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PEDI FRACTURES

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Melissa Bent

on 6 May 2015

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Transcript of PEDI FRACTURES

PEDIATRIC FRACTURES 101
EMERGENCY STAT!
Polytrauma/hemodynamic instability
Open fracture:
finger/toes with nail bed avulsion = OPEN
Compartment syndrome
Fractures --> neurovascular compromise, skin tenting, etc
URGENT/NON URGENT
Physeal
Metaphyseal
Displaced, comminuted
Nondisplaced
Overuse/stress fractures
Complications
Treatment Principles
Conclusion
6M Urgent Care
6 yo right hand dominant female fell off the monkey bars at school approximately 6 ft onto her right outstretched hand with immediate pain and deformity to the right elbow. No open injury, no pain of right neck, shoulder, or wrist.

What do you do next?


1. X-ray? What part of the body?
2. NPO, Ortho for OR vs splint and follow up
3. Additional imaging/CT Scan/MRI
PREP 2013
A 16-year-old boy sustained tibial and fibular fractures of his left leg yesterday during a soccer game. In the emergency department, he underwent closed reduction of the fractures and his leg was splinted with a posterior long leg splint. His mother calls you today because, over the past 4 hours, he has been complaining of worsening pain in his lower leg that has not improved despite several doses of hydrocodone and loosening of the splint. In addition, he says it is difficult to move the toes on his left foot and that his toes are pale and “feel numb."

Of the following, the MOST common complication of this patient’s condition if it is left untreated is

A. avascular necrosis of the tibial plateau
B. equinovarus foot deformity
C. fracture malunion
D. leg length discrepancy
E. osteomyelitis
Anatomy
Unique features of growing bones:

1. Periosteum
Thicker
More osteogenic
Promotes rapid healing
Attached firmly at periphery of physes
Hinge for reduction

2. Physis (Growth plate)

3. Mechanical/physical properties:
More porous
More ductile


Objectives
Understand the unique anatomy related to pediatric fractures
Distinguish emergent vs urgent vs non-urgent fractures
Apply Salter Harris Classification to real fractures and management
Understand basic fracture management
Stabilization
Splint
Cast
Identify complications related to fracture and management
Common Pediatric Fracture Types
Buckle or Torus
Compression failure
Stable
Usually at metaphyseal / diaphyseal junction

Plastic Deformation
These do not remodel well
Forearm, fibula common

Greenstick
Bending mechanism
Incomplete fracture
May need to complete fracture to realign


Salter Harris
JBJS 1963
Type II - most common 75%
**
Pre-op Antibiotics
Randomized prospective study Prevent Infection

Treatment

Infection
Cephalosporin 2%
Pcn and Streptomycin 10%
No Abx 14

Patzakis MJ, Harvey JP Jr, Ivler D: The role of antibiotics in
the management of open fractures. JBJS 1974.

Infection Rate in 1,104 open fractures
• 7.4% if Abx started > 3 hours after injury
• 4.7% if Abx started < 3 hours after injury
•Early administration of Abx
“The single most important factor in reducing the infection rate”
-------------------------------------------------------------------------------------
**
IV Antibiotics- ASAP!!
Type I Ancef (100mg/kg/day q8H)
Type II /III Ancef + Gent (5–7.5 mg/kg/day q8 H)

Farm or vascular PCN 150,000 units/kg/day q6 H
(clostridium and other anaerobes)
Physeal Fractures

Basic Fracture
Principles
Type I & Type II
Closed reduction & immobilization
Exceptions
Proximal femur
Distal femur

Type III & IV
Intra-articular and physeal step-off
needs anatomic reduction
Open reduction, internal fixation (ORIF)

Evaluation:
Physical Exam:
Assess location of deformity or tenderness
Carefully assess and document specifically distal neurologic and circulatory function

X-Rays:
Focal bony tenderness + history of acute trauma
At least 2 orthogonal views
Include joint above and below fracture
Try to get the whole bone (forearm vs wrist)

Treatment:
NPO (is this patient a surgical candidate or requires sedation?)
Pain
medications
ice/elevate
Immobilize:
1. decrease pain
2. allow healing
3. avoid repeat injury
4. reduce fracture movement in unstable fractures:
Restore:
Length
Alignment
Rotation

As the ossification center enlarges, becomes stiffer and more risk to fracture
S
ame
A
bove
L
ower
T
hrough
E
verything
c
R
ushed
20% of all pedi fractures
Peak 11-12 yo
Distal locations
wrist - radius
knee - femur
ankle - tibia
Mechanism: Torsion/shearing
Bone

Malunion
Limb length discrepancy
Physeal arrest
Nonunion (rare)
Crossunion
Osteonecrosis/Avascular necrosis

Soft Tissue

Vascular Injury
elbow/knee
Neurologic Injury
Usually neuropraxia
Compartment Syndrome
leg/forearm
Cast burns/sores/pressure ulcers

Compartment Syndrome in Pediatrics

Pain, pallor, paresthesia, paralysis,
and
pulselessness
unreliable signs and symptoms of compartment syndrome in these children.
Increasing analgesia
requirement in combination with other clinical signsmore sensitive indicator of compartment
If patient comes in with pain after fracture with "a tight cast" or splint, remove the splint or bivalve the cast

Bae et al J Pediatric Orthopaedics 2001

Pain control & relaxation
Well molded casts/splints
3-point fixation principle
Consider immobilization method on day of injury that will last through entire course of treatment
Limit splint or cast changes
Consider likelihood of post-reduction swelling
Orthoglass
Cast splitting or splint

Elbow: Supracondylar
Common Fractures

Femur:
Mid-shaft
Wrist: Distal Radius
Ankle:
Tillaux/Triplane
Non-accidental Trauma/Injury (NAT/NAI)
Fractures are the 2nd most common presenting lesion (Skin=1st)
History:
Injury often inconsistent with history
Red flags :
long bone fxs in infant not yet walking
multiple bruises
multiple fxs in various stages of healing
corner fxs
primary spongiosa (metaphyseal)
high specificity for child abuse
posterior rib fractures
bucket handle fractures
transphyseal separation of the distal humerus
Mechanism: fall
Associated injuries:
Neuropraxia:
Anterior interosseous nerve injury:
No A-OK
Radial nerve -
No wrist extension
Ulnar nerve
Vascular injury
Evaluate: AP and Lateral Elbow XR
Classification/Treatment
Who?
Toddlers 2-4 --> Falls
Adolescents --> MVA/trauma





Classify/Describe:
Oblique, transverse, comminuted
Open vs closed


Treatment Options
< 6 m
6m-5 yo

Tillaux:
avulsion of anterior inferior tibiofibular ligament
Salter Harris III
Treatment:
Closed reduction by internally rotating the foot and apply long leg cast
Open reduction, internal fixation

Triplane:
12-15 yo
Result of ossification of distal tibia physis - central-->medial --> lateral
Salter Harris IV:
AP : SH 3
Lateral : SH 2
Treatment:
<2 mm displacement: Cast
>2 mm: Surgery
AP, lateral and mortise views
30% of all pediatric fxs
Mechanism: fall onto outstretched
hand
Types
Metaphyseal
Physeal
Salter II most common
Torus
Greenstick
Complete

Apophyseal Injuries
Other Fracture Types

Apophysis - a secondary ossification center which acts as an insertion site for a tendon
Locations:
Tibial tubercle
Medial Epicondyle
Often associated with dislocation
May be preceded by chronic injury/repetitive process

Pathologic Fractures
Diagnostic workup important
Local bone lesion
Generalized bone weakness
Prognosis dependent on biology of lesion
Often need surgery

Common cause of open fractures & amputations in children
Most are:
A rider or bystander (70%)
Under 5 years old (78%)
High complication rate
Infection
Growth arrest
Amputation
> 50% poor results
Education/ Prevention key!
Children < 14 y
Shouldn’t operate
Keep out of yard
No riders other than mower operator
Lawn Mower Injuries
Overuse Injuries
More common as children and
adolescents participate in
high level athletics
Soccer, dance, baseball, gymnastics
Ask about training regimens
Mechanical pain
Diagnosis
History/Exam
Serial radiographs
Bone scan
CT/MRI
Treatment
Stop the sport/activity
Cast if overly active
Spica/Fixation for all femoral neck stress fractures

Tibia:
Toddlers Fracture
Clavicle
Short Arm Cast
Volar (palmar) slab splint
Velcro wrist splint
Mechanism: Direct blow to clavicle, fall onto shoulder, fall onto hand, birth
Most common birth related fracture --> brachial plexus
Common in children age 4-5 thru adolescence
Occurrence: up to 15% of all fractures
These heal really well

Middle third fractures with angulation less than 60 degrees and 2cm overlap

Treatment:
Sling for 3-4 weeks; (Avoid Figure of Eight Device)
Infants: Nothing or consider onesie/t-shirt and safety pin
Counseling: Tell parents about the lump!
Also: shortening and cosmetic deformity are possible.
Nice to document: Distal sensation and perfusion, normal lungs
Refer: Skin tenting, proximal or distal third fractures, respiratory compromise

Spiral Fracture of the tibia
Age: 12 months to 4 years
Mechanism: Minimal trauma; often a simple fall
with a twist (going down a slide with an adult)
Tenderness at the shaft of the tibia is a key element
On X-ray:
involve the distal or middle third of tibia
no displacement
no step off
fibula should be normal


Treatment:

Posterior splint for 3-7 days followed by a short leg walking cast or a CAM walker to complete 4 weeks of immobilization
If displaced (>2mm),
- short or long walking leg cast
If severe pain with internal & external rotation
- long leg cast.


1. Pediatric musculoskeletal injuries are relatively common

2. Remember unique aspects of pediatric musculoskeletal differences

3. Most fractures heal, regardless of treatment

4. Fracture principles: try to restore length, alignment, rotation and immobilize to reduce pain and allow healing

5. Focal tenderness and history of acute trauma
Basics ...
1. What bone is affected?
- What part of the bone (proximal, mid-shaft, distal)
2. What type of fracture?
- open vs close (check skin)
- displacement, angulated, comminuted
- neurovascular status

3. Context?
UE: Hand dominance
LE: Ambulatory vs non-ambulatory

4. Stable vs unstable
C. Equinovarus foot deformity

The patient described in the vignette is demonstrating signs and complaining of symptoms that raise the clinical suspicion for compartment syndrome. Compartment syndrome is a potentially limb-threatening complication that results when increased tissue pressures (typically related to muscle and soft-tissue edema) within closed osteofascial compartments cause decreased muscle perfusion and ischemia. Most commonly seen after extremity fractures, compartment syndrome may also complicate burns, snakebites, and crush injuries. The lower leg is affected most commonly, with tibial fractures accounting for 20% to 40% of fracture-related compartment syndromes. Rapid evaluation should be performed in patients with fractures like the boy in the vignette who complain of worsening pain, pain out of proportion to the injury, distal numbness, or extremity pallor. It is important to remember that with the exception of pain, most of the classically described clinical features of compartment syndrome (the 5 Ps: pain, pallor, paresthesias, paralysis, and pulselessness) are late findings. It is also unusual for the muscle group to feel “tight” to the examiner despite rising pressures. A high index of clinical suspicion should prompt the clinician to evaluate high-risk patients before neurovascular compromise is evident.

If compartment syndrome is suspected, immediate orthopedic consultation is indicated, and compartment pressures should be measured. Normal muscle compartment pressure is typically less than 10 to 12 mm Hg. Subtracting the measured intracompartmental pressure from the diastolic blood pressure provides a measure of the compartmental perfusion pressure. A compartmental perfusion pressure of 30 mm Hg or less is indicative of ischemic compromise and should prompt consideration of surgical intervention to relieve the compartment pressure.

Prompt release of intracompartmental pressure (within 6 to 12 hours of onset) is critical for a favorable outcome. Initial treatment of compartment syndrome involves removal of constricting dressings, splints, or casts and maintenance of the extremity at “heart level” to maximize perfusion and minimize further dependent edema. Fasciotomy of the affected compartments may be necessary to release the intracompartmental pressure and restore muscle perfusion.

The most common complication of compartment syndrome is ischemic injury of the affected muscles with resultant contracture formation. When the lower leg is involved, contractures most commonly lead to equinovarus foot deformity. Other, less common complications include infection, delayed fracture healing, and malunion with or without the development of leg length discrepancy. Avascular necrosis, a condition that occurs when there is ischemia in an area of bone with tenuous vascular supply, would not be a likely complication of lower extremity compartment syndrome because it does not typically occur in the tibia or fibula.
6-11 yo, >100 lbs
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