Common Pediatric Fractures & Trauma - PowerPoint Presentation

1. Common Pediatric Fractures & TraumaDr.Kholoud Al-ZainProf. ZamzamAss. Professor and Consultant Pediatric Orthopedic SurgeonNov 2018

2. ObjectivesIntroductionDifference between Ped & adult Physis #  Salter-Harris classificationIndications of operative treatmentMethods of treatment of Ped # & traumaCommon Ped #:U.L  clavicle, humeral supracondylar, distal radius L.L  femur shaftExample

3. Pediatric Fractures

4. IntroductionFractures account for ~15% of all injuries in childrenBoys > girlsRate increases with ageType of fractures vary in various age groups (infants, children, adolescents )Mizulta, 1987

5. Difference BetweenA Child & Adult’s Fractures

6. Why are Children’s Fractures Different ?Growth plate:Perfect remodeling powerInjury of growth plate may cause:Angular deformityOr leg length inequality (L.L.I)

7. Why are Children’s Fractures Different ?Bone:Increased (collagen:bone) ratioLess brittleDeformation

8. Why are Children’s Fractures Different ?Cartilage:Difficult X-ray evaluationSize of articular fragment often under-estimated

9. Why are Children’s Fractures Different ?Periosteum:Metabolically activeMore callus, rapid union, increased remodelingThickness and strengthMay aid reduction

10. Why are Children’s Fractures Different ?Ligaments:Functionally stronger than bone. Higher proportion of injuries that produce sprains in adults result in fractures in children.

11. Why are Children’s Fractures Different ?Age related fracture pattern:Infants  diaphyseal #Children  metaphyseal #Adolescents  epiphyseal

12. Why are Children’s Fractures Different ?PhysiologyBetter blood supply  rare delayed and non-union

13. Remodeling

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16. Physis Fractures

17. Physis InjuriesAccount for ~25% of all children’s #More in boysMore in upper limbMost heal well rapidly with good remodelingGrowth may be affected

18. Physis Injuries- ClassificationsSalter-Harris

19. Salter-Harris Classification

20. Salter-Harris Classification

21. Physis Injuries- ComplicationsPhyseal bridging  < 1% Cause  affecting growth (varus, valgus, or even L.L.I)Keep in mind:Small bridges (<10%)  may lyse spontaneouslyCentral bridges  more likely to lysePeripheral bridges  more likely to cause deformity

22. Physis Injuries- ComplicationsTake care with:Avoid injury to physis during fixationMonitor growth over a long period (18-24 m)When suspecting physeal bar  do MRI

23. Indications of Operative Treatment

24. General ManagementIndications for surgery Open fracturesSevere soft-tissue injuryFractures with vascular injuryCompartment syndromeMultiple injuriesDisplaced intra articular fractures (Salter-Harris III-IV )Failure of conservative means (irreducible or unstable #’s)Malunion and delayed unionAdolescenceHead injuryNeurological disorder Uncooperative patient

25. Methods of Treatmentof PediatricFractures & Trauma

26. 1) Casting  still the commonest

27. 1) Casting  still the commonest

28. 1) Casting  still the commonest

29. 2) K-wires Most commonly used internal fixation (I.F)Usually used in  metaphyseal fractures

30. 3) Intramedullary wires (Elastic nails)

31. 4) Screws

32. 5) Plates  specially in multiple trauma

33. 6) I.M.N  only in adolescents (>12y)

34. 7) Ex-fix  usually in open #

35. Methods of FixationCombination

36. Common Pediatric Fractures

37. Common Pediatric Fractures Upper limb:ClavicleHumeral supracondylarDistal radius Lower Limbs:Femur shaft (diaphysis)

38. Clavicle Fractures

39. Clavicle # - Incidents8-15%  of all pediatric #0.5%  of normal SVD1.6%  of breech deliveries 90%  of obstetric #The periosteal sleeve always remains in the anatomic position (remodeling is ensured)

40. Clavicle # - Mechanism InjuryIndirect  fall onto an outstretched handDirect:The most common mechanismHas highest incidence of injury to the underlying:N.V &, Pulmonary structuresBirth injury

41. Clavicle # - ExaminationLook  EcchymosisFeel:Tender # siteAs a palpable mass along the clavicle (as in displaced #)Crepitus (when lung is compromised)Special tests  Must assesse for any:N.V injuryPulmonary injury

42. Clavicle # - Reading XRLocation:(medial, middle, lateral) ⅓  commonest middle ⅓Commonest # site  middle/lateral ⅓Open or closed  see air on XRDisplacement  %Fracture type

43. Clavicle # - TreatmentNewborn (< 28 days):No orthotics Unite in 1w1m – 2y: Figure-of-eight For 2w2 – 12y:Figure-of-eight or sling For 2-4 weeks

44. Clavicle # - Remodeling

45. Clavicle # - Treatment Indications of operative treatment: Open #’s, orNeurovascular compromise

46. Clavicle # - Complications (rare) From the #:MalunionNonunionSecondary from healing:Neurovascular compromisePulmonary injuryIn the wound:Bad healed scarDehiscence Infection

47. Humeral Supracondylar Fractures

48. Supracondylar #- Incidences55-75%  of all elbow #M:F 3:2Age  5 - 8 years Left (non-dominant) side  most frequently #

49. Supracondylar #- Mechanism of InjuryIndirect:Extension type >95%Direct:Flexion type < 3%

50. Supracondylar #- Clinical EvaluationLook:SwollenS-shaped angulation Pucker sign (dimpling of the skin anteriorly)May have burses Feel:Tender elbowMove:Painful & can’t really move itNeurovascular examination

51. Supracondylar #- Gartland ClassificationType-III Complete displacement (extension type) may be:Posteromedial (75%), orPosterolateral (25%)

52. Supracondylar #- Gartland ClassificationType-III Complete displacement (extension type) may be:Posteromedial (75%), orPosterolateral (25%)

53. Supracondylar #- Gartland Classification

54. Normal XR LinesAnterior Humeral LineHour-glass appearanceFat-pad signRadio-capitellar line

55. Type 1Anterior Humeral LineHour-glass appearanceFat-pad signRadio-capitellar line

56. Type 2

57. Type 3

58. Supracondylar #- TreatmentType-I: Above elbow cast (or splint)For 2-3 weeksType-II:Closed reduction & above elbow casting, orClosed reduction with percutaneous pinning (if: unstable or sever swelling), & above elbow cast (splint)For 4-6 weeksType III:Attempt closed reduction & percutaneous pinningIf fails  open reduction & pinning (ORIF)For 4-6 weeksDirect ORIF if  open #

59. Supracondylar #- Treatment

60. Supracondylar #- Treatment

61. Supracondylar #- ComplicationsNeurologic injury (7% to 10%):Median and anterior interosseous nerves (most common)Most are neurapraxiasRequiring no treatmentVascular injury (0.5%):Direct injury to the brachial artery, orSecondary to swelling (compartment syndrome)

62. Supracondylar #- ComplicationsLoss of motion (stiffness)Myositis ossificansAngular deformity (cubitus varus)Compartment syndrome

63. Supracondylar #- Flexion Type 3

64. Distal Radial Fractures(Metaphysis)

65. ClassificationDepending on pattern:Torus (buckle)  only one cortex is involvedIncomplete (greenstick)Complete

66. Distal Radius Metaphyseal InjuriesTorus (buckle) fracture:Are stableImmobilized for pain relief in below elbow cast, 2-3 weeks

67. Distal Radius Metaphyseal InjuriesTorus (buckle) fracture:

68. Distal Radius Metaphyseal InjuriesTorus (buckle) fracture:

69. Distal Radius Metaphyseal InjuriesIncomplete (greenstick):Greater ability to remodel (why ?)Closed reduction and above elbow cast

70. Distal Radius Metaphyseal InjuriesIncomplete (greenstick):

71. Distal Radius Metaphyseal InjuriesComplete fracture:Closed reduction, then well molded above elbow cast for 6-8 wOr open reduction and fixation (internal or external)

72. Distal Radius Metaphyseal InjuriesComplete fracture:Closed reduction, then well molded above elbow cast for 6-8 w

73. Distal Radius Metaphyseal InjuriesComplete fracture: (treatment in O.R)

74. Distal Radius Metaphyseal InjuriesComplete fracture: (treatment in O.R)

75. Distal Radius Metaphyseal InjuriesComplete fracture:Or open reduction and fixation (internal or external)

76. Distal Radius Metaphyseal InjuriesComplete fracture:Indications for ORIF:Irreducible fractureOpen fracture Compartment syndrome

77. Distal Radius Meta. Injuries- ComplicationsMalunionResidual angulation may result in loss of forearm rotationNonunionRareRefractureWith early return to activity (before 6 w)Growth disturbance Overgrowth or undergrowthNeurovascular injuriesWith extreme positions of immobilization

78. Examples ofDistal Radial Fractures

79. Distal Radial FracturesPhyseal Injuries

80. Distal Radial Physeal #- “S.H” Type I

81. Distal Radial Physeal #- “S.H” Type II

82. Distal Radial Physeal #- “S.H” Type III

83. Distal Radial Physeal #- TreatmentTypes I & IIClosed reduction followed by above elbow castWe can accept deformity:50% translationWith no  angulation or rotationGrowth arrest can occur in 25%  with repeated closed reduction manipulationsOpen reduction is indicated in:Irreducible #Open #

84. Distal Radial Physeal #- TreatmentTypes I & IIClosed reduction,Followed by long arm cast,With the forearm pronated

85. Distal Radial Physeal #- TreatmentTypes IIAPLat

86. Distal Radial Physeal #- TreatmentTypes II

87. Distal Radial Physeal #- Types III

88. Distal Radial Physeal #- TreatmentTypes IIIAnatomic reduction necessary  intra-articularORIF with smooth pins or screws

89. Distal Radial Physeal #- TreatmentTypes IV & VRare injuriesNeed ORIF

90. Distal Radial Physeal #- ComplicationsPhyseal arrestShorteningAngular deformityUlnar styloid nonunion Carpal tunnel syndrome

91. Femoral Shaft Fractures

92. Femoral Shaft #1.6%  of all pediatric #M > FAge:(2 – 4) years years old Mid-adolescenceAdolescence  >90% due to RTA

93. Femoral Shaft #- Mechanism of InjuryDirect trauma:RTA, Fall, or Indirect trauma:Rotational injuryPathologic #:Osteogenesis imperfectaNonossifying fibromaBone cystsTumors

94. Femoral Shaft #- Clinical Evaluation Look:Pain, Swelling of the thigh, Inability to ambulate, and Variable gross deformityCareful O/E of the overlying soft tissues to rule out the possibility of an open fracture (puncture wound)Feel:Tender # siteCareful neurovascular examination is essential

95. Femoral Shaft #- Treatment< 6m:Pavlik HarnessClosed reduction & immediate hip spica castingOr traction 1-2w, then hip spica casting

96. Femoral Shaft #- Treatment6m – 6y:Closed reduction & immediate hip spica casting (>95%)Or traction 1-2w, then hip spica casting

97. Femoral Shaft #- Treatment6 – 12y:Flexible I.M.NBridge PlatingExternal Fixation

98. Femoral Shaft #- Treatment6 – 12y:Flexible IMNBridge PlatingExternal Fixation

99. Femoral Shaft #- Treatment6 – 12y:Flexible IMNBridge PlatingExternal Fixation:Multiple injuriesOpen fractureComminuted #Unstable patient

100. Femoral Shaft #- Treatment12y to skeletal maturity:Intramedullary fixation with either:Flexible nails, or Locked I.M nail

101. Femoral Shaft #- TreatmentOperative Indications:Multiple trauma, including head injuryOpen fractureVascular injuryPathologic fractureUncooperative patient

102. Femoral Shaft #- ComplicationsMalunionRemodeling will not correct rotational deformitiesLeg length discrepancySecondary to shortening or overgrowthMuscle weaknessNonunion (rare)

103. Any Questions?

104. Remember …

105. RememberPediatric fractures have great remodeling potentialsThe importance of growth plates & periosteum in remodelingA good number of cases can be treated conservativelyOperative fixations aids in avoiding complications

106. ObjectivesDifference between adult & pediatric #Growth plate #  Salter-Harris classification, treatments, & complicationsMethods of treatment of pediatric # & there indicationsKnow the common pediatric #: mechanism of injury, evaluations (clinical & radiological), treatments, and complications