Extract
Although the vast majority of orthopaedists do not specialize in pediatrics, almost all practicing orthopaedists, and certainly anyone on emergency trauma call, will be called on at some point to treat a child with a fracture. It is therefore imperative for practitioners to have some working knowledge of current pediatric fracture care. At a minimum, all orthopaedists should have an understanding of which pediatric fractures are emergencies and why, how to treat these fractures or at least temporize before definitive treatment, and how and why the treatment of children's fractures sometimes differs from that of adult fractures.
Although the vast majority of orthopaedists do not specialize in pediatrics, almost all practicing orthopaedists, and certainly anyone on emergency trauma call, will be called on at some point to treat a child with a fracture. It is therefore imperative for practitioners to have some working knowledge of current pediatric fracture care. At a minimum, all orthopaedists should have an understanding of which pediatric fractures are emergencies and why, how to treat these fractures or at least temporize before definitive treatment, and how and why the treatment of children's fractures sometimes differs from that of adult fractures.
This article does not address emergent problems that present and are managed similarly in adults and children (for example, compartment syndrome, pelvic fractures with hemodynamic instability, and traumatic amputations and open fractures). Instead, it focuses on entities that are either unique to children or are managed differently in children and adults. Specifically, we discuss supracondylar humeral fractures and other specific elbow fractures, hip fractures and dislocations, and physeal fractures about the knee.
Look for this and other related articles in Instructional Course Lectures, Volume 59, which will be published by the American Academy of Orthopaedic Surgeons in March 2010:
- "Acute Trauma to the Upper Extremity: What to Do and When to Do It," by Jennifer Moriatis Wolf, MD, George S. Athwal, MD, FRCS(C), Alexander Y. Shin, MD, and David G. Dennison, MD
Supracondylar humeral fractures are relatively common. They account for 30% of extremity fractures in children under the age of seven and 60% of elbow fractures in that age group. They are most common in the first decade of life. Extension-type injuries account for 96% of supracondylar humeral fractures and result from a fall on an outstretched arm that forces the elbow into hyperextension. The much less common flexion-type injuries occur from a fall onto the point of the olecranon with the elbow flexed. According to the commonly used Gartland classification1, type-I injuries are nondisplaced; type-II injuries are angulated posteriorly but the posterior cortex is intact; and type-III injuries are completely displaced, usually with the distal part of the humerus and the elbow displaced posteromedially.
A patient with a supracondylar humeral fracture presents after a specific injury; has pain, swelling, and a decreased range of motion of the elbow; and usually has pain when motion of the arm is attempted. There is tenderness over the distal part of the humerus and, typically, an obvious deformity. There may be ecchymosis or buttonholing of the skin at the fracture site. The child holds the arm in extension and pronated at the forearm. A careful neurovascular examination is imperative. On initial presentation, the radial pulse may be absent secondary to draping of the artery over the spike of the proximal fracture fragment. Often, the pulse returns after fracture reduction. One must document the function of the median, ulnar, radial, and anterior interosseous nerves as well as assess the forearm for signs of ischemia or compartment syndrome.
Anteroposterior and lateral radiographs of the elbow should be made. Comparison radiographs of the contralateral elbow can aid in the interpretation of the images. On the lateral radiograph, a line drawn along the anterior border of the humerus should pass through the center of the capitellum if there is no displacement. A posterior fat-pad sign (a radiolucent area seen posterior to the distal part of the humerus, adjacent to the olecranon fossa, on a plain lateral radiograph) indicates a hemarthrosis and suggests an occult elbow fracture2.
Vascular injury occurs in about 1% of cases. Indications for vascular exploration are clinically obvious ischemia or loss of a pulse that had been previously palpable or apparent on Doppler examination after fracture reduction, as this may indicate that the vascular bundle has become entrapped in the fracture site. The use of arteriography in children is controversial, as is the management of the "pink, pulseless hand"; the usual recommendation is observation without vascular exploration in such a case3.
Neurologic injury occurs in about 7% of cases. The large majority of the nerve injuries are neurapraxias that resolve with time. The radial nerve is at the most risk of transection, which usually occurs with open fractures. The anterior interosseous nerve is the most frequently injured4. This nerve is injured when the posterolateral part of the distal fracture fragment compresses the nerve against the anterior structures in the forearm. Injury to the anterior interosseous nerve results in weak flexion of the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger. The radial nerve is more commonly injured in patients with a posteromedial fracture. The median nerve is more commonly injured in those with a posterolateral fracture, often in association with a brachial artery injury. A median-nerve injury can mask a compartment syndrome because of the associated sensory loss in the forearm. Ulnar nerve injury is often iatrogenic, secondary to medial pin placement, but it also occurs in conjunction with a flexion-type supracondylar humeral fracture.
The treatment of supracondylar humeral fractures depends on the direction and degree of displacement. Gartland type-I injuries may be treated, without reduction, in a long arm cast with the elbow flexed 90° to 110° for three to four weeks. Displaced Gartland type-II and III injuries are treated with closed reduction and percutaneous pinning, with either two or three lateral pins or crossed medial and lateral pins. There is no substantial difference in the stability provided by the lateral and crossed-pin methods if proper technique and pin placement are utilized. The two lateral pins should be divergent, with one running up the lateral column and one crossing over to the medial column; the two pins should not cross at the fracture site; and a third pin should be added when there is medial comminution or persistent instability with motion (Figs. 1-A and 1-B and Table I)5-7.
The timing of surgery for a displaced supracondylar humeral fracture is controversial. A supracondylar humeral fracture is one of the classic pediatric orthopaedic emergencies, but the need to perform surgery in the middle of the night for these injuries has recently been challenged. Four retrospective studies showed no increase in complications in children for whom surgery had been delayed longer than twelve hours8-11. Another study showed a possible increase in the prevalence of compartment syndrome in children with a delay of more than twenty-two hours before surgery12. In our opinion, if a delay of twelve to twenty-four hours is necessary or inevitable, the outcome should not be adversely affected. However, waiting is not better. Surgery should not be delayed unless the child has normal neurovascular function. Furthermore, surgery should not be delayed if there is excessive swelling or soft-tissue damage, and the case must still be considered urgent, with the surgery being done at the earliest possible opportunity the following morning and not after the next day's elective surgery schedule, for example.
Vascular injury or interposition of the neurovascular bundle are the two most definitive indications for open reduction13. The antecubital approach is useful in both cases. Although vascular compromise usually can be managed without the need to operate on the artery, arterial repair may be needed and should be planned for. An inability to achieve an acceptable closed reduction because of lateral or medial soft-tissue or periosteal interposition is another indication for open reduction. An approach from the affected side allows removal of the offending soft tissue.
The pins are removed in the physician's office after periosteal new bone is visible radiographically, generally at three to four weeks. Additional protective immobilization is usually not necessary. Children generally regain the range of motion within about three to four weeks without physical therapy, although the last few degrees of flexion may lag. Follow-up with radiographs and physical examination is recommended at three, six, and twelve months after injury.
Fortunately, complications are infrequent after supracondylar humeral fractures, and most are avoided by attention to detail during treatment14,15. Ulnar nerve injury—usually a neurapraxia that resolves in three to six months—is often the result of medial pin placement. Occupational therapy during resolution may be beneficial. Cubitus varus is caused by varus positioning of the fracture fragment as well as residual rotational deformity. Although cubitus varus is generally a cosmetic problem, tardy ulnar nerve palsy can occur, and a distal humeral osteotomy is occasionally necessary. Loss of reduction is usually a result of technical problems with pin placement15. Pin site infections are rare.
The prevalence of transphyseal fractures of the distal part of the humerus is unknown, as these injuries are sometimes missed or misdiagnosed. They occur primarily in children under the age of four years. They occur as a result of a fall on an outstretched arm but may be the result of abuse if the child is not yet walking, and one should maintain a high index of suspicion in such cases. The fractures usually have a Salter-Harris type-I or II pattern16. The diagnosis of transphyseal elbow fracture should be considered when a very young child presents with pain, swelling, and decreased use of the upper extremity. These injuries are frequently mistaken for elbow dislocations.
Because these fractures occur in very young children, in whom much of the distal part of the humerus (often including the capitellum) is not yet ossified, radiographs may be difficult to interpret. When the elbow is dislocated, the normal radiocapitellar relationship is disrupted, but it is preserved with a transphyseal fracture. An arthrogram, magnetic resonance imaging scan, or sonogram, all of which allow visualization of the nonossified capitellum, may aid in the diagnosis. A closed reduction, with or without percutaneous pinning, is needed. Often, these injuries present late, when there is already a periosteal reaction indicating healing. Reduction is not indicated in these cases.
The most common complication is malunion as a result of a late diagnosis. Luckily, there is substantial remodeling potential in young children. Rarely, osteonecrosis of the trochlea occurs.
Seventeen percent of elbow fractures in children are fractures of the lateral condyle. The peak incidence is between five and ten years of age. These injuries are caused by varus stress to an extended elbow with the forearm in supination. Children with a fracture of the lateral condyle present with lateral swelling and pain in the elbow. These fractures are much less likely to be associated with neurovascular injury than are supracondylar humeral fractures. Anteroposterior and lateral radiographs of the elbow are essential. Sometimes, oblique radiographs help to visualize the fracture. Fractures of the lateral condyle are often mistaken for "chip" or "avulsion" fractures in very young children, since the majority of the distal fracture fragment, including its articular surface, is not ossified. Although fractures of the lateral condyle may be classified with the Salter-Harris classification16 or the anatomically-based Milch classification17, many pediatric orthopaedists classify them simply on the basis of whether they are displaced because displacement dictates treatment.
Nondisplaced fractures of the lateral condyle may be treated in a long arm cast with the elbow in 90° of flexion. Frequent follow-up and repeat imaging are necessary in order to watch for late displacement and the subsequent need for operative treatment. Displaced fractures are best treated with an open reduction and pinning with two or three lateral pins. Direct visualization prior to pinning is necessary to ensure an anatomic reduction of the articular surface. An arthrogram can be made for minimally displaced fractures, and, if the articular surface of the humerus is congruent, the pins may be placed without opening the fracture. Because fractures of the lateral condyle are not likely to be associated with neurovascular injury, they are considered urgent but not in need of emergent operative treatment.
Fractures of the lateral condyle are prone to late complications, including late displacement; malunion and nonunion, even after appropriate fixation; growth disturbance; late deformity; and loss of motion. Parents should be warned of these possibilities at the time of injury.
Monteggia fractures involve the proximal part of the ulna and are associated with a dislocation of the radial head. They are rare in children, accounting for about 0.4% of all forearm fractures. The peak incidence is between four and ten years of age. The Bado classification is used to describe these injuries in children as well as in adults18. Bado type-I injuries, which involve anterior angulation of the ulna and anterior dislocation of the radial head, are the most common variant in children, accounting for 70% of the fractures. Monteggia fractures in children are easy to miss. On all radiographic views, a line drawn through the center of the radial head should pass through the center of the capitellum. Any deviation from this is not normal and requires further evaluation. "Pure" radial head dislocations may not exist in children; one should look for plastic deformation of the ulna in children with a dislocated radial head.
Monteggia fractures can usually be treated with closed reduction (probably best performed with the patient under general anesthesia) and immobilization with the elbow in 90° to 110° of flexion and the forearm in full supination. Reduction is achieved by first correcting the ulnar deformity, then reducing the radial head, and finally relieving the deforming forces by positioning the elbow in flexion and the forearm in supination. Plastic deformation of the ulna is sometimes particularly difficult to reduce.
Associated neurovascular injuries are rare. A late diagnosis can be associated with so much fracture-healing that an osteotomy of the ulna, open reduction of the radial head, and anular ligament reconstruction are necessary.
Femoral neck and intertrochanteric femoral fractures are rare in children, accounting for <1% of all childhood fractures19. They are usually due to high-energy trauma, and associated injuries, including other fractures, head injuries, and abdominal injuries, are common. Proximal femoral fractures in children are classified according to the scheme first reported in the French literature by Delbet in 1907, and popularized by Colonna in 192920. In this classification, type I consists of transphyseal separation. This is an uncommon variant, accounting for 7% of these fractures. Fifty percent of type-I fractures occur with a femoral head dislocation, there is an extremely high rate of osteonecrosis (up to 100%), and there is a high rate of growth arrest. Type-II fractures are transcervical, and they are the most common, accounting for 50% of these fractures. Up to 80% of type-II fractures are displaced, and there is a high rate of osteonecrosis (40% to 50%). Type-III fractures are cervicotrochanteric, and they account for 31% of these fractures. Fifty percent are displaced, and, although the risk of osteonecrosis is lower than the risk with type-I and II fractures, it is still real. Finally, type-IV fractures are intertrochanteric. This is an uncommon variant, it is associated with the fewest complications, and healing is rapid.
Transphyseal separations (type I) are treated with either closed or open reduction and transphyseal pinning (Table II). Femoral neck fractures (type II) are also treated with closed or open reduction and pin fixation of the femoral neck. Cervicotrochanteric fractures (type III) are treated similarly but also can be managed with a spica cast if the fracture is not displaced. Finally, intertrochanteric fractures (type IV) can be treated with either a spica cast or internal fixation with a pediatric hip screw, depending on the size of the child and the degree of displacement.
Hip fractures in children are associated with an overall complication rate of 60%. Most complications are evident within six to nine months after the injury. Necrosis of the femoral head is the most serious complication and is in large part a function of the initial fracture pattern. Coxa vara and coxa valga result from malunion, as does limb-length discrepancy. Nonunion is rare but can occur. Late arthritis can develop secondary to osteonecrosis and malunion.
Hip dislocations are uncommon in children, but they are more common than hip fractures. They can occur with relatively minor trauma. The majority (90%) are posterior, and 15% to 20% are associated with a hip fracture. Hip dislocations are usually easy to diagnose on the basis of the history, physical examination, an anteroposterior radiograph of the pelvis, and a cross-table lateral radiograph of the hip. Typically, with a posterior dislocation, the hip is flexed, adducted, and internally rotated. With an anterior dislocation, the hip is extended, abducted, and externally rotated.
A closed reduction should be performed with the patient under general anesthesia and with use of muscle relaxation to minimize the risk of creating a transphyseal fracture when the femoral head contacts the acetabular rim (Figs. 2-A, 2-B, and 2-C). Preferably, the reduction should be performed within six hours after the injury, to reduce the chance of subsequent femoral head necrosis. The reduction maneuver for a posterior dislocation involves anterior traction with the hip and knee flexed. Longitudinal traction with the hip extended and the knee slightly flexed is used for an anterior dislocation. One should proceed to open reduction from the direction of the dislocation if it is irreducible. After reduction, the stability and congruency of the joint should be assessed. If there is any doubt about the quality of the reduction, a computed tomography scan should be performed to identify interposed soft tissue or intra-articular loose fragments. A spica cast or hip abduction brace is used for six weeks.
Femoral head necrosis develops after 10% to 16% of hip dislocations. Some patients experience a transient sciatic neurapraxia. Recurrent dislocation is rare in children.
Physeal fractures about the knee are relatively rare; they account for 1% to 6% of physeal injuries in children. The Salter-Harris system is used to classify these injuries16. Fractures through the growth plate should be anatomically reduced if the child has more than two years of growth remaining, and restoration of the articular surface is critical to achieve a good outcome. Salter-Harris type-I and II fractures can be treated with closed reduction and cast immobilization or with closed reduction and percutaneous pin or screw fixation. Salter-Harris type-III and IV fractures are best treated with an open reduction and percutaneous or internal fixation, usually with screws that do not cross the physis.
These fractures are usually hyperextension injuries, but they can be due to a hyperflexion force. They are a childhood analog of a knee dislocation, and injury to the neurovascular structures is a risk. Motor and sensory function and vascular supply to the distal part of the lower limb should be carefully examined. As is the case for a patient with a neurovascular injury after a supracondylar fracture, insufficiency of the vascular supply to the distal part of the lower limb requires emergent care.
Treatment of the fracture depends on the fracture pattern, the amount of displacement, and the nature of the physeal injury, as described according to the Salter-Harris classification16 (Table III). Salter-Harris type-I fractures that are not displaced can be treated in a long leg cast, with or without a pelvic band, for four to six weeks. The prevalence of growth arrest is low after such injuries. Displaced Salter-Harris type-I fractures should be reduced (usually with a closed reduction), and cross-pins should be placed to maintain the reduction. Reduction should be achieved, with the patient under general anesthesia, by applying traction in extension supplemented by slight flexion or extension of the distal fragment as needed. Cross-pin fixation is accomplished with smooth Steinmann pins that cross proximal to the fracture site. The pins are typically inserted retrograde, from distal to proximal, starting just posterior to the midpoint of the condyle and aiming 10° anteriorly. Alternatively, they may be inserted antegrade, from proximal to distal. This method is technically more demanding, but the advantage is that pins do not pass through the joint (Figs. 3-A, 3-B, and 3-C). The pins may be buried or be left outside of the skin and can be removed in four weeks. The rate of growth arrest in association with displaced injuries is high (up to 40%).
Salter-Harris type-II fractures are treated with closed reduction and percutaneous pin fixation. To treat these fractures, one should place the pins or screws in the metaphyseal (Thurston-Holland) fragment, if it is large enough, and parallel to the physis (Figs. 4-A and 4-B). Placing pins or screws across the physis should be avoided whenever possible.
Salter-Harris type-III and IV fractures have intra-articular extensions, and they should be reduced with an open procedure and internally fixed with pins or screws placed parallel to the physis. Crossing the physis with hardware should be avoided whenever possible. All patients with physeal injuries should be followed to determine if there is a growth disturbance, and the patient and parents should be advised of this risk at the initial assessment.
Fractures through the growth plate of the proximal part of the tibia are uncommon but, like distal femoral physeal injuries, they are a childhood analog of a knee dislocation and can therefore be associated with neurovascular injury or compartment syndrome.
Most Salter-Harris type-I and II injuries can be treated with closed reduction and cast immobilization or percutaneous pinning (Table IV). Salter-Harris type-III and IV fractures require open reduction and internal fixation.
Pediatric fractures for which one should consider an emergent trip to the operating room include supracondylar humeral fractures, Monteggia fracture-dislocations, hip fractures and dislocations, and physeal fractures about the knee. These fractures are prone to neurovascular compromise and compartment syndrome, osteonecrosis, or growth arrest, which may be avoided by timely and accurate reduction and fixation.
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