Common Pediatric Fractures Research Articles

Titanium elastic nailing for paediatric femoral shaft fractures: a prospective descriptive study

<p class="abstract"><strong>Background:</strong> Femoral shaft fracture is the most common major paediatric orthopaedic fractures. For generations traction and casting was the standard treatment for all femoral shaft fractures in children. Over the past two decades the advantages of fixation and rapid mobilisation have been increasingly recognised. Aim: To assess the functional and clinical outcome after closed reduction and internal fixation with titanium elastic nail in diaphyseal femoral fractures between 5 to 16 years.</p><p class="abstract"><strong>Methods:</strong> The study was conducted in the Department of Orthopaedic Surgery, Regional Institute of Medical Sciences (RIMS), Imphal, Manipur, from September 2013 to April 2015. Thirty children (20 boys and 10 girls) in the age group of 5 to 16 years with recent femoral diaphyseal fractures were stabilised by titanium elastic nails [TENS]. Results were evaluated according to Flynn’s scoring criteria.<strong></strong></p><p class="abstract"><strong>Results:</strong> After 25 months of follow up all thirty patients were available for evaluation. Radiological union were achieved in a mean time of 11.5 weeks. Mean duration of hospital stay was 15.23 days. According to Flynn’s criteria of TENS outcome score results were excellent in 66.7% patients, Satisfactory in 30% patients, Poor in 3.3% patient. All patients had early return to school. Per operative technical problems included failure of closed reduction in 2 cases.</p><p><strong>Conclusions:</strong> Titanium elastic nailing is an effective treatment in diaphyseal fractures of femur in properly selected patients. </p>

Return to Play After Common Pediatric Fractures: Is There Consensus?

Return to Play After Common Pediatric Fractures: Is There Consensus?

An Update on Common Orthopedic Injuries and Fractures in Children: Is Cast Immobilization Always Necessary?

Children frequently visit emergency departments for injuries and fractures related to sports and recreational activities; however, the routine care of these acute minor injuries is shifting to the domain of urgent care centers. Physicians on the front lines may not have access to real-time orthopedic consultation and therefore need to be versed in the diagnosis and treatment of common pediatric fracture patterns recognizing potentially operative fractures as well as injuries that may not even require follow-up care. Unlike adults, the pediatric bone remodels quickly, and many fractures heal well without surgical intervention or even cast immobilization. Unnecessary immobilization of injuries can be detrimental to healing, and unnecessary orthopedic follow-up can be costly and straining on our health care system. This article reviews common upper and lower extremity injuries in children highlighting some of the fractures where neither cast immobilization nor urgent/emergent orthopedic consultation is always necessary.

When is it ok to use a splint versus cast and what remodeling can one expect for common pediatric forearm fractures.

The purpose of this review is to provide an overview of common pediatric forearm fractures, clarify the descriptions used to identify and thereby appropriately treat them with a splint or cast, and explain osseous remodeling that is unique to the skeletally immature. Recent literature addresses the gap in standard treatment protocols. There is variability in the management of pediatric forearm fractures because of the multiple subspecialty physicians that care for children's fractures and a lack of well established guidelines. The following review will expound upon the assortment of pediatric forearm fractures, address suitable treatment options, and illustrate the expected restoration of bony deformity in an effort to update practitioners of the most recent advances in research and clinical practice of this common orthopedic injury.

Epidemiology of Pediatric Fractures Presenting to Emergency Departments in the United States.

Fractures in children are an important public health issue and a frequent cause of emergency room visits. The purpose of this descriptive epidemiological study was to identify the most frequent pediatric fractures per 1000 population at risk in the United States using the 2010 National Electronic Injury Surveillance System (NEISS) database and 2010 US Census information. The NEISS database was queried for all fractures in 2010 in children between the ages of 0 and 19 years. The NEISS national estimates were compared with the 2010 US Census data to extrapolate national occurrence rates. The annual occurrence of fractures increased from ages 0 to 14, peaking in the 10 to 14 age range (15.23 per 1000 children). The annual occurrence rate for the entire pediatric population (0 to 19 y) was 9.47 per 1000 children. Fractures of the lower arm (forearm) were the most common among the entire study population, accounting for 17.8% of all fractures, whereas finger and wrist fractures were the second and third most common, respectively. Finger and hand fractures were most common for age groups 10 to 14 and 15 to 19 years, respectively. The overall risk of a fracture occurring throughout childhood and adolescence was 180 per 1000 children, or just under 1 in every 5 children. Pediatric fractures represent a significant proportion of pediatric emergency department visits in the United States. Children between 10 and 14 years of age have the highest risk of having fractures. Overall, forearm fractures were the most common pediatric fractures. Most pediatric fractures can be treated on outpatient basis, with only 1 of 18 fractures requiring hospitalization or observation. Level III-Retrospective comparative study.

Assessment of the Outcome of Anterior versus Posterior Approach in the Management of Displaced Pediatric Supracondylar Humerus Fracture

Background: Supracondylar fractures of the humerus are among the most common type of pediatric fractures. The outcome of severely displaced supracondylar fracture of the humerus in children subjected to wide controversies in term of safety, functional and cosmetic outcome. Closed reduction and percutaneous pinning is now considered as the gold standard rule, but open reduction still applicable in certain cases where intraoperative imaging is not available, in comminuted lateral column fractures and uneducable fractures. Aim of the Study: To compare the outcome (functional and cosmetic) of anterior (Henry) approach with the posterior (Campbell) approach used in two groups of patients’ sustained displaced supracondylar fractures. Patients and Methods: This prospective study was performed on 48 pediatric patients who were been admitted to the Emergency Hospital in Sulaimani province sustained displaced supracondylar humeral fractures and treated during the period from the first of October 2009 to the thirty-one of January 2011. The study included 28 boys, 20 girls; their mean age was 7.5 years; their ages range 2 - 13 years. We used the modified Gartland classification to assess the fractures displacement and only Gartland type II B and III were included and managed operatively by open reduction and internal fixation with 2 crossed K-wires. Follow up continued for 6 months and the results finally assessed using Flynn’s criteria. Results: According to the criteria of Flynn et al., 20 patients (83.3%) treated by the anterior approach had excellent functional results while 4 patients (16.7%) had good functional results. While those treated by the posterior approach, 16 patients (66.6%) had excellent functional results, 6 patients (25%) had good results and 2 (8.3%) patients had fair outcome. Cosmetic results were excellent in 22 patients in the anterior approach group and 20 patients in the posterior approach group. Conclusion: Posterior Campbell approach is simpler than anterior Henry approach, but it creates additional soft tissue damage that can affect the circulatory status and hence possible osteonecrosis of the trochlea and a higher percentage of limitation in joint mobility. While the anterior approach is technically more demanding, but it gives better functional results.

Neurological and Vascular Complications Associated with Supracondylar Humeral Fractures in Children.

Supracondylar humeral fractures are one of the most common pediatric elbow fractures, accounting for 55% to 80% of such fractures1. The majority of these fractures occur as the result of a fall onto an outstretched upper extremity2,3. Extension-type fractures account for 98% of supracondylar fractures after a fall onto an outstretched hand with the elbow hyperextended, resulting in posterior displacement of the fracture4. Flexion-type injuries occur approximately 2% of the time after a fall onto a flexed elbow, resulting in anterolateral displacement of the fracture4. The intimacy of the neurological and vascular structures to the distal aspect of the humerus put them at substantial risk in the setting of a supracondylar humeral fracture. The frequency of neurological deficit after supracondylar humeral fractures …

Paediatrician office follow-up of common minor fractures.

Evidence suggests that minor paediatric fractures can be followed by primary care paediatricians (PCPs). To determine PCP opinions, knowledge and perceived barriers to managing minor paediatric fractures in the office. An online survey was sent between June and September 2013 to all paediatricians who subscribed to the American Academy of Pediatrics PROS-Net Listerv and to those who were registered with the Scott's Canadian Medical Directory as paediatricians who treated children in a primary care capacity. The primary outcome was the proportion of PCPs who agreed with PCP follow-up of minor paediatric fractures. Secondary outcomes included PCP's perceived barriers to office follow-up. A total of 1752 surveys were sent; 1235 were eligible and 459 (37.2%) responded to the survey. Overall, 296 (69.5% [95% CI 65.2% to 74.0%]) PCPs agreed that minor paediatric fractures could be followed in a PCP office. The most frequently reported barriers were lack of materials to replace immobilization (58.1%), PCP knowledge deficits (44.8%) and a perceived parental preference for an orthopedic surgeon (38.6%). Finally, 58.8% of respondents believed that further education was necessary if PCPs assumed responsibility for follow-up of midshaft clavicle fractures, while 66.5% and 77.1% (P<0.0001) believed this was necessary for distal radius buckle and fibular fractures, respectively. More than two-thirds of responding PCPs in Canada and the United States agreed that minor common paediatric fractures can be followed-up by paediatricians. However, PCPs reported some barriers to this management strategy, including a desire for more education on this topic.

English

INTRODUCTION: The supracondylar fracture of the distal humerus is the most common pediatric fracture in the elbow. The purpose of this study was to compare the infection rate of lateral entry pin fixation with that of medial and lateral entry pin fixation for the operative treatment of completely displaced extension supracondylar fractures of the humerus in children. MATERIAL & METHODS: Only the 81 patients who were able to follow up to final examination were included in the assessment. The patients were allocated randomly into two groups according to the pin configuration used. Group 1 comprised 40 patients, 30 male and 10 female, with a mean age of 7.5 years (range, 1.5–14 years). After closed reduction, fixation was achieved with K-wires placed from the lateral condyle. Group 2 comprised 41 patients, 28 males and 13 females, with a mean age of 7.8 years (range, 2–13 years). After closed reduction, two cross-wires passed—one from medial and one from lateral. RESULTS & CONCLUSION: On statistical evaluation, no significant difference was seen between the two groups With use of the specific techniques employed in this study, both lateral entry pin fixation and medial and lateral entry pin fixation are effective in the treatment of completely displaced (type-III) extension supracondylar fractures of the humerus in children however percentage wise lateral entry group was associated with pin tract infection more as compared to lateral and medial entry group may be because of small sample size so further studies needed with large sample size.

Physeal arrest of the distal radius.

Fractures of the distal radius are among the most common pediatric fractures. Although most of these fractures heal without complication, some result in partial or complete physeal arrest. The risk of physeal arrest can be reduced by avoiding known risk factors during fracture management, including multiple attempts at fracture reduction. Athletes may place substantial compressive and shear forces across the distal radial physes, making them prone to growth arrest. Timely recognition of physeal arrest can allow for more predictable procedures to be performed, such as distal ulnar epiphysiodesis. In cases of partial arrest, physeal bar excision with interposition grafting can be performed. Once ulnar abutment is present, more invasive procedures may be required, including ulnar shortening osteotomy or radial lengthening.

Pediatrics Tibial Open Fractures Treatment Used by External Fixator Versus Flexible Intramedullary Nails

BackgroundTibial fractures are the third most common pediatric long-bone fracture after forearm and femoral fractures. Approximately 50% of pediatric tibial fractures occur in the distal third of the tibia. This is followed by midshaft tibial fractures (39%), and least commonly, the proximal third of the tibia is involved. Tibial fractures in the skeletally immature patient can usually be treated without surgery but tibial fractures resulting from high energy traumas are of special importance considering type of the selected treatment method affecting the children future. Manipulation and casting are regarded as definite treatments for children tibial fractures. They are used following compartment syndrome in poly-trauma, neurovascular damages, open fractures, and fasciotomy cases.ObjectivesIn children, most open fractures occur due to high energy traumas and inappropriate treatment of the fractures may result in several complications. Flexible intramedullary nailing is one of the popular options as an effective method of treating long-bone fractures in children. The external fixator is used in cases with severe injuries and open fractures. The present study aims at comparing results of these two treatment methods in the open pediatric tibial fractures.Materials and MethodsIn this descriptive analytical study, 32 patients with open tibial fractures were treated with either fixator (n = 18) or TEN nails (n=14) during 2006-2011. Some patients were treated with a combination method of TEN and pin. The results were evaluated considering infection, union, mal-union, and re-fracture and the patients were followed up for two years.ResultsMean time required for fracture union was 12.5 (11-14) and 11.8 (10-12) weeks for the external fixator and TEN groups, respectively. There was no statistical difference in time of union between the two methods. The main complications in external fixation were infection around the pin 4 (22.2%), leg-length discrepancy 2 (11.1%) and re-fracture 4 (22.2%). In the TEN group, 2 cases (14.2%) of painful bursitis were observed at the entry point of TEN and the pin was removed earlier. There was not any report of mal-union requiring correction in the groups. No complication was seen in 6 patients treated with a combined method of pin and flexible intramedullary nails.ConclusionsAlthough external fixation in open pediatric fractures and severe injuries is recommended, intramedullary nailing is also an effective method with low complications. Combining pins and flexible intramedullary nails is effective in developing more stability and is not associated with more complications.

Ultrasound Evaluation of Ulnar Nerve Anatomy in the Pediatric Population

Ulnar nerve instability has been reported in up to 17% of children. Accurate assessment is important to achieve because of potential nerve complications that can arise from treatment of common pediatric fractures, including supracondylar humerus fractures. The objective of our study was to evaluate our ability to use ultrasonography to determine the extent of ulnar nerve dislocation in the normal pediatric population and to determine if there is a relationship between ulnar nerve instability and ligamentous laxity. We conducted a prospective ultrasound evaluation of 51 children, examining the excursion of the ulnar nerve through full range of motion. On the basis of its movement during flexion, the ulnar nerve was categorized as stable, subluxating, or dislocating. In addition, we assessed all subjects for ligamentous laxity using the Wynne-Davies signs of joint laxity. The subjects were then divided into groups based on age or ligamentous laxity, and statistical analysis was performed. Most of the elbows evaluated had stable ulnar nerves (64/102, 62.7%), 27.5% (28/102) had subluxating nerves, and 9.8% (10/102) had dislocating nerves. Patients aged between 6 and 10 showed the highest rate of dislocating or subluxating nerves, with 50%, and also the highest average laxity score, 2.0. When grouped according to ligamentous laxity, patients who had multiple signs of ligamentous laxity had statistically higher numbers of subluxating and dislocating nerves (91.6%, 11/12) than those with lower laxity scores (25.6%, 10/39). There are a substantial number of subluxating or dislocating ulnar nerves in children, and the incidence is often bilateral. Patients with ligamentous laxity are more likely to possess unstable ulnar nerves. Ultrasound evaluation and assessment of ligamentous laxity are additional tools that can be used to assess elbow anatomy and identify children at risk for iatrogenic nerve injury. Level III, diagnostic study.

Pediatric Clavicular Fractures: Assessment of Fracture Patterns and Predictors of Complicated Outcome

BackgroundClavicular fractures are the most common pediatric long-bone fracture, and although the vast majority heal with supportive treatment, complications do occur and can lead to pain and disability. Although many studies have characterized adult complication rates and risk factors, to our knowledge no comparable studies to date have looked at clavicular fractures in the pediatric population. Study ObjectivesThe study aim was to identify the radiological and clinical variables that increase the complication rate of clavicular fractures. Identification of these variables would help emergency physicians identify patients who require more thorough follow-up or surgical intervention. MethodsWe analyzed radiographs of 537 clavicular fractures on initial presentation to the Pediatric Emergency Department at the Children's Hospital at London Health Sciences Center over a 4-year period, collecting data on variables such as displacement, angulation, and comminution, as well as demographic data such as age and gender. We then determined the outcome of each fracture by reviewing each patient’s chart, and through a logistic regression analysis, determined the variables associated with complications. ResultsOf all the fractures treated supportively (i.e., non-operatively), only 2.5% resulted in a complication. Our analysis determined that patient age was an independent predictor of complications, with each year past zero conferring an 18.1% increase in risk of complication. Furthermore, completely displaced fractures were shown to increase the odds of complication by a factor of 3.2. ConclusionThese findings help the emergency physician identify a group of high-risk pediatric patients with clavicular fractures for which more thorough follow-up should be considered.

Restoration of longitudinal growth by bioengineered cartilage pellet in physeal injury is not affected by low intensity pulsed ultrasound

Physeal fracture is a common pediatric fracture that would result in premature physeal closure in long bones, and there is currently no gold standard for its management. In this study, we investigated the application of a Bioengineered Cartilage Pellet (BCP) in repairing a rabbit physeal fracture model, and the possible effects of Low Intensity Pulsed Ultrasound (LIPUS) treatment. Rabbits with physeal fracture created were assigned to the NC group (no BCP, no LIPUS), GC group (BCP, no LIPUS), and GT group (BCP and LIPUS). Femoral lengths and cartilage area were assessed at 4, 8, and 16 weeks post-defect. After transplantation, the BCP showed continuous growth in the host and demonstrated resemblance to a natural growth plate. The GC group showed 34.1, 32.1, and 41.1% advantage in lengthening over the NC group and the GT group showed 51.1, 41.6, and 26.9% improved lengthening than the NC group, at 4 (p = 0.203), 8 (p = 0.543) and 16 weeks (p = 0.049), respectively. Cartilage area was shown to be significantly higher in GC and GT group compared to NC group (p < 0.05). No significant difference was found between GC and GT group. Femoral longitudinal growth was shown to be improved by the BCP, however no additional enhancement effect was shown to be provided by LIPUS.

Common Pediatric Elbow Fractures

Fractures of the elbow are a very common injury in children. The most common mechanism of injury is a fall on an outstretched upper extremity during play. Ranging in complexity from low-energy nondisplaced occult fractures to high-energy fractures with associated severe soft-tissue and neurovascular injuries, elbow fractures are a challenging problem for all pediatric healthcare providers. Because of the wide spectrum of fracture severity and associated bony and ligamentous injury, a very diverse spectrum of treatment modalities is necessary for optimal results. Management is based on fracture pattern, patient age and bone quality, extent of soft tissue damage, functional needs of the patient, and the presence of associated injuries. This article will give a brief overview of 4 common pediatric fractures, current treatment algorithms, and frequent complications associated with these injuries.

Percutaneous Pinning of Supracondylar Fractures: A Simple Modification in Technique to Minimize Growth Plate Damage

Supracondylar fracture of humerus is one of the common pediatric fractures encountered by an orthopedic surgeon. Closed reduction and percutaneous pinning is one of the recommended treatments for displaced-supracondylar fracture of humerus. The growth plate of distal humerus in the pediatric age group is a relatively small area and drilling Kirschner (K)-wires across the physes will cause physical, thermal, and vascular damage to it. It is a very common scenario where a K-wire is drilled multiple times to achieve acceptable position and the damage to the growth plate gets added with every new attempt and is further compounded as the number of K-wires required to achieve stability increases. Thus, we may achieve a good reduction and a stable fixation but still cause irreversible damage to the growth plate and end up with resultant deformity. We suggest a simple modification in the pinning technique by using a bone marrow aspiration needle to act as a guide and sleeve. This technique helps in reducing the number of attempts required to achieve acceptable position of the pins thereby reducing above-mentioned iatrogenic damage to the physes. It not only prevents soft tissue injury by acting as a sleeve but also gives mechanical advantage during passage of thin diameter K-wire in small children. It can also be used to find the proximity of ulnar nerve by stimulating it, thereby reducing the chance to damage the nerve during medial pinning.

Common Pediatric Fractures Treated With Minimal Intervention

The unlikely event of long-term complications in some pediatric fractures, such as midclavicular fractures, has allowed for management of these injuries with interventions that support the injured extremity rather than immobilize it while healing occurs. However, there is currently a growing body of evidence that advocates for this approach for some of the most frequently encountered pediatric fractures also at very low risk of future problems but, in contrast, have conventionally been managed with orthopedic consultation and rigid casting for several weeks. Therefore, this article will review the evidence that recommends that management of some of the most common upper and lower pediatric extremity fractures be treated with minimal interventions, such as removable splints and follow-up with a primary care provider.

Common Pediatric Fractures Treated With Minimal Intervention

Pediatric Emergency Care: February 2010 - Volume 26 - Issue 2 - p 158-162 doi: 10.1097/01.pec.0000368299.77650.c5

ANKLE FRACTURES IN CHILDREN. A REVIEW

The biomechanical differences between mature and immature bones, as well as the differing forces applied to those bones, help explain the differences between adult and pediatric fractures. The potential complications associated with pediatric ankle fractures include those seen with adult fractures (such as posttraumatic arthritis, stiffness, and reflex sympathet-ic dystrophy) as well as those that result from physeal damage (including leg-length discrepancy, angular deformity). The goals of treatment are to achieve and maintain a satisfactory reduction and to avoid physeal arrest. A knowledge of common pediatric ankle fracture patterns and the pitfalls associated with their evaluation and treatment will aid in the effective management of these injuries.

A Systematic Review of Medial and Lateral Entry Pinning Versus Lateral Entry Pinning for Supracondylar Fractures of the Humerus

The supracondylar fracture of the distal humerus is the most common pediatric fracture in the elbow. This systematic review summarizes the existing data about the effect of medial and lateral (medial/lateral) entry pins versus only lateral entry pin fixation on the risk of iatrogenic nerve injury and deformity or loss of reduction. A literature search identified clinical trials and observational studies presenting the probability of nerve injury and/or deformity or loss of reduction associated with closed reduction and either medial/lateral entry or lateral entry pinning of supracondylar fractures in pediatric patients. Data from 2054 children were identified from 35 studies; 2 randomized trials, 6 cohort studies, and 25 case series. For operative fixation with medial/lateral entry pins, the probability of ulnar nerve injury is 5.04 times higher than with lateral entry pins. When all documented operative nerve injuries are included, the probability of iatrogenic nerve injury is 1.84 times higher with medial/lateral entry pins than with isolated lateral pins. Medial/lateral pin entry provides a more stable configuration, and the probability of deformity or loss of reduction is 0.58 times lower than with isolated lateral pin entry. When the prospective studies alone were analyzed, there were no significant difference in the probability of iatrogenic nerve injury or deformity and displacement, although the confidence intervals were wide. This systematic review indicates that medial/lateral entry pinning, of pediatric supracondylar fractures, remains the most stable configuration and that care needs to be taken regardless of technique to avoid iatrogenic nerve injury and loss of reduction.