12 Principles of Pediatric Fracture Management

10.1055/b-0040-176953

12 Principles of Pediatric Fracture Management

George Gantsoudes

Introduction

Children are not small adults. They have different anatomy (physes, thicker periosteum, etc.), different physiology (faster healing), and have the potential to remodel angulated fractures. This chapter will discuss the unique treatment of pediatric fractures about the elbow, forearm, knee, and ankle. The Salter–Harris classification is the most frequently used classification to describe physeal injury (▶ Fig. 12.1; ▶Video 12.1, ▶Video 12.2).

**Fig. 12.1** The Salter–Harris classification of physeal fractures. The distal tibia is shown here as an example.

Pediatric Elbow Fractures

I. Preoperative

Obtain a good history
1. These injuries often occur from falls greater than 6 feet (frequently from the monkey bars).
2. Make sure that there has not been any head or neck trauma or loss of consciousness that will require further work-up.
Physical exam
1. Check all four limbs for additional injury—remember that the most commonly missed fracture is “the second one.”
2. Assess the antecubital fossa for puckering or hematoma—this indicates a more significant injury and should push for earlier surgical management.
Neurologic exam
1. Children in pain are often scared and can be uncooperative with a physician in a rush.
2. A little bit of effort to make the child feel comfortable can go a long way.
3. There are many simple exams to look for radial, median, ulnar, anterior interosseous (AIN) and posterior interosseous (PIN) nerve function.
  1. Minimize motion of the elbow and wrist, as these are frequently the most injured areas.
  2. A simplified approach is to check for:
    - i. PIN: thumb interphalangeal (IP) extension, “thumbs up.”
    - ii. AIN: thumb IP and index distal IP flexion, “A-OK sign.”
    - iii. Ulnar: interosseous muscle function, “cross-fingers” or “scissors.”
    - iv. Median: isolate flexor digitorum superficialis function to middle finger.
4. Sensory exam to light touch is acceptable, but this is a subjective exam.
  1. A frightened child may just tell you what you want to hear to make you go away.
  2. If there is sufficient concern that a nerve may be damaged and the child cannot or will not cooperate, a moist towel may be wrapped around the fingers for 5 minutes. There will not be any skin wrinkling to insensate fingers.
Vascular exam
1. Check for pulses at the wrist.
2. If the pulses cannot be palpated or cannot be auscultated with a Doppler, assess the capillary refill. There can be sufficient arterial flow to the hand even in cases of brachial artery disruption due to abundant collateral supply.
  1. Pink hand: the capillary refill matches that of the other side. It signifies sufficient flow and should be treated urgently.
  2. White hand: if there is no, or severely diminished, capillary refill:
    - i. Signifies insufficient flow, should be treated emergently.
    - ii. Consult vascular surgery immediately if flow does not return with reduction.

II. Anatomy and Imaging

The elbow has six secondary centers of ossification that ossify and fuse at different times. Knowledge of these can help an orthopaedist tell the difference between a normal and abnormal elbow radiograph (▶ Fig. 12.2 ).

Fig. 12.2 Secondary ossification centers of the elbow with approximate ages of appearance.
1. Below are average ages of appearance of secondary ossification centers—boys tend to lag behind girls by 1 to 2 years.
2. Capitellum: 1 to 2 years.
3. Radial head: 3 to 5 years.
4. Medial epicondyle: 5 to 8 years.
5. Trochlea: 7 to 10 years.
6. Olecranon: 8 to 10 years.
7. Lateral epicondyle: 11 to 13 years.
The “fat pad signs” can be seen on the lateral radiograph and especially the posterior fat pad sign can help identify an “occult” fracture that cannot be easily visualized on emergency department (ED) radiographs (▶ Fig. 12.3a, b ).

Fig. 12.3 (a) Lateral view of the elbow showing a type I supracondylar humerus fracture with anterior and posterior fat pads visible. (b) Lateral view of the elbow with fat pads outlined.
Assess the angles on the anteroposterior and lateral views—if you are not sure if the angles are appropriate, obtain a radiograph of the normal limb for comparison.
Obtain oblique views (internal oblique) to visualize maximum displacement of lateral condyle fractures.

III. Classification

Supracondylar humerus fractures
1. Gartland (extension type makes up 95%) (▶ Fig. 12.4 ):
  
  Fig. 12.4 The Gartland classification of extension-type supracondylar distal humerus fractures; types I to III.
  1. I—nondisplaced.
  2. II—angulated, but at least one cortex intact.
  3. III—no continuity between cortices.
  4. IV—this is an intraoperative assessment and is a type III without an intact periosteal hinge; can be iatrogenically created from hyperflexion of a malreduced type III.
Lateral condyle fractures
1. Most commonly used classification is Jakob.
  1. I—nondisplaced with intact articular cartilage hinge.
  2. II—complete fracture, but minimally displaced (2–4 mm).
  3. III—complete fracture and malrotated out of the joint.

IV. Initial Management

Supracondylar humerus fractures
1. Type I—unless there is significant varus (type Ib) on the anteroposterior image, these are treated in a cast for 3 to 4 weeks.
2. Type II—splint in the ED and should undergo closed reduction and percutaneous pinning (can be done electively).
3. Type III—splint in a position of comfort and treat with closed (possible open) reduction and percutaneous pinning. The soft tissue and neurovascular status will determine if this is done same day or next day.
4. Transphyseal fractures—can occur in the very young patients (usually less than 3 years old).
  1. Fifty percent of these patients present because of nonaccidental trauma (NAT).
Lateral condyle fractures
1. Type I—placed into a long arm cast/splint and given weekly follow-up for 2 weeks to check for further displacement.
2. Type II—closed (possible open) reduction and percutaneous pinning (electively); assess articular congruency with an arthrogram.
3. Type III—splint position of comfort, followed by open reduction and percutaneous pinning (or screws, if fracture pattern allows). This should be done when the best team is available; not in an emergency.

V. Definitive Management

Supracondylar humerus fractures
1. Pinning technique is almost always done from the lateral side, unless the fracture pattern necessitates a medial pin.
2. Pin spread across the fracture site is crucial for stability.
3. A good rule of thumb is two pins are required for a type II and three (or more) are required for a type III (▶ Fig. 12.5 ).
  
  Fig. 12.5 Three lateral entry pins demonstrating good spread across the supracondylar distal humerus fracture site, crossing the lateral, middle, and medial columns.
4. Medial pins should be placed after initial stabilization is performed laterally and with the elbow in slight extension to protect the ulnar nerve—in meta-analyses, 3 to 4% patients had injury to the ulnar nerve with a medial pin technique.
5. Large C-arm positioning:
  1. Place the C-arm parallel to the long axis of the patient, and swing it around to check the lateral image prior to pinning.
  2. This prevents undesired rotation that may occur through the fracture site if one rotates the arm instead.
6. A long-arm cast (which is subsequently univalved/bivalved) is placed over sterile dressing.
7. Follow-up in 1 week to overwrap the cast.
8. Pin pull is done in the clinic after 3 to 4 weeks (longer for older children).
  1. Activity restrictions are in place for 6 to 8 weeks postoperatively.
  2. Further cast immobilization is rare.
Lateral condyle fractures
1. Pinning technique maximizes pin spread across the fracture site.
2. Stability is key to prevent nonunions (which can happen in lateral condyle fractures).
3. For open reduction, consider a head lamp to aid in visualization.
4. The goal is to reduce the articular surface; anatomic reduction of the articular surface with metaphyseal abnormalities typically will not result in adverse outcomes.
5. A long-arm cast (which is subsequently univalved/bivalved) is placed.
6. Follow-up in 1 week to overwrap the cast.
7. Pins are pulled after 4 weeks, and only if there is sufficient bridging callus. Sometimes 6 weeks’ time is required.

VI. Complications

Supracondylar humerus fractures
1. Complications are almost always related to the nonosseous injuries.
2. Nerve injuries are usually neuropraxias that can take months (but frequently just weeks) to resolve.
  1. AIN is most common.
  2. Radial nerve less common.
  3. Ulnar nerve more common with flexion type.
3. Compartment syndrome is more frequent with ipsilateral radius/ulna fractures. Cases with a median nerve injury need to be very closely monitored, as the patient may not have sensation sufficient to alert the physician to worsening pain.
4. Vascular injuries require close attention.
  1. A preoperative pink, pulseless hand that fails to regain pulses should be monitored for at least 24 hours postoperatively.
  2. A white pulseless hand that fails to revascularize after closed reduction should be opened (with the appropriate vascular staff available).
5. Pin infection.
6. Malunion.
Lateral condyle fractures
1. Nonunion.
2. Avascular necrosis.
3. Stiffness (most common complication).
4. Malunion.
5. Lateral overgrowth.