Surgical fixation of fractures in children Alwyn Abraham CONSULTANT IN TRAUMA (ADULT & CHILDREN) & ELECTIVE CHILDREN’S ORTHOPAEDIC SURGERY Leicester Royal.

Surgical fixation of fractures in children

Alwyn AbrahamCONSULTANT IN TRAUMA (ADULT & CHILDREN)

& ELECTIVE CHILDREN’S ORTHOPAEDIC SURGERYLeicester Royal Infirmary

Overview

1. Properties of paediatric bone are different.

2. The pattern of fractures are different in children

3. What are the common children’s injuries that require stabilisation?

Summary

• Have a low threshold to K-wire displaced distal metaphyseal fractures

• Radius shaft fractures: ESIN• Femoral fractures – spica or ESIN• Tibial fractures – cast/ ESIN/ bone transport

for severe injuries.

Bony anatomy in children

Plastic Deformation

• A result of the different composition of paediatric bone

• Energy absorbed prior to fracture• Affects reduction.

Bony anatomy in children

Remodelling potential

• Related to site• Related to age• Related to severity of deformity• Related to plane of deformity• Phenomenon of overgrowth

Pattern of injuries in children

Epidemiology of children’s fractures

Worlock P & Stower M. Fracture patterns in Nottingham Children. J.Paed.Orth;1986 6(6):656-660

• Calendar year 1981• in age < 12 years• 826 patients with 923#s (pop 102841)• Injuries and causes and in

– 0-18 mths– 18-60 mths– > 5yrs of age

Pattern of injuries in children

Worlock P & Stower M. Fracture patterns in Nottingham Children. J.Paed.Orth;1986 6(6):656-660

Pattern of injuries in children

Worlock P & Stower M. Fracture patterns in Nottingham Children. J.Paed.Orth;1986 6(6):656-660

Pattern of injuries in children

Worlock P & Stower M. Fracture patterns in Nottingham Children. J.Paed.Orth;1986 6(6):656-660

Wrist fractures in children

Wrist fractures

Interventions for treating metaphyseal distal radius fractures in children

A Cochrane Systematic Review and Meta analysis (in press)

Alwyn Abraham* Helen Handoll§ & Tahir Khan†

*Consultant Orthopaedic Surgeon, University Hospital of Leicester§ University of Teesside

† Consultant Orthopaedic Surgeon, Manchester Children’s Hospitals

Wrist fractures in children

Synopsis

• use removable splint for buckle fractures

• after an MUA use a below elbow cast

• after an MUA use a K wire

Wrist fractures in children

Search strategy• Cochrane Bone Joint and Muscle Trauma Group Specialised

Register (to Jan 2008), • Cochrane Central Register of Controlled Trials (The Cochrane

Library Jan 2008)• MEDLINE (1966 to Jan 2008)• MEDLINE pending (accessed Jan 2008)• EMBASE (1988 to Jan 2008)• CINAHL (1982 to Jan 2008)• reference lists of articles.• Only English language studies were reviewed.

Wrist fractures in children

Subject-specific strategy

• 1. Ulna Fractures/ or Radius Fractures/• 2. (distal or metaphys$ or epiphys$ or torus or wrist).tw.• 3. and/1-2• 4. Wrist Injuries/ or Forearm Injuries/• 5. fracture$.tw.• 6. and/4-5• 7. (ulna$1 or radius or radial or forearm$1 or wrist$1).tw.• 8. and/2,5,7• 9. or/3,6,8• 10. exp Pediatrics/• 11. Infant, Newborn/• 12. Infant/• 13. exp Child/• 14. Adolescent/ not exp Adult/• 15. (paediatr$ or pediatr$ or neonate$ or bab$3 or infant$ or child$ or teenage$ or

adolescen$).tw.• 16. or/10-15• 17. and/9,16

12th May, 2007 Wrist fractures in children 15

Wrist fractures requiring surgical stabilisation

MUA and above elbow cast vs. MUA K-wireGibbons 1994, McLauchlan 2002, Miller 2005

Radius shaft fractures in children

Radius shaft fractures

Interventions for treating radius shaft fractures in children

A Cochrane Systematic Review and Meta analysis (in progress)

Alwyn Abraham* Sujit Kumar§ & Sameena Choudhary†

*Consultant Orthopaedic Surgeon, University Hospital of Leicester§ SpR Orthopaedics, London

† SpR Orthopaedics, Birmingham

Radius shaft fractures in children

Deformity remodelling depends on :• Age 8-10• Severity >10º• Plastic deformity

Radius shaft fractures

Radius shaft literatureZionts JPO 2005 casts n-=25 8-15 Deformity 10

deg FROM

Bhaskar JBJSBr 2001

ORIF single vs. both

N=12 vs. 20 Ave = 11 No major complications

Houshian injury 2005

Single bone ESIN N=20 6-15 No complications up to 20mths

Fernandez Injury 2005

ORIF vs. ESIN N=19 vs. 45 2 re-operations each group

Lacombes 2005 ESIN N=121 >8 5 re-operations

Jubel JPOB 2005 ESIN N=51 No major complications

Myers 2004 Single bone ESIN =25 4-15 No major complications

Radius shaft fractures

ESIN minor complications

• Superficial Radial nerve injury• Prominent nail• Open reduction• Keloid/ hypertrophic scars

Radius shaft fractures

Femoral shaft fractures in children

Femoral fractures

Selection based on• Age• bodyweight• Fracture configuration

Femoral shaft fractures in preschool children

N=72

1.5-5.9 yrs

9/72 nail adjustment

Early weight bearing in all

Body weight

Femoral fractures

Body weight

Femoral fractures

N=39

25 short fractures vs. 15 long fractures

Re-operation rate 2/24 vs. 6/15

Femoral fractures

Femoral fractures

Femoral fractures

Femoral fractures

Femoral fractures

Femoral fractures

Tibial fractures in children

• 5 yr period• 16#s in 14 patients• Ave age 10yrs 4 mths• 3 open fractures• Union 8 wks (15 wks for open #s)

Tibial fractures

Tibial fractures

Tibial fractures

Tibial fractures

Tibial fractures

Recap

1. Properties of paediatric bone are different.

2. The pattern of fractures are different in children

3. What are the common children’s injuries that require stabilisation?

4. The techniques used are a bit different in children

Summary

• Have a low threshold to K-wire displaced distal metaphyseal fractures

• Radius shaft fractures: ESIN for displaced/ angulated fractures

• Femoral fractures – spica or ESIN• Tibial fractures – cast/ ESIN/ bone transport

for severe injuries.

Tibial fractures