‫بسم هللا الرحمن الرحيم‬

Principles of management
Pediatric Fractures
Objectives

• Statistics about fractures in children

• How children’s bones are different
• Outline principles of management
• Point out specific precautions

Acknowledgement and recommendation

Lynn T Staheli
 introduction

• In Middle East ~60% of population are < 20 yrs.

• Fractures account for ~15% of all injuries in children.

• Different from adult fractures
• Vary in various age groups
( Infants, children, adolescents )
 Statistics

• ~ 50% of boys and 25% of girls, expected to have a

fracture during childhood.

• Boys > girls

• Rate increases with age.

Mizulta, 1987
 Statistics

• ~ 50% of boys and 25% of girls, expected to have a

fracture during childhood.

• Boys > girls

• Rate increases with age.

• Physeal injuries with age.

Mizulta, 1987
 Statistics

Most frequent sites

(sample of 923 children, Mizulta, 1987)
 Why are children’s fractures different?

Children have different physiology and anatomy

• Growth plate.
• Bone.
• Cartilage.
• Periosteum.
• Ligaments.
• Age-related
• physiology
 Why are children’s fractures different?

Children have different physiology and anatomy

• Growth plate:

– In infants, GP is stronger than bone

increased diaphyseal fractures
– Provides perfect remodeling power.
– Injury of growth plate causes deformity.
– A fracture might lead to overgrowth.
 Why are children’s fractures different?

Children have different physiology and anatomy

• Bone:

– Increased collagen: bone ratio

- lowers modulus of elasticity
 Why are children’s fractures different?

Children have different physiology and anatomy

• Bone:

– Increased collagen: bone ratio

- lowers modulus of elasticity
– Increased cancellous bone
- reduces tensile strength
- reduces tendency of fracture to propagate
less comminuted fractures
– Bone fails on both tension and compression
- commonly seen “buckle” fracture
 Why are children’s fractures different?

Children have different physiology and anatomy

• Cartilage:

– Increased ratio of cartilage to bone

- better resilience
- difficult x-ray evaluation
- size of articular fragment often under-estimated
 Why are children’s fractures different?

Children have different physiology and anatomy

• Periosteum:

– Metabolically active
• more callus, rapid union, increased remodeling
– Thickness and strength
• Intact periosteal hinge affects fracture pattern
• May aid reduction
 Why are children’s fractures different?

Children have different physiology and anatomy

• Age related fracture pattern:

– Infants: diaphyseal fractures

– Children: metaphyseal fractures
– Adolescents: epiphyseal injuries
 Why are children’s fractures different?

Children have different physiology and anatomy

• Physiology

– Better blood supply

rare incidence of delayed and non-union
 Physeal injuries

• Account for ~25% of all children’s fractures.

• More in boys.
• More in upper limb.
• Most heal well rapidly with good remodeling.
• Growth may be affected.
 Physeal injuries
Classification: Salter-Harris, Peterson, Ogden
 Physeal injuries

• Less than 1% cause physeal bridging affecting growth.

– Small bridges (<10%) may lyse spontaneously.
– Central bridges more likely to lyse.
– Peripheral bridges more likely to cause deformity

– Avoid injury to physis during fixation.

– Monitor growth over a long period.
– Image suspected physeal bar (CT, MRI)
 The power of remodeling

• Tremendous power of remodeling

• Can accept more angulation and displacement
• Rotational mal-alignment ?does not remodel
 The power of remodeling

Factors affecting remodeling potential

• Years of remaining growth – most important factor

• Position in the bone – the nearer to physis the better
• Plane of motion –
greatest in sagittal, the frontal, and least for transverse plane
• Physeal status – if damaged, less potential for correction
• Growth potential of adjacent physis
e.g. upper humerus better than lower humerus
 The power of remodeling

Factors affecting remodeling potential

• Growth potential of adjacent physis

e.g. upper humerus better than lower humerus
 Indications for operative fixation

• Open fractures
• Displaced intra articular fractures
( Salter-Harris III-IV )
• fractures with vascular injury
• ? Compartment syndrome
• Fractures not reduced by closed reduction
( soft tissue interposition, button-holing of periosteum )
• If reduction could be only maintained in an abnormal
position
Indications for operative fixation
 Methods of fixation

• Casting - still the commonest

 Methods of fixation

• Casting - still the commonest

• K-wires
– most commonly used
– Metaphyseal fractures
 Methods of fixation

• Casting - still the commonest

• K-wires
– most commonly used
– Metaphyseal fractures
• K- wires could be replaced by absorbable rods
 Methods of fixation

• Casting - still the commonest

• K-wires
– most commonly used
– Metaphyseal fractures
• K- wires could be replaced by absorbable rods

Preoperative immediate 6 months 12 months

Hope et al , JBJS 73B(6) ,1991

 Methods of fixation

• Casting - still the commonest

• K-wires
– most commonly used
– Metaphyseal fractures
• Intramedullary wires, elastic nails
– Very useful
– Diaphyseal fractures
 Methods of fixation

• Casting - still the commonest

• K-wires
– most commonly used
– Metaphyseal fractures
• Intramedullary wires, elastic nails
– Very useful
– Diaphyseal fractures
• Screws
 Methods of fixation

• Casting - still the commonest

• K-wires
– most commonly used
– Metaphyseal fractures
• Intramedullary wires, elastic nails
– Very useful
– Diaphyseal fractures
• Screws
 Methods of fixation

• Casting - still the commonest

• K-wires
– most commonly used
– Metaphyseal fractures
• Intramedullary wires, elastic nails
– Very useful
– Diaphyseal fractures
• Screws
• Plates – multiple trauma
 Methods of fixation

• Casting - still the commonest

• K-wires
– most commonly used
– Metaphyseal fractures
• Intramedullary wires, elastic nails
– Very useful
– Diaphyseal fractures
• Screws
• Plates – multiple trauma
• IMN - adolescents only (injury to growth)
 Methods of fixation
• Casting - still the commonest
• K-wires
– most commonly used
– Metaphyseal fractures
• Intramedullary wires, elastic nails
– Very useful
– Diaphyseal fractures
• Screws
• Plates – multiple trauma
• IMN - adolescents
• Ex-fix – usually in open fractures
 Methods of fixation
• Casting - still the commonest
• K-wires
– most commonly used
– Metaphyseal fractures
• Intramedullary wires, elastic nails
– Very useful
– Diaphyseal fractures
• Screws
• Plates – multiple trauma
• IMN - adolescents
• Ex-fix
 Fixation and stability

• Fixation methods provide

varying degrees of
stability.

• Ideal fixation should

provide adequate stability
and allow normal flexibility.

• Often combination methods

are best.
 Complications

• Ma-lunion is not usually a problem

( except cubitus varus )
• Non-union is hardly seen
( except in the lateral condyle )
• Growth disturbance – epiphyseal damage
• Vascular – volkmann’s ischemia
• Infection - rare
 Beware!

Non-accidental injuries
 Beware!

Non-accidental injuries
• ?Multiple
• At various levels of healing
• Unclear history – mismatching with injury
• Circumstantial evidence
 Beware!

Non-accidental injuries
• Circumstantial evidence
• Soft tissue injuries - bruising, burns
• Intraabdominal injuries
• Intracranial injuries
• Delay in seeking treatment
 Beware!

Non-accidental injuries
• Specific pattern
– Posterior ribs
– Skull
 Beware!
Non-accidental injuries
• Specific pattern
– Corner fractures (traction & rotation)
 Beware!
Non-accidental injuries
• Specific pattern
– Bucket handle fractures (traction & rotation)
 Beware!

Non-accidental injuries
• Specific pattern
– Femur shaft fracture
• <1 year of age ( 60-70% non accidental)
• Transverse fracture
– Humeral shaft fracture <3 years of age
– Sternal fractures
 Beware!

Malignant tumours

• Can present as injury.

• History of trauma usual.
• 12y old girl
• History of trauma
• mild tenderness
• Periosteal reaction

• 2m later, still tender

• Ewings sarcoma
Special considerations

During resuscitation
 summary
Children’s bones are different
 summary

• About 60% of population in ME are children!

• Fractures in children are common.
• Children’s bones are different
• Outline principles of management.
• Specific treatment plans (combinations possible)
• Specific precautions.
• Beware
– Non-accidental trauma
– Malignant tumors
AO Courses, Riyadh 1-5 May 2005