Management of fractures in adolescents
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Management of Fractures in Adolescents. Friday Registrar Presentation Dr. Stewart Morrison MBBS Western Health Orthopaedic Department. Introduction. Adolescence Puberty: acceleration phase, peak height velocity, deceleration phase Peak height velocity: Girls 12 years, Boys 14 years

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Management of Fractures in Adolescents

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Management of fractures in adolescents

Management of Fractures in Adolescents

Friday Registrar Presentation

Dr. Stewart Morrison MBBS

Western Health Orthopaedic Department


Introduction

Introduction

Adolescence

  • Puberty: acceleration phase, peak height velocity, deceleration phase

  • Peak height velocity: Girls 12 years, Boys 14 years

  • Fall between management parameters for adults, and those for children

  • Quality of Bone .Less mineralised, more vascular, greater callus

    .greater energy dissipation, less comminution, quicker healing

  • Structure of Bone.Physeal Plate

    .Closure of Physeal Plate

  • Psychosocial


Estimation of maturity

Estimation of Maturity

  • Various Methods.Sauvegrain

    .Oxford Score

    .Greulich’s and Pyle’s Atlas

    .Tanner-Whitehouse-III RUS Score

    .Sanders modification of TWIIIRUS Score

  • Biological Staging.Tanner Stages

    .Secondary Sexual Characteristics


Classification of physeal fractures

Classification of Physeal Fractures

  • Salter-Harris

  • Perichondral ring of La Croix

  • Communication

  • Prognosis


Imaging

Imaging

General Principles

  • Joint above, joint below

  • Comparison views

  • CT

  • MRI


Principles of treatment physeal fractures

Principles of Treatment: Physeal Fractures

Reduction

  • Traction, gentle manipulation

  • Open preferable to multiple closed attempts

  • No reduction after 7-10 days, unless > 2mm step-off

    Fixation

  • Pins, screws should be parallel to the physis

  • Single pass, single smooth K-wire

  • Resection of periosteum

  • Langenskiöld procedure

  • No reduction after 7-10 days, unless > 2mm step-off

Most heal in 3 weeks.

Growth disturbance monitoring.


Management of fractures in adolescents

Park-Harris Lines


Management of fractures in adolescents

How to succinctly and clearly explain this algorithm to parents?

… when often they only hear the word ‘deformity’


Principles of treatment non physeal fractures

Principles of Treatment: Non-Physeal Fractures

  • Adolescent bone does not have the remodelling capacity of childrens’

  • Weight and specific characteristics need to be taken into account

  • Displaced diaphyseal fractures – Titanium Elastic Nails

  • Displaced metaphyseal fractures – Percutaneous Pin Fixation

  • Supplementation of fixation by splint or cast

  • Locking plates not usually required

  • Implant removal


Clavicle

Clavicle

  • First bone to begin ossification, and the last to finish it.

  • Threshold of > 2 cm of displacement often cited

    Operative Considerations

  • ORIF

  • Supraclavicular nerve

  • Neurovascular bundle

  • Earlier return to full activities (12 vs 16 weeks)


Radial and ulnar shafts

Radial and Ulnar Shafts

  • Studies often convoluted by pediatric participants, and inclusion of metaphyseal fractures

  • More difficult to manage than previously thought

  • Greenstick

  • Plastic Deformation

  • Complete

  • Comminuted

  • If a deformity is present in two orthogonal radiographs, the true deformity will be greater than appreciated on either single view


Radial and ulnar shafts1

Radial and Ulnar Shafts

  • Operative Considerations

  • 1.5 – 2.0 mm Titanium Elastic Nails (TENS)

  • Closed Reduction closed reduction with percutanous fixation  open reduction

  • Reestablish radial bow, eliminate any bowing of ulna

  • Fix radius first

  • Narrowest point of radius is central

  • Narrowest point of ulna is within the distal third

  • Do not cross physes

  • Removal at six months or more


Femoral shaft

Femoral Shaft

Principles

  • Timely union

  • No rotational deformity

  • < 2 cm shortening

  • Deformity of < 10-20° (sagittal plane), < 5-10° (coronal plane)

    Operative Considerations

  • In adolescents, surgical treatment favoured

  • Elastic intramedullary nails (< 11 yrs, < 49 kg ) .require removal

  • Rigid nails, plating (> 11 yrs, length ‘unstable’ fractures) .require removal

  • No randomized trials

  • External Fixation


Distal femur

Distal Femur

  • High Energy

    Metaphyseal Fractures

  • < 10 years; closed reduction + percutaneous cross-pin fixation + long leg cast

  • > 10 years or unstable fracture, consider plating or external fixation

  • Physeal Fractures

  • SHI + SH II, undisplaced – long leg cast

  • SHI + II, mildly displaced – closed reduction, percutaneous pinning, long leg cast

  • SH II, large metaphyseal fragment – cannulated screws, long leg cast

  • SH III + IV, displaced – cannulated compression screws

  • All should remain NWB following fixation

  • 50% of distal femoral fractures lead to growth disturbance (SH II highest risk)


Proximal tibia

Proximal Tibia

  • Physeal Fractures

  • High energy

  • CT recommended

  • Similar management principles to distal femoral fractures

  • Metaphyseal Fractures

  • “Cozen Fractures”

  • Closed reduction, long leg casting

  • Genu valgum is most common complication


Proximal tibia1

Proximal Tibia

Tibial Spine Fractures

  • Hyperextension of the knee

  • ACL avulsion injury

  • Tibial Tubercle Fractures

  • Repetitive jumping sports

  • Ogden modification of Watson-Jones Classification

  • Open reduction, internal fixation for II, III, IV

  • V should have periosteal sleeve reattached

  • Genu recuvatum


Ankle

Ankle

Considerations

  • Fibular physis closes later than the tibial physis (12-14, 15-18 vs. 19-20 yrs)

  • Tibial physis closes in a circular pattern – centre to medial to lateral

  • CT scan recommended

  • Management

  • SH I or SHII, undisplaced – BK walking cast 3-4 weeks

  • SH I or SHII, displaced – closed reduction, AK cast 3 weeks, then BK 3 weeks

  • SH III or SHIV – often require open reduction, internal fixation

  • If periosteal flap not removed, 60% incidence of plate closure

  • No more than 5% of angulation in any plane should be accepted


Ankle1

Ankle

Tillaux Fracture

  • SHIII of anterolateral distal tibial epiphysis (final area to close)

  • Internal rotation can provide closed reduction, however often need open reduction

  • Triplanar Fracture

  • SHIII or SH IV

  • Appears as SH II on lateral radiograph, SH III on anteroposterior radiograph

  • Younger patient than Tillaux fracture

  • Growth arrest not clinically important

  • Flexion of Knee to 90 degrees, plantar flexion and internal rotation of the foot, with AK cast for 3/52

  • If unsuccessful, proceed to percutaneous or open reduction/fixation


Thank you

Thank you

Salter RB, Harris WR. Injuries Involving The Epiphyseal Plate. J Bone Joint Surg Am. 1963;45: 587-622.

Khan La, Bradnock Tj, Scott C, Robinson Cm. Fractures Of The Clavicle. J Bone Joint Surg Am. 2009 Feb;91(2):447-60.

Egol Ka Et Al. Management Of Fractures In Adolescents. J Bone Joint Surg. Am. 2010 Dec;92(18) 2947

Zionts Le. Fractures Around The Knee In Children. JAAOS Vol. 10 No. 5 September/October 2002

Alain Diméglio; Yann Philippe Charles; Jean-pierre Daures; Vincenzo De Rosa; Accuracy Of The Sauvegrain Method In Determining Skeletal Age During Puberty. Journal Of Bone And Joint Surgery; Aug 2005; 87, 8; Health & Medical Complete

Momberger N, Stevens P, Smith J, Santora S, Scott S, Anderson J. Intramedullary nailing of femoral fractures in adolescents. J Pediatr Orthop. 2000;20: 482-4.


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