Diaphyseal fractures in children

Mohamed M. Zamzam
Associate Professor & Consultant Pediatric Orthopedic Surgeon KKUH !i"adh Saudi Ara#ia

'iaph"seal (ractures in Children

Objectives
$ $ $ $ %o recall specific considerations of diaph"seal fractures in children %o #e a&are of common possi#le complications %o identif" the treatment of choice in each particular situation among a #ig list of management options %o create an algorithm as a guide for managing long #one shaft fractures in pediatric population

'iaph"seal (ractures in Children

General Principles
$ $
. . . .

A#out )*+ of in,uries in children are s-eletal Out of all s-eletal in,uries in children
!adial shaft fractures %i#ial shaft fractures (emoral shaft fractures Pro2imal & shaft humerus fractures /.0 + /.1 + 1.) + ).0 +

'iaph"seal (ractures in Children

Specific Problems
$ $ $ $ Premature complete physeal closure Progressive limb length discrepancy Nonunion Open reduction and internal fixation

'iaph"seal (ractures in Children

General management
$ Cast $ Internal fixation $ External fixation

'iaph"seal (ractures in Children

General management
$ Cast $ Internal fixation $ External fixation

'iaph"seal (ractures in Children

General management
$ Cast $ Internal fixation $ External fixation

'iaph"seal (ractures in Children

General management
Indications for surgery
$ $ $ $ $ $ $ Head in,ur" Multiple in,uries Adolescence (ailure of conser3ati3e means Se3ere soft4tissue in,ur" 5eurological disorder Malunion and dela"ed union

'iaph"seal (ractures in Children

Elastic stable intramedullary nailing (ESIN

The principle
$ $ $ $ $ 1 elastic nails Ma2imum cur3e Orientation %he size 6ood -no&ledge of the techni7ue

'iaph"seal (ractures in Children

Elastic stable intramedullary nailing (ESIN

Advantages
$ $ $ $ $ 5o need for postoperati3e cast Primar" #one union A3oidance of gro&th plate in,ur" Minimum in3asi3e surger" 82cellent functional and cosmetic results

'iaph"seal (ractures in Children

Elastic stable intramedullary nailing (ESIN

Complications
$ $ $ $ $ $ 5onunion 99 Osteom"elitis :rate is 1+; O3ergro&th : <)= mm #efore age of )= "ears; Cortical perforation !e4fractures 9 S-in irritation

'iaph"seal (ractures in Children

Forearm
$ %he distal radial epiph"seal plate realigned &ell in children #elo& )= "ears $ !adioulnar angulation usuall" associated &ith loss of motion $ %he ris- of refracture

'iaph"seal (ractures in Children

Forearm
Treatment options
$ Closed reduction > cast $ AO plates $ ?ntramedullar" fi2ation

'iaph"seal (ractures in Children

Forearm
Closed intramedullary nailing
$ Specific anatomic considerations $ %he isthmus of radius and ulna is narro& :range @ A4/ mm; $ Optimum entr" points

'iaph"seal (ractures in Children

Forearm
Closed intramedullary nailing
$ ?nternal fi2ation of the radius onl" $ %he radius has the more complicated function $ Better alignment of the ulnar fracture

Forearm diaphyseal fracture

Open Debridement in OR

Closed

Forearm diaphyseal fracture

Open Debridement in OR

Closed

Angulation 0-10 Angulation 10-20

Angulation +20

Forearm diaphyseal fracture

Open Debridement in OR

Closed

Angulation 0-10 Angulation 10-20 All ages years 0-5 Long arm cast or splint uccess!ul i! " 10

Angulation +20

years 5+ Closed reduction

Forearm diaphyseal fracture

Open Debridement in OR

Closed

Angulation 0-10 Angulation 10-20 All ages years 0-5 Long arm cast or splint uccess!ul i! " 10

Angulation +20

years 5+ Closed reduction

uccess!ul but unstable Closed reduction + # $%

&nsuccess!ul

Open reduction +# $%

'iaph"seal (ractures in Children

Humerus
$ ?ncidence is related to the cause and age group $ Classified according to
. (racture pattern . Cocation . %issues damaged

'iaph"seal (ractures in Children

Humerus
$ $ $ Priorit" is gi3en to conser3ati3e treatment Osteos"nthesis :)=+; 82ternal fi2ation

'iaph"seal (ractures in Children

Humerus
potential operative indications
$ $ $ $ $ $ $ Open fractures Multiple trauma Bilateral in,uries Compartment s"ndromes Pathological fracture Significant ner3e in,uries ?nade7uate closed reduction

Humeral diaphyseal fracture

Adolescents ' Older c(ildren Open Closed

$n!ants ' younger c(ildren

$mmobili)e in a sling ' s*at(

Humeral diaphyseal fracture

Adolescents Adolescents ' Older Older c(ildren c(ildren Open Closed

$n!ants ' younger c(ildren

$mmobili)e in a sling ' s*at(

Debridement in OR

$$$

$ ' $$

Closed reduction + # $% #+ternal !i+ator

Humeral diaphyseal fracture

Adolescents Adolescents ' Older Older c(ildren c(ildren Open Closed

$n!ants ' younger c(ildren

$mmobili)e in a sling ' s*at(

Debridement in OR

Closed reduction urgical indications ,ids(a!t angulation 20 " Closed reduction + # $% $mmobili)e in so!t dressing 20 -

$$$

$ ' $$

#+ternal !i+ator

'iaph"seal (ractures in Children

Femur
$ Stress fracture $ Pulmonary complications $ ro!th disturbances resulting in ). accelerated gro&th 1. retarded gro&th A. a2ial deformities 0. rotational deformities $ Spontaneous correction

'iaph"seal (ractures in Children

Femur
$ Stress fracture $ Pulmonary complications $ ro!th disturbances resulting in ). accelerated gro&th 1. retarded gro&th A. a2ial deformities 0. rotational deformities $ Spontaneous correction

'iaph"seal (ractures in Children

Femur
$ Stress fracture $ Pulmonary complications $ ro!th disturbances resulting in ). accelerated gro&th 1. retarded gro&th A. a2ial deformities 0. rotational deformities $ Spontaneous correction

'iaph"seal (ractures in Children

Femur
$ Stress fracture $ Pulmonary complications $ ro!th disturbances resulting in ). accelerated gro&th 1. retarded gro&th A. a2ial deformities 0. rotational deformities $ Spontaneous correction

'iaph"seal (ractures in Children

Femur
$ $ $ $ Ade"uately managed non#operatively Operative approach $#% years post#in&ury non#debilitating pain Strict adherence to a surgical techni"ue

'iaph"seal (ractures in Children

Femur
Treatment options
$ $ $ $ $ $ $ ?mmediate hip spica 'ela"ed hip spica Plate osteos"nthesis Con3entional ?M5 Stainless steel K4&ires %itanium elastic nailing 82ternal fi2ation

'iaph"seal (ractures in Children

Femur
$ $ $ $ %he optimal method 8conomic reasons ParentsD decision E 4 )= "ears :no manFs land;

'iaph"seal (ractures in Children

Femur
Conservative mode
$ Co& ris- of o3ergro&th $ !otational malalignment of up to 1= degrees corrects during gro&th $ 8conomicall" cheap

'iaph"seal (ractures in Children

Femur
Narro! lo!#contact 'CP
$ $ $ $ $ Minimal e2posure Percutaneous scre& placement Sta#le mode of fi2ation Biologic healing potential 8arl" patient mo#ilization

'iaph"seal (ractures in Children

Femur
(igid intramedullary nail
$ $ ?n older children and adolescents Placement through the lateral aspect of 6%
). Safe techni7ue 1. 8ffecti3e A. Gell tolerated

$ $

6ro&th arrest of the greater trochanter Hip function

'iaph"seal (ractures in Children

Femur
ESIN
$ $ $ $ $ $ simple procedure Minimal #lood loss Short operati3e time K4&ires H %itanium 1 to )0 "ears H 8nder nails

'iaph"seal (ractures in Children

Femur
External fixation
$ $ $ $ $ Simple and elegant !is- of refracture Cength of hospital sta" %ime to union Gire site infection

Open
Debridement in OR

Femoral shaft fracture

$n!ants

.ounger c(ild

Older c(ild

Adolescent

Open
Debridement in OR

Femoral shaft fracture

$n!ants

.ounger c(ild

Older c(ild

Adolescent

Abused

.es

%o

/ospital 1in0est'

$mmediate /ip spica

Open
Debridement in OR

Femoral shaft fracture

$n!ants

.ounger c(ild

Older c(ild

Adolescent

Abused

#+cessi0e s(ortening

.es

%o

%o

.es C(oice

/ospital 1in0est'

$mmediate /ip spica

2raction 2(en cast

# $%

Open
Debridement in OR

Femoral shaft fracture

$n!ants

.ounger c(ild

Older c(ild

Adolescent

Abused

#+cessi0e s(ortening

Comminution

.es

%o

%o

.es C(oice

%o

.es

/ospital 1in0est'

$mmediate /ip spica

2raction 2(en cast

# $%

#+ternal !i+ator

Open
Debridement in OR

Femoral shaft fracture

$n!ants

.ounger c(ild

Older c(ild

Adolescent

Abused

#+cessi0e s(ortening

Comminution

.es

%o

%o

.es C(oice

%o

.es

/ospital 1in0est'

$mmediate /ip spica

2raction 2(en cast

# $%

#+ternal !i+ator

Reamed rod

'iaph"seal (ractures in Children

Tibia
Special considerations
$ $ $ $ $ Child abuse Isolated tibial fractures Open fractures Pathological fractures Stress fractures

'iaph"seal (ractures in Children

Tibia
Special considerations
$ $ $ $ $ Child abuse Isolated tibial fractures Open fractures Pathological fractures Stress fractures

'iaph"seal (ractures in Children

Tibia
Special considerations
$ $ $ $ $ Child abuse Isolated tibial fractures Open fractures Pathological fractures Stress fractures

'iaph"seal (ractures in Children

Tibia
Special considerations
$ $ $ $ $ Child abuse Isolated tibial fractures Open fractures Pathological fractures Stress fractures

'iaph"seal (ractures in Children

Tibia
Special considerations
$ $ $ $ $ Child abuse Isolated tibial fractures Open fractures Pathological fractures Stress fractures

'iaph"seal (ractures in Children

Tibia
Specific problems
$ 'elayed unions $ Nonunion $ )alunion $ Compartment syndromes

'iaph"seal (ractures in Children

Tibia
Specific problems
$ 'elayed unions $ Nonunion $ )alunion $ Compartment syndromes

'iaph"seal (ractures in Children

Tibia
Specific problems
$ 'elayed unions $ Nonunion $ )alunion $ Compartment syndromes

'iaph"seal (ractures in Children

Tibia
Specific problems
$ 'elayed unions $ Nonunion $ )alunion $ Compartment syndromes

'iaph"seal (ractures in Children

Tibia
Treatment is based on*
$ $ $ $ patient age concomitant in&uries fracture pattern surgeon experience

'iaph"seal (ractures in Children

Tibia
Treatment options
$ $ $ $ Closed reduction and casting External fixation Internal fixation ESIN

'iaph"seal (ractures in Children

Tibia
Treatment of se"uelae after union*
$ Physeal closure $ +eg#length discrepancy $ Progressive valgus deformity

'iaph"seal (ractures in Children

Tibia
Treatment of se"uelae after union*
$ Physeal closure $ +eg#length discrepancy $ Progressive valgus deformity

'iaph"seal (ractures in Children

Tibia
Treatment of se"uelae after union*
$ Physeal closure $ +eg#length discrepancy $ Progressive valgus deformity

Tibial shaft fracture

Open
Debridement in OR

Closed 3olytrauma

$$$

$ ' $$

#+ternal !i+ator

Closed reduction + # $%

Tibial shaft fracture

Open
Debridement in OR

Closed 3olytrauma

$$$

$ ' $$

#+ternal !i+ator

Closed reduction + # $%

Tibial shaft fracture

Open
Debridement in OR

Closed 3olytrauma
Closed reduction ' cast

$$$

$ ' $$

4ailed

ucceed

#+ternal !i+ator

Closed reduction + # $%

Consider *edging t(e cast

'iaph"seal (ractures in Children

Summary
$ Non surgical treatment is the treatment of choice in most diaphyseal fractures in children $ If surgery is indicated, ESIN is the best option $ Special attention is directed to
. Open fractures . Child abuse . Pathological fractures

$ Al!ays, consider the high healing po!er of children

Thank you