1. 嘉義長庚 骨科部
沈世勛
Pediatric fractures

2. Introduction
Skeletal trauma accounts for % of all childhood injuries
Immature skeleton differs from that of the adult
Vary in different age groups
Growth plate, periosteum, bone, cartilage...

3. Periosteum Thicker Greater osteogenic potential Callus formation
An effective internal restraint in
close reduction

4. Injury pattern
Buckle
Greenstick
Plastic Deformity

5. Injury pattern
Patterns of fracture
– Variations with age

6. Physis

7. Salter-Harris fracture type

8. Changes in treatment philosophy
Blount’s Non-operative axioms – mid-1950s
Complications with operation intervention
The trend toward minimal invasion

9. Factors creating the trend toward operative intervention
Improvement in technology
Rapid healing
Minimal hospitalization
The perfect result

10. Are the results better with operative intervention ?
Yes, for supracondylar humeral fractures
Universal acceptance of percutaneous pin fixation
Lower readmission rates
Non-operative techniques need to be maintained

11. Fractures about the elbow
“Pity the young surgeon whose first case is a fracture around the elbow”
~ Mercer Rang
With an understanding of the anatomy and adherence of a few basic principles, treatment of such fractures can be straightforward
5%-10% of all fractures in children

12. Anatomy (CRITOE)
Distinguishing fractures from the six normal secondary ossification centers

13. Radiographs interpretation

14. Radiographs interpretation
A, Circular appearance of the hourglass. B, Radiocapitellar angle (40 degrees). C, Anterior humeral line passing through the center of the capitellum. D, The coronoid line touching the anterior capitellar border

15. Baumann’s angle Normal range 64 to 81 degrees
Difference > 5 degrees
should not be accept

16. Fat pad sign
Occult fracture, subperiosteal bleeding

17. Supracondylar fracture
Most common type of elbow fracture in children and adolescents
50% to 70%
Most frequently in children between the ages of 3 and 10 years
High incidence of residual deformity and potential for neurovascular complications

18. Mechanism of injury Extension or flexion force on the distal humerus
Extension type
95% to 98%
Fall on an outstretched hand

19. Mechanism of injury Flexion type 2% to 5%
Direct blow on the posterior aspect of a flexed elbow

20. Classification Modified Gartland’s classification
Type I: non-displaced or minimal displaced
Type II: angulation of the distal fragment, one cortex remains intact
Type III: complete displaced
Type IV: multidirectional instability

21. Goal of treatment To avoid catastrophes Minimize embarrasments
vascular compromised
compartment syndrome
Minimize embarrasments
Cubitus varus
Iatrogenic nerve palsies

22. Treatment Type I fracture Type II fracture Type III fracture
Long arm cast – 3 weeks
Type II fracture
Close reduction plus percutaneous pinning (or long arm cast )
Type III fracture
Close reduction plus percutaneous pinning
Excess swelling, extension - failure of casting , 17% loss reduction

23. Pin configuration Biomechanical studies
Crossed pins are stronger in torsion than a lateral lateral-entry construct
A systemic review (crossed vs. lateral only)
1.84 times – iatrogenic nerve injury
0.58 times – loss of reduction
Recent prospective studies – no difference in loss of reduction or iatrogenic nerve injury
Pin 經過fracture site的距離愈大愈好

24. Medial pin Placed with the arm in extension
Sweeping the soft tissue posteriorly away from the medial epicondyle
Remove medial pin if an iatrogenic ulnar nerve injury noted postoperatively

25. Immobilization after pinning
Immobilized in 30 to 60 degrees of flexion in a posterior splint or bivalved cast
Return in 7 to 10 days to check for maintenance of reduction
Pins are removed and immobilization is discontinued in 3 to 4 weeks after the injury

26. Vascular injury 2% to 38% manipulation and close observation
Failed to provided distal circulation  immediately CR + pinning
Considered surgical exploration and repair if the limb remains ischemic
Abundant collateral circulation

27. Peripheral nerve injury
10% to 15%
Extension type – anterior interosseous nerve (AIN)
Posterolaterally displaced – median nerve
Posteromedially displaced – radial nerve
Ulnar nerve – iatrogenic injury
If function is not return within 8 to 12 weeks, NCV and EMG should be given to ensure the nerve has not been transected

28. Volkmann’s Ischemic Contracture
Compartment syndrome
Improved management  Incidence decreased
Floating elbow may be at increased risk
A supracondylar fracture associated with a compartment syndrome is generally best managed by closed reduction and pinning.

29. Malunion Cubitus varus is more common
Functional problems are uncommon with either deformity
Cosmetic disturbance
和carry angle(5~10 度)比較

30. Lateral condyle fracture
The second most common operative elbow injury in children
May be difficult to diagnose and have a propensity for late displacement
 high complication rate

31. Mechanism of injury Fall on an outstretched arm
A varus stress that avulses the lateral condyle
A valgus force in which the radial head directly pushes off the lateral condyle

32. Diagnosis
The hallmark radiographic finding is the posteriorly base Thurston-Holland fragment in lateral view
Oblique view or arthrograms are helpful in identifying minimal displaced fractures

33. Classification Milch’s classification
provides little prognostic information regarding treatment and potential complications
Type I = SH type IV, type II = SH type II

34. Classification
Jakob classification
Stable type
Unstable type

35. Classification According to displacement Non-displaced: < 2 mm
Minimally displaced: 2-4 mm
Displaced: > 4mm

36. Treatment Non-displaced fracture Minimally displaced fracture
Cast immobilization
Close follow-up
Minimally displaced fracture
Late displacement  delay union or nonunion
Close reduction and pinning
arthrography intraoperatively
arthrography to confirm a reduced articular surface

37. Treatment Displaced fracture Open reduction and pinning
Posterolateral approach  possibility of injury to blood supply
Lateral approach  judge the reduction of the articular surface

38. Lateral condyle nonunion
The most frequent problematic complication
Fracture constant exposed to synovial fluid
Lateral condyle has a poor blood supply
Constant motion at the fracture site from the pull of the wrist extensors of the distal fragment
growth arrest  rare

39. Lateral condyle nonunion
A nonunion can present with one of three scenarios
Painful nonunion
Osteosynthesis ± bone grafting
Cosmetic unacceptable valgus deformity
Corrective osteotomy
Tardy ulnar nerve palsy
Anterior transposition

40. Transphyseal fracture
Most common in children younger than 2 years
Result from child abuse (up to 50%) or birth trauma
Diagnosis can be challenging
Often misdiagnosed as elbow dislocation or lateral condyle fracture
Ultrasound, MRI, arthrogram can be helpful

41. Transphyseal fracture

42. Mechanism of injury Depends on the age of the patient
Newborns and infants
Rotatory or shear force associated with birth trauma or child abuse
Older children
Usually a hyperextension force from a fall on an outstretched hand

43. Different diagnosis Elbow dislocation Lateral condyle fracture
Abnormal radial head-capitellum relationship
Rarely occurred in this age group
Lateral condyle fracture
Oblique radiographs, arthrogram, MRI
Metaphyseal fragment are displaced laterally
Supracondylar fracture
Fracture usually at the level of the olecranon fossa

44. Treatment Simple immobilization Close reduction and pinning
Cubitus varus occurs frequently
Close reduction and pinning

45. Medial condyle fracture
Around 50% are associated with elbow dislocation
Usually occur between 7 to 15 years of age
Account for approximately 10% of all children’s elbow fracture

46. Mechanism of injury
A valgus stress producing traction on the medial epicondylar trough the flexor muscle

47. Treatment Nonsurgical treatment, even displaced
Immobilization – 1 to 2 weeks

48. Treatment Indication for surgical treatment Absolute indication
Fragment incarcerated in joint
Open fracture
Gross elbow instability
Relative indication
High-demand, over head athlete, such as a pitcher

49. Complications Stiffness Ulnar nerve dysfunction Symptomatic nonunion
Most common complication
Immobilization no more than 3 weeks to avoid complication
Ulnar nerve dysfunction
Varies from 10% to 16%
Symptomatic nonunion
Difficult to treat
In situ fixation or simple excision have been advocated

50. Olecranon fracture Relative uncommon, 5% of elbow fractures
20% to 50% associated with other elbow injuries
Usually medial condyle

51. Mechanism of injury Usually hyperextension injury
Direct blow to the flexed elbow
Hyperflexion injury
Shear force

52. Treatment Intra-articular fracture with step off > 2mm  ORIF
Extra-articular fracture displacement > 5mm  ORIF
Conservative treatment  immobilization in about 20 degrees of flexion

53. Radial neck fracture Cartilage radial head is resistant to fracture
More radial neck fracture
About 50% of radial neck fractures are associated with other injuries to the elbow

54. Mechanism of injury
Fall onto a outstretched hand, with elbow in extension and valgus

55. Mechanism of injury
Fracture by impact against the inferior aspect of the capitellum at the time of dislocation or at the time of spontaneous reduction

56. Classification O’Brien’s classification system
Proximal radial physeal fractures are usually Salter-Harris type II injuries. Younger children may sustain Salter-Harris type I injuries

57. Treatment Type I Type II and III Simple immobilization for 1-2 weeks
Close reduction if > 15 degrees (> 10 y/o)
Type II and III
Close reduction
Percutaneous or intramedullary reduction

58. Treatment
Patterson technique

59. Treatment
Kaufman technique

60. Treatment
Wrapping technique

61. Treatment
Percutaneous reduction
Intramedullary reduction

62. Treatment Open reduction
Failed to achieve stable reduction with closed reduction or minimal invasive techniques
Post reduction supination and pronation < 60 degrees
Radial head fracture complete displaced