Pediatric Fracture Management Atul R Bhaskar
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1Pediatric Fracture Management2
3Pediatric Fracture Management
Atul R Bhaskar FRCS (Orth), FRCS (Surg), MS (Orth), DNB, MCh (Orth) UK Asst. Professor, KJ Somaiya Hospital and Research Center Everad Nagar, Off Eastern Express Highway Sion, Mumbai 400022 Hon. Consultant in Paediatric Orthopaedics BSES MG Global Hospital, Andheri West, Mumbai Dr LH Hiranandani Hospital, Powai, Mumbai Guru Nanak Hospital, Bandra, Mumbai
4Published by
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Pediatric Fracture Management
© 2007, Jaypee Brothers Medical Publishers
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
First Edition: 2007
9788184480313
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5I would like to dedicate this book to my parents and family6
7Foreword
About a third of all children will sustain a fracture, and as such the general orthopaedists will treat many childhood injuries. Applying adult principles to childhood injuries has a high chance of resulting in unnecessary open surgical procedures and a worse outcome than if pediatric fracture management principles had been adhered to. Thus, an easy to use reference of childhood fractures is needed to allow physicians to provide the best care possible for children. Despite the large number of fracture textbooks available, few provide practical advice on how to manage children's injuries in a succinct and practical manner. While the general principles of childhood fracture management have not changed, there have been substantial advances in how these principles are applied to childhood fractures. Comprehensive studies of patient outcome and the development of new fracture fixation techniques have resulted in improved management techniques. Using modern treatment approaches, bad outcomes should be very rare. It is unusual that there is only one successful way to manage a fracture. The best treatments for an injury will depend on the experience of the treating physician, equipment and surgical instruments available, and the desires of the patient. This text captures the advances in fracture management, and presents them in a way that gives practical information on how to manage childhood injuries. The treatment protocols are presented in a rationale and easy to follow way, so that the novice can use this book to make practical decisions on how to treat injuries. The experienced orthopaedic surgeon can also use the information as a succinct review. Treatment options are presented, so that the treating doctor can select between those that will work best given their skill set, the environment they are working in, and patient preferences. The practical information given in this text, it is poised to become a widely used standard in the management of children's fractures.
Benjamin Alman
Canadian Research Chair, AJ Latner Professor and
Chair of Orthopaedic Surgery, Vice Chair Research
Department of Surgery, University of Toronto
Head, Division of Orthopaedic Surgery and
Senior Scientist, Program in Developmental Biology
Hospital for Sick Children
Toronto, Ontario, Canada8
9Preface
Treatment of children's fractures, unlike in adults, offers special challenges: the dilemma of diagnosis, the problem of the ‘acceptable position’, the effect of fracture on growth of child, and most importantly, the effect of growth on fracture.
Most adult fractures cannot tolerate the rigors of conservative treatment, and hence ‘go under the knife’ to achieve timely union and anatomical alignment.
It is the skeletal dynamics that makes management of children's fractures challenging. In the past, the ‘acceptable position’, as taught in residency was partly a matter of conjecture and partly experience. The latter is important as one may have seen different behavior patterns in fracture healing. Also, experience, positive or otherwise, guides our opinion. The ‘conjecture’ part is more exacting now, as the ‘Guru's’ of pediatric fracture management have laid criteria for an ‘acceptable position’.
In treating pediatric fractures, age and timing of presentation has the most significant impact on treatment options. A window period exists after which intervention can produce more harm. This is particularly true for fractures around the elbow region, and growth plate injuries
This book is an attempt to present the salient features of pediatric fracture care both for the in-training residents, as well as for practising orthopedic surgeons.
The book is divided into four main sections: upper limb, spine, pelvis and acetabulum, and lower limb fractures. Each section has sub-headings to cover all anatomical areas for easy reference to a particular fracture/topic. Relevant remarks, features and complications are listed for easy reading.
Delayed presentation and neglected trauma constitute a bulk of pediatric trauma practice in our teaching hospitals. It is only through pooling of clinical cases and multicenter studies, that one can make sensible decisions in this relatively difficult group.
I welcome any comments, suggestions, or a critique towards enhancing the utility of this book. Kindly send your views to the publisher or e-mail to me at <arb_25@yahoo.com>.
A comprehensive bibliography at the end provides additional information for those who seek finer details.
Atul R Bhaskar10
11Acknowledgements
I am highly indebted to the staff at Division of Orthopedics, Hospital for Sick Children, Toronto, Canada for their insightful comments during the weekly trauma rounds. I would like to thank Dr Benjamin Alman, Dr James Wright, Dr William Cole, Dr Douglas Hedden, Dr Andrew Howard, Dr John Wedge, Dr Unni Narayan, and Dr Robert Salter, who, has an extremely keen eye for detail in reading radiographs.
I would also like to thank my teachers at the KEM Hospital, Mumbai, for stimulating my interest in orthopedics. My special thanks to my teachers at the ‘Yorkshire Orthopaedic Training Program’ who help shape my career.
I would like to thank Dr Rajeshwar Singh who has read, edited and revised the manuscript. Mr Parde, artist, at the KJ Somaiya Hospital, for his drawing and line diagrams.
12Introduction  
Children Versus Adults
There are Anatomical, Biochemical and Biomechanical Differences between children and adult bones:
 
Principles of Treatment in Children Fractures
 
Imaging Rules
Fig. A: Ossification centers in the human fetus at the end of first trimester
 
Growth Plate (physis)
Fig. B: Zones of the growth plate. The site of separation in fractures is usually the junction between hypertropic zone and zone of calcification where the matrix is less dense to protect against shear forces
14
Fig. C: Types of growth plate injuries. John Poland first described physeal injuries in 1898. Dr Salter and Dr Harris proposed a classification of physeal injuries in 1965 which remains popular to date