嘉義長庚 骨科部 沈世勛 Pediatric fractures

Introduction Skeletal trauma accounts for 10-15 % of all childhood injuries Immature skeleton differs from that of the adult Vary in different age groups Growth plate, periosteum, bone, cartilage...

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

Injury pattern Buckle Greenstick Plastic Deformity

Injury pattern Patterns of fracture – Variations with age

Physis

Salter-Harris fracture type

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

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

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

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

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

Radiographs interpretation

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

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

Fat pad sign Occult fracture, subperiosteal bleeding

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

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

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

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

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

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

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

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

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

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

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

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.

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

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

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

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

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

Classification Jakob classification Stable type Unstable type

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

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

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

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

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

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

Transphyseal fracture

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Treatment Patterson technique

Treatment Kaufman technique

Treatment Wrapping technique

Treatment Percutaneous reduction Intramedullary reduction

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