Fractures in ChildrenProf. Dr. Shrikant GoreDept. of Orthopaedics

G.M.C. Latur

The Bones

Soft & Malleable -Bowing, Greenstick Growing - Physis & Epiphysis Growth

disturbanceThick periosteum - Intraperiosteal

Fractures Less - displacement & Compound Remodeling - in the direction of

movements poor in rotational & Varus -Valgus

Physeal Injuries

30% of childhood fractures

Upper/Lower extremity ratio 2 : 1

Relative radiolucency difficult to diagnose underestimation of displacement

Extension of fracture in joint common

Growth disturbance & secondary arthritis common

Salter-Harris classification

Type-1 Epiphyseal Separation

Type-2 Epiphyseal Separation with metaphyseal spike

Type-3 Epiphyseal Separation with fracture of epiphysis

Type-4 fracture through Metaphysis Physis Epiphysis entering in joint

Type-5 Compression if physis

Type-6 Peripheral contusion

Salter-Harris classification1,2,3—4,5,6

Treatment

Closed reduction under anesthesia & immobilization in plaster

cast

Manipulation should be gentle not multiple times to avoid

injury to physis & growth disturbance

As remodeling has its limitations open reduction & int. fixation is needed in certain cases when satisfactory reduction & stabilization is either not possible or failed

Surgery- Gen. principlesExposure

Minimal exposure

Minimal soft tissue & periosteal stripping

Gentle handling of soft immature bone & physis

Anatomical closure of wound

Surgery- Gen. principlesImplant

Fixation

Adequate

Easily removable

Smooth rather than threaded implants

implant not to cross epiphysis

Complications

Bony bridge

AVN

Deformity - angular, rotational

Growth disturbance

Infection

Functional Loss

More if deformity is Varus, Extension, distally

placed in both extremities length discrepancy In lower

extremity-

Progressive if associated with injury to

epi-physis resulting in late progressive deformity with growth even if immediate results are satisfactory

S/C # Humerus

Age 5 to 10 yrs Sex Male

Thin flat bone- Three dimensional displacement * Difficult X-ray reading varus/valgus &

rotational displacement Pre & post reduction * Unstable reduction tendency to

re displace * Sharp spike at proximal fragment – * Buttonholing in Brachialis muscle - skin - Compound #

Close vicinity of- Radial, Ulnar, Median nerves & Brachial artery - Prone to neuro - vascular

injuries

S/C # Humerus

Large hematoma – edema – massive swelling skin vascularity – Blebs

Vascular compression – Compartment syndrome - VIC

Proximity to epiphyseal plate -Growth disturbance

Proximity to joint -deformity, stiffness

Massive displacement -periosteal stripping –Myositis ossificanse

S/C # HumerusMechanism of injury

Posterior tilt

Posterior displacement

Proximal displacement

Lateral or medial displacement

Rotation pronation or supination

DisplacementsGrade

1 Un displaced

2 Displaced with intact post cortex

3 Displaced with loss of contact

Clinical features

Age 3 to 10 years Sex Male

Pain, Swelling, Deformity around elbow following H/O fall

Swelling, Deformity around elbow maintaining three point relation, shortening of arm

May be associated with neurovascular complication

Clinical

Investigations

X-Ray elbow AP/LAT view

Pre anesthesia assessment investigations

Color Doppler Vascular integrity

Nerve conduction Integrity of nerves

Intra compartmental Pressure measurement

MRI Compression injury

– X-Ray AP

X-ray- lateral

Radiological Tips

Move C-arm not the limb while taking AP/Lat Xray

Crescent sign Medial or lateral tilt

Unequal width of fragments Rotational malposition

Ant. spike on lat. X-ray Rotational malposition

Baumann angle - (Long axis of humerus with lat. Condylar epiphysis)

Average 72 degree (64 to 81) Better assessed by comparing with normal

Crescent sign

Crescent sign

Baumann’s angle

Neurovascular

Brachial artery Radial pulse, nail bed circulation

Skin Blebs

Compartment Finger movements, stretch sign compartmental tenseness

Radial nerve Wrist drop

Median nerve pointing finger

Ulnar nerveulnar claw

Swelling, edema, eccimosis

Management

Gentle CR under anesthesia under radiological control & immobilization in plaster slab

Gentle CR under anesthesia under radiological control & Stabilization by closed pining

Open reduction & internal fixation

Perfect anatomical reduction is essential to avoid deformity

Closed reduction

Supine position

General anesthesia Avoid Ketamine

Correction of rotation - Reversal of pronation/supination

Correction of lat. Shift – gentle push by palm

Correction of over riding - Traction in 30degree elbow flection

Correction of post. Shift -pushing with thumbs

Closed reduction

Correction of post. Angulation – flexing the elbow

Pronation to prevent varus tilt

Check distal circulation- Radial pulse & nail bed

Radiograph AP & Lat. View by moving the C-arm not the limb if red. Not satisfactory manipulation repeated not more than twice

AE slab in maximum flexion after conforming anatomical reduction in both views

ComplicationsEarly

Injury to Brachial artery

Injury to Radial, Median, Ulnar nerves

Massive swelling & edema - Skin blebs, Vascular compression, Compartment syndrome

Button holing of proximal fragment in Brachialis muscle soft tissue interposition & injury to skin –skin necrosis

Management of vascular complication

Immediate release of encircling bandage

Extension of elbow

Color Doppler

Dunlop Traction

Vascular repair

Decompression - faciotomy

Post Op Care

Post operative elevation

Watch for Distal edema, Nail bed circulation Finger movements, Stretch test, pain

Check x-ray 3rd & 7th day ? Re displacement

Active movements of fingers encouraged

Removal of slab at 4 weeks

Mobilization

Active exercises to develop muscles of arm, forearm, shoulder & hand - static exercises

Smooth, repeated, continuous, Active stretching within limit of pain - dynamic exercises avoiding jerky movements

Takes few weeks to months for complete recovery

ComplicationsIntermediate

Vascular compression due to flexion position tight bandage & edema

Compartment syndrome

Nerve entrapment during reduction Nerve compression due

to edema, positioning, tight bandaging

ComplicationsLate

Mal union Cubitus varus

Myositis ossificanse - Massage, vigorous jerky mobilization

Progressive deformity due to epiphyseal damage

Volkmann's ischemic contracture - Undiagnosed compartment syndrome

Cubitus varus