Post on 15-Dec-2015
Management of Fractures in Adolescents
Friday Registrar Presentation
Dr. Stewart Morrison MBBS
Western Health Orthopaedic Department
IntroductionAdolescence✚ 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✚ 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
✚ Salter-Harris
✚ Perichondral ring of La Croix
✚ Communication✚ Prognosis
ImagingGeneral Principles✚ Joint above, joint below✚ Comparison views
✚ CT✚ MRI
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.
Park-Harris Lines
How to succinctly and clearly explain this algorithm to parents?
… when often they only hear the word ‘deformity’
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✚ 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
✚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 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 ShaftPrinciples✚ 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✚ 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 TibiaPhyseal 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 TibiaTibial 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
AnkleConsiderations✚ 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
AnkleTillaux 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
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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
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