Principles of Pediatric Fracture Care

Fig. 26.1

(a, b) This forearm fracture was treated by a locally made splint. (c) In a similar case, the fracture healed in excellent alignment; (d) however, the treatment was complicated by compartment syndrome and a Volkmann’s ischemic contracture. (e) Gangrene can complicate casting

The most common anesthetic technique for reduction is the hematoma block, performed using the barbotage technique . Approximately half the local anesthetic is injected into the fracture, and the hematoma is aspirated to restore the initial fluid volume within the syringe. This process is repeated several times to distribute the anesthetic. After the final aspiration, the volume of the hematoma should be unchanged. Ketamine is also useful when available.

A subset of fractures—displaced intra-articular, irreducible fractures and unstable fractures—require open surgical treatment and/or fixation to achieve the best results, recognizing that open approaches increase the risk of infection (Fig. 26.2). A prompt diagnosis and early referral are essential if the resources and expertise are unavailable locally. Fracture fixation can usually be done with Kirschner wires or Steinmann pins. Without an image intensifier, “blind pinning” may be considered in selected cases, after which alignment and pin placement are assessed with radiographs, although an open reduction is often more appropriate. Open reduction via small incisions can facilitate minimally invasive fixation techniques such as intramedullary nailing of diaphyseal fractures.

../images/270913_2_En_26_Chapter/270913_2_En_26_Fig2a_HTML.jpg — Fig. 26.2

(a) X-rays of a distal radius and ulna fracture with dislocation of proximal radius (Monteggia variant) was (b) initially treated by open reduction and nailing. The patient developed an infection which was (c) treated by irrigation and debridement followed by plating. This was complicated by extensive osteomyelitis, a difficult problem to solve

../images/270913_2_En_26_Chapter/270913_2_En_26_Fig2b_HTML.jpg — Fig. 26.2

(a) X-rays of a distal radius and ulna fracture with dislocation of proximal radius (Monteggia variant) was (b) initially treated by open reduction and nailing. The patient developed an infection which was (c) treated by irrigation and debridement followed by plating. This was complicated by extensive osteomyelitis, a difficult problem to solve

Fracture Healing and Remodeling

The inflammatory stage of fracture healing begins immediately after the injury and involves hematoma formation around the fracture ends. In the second or reparative phase, random bone is laid down by the endosteum (endochondral) and the periosteum (intramembranous). The last stage of healing involves remodeling, the extent of which is determined by (1) skeletal age, (2) the specific bone involved, (3) fracture location within the bone, (4) distance of the fracture from a joint, and (5) whether the angulation occurs in the plane of motion of the neighboring joint.

The remodeling potential is greater when more than 2 years of growth remain and is especially good in children less than 8–10 years of age and in metaphyseal fractures and when the angulation is in the plane of motion of the joint. Seventy-five percent of remodeling occurs from asymmetric physeal growth, while 25% is due to a combination of appositional bone growth on the concavity and resorption of bone on the convexity. General guidelines for acceptable alignment are illustrated in Table 26.1.

Table 26.1

General guidelines for acceptable alignment of fractures in children and adolescents

General guidelines for acceptable alignment of common children’s fractures
Lower extremity
Femoral shaft	Age (years)	Varus/valgus (°)	Anterior/post-angulation (°)	Shortening (mm)
	Birth–2	30	30	15
	2–5	15	20	20
	6–10	10	15	15
	>11	5	10	10
Tibia and fibular shaft			≤8 years	>8 years
	Valgus		≤5°	≤5°
	Varus		≤10°	≤5°
	Anterior angulation		≤10°	≤5°
	Posterior angulation		≤5°	0°
	Shortening		10 mm	5 mm
	Rotation		≤5°	≤5°