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
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Hon. Consultant in Paediatric Orthopaedics BSES MG Global Hospital,
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Dr LH Hiranandani Hospital,
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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
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd, Sector 60, Noida
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
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.
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:
- AnatomicalPresence of growth plateThick, vascular periosteumCambium layer has increased osteoblastic activity.
- BiochemicalMore collagen per unit area of mineralized boneCollagen is mainly type 1
- BiomechanicalBone is more porousThe bone has lower modulus of elasticityLesser bending strength required to produce deformity.
Principles of Treatment in Children Fractures
- Union is almost always possible
- Angulation must be kept as small as possible
- Malrotation is unacceptable at any age
- The ability of the bones to remodel in the immature skeleton forms the basis of “limits of acceptability” in children fracture.
- This remodeling ability depends on:
- Age
- Anatomical location of fracture
- Degree of deformity
- Plane of fracture
- Movement of adjacent joints
Imaging Rules
- Knowledge of ossification centers is essential when interpreting radiographs in children ().
- The appearance and fusion of various ossification centers helps to differentiate normal variants from abnormal lesions.
- Never hesitate to ask for contra-lateral radiographs.
- Beware of dual or multiple fractures in the same limb or at other sites
- Fracture lesions are always larger than what appears on radiographs because of presence of unossified cartilage
Growth Plate (physis)
- Main difference between children and adult bone is presence of a growth plate ().
- It is the site of active bone formation until skeletal maturity.
- Growth plate (physis) is influenced by both external and internal factors. The mechanical forces, muscle action, hormones, and various growth factors modulate the development of the physis.
- Physis is the vulnerable area for injury in a child ().
- Growth plate injuries can be missed; hence a high index of suspicion is required. Also, variations in physis appearance can lead to confusion in diagnosis.
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