4/19/2019 Disclosures • Consultant – Depuy-Synthes Spine – Orthopediatrics Common Things Seen in the PEDIATRIC ORTHOPAEDIC TRAUMA • Editorial Boards Pediatric Orthopaedic Office – Journal of Pediatric Orthopaedics Joshua S. Murphy, MD – Spine Deformity Journal -Buckle/Torus Fracture Pediatric Orthopaedic & Spine Surgeon -Distal Radius Fractures – The Spine Journal 2019 Atlanta Trauma Symposium -Limping Child Westin Buckhead -Transitional Age Ankle Fractures • Committees April 18-20, 2019 – POSNA – Scoliosis Research Society Children’s Healthcare of Atlanta 1 2 3 1 4/19/2019 Buckle/Torus Fractures Buckle Fracture Management • 2-3 weeks of immobilization • Cast • Splint • Removable Brace • Accurate diagnosis important! – Greenstick – Non-displaced metaphyseal fracture Children’s Healthcare of Atlanta Children’s Healthcare of Atlanta Children’s Healthcare of Atlanta 4 5 6 2 4/19/2019 Distal Radius Fractures Treatment Distal Radius Fractures • Most common fracture <16 y/o – Location: Metaphyseal > physeal • General Rule of Thumb – ~5 degrees remodeling per year of growth remaining • Distal radius physis Distal Radius Fractures – ~75% growth of radius Age Angulation Malrotation Bayonet Apposition – Growth ~5.25mm per year <9 y/o 30 degrees 45 degrees <1 cm • Remodeling – Greater potential closer to the physis >9 y/o 20 degrees 30 degrees <1 cm – Greater potential in plane of motion • Flexion/Extension best • Rotational deformity least Children’s Healthcare of Atlanta Children’s Healthcare of Atlanta 7 8 9 3 4/19/2019 Treatment Distal Radius Fractures • Short Arm Cast JAAOS 2001;9:89-98. – Fracture Location • Metaphyseal or distal – Duration: 3-4 weeks Limping Child • Long Arm Cast – Fracture Location • Meta-diaphyseal or proximal – Duration: 4-6 weeks • LAC 2-3 weeks, • SAC x2-3 weeks Children’s Healthcare of Atlanta Children’s Healthcare of Atlanta 10 11 12 4 4/19/2019 Diagnostic Work-up Transitional Age Ankle Fractures • Definition: Fracture during adolescence prior to complete • Physical Exam closure of the distal tibia physis – Triplane: younger patient relative to Tillaux • Radiograph area of interest – Young child, consider bilateral LE • Distal tibia physis • Labs Fractures of Transitional Age – 35-40% overall tibia growth – CBC w/ Diff, ESR, CRP – 3-4 mm/year Tillaux Fracture • Advanced Imaging Triplane Fracture – Ultrasound – Hip & Shoulder • Closure – MRI – May require sedation in young patient – Central Anteromedial posteromedial lateral • Refer to Tertiary Care Hospital – Uncertain of etiology Children’s Healthcare of Atlanta Children’s Healthcare of Atlanta 13 14 15 5 4/19/2019 Tillaux Fracture Triplane Fracture Triplane Fracture • Anterior Inferior Tibiofibular • SH IV fracture in multiple planes Ligament • Older Age than Triplane • Younger age than Tillaux fracture • Treatment • 2, 3, or 4 part fracture – <2mm: Casting – >2mm: – Epiphysis: Often Tillaux fragment seen on AP • Percutaneous Screw – Physis: Axial displacement • ORIF – Metaphysis: Coronal plane seen on lateral • CT Scan – Consider for non-op treatment • Treatment – <2mm: Cast Children’s Healthcare of Atlanta – >2mm: ORIF Children’s Healthcare of Atlanta Children’s Healthcare of Atlanta 16 17 18 6 4/19/2019 ORIF – Direct Anterior Approach Conclusion • • Provisionally reduce physeal Fractures in the pediatric population are common fracture • Many can be treated non-operatively SUPRACONDYLAR HUMERUS FRACTURES • Reduce articular fracture • Important • Screw fixation of epiphysis – Accurate Diagnosis CASE PRESENTATIONS – Angular/Rotational Deformity • Screw fixation of metaphysis – Appreciation of Patient Age/Remodeling Potential • Refer to tertiary care hospital if needed Children’s Healthcare of Atlanta Children’s Healthcare of Atlanta 20 19 20 21 7 4/19/2019 SUPRACONDYLAR HUMERUS FRACTURE OUTLINE Background Gartland Classification • Supracondylar humerus fractures – 60-70% pediatric elbow fractures – • TYPE 2A VERSUS 2B 3% all pediatric fractures • • PINK, PULSELESS Most common pediatric elbow injury requiring reduction and fixation • COMPARTMENT SYNDROME • Neurologic Injury – 10-20% • Vascular Injury – 2-20% 4/19/2019 Mencio, Green’s Skeletal Trauma in Children, 2015 Children’s Healthcare of Atlanta Badkoobehi et al, 2015 Children’s Healthcare of Atlanta Children’s Healthcare of Atlanta 22 23 24 8 4/19/2019 Type 2A Type 2B Type 2A Type 2B TYPE 2 SUPRACONDYLAR HUMERUS FRACTURES TYPE 2A VERSUS 2B 4/19/2019 Children’s Healthcare of Atlanta 4/19/2019 Children’s Healthcare of Atlanta 25 26 27 9 4/19/2019 What’s the difference between 2A & 2B? • Non-op slight increase cubitus varus, mild increase elbow extension Type 2A Type 2B • Functional results excellent in 80% of patients • Posterior Hinge • Posterior Hinge • NO • WITH – Coronal – Coronal malalignment malalignment – Rotation PINK, PULSELESS EXTREMITY • Malrotation, coronal malalignment, significant extension may fail non-op tx – Rotation – Medial Comminution – Medial Comminution – Excessive posterior displacement – Excessive posterior displacement • Tx: CRPP • Tx: CR, Cast • Lateral capitellohumeral angle or shaft condylar angle <18 deg from uninjured side • Casting Acceptable 3 0 Children’s Healthcare of Atlanta 28 Ariyawatkul T, et al. 2016 Children’s Healthcare of Atlanta 29 28 29 30 10 4/19/2019 7 y/o female s/p fall from monkey bars Type 3 SC Humerus Fracture Pink, Pulseless SC Humerus Fracture • Pre-op Exam: • Plan: Urgent CRPP – Decreased sensation Median NN – 1/5 AIN motor – No palpable radial AA pulse, BCR – (+) swelling, ecchymosis antecubital fossa 4/19/2019 4/19/2019 Children’s Healthcare of Atlanta Children’s Healthcare of Atlanta Children’s Healthcare of Atlanta 31 32 33 11 4/19/2019 3 MONTHS POST-OP Vascular Injury Neurovascular Injury • Brachial Artery – Stretched/Kinked • Elevated suspicion in – Soft tissue pulseless extremity compression – Median NN – Arteriospasm – Intimal Injury • Significant association – Laceration between brachial artery – Complete and median nerve injury Transection Median NN – Fracture Rowell PJ, 1975 Brachial AA Entrapment 4/19/2019 Badkoobehi 2015 Children’s Healthcare of Atlanta Luria, 2007; Mangat, 2009; Lyons, 2000 Children’s Healthcare of Atlanta Children’s Healthcare of Atlanta 34 35 36 12 4/19/2019 Well Perfused (Pink), Pulseless Extremity 10 y/o female cheerleader, trampoline • Conservative Approach – Urgent Operative Reduction and Fixation – +/- Doppler Ultrasound Intra-op – Inpatient Serial Exams 24– 48 hours COMPARTMENT SYNDROME • Analgesics Compartment Syndrome • Anxiety Vascular Decompensation • Agitation – Low Threshold to return to the OR • Compartment release, exploration, possible reconstruction 4/19/2019 Weller, 2013; Scannell, 2013; Badkoobehi, 2015 Children’s Healthcare of Atlanta Children’s Healthcare of Atlanta 37 38 39 13 4/19/2019 Type 3 SC Humerus Fracture Type 3 SC Humerus Fracture POST-OP EXAM • Pre-Op Exam: • Plan: • No changes in exam throughout day – Median NN paresthesias – CRPP in AM – Normal Motor Exam • ~8:30PM Examination – 2+ Radial AA Pulse – 1/5 AIN – Worsening Median Nerve Paresthesias – Minimal Pain with PROM • Antecubital Fascotomies – Biphasic waveform of brachial artery – Minimal hematoma, no arterial injury 4/19/2019 Children’s Healthcare of Atlanta 4/19/2019 Children’s Healthcare of Atlanta Children’s Healthcare of Atlanta 40 41 42 14 4/19/2019 Antecubital Fasciotomies 4 week follow-up SC Humerus Fx & Compartment Syndrome • 0.2% (67/814) pediatric supracondylar humerus fractures – 0.36% (3 patients) isolated SCH • Risk Factors – Neurovascular injury – Floating elbow – Male – Older patients • Rare, but potentially devastating 4/19/2019 Robertson et al, 2018 Children’s Healthcare of Atlanta Children’s Healthcare of Atlanta Children’s Healthcare of Atlanta 43 44 45 15 4/19/2019 CONCLUSION Case Presentation • Common injury injury in the pediatric population • 9 y/o female fall from tree • Left Grade 1 open distal radius and ulna fracture • Management is based upon perfusion and soft tissue injury • Left Type 3 supracondylar humerus fracture • Pre-op Exam • High index of suspicion Case Presentations – NV Intact – Median Nerve Injury – ~1cm laceration over volar wrist – Pink, pulseless extremity – Ecchymosis/puckering of antecubital fossa – 24-48 hours observation • Low Threshold to return to OR 4/19/20 Children’s Healthcare of Atlanta Children’s Healthcare of Atlanta 48 19 47 46 47 48 16 4/19/2019 9 y/o female fall from tree Plan? Children’s Healthcare of Atlanta 49 50 Children’s Healthcare of Atlanta 51 49 50 51 17 4/19/2019 5 month follow-up 7 y/o female s/p fall from bike Post-operative Protocols? 52 Children’s Healthcare of Atlanta 53 Children’s Healthcare of Atlanta 54 52 53 54 18 4/19/2019 Type 4 SC Humerus Fracture • Pre-Op Exam – NVI – Ecchyosis Plan? – No puckering – Significant swelling • Intra-op Findings – Grossly unstable – Type 4 SC Humerus Fracture 55 Children’s Healthcare of Atlanta 56 Children’s Healthcare of Atlanta 57 55 56 57 19 4/19/2019 4 week follow-up Transolecranon Pin Technique Post-op Protocol? Green et al, JPO 2017 58 Children’s Healthcare of Atlanta 59 Children’s Healthcare of Atlanta 60 58 59 60 20 4/19/2019 TREATMENT ALGORITHM 0-6 MONTHS -PAVLIK HARNESS -ABDUCTION BRACE -SPLINT 6 MONTHS -6 YEARS -SPICA CAST Questions? -FLEXIBLE NAILS (Specific Scenarios) FEMUR FRACTURES -EXTERNAL FIXATOR 6 YEARS – 10 YEARS -FLEXIBLE NAILS BIRTH TO SKELETALLY MATURE -SUB-MUSCULAR PLATE -EXTERNAL FIXATOR >10 YEARS -RIGID NAILS -SUB-MUSCULAR PLATE -EXTERNAL FIXATOR -FLEXIBLE NAILS (Meets Criteria?) 61