PEDIATRIC FRACTURES

嘉義長庚 骨科部沈世勛

Introduction

Skeletal trauma accounts for 10-15 % of all childhood injuries

Immature skeleton differs from that of the adult

Vary in different age groups

Periosteum

Thicker Greater osteogenic potential Callus formation An effective internal restraint in close reduction

Injury pattern

Buckle

Plastic Deformity

Greenstick

Injury pattern

Patterns of fracture – Variations with age

Physis

Salter-Harris fracture type

Changes in treatment philosophy Blount’s Non-operative axioms –

mid-1950s

Complications with operation intervention

The trend toward minimal invasion

Factors creating the trend toward operative intervention Improvement in technology

Rapid healing

Minimal hospitalization

The perfect result

Fractures about the elbow

“Pity the young surgeon whose first case is a fracture around the elbow”

~ Mercer Rang

With an understanding of the anatomy and adherence of a few basic principles, treatment of such fractures can be straightforward

Anatomy (CRITOE)

Radiographs interpretation

Radiographs interpretation

Baumann’s angle

Normal range 64 to 81 degrees

Difference > 5 degrees should not be accept

Fat pad sign

Supracondylar fracture

Most common type of elbow fracture in children and adolescents 50% to 70%

Most frequently in children between the ages of 3 and 10 years

High incidence of residual deformity and potential for neurovascular complications

Mechanism of injury

Extension or flexion force on the distal humerus

Extension type 95% to 98% Fall on an

outstretched hand

Mechanism of injury

Flexion type 2% to 5% Direct blow on the

posterior aspect of a flexed elbow

Classification

Modified Gartland’s classification Type I: non-displaced or

minimal displaced

Type II: angulation of the distal fragment, one cortex remains intact

Type III: complete displaced

Type IV: multidirectional instability

Treatment

Type I fracture Long arm cast – 3 weeks

Type II fracture Close reduction plus percutaneous

pinning (or long arm cast ) Type III fracture

Close reduction plus percutaneous pinning

Pin configuration

Biomechanical studies Crossed pins are stronger in torsion than a lateral

lateral-entry construct

A systemic review (crossed vs. lateral only) 1.84 times – iatrogenic nerve injury 0.58 times – loss of reduction

Recent prospective studies – no difference in loss of reduction or iatrogenic nerve injury

Medial pin

Placed with the arm in extension

Sweeping the soft tissue posteriorly away from the medial epicondyle

Remove medial pin if an iatrogenic ulnar nerve injury noted postoperatively

Immobilization after pinning Immobilized in 30 to 60 degrees of

flexion in a posterior splint or bivalved cast

Return in 7 to 10 days to check for maintenance of reduction

Pins are removed and immobilization is discontinued in 3 to 4 weeks after the injury

Vascular injury

2% to 38%

manipulation and close observation Failed to provided distal circulation

immediately CR + pinning

Considered surgical exploration and repair if the limb remains ischemic

Peripheral nerve injury

10% to 15% Extension type – anterior interosseous

nerve (AIN) Posterolaterally displaced – median

nerve Posteromedially displaced – radial nerve Ulnar nerve – iatrogenic injury

If function is not return within 8 to 12 weeks, NCV and EMG should be given to ensure the nerve has not been transected

Volkmann’s Ischemic Contracture Compartment syndrome

Improved management Incidence decreased

Floating elbow may be at increased risk

A supracondylar fracture associated with a compartment syndrome is generally best managed by closed reduction and pinning.

Malunion

Cubitus varus is more common

Functional problems are uncommon with either deformity

Cosmetic disturbance

Lateral condyle fracture

The second most common operative elbow injury in children

May be difficult to diagnose and have a propensity for late displacement

high complication rate

Mechanism of injury

Fall on an outstretched arm A varus stress that avulses the lateral

condyle A valgus force in which the radial head

directly pushes off the lateral condyle

Diagnosis

The hallmark radiographic finding is the posteriorly base Thurston-Holland fragment in lateral view

Oblique view or arthrograms are helpful in identifying minimal displaced fractures

Classification

Milch’s classification

Classification

Jakob classification

Stable type

Unstable type

Classification

According to displacement Non-displaced: < 2 mm Minimally displaced: 2-4 mm Displaced: > 4mm

Treatment

Non-displaced fracture Cast immobilization Close follow-up

Minimally displaced fracture Cast immobilization

Late displacement delay union or nonunion

Close reduction and pinning arthrography intraoperatively

Treatment

Displaced fracture Open reduction and pinning

Posterolateral approach possibility of injury to blood supply

Lateral approach judge the reduction of the articular surface

Lateral condyle nonunion

The most frequent problematic complication

Fracture constant exposed to synovial fluid

Lateral condyle has a poor blood supply

Constant motion at the fracture site from the pull of the wrist extensors of the distal fragment

Lateral condyle nonunion

A nonunion can present with one of three scenarios Painful nonunion

Osteosynthesis ± bone grafting

Cosmetic unacceptable valgus deformity Corrective osteotomy

Tardy ulnar nerve palsy Anterior transposition

Transphyseal fracture

Most common in children younger than 2 years

Result from child abuse (up to 50%) or birth trauma

Diagnosis can be challenging Often misdiagnosed as elbow dislocation or

lateral condyle fracture Ultrasound, MRI, arthrogram can be helpful

Transphyseal fracture

Mechanism of injury

Depends on the age of the patient Newborns and infants

Rotatory or shear force associated with birth trauma or child abuse

Older children Usually a hyperextension force from a fall

on an outstretched hand

Different diagnosis

Elbow dislocation Abnormal radial head-capitellum relationship Rarely occurred in this age group

Lateral condyle fracture Oblique radiographs, arthrogram, MRI Metaphyseal fragment are displaced laterally

Supracondylar fracture Fracture usually at the level of the olecranon

fossa

Treatment

Simple immobilization Cubitus varus occurs frequently

Close reduction and pinning

Medial condyle fracture

Around 50% are associated with elbow dislocation

Usually occur between 7 to 15 years of age

Account for approximately 10% of all children’s elbow fracture

Mechanism of injury

A valgus stress producing traction on the medial epicondylar trough the flexor muscle

Treatment

Nonsurgical treatment, even displaced

Immobilization – 1 to 2 weeks

Treatment

Indication for surgical treatment Absolute indication

Fragment incarcerated in joint Open fracture Gross elbow instability

Relative indication High-demand, over head athlete, such as

a pitcher

Complications

Stiffness Most common complication Immobilization no more than 3 weeks to

avoid complication

Ulnar nerve dysfunction Varies from 10% to 16%

Symptomatic nonunion Difficult to treat In situ fixation or simple excision have

been advocated

Olecranon fracture

Relative uncommon, 5% of elbow fractures

20% to 50% associated with other elbow injuries Usually medial condyle

Treatment

Intra-articular fracture with step off > 2mm ORIF

Extra-articular fracture displacement > 5mm ORIF

Conservative treatment immobilization in about 20 degrees of flexion

Radial neck fracture

Cartilage radial head is resistant to fracture More radial neck fracture

About 50% of radial neck fractures are associated with other injuries to the elbow

Mechanism of injury

Fall onto a outstretched hand, with elbow in extension and valgus

Mechanism of injury

Fracture by impact against the inferior aspect of the capitellum at the time of dislocation or at the time of spontaneous reduction

Classification

O’Brien’s classification system

Treatment

Type I Simple immobilization for 1-2 weeks Close reduction if > 15 degrees (> 10

y/o)

Type II and III Close reduction Percutaneous or intramedullary

reduction

Treatment

Patterson technique

Treatment

Kaufman technique

Treatment

Wrapping technique

Treatment

Percutaneous reduction

Intramedullary reduction

Treatment

Open reduction Failed to achieve stable reduction with

closed reduction or minimal invasive techniques

Post reduction supination and pronation < 60 degrees

Radial head fracture complete displaced