Fractures In Pediatric Patients Research Articles

Complications of tibial eminence and diaphyseal fractures in children: prevention and treatment.

Fractures of the tibial eminence and of the diaphyseal tibia are common pediatric orthopaedic injuries. Although most tibial fractures can be treated nonsurgically, those that require surgical intervention may encounter specific complications. Surgical treatment of fractures of the tibial eminence may be complicated by failed fixation, knee joint stiffness, and arthrofibrosis of the knee, a complication rarely seen in children but occurring most frequently after tibial eminence injuries. Complications of healing after tibial fractures in pediatric patients are uncommon, although some tibial shaft fractures exhibit delayed union or nonunion, infection, and soft-tissue complications.

Diagnostic Accuracy of Ultrasonography for Hand Bony Fractures in Paediatric Patients: Neri E, Barbi E, Rabach I, et al. Arch Dis Child 2014;0:1–4.

Diagnostic Accuracy of Ultrasonography for Hand Bony Fractures in Paediatric Patients: Neri E, Barbi E, Rabach I, et al. Arch Dis Child 2014;0:1–4.

Twenty-Year Experience with Rigid Intramedullary Nailing of Femoral Shaft Fractures in Skeletally Immature Patients.

Debate exists over the safety of rigid intramedullary nailing of femoral shaft fractures in skeletally immature patients. The goal of this study was to describe functional outcomes and complication rates of rigid intramedullary nailing in pediatric patients. A retrospective review was performed of femoral shaft fractures in skeletally immature patients treated with trochanteric rigid intramedullary nailing from 1987 to 2009. Radiographs made at initial injury, immediately postoperatively, and at the latest follow-up were reviewed. Patients were administered the Nonarthritic Hip Score and a survey. The study population of 241 patients with 246 fractures was primarily male (75%) with a mean age of 12.9 years (range, eight to seventeen years). The majority of fractures were closed (92%) and associated injuries were common (45%). The mean operative time was 119 minutes, and the mean estimated blood loss was 202 mL. The mean clinical follow-up time was 16.2 months (range, three to seventy-nine months), and there were ninety-three patients with a minimum two-year clinical and radiographic follow-up. An increase of articulotrochanteric distance of >5 mm was noted in 15.1% (fourteen of ninety-three patients) at a minimum two-year follow-up; however, clinically relevant growth disturbance was only observed in two patients (2.2%) with the development of asymptomatic coxa valga. There was no femoral head osteonecrosis. Among the 246 fractures, twenty-four complications (9.8%) occurred. At the time of the latest follow-up, 1.7% (four of 241 patients) reported pain. The average Nonarthritic Hip Score was 92.4 points (range, 51 to 100 points), and 100% of patients reported satisfaction with their treatment. Rigid intramedullary nailing is an effective technique for treatment of femoral shaft fractures in pediatric patients with an acceptable rate of complications. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

U-shaped Sacral Fracture With Iliac Crest Apophyseal Avulsion in a Young Child

U-shaped sacral fractures or Jumper's fractures are rare injuries in adults and are even rarer in the pediatric population. These fractures share a common pathoanatomy where the pelvis as a unit together with the bilateral alar parts and the lower part of the sacrum, loses its skeletal and soft tissue connections to the remaining axial skeleton and hence the term spinopelvic dissociation. This report describes an unusual pattern of spinopelvic dissociation in a young child where the transverse process of the fifth lumbar vertebra was avulsed on one side (spinal side avulsion), whereas on the other side, complete iliac crest apophyseal avulsion took place (pelvic sided avulsion). To our knowledge, this combination of injuries was not reported before. The available literature describing pediatric U-shaped sacral fractures were also reviewed to help explain the pathoanatomic basis of this association. An 8-year-old boy sustained a U-shaped sacral fracture with avulsion of the left iliac crest apophysis. A search in the English literature was performed for all reports of U-shaped sacral fractures in pediatric patients (≤ 18 y of age), as well as the relevant literature, which describes the pathoanatomy, possible radiologic findings, and current classification systems and treatment options. Fixation using a 7.3 mm percutaneous iliosacral screw was performed. At the latest follow-up, the child had no pain, was fully bearing weight on lower extremities, and was neurologically intact. The literature review yielded 6 other pediatric patients with U-shaped sacral fractures in 4 articles. In young children with immature pelvis, the iliac apophysis may be avulsed instead of the transverse process of the fifth lumbar vertebra by forces transmitted through the iliolumbar ligament. The apophysis will therefore keep its attachment to the abdominal and trunk muscles, whereas the bony iliac wing and the pelvis would be dissociated from the axial skeleton. Otherwise, the pathoanatomy of these injuries is the same as described in adults. Level IV.

Diagnostic accuracy of ultrasonography for hand bony fractures in paediatric patients

ObjectiveHand fractures are common in childhood, and radiography is the standard diagnostic procedure. US has been used to evaluate bone injuries, mainly in adults for long-bone trauma; there are only...

FRATURA DE CÔNDILO MANDIBULAR: TRATAMENTO CIRÚRGICO OU CONSERVADOR?

O tipo do trauma, a gravidade da lesão e a etiologia das fraturas faciais variam de acordo com a população estudada. Porém, com o aumento das leis rigorosas de trânsito, houve uma diminuição das fraturas faciais decorrentes de acidentes automobilísticos; apesar disto, o mesmo ainda aparece como a principal causa e o sexo masculino com a maior prevalência das fraturas faciais. Dessas fraturas, as de côndilo mandibular correspondem de 25 a 35% das fraturas mandibulares diagnosticadas através das radiografias de projeção de Towne, panorâmica e tomografia computadorizada. As mesmas possuem como principais fatores etiológicos trauma por agressão direta, acidentes automobilísticos, queda de bicicleta, queda da própria altura e lesão por arma de fogo. Apesar de menos frequentes as fraturas de côndilo em pacientes pediátricos são um grande desafio à equipe multidisciplinar que o atende após o trauma. Os exames em pacientes pediátricos pós-trauma devem ser bastante rigorosos, pela dificuldade de obter detalhes sobre a história do trauma devido à idade e articulação dos fatos pelos pacientes atingidos. A etiologia das fraturas de côndilo em pacientes pediátricos varia de acordo com a fase de vida da criança (do 0 ao 6º ano de vida e a partir do 6º ano de vida). O tratamento dessas fraturas, principalmente em pediátricos, quando mal conduzidos podem causar sequelas. A escolha do tratamento, entre o cirúrgico ou o conservador, deve ser feita após a análise da idade e gênero do paciente, etiologia e condições clínicas da fratura, tempo decorrido do trauma, oclusão e condição dentária. Em pacientes pediátricos, na maioria dos casos, o tratamento de primeira escolha é o conservador devido a capacidade de remodelação óssea e crescimento ósseo mandibular que ocorre principalmente em nível do côndilo. Porém, na literatura não existe uma consenso sobre este tipo de tratamento ou a aplicação de terapêuticas mais agressivas. Intenciona-se discutir a literatira mais atual e pertinente sobre as fraturas de côndilo mandibular em pacientes pediátricos.

FRATURA DE CÔNDILO MANDIBULAR: TRATAMENTO CIRÚRGICO OU CONSERVADOR?

The type and severity of trauma injury; and the etiology of facial fractures is different according to the population studied. With the more stringent traffic laws, there was a reduction of facial fractures caused by automobiles accidents, but it still appears as the main cause and the prevalence of male and facial fractures. These fractures of the mandible condyle correspond 25-35% of mandible fractures diagnosed through radiographs projection Towne, panoramic and computed tomography. The same feature as the main etiological factors trauma by direct assault, car accidents, bicycle fall, fall from height and injury by firearms. Diagnosis of condylar fractures in pediatric patients should be very strict by the difficulty of obtaining information about the history of trauma, especially due to age of the patients affected. The etiology of condylar fractures in pediatric patients varies according to the stage of the child’s life (the 0-6 year of life and from the 6th year of life). The treatment of these fractures, especially in pediatric, when mishandled can cause permanent deformity. The treatment can be surgical or conservative, and should be made after the analysis of the age and gender of the patient, etiology and clinical conditions of fracture, time from the trauma, and dental occlusion. In pediatric patients, in most cases, the of first choice treatment is the conservative approach, because the ability of bone growth and bone remodeling that occurs.

SOMI brace immobilization as a treatment option for inveterate hangman’s fracture in pediatric patients

Abstract Traumatic spondylolisthesis of C2 occurs when the mechanical event at the base of the trauma is a compression force on the vertex. Management of this is well defined in literature, and both surgical and conservative treatments have been proposed in adults. In contrast, the principles of treatment are somewhat more uncertain and less well defined in children. One of the most frequently suggested treatments is the early reduction of the fracture, with immobilization in halo. Other types of cervical orthoses are not recommended. This article reports on a rare case of an inveterate hangman’s fracture in a 12-year-old girl that is healing completely through immobilization in a SOMI brace that was applied 4 months after the trauma. In our experience, hangman’s fracture is poorly defined with regard to the treatment of pediatric patients, and there are currently no established guidelines. If dynamic X-ray scans show complete reduction of the fracture, conservative treatment is an efficient, effective, and noninvasive solution, even in case of inveterate fractures. Halo vest and SOMI brace are good solutions. SOMI brace is an available option because it is less traumatic for the patient.

Tratamiento conservador de fracturas mandibulares en pacientes pediátricos

Los traumas faciales en pacientes pediátricos presentan especiales consideraciones en lo que respecta a su prevalencia, diagnóstico y tratamiento, las cuales difieren de las encontradas en los adultos. La prevalencia de fracturas faciales en niños es baja, variando de 13 a 15%, lo cual puede deberse tanto a factores anatómicos como ambientales, siendo las causas principales los accidentes de tránsito, caídas de propia altura y los accidentes deportivos. La elección de la alternativa de tratamiento dependerá de las características intrínsecas de la fractura, la edad del paciente y de la etapa de dentición que éste presente. Esta heterogeneidad, unida a la baja incidencia de fracturas faciales en niños y la limitada experiencia de muchos clínicos y cirujanos en el manejo de traumas significativos en pacientes pediátricos puede justificar la falta de consenso en el tratamiento. En general, a menor edad del paciente, se tiende a un manejo conservador de la fractura. Fracturas con mínimo desplazamiento pueden ser tratadas de manera conservadora, mediante fijación maxilomandibular, observación e indicación de dieta blanda y reposo o mediante medicación analgésica cuando fuera necesario. Fracturas que presenten de moderado a severo desplazamiento pueden necesitar de reducción abierta con fijación interna rígida.

Pelvis fractures in children

Injuries of the pelvis causing fractures in paediatric patients are rare injuries due to the elasticity of the bones and joints and account for 1-2% of all fractures in children. Injuries involving the tri-radiate cartilage are difficult to diagnose and have sequelae of growth arrest which are difficult to treat. Bony avulsion fractures are common in young children while acetabular and pubic or sacroiliac diastases are more common in adolescents. These injuries need radiographs and CT scanning for accurate characterization. Most injuries can be treated conservatively; however treatment needs to be individualized depending on the personality of the injury.

Unfolding the hidden facts of paediatric maxillofacial trauma.

Hard tissue injuries are uncommon in the paediatric patient; the paediatric population sustains 1 to 14.7% of all facial fractures. The management of the paediatric patient with maxillofacial injury should take into consideration, the differences in anatomy and physiology between children and adults, the presence of concomitant injury, the particular stage in growth and development and the specific injuries and anatomic sites that the injuries affect. Minimally displaced fractures in paediatric patients can be managed conservatively, while displaced fractures may require open approaches and rigid fixation. Hence, the present article presents an overview of the available published literature on maxillofacial trauma in paediatric patient.

Treatment and Management Outcomes of Tibial Eminence Fractures in Pediatric Patients

Background: Tibial eminence fractures are rare but occur more frequently in children and adolescents. There are a variety of methods to surgically treat these fractures, but surgeons disagree about the optimal method of reduction and fixation. Hypotheses: Regarding clinical results and complications after treatment in children and adolescent patients with tibial eminence fractures, the authors hypothesize that (1) there is no difference between reduction and fixation with screws versus sutures, (2) there is no difference in arthroscopic versus open reduction and fixation, and (3) outcomes are better in patients with minimally displaced (types I and II) versus completely displaced (types III and IV) fractures. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature was performed studying the treatment of tibial eminence fractures in children and adolescents to determine clinical results, functional outcomes, and complications. A meta-analytic technique on observational studies was used to compare outcomes when sufficient data were available. Results: The review identified 26 articles with extractable clinical results and data on complications: 1 level 3 article and 25 level 4 articles. Ten of 580 tibial eminence fractures identified in the literature had nonunion, with 60% of nonunions occurring in type III fractures treated by nonoperative modalities. Appreciable healing was noted for both open and arthroscopic fixation techniques as well as patients treated by screw or suture fixation. Laxity (P < .001) and loss of range of motion (P = .009) occurred significantly less after the treatment of minimally displaced fractures (types I and II). Conclusion: The level of evidence supporting various treatments of tibial eminence fractures in children and adolescents is low. There is insufficient evidence to conclude the superiority of open versus arthroscopic fixation or screw versus suture fixation techniques. Nonoperative treatment of completely displaced tibial eminence fractures results in higher rates of nonunion. Type III and IV fractures heal with greater laxity and greater loss of range of motion after treatment. Higher level studies are necessary to determine the optimal method of fixation for tibial eminence fractures.

Pathological fractures in paediatric patients with inflammatory bowel disease

Paediatric inflammatory bowel disease (IBD), especially Crohn's disease (CD), is commonly associated with poor skeletal health, related to the direct effects of chronic inflammation, prolonged use of glucocorticoid (GC), poor nutrition, delayed puberty and low muscle mass. Low bone mineral density is commonly reported, although the prevalence of long bone fractures may not be increased in these patients. Emerging evidence however suggests that there may be an increased risk of vertebral fractures (VFs) in this group. VFs presenting at diagnosis of paediatric CD, prior to any GC exposure, have been reported, highlighting the deleterious effect of inflammation on skeletal health. This paper reviews the published literature on pathophysiology of skeletal morbidity and fractures in paediatric IBD, illustrated with a new case report of multiple VFs in a prepubertal girl with CD, soon after diagnosis, who received minimal amounts of oral GC. Optimising control of disease, addressing vitamin D deficiency, encouraging physical activity and ensuring normal growth and pubertal progression are paramount to management of bone health in these patients. Despite the lack of evidence, there may be a place for bisphosphonate treatment, especially in the presence of symptomatic pathological fractures, but this requires close monitoring by clinicians with expertise in paediatric bone health. Chronic inflammation mediated by pro-inflammatory cytokines may have adverse effects on skeletal health in paediatric patients with IBD. The risk of vertebral fractures may be increased, even without exposure to glucocorticoid. Clinical monitoring of these patients requires careful attention to the various factors that impact on bone health.

Comparison of Nonsurgical Treatment Options in Pediatric Condylar Fractures

A prospective study was done to compare rigid intermaxillary fixation and guiding elastic for treatment of condylar fractures in pediatric patients. Sixty-one children younger than 12 years with condylar fractures were studied in 2 groups. Group 1 consisted of 31 patients who were treated with arch bar and intermaxillary fixation for 7 to 12 days, and group 2 consisted of 30 patients who were treated with arch bar and elastics without rigid intermaxillary fixation. Patients had minimal function during treatment time, which lasted 7 to 12 days. Evaluation of deviation on opening between both groups (groups 1 and 2) with a χ test did not show any relationship between them. Incidence of temporomandibular dysfunction signs was 25.8% in group 1 patients and 23.3% in group 2 patients. Comparison of temporomandibular dysfunction signs in both treatment groups did not show a statistically significant relationship. Our study showed the same results using guiding elastics as using rigid intermaxillary fixation in pediatric condylar fractures. Guiding elastic is more tolerable, and children have function during treatment.

Comparison of temporal bone fractures in children and adults

Conclusion: Contrary to our expectation, that the clinical characteristics of temporal bone fracture would differ in children and adults, we found that the two groups were similar. Objectives: Most studies of temporal bone fractures have been performed in adults. To our knowledge, no study has investigated differences in temporal bone fractures in children and adults. We therefore investigated differences in temporal bone fractures in adults and children by examining the manifestations and clinical symptoms of temporal bone fractures in pediatric patients. Methods: The demographic and clinical characteristics were assessed in 32 children and 186 adults with temporal bone fractures. All patients underwent computed tomography of the temporal bone. Results: Causes of fracture, gender distribution, manifestations of temporal bone fracture, and clinical symptoms were similar in adults and children (p > 0.05 each). Petrous fracture, ear fullness, dizziness, and tinnitus were significantly more frequent in adults than in children (p < 0.05 each).

Circummandibular Wiring of Symphysis Fracture in a Five-Year-Old Child

The treatment of pediatric maxillofacial fractures is unique due to the psychological, physiological, developmental, and anatomical characteristics of children. Method. This case report describes the management of symphysis fracture of mandible in a 5-year-old boy. The fracture was treated by acrylic splint with circummandibular wiring. Results. The splint was removed after 3 weeks. The patient had no complaints, and radiograph revealed a healed fracture. Conclusion. The clinical outcome in the present case indicates the management of mandibular fractures in pediatric patients using acrylic splint with circummandibular wiring.

The Efficacy of Intra-Articular Injections for Pain Control Following the Closed Reduction and Percutaneous Pinning of Pediatric Supracondylar Humeral Fractures

The purpose of this single-blinded, randomized, controlled trial was to compare the analgesic efficacy of intra-articular injections of bupivacaine or ropivacaine with that of no injection for postoperative pain control after the operative treatment of supracondylar humeral fractures in a pediatric population. Subjects (n=124) were randomized to treatment with 0.25% bupivacaine (Group B) (n=42), 0.20% ropivacaine (Group R) (n=39), or no injection (Group C) (n=43). The opioid doses and the times of administration as well as child-reported pain severity (Faces Pain Scale-Revised) and parent-reported pain severity (Total Quality Pain Management survey) were recorded. The proportion of subjects who required morphine and/or fentanyl injections was significantly (p=0.004) lower in Group B (10%) as compared with Group R (36%) and Group C (44%). On the basis of the log-rank test, the opioid-free survival rates were significantly greater in Group B as compared to Groups C and R. Total opioid consumption (morphine equivalent mg/kg) in the first seventy-two hours postoperatively was significantly less in Group B as compared with Group C (mean difference, 0.225; [95% confidence interval (CI), 0.0152 to 0.435]; p=0.036). Parent-reported pain scores were also significantly lower in Group B as compared with both Group C (mean difference, 1.81 [95% CI, 0.38 to 3.25]; p=0.014) and Group R (mean difference, 1.66; 95% CI, 0.20 to 3.12; p=0.027). There were no significant differences across the three groups in terms of self-reported pain. Differences between Groups R and C were not significant for any of the outcome variables. The intra-articular injection of 0.25% bupivacaine significantly improves postoperative pain control following the closed reduction and percutaneous pinning of supracondylar humeral fractures in pediatric patients.

Comparison of complications and results of early versus delayed surgery for Gartland type III supracondylar humeral fractures in pediatric patients

To investigate the effect of timing of surgery on clinical results and perioperative complications in pediatric patients with Gartland III type supracondylar humeral fractures without neurovascular compromise. Eighty-six consecutive children treated surgically at our hospital from April 2005 to June 2007 for displaced supracondylar humeral fractures were reviewed. All these patients were treated by the same group of doctors. The children were divided into two groups: early if treated within 12 hours after injury and delayed if treated later than that. Perioperative complications and clinical results, especially for open surgery, were compared between the two groups. Forty pediatric patients underwent surgery in the early group and 46 in the delayed group. There were no significant differences between the two groups in perioperative complications such as pin tract infection, iatrogenic nerve injury, compartment syndrome and conversion to open surgery. For open surgery, both the clinical results and perioperative complications were not affected by delaying for more than 12 hours after injury. However, blood loss and operation time were greater in the early than in the delayed group, possibly due to relatively more edema. Delay in surgery, regardless of whether it is closed or open, for more than 12 hours after injury does not influence the perioperative complications and clinical results for displaced supracondylar humeral fractures in children. However early open reduction and pinning may increase intra-operative blood loss and take longer.

Severe pelvic fracture-related bleeding in pediatric patients: does it occur?

Pediatric pelvic fractures are rare and less likely to cause hemodynamic instability than similar injuries in adult patients. The associated injuries are common, and they have a major impact on mortality. The aim of the present study was to evaluate the risk of life-threatening hemorrhage associated with unstable pelvic fractures in children. We identified retrospectively all pediatric pelvic fractures (ring and acetabulum) treated at Helsinki University Central Hospital during a 10-year period (1998-2007). Stable A-type fractures (fractures not involving the pelvic ring) were excluded. All available pre- and in-hospital medical records were reviewed. The collected data consisted of patient characteristics, mechanisms of injury, vital signs, laboratory tests, care given, other injuries diagnosed, and the 30-day survival rate. There were 71 (40 males) pediatric patients (median age 14, range 1-16years) with unstable pelvic fractures; 66 pelvic ring and 5 acetabulum fractures. The most common mechanism of injury was traffic accident (69%). Four patients had life-threatening bleeding. All had fracture of a mature pelvic ring, but the source of massive bleeding was pelvic ring fracture in only two patients (2.8% of all patients). No acetabulum fracture-related major pelvic bleeding was observed. One patient (age 16years) required emergency surgery and angioembolization for pelvic bleeding. No life-threatening pelvic bleeding was seen among patients with immature bony pelvis. Pelvic ring fractures were surgically treated in 25 patients. Two patients died from head injuries (overall mortality 2.8%), but there were no bleeding-related deaths. We conclude that life-threatening bleeding from pelvic or acetabular fractures in pediatric patients is rare (2.8%), and does not contribute to the overall mortality.

Bedside Ultrasound in the Diagnosis of Skull Fractures in the Pediatric Emergency Department

Bedside ultrasound has become a diagnostic tool that is commonly used in the emergency department. In trained hands, it can be used to diagnose multiple pathologies. In this case series, we describe the utility of ultrasound in diagnosing skull fractures in pediatric patients with scalp hematomas.