Surgical fixation of fractures in children Alwyn Abraham CONSULTANT IN TRAUMA (ADULT & CHILDREN) & ELECTIVE CHILDREN’S ORTHOPAEDIC SURGERY Leicester Royal Infirmary
Dec 20, 2015
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