Presentation is loading. Please wait.

Presentation is loading. Please wait.

Management of Fractures in Adolescents Friday Registrar Presentation Dr. Stewart Morrison MBBS Western Health Orthopaedic Department.

Similar presentations


Presentation on theme: "Management of Fractures in Adolescents Friday Registrar Presentation Dr. Stewart Morrison MBBS Western Health Orthopaedic Department."— Presentation transcript:

1 Management of Fractures in Adolescents Friday Registrar Presentation Dr. Stewart Morrison MBBS Western Health Orthopaedic Department

2 Introduction Adolescence ✚ Puberty: acceleration phase, peak height velocity, deceleration phase ✚ Peak height velocity: Girls 12 years, Boys 14 years ✚ Fall between management parameters for adults, and those for children ✚ Quality of Bone.Less mineralised, more vascular, greater callus.greater energy dissipation, less comminution, quicker healing ✚ Structure of Bone.Physeal Plate.Closure of Physeal Plate ✚ Psychosocial

3 Estimation of Maturity ✚ Various Methods.Sauvegrain.Oxford Score.Greulich’s and Pyle’s Atlas.Tanner-Whitehouse-III RUS Score.Sanders modification of TWIIIRUS Score ✚ Biological Staging.Tanner Stages.Secondary Sexual Characteristics

4

5

6

7 Classification of Physeal Fractures ✚ Salter-Harris ✚ Perichondral ring of La Croix ✚ Communication ✚ Prognosis

8 Imaging General Principles ✚ Joint above, joint below ✚ Comparison views ✚ CT ✚ MRI

9 Principles of Treatment: Physeal Fractures Reduction ✚ Traction, gentle manipulation ✚ Open preferable to multiple closed attempts ✚ No reduction after 7-10 days, unless > 2mm step-off Fixation ✚ Pins, screws should be parallel to the physis ✚ Single pass, single smooth K-wire ✚ Resection of periosteum ✚ Langenskiöld procedure ✚ No reduction after 7-10 days, unless > 2mm step-off Most heal in 3 weeks. Growth disturbance monitoring.

10 Park-Harris Lines

11 How to succinctly and clearly explain this algorithm to parents? … when often they only hear the word ‘deformity’

12 Principles of Treatment: Non-Physeal Fractures ✚ Adolescent bone does not have the remodelling capacity of childrens’ ✚ Weight and specific characteristics need to be taken into account ✚ Displaced diaphyseal fractures – Titanium Elastic Nails ✚ Displaced metaphyseal fractures – Percutaneous Pin Fixation ✚ Supplementation of fixation by splint or cast ✚ Locking plates not usually required ✚ Implant removal

13

14

15 Clavicle ✚ First bone to begin ossification, and the last to finish it. ✚ Threshold of > 2 cm of displacement often cited Operative Considerations ✚ ORIF ✚ Supraclavicular nerve ✚ Neurovascular bundle ✚ Earlier return to full activities (12 vs 16 weeks)

16 Radial and Ulnar Shafts ✚ Studies often convoluted by pediatric participants, and inclusion of metaphyseal fractures ✚ More difficult to manage than previously thought ✚ Greenstick ✚ Plastic Deformation ✚ Complete ✚ Comminuted If a deformity is present in two orthogonal radiographs, the true deformity will be greater than appreciated on either single view

17 Radial and Ulnar Shafts Operative Considerations ✚ 1.5 – 2.0 mm Titanium Elastic Nails (TENS) ✚ Closed Reduction  closed reduction with percutanous fixation  open reduction ✚ Reestablish radial bow, eliminate any bowing of ulna ✚ Fix radius first ✚ Narrowest point of radius is central ✚ Narrowest point of ulna is within the distal third ✚ Do not cross physes ✚ Removal at six months or more

18 Femoral Shaft Principles ✚ Timely union ✚ No rotational deformity ✚ < 2 cm shortening ✚ Deformity of < 10-20° (sagittal plane), < 5-10° (coronal plane) Operative Considerations ✚ In adolescents, surgical treatment favoured ✚ Elastic intramedullary nails (< 11 yrs, < 49 kg ).require removal ✚ Rigid nails, plating (> 11 yrs, length ‘unstable’ fractures).require removal ✚ No randomized trials ✚ External Fixation

19 Distal Femur ✚ High Energy Metaphyseal Fractures ✚ < 10 years; closed reduction + percutaneous cross-pin fixation + long leg cast ✚ > 10 years or unstable fracture, consider plating or external fixation Physeal Fractures ✚ SHI + SH II, undisplaced – long leg cast ✚ SHI + II, mildly displaced – closed reduction, percutaneous pinning, long leg cast ✚ SH II, large metaphyseal fragment – cannulated screws, long leg cast ✚ SH III + IV, displaced – cannulated compression screws ✚ All should remain NWB following fixation ✚ 50% of distal femoral fractures lead to growth disturbance (SH II highest risk)

20 Proximal Tibia Physeal Fractures ✚ High energy ✚ CT recommended ✚ Similar management principles to distal femoral fractures Metaphyseal Fractures ✚ “Cozen Fractures” ✚ Closed reduction, long leg casting ✚ Genu valgum is most common complication

21 Proximal Tibia Tibial Spine Fractures ✚ Hyperextension of the knee ✚ ACL avulsion injury Tibial Tubercle Fractures ✚ Repetitive jumping sports ✚ Ogden modification of Watson-Jones Classification ✚ Open reduction, internal fixation for II, III, IV ✚ V should have periosteal sleeve reattached ✚ Genu recuvatum

22 Ankle Considerations ✚ Fibular physis closes later than the tibial physis (12-14, vs yrs) ✚ Tibial physis closes in a circular pattern – centre to medial to lateral ✚ CT scan recommended Management ✚ SH I or SHII, undisplaced – BK walking cast 3-4 weeks ✚ SH I or SHII, displaced – closed reduction, AK cast 3 weeks, then BK 3 weeks ✚ SH III or SHIV – often require open reduction, internal fixation ✚ If periosteal flap not removed, 60% incidence of plate closure ✚ No more than 5% of angulation in any plane should be accepted

23 Ankle Tillaux Fracture ✚ SHIII of anterolateral distal tibial epiphysis (final area to close) ✚ Internal rotation can provide closed reduction, however often need open reduction Triplanar Fracture ✚ SHIII or SH IV ✚ Appears as SH II on lateral radiograph, SH III on anteroposterior radiograph ✚ Younger patient than Tillaux fracture ✚ Growth arrest not clinically important ✚ Flexion of Knee to 90 degrees, plantar flexion and internal rotation of the foot, with AK cast for 3/52 ✚ If unsuccessful, proceed to percutaneous or open reduction/fixation

24 Thank you Salter RB, Harris WR. Injuries Involving The Epiphyseal Plate. J Bone Joint Surg Am. 1963;45: Khan La, Bradnock Tj, Scott C, Robinson Cm. Fractures Of The Clavicle. J Bone Joint Surg Am Feb;91(2): Egol Ka Et Al. Management Of Fractures In Adolescents. J Bone Joint Surg. Am Dec;92(18) 2947 Zionts Le. Fractures Around The Knee In Children. JAAOS Vol. 10 No. 5 September/October 2002 Alain Diméglio; Yann Philippe Charles; Jean-pierre Daures; Vincenzo De Rosa; Accuracy Of The Sauvegrain Method In Determining Skeletal Age During Puberty. Journal Of Bone And Joint Surgery; Aug 2005; 87, 8; Health & Medical Complete Momberger N, Stevens P, Smith J, Santora S, Scott S, Anderson J. Intramedullary nailing of femoral fractures in adolescents. J Pediatr Orthop. 2000;20:


Download ppt "Management of Fractures in Adolescents Friday Registrar Presentation Dr. Stewart Morrison MBBS Western Health Orthopaedic Department."

Similar presentations


Ads by Google