Lower Extremity Fractures in Children - University of Utah · 2020. 5. 6. · Lower Extremity...
Transcript of Lower Extremity Fractures in Children - University of Utah · 2020. 5. 6. · Lower Extremity...
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Lower Extremity Fracturesin ChildrenStephanie M. Holmes, MD
Department of Orthopaedic SurgeryPediatric Orthopaedic Division
University of Utah School of Medicine
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Overview
• Hip injuries• avulsion fractures, other fractures
• Femur fractures• shaft and distal femur
• Tibia fractures• proximal, shaft, patella
• Ankle fractures• Metatarsal fractures
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Avulsion Fractures
• Almost always nonoperative tx
• Exception:• Ischial tuberosity fx >1.5-2 cm displaced or pain with sitting
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Avulsion Fractures• ASIS
• Sartorius• AIIS
• Rectus femoris• Ischial tuberosity
• Hamstrings• Greater trochanter
• Gluteus medius/minimus• Lesser trochanter
• Iliopsoas• Symphysis
• Adductors
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1—Iliac crest; abdominal obliques
2—ASIS; sartorius
3—AIIS; rectus femoris
4—Lesser trochanter; iliopsoas
5—Ischial tuberosity; hamstrings
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Findings
• Recognition• History
• Age: Usually 14-25 yo• Sudden pain with specific event• Pop• Common sports: soccer, gymnastics, sprinting
• Exam• Local tenderness• Weakness with contraction• Pain with passive stretch
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Lesser Trochanteric Avulsion14 y/o F kicking soccer ball and was slide tackled with hyper extension of right leg while kicking
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Ischial Tuberosity Avulsion (Non-op) 14 y/o M landed a ski jump and leg hyperflexedwhen ski popped off
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Ischial tuberosity avulsion – Operative (>1.5-2 cm displaced)13 y/o F s/p doing the splits in dance
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6 months post-op
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Case
• 20 year old thin female• Recently increased training for a marathon• Two weeks away from competition• Hip pain for one month, difficulty training
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Stress Fractures• Fatigue fractures
• Normal bone, abnormal stresses
• Insufficiency fractures• Abnormal bone, normal stress
• Sites of stress fractures• Femoral neck• Sacrum• Pubic rami• Acetabulum• Femoral head
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Femoral Neck Stress Fractures• Exercise induced pain
• Hip, groin, thigh, referred knee pain
• Classic description• Female triad
• Eating disorder• Amenorrhea• Osteoporosis
• Military recruits• Risk factors
• Sudden increase in activity• Smoking• Steroid use
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Femoral Neck Stress Fractures• Studies• Radiographs
• Not helpful if symptoms early
• MRI• Bone scan
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Stress Fractures• Tension sided• Superior neck
• Compression sided• Inferior neck
• Treatment• Weight bearing
restrictions• Surgical pinning
• >50% neck width• Tension sided injuries
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Proximal Femur Fractures
• 90% from high-energy trauma
• Complications:• AVN is most common complication
• Location predicts risk (Delbet classification)• Coxa Vara (10-30%)• Physeal closure (5-65%)
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Delbet ClassificationRisk of AVN:
Type I: 80-100%Type II: 50-60%Type III: 25-40%Type IV: not expected
Treat types I-III emergentlywith ORIF (pins or screws);
Capsulotomy decompresseshematoma
Type IV can be reduced closed and fixed if reduction acceptable
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Femoral Shaft Fractures
• Most important to know:• Treatment options in each age group• Remodeling and overgrowth potentials• When to be concerned about NAT
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Treatment by age-guideline
• < 6 months• Pavlik harness
• 6 months-5 years• Spica cast• Can plate or ex fix if too short (>3 cm) or not controllable in spica• Traction is now historical
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Treatment by age--guideline
• 5-11 years• Length stable, diaphyseal, <49 kg: flexible IM nails• Length unstable, proximal/distal: plating, ex fix (less common)
• >11 years• Rigid TAN• Plating if fx pattern not amenable to nail (subtroch, distal metadiaphyseal)
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Overgrowth
• Most common in younger age group (2-5y) but can occur outside range• Usually about 1-1.5 cm; can be 2+ cm• Happens primarily in first 2 years after injury
• Set fx treated with spica about 1-2 cm short if possible
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1 week old, birth trauma
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2 y/o tripped over dog
• 1 cm short• Expect 1 to 1.5 cm of
overgrowth on fractured side in kids younger than 6• This is why we like them
overlapped to start with when they are younger
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2 y/o NAT
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2 y/o NAT
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1.5 cm short in spica—ideal position
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NAT
• 2009 AAOS CPG found that all children younger than 36 months with diaphyseal femur fracture should be evaluated for NAT
• Fracture pattern alone is not indicative of NAT• Fx from NAT more common in distal femur
• Most common cause of femur fractures in nonambulatory patients is NAT
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5 y/o male, 45 lbs, fell out of tree2.8 cm short
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• 3 mo• 3 cm
• 9 mo• 2.2 cm
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• 5 years later, 3.5 cm • 18 mo after epiphyseodesis
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8 y/o crashed ATV
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2 years post op
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8 y/o M skiing
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13 y/o M ski jumping
Proximal shaft• Physis closing• 145 lbs
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17 y/o shooting a layup
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Reconstruction nail, bone graft
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Distal Femur Fractures
• Metaphyseal• Can treat with CRPP/cast or ORIF
• Physeal (Salter I-IV)• 50-80% risk of growth disturbance
• Risk is higher with displacement and younger age
• Can treat with CRPP/cast or ORIF
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Salter-Harris classification
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13 y/o M, ATV, “reduced” in WY
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Reduce and pin urgently
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Distal femoral buckle fx
• Parent/sibling drops/falls while holding infant• Usually pre-ambulatory• Heals in 3 weeks• Can splint, with splint from ankle to lumbar area
• Hard to cast, but some parents want it
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Patellar Sleeve Fracture
• Avulsion of inferior (usually) patella with small bony fragment but large articular cartilage piece• Usually during eccentric contraction
• Lack of active knee extension• Palpable gap between patella and tibial tubercule• Patella alta, small distal fragment
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Usually fixed with suture (woven through distal tendon, brought up through 2 bone tunnels and tied over superior patella
Can be fixed with traditional tension band if distal piece big enough
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Proximal Tibial Physeal and MetaphysealFractures• Popliteal artery is close to the physis, so displacement in the sagittal
plane can cause vascular injury (like a knee dislocation!)
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Proximal Tibia Fractures
• Nondisplaced• Cylinder cast, WBAT
• Displaced• Hard to hold without fixation• Usually pins/cast for 4-6 weeks• Watch for compartment syndrome, vascular insult!
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Cozen’s phenomenon (posttraumatic genu valgum)• Usually after nondisplaced proximal tibia fractures• 5% of all nondisplaced proximal tibia fractures
• Presents between 6-18 months after injury• 2/3 correct spontaneously, 1/3 need hemiepiphyseodesis
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Tibia Shaft Fractures
• Almost all can be treated by closed methods• Indications for operative stabilization:• Open (sometimes)• Multiply injured• Floating knee• Unstable/can’t hold alignment in cast
• Plate• Flex nails• Ex fix
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Tibial Shaft Fractures
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Tibial Shaft Fractures
• Toddler’s fracture:• Nondisplaced tibial shaft fracture in walking age children (18 mo-4
years)• First xrays often normal• Diagnose by palpation along tibial diaphysis• Treat with BKC and WBAT for 4 weeks
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Toddler’s fracture
• Can treat in a boot in older children (3-5)
• Most pts with this injury are too small for the smallest boot and need a cast below the knee
• VERY important to have the ankle at 90 deg to prevent heel sore
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Ankle Fractures
• Distal tibia• Many are operative, due to physis or joint involvement
• Distal fibula• When isolated, most are nonoperative
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The fracture that acts like a sprain
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Salter-Harris classification
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SH I or SH II distal fibula fractures
• “The fracture that acts like a sprain”
• Ankle XR are often normal
• Tender right over distal fibular physis and NOWHERE ELSE (no medial tenderness)
• Swelling is only lateral
• Treat in walking boot for 4-6 weeks
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Ankle Fx
• Refer anything that involves the distal tibial physis or the ankle joint
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Ankle Fractures
• Distal tibial physeal fractures arrest 10-25%• Younger = more likely to create a deformity
• “Transitional” fractures• Older, physis closing so less likely to cause deformity if arrest• Triplane (age 10-13)• Tillaux (age 12-15)
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Triplane Fracture
• Salter IV fx• Distal tibial physis closes medially first• 2-, 3-, and 4-part
• When is CT helpful?• Determine displacement?• Surgical planning
• screw trajectory
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Tillaux Fractures
• Slightly older (12-15 y)• Medial physis closed, posterolateral physis closing• Open physis remains at anterolateral corner
• Fix when displaced >2 mm
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Metatarsal fractures
• Minimally displaced fractures can be treated in a boot or a cast (4-6 weeks) and WBAT
• Involvement of physis is NOT worrisome
• Beware the displaced ones and the 5th MT fx
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Refer this
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Beware
• Jones fracture
• = 5th MT at metadiaphysealjunction
• *refer this*
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What can you treat yourself?
What you can treat if you have the resources:• Time• Staff• Staff who knows how to cast without damage
• Willingness to assume risk
• These are injuries that will still heal easily but patients often require casting or specialized splinting
• Toddler’s fractures• SH I and II distal fibula fractures• Minimally displaced metatarsal fractures, some fifth metatarsal fractures (not
Jones)
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Splinting Malfeasance
• NEVER put splint material behind the heel in a child younger than 12 years old
• Heel sores are a common and completely avoidable complication that are often much worse than the injury itself!
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Splinting
• Need to avoid skin complications (heel sores, wrinkling in splint)
• Do not overpad
• Get position before applying any material, and do not let it change
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U splint-leg
• For ankle sprains and fractures• Sometimes for tibia fractures (stable)
• Better than a posterior splint because avoids heel sores
• NEVER put on a posterior splint behind the heel unless ankle is neutral and absolutely necessary and >12 years of age
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Sugar tong splint-arm
• For wrist and forearm fractures
• Needs to be supplemented with a sling
• Does NOT adequately immobilize the elbow when the elbow is injured (see next splint)
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Posterior splint (arm)
• For elbow injuries
• Supracondylar fx need to be at 90 degrees of elbow flexion (if type I)•• Operative, displaced supracondylar fx need to be at 60 degrees (not
extension) to protect skin
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