter-Harris
✚ Perichondral ring of La Croix
✚ Communication
✚ Prognosis
Imaging
General Principles
✚ Joint above, joint below
✚ Comparison views
✚ CT
✚ MRI
Principles of Treatment: Physeal Fractures
Reduction
✚ Traction, gentle manipulation
✚ Open preferable to multiple closed attempts
✚ No reduction after 7-10 days, unless > 2mm step-off
Fixation
✚ Pins, screws should be parallel to the physis
✚ Single pass, single smooth K-wire
✚ Resection of periosteum
✚ Langenskiöld procedure
✚ No reduction after 7-10 days, unless > 2mm step-off
Most heal in 3 weeks.
Growth disturbance
monitoring.
Park-Harris Lines
How to succinctly and clearly explain this algorithm to parents?
… when often they only hear the word ‘deformity’
Principles of Treatment:
Non-Physeal Fractures
✚ Adolescent bone does not have the remodelling capacity of childrens’
✚ Weight and specific characteristics need to be taken into account
✚ Displaced diaphyseal fractures – Titanium Elastic Nails
✚ Displaced metaphyseal fractures – Percutaneous Pin Fixation
✚ Supplementation of fixation by splint or cast
✚ Locking plates not usually required
✚ Implant removal
Clavicle
✚ First bone to begin ossification, and the last to finish it.
✚ Threshold of > 2 cm of displacement often cited
Operative Considerations
✚ ORIF
✚ Supraclavicular nerve
✚ Neurovascular bundle
✚ Earlier return to full activities (12 vs 16 weeks)
Radial and Ulnar Shafts
✚Studies often convoluted by pediatric participants, and inclusion of metaphyseal fractures
✚ More difficult to manage than previously thought
✚ Greenstick
✚ Plastic Deformation
✚ Complete
✚ Comminuted
If a deformity is present in two orthogonal radiographs, the true deformity will be
greater than appreciated on either single view
Radial and Ulnar Shafts
Operative Considerations
✚1.5 – 2.0 mm Titanium Elastic Nails (TENS)
✚ Closed Reduction  closed reduction with percutanous fixation  open reduction
✚ Reestablish radial bow, eliminate any bowing of ulna
✚ Fix radius first
✚ Narrowest point of radius is central
✚ Narrowest point of ulna is within the distal third
✚ Do not cross physes
✚ Removal at six months or more
Femoral Shaft
Principles
✚ Timely union
✚ No rotational deformity
✚ < 2 cm shortening
✚ Deformity of < 10-20° (sagittal plane), < 5-10° (coronal plane)
Operative Considerations
✚ In adolescents, surgical treatment favoured
✚ Elastic intramedullary nails (< 11 yrs, < 49 kg ) .require removal
✚ Rigid nails, plating (> 11 yrs, length ‘unstable’ fractures) .require removal
✚ No randomized trials
✚ External Fixation
Distal Femur
✚ High Energy
Metaphyseal Fractures
✚ < 10 years; closed reduction + percutaneous cross-pin fixation + long leg cast
✚ > 10 years or unstable fracture, consider plating or external fixation
Physeal Fractures
✚ SHI + SH II, undisplaced – long leg cast
✚ SHI + II, mildly displaced – closed reduction, percutaneous pinning, long leg cast
✚ SH II, large metaphyseal fragment – cannulated screws, long leg cast
✚ SH III + IV, displaced – cannulated compression screws
✚ All should remain NWB following fixation
✚ 50% of distal femoral fractures lead to growth disturbance (SH II highest risk)
Proximal Tibia
Physeal Fractures
✚ High energy
✚ CT recommended
✚ Similar management principles to distal femoral fractures
Metaphyseal Fractures
✚ “Cozen Fractures”
✚ Closed reduction, long leg casting
✚ Genu valgum is most common complication
Proximal Tibia
Tibial Spine Fractures
✚ Hyperextension of the knee
✚ ACL avulsion injury
Tibial Tubercle Fractures
✚ Repetitive jumping sports
✚ Ogden modification of Watson-Jones Classification
✚ Open reduction, internal fixation for II, III, IV
✚ V should have periosteal sleeve reattached
✚ Genu recuvatum
Ankle
Considerations
✚ Fibular physis closes later than the tibial physis (12-14, 15-18 vs. 19-20 yrs)
✚ Tibial physis closes in a circular pattern – centre to medial to lateral
✚ CT scan recommended
Management
✚ SH I or SHII, undisplaced – BK walking cast 3-4 weeks
✚ SH I or SHII, displaced – closed reduction, AK cast 3 weeks, then BK 3 weeks
✚SH III or SHIV – often require open reduction, internal fixation
✚ If periosteal flap not removed, 60% incidence of plate closure
✚ No more than 5% of angulation in any plane should be accepted
Ankle
Tillaux Fracture
✚ SHIII of anterolateral distal tibial epiphysis (final area to close)
✚ Internal rotation can provide closed reduction, however often need open reduction
Triplanar Fracture
✚ SHIII or SH IV
✚ Appears as SH II on lateral radiograph, SH III on anteroposterior radiograph
✚ Younger patient than Tillaux fracture
✚ Growth arrest not clinically important
✚ Flexion of Knee to 90 degrees, plantar flexion and internal rotation of the foot, with AK cast for 3/52
✚ If unsuccessful, proceed to percutaneous or open reduction/fixation
Thank you
Salter RB, Harris WR. Injuries Involving The Epiphyseal Plate. J Bone Joint Surg Am. 1963;45: 587-622.
Khan La, Bradnock Tj, Scott C, Robinson Cm. Fractures Of The Clavicle. J Bone Joint Surg Am. 2009 Feb;91(2):447-60.
Egol Ka Et Al. Management Of Fractures In Adolescents. J Bone Joint Surg. Am. 2010 Dec;92(18) 2947
Zionts Le. Fractures Around The Knee In Children. JAAOS Vol. 10 No. 5 September/October 2002
Alain Diméglio; Yann Philippe Charles; Jean-pierre Daures; Vincenzo De Rosa; Accuracy Of The Sauvegrain Method In Determining Skeletal Age During
Puberty. Journal Of Bone And Joint Surgery; Aug 2005; 87, 8; Health & Medical Complete
Momberger N, Stevens P, Smith J, Santora S, Scott S, Anderson J. Intramedullary nailing of femoral fractures in adolescents. J Pediatr Orthop. 2000;20: 482-4.