Skeletal System

Abstract

One of the reasons that child injuries have increased in recent years lies in the development of a variety of sports and sporting equipment that is now used even by younger children, which are sustaining injuries, and fractures that normally older children were incurring. A new “code of procedure” has been created in order for children to be correctly treated in every hospital. In this chapter, we present a holistic approach for almost all fractures acquired by children taking into consideration the specific injuries of the growth plate, the joints as well as special fractures like the Greenstick and Bowing fracture.

1 General Considerations

Child are injuries have increased in relation to the past. New variety of sports and sporting equipment have been introduced over the past years so that even younger children are sustaining injuries and fractures that normally older children were incurring. This new equipment enables children to driving and run at higher speeds and the incurred fractures are becoming more complex. A new “code of procedure” has to be developed so that children are correctly treated in every hospital. Unfortunately, these new types of fractures are not being treated correctly. Too often, children are considered only small adults and that child’s fractures always heal more easily. However, specific injuries of the growth plate, the joints as well as special fractures like the greenstick and bowing fracture are too often assessed wrongly in their healing behavior.

Factors Influencing the Treatment

• In childhood with its growing skeleton, the following parameters have to be taken into consideration:

  • Adequate, correct diagnostics

  • Type of the fracture

  • Bone and segment

  • Age according bone size and physeal growth

  • Weight

  • Option of treatment: Non-surgical or surgical

  • If surgical treatment: Kind of equipment

  • Own experience

  • Healing time according age

  • Practicability of postoperative management

  • Cost effectiveness

• These factors are not to be regarded solely but in the sum. Thus, not only the X-ray image has to be studied, but also individual condition and surroundings. If, for example, the child already goes to school, a cast may be a handicap

• The aim of child-oriented treatment must be to achieve the greatest possible clinical efficiency, e.g., excellent results with minimal intervention

• Hence, the only treatment strategy is:

The first treatment should be the correct and the definitive treatment

Development and Growth

• Compared to mature bone, immature bone is more capable of reaction and adaptation, but it is also more vulnerable

• A fracture in an immature bone signals either the acceleration or deceleration of growth, which has the potential to induce deformity, and adds to the complications of the fracture itself

• Age is one of the most important aspects as children’s fractures heal more rapidly the younger the child. Depending on the child’s age and the direction of the deformity, the bone can remodel to correct even the most angular of malunions

• The most important area of injury in the immature skeleton is the growth plate or epiphysis

• While treatment generally does not differ in adults between 20–60 years, in childhood large differences exist within the different ages (0–19 years of age). For example, the treatment of a fracture in a five-year-old child does not have to correspond and may even be inappropriate in a 12–14-year-old

Regulation of Epiphyseal Growth

• The growth plate (physeal line) is the primary center for growth in most bones and may be divided into two zones according to function:

  • The zone of growth, involved in both longitudinal and circumferential bone growth

  • The zone of matrix formation

• The growth plate is capable of responding to different stimuli (e.g., fracture or injury) with either compression (e.g., cessation of growth) or tension (e.g., bone resorption). This can have positive or negative influence on growing and axis

Growth and Remodeling of Metaphyseal and Diaphyseal Bone

• The metaphysis is the site of most rapid change in bone structure, as the deeper zones of the growth plate mature and the growth plate produces primarily trabeculae

• Circumferential growth of the diaphysis is a function of appositional bone formation by the periosteum, together with osteoclast resorption by the endosteum so as to enlarge the medullary cavity

• As growth continues, the bone is capable of reducing, or even correcting, angular deformity by selective resorption and apposition, possibly driven by compression and tension forces (Table 40.1)

Table 40.1 Self-correction potential of the growing skeleton

Radiological Anatomy

• On X-ray, children’s joints seem much greater than they really are (Fig. 40.1)

• The reason for this is the thick cartilage around the epiphysis

Fig. 40.1

Radiological anatomy of the joint in childhood. (a) 4 years old child, (b) 14 years old child

2 Classification

• There are numerous systems for classifying bone fractures:

  • According to localization, displacement and stability (Table 40.2)

  • According to localization and involvement of the growth plate (Table 40.3)

  • According to the Salter–Harris/Aitken system (Fig. 40.2, Table 40.4)

  • According to the (Table 40.5 and Table 40.6)

Table 40.2 Bone fracture classification according to location, displacement, and stability

Table 40.3 Classification according to location and growth plate involvement

Fig. 40.2

Fracture location related to bone segments and sub-segments. For children the defined square must be placed over the larger parts of the growth plate

Table 40.4 Salter–Harris/Aitken classification

Table 40.5 Overall classification system of pediatric fracture classification

Table 40.6 Classification of pediatric fractures

AO Pediatric Comprehensive Classification of Long-Bone Fractures (PCCF)

• The AO Pediatric Comprehensive Classification of Long-Bone Fractures (PCCF) is available to all surgeons as a software package at www.aofoundation.org/aocoiac

• Fracture location is related to the four long bones and their three segments, as well as the specific pediatric sub-segments. The bones and segments within the bones follow a coding scheme similar to that in adults, but the identification of the segments differs. For pediatric long-bone fractures, the end segment has two subsegments:

  • Segment 1: Proximal – including epiphysis (E) and metaphysic (M) subsegments

  • Segment 2: Diaphysis (D)

• Segment 3: Distal – including metaphysic (M) and epiphysis (E) subsegments

• For the radius/ulna and tibia/fibula bone pairs, both bones must be included in the defined square (Fig. 40.2)

• As malleolar fractures are uncommon in children, they are simply coded as distal tibia fractures (e.g., the fracture of the medial malleolus is a typical Salter–Harris III or IV fracture of the distal tibia, coded as 43)

• The original severity coding of A–B–C used in adults is replaced by a classification system that is known and accepted all over the world, determined according to diaphysis (D), metaphysis (M) and epiphysis (E)

• Epiphyseal fractures (E) involve the epiphysis and its growth plates

• Metaphyseal fractures (M) are identified according to the position of the defined square (where the center of the fracture lines must be located in the defined square) with one side over the growth plate

• For easier and more accurate application of the squares, and thus more reliable classification, a series of defined squares is copied to a transparency that is overlaid on the a.p. radiographic view

• Nowadays, with the PACS system, the drawing of this square is easy and much more precise

• The defined square does not apply to the proximal femur, where metaphyseal fractures are located between the growth plate of the head and the intertrochanteric line

• The morphology of the fracture is documented by a type-specific child code and a severity code, as well as an additional code for displacement of specific fractures

Overall Structure of Pediatric Fracture Classification (Table 40.5)

• Relevant pediatric fracture patterns, transformed into a “child code,” are specific and grouped according to each of the fracture location categories of E, M or D (Table 40.6, Fig. 40.2)

  • Patterns of epiphyseal fractures include the known epiphyseal injuries I–IV according to Salter–Harris using the child codes E/1 to E/4. Other child codes (E/5 to E/9) are used to identify Tillaux (two-plane) fractures (E/5), tri-plane fractures (E/6), ligament avulsions (E/7), and flake fractures (E/8)

  • Three child patterns are identified for metaphyseal fractures, e.g., the buckle/torus or greenstick fractures (M/2), complete fractures (M/3) and osteoligamentous, musculo-ligamentous avulsion or just avulsion injuries (M/7)

  • Child patterns within segment 2 (diaphyseal fractures) include bowing fractures (D/1), greenstick fractures (D/2), complete transverse fractures (angle ≤30°; D/4), complete oblique/spiral fractures (angle >30°; D/5), Monteggia (D/6), and Galeazzi lesions (D/7)

• The grade of fracture severity distinguishes between simple (noted as .1) and wedge (partially unstable fractures with three fragments including a fully separated fragment) or complex fractures, e.g., totally unstable fractures with more than three fragments (noted as .2) (Fig. 40.3)

• Severity implies anticipated difficulties and method of treatment, not the prognosis

• Fracture displacement for specific fractures (Fig. 40.4)

  • Supracondylar humeral fractures (code 13-M/3) are given an additional code regarding the grade of displacement at four levels (I–IV)

  • Radial head fractures (code 21-M/2 or /3, or 21-E/1 or /2) are given an additional code (I–III) regarding the axial deviation and level of displacement (I = no angulation and no displacement, II = angulation with displacement that is less than half the bone diameter, III = angulation with displacement that is more than half the bone diameter)

• Paired bones

  • Except for the known Monteggia and Galeazzi lesions, when paired bones (e.g., radius/ulna or tibia/fibula) are both fractured with the same child pattern, a single classification code should be used with the severity code used to describe the worst of the two fractures

  • When a single bone is fractured, a small letter describing that bone (e.g., “r,” “u,” “t” or “f”) should be added after the segment code (e.g., the code “22u” identifies an isolated diaphyseal fracture of the ulna)

  • When paired bones are fractured, each with a different child pattern (e.g., complete fracture of the radius and a bowing fracture of the ulna), each bone must be coded separately including the appropriate small letter (22r-D/5.1 and 22u-D/1.1). This allows for the detailed documentation of combined fractures of the radius and ulna, or those of the tibia and fibula in clinical studies, so their relative influence on treatment outcomes can be properly evaluated

Fig. 40.3

Fracture severity: (a) simple (noted as .1), (b) partially unstable or totally unstable fractures with more than three fragments (noted as .2)

Fig. 40.4

Fracture displacement for specific fractures

Further Rules for Correct Classification

• Fractures of the apophysis are recognized as metaphyseal injuries

• Transitional fractures with or without a metaphyseal wedge are classified as epiphyseal fractures

• Ligament avulsions

  • Intra-articular and extra-articular ligament avulsions are epiphyseal and metaphyseal injuries, respectively

  • The side of ligament-avulsion fractures of the distal humerus and of the distal femur is indicated by the small letter “u” (ulnar/medial) or “r” (radial/lateral) for the humerus and by “t” (tibial/medial) or “f” (fibula/lateral) for the femur

• Femoral neck fractures

  • Epiphysiolysis and epiphysiolysis with a metaphyseal wedge are coded as normal type-E epiphyseal Salter–Harris I and II fractures, E/1 and E/2

  • Fractures of the femoral neck are coded as normal type-M metaphyseal fractures coded from I to III

  • On the proximal femur, the intertrochanteric line limits the metaphysis

3 Skeleton Standard and Special X-Rays

General Considerations

• Not every fracture is visible on the X-ray in childhood

• An X-ray is only indicated if it has a therapeutic consequence

• If the decision to X-ray has been made, then it should be taken appropriately to provide the information desired

• It is obligatory to take X-rays in two planes, a.p. and lateral, even in emergency situations, including the proximal and distal joint of the broken segment

• X-ray of the opposite extremity is unnecessary, since no new knowledge or additional information can be gained

• A guide to radiological investigation of the skeleton is given in Table 40.7

Table 40.7 A guide to radiological investigation of the skeleton

4 Development of Ossification Centers

• Figures 40.5, 40.6, 40.7 show the normal development of ossification centers

Fig. 40.5

Normal development of ossification centers upper extremities

Fig. 40.6

Normal development of ossification centers pelvis, lower extremities

Fig. 40.7

Normal development of ossification centers spine, foot

5 Plaster Immobilization

• Every physician who deals with fractures must know how to apply a cast

Plaster Splint

• Indications

  • Stable fractures

  • Distortions

  • Pain after bone bruises

• The extremity must be covered with a cotton tube

• Wrapped with a thin half elastic cushion cotton

• Wrapped with a paper bandage

• Plaster gauzes are placed longitudinally along both sides of the extremity with a 3-cm plaster-free gap between them

• Today, fiberglass pre-fabricated splints are available and very user friendly

• After edema regression the cast can be closed circularly

Circular Plaster Cast

• Indications

  • Unstable fractures

  • Functional treatment

  • Secondary post-plaster splint (after edema regression)

• Same steps as above

• The extremity is enclosed in a circular plaster of paris or fiberglass cast

• Drying time for plaster: ~1.5 h; for Scotch cast ~30 min

• A primarily applied circular plaster should be opened longitudinately, especially when the tissue is swollen after fresh injuries

• When swelling subsides, the plaster can be closed again

Plaster Cast Windows

• Indications

  • Open wounds

  • Pins / K-wires

• The earliest that windows can be made in the plaster is after drying

• The window in the plaster must always be covered with the piece that was taken out in order to prevent edema in this region

• The window in the plaster must not impair the stability

Plaster Cast Wedging

• Indications

  • Remaining angulation of an undisplaced, stable fracture, after fracture stabilization without reduction

• The earliest the wedging of the plaster can be made is after 1 week. Swellings and pain must have gone completely

• The cut for the wedge must be at the deepest point of the concavity of the deformity

• The more peripheral the fracture, the more proximal should be the point for the wedge

• The child should not have any pain during this procedure

6 Therapy Principles

Closed Reduction (Mainly Used for the Upper Extremity)

• Every fracture reduction should be carried out under anesthesia (plexus block, general anesthesia)

• Extend the fingers (use of finger traps), hang a weight at the humerus and maintain the upper extremity with 90° flexion at the elbow for 20–30 min

• Reduce the fracture using a reduction maneuver that mimics the movement that led to the fracture in the first place

• Apply the plaster in the hanging position

• Immobilization of the fracture with a dorso-volar plaster splint

So-called Semi Open Reduction

• Indication

  • Partial or total unstable displaced fractures that can be definitively reduced

• Closed reduction under sterile conditions as described above

• Followed by percutaneous K-wire fixation

• In addition, immobilization with a plaster splint is required

Traction

• Indications

  • Limited nowadays

  • The main indication is in fractures of the femur in children between birth and 3 (4) years of age, depending on the child’s weight of the child; known as overhead traction

• Sufficient analgesia and sedation of the child

• First the plaster is placed on the healthy leg over its full length

• Then the injured leg is covered with plaster, however only distal to the fracture

• Fixation of the extension on the overhead arch so that the child’s buttocks are raised (there should be space for a flat hand to move freely under the buttocks without touching them)

Possibilities for Osteosynthesis

• Possibilities for osteosynthesis are illustrated in Fig. 40.8

Fig. 40.8

(a–f) Possibilities for osteosynthesis. (a) Kirschner wire, (b) combination Kirschner wire/external fixation, (c) external fixator, (d) elastic stable intramedullary nailing, (e) plate osteosynthesis, (f) lag screw osteosynthesis

Osteosynthesis with K-wires

• Indications

  • Closed or open reduced metaphyseal fractures

  • Fractures of the hand and foot

• Fixation with K-wires is not suitable for stabilization of diaphyseal fractures

• Whenever possible, the K-wires should be placed percutaneously so that they can be removed without anesthesia

• The crossing points of the K-wires should be proximal to the fracture line

• If the epiphysis must be crossed, repeated attempts to fix it should be avoided

• In cases such as this, thin K-wires should be used instead

• Ensure that the K-wires penetrate the opposite cortex

• Daily care of the pins reduces the risk of infection

• Normally K-wires can be removed after 3–4 weeks

Osteosynthesis with External Fixator (Ex-Fix)

• Indications

  • Comminuted fractures mainly in older children (femur, tibia, forearm)

  • Polytrauma

  • Long spiral fractures, e.g., spiral wedge of the femur in older children

• Normally closed reduction with or without traction table

• Type: Monotube®, tubular system, circular frame

• Place the Schanz screws under imaging intensifier

• In Monotube® systems, the distances between the entry points are predefined

• In “frame systems” one entry point should be near the fracture, the other further away from it

• All clamps must be open for reduction

• After sufficient reduction all clamps have to be closed and secured

• Daily care of the pins reduces the infection risk

• Elastic stable intramedullary nailing (ESIN)

• Indications

  • Transverse, oblique and short spiral, diaphyseal fractures in childhood (3–15 years)

• ESIN is minimally invasive, minimally traumatic, and sufficiently stable for movement and partial weight bearing; it is biologically and child friendly way, using special elastic nails, of enabling osteosynthesis

  • Operation technique: see Sect. 40.15

Lag Screw Osteosynthesis

• Indication

  • Articular and peri-articular fractures, Salter–Harris II fractures, mainly in the distal tibi and femur, femoral neck fractures

• Self-drilling and taping cannulated screws (dimensions 4/4.5/6.5 mm) are mainly used

• Directly position the extremity on the intensifier

• Rotate the extremity so that the fracture line is visible in a proper a.p. view

• Put the guide wire on the fragment parallel to the table of the intensifier

• Drill the guide wire into the bone to the contralateral cortex

• Measure the length

• Put the correct-sized cannulated screw over the guide wire

• Tighten the screws until the fracture is closed

Plate Osteosynthesis

• Indications

  • Comminuted fractures, mainly in older children (femur, tibia, forearm), long spiral fractures with/without spiral wedge of the femur in older children

  • Today, ESIN and EndCaps can be used for such fractures as well

• Usage of plates is reserved to exceptions and in special cases

• When an osteosynthesis with a plate is indicated, we recommend the application of new types of plates such as LC-DCP and LCP plates. If possible, these types of plates can be applied using a minimally invasive technique (MIPO)

Knee Joint Puncture (Fig. 40.9)

• Indications

  • Posttraumatic hemarthros (not before 24 h!)

  • Signs or suspicion of infection

• Procedure

  • Apply local anesthesia or anesthetic cream well before the puncture

  • Puncture in the lateral proximal recess

Fig. 40.9

Knee joint puncture

Hip Joint Puncture (Fig. 40.10)

• Indications

  • Posttraumatic hemarthros (not before 24 h!)

  • Sings or suspicion of infection

• Procedure (three different approaches)

  • From lateral approach

  • From anterior approach (take care to avoid the artery and nerve!)

  • Ludloff approach (preferred by author)

Fig. 40.10

Hip joint puncture

Period of Healing

• Guidelines for fracture immobilization in childhood are given in Table 40.8

• Metaphyseal fractures heal in half the time of the diaphyseal fractures

• Diaphyseal transverse fractures heal more slowly than diaphyseal oblique fractures

Table 40.8 Guidelines for fracture immobilization in childhood

7 Spinal Injuries

General Considerations

• Spinal injuries in childhood are not as rare as one assumes

• The most common injuries are simple fractures after anterior crush injuries or compression fractures of the vertebral body

• In injuries involving the atlas and axis, rotatory subluxation or dislocation is one of the most common lesions in children, rather than fractures of the atlanto-axial articulation

• Injuries of the thoracic and lumbar spine are more common in childhood than in adulthood. The majority of these fractures result from traffic accidents. Child abuse should also be considered

• Obstetric fractures involve mostly the cervical spine (with high mortality)

• End-plate fractures in younger children are followed by scoliosis

• Fractures of vertebral bodies have good remodeling capacity, depending of the child’s age

• Diagnosis can be difficult due to congenital malformations (congenital non-union, hemivertebra, congenital vertebral fusions) or following diseases (post-traumatic malformations or Scheuermann’s disease)

• The normal spine in children differs considerably from that in adults, especially in the cervical region

Classification

• Stable spine fractures with compression of the vertebral body or “end-plate” injuries

• Unstable fractures with involvement of the vertebral arch and the pedicles

• Ligament avulsion

  Or

• Fractures involving end-plates with growth disturbance

• Fractures not involving end-plates

Diagnostic Work-Up

• Diagnosis includes accurate evaluation of the level and extent of injuries to both chondro-osseous and nervous system tissues

• Radiographic evaluation must be carried out paying due attention to potentially severe unstable injuries and must include prior adequate immobilization of the spine

• Osseous injuries can be seen on an adequate a.p. and lateral view

• Oblique views may be necessary

• CT scan or MRI may be indicated

Treatment

• A number of unique problems can be encountered in the treatment of infants, children, and adolescents with spine injuries

• In any closed, non-surgical treatment regime, the spinal deformity must be reduced and adequately stabilized, and protected from re-displacement during the healing process

• Treatment guidelines are given in Table 40.9

Table 40.9 Treatment guidelines for spinal injuries in infants, children, and adolescents

Prognosis

• The prognosis of undisplaced stable fractures is good, depending on the type of injury (growth plate/end-plates, wedge compression)

• The prognosis of displaced fractures depends on the accompanying neurological problems

8 Sling-Shot Injury of the Cervical Spine

General Considerations

• Sling-shot injury of the cervical spine happens more frequently than fractures in childhood

Diagnostic Work-Up

• Normal X-ray indicating a straightened position of the cervical spine

Treatment

• Pain management

• Immobilization with a soft ruff

• Physiotherapy

Prognosis

• Good

9 Pectoral Girdle and Clavicle

General Considerations

• Fractures of the clavicle (Table 40.10) occur most frequently in children during the first 10 years

• Fractures of the scapula, which is highly mobile and well protected by muscles, are rare

• Fractures of the scapula result from direct violence, such as crushing injury, and traffic accidents

Table 40.10 Fractures of the clavicle

Gleno-Humeral Joint Dislocation

• Subluxation and dislocation of the shoulder (Table 40.11) are rare in infants or young children

• The capsule of the shoulder joint has some intrinsic laxity that allows some displacement during stress

• “Dislocation” of the shoulder has also been described as a birth injury. However, great care should be taken before making such a diagnosis, as the proximal humerus is most likely to be fractured through the epiphysis

Table 40.11 Gleno-humeral joint dislocation

Prognosis

• For clavicle fractures, very good

• Prognosis of dislocation of the gleno-humeral joint depends on the time lapsed since the incident and the type of injury

10 Humeral Fractures

General Considerations

• Rare in childhood, following direct trauma or obstetric injury

• Mostly transverse or oblique fractures

Fractures of the Proximal Humerus

• Proximal humeral fractures and their management are detailed in Table 40.12

Table 40.12 Proximal humeral fractures and their management

Fractures of the Distal Humerus

• Distal humeral fractures and their management are detailed in Table 40.13

Table 40.13 Supracondylar humerus fracture

Fracture of the Humerus shaft (Diaphyseal Fractures)

• Fractures of the humeral shaft and their management are detailed in Table 40.14

Table 40.14 Fracture of the humerus shaft (diaphyseal fractures) and their management

Prognosis

• Very good

11 Elbow Joint Region Fractures

General Considerations

• Mostly children between 3 and 10 years old sustain these fractures

• Good knowledge of the child’s anatomy of the distal humerus and the proximal forearm is imperative

• The X-ray is often difficult to interpret, nevertheless an X-ray of contralateral, uninjured site is unnecessary and no longer required

• Correct diagnosis should always be achieved before starting treatment

• Special fractures

  • Non-displaced fractures of the lateral condyle

  • Isolated fractures of the radial neck

  • Monteggia fractures

  • Rotation failures in supracondylar humerus fractures due to varus or valgus deformity resulting from the fracture

Classification

• Fractures in the region of the elbow joint are discussed in Tables 40.13, 40.14, 40.15, 40.16, 40.17, 40.18, 40.19, 40.20, 40.21, 40.22, 40.23, 40.24, 40.25, and 40.26

Table 40.15 Regarding the joint

Table 40.16 Regarding the direction of displacement of the distal fragment

Table 40.17 Localization of elbow fractures according to frequency

Table 40.18 Epiphysiolysis of the distal humerus

Table 40.19 Transcondylar, intercondylar fractures

Table 40.20 Proximal radial fractures

Table 40.21 Dislocation of the elbow

Table 40.22 Fracture of the medial or lateral epicondyle

Table 40.23 Olecranon fractures

Table 40.24 Subluxation of the radial head (Chassaignac)

Table 40.25 Radial neck fractures

Table 40.26 Monteggia lesions

12 Forearm Fractures

General Considerations

• Diaphyseal injuries are common in children

• The severity may vary from pure bowing (Table 40.27) to greenstick (Table 40.28) or even to a complete fracture (Table 40.29) with or without displacement

• The level of the fracture varies

• In children, the tendency for the radius and ulna fractures to be aligned is greater than in adults

• Great fracture variability

  • Same fracture type in both bones, but not aligned

  • Isolated fracture of the radius

  • Bowing of radius and ulna (Table 40.27)

  • Fracture of the ulna and bowing of the radius or reversed

• A Galeazzi fracture is the name given to fracture of the distal radius with dislocation of the distal radio-ulnar joint (Table 40.30)

Table 40.27 Bowing fracture of the forearm

Table 40.28 Greenstick fracture of the forearm shaft

Table 40.29 Complete diaphyseal forearm fracture

Table 40.30 Forearm fractures – distal third (metaphyseal fractures)

Treatment of Forearm Fractures without Anesthesia

• Place child in supine position (Fig. 40.11)

• Place upper extremity in 90° abduction on the edge of the table with their elbow in 90° flexion

• Cover the whole arm with a stocking

• Elevate the forearm using finger traps

• A counterweight is attached across the upper arm with the elbow at 90° flexion, to an extent that the child can still tolerate

• This position is maintained for 15–20 min

• Reduce the fracture by pressing both hands together to stretch the interosseous membrane

• X-ray control

• Apply a well padded dressing

• Apply a well molded long arm cast (must be opened after drying) or dorso-volar long arm splint (author’s preferred method)

Fig. 40.11

Treatment of forearm fractures without anesthesia

13 Wrist and Hand Fractures

General Considerations

• Whereas carpal injuries and multiple unstable fractures of the metacarpals are rare in children, other hand and finger fractures are frequent in children, especially phalangeal fractures and interphalangeal dislocations

• Fractures of the scaphoid are rare in children under 12 years of age. The treatment is Non-surgical with a scaphoid cast for 6 weeks

• Displaced fractures are treated operatively, similar to fractures in adults

• Diagnosis can be difficult and often requires special X-ray techniques

• Fractures of the metacarpals are the most frequent hand fractures

• Each metacarpal has only one epiphysis; for MC I it is proximal (Table 40.31), for MC II–V, distal (Table 40.32)

• Hence, more proximal fractures can be found on the MC I and more distal fractures on the MC II-V

Table 40.31 Fracture of the first metacarpal

Table 40.32 Fracture of metacarpals II–V

14 Pelvic Ring Fractures

General Considerations

• Pelvic fractures are rarely isolated; most appear as accompanying injuries after heavy direct or multiple trauma

• The degree of severity ranges from a simple fracture of the pubic bone to a complete pelvic ring disruption

Classification

• The classification of pelvic ring fractures is given in Table 40.33

Table 40.33 Classification of pelvic ring fractures

Treatment

• Treatment of pelvic ring fractures is given in Table 40.34

Table 40.34 Treatment of pelvic ring fractures

Hip Dislocation

• Hip dislocation and its management is discussed in Table 40.35

Table 40.35 Hip dislocation and its management

15 Lower Limb Fractures

Femoral Neck Fractures

• Femoral neck fractures and their management are discussed in Table 40.36

• The capital femoral and trochanteric epiphyses have cartilaginous continuity along the posterior superior femoral neck due to embryonal development

• Damage to this cartilaginous continuity, as in a femoral neck fracture, may seriously impair normal development of the neck

• Femoral head necrosis results from vessel damage in this region!

Table 40.36 Femoral neck fractures and their management

Femoral Shaft Fractures

• Femoral shaft fractures and their management are discussed in Table 40.37

Table 40.37 Femoral shaft fractures and their management

Operative Technique with Elastic Stable Intramedullary Nailing (ESIN)

• Child in supine position

• For children <8 years: free position, fixed on the standard table

• For children >8 years: fracture table is recommended (especially for transverse fractures)

• Decide on the direction of the nailing:

  • Rretrograde (normally)

  • Antegrade (special situations)

• A preliminary reduction with the aid of an image intensifier on the fracture table is performed

• The nail entry point is normally one finger’s breadth about the proximal tip of the patella, which corresponds to 2–3 cm proximal the epiphyseal line

• Aa skin incision about 3–4 cm in the distal direction from the planned entry point in the bone is performed

• The nail entry point is created by penetrating the near cortex with the awl or drill bit

• The awl is inserted vertically down to the bone, then lowered about 45° to the cortical surface whilst rotating it so that the bone cortex is perforated in an upwards showing angle. With a rotating motion, continue to penetrate the cortical bone at an upward angle

• The nail diameter should be one-third of the narrowest diameter of the medullary canal and as long as the bone when bent. Both nails must be bent in the same way

• The greatest curvature of the nails must be at the level of the fracture

• The first nail is driven to the level of the fracture

• In a similar manner to that previously described, the femur is opened on the opposite side

• The second nail is driven up to the level of the fracture

• The fracture is visualized with fluoroscopy and a decision is taken, which nail will be easier to pass across the fracture and will most effectively pull the proximal fragment into alignment

• This nail is driven across the fracture, monitoring its position with fluoroscopy

• This nail is advanced into the proximal fragment only so far as to ensure that the reduction is maintained

• The second nail is positioned in the same manner

• Both nails can now be advanced to the proximal epiphysis

• Both nails are cut to the right length outside of the skin

• The rotation of the leg is controled

• The final position of the nails is achieved when the end points are placed in the proximal fragment

• The proximal ends of the nails should poke out at least 8 mm from the cortex in order to facilitate easy removal, whilst the low profile minimizes soft-tissue irritation

• If the fracture is distracted, traction is released and the patient’s heel is impacted

• In case of axial instability (long oblique or spiral or comminuted fractures, today EndCaps can be used to increase axial stability

• Skin closure

• The nails are not removed before complete consolidation, at least 4–5 months

• Figure 40.12 shows the operative steps

Fig. 40.12

Operative technique with Elastic-Stable-Intramedullary-Nailing (ESIN)

16 Distal Femur and Proximal Tibia Fractures

General Considerations

• Very rare fractures in childhood, following high-energy trauma or traffic accidents

• The radiological diagnosis is not easy, however it is not as difficult as for the elbow

• Hemarthros indicates a severe trauma

• Osteochondral fragments, “flake fractures,” must be looked for

Classification

• Distal femur and proximal tibia fractures are described in Table 40.38

• Supracondylar and condylar fractures of the femur and their management are described in Table 40.39

• Fractures of the proximal tibial epiphysis and their management are detailed in Table 40.40

Table 40.38 Distal and proximal tibia fractures

Table 40.39 Supracondylar and condylar fractures of the femur

Table 40.40 Fractures of the proximal tibial epiphysis and their management

17 Patella Fractures and Dislocations

General Considerations

• Patellar dislocations (Table 40.41) are common when considering the entire spectrum of acute and chronic subluxation and dislocation injuries

• More frequently, chronic subluxation mimics actual dislocation

• Dislocation of the patella is frequent in young girls

• Prerequisites are “genua valga,” being overweight, and “patella alta”

• Fractures of the patella (Table 40.42) result from direct trauma and high-energy extension trauma (such as high jumping)

Table 40.41 Patellar dislocation and its management

Table 40.42 Patellar fractures and their management

18 Tibial Shaft Fractures

General Considerations

• Fracture of the tibial shaft (Table 40.43) is one of the most frequent fractures of the lower leg in childhood

• Injuries of this region vary considerably with both age and mechanism of injury

• In infants and children, the typical injury is a spiral tibial fracture with an intact fibula

• This circumstance influences the kind of treatment and the outcome

• Complete fractures of the tibia and fibula (Table 40.44) are unstable, and often shortened with rotational failures

• Special types: toddler fractures or bowing of the fibula or (rarely) of the tibia

• Fractures of the tibial shaft (isolated tibial fractures)

Table 40.43 Tibial shaft fractures

Table 40.44 Complete fracture of the tibia and fibula

19 Distal Tibia and Ankle Joint Fractures

General Considerations

• Like the proximal region, the distal metaphysis may sustain injury in patterns of varying severity

• Due to the microstructural differences between the thick diaphysis and the thinner metaphysis, greenstick and torus fractures are common

• Fractures of the ankle joint are classified according to the maturation of the epiphysis and the child’s age (Table 40.45)

• The epiphysis begins to close from the age of 12 in girls, 14 in boys

• Fracture types vary depending on epiphyseal maturation

• Extra-articular (Table 40.46) and intra-articular (Table 40.47) fractures and their management are discussed below

Table 40.45 Classification of isolated distal tibia and ankle joint fractures

Table 40.46 Distal tibia extra-articular fractures and their management

Table 40.47 Distal tibia intra-articular fractures (Salter–Harris III and IV) and their management

19.1 Bi- and Tri-plane Fractures: “Fractures of Tillaux”

General Considerations

• This particular type of injury affects a part of the anterolateral tibial epiphysis

• The segment may extrude anteriorly and laterally

• Ankle congruity is of concern because juvenile two-plane fractures involve the weight-bearing articular surface

• The fracture may be accompanied by a posterior metaphyseal fragment and in this case the fracture is called a “tri-plane fracture”

• The exact diagnosis can often be difficult when only based on standard a.p. X-ray projection of the distal tibia and fibula

• Exact examination under the image intensifier can clarify the diagnosis

• However, CT may exhibit far greater accuracy than plain radiographs in delineating the degree of joint displacement and fragment separation

• This fracture type occurs especially in adolescents

• A schematic and model illustration of a bi-plane fracture at the ankle joint is shown in Fig. 40.13

• A schematic and model illustration of a tri-plane fracture at the ankle joint is shown in Fig. 40.14

Fig. 40.13

Schematic and model illustration of a bi-better we say two-plane as this is the international term plane fracture at the ankle joint

Fig. 40.14

Schematic and model illustration of a tri-plane fracture at the ankle joint

Treatment

• The aim of therapy is exact reconstruction of the joint surface

• Undisplaced (<2-mm gap) bi-plane and tri-plane fractures are treated non-surgically by a well-padded compression dressing and posterior splint. After the swelling has disappeared the fixation is changed to a Sarmiento type cast

• Displaced bi- and tri-plane fractures are treated surgically

• Reduction of the fracture and retention are achieved using a minimally invasive technique such as that using cannulated, self-drilling, self-tapping screws

• The extremity is placed directly on the image intensifier

• The leg must be turned so that the fracture can be seen exactly in an a.p. view

• The screws must be placed exactly perpendicular to this plane. The adaptation of the fracture can easily be observed with the intensifier

20 Foot Fractures

General Considerations

• Fractures of the talus and the calcaneus are rare in childhood

• Fractures of the metatarsals are frequent, the first and fifth rays in particular are involved

• The first metatarsal may be injured proximally, either in the metaphysis or the proximal growth plate

• Solitary fractures of the metatarsal diaphysis are usually undisplaced

• Symptomatic accessory bones make diagnosis difficult

Treatment

• The treatment of foot fractures is detailed in Table 40.48 and complications arising are listed in Table 40.49

Table 40.48 The treatment of foot fractures

Table 40.49 Complications of foot fractures