Pediatric Fractures - PDF document

S Pediatric Fractures Joshua L. Moore DPM FACFAS Clinical Assistant Professor – Department of Surgery Assistant Dean of Educational Affairs - TUSPM Objectives S Background S Incidence S Anatomy S Classification S Diagnosis S Treatment S Summary S References Background S Management requires awareness of unique anatomy of

pediatric patient. S Physis is the weakest area of the skeletally immature bone. S Higher water content in pediatric bone, so more likely to bend rather than fail . S Pediatric ankle fractures often missed . S Children cannot always accurately convey their symptoms. Incidence S Tibial and fibular epiphyseal injuries make

up 15 - 38% of all epiphyseal injuries. S Ankle fractures account for approximately 5% of all pediatric fractures. S Most prevalent between ages 8 - 15. S Premature physeal closure only about 2%. Anatomy S Epiphyses S secondary ossification center S Physis S growth plate S Metaphysis S Location of active bone growth a

nd vascular elements S Diaphysis S primary growth center S Zone of Ranvier S Circumferential groove surrounding periphery of the physis S Supports physis Anatomy S Pediatric bone is more porous than adult bone. S Increased water content makes bone more malleable. S Pediatric bone: S More likely to bend than fail S Uni

que fracture patterns S Greenstick fractures S Torus fractures Anatomy S Damage to the germinal cells of the physis can lead to growth arrest - partial or complete. S After trauma, growth at the physis temporarily stops. S When growth resumes, radiopaque line can be seen denoting growth recovery (Harris Growth Lines)

S May see 6 weeks following trauma Classification S Salter Harris – growth plate injury anatomic classification scheme. S Dias and Tachdjian – merged Lauge - Hansen and Salter Harris classifications. S Transitional Fractures S Triplane fracture S Juvenile Tillaux fracture Salter - Harris S Type I S Complete sepa

ration of the epiphysis from the metaphysis S Line of fracture passes through physis S 6 – 8.5% of physeal injuries S Minimal displacement due to strong periosteal adhesions S Minimal risk for premature physeal closure. Salter - Harris S Type II S 7 3 – 75% of all physeal injuries S Fracture through the physis and

exiting through metaphysis S Metaphyseal avulsion – Thurston - Holland Sign Salter - Harris S Type III S Begins at the joint surface and exits through physis S Occur in older children where physis is nearing closure S May have ischemic necrosis due to epiphyseal blood vessel damage. Salter - Harris S Type IV S Fr

acture begins at the joint and extends through epiphysis, physis and exits through metaphysis. S More likely to displace S Higher likelihood of growth arrest and post traumatic arthritis. S Goal of treatment: S Prevent physeal bridging/growth arrest S Preservation of joint surface Salter - Harris S Type V S Crush i

njury to physis S Destroys structural integrity of physis S Often times diagnosed retrospectively Juvenile Tillaux Fracture S 3 - 5% of all pediatric ankle fractures S Salter - Harris III fracture of the lateral aspect of the tibial physis S Anterolateral aspect of the physis still open while the remaining plate is cl

osed S External rotation of the fibula causes the anterior tibiofibular ligament to avulse the anterolateral epiphysis through the growth plate S CT to fully evaluate injury Triplane Fractures S First described by Marmor in 1970 S 5 - 7% of all pediatric fractures S Children reaching skeletal maturity S May consist of

2 , 3 or 4 fragments S Number of fragments related to age of child and maturity of physis S 3 planes S Sagittal fracture extending from the joint, through the epiphysis of the tibia to the level of the physis S Transverse fracture through the physis S Coronal fracture of the posterior tibial metaphysis Triplane Fractu

res Diagnosis S Clinical exam S P ain S Limping/refusal to walk S Decrease in activity/regression of developmental landmark S Guarding S Edema S Ecchymosis S Deformity Diagnosis S X - ray S Clinical correlation S May require imaging of contralateral limb S Physis may appear wider S CT S Better able to evaluate physis,

ankle articular surface S Surgical planning S Bone Scan S MRI S If suspect tendon or ligament injury S New literature suggests SHI of fibula more likely ligamentous injury Treatment S Reduce displaced physeal fractures with gentle traction and manipulation. S Closed reduction should not be attempted �7 days after

injury unless intra - articular step - off � 2mm. S Compressive fixation parallel to the physis. S If must cross physis use smooth pins, remove after healing. S Most physeal fractures have significant healing within 3 weeks. S Monitor for growth disturbances at least 6 months or until skeletal maturity. Treatme

nt S Type I and II Salter Harris fractures S Closed reduction S 7 - 10 days post injury, callus well established, better left alone S Remodeling of minor displacement will take place S Advocates for removable splint and return to activity as tolerated for SHI lateral malleoli injuries Treatment S Type III and IV Salter H

arris fractures S Require adequate reduction S Restore physis and preserve articular surface S Open reduction: periosteum handled with care S Fine, smooth K - wires can transverse the growth plate for a few weeks without interruption S Percutaneous cannulated screw fixation parallel to the physis Pearls S Minimally displ

aced fractures with anatomic alignment - percutaneous fixation with k - wires and cannulated screws. S Larger fracture fragments and those with greater displacement may benefit most from ORIF. S Closed reduction and percutaneous fixation best achieved within 24 hours of injury. S Closure with absorbable sutures S Early

ROM and return to weight bearing achieves best results Complications S Premature or asymmetric growth arrest S 2 - 5% S Reported in upwards of 14 - 40% in Salter III and IV S Rotational deformities S Infection S Wound healing S CRPS S Post traumatic arthritis Premature Physeal Closure S If less than 40 - 50%: S Rese

ct osseous bridge S Interpose adipose tissue or methyl methacrylate S If greater than 40 - 50%: S Supramalleolar osteotomy (opening wedge) > 10˚ S Epiphysiodesis - 2 - 5 cm anticipated growth S Limb lengthening via Illizarov technique � 5cm difference Summary S SH I and II injuries do well with closed reduction an

d modified immobilization. S SH III and IV anatomic reduction necessary � 2mm displacement. S Transitional fractures have less likely chance of growth disturbances. S No compression across the physis. S CT scan for best evaluation and surgical planning. References S Banks, AS . Downey, MS. Martin, DE. Miller, SJ

. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Vol 2, Ed 3. Lippincott Williams & Wilkins. Philadelphia, PA. 2001. S Cicekli O et al. Percutaneous cannulated screw fixation for pediatric epiphyseal ankle fractures. SingerPLus 5:1925, 2016. S Barmada , A. Gaynor, T. Scoot, J. Premature Physeal Closure

Following Distal Tibia Physeal Fractures: A New Radiographic Predictor. Journal of Pediatric Orthopaedics Vol 23(6), November/December 2003, 733 - 739. S Berquist , TH. Radiology of the Foot and Ankle. Ed.2. Lippincott Williams & Wilkins. 2000. S Boutis K et al. Radiograph - negative lateral ankle injuries in childre

n occult growth plate fracture or sprain? JAMA Pediatr 170(1), January 2016. S Denning JR. Complication of pediatric foot and ankle fractures. Orthop Clin N Am. 48, 2017 59 - 70. S Flynn, JM. Skaggs, D. Sponseller , PD. Ganley , TJ. Kay, RM. Leitch, KK. The operative management of pediatric fractures of the lower ext

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