docFractures In Children
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Fractures In Children
Fractures In Children Kitiwan Vipulakorn Department of Orthopedics Faculty of Medicine KKU Objectives เกณฑมาตรฐานการประกอบวิชาชีพเวชกรรม • 2.2 โรค/ภาวะ/กลุมอาการฉุกเฉิน (รวมทุกระบบ) กลุมที่ 1 โรค/กลุมอาการ/ภาวะฉุกเฉินที่ตอ งรูกลไกการเกิดโรค สามารถ ใหการวินิจฉัยเบื้องตนและใหการบําบัดการรักษาไดอยางทันทวงทีตาม ความเหมาะสมของสถานการณ รูข อ จํากัดของตนเอง และปรึกษา ผูเชี่ยวชาญหรือผูมีประสบการณมากกวาไดอยางเหมาะสม • injury /accident : head & neck injury, fracture, dislocation, body and limb injuries, serious injury, electrical injury, burns, near-drowning & submersion Incidence • 1.5-2% per year • 17.8% in patient presented with injuries • Peak in 12-15 years old Incidence of fractures in long bones Radius 45.1% Humerus 18.4% Tibia 15.1% Clavicle 13.8% Femur 7.6% Incidence • Physeal injuries 14.7% • Open fractures 2.9% • Multiple fractures 3.6% Etiologic factors • Home environment 83% of all injuries / 37% of all fractures • School environment 53% of injuries related to athletic events /20% of all fractures • Motor vehicle accidents 10% of all injuries / high incidence of femoral shaft fracture in pedestrian / high incidence of spinal and pelvic fractures Prevention is important Prevention is important Biological aspects • Anatomical difference • Histological difference • Remaining of growth and remodeling potentials Anatomical differences Anatomical difference Apophysis Epiphyseal plate or physis Metaphysis Epiphysis Secondary ossification center Physis / Epiphyseal plate • Rapid , integrated longitudinal and latitudinal growth Metaphysis • Thinner cortex and more porous Torus of Buckle fracture Diaphysis • Extremely vascular in neonate and young children , less dense than maturing bone Affected rate of healing • More elasticity : resisted to tensile stress Produce plastic deformation / incomplete or greenstick fracture Plastic deformation Incomplete or greenstick fracture Periosteum • Thicker , greater osteogenic potentials • Loosely attach to diaphysis and metaphysis , dense attach to physeal periphery Affected fracture displacement and reduction , rate of subperiosteal callus Effective internal restrain in reduction Periosteum Apophysis • Epiphysis functioned as attachment of muscle or ligament : tibial tuberosity , greater trochanter , greater tuberosity of humerus • Tensile responsive structure Reactive overgrowth : Osgood-Schlatter’s lesion Biological aspects • Anatomical difference • Histological difference • Remaining of growth and remodeling potentials Fracture repair Fracture healing • Rapid healing • Healing in side to side apposition ( bayonet ) is possible • Spontaneous correction of residual angulation Younger , fracture site is close to physis, angulation in plane of joint motion • Fracture may stimulate longitudinal growth by increasing of blood supply : overgrowth phenomena Physeal injuries • Common in injuries at or close to joint in children Salter-Harris’ classification Salter-Harris’ classification Salter-Harris’ classification Thurston-Holland fragment or sign Salter-Harris’ classification Articular surface incongruity Physeal arrest Salter-Harris’ classification Articular surface incongruity Physeal arrest Salter-Harris’ classification Physeal healing • Through the cell column Continue increase of cell number in cell column Metaphyseal response increase bone replacement in hypertrophic zone Restore in 3-4 weeks Physeal healing • Through the transition of hypertrophic zone and primary spongiosa Fill with hematoma and fibroblastic tissue Disorganized cartilage Metaphyseal vascular invasion Vascular mediated bone formation Physeal healing • Extended across all layer Fibrous tissue fill gap of physis and callus at metaphysis Cell in germinal and hypertrophic zone expand by divison , maturation and matrix expansion In large gap , fibrosis is remaining and from osseous bridge Physeal growth disturbance • Physeal arrest Central Peripheral Linear Physeal arrest • Entire physis : shortening • Partial physis : angular deformity , progressively Diagnosis Symptoms & Signs • Pain • Swelling • Deformity • Loss of functions Symptoms & Signs swelling Symptoms & Signs Deformity Symptoms & Signs • Assessment of neurological signs and vascular status are important but difficult. Paper position : radial nerve Rock position : median nerve OK position : anterior interosseous nerve Scissor : ulnar nerve Radiological examination • Diaphyseal fractures : one joint above and one joint below • Physeal fractures : x-ray of the joint , normal side may require • Splint is necessary Principles of Treatment Fractures • Rapid and high rate of union • Potential of remodeling • Most fractures treated by non-operative treatment • Surgical indications : un-accepatable reduction , specific site ,open fractures , multiple injuries Traction Cast Reduction or not ? Immobilization or fixation Physeal injuries • Salter-Harris type I , II : no or less growth disturbance : non-operative treatment • Salter-Harris type III , IV : if displaced surgical treatment is required • Salter-Harris type IV : prevent further physeal damage : immobilization , decrease activity or non-weight bearing Q&A Common Pediatric Fractures Incidence of fractures in long bones Radius 45.1% Humerus 18.4% Tibia 15.1% Clavicle 13.8% Femur 7.6% Fracture of distal part of radius & ulna • Most common in forearm fractures • Physeal fracture of radius , ulna • Distal metaphyseal fracture Torus , Greenstick , complete • Galeazzi fracture-dislocation 10-year-old girl fall in outstretched hand. Pain at right wrist Physeal injuries of distal radius • Common associated ulnar fracture • Neurovascular compromised : uncommon , median nerve • Salter-Harris type II : most common • Treatment : displacement & Salter-Harris type I ,II : closed reduction , short/long arm cast Displaced III , IV , irreducible : surgery A 10-year-old girl fall on outstretched hand. Pain at distal right forearm Torus or Buckle fracture • One cortex Protected immobilization , relief pain Heal in 2-4 weeks • Bicortical disruption Prolong immobilization Heal in 3-6 weeks Greenstick Fracture • • • Treatment depend on age , degree and direction of displacement Displaced should be closed reduction Acceptable angular correction Age Saggital : boy Saggital : Girls Frontal plane 4-9 20 15 15 9-11 15 10 5 11-13 10 10 0 >13 5 0 0 Complete fracture of distal radius Closed reduction and casting or percutaneous pinning in unstable fracture A 10-year-old boy fall on outstretched hand. Pain and deformity of right side Galeazzi fracture-dislocation Galeazzi fracture-dislocation • Fracture distal radius and dislocation of distal radio-ulnar joint Dorsal / volar • Closed reduction and long arm cast 6-10 weeks Plastic deformation • Failure of bending force • Limitation of remodeling in older child • Angulation > 10 in older > 6 years old : reduction , 3points molded Monteggia fracture-dislocation CLASSIFICATION • Bado's classification – Divides into 4 types of true Monteggia lesions and equivalent lesions True Monteggia Lesions • Type I – Anterior dislocation of the radial head with a fracture of the ulnar diaphysis (mid-shaft) – The most common Monteggia injury in children – 70% in most series True Monteggia Lesions • Type II – The posterior dislocation of the radial head with an associated ulnar diaphyseal or metaphyseal fracture with posterior angulation – Most cases is an adult injury True Monteggia Lesions • Type III – Lateral or anterolateral dislocation of the radial head with a fracture of the ulnar metaphysis – Usually is a greenstick type – The second most common (23%) True Monteggia Lesions • Type IV – Anterior dislocation of the radial head with fractures of the ulna and radius – The least common (1%) in both children and adults Monteggia fracture-dislocation • Closed reduction , long arm cast Pulled elbow Forearm in pronation Reduced by flexion and supination Incidence of fractures in long bones Radius 45.1% Humerus 18.4% Tibia 15.1% Clavicle 13.8% Femur 7.6% 4-year-old girl fall down. Pain at right elbow Supracondylar fracture of humerus • Fall on outstretched hand in elbow hyperextension • Posterior displacement Gartland’s classification • • • Type I—the anterior cortex is broken. The posterior cortex remains intact, and there is no or minimal angulation of the distal fragment. Type II—the anterior cortex is fractured and the posterior cortex remains intact. However, plastic deformation of the posterior cortex, or “greensticking,” allows angulation of the distal fragment. Type III—the distal fragment is completely displaced posteriorly. Treatment • Gartland type I : casting • Gartland type II and III : closed reduction and percutaneous pinning • Open reduction in irreducible Neurovascular injuries Malunion : cubitus varus A 4-year-old boy fall on outstretched hand. Pain at left elbow Lateral condylar of humerus • Physeal injury of distal humerus Milch classification Fat pad sign Treatment • Type I : < 2mm displacement : long arm cast 3-5 days and repeat x-ray , continue 3-5 weeks • Type II : 2-4 mm displacement : closed reduction and percutaneous pinning • Type III : Open reduction and internal fixation Nonunion : cubitus valgus Physeal arrest Q&A A 10-year-old boy got a car accident. Pain at left thigh , could not walk Femoral shaft fracture • High energy trauma • Associated injuries common Age Treatment NB- 24months Pavlik harness Immediate hip spica Traction and hip spica 2-5 years Immediate hip spica Traction and hip spica External fixation Flexible IM rod 6-11y Traction and hip spica Flexible IM rod Compression plate External fixation >12y to maturity Flexible IM rod Compression plate Locked IM rod External fixation Traction Bryant’s Bryant’s traction traction Hip spica cast Acceptable angulation Age Varus/valgus Anterior/posterio r Shortening (mm) NB-2years 30 30 15 2-5 years 15 20 20 6-10 years 10 15 15 11yeras to maturity 5 10 10 Flexible intramedullary rod Compression plate 2-year-old boy , limping Toddler fracture Toddler fracture • Long leg cast 3 weeks ( + 2 weeks short leg walking cast)
