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

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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




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



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, 15-18 vs. 19-20 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: 587-622. Khan La, Bradnock Tj, Scott C, Robinson Cm. Fractures Of The Clavicle. J Bone Joint Surg Am. 2009 Feb;91(2):447-60. Egol Ka Et Al. Management Of Fractures In Adolescents. J Bone Joint Surg. Am. 2010 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: 482-4.

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