Growth changes of the musculoskeletal · PDF fileGrowth changes of the musculoskeletal system...
Transcript of Growth changes of the musculoskeletal · PDF fileGrowth changes of the musculoskeletal system...
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Growth changes of the
musculoskeletal system Children fracture healing and
remodeling
Dr KL Liu
Department of Orthopaedics
and Traumatology
PWH
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Agenda
• Basic Principles in Fracture Healing and
Remodeling
• Non Accidental Injury
• Principles of Treatment Options
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Epidemiology of children fracture • 1 Distal radius fracture 20.2%
• 2 Supracondylar humeral 17.9%
• 3 Forearm shaft 14.9%
• 4 Tibial Shaft 11.9%
• 5 Fingers & hand 4.9%
• 6 Lateral condyle 4.8%
• 7 Femoral shaft 4.6%
• 8 Ankle 3.1%
• 9 Proximal radius (head & neck) 2.9%
• 10 Humeral shaft 2.8%
• 11 Medial Condyle humeral 2.5%
• 12 Olecranon 1.7%
• 13 Distal radius epiphyseal 1.7%
• 14 Elbow dislocation 0.8%
• 15 Rarities 5.4%
Review of 6493 fractures JCY Cheng et al JPO 19:344-350 1999
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Paediatric Fracture Patterns
20.2
17.9
14.9
11.9
5.44.94.84.63.12.92.82.5
1.71.70.8
0
5
10
15
20
25
1
Fracture types
% o
f T
ota
lDistal Radius
Supracondylar humeral
Forearm shaft
Tibial shaft
Others
Fingers & Hand
Lateral Condyle
humeralFemoral shaft
Ankle
Proximal radius(head &
neck)Humeral shaft
Medial condyle humeral
Olecranon
Distal radius epiphyseal
Elbow dislocation
65%
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Chilren
Small adult
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Chilren
Small adult
•Bone quality
•Periosteum
•Ligament
•Growth plate
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Bone
Higher collagen to bone ratio in paediatric bone
• Lower modulus of elasticity (less brittle ) and higher ultimate strain to failure ratio than adult
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Plastic Deformation
• Fixed bending remains
when bone deformed
past elastic limit
• Most commonly in
forearm, fibula
• Periosteum intact and
thus usually no periosteal
callus
• Permanent deformity can
result
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(A) direct impact perpendicular to the axis of the long bone: -periosteal stripping on convex side of the fracture:
greenstick
fracture
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(B) longitudinal compression – impact parallel to the axis of the long bone results in incomplete fractures
(1) bowing (plastic deformity)
Plastic Deformation
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Plastic Deformation
• Remodeling not as reliable
• Significant curvature should be corrected
• General anesthesia
• Considerable force
• Slowly applied over a padded fulcrum
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Comminuted fracture uncommon
–Higher cellular and porous •Reduce tensile strength
•Reduce the tendency of fractures to propagates
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Bone
–Bone fails in both tension and compression
•Mechanism of buckle fracture in children
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Bone –Bone transitions •Between the metaphysis and diaphysis cause a mechanical discontinuity leading to certain fracture types
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Buckle or Torus Fracture
• Compression failure
• Stable
• Usually at
metaphyseal /
diaphyseal junction
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Bone-Blood Supply –The blood supply is different
• a rich metaphyseal circulation with fine capillary loops ending at the physis
• In neonate, small vessels may transverse the physis and end in epiphysis
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Periosteum • Periosteum in children is thicker
and stronger
–Offer additional resistance to shear force
–Little displacement, help in reduction
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Greenstick Fractures
• Bending mechanism
• Failure on tension side
• Incomplete fracture,
plastic deformation on
compression side
• May need to complete
fracture to realign
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Ligaments
• Ligaments in children are functionally stronger than bone
–Force that procedure sprains in adults result in fracture in children
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Physeal Fractures
• Traditionally believed to occur primarily
through zone of hypertrophy
• Some fractures may traverse more than one zone
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Growth plate
–The physis is weaker than bone in torsion, shear and bending
–Potential for remodeling
–Growth plate injury causes deformity
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Physeal fractures
• Salter-Harris classification – I - # across physis
– II - # across physis and metaphysis
– III - # across part of physis & epiphysis
– IV - # across metaphysis, physis & epiphysis
– V - crush injury of physis without fracture
– VI - Perichondral ring injury
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Physeal fracture
• Type I
–Transphyseal fracture involving the
hypertrophic and calcified zones
–Prognosis is excellent, although
complete or partial growth arrest may
occur in displaced fracture
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• Type II
– Transphyseal fracture that exits the metaphysis
– The metaphyseal fragment is call Thurston Holland fragment
– The periosteal hinge is intact on the side with metaphyseal fragment
– Prognosis is excellent, although complete or partial growth arrest may occur in displaced fracture
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• Type III
– Exits the epiphysis, causing intra-articular disruption
– anatomic reduction and fixation without violating the physis are essential
– Prognosis is guarded, partial growth arrest and angular deformity are common
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• Type IV – Transverse epiphysis, physis and
metaphysis
– anatomic reduction and fixation without violating the physis are essential
– Prognosis is guarded, partial growth arrest and angular deformity are common
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• Type V –Diagnosis is generally made
retrospectively
–Prognosis is poor
–growth arrest and partial physeal closure common
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Growth Arrest Secondary to
Physeal Injury
• Complete cessation
limb length discrepancy
• Partial cessation
angular deformity if
peripheral
progressive shortening if
central
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Epiphysis or Apophysis?
• Epiphysis - forces
are compressive
on physeal plate
• Apophysis - forces
are tensile
• Histologically
distinct
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Apophyseal Injuries
• Tibial tubercle
• Medial Epicondyle
• May be preceded by chronic
injury/repetitive processes
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Non-accidental injury
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Radiographic Findings in NAI
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Radiographic Findings in NAI
• Fracture pattern not specific (spiral,
transverse, etc.)
• Metaphyseal Corner # or Bucket
Handle #
• Multiple fractures at different stages
of healing highly specific
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• Humerus diaphyseal # < 3 yo are almost always associated with NAI
• Femur # < 1 yo are usually due to NAI
• Risk or re-abuse is 35% and risk of death 5-10%
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Metaphyseal Corner # or Bucket Handle #
• Pathognomonic of
NAI
• Traction/rotation
mechanism of injury
• Planar fracture
through primary
spongiosa
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DDX: NAI #
• Accidental trauma/Birth trauma
• Osteogenesis Imperfecta
• Metabolic Bone Disease (rickets, etc.)
• Physiologic periostitis
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Management
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General Principles
• Acute Fracture Care
– immobilization of joints above and below
•provides comfort, reduces deformity, reduces risk of additional injury
•cast or splint depending on anticipated swelling & compartment syndrome
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Post-fracture care
• Post-fracture Care
–F/U to ensure union & restoration of alignment and length
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Special Considerations • Open fracture
• Compartment Syndrome
• Pathologic Fracture
– tumors e.g. osteosarcoma
– hereditary diseases e.g. osteogenesis imperfecta
– metabolic diseases e.g. rickets
– neuromuscular diseases e.g. Muscular Dystrophy
– infectious diseases e.g. osteomyelitis
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Treatment options
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Most upper limb #- 90/90 elevation
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Most Lower limb #
Back slab
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Treatment of minimal / Un-displaced #
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Completely Displaced Fractures
Closed/ Open Reduction + K-wire Fiation + Casting
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Excellent remodelling power
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Forearm shaft
#
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Tibial Shaft , Wedging
Works Beautifully !
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Traction Principle
• Traction produces a reduction through the
surrounding soft parts which align the
fragments by their tension.
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Purpose
*Regain normal length and alignment of involved bone
*Reduce and immobilize a fractured bone
*Lessen or eliminate muscle spasms
*Relieve pressure on nerves, especially spinal
*Prevent or reduce skeletal deformities or muscle contractures
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Mechanism of traction
• Every force has an equal and opposite force
• Applied in different ways
–Fixed traction with a splint
–Fixed traction using gravity
–Sliding traction
–Balanced traction
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Classification
• Defined by force
– Traction by gravity
– Skin traction
– Skeletal traction
• Defined by
configuration
– Fixed traction
– Balance traction
– Combined traction
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A: Traction by
Gravity
B: Fixed skin traction
C: Balanced skin
traction
D: Russell skin traction
E: Skeletal traction with splint + knee
flexion piece
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Skin traction
• 12 lb (5kg) is the upper limit
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Skeletal Traction
• Max. 18kg(40lb) can be used
• Allow joint motion exercise
• Useful for femur fracture in paediatric
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External fixation
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Flexible and Rigid
Intramedullary Nail
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Compression plating
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Children Small Adult
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