Professional Documents
Culture Documents
Pediatric Fractures
Presented by:
Dr. Harjot Singh Gurudatta
Special considerations :
• 1° ossification center
• Diaphyseal
• 2° ossification centers
• Epiphyseal
• Occur at different stages of
development
• Usually occurs earlier in girls than
boys
source: http://training.seer.cancer.gov
General Principles
Regulation of Epiphyseal Growth
Physis is the primary centre for growth
in most bones. EPIPHYSIS
Try not to cross the physis, but rather parallel it in the epiphysis or
pin the fracture spike in the metaphysis
Growth Arrest Secondary to Physeal Injury
Address Assess
• Angular • Growth
deformity remaining
• Limb length • Amount of
discrepancy physis
involved
• Degree of
angular
deformity
• Projected
LLD at
maturity
Physeal Bar Resection
- Indications -
• >2 years remaining growth
• <50% physeal involvement
(cross-sectional)
• Concomitant osteotomy for
>15-20º deformity
• Completion epiphyseodesis
(tethering physis with staple
screw)and contralateral
epiphyseodesis may be
more reliable in older child
• Central bar> peripheral bar
Physeal Bar Resection - Techniques
Direct visualization
Burr/currettes
Interpositional material
(fat, cranioplast) easiest to prevent
reformation
The arrest is removed, leaving in
its place a metaphyseal-epiphyseal
cavity with intact physis
surrounding the area of resection
Torus Fracture
A greenstick fracture is a fracture in a young, soft
bone in which the bone bends and partially
breaks. This is owing in large part to the thick
fiborous periosteum of immature bone
here are three basic forms of greenstick fracture.
In the first a transverse fracture occurs in the
cortex, extends into the midportion of the bone
and becomes oriented along the longitudinal axis
of the bone without disrupting the opposite
cortex.
The second form is a torus or buckling fracture,
caused by impaction , The word torus is derived
from the Latin word 'Tori' meaning swelling or
protuberance.
The third is a bow fracture in which the bone
becomes curved along its longitudinal axis.
Usually pop splint is given!
DIAPHYSEAL FRACTURE
, "
~rticular Growth plate Metaphysis or diaphysis Consider:
.... Remodeling potential
...
End of growth
~---
_
...
...
Age of patient
Growth rate of physis
Plan of joint motion
Position in bone
Displacement
>2mm
Growth remaining
I - Other factors
Deformity visible?
Parents' values
placement SH-1 and SH-2 Special anatomic features
"2 mm
/ I
•
Unacceptable Acceptable
I " r /
Accept
position
I~=-I Functlonal-
coametlc
reductio
Accept position
ACCEPTABLE REDUCTION
- initial considerations:
growth will not correct rotational deformity
age
distance from physis
amount of deformity
- bayonette apposition
- generally bayonette apposition will require operative reduction
- historically, overriding of a both bones forearm fracture was acceptable if...
- there was no deviation of radius and ulna toward each other;
- there was no encroachment of the interosseous space;
- pt is less than 10 yrs of age;
- in pts < 6 yrs of age:
- upto 15 deg of angulation &<5 deg rotation is acceptable;
- between ages of 6-10 yrs:
- less than 10 deg of angulation should remodel especially if frx is close to distal epiphysis;
- bayonet apposition may be acceptable, although end to end apposition is preferred;
- pts > 12 yrs of age:
- no angulatory or rotational deformity is considered acceptable;
- more aggressive treatment is required, including open reduction and compression plating may be
required;
- Displaced Distal Third Frx:
- angulation up to 20-25 deg during first ten years is OK;
- angulation > 10 deg is unlikely to correct after 10 yrs
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
Forearm diaphyseal fracture
Open
Debridement in OR Closed
Adolescents &
Older
Older
children
children Infants & younger children
Open Closed
Immobilize in a sling & swath
Choice
Open Closed
traction