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0. Harty > Paeds Trauma > Flashcards

Paeds Trauma Flashcards

1
Q

What children are at greatest risk of child abuse?

[Clin Orthop Relat Res (2011) 469:790–797] [JAAOS 2000;8:10-20]

A
  1. First-born children, unplanned children, premature infants, stepchildren, and handicapped children
  2. Single-parent homes, drug abusing parents, parents who were themselves abused, unemployed parents, and families of lower socioeconomic status
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2
Q

When present, which fracture has the highest probability of abuse?

[Clin Orthop Relat Res (2011) 469:790–797]

A

Rib fractures (70% chance of abuse)

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3
Q

What percentage of femur fractures in children less than 3 (and less than 1) are due to child abuse?

[Clin Orthop Relat Res (2011) 469:790–797]

A
  1. Less than 3 = 12-13%
  2. Less than 1 = 30%
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4
Q

What are the orthopedic manifestations of child abuse?

[JAAOS 2000;8:10-20]

A
  1. Long bone fractures in nonambulatory child
  2. Multiple fractures in various stages of healing
    * Occurs in 70% of abused children less than 1 year of age and more than 50% of all abused children
  3. Rib fractures (posterior and posterolateral)
  4. Transphyseal fracture of the distal humerus
  5. Metaphyseal ‘corner fracture’ or ‘bucket handle fracture’
  6. Vertebral compression fractures
  7. Spinous process avulsions
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5
Q

What are nonorthopedic manifestations of child abuse?

[JAAOS 2000;8:10-20]

A
  1. Bruises
  • Suggestive locations include perineum, buttock, genitalia, trunk, back of legs, back of head
  • Multiple and in different stages of healing
  1. Skull fractures
    * Suggestive types include multiple, crossing suture lines, depressed, bilateral, skull base
  2. Retinal hemorrhages
  3. Subdural hematoma
  4. Visceral injury
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6
Q

What age is the typical presentation for a transphyseal distal humerus fracture?

[JAAOS 2016;24:e39-e44]

A

<3

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7
Q

What are three common mechanisms of injury for a transphyseal distal humerus fracture?

[JAAOS 2016;24:e39-e44]

A
  1. Birth injury
  2. Nonaccidental trauma
  3. FOOSH
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8
Q

What are the radiographic features of transphyseal distal humerus fracture?

[JAAOS 2016;24:e39-e44]

A
  1. Key – forearm is not aligned with the humeral shaft
  2. If capitellum present it will be aligned with the radial shaft
  3. Most common direction is posteromedial displacement of the forearm
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9
Q

What is the management of transphyseal distal humerus fractures?

[JAAOS 2016;24:e39-e44]

A

CRPP with arthrogram

  • Arthrogram is performed and direction of displacement is confirmed
  • Closed reduction is performed similar to supracondylar fractures
  • 2-3 lateral pins – divergent, engaging opposite cortex and wide spread
  • Pins removed at 3 weeks
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10
Q

What is the most common complication of a transphyseal distal humerus fracture?

[JAAOS 2016;24:e39-e44]

A

Cubitus varus

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11
Q

What percentage of growth does the proximal humerus growth plate contribute to longitudinal growth?

[JAAOS 2015;23:77-86]

A

80%

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12
Q

What is the most common proximal humerus fracture angulation?

[JAAOS 2015;23:77-86]

A

Apex anterior

  • Hinges on the thicker intact posteromedial periosteum
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13
Q

What is Little League Shoulder?

[JAAOS 2015;23:77-86]

A
  1. Fracture of the proximal humeral growth plate as a result of overthrowing
  2. Imaging will reveal widening of the proximal humeral growth plate and, in more advanced cases, fragmentation, sclerosis, and even cyst formation
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14
Q

What is the most common classification of pediatric proximal humerus fractures?

[JAAOS 2015;23:77-86]

A

Neer and Horwitz Classification

  • Grade I - <5mm displacement
  • Grade II - <1/3 of the shaft width
  • Grade III - 2/3 of the shaft width
  • Grade IV - >2/3 of the shaft width
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15
Q

What is the management of pediatric proximal humerus fractures?

[JAAOS 2015;23:77-86]

A
  1. Nonoperative
  • Birth fractures
  • Grade I and II
  1. Operative
  • Grade I and II with open fractures, vascular injury or polytrauma
  • Grade III and IV
    • Controversial
      • Generally, surgical indications include:
        • Age >11
        • Neuromuscular disorders
        • Nerve palsies
        • Anticipated deformity after fracture healing
        • e.Irreducible fracture dislocation
      • No consensus on acceptable angulation
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16
Q

What are blocks to closed reduction of proximal humerus fractures?

[JAAOS 2015;23:77-86]

A
  1. LHB tendon
  2. Capsule
  3. Periosteum
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17
Q

What is the closed reduction maneuver for proximal humerus fractures?

[Orthobullets]

A
  1. Longitudinal traction
  2. Abduction to 90°
  3. ER
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18
Q

What are the surgical options for proximal humerus fractures?

[JAAOS 2015;23:77-86]

A

CRPP – 2-3 lateral pins

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19
Q

What is the most common age range for supracondylar humerus fractures?

[JAAOS 2012;20:69-77]

A

5-7

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20
Q

What extremity is most commonly affected in SCHF?

[JAAOS 2012;20:69-77]

A

Left or nondominant

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21
Q

What percentage pf SCHF are extension type?

[JAAOS 2015;23:e72-e80]

A

95%

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22
Q

What is the most common associated fracture with a supracondylar humerus fracture?

[JAAOS 2012;20:69-77]

A

Ipsilateral distal radius

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23
Q

A supracondylar humerus fracture with an ipsilateral forearm fracture places a patient at increased risk for what complication?

[JAAOS 2012;20:69-77]

A

Compartment syndrome

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24
Q

What is the most common nerve injury associated with an extension type supracondylar fracture?

[JAAOS 2012;20:69-77] [JAAOS 2015;23:e72-e80]

A
  1. Extension type
  • Anterior interosseous nerve
  • Followed by median, radial and ulnar
  1. Flexion type
    * Ulnar nerve
  2. Posterolateral displacement
    * Median and anterior interosseous nerve
  3. Posteromedial displacement
    * Radial nerve
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25
Q

In the absence of a distal radial pulse, what are clinical indicators of sufficient perfusion?

[JAAOS 2012;20:69-77]

A
  • Normal capillary refill
  • Temperature
  • Color (typically described as pink)
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26
Q

What are the 3 categories of vascular status following a supracondylar humerus fracture?

[JAAOS 2012;20:69-77]

A
  1. Normal
  2. Pulseless with a pink hand (perfused)
  3. Dysvascular (pulseless with a white hand)
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27
Q

The presence of which fat pad sign is indicative of an occult SCHF?

[JAAOS 2012;20:69-77]

A

Posterior fat pad

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28
Q

The anterior humeral line intersects what portion of the capitellum?

[JAAOS 2012;20:69-77]

A
  1. >4 years of age = middle 1/3
  2. <4 years of age = may lie in anterior 1/3
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29
Q

What is the classification of supracondylar humerus fractures?

[JAAOS 2012;20:69-77][CORR 201;473(2) 738–741]

A

Gartland classification (describes extension type)

  • .Type I - nondisplaced
  • Type II - displaced with intact posterior hinge
    • Type IIA – no rotation or translation
    • .Type IIB – rotation or translation
  • Type III - complete displacement
  • Type IV - unstable in flexion and extension (complete disruption of periosteal hinge)
  • Medial comminution – collapse of medial column with resulting loss of Baumann’s angle
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30
Q

What is Baumann’s angle?

[Orthobullets]

A
  1. Angle formed between a line parallel to the longitudinal axis of the humeral shaft and a line along the lateral condylar physis as viewed on the AP image
  2. Normal = 70-75 (compare to contralateral side)
  3. Deviation >5-10 should not be accepted
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31
Q

What is the management of supracondylar fractures based on Gartland classification?

[JAAOS 2012;20:69-77]

A
  1. Type I
  • Nonoperative
    • Long arm cast 90° elbow flexion for 3-4 weeks
  1. Type II
  • Nonoperative
    • Type IIA – controversial, some authors treat these nonoperative with closed reduction, casting and close followup (consider if minimal swelling)
  • Operative
    • Type IIB – CRPP
      1. Type III
  • Operative
    • CRPP, long arm splinting with elbow at 60-80°, pins removed at 3-4 weeks
  1. Type IV
  • Operative
    • CRPP
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32
Q

What are blocks to closed reduction of supracondylar fractures?

[JAAOS 2015;23:e72-e80]

A
  1. Brachialis muscle interposition
  2. Button-holing of metaphyseal spike through brachialis
  3. Brachial artery
  4. Nerve
  5. Periosteum
  6. Joint capsule
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33
Q

What is the technique for closed reduction of an extension type supracondylar fracture?

[CORR course]

A
  1. Elbow extension, longitudinal traction, correct varus/valgus and medial/lateral translation and rotation, flex elbow with thumb pressure over olecranon to correct sagittal alignment
  2. Consider milking brachialis if distal humerus buttonholed through
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34
Q

What is the technique for closed reduction of a flexion type supracondylar humerus fracture?

A
  1. “push-pull technique” [Journal of Pediatric Orthopaedics B 2016, 25:412–416]
    * With elbow at 45 correct coronal plane deformity (varus/valgus/translation), flex elbow to 90 with towel under apex of deformity apply a posterior directed force along the axis of the forearm, slight over correction can be corrected with a pull along the axis of the forearm
  2. Traditionally done in extension
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35
Q

What are the complications associated with operative treatment of supracondylar fracture?

[JAAOS 2012;20:69-77]

A
  1. Pin migration
  2. Pin tract infection
  3. Osteomyelitis/septic arthritis
  4. Malunion
  5. Compartment syndrome
  6. Ulnar nerve injury
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36
Q

What are indications for emergent management of supracondylar humerus fractures?

[JAAOS 2012;20:69-77]

A
  1. Open fracture
  2. Dysvascular limb
  3. Skin puckering
  4. Floating elbow
  5. Median nerve palsy
  6. Evolving compartment syndrome
  7. Young age (unreliable exam)
  8. Cognitive disability (unreliable exam)
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37
Q

What is the timing of surgical intervention for Type III supracondylar humerus fractures?

[JAAOS 2012;20:69-77]

A
  1. Safe to delay 12-18 hours
  2. Arm is splinted in 20-40° of flexion, neurovascular checks
  3. Nurse q2h, no sedating analgesics
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38
Q

What is the incidence of ulnar nerve injury with medial pin placement?

[JAAOS 2012;20:69-77]

A

10%

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39
Q

What is the recommended pin placement in management of supracondylar fractures?

[JAAOS 2012;20:69-77]

A
  1. Adequate number of lateral pins
    * In general, Type II – 2 pins, Type III – 3 pins
  2. As far apart as possible
  3. Pins should be divergent
  4. Pins should not converge or cross at fracture site
  5. Pins should engage both the medial and lateral columns
  6. Consider a medial pin if fracture remains unstable or in presence of comminution
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40
Q

What is the technique for medial pin placement in SCHF?

[JAAOS 2012;20:69-77]

A
  1. Small incision over medial epicondyle
  2. Elbow in extension (prevents ulnar nerve from subluxing anterior)
  3. Identify and protect ulnar nerve
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41
Q

What are the indications for a medial pin in SCHF?

[CORR course]

A
  • Reverse obliquity
  • Very distal fractures
  • Very young
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42
Q

What are technical errors in lateral pin placement that can lead to loss of reduction of a SCHF?

[JAAOS 2012;20:69-77]

A
  1. Failure to engage both fragments with at least two pins
  2. Failure to achieve bicortical fixation with at least two pins
  3. Failure to achieve ≥2 mm of pin separation at the fracture site
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43
Q

What is the management of the pulseless hand in the setting of a supracondylar humerus fractures?

[JAAOS 2012;20:69-77]

A
  1. In the presence of adequate perfusion (pink)
  • Reduce fracture and pin
  • If adequate perfusion remains – admit for observation with elbow in approx. 45° flexion
  1. In the presence of pulseless extremity and inadequate perfusion (white)
  • Reduce the fracture and pin
    • If remains dysvascular – explore artery and monitor for compartment syndrome (consider fasciotomy)
    • If adequate perfusion - admit for observation with elbow in approx. 45° flexion
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44
Q

What neurological injury is associated with injury to the brachial artery in SCHF?

[JBJS 2015;97:937-43]

A

Median nerve

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45
Q

In a SCHF, if an open exploration is performed and there is still inadequate distal perfusion despite the brachial artery being in continuity and decompressed, what can be attempted relieve vasospasm?

[JBJS 2015;97:937-43]

A
  1. Increase ambient temperature
  2. Apply topical lidocaine or papaverine
  3. Stellate ganglion block
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46
Q

What are the indications for open reduction of supracondylar fractures?

[JAAOS 2015;23:e72-e80]

A
  1. Failed closed reduction
  2. Open fracture
  3. Compartment syndrome
  4. Neurologic and/or vascular injury requiring open exploration
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47
Q

What approaches are used for management of open reduction of supracondylar fractures?

[JAAOS 2015;23:e72-e80]

A

“go to the metaphyseal spike”- [CORR course]

  1. Anterior approach = extension type
  • Transverse or ‘lazy S’ over flexion crease of antecubital fossa
  • If releasing blocks to reduction – stay lateral to biceps tendon to avoid neurovascular structures
  • If exploring neurovascular bundle – identify proximal to fracture site
  1. Lateral approach = posteromedial displacement
    * Plane between BR and triceps
  2. Medial approach = posterolateral displacement and flexion type
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48
Q

What are the disadvantages of the posterior approach to opening a SCHF?

[JAAOS 2015;23:e72-e80]

A
  1. Increased elbow stiffness
  2. Difficult access to interposed anterior structures
  3. Risk of trochlear osteonecrosis
  4. Less cosmetic
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49
Q

What are the complications associated with supracondylar humerus fractures?

[JAAOS 2012;20:69-77]

A
  1. Cubitus varus
  • Can lead to cosmetic concerns and tardy posterolateral rotatory instability b
  • No effect on elbow ROM
  • Correctional osteotomy should be considered if significant varus present
    • Performed at >1 year
    • Lateral closing wedge osteotomy with pin fixation
  • What is the Skaggs osteotomy? [J Child Orthop. 2011 Aug; 5(4): 305–312]
    • Interlocking lateral wedge osteotomy with lateral pin fixation
    • Corrects cubitus varus and extension
    • Enhanced stability and less lateral prominence than closing wedge
  1. Compartment syndrome
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50
Q

What is the typical age in which a lateral humeral condylar fracture occurs?

[J Am Acad Orthop Surg 2011;19:350-358]

A

Typically 6 years of age

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51
Q

What radiographic view best demonstrates a lateral condyle fracture?

[J Am Acad Orthop Surg 2011;19:350-358]

A

Internal oblique view (fragment often lies posterolateral)

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52
Q

What is the role of an arthrogram in the management of a lateral condyle humerus fracture?

[J Am Acad Orthop Surg 2011;19:350-358]

A
  1. Limited diagnostic value as it is performed in the OR with patient under sedation
  2. Useful for intra-operative assessment
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53
Q

How is an arthrogram administered in the context of distal humerus lateral condyle fracture?

[J Am Acad Orthop Surg 2011;19:350-358]

A

Traditionally performed via the lateral soft spot, which is a triangle formed by the radial head, olecranon, and lateral column of the humerus.

  • This area may be distorted in patients with lateral condylar fracture
  • Alternatively, the needle may be placed directly into the posterior surface of the olecranon fossa.
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54
Q

How are lateral condyle fractures classified?

[J Am Acad Orthop Surg 2011;19:350-358]

A
  1. Milch classification (historical)
  • Type I – fracture line that courses lateral to the trochlea and into the capitulotrochlear groove
    • Elbow is stable as the trochlea is intact
  • Type II – fracture line that extends into the apex of the trochlea
    • Elbow is unstable as the trochlea is disrupted
  1. Jakob classification (based on fracture fragment displacement)
  • Type I – nondisplaced, intact articular surface
  • Type II – fracture is complete extending through the articular surface, may be moderately displaced
  • Type III – complete displacement and fragment rotation, loss of relationship between capitellum and radius
  1. WEISS Classification (based on displacement and articular cartilage)
  • Based on fracture displacement and articular congruity
    • TYPE I
      • Fracture is displaced < 2 mm
    • TYPE II
      • Fracture displaced ≥2mm with intact articular cartilage, as demonstrated by arthrogram (i.e. articular hinge)
    • TYPE III
      • Fracture displaced ≥2mm and the articular surface is not intact (i.e. no hinge)
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55
Q

What are the indications for nonop vs. operative management in lateral condyle humerus fractures?

[J Am Acad Orthop Surg 2011;19:350-358]

A
  1. Nonoperative indications
  • Type I, nondisplaced
  • Fractures with an intact cartilage hinge that has been confirmed on MRI
  • ≤2 mm displacement on all radiographic views
  1. Operative indications
  • >2mm displacement
    • 2-4mm = CRPP
    • >4mm = ORIF
  • Nonunion
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56
Q

Operative options for lateral condyle humerus fracture?

A
  1. CRPP
  • Weiss Type II (2-4mm displacement, intact articular cartilage)
  • Technique
    • Closed reduction performed with forearm supinated, elbow extended, varus stress to elbow followed by fragment manipulation anteromedially
    • Two parallel or slightly divergent K-wires plus a transverse pin to control rotation
  1. Open reduction
  • Weiss and Jakob Type III (articular cartilage disruption, displaced >4mm, fragment malrotation)
  • Technique
    • Kocher interval (anconeus and ECU)
    • Avoid posterior and distal dissection (risk of fragment AVN)
    • Anatomic reduction under direct visualization with fluoro confirmation
    • Fixation
      • K-wire OR Partially threaded screw
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57
Q

What complications are associated with lateral condylar fractures +/- surgical management?

[J Am Acad Orthop Surg 2011;19:350-358]

A
  1. Lateral spur
  2. Nonunion (due to synovial fluid, pull of common extensor origin, poor metaphyseal circulation to distal fragment)
    * More common with nonoperative treatment
  3. Cubitus varus (20%)
    * More common in nondisplaced and minimally displaced fractures
  4. Cubitus valgus (10%)
  5. Tardy ulnar nerve palsy
  • Progressive ulnar nerve paralysis developing late (average 22 years post injury)
  • Manage with anterior ulnar nerve transposition
  1. Fishtail deformity
    * Deepening of the trochlear groove, no clinical significance
  2. Growth disturbance
    * Minimal and involved medial aspect of the condyle (little effect on length or deviation)
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58
Q

What percentage of medial epicondyle fractures are associated with an elbow dislocation?

[JAAOS 2012;20:223-232]

A

60%

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59
Q

What is the last ossification center to fuse to the distal humerus?

[JAAOS 2012;20:223-232]

A

Medial epicondyle

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60
Q

What is the peak age for medial epicondyle fractures?

[JAAOS 2012;20:223-232]

A

11-12

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61
Q

What are the proposed mechanisms of injury of medial epicondyle of humerus?

[JAAOS 2012;20:223-232]

A
  1. Direct trauma
  2. FOOSH – elbow extension, wrist extension, forearm supination and elbow valgus
    * Flexor pronator avulsion
  3. Elbow dislocation (usually posterolateral)
    * UCL avulsion
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62
Q

What percentage of elbow dislocations have an associated incarcerated medial epicondyle?

[JAAOS 2012;20:223-232]

A

15-25%

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63
Q

What is the general classification of medial epicondyle fractures?

[JAAOS 2012;20:223-232]

A
  1. Acute
  • Non-displaced
  • Minimally displaced
  • Significantly displaced (>5mm)
  • Entrapment of fragment in joint
  • Fracture through epicondylar apophysis
  1. Chronic
    * Little League elbow syndrome
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64
Q

What is the direction of displacement of the medial epicondyle fragment?

[JAAOS 2012;20:223-232]

A

Anterior and distal

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65
Q

What are the features of an incarcerated medial epicondyle?

[JAAOS 2012;20:223-232]

A
  1. Block to elbow extension
  2. Fragment at level of joint radiographically
    * A significantly displaced (>5mm) epicondyle remains proximal to the joint
  3. Malreduction of joint radiographically
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66
Q

What is the closed reduction maneuver for an incarcerated medial epicondyle? [POSNA]

A

Roberts maneuver

  • Elbow valgus
  • Forearm supination
  • Elbow extension
  • Wrist extension
67
Q

What are the indications for surgery in pediatric medial epicondyle fractures?

[JAAOS 2012;20:223-232]

A
  1. Open fractures
  2. Failed closed reduction of an incarcerated medial epicondyle
  3. Ulnar nerve dysfunction (relative)
  4. Valgus elbow instability (relative)
  5. High demand upper extremity function (relative)
  6. Displacement >5mm (relative)
68
Q

Describe the surgical fixation of a medial epicondyle fracture?

[JAAOS 2012;20:223-232]

A
  1. Supine
  2. Tourniquet and Esmarch
  3. Medial incision just anterior to the medial epicondyle
  4. Identify fragment and ulnar nerve
    * Ulnar nerve does not need to be released – protect throughout with blunt retractor
  5. Reduction with “milking” technique
    * Flex wrist, supinate forearm, flex elbow and apply Esmarch from distal to proximal
  6. Place wire through medial epicondyle fragment from inside out
  7. Use wire to reduce fracture to distal humerus site and hold with additional small wire or 18 gauge needle
  8. Drill and advance a 4.0mm partially threaded cannulated screw with washer up the medial column
  • Avoid bicortical fixation
  • Avoid olecranon fossa
  • Usual length is 35-40mm
69
Q

What are the risks associated with bicortical fixation for medial epicondyle fractures?

[JAAOS 2012;20:223-232]

A
  1. Radial nerve injury
  2. Stress riser in lateral cortex (fracture risk)
70
Q

What are complications of medial epicondyle fractures (operative and nonoperative)?

[JAAOS 2012;20:223-232]

A
  1. Loss of motion
  2. Cubitus valgus
  3. Nonunion
  • Nonoperative (49.2% union)
  • Operative (92.5% union)
  1. Ulnar nerve symptoms
    * No difference in operative vs. nonoperative
  2. Operative
  • Septic arthritis
  • Myositis ossificans
  • Pin tract infections
  • Radial nerve injury
71
Q

What angulation is acceptable in radial neck fractures?

[J Pediatr Orthop 2012;32:S14–S21]

A
  1. <30 = acceptable
  2. 30-60 = no consensus
    * More angulation tolerated better in younger patients with remodeling potential
  3. >60 = unacceptable
72
Q

What is the management of pediatric radial neck fractures?

[J Pediatr Orthop 2012;32:S14–S21]

A
  1. Nonoperative
  • 2-3 weeks in cast followed by progressive ROM
  • Indications
    • <30° angulation and <2mm translation
    • Full pronation and supination
  1. Closed reduction
  • Indications
    • Unacceptable angulation
    • Block to supination or pronation
  • Techniques
    • Patterson – hold the elbow in extension and apply distal traction with the forearm supinated and pull the forearm into varus while applying direct pressure over the radial head
    • Israeli – with elbow flexed 90 and forearm in supination apply thumb pressure to anterolateral radial head while forearm is gradually taken into pronation
    • Esmarch – wrap forearm distal to proximal while holding elbow in varus
  1. Percutaneous reduction
  • Indications
    • Failed closed reduction after limited number of attempts
  • Techniques
    • K-wire joystick technique
      • Leverage technique – pin is inserted into the fracture site and levered into position
      • Push technique – blunt end of large K-wire is pushed against the posterolateral aspect of the radial head
    • Metaizeau technique
      • A thin flexible nail or smooth wire with a curved tip is inserted from the distal radius into the intramedullary canal of the radius. The tip of the flexible nail is advanced to the fracture site and into the radial head. The nail is then rotated to rotate the radial head onto the shaft
        4. Open reduction
  • Indications
    • Failed closed and percutaneous reduction attempts
    • Gap at fracture site after reduction (indicates soft tissue interposition)
  • Technique
    • Lateral approach
    • 1-2 K-wires from radial head (non-articular zone) to radial metaphysis
73
Q

What is the definition of a pediatric Monteggia fracture?

[Orthobullets]

A
  1. Proximal ulna fracture OR plastic deformation of the ulna
  2. Radial head dislocation
74
Q

What is the classification of pediatric Monteggia fractures?

[Orthobullets]

A

Bado

  • Type 1: Apex anterior proximal ulna fracture with anterior dislocation of the radial head
  • Type 2: Apex posterior proximal ulna fracture with posterior dislocation of the radial head
  • Type 3: Apex lateral proximal ulna fracture with lateral dislocation of the radial head
  • Type 4: Fractures of both the radius and ulna at the same level with an anterior dislocation of the radial head (1-11% of cases)
75
Q

What is the management of acute pediatric Monteggia fracture?

[Orthobullets]

A
  1. Nonoperative
  • Bado I, II and III
  • Technique
    • Closed reduction
      • Successful when ulnar length is restored, pattern is length stable and radial head reduces spontaneously
  1. Operative
  • Bado I, II, and III with failed closed reduction
  • Length unstable ulnar fracture
  • Bado IV
  • Technique
    • Intramedullary nail for length stable patterns
    • Plate fixation for length unstable/comminuted patterns
  • Note – annular ligament reconstruction is rarely indicated with restoration of ulnar length
76
Q

What is the management of chronic pediatric Monteggia fracture?

[Instr Course Lec 2015; 64:493]

A
  1. Ulnar osteotomy
  • Osteotomy at point of maximum angulation
  • Gains length
  • Redirects radial head to capitellum (apex of ulnar osteotomy correction should point to the direction you want the radial head to go)
  • fixed with plate and screw
  1. Radial head reduction
    * initially, attempt to reduce radial head into intact annular ligament
    * if unsuccessful, pie-crust annular ligament and attempt second reduction
    * if unsuccessful, incise annular ligament and repair around radial neck following reduction
  2. +/- annular ligament repair/reconstruction
    * indicated after ulnar osteotomy reassessed and determined to be adequate or optimized and radial head still unstable
    * Bell Tawse technique – lateral triceps tendon
77
Q

What are the features of congenital radial head dislocation that differentiate it from chronic monteggia?

A
  1. Features
  • Posterior dislocation
  • Round radial head
  • Hypoplastic capitellum
  • Bilateral
  • No history of trauma
  1. Treatment
    * Nonoperative, consider operative in adulthood if symptomatic or restricts ROM (radial head resection)
78
Q

What are acceptable reduction parameters for forearm fractures in pediatric and adolescents with ≥2 years for remaining growth?

[JAAOS 2016;24:780-788]

79
Q

When is cast wedging acceptable in the management of pediatric forearm fractures?

[JAAOS 2016;24:780-788]

A
  1. Early loss of reduction
  2. Midshaft and distal shaft fractures displaced 5-10° above acceptable limits
80
Q

What are the surgical indications for pediatric forerarm fractures?

[JAAOS 2016;24:780-788]

A
  1. Unacceptable reduction
  2. Loss of reduction
  3. Fractures with ≤1 to 2 years of remaining growth
  4. Open fractures
  5. Pathological
  6. Floating elbow
  7. Associated neurovascular injury
81
Q

What are the advantages of elastic titanium IM nails in the treatment of pediatric forearm fractures?

[JAAOS 2016;24:780-788]

A
  1. Small incisions (cosmetic)
    * 30-75% require small incision at fracture site to assist reduction and passage of nail
  2. Little to no periosteal stripping
  3. Minimal fracture hematoma disruption
  4. Less expensive
  5. Less tourniquet time
  6. Can take less time to insert
82
Q

What are the disadvantages of elastic titanium IM nails in treating pediatric forearm fractures?

[JAAOS 2016;24:780-788]

A
  1. Implant prominence
  2. Second procedure for implant removal
  3. Less rigid than plates which often requires period of immobilization
83
Q

What are the complications of IM nails?

[JAAOS 2016;24:780-788]

A

Prominent implants, delayed union, nonunion, implant migration, bursitis, hypertrophic scars, neuropathy, refracture, tendon laceration, synostosis, infection

84
Q

Describe the technique for elastic titanium IM nailing in both bone forearm fractures?

[JAAOS 2016;24:780-788]

A
  1. Start with ulna (easier nail passage)
  2. Ulna start point either olecranon or lateral to olecranon through anconeus split
  3. Radius start point is just proximal to the distal radial physis between the 1st and 2nd compartments
  4. Nails are cut as close to bone to minimize irritation but long enough to allow retrieval
  5. Tourniquet is not routinely used
85
Q

What are the advantages of plate osteosynthesis in the treatment of pediatric forearm fractures?

[JAAOS 2016;24:780-788]

A
  1. Rigid fixation
  2. Anatomic reduction
  3. Early range of motion
  4. Complete correction of malrotation and restoration of radial bow
86
Q

What are the disadvantages of plate osteosynthesis in the treatment of pediatric forearm fractures?

[JAAOS 2016;24:780-788]

A
  1. Large incisions
  2. More expensive
  3. Increased tourniquet time
87
Q

What are the complications of plate osteosynthesis?

[JAAOS 2016;24:780-788]

A

Painful implants, nonunion, malunion, neuropathy, hypertrophic scars, refracture, weakness, implant failure, infection, synostosis, carpal tunnel

88
Q

What is the general treatment choice (IM nail vs. plate) based on age in the treatment of pediatric forearm fractures?

[JAAOS 2016;24:780-788]

A
  1. <10 = IM nail
  2. >10 with growth remaining = IM nail or plate (surgeon or patient preference)
  3. >10 with <1 year of growth = plate
89
Q

What are causes of physeal arrest of the distal radius?

[JAAOS 2014;22:381-389]

A
  1. Fracture (most common)
  2. Repetitive stress (Eg. gymnasts)
  3. Infection, irradiation, tumor, ischemia, iatrogenic
90
Q

What percentage of growth does the distal radius physis contribute to longitudinal growth?

[JAAOS 2014;22:381-389]

91
Q

Injury through what zone of the physis results in physeal growth arrest?

[JAAOS 2014;22:381-389]

A

Resting/reserve zone (contains the pluripotent chondrocytes) OR proliferative zone

92
Q

What zone of the physis do growth plate fractures occur through?

[JAAOS 2014;22:381-389]

A

Zone of provisional calcification (component of the hypertrophic zone)

93
Q

What are radiographic signs of distal radius physeal arrest?

[JAAOS 2014;22:381-389]d

A
  1. Parallel Park-Harris lines through the metaphysis of the distal radius
  2. Presence of physeal bar
  3. Positive ulnar variance
  4. Angular deformity
94
Q

Following distal radius physeal fracture what is recommended to prevent physeal arrest?

[JAAOS 2014;22:381-389]

A
  1. Limit gentle closed reduction attempts to 1-2 in ED
  2. Limit gentle closed reduction attempts to 1-2 in OR (after failed ED attempt)
  3. Do not reattempt closed reduction after 7-10 days following injury
95
Q

What is the management of distal radius physeal arrest?

[JAAOS 2014;22:381-389]

A
  1. Nonoperative
  • Indications
    • Minimal growth remaining
  1. Operative
  • Indications
    • >2mm growth remaining
    • Progressive deformity
    • Ulnar sided wrist pain
    • Limited ROM
  • Options
    • Physeal bar resection and interposition
    • Epiphysiodesis
      • Partial arrest = epiphysiodesis of remaining growth plate
      • Complete arrest = ulnar epiphysiodesis
    • Ulnar shortening osteotomy
    • Radial osteotomy
      • Corrects angular deformity
    • Distraction osteogenesis
96
Q

What is the blood supply to the to the femoral head before and after age 4?

[JAAOS 2009;17:162-173]

A
  1. <4 = MFCA, LFCA and artery of ligamentum teres
  2. > 4= MFCA predominately
97
Q

How do you avoid disruption of the femoral head blood supply during open reduction and capsulotomy (for hip fracture)?

[JAAOS 2009;17:162-173]

A
  1. Avoid incising capsule across intertrochanteric line
  2. Avoid posterior dissection of the femoral neck
98
Q

What are causes of pathological hip fractures in children?

[JAAOS 2009;17:162-173]

A
  1. Osteomyelitis
  2. Simple and aneurysmal bone cysts
  3. Fibrous dysplasia
  4. Langerhans cell histiocytosis
  5. Osteogenesis imperfecta
  6. Disuse osteopenia
  7. Metabolic bone disease
  8. Malignancy
99
Q

Where does the pediatric femoral neck stress fracture occur?

[JAAOS 2018;26:411-419]

A

Inferior compression side of the neck

100
Q

What is the classification of pediatric hip fractures?

[JAAOS 2009;17:162-173]

A

Delbet classification

  • Type IA = transphyseal without dislocation of epiphysis
  • Type IB = transphyseal with dislocation of epiphysis
  • Type II = transcervical
  • Type III = cervicotrochanteric
  • Type IV = intertrochanteric
101
Q

What are the considerations for closed reduction of hip fractures?

[JAAOS 2009;17:162-173]

A
  1. Perform urgently within 24 hours
  2. Age <10 perform on radiolucent operating table, ≥10 perform on fracture table
  3. Perform with hip in extension, slight abduction and internal rotation, apply longitudinal traction and gentle adjustments in leg position
  4. Avoid forceful manipulation
  5. Anatomic reduction is desired but some angulation is acceptable
  6. Closed reduction is preferred and usually successful
102
Q

What are the indications for open reduction?

[JAAOS 2009;17:162-173]

A
  1. Open hip fracture
  2. Vascular injury requiring repair
  3. Pathological hip fracture requiring bone culture, biopsy, or grafting
  4. Failed closed reduction
103
Q

What approaches are used for open reduction of pediatric hip fractures?

[JAAOS 2018;26:411-419]

A
  1. Anterior (Smith-Peterson)
    * Requires separate incision for fixation
  2. Anterolateral (Watson-Jones)
  3. Lateral (Hardinge)
104
Q

What are the general principles of treatment of pediatric hip fractures?

[JAAOS 2009;17:162-173]

A
  1. Fracture stability is more important than preservation of the physis
  2. Transphyseal screw fixation is the most stable and is recommended for most fractures
  3. Physis-sparing fixation is less stable (recommended only in children <4 to 6)
  4. Fracture fixation is dependent on patient age, patient size and skeletal maturity
  5. Capsular decompression should be performed after fracture reduction and fixation
  6. Spica cast use is dependent on fracture type, fracture fixation and patient size
105
Q

General indications for spica cast following surgical fixation of hip fractures include?

[JAAOS 2009;17:162-173]

A
  1. Children <8 years
  2. Pathological fractures that are not stable after fixation
  3. Fractures treated with smooth K-wires
  4. Fractures treated with physeal sparing technique
106
Q

What is the management of pediatric hip fractures based on the Delbet classification?

[JAAOS 2018;26:411-419]

A
  1. Type IA
  • Age <2 = closed reduction spica cast
  • Age 2-9 = 2 smooth pins and spica cast
  • Age ≥10 = transphyseal fixation
  1. Type IB
    * Open reduction
  2. Type II and III
  • Age <6 = closed reduction and spica casting
    • +/- supplemental fixation in patients ≥2 years in spica cast
    • Acceptable reduction Type II = <5° angulation and <2mm cortical translation
    • Acceptable reduction Type III = <10° angulation (varus more common)
  • Displaced fractures (if unable to be managed by closed reduction)
    • <4 years = smooth K wires
    • 4-9 years = physeal sparing cannulated screws
    • >10 years = Transphyseal cannulated screws, proximal locking plate (unstable patterns)
  1. Type IV
  • Age <6 = closed reduction and spica casting
    • +/- supplemental fixation in patients ≥2 years in spica cast
    • Acceptable reduction Type IV = <10° angulation
  • Age >6 = stabilization with a pediatric sliding hip screw, blade plate, or proximal femoral locking plate
    • <10 consider physeal sparing screw
    • >10 consider transphyseal screw
107
Q

What are the technical points of transphyseal fixation in pediatric hip fractures?

[JAAOS 2018;26:411-419]

A
  1. Placed no less than 5mm from the subchondral bone
  2. Avoid posterior perforation or screw placement in the anterolateral quadrant of the epiphysis (reduce risk of iatrogenic injury to blood vessels)
  3. Avoid transphyseal fixation in patients <10 (however stable fixation should not be compromised to spare the physis)
  4. Postoperatively can TTWB with crutches if stable pattern
108
Q

What complications are associated with pediatric hip fractures?

[JAAOS 2009;17:162-173] [JAAOS 2018;26:411-419]

A

1.Osteonecrosis (most common)

  • What are the predictors for osteonecrosis?
    • Fracture type
      • Type IB = highest risk (100%)
      • Type I (38%) > Type II (28%) > Type III (18%) > Type IV (5%)
      • Reported rates of osteonecrosis according to the Delbet classification are 38% to 50% for type I, 28% for type II, 8% to 18% for type III, and 5% to 10% for type IV.
    • Older patient
      • Age >10
    • Displaced fractures
  • What is the Ratliff classification of osteonecrosis?
    • Type I = entire femoral head
    • Type II = segments of femoral head
    • Type III = femoral neck
      1. Coxa vara
  • Femoral neck shaft angle <120
    3. Premature physeal closure
  • Can lead to coxa valga or vara (asymmetric arrest)
  • Can lead to LLD
  1. Nonunion
  • Up to 10%
  • Most common in Type II
  • Management is a valgus osteotomy
  1. Chondrolysis
  2. Infection
  3. Posttraumatic SCFE
  4. Overgrowth of the femoral shaft
109
Q

At what age should a child be screened for child abuse when presenting with a femur fracture?

[JAAOS 2009;17:718-725]

A

<36 months

110
Q

What is the treatment algorithm for femur fractures based on age and weight?

[JAAOS 2011;19:472-481][Orthobullets]

A
  1. ≤6 months a.Pavlik harness
    * Early spica casting
  2. 6 months – 5 years
  • Stable fracture pattern
    • Early spica casting
  • Unstable fracture pattern
    • Traction with delayed spica casting
    • External fixator
  1. 5-11 years
  • Length stable fracture and patient <100lbs
    • Flexible IM nails
  • Length unstable fracture OR very proximal/distal fracture OR any weight
    • Submuscular plating
  1. ≥11 years
  • Patient ≤100lbs
    • Flexible IM nails
  • Patient >100lbs
    • Antegrade rigid IM nail
  • Proximal or distal fracture OR comminution
    • Submuscular plating
111
Q

What are the technical points of flexible intramedullary nailing?

[JAAOS 2011;19:472-481]

A
  1. Patient is supine on a radiolucent flattop table
  2. Fracture reduction is achieved with knee flexion, traction and F-tool
  3. Use two nails with a combined diameter equal to 80% of the IM canal at its narrowest width
  4. Retrograde start point is ~2.5cm from the distal femoral physis
  5. Nails are rotated so the concavities face each other and remain symmetric
  6. For better rotational control, one nail is advanced to the femoral neck and the other to the greater trochanter
  7. Only 1-1.5cm of the nail should remain outside the bone
  8. A knee immobilizer is applied at completion of case
112
Q

What are 5 technical points to maintain reduction of pediatric femoral shaft fractures when using flexible nails?

[Rockwood and Wilkins’ Fractures in Children 2015]

A
  1. Largest nail possible
    * Each nail should be 40% of the minimum diameter of the diaphysis
  2. Two nails
    * Achieving 80% canal fill
  3. Prebend nails
    * 30 degree C-shaped bend at the level of the fracture
  4. Opposite bends of the two rods at the fracture site (spread within the diaphysis)
    * Resists bending
  5. Divergence of rods in metaphysis
    * Torsional control
113
Q

What is the preferred trochanteric entry point for a rigid femoral nail?

[JAAOS 2011;19:472-481]

A

Lateral trochanteric entry point

114
Q

What are the risks of nail placement through a piriformis fossa or GT tip start point?

[JAAOS 2011;19:472-481]

A
  1. Piriformis
    * Femoral head osteonecrosis
  2. GT tip
  • Proximal femoral valgus
  • Femoral neck narrowing
  • GT physeal arrest
115
Q

When should an implant (for femur fracture) be removed?

[JAAOS 2011;19:472-481]

A
  1. Symptomatic – soft-tissue irritation, knee effusion, loss of knee ROM
  2. Asymptomatic – no consensus on removal
116
Q

What is the management of distal femur fractures?

[JAAOS 2015;23:571-580]

A
  1. Salter-Harris I – II
  • Nonoperative (bivalved long leg cast)
    • Nondisplaced
    • <2mm displacement after closed reduction
  • Operative
    • Reducible but unstable
      • Two crossed transphyseal smooth pins (antegrade or retrograde)
        2. SH II with large Thurston-Holland fragment
  • Percutaneous partially threaded cannulated screw
    • In metaphysis parallel to physis and perpendicular to fracture

3.SH III – IV

  • Nonoperative
    • Nondisplaced
  • Operative
    • >2mm displacement
      • Closed possible open reduction to achieve reduction
      • 4.5- to 7.3-mm cannulated screws are placed parallel to the articular surface of the epiphysis and/or metaphysis
117
Q

What is the risk of growth arrest in distal femur physeal fractures?

[JAAOS 2015;23:571-580]

A

40-90%

  • Higher in distal femur than other locations
  • Risk depends on SH type (SH IV > SH I)
118
Q

What is the management of proximal tibia fractures?

[JAAOS 2015;23:571-580]

A
  1. Salter Harris I – II
  • Nonoperative
    • Nondisplaced
    • <2mm displacement after closed reduction
  • Operative
    • >2mm displacement after closed reduction
      • Remove blocks to reduction – periosteum, pes anserine tendons, ligament
      • Two crossed transphyseal smooth pins
        • Retrograde are farther from joint
        • Antegrade are less technically challenging
          2. Salter Harris III – IV
  • Nonoperative
    • Nondisplaced
  • Operative
    • >2mm displacement
      • Direct visualization – screws or wires parallel to physis in epiphysis or metaphysis
119
Q

What is the progression of tibial tubercle apophyseal closure?

[JAAOS 2015;23:571-580]

A

Proximal to distal

120
Q

What is the usual age range at time of tibial tubercle avulsion injury?

[JAAOS 2015;23:571-580]

A

12-17, usually male

121
Q

What is the classification of pediatric tibial tubercle avulsion fractures?

[J Child Orthop. 2008 Dec; 2(6): 469–474.] [JAAOS 2015;23:571-580]

A
  1. Type I - junction of the distal and proximal apophysis
  • Type IA = nondisplaced/minimally displaced
  • Type IB = displaced and hinged at junction
  • Type IC = patellar tendon periosteal sleeve avulsion
  1. Type II - junction of tibial tubercle and proximal epiphysis
    * Type IIA = not comminuted b.Type IIB = comminuted
  2. Type III - extend intra-articular (most common)
  • Type IIIA = not comminuted
  • Type IIIB = comminuted
  1. Type IV - fracture of the tibial tuberosity that extends posteriorly along the proximal tibial physis creating an avulsion of the entire proximal epiphysis
  2. Type V - extends intra-articular and posteriorly along physis of proximal tibia (‘Y’ pattern)

Note: Ogden modification of Watson-Jones classification was from Type I-III with subclassification A/B

  • Frankl added type IC
122
Q

What is the management of tibial tubercle avulsion fractures?

[JAAOS 2015;23:571-580]

A
  1. Nonoperative
    * Nondisplaced or minimally displaced (<2-3mm) Type I
  2. Operative
  • Displaced Type I
  • Type II-V
    • Midline anterior incision
    • Parapatellar arthrotomy or arthroscopy if intra-articular extension
    • Generally, 2-3 4.0mm cannulated screws with washers are inserted through the tubercle into the metaphysis and epiphysis
    • Consider prophylactic anterior compartment fasciotomy
123
Q

What are the complications associated with pediatric tibial tubercle avulsion fractures?

[JAAOS 2015;23:571-580]

A
  1. Genu recurvatum
    * Rare as most injuries occur as growth is slowing down
  2. Compartment syndrome
    * Anterior tibial recurrent artery at risk
  3. Hardware irritation
124
Q

What is the usual age range for pediatric tibial eminence fractures?

[JAAOS 2014;22:730-741]

A

8-14 years

125
Q

What is the classification of tibial eminence fractures?

[JAAOS 2014;22:730-741][JAAOS 2010;18:395-405]

A

Meyers and McKeever classification

  • Type I - minimally displaced
  • Type II - anterior displacement with intact posterior hinge
  • Type III - complete fracture displacement
  • Type IV - complete fracture displacement with fragment rotating out of fracture bed OR comminuted
126
Q

What is the management of tibial eminence fractures?

[JAAOS 2014;22:730-741]

A
  1. Type I
    * Nonoperative, long leg cast in slight flexion
  2. Type II
  • Closed reduction and casting
    • Aspiration of hematoma and injection of local anaesthetic, extend knee fully or near full, long leg cast
    • Acceptable reduction is <3mm displacement on lateral view
  • Operative
    • >3mm displacement on lateral view
    • Open arthrotomy or arthroscopic
    • Suture fixation through tibial tunnel OR antegrade cannulated screws in epiphysis OR combination
      • Perform EUA following fixation
127
Q

What are blocks to reduction of the tibial eminence fragment?

[JAAOS 2014;22:730-741]

A
  1. Anterior horn of meniscus (medial > lateral)
  2. Intermeniscal ligament
  3. Rotated fracture fragment
128
Q

What are the complications of tibial eminence fracture?

[JAAOS 2014;22:730-741]

A
  1. Loss of fixation
  2. Prominence of hardware
  3. Loss of motion
  4. Reoperation
    * Higher in screw vs. suture fixation
  5. ACL laxity
  6. Arthrofibrosis
  7. Nonunion
129
Q

What are the pearls/pitfalls/potential complications with surgical management of tibial spine avulsion fractures?

[JAAOS 2018;26:360-367]

A
  1. Pearls
  • Continually palpate calf compartments.
  • Address concomitant pathology before managing the avulsion fracture
  • Disengage any interposed soft tissue
  1. Pitfalls
  • Remove only the necessary portions of the intermeniscal ligament
  • Leave at least 1 to 2 cm between tunnels
  • Maintain tension on all sutures while each one is tied
  1. Potential Complications
  • Loss of motion/arthrofibrosis
  • Residual displacement or laxity
  • Nonunion or malunion
  • Growth disturbance
130
Q

What are the advantages and disadvantages of arthroscopic vs. open and screw vs. suture fixation of tibial eminence fractures?

[JAAOS 2018;26:360-367]

131
Q

What are the features of a toddler fracture?

[JAAOS 2005;13:345-352]

A
  1. Minimally displaced, short spiral or oblique fracture of the tibia shaft without fracture of the fibula
  2. Caused by low energy twist or fall
132
Q

What is the management of pediatric tibia shaft fractures?

[JAAOS 2005;13:345-352]

A
  1. Nonoperative
  • Long leg cast for 4-6 weeks, then short leg cast for 4-6 weeks (PTB cast if proximal shaft)
  • Indications: Nondisplaced fractures, Displaced fractures with acceptable closed reduction
    * Age >8
    * <5° varus/valgus
    * <5° sagittal malalignment
    * <1cm of shortening
    * <50% translation
    * Age <8
    * <10° varus/valgus
    * <10° sagittal malalignment
    * <1cm shortening
    * 100% translation
    • Toddler fracture
      • 4 weeks immobilization
  1. Operative
    * indications: open fracture, polytrauma, floating knee, some segmental fractures, severe swelling, concern for compartment syndrome, vascular injury, unstable fractures not maintained by nonoperative means

Surgical options for the management of tibial diaphyseal fractures
* uniplanar and multiplanar External fixation
* Indications: high energy unstable fracture, Severe soft tissue injury

  • compressive plating
    • Indications: low grade open fractures with simple pattern (soft tissue dissection and exposure already performed
  • Lateral limited contact locked plating
    • Indications: open (potentially closed) comminuted or segmental fractures (patterns otherwise difficult to maintain reduction with flexible nails or ex fix)
    • Technique: 2 small incisions are made proximal and distal to the fracture site on the lateral side of the tibia, using blunt dissection to the periosteum to minimize inadvertent damage to the peroneal nerve. 3.5mm or 4.5mm LCP is then advanced in the sub muscular plane and secured with at least percutaneous 3 locking screws proximal and distal to the fracture site
  • Elastic stable IM nailing
    • Indications: closed fractures not amenable to cast treatment
    • advantages: extraphyseal, allows early WB, early activity and joint mobility, minimally invasive, allows monitoring of soft tissue and compartments
133
Q

What is the first option to consider when loss of reduction of a tibial shaft fracture occurs in a cast?

[JAAOS 2005;13:345-352]

A

Cast wedging

134
Q

What is the location of tibial stress fracture?

[JAAOS 2005;13:345-352]

A

Proximal 1/3

135
Q

What is the contribution of the distal tibia physis to tibia growth?

[JAAOS 2013;21:234-244]

136
Q

Describe the timing and progression of distal tibial physeal closure?

[JAAOS 2013;21:234-244]

A
  1. Timing
  • 18 month transitional period prior to complete closure
  • Complete closure at 14 in girls and 16 in boys
  1. Progression of closure
    * Central > anteromedial > posteromedial > posterolateral > anterolateral
137
Q

What is the management of SH I and II fractures of the distal tibia? [JAAOS 2013;21:234-244]

A
  1. Nonoperative
  • Closed reduction and casting
  • Delay greater than a week increases risk of physeal injury with closed reduction

Operative

  • Failure of closed reduction
    • Open reduction and casting
  • Unstable fracture
    • Percutaneous fixation
    • ORIF
      • Thurston-Holland fragment allows for screw fixation parallel to physis and perpendicular to fracture
138
Q

What is the management of SH III fractures of the distal tibia?

[JAAOS 2013;21:234-244]

A
  1. Presentation
  • Medial malleolus fractures
  • Tillaux fractures – avulsion of anterolateral distal tibia epiphysis (AITFL insertion)
  1. Nonoperative
    * <2mm displacement
  2. Operative
  • >2mm displacement
  • Anterolateral approach for Tillaux fractures
  • Medial approach for medial malleolus fractures
  • Screw fixation within the epiphysis parallel to physis
139
Q

What is the management of SH IV fractures of the distal tibia?

[JAAOS 2013;21:234-244]

A
  1. Presentation
  • Triplane
    • Sagittal plane through epiphysis, axial plane through physis and coronal plane through metaphysis
  • Medial malleolus (vertical)
  1. Nonoperative
    * <2mm displacement
  2. Operative
  • >2mm displacement or >2mm physeal gap
  • Medial malleolus fracture
    • Medial approach
    • Screw into epiphysis and metaphysis parallel to physis
  • Triplane fracture
  • closed reduction and perc screws OR open reduction if reduction not achieve by closed means
  • epiphyseal fracture is usually amenable to anteroalteral or posteromedial placed screws parallel to the physis
  • metaphyseal fragment usually gets captured wit direct anterior to posterior based screws
140
Q

What are risk factors for growth arrest following distal tibia physeal fractures?

[JAAOS 2013;21:234-244]

A
  1. Increasing Salter Harris classification (SHV > SHI)
  2. Physeal gap >3mm
  3. Periosteum entrapped in fractures site
  4. High energy injury
141
Q

What is the management of growth arrest of the distal tibia physis?

[JAAOS 2013;21:234-244]

A
  1. Corrective osteotomy for angular deformity
  2. Fibular epiphysiodesis to limit overgrowth and lateral impingement
  3. Physeal bar resection may be considered if <50% of the physis is compromised and >2 years or >2cm of growth remain
  • Peripheral bars approached directly
  • Central bars through metaphyseal window

Best indications for bar resection (as per Jarvis)

  • Younger children
  • Smaller bar
  • Shorter time interval (since bar development)
  • Central is better than peripheral
  • Traumatic etiology (as opposed to infectious, etc)
  • Healthy surrounding physis
142
Q

What is the weakest part of the musculotendinous junction in pediatrics?

143
Q

What secondary ossification centre of the lower extremity is the earliest to appear and which is last to fuse?

A
  1. First to appear = greater trochanter
  2. Last to fuse = ASIS
144
Q

What is the classification for apophyseal avulsion fractures?

A

McKinney Modified Classification

  • Type I - Nondisplaced
  • Type II - Displacement <2cm
  • Type III - Displacement ≥2 cm
  • Type IV - Symptomatic nonunion; painful heterotopic bone growth
145
Q

What is the management of avulsion fractures of the pelvis?

A
  1. Ischial tuberosity, ASIS, AIIS, pubic symphysis and iliac crest
  2. Nonoperative
    * Indicated for all nondisplaced and minimally displaced
  3. Operative
  • Displacement >2cm
  • Persistent pain following nonoperative
  • Impingement syndrome (AIIS)
146
Q

What is the definition of nonaccidental trauma (NAT)

A

Child abuse prevention and treatment act (american): any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse, or exploitation; or an act or failure to act, which presents an imminent risk of serious harm

147
Q

What indicators during the history should raise suspicion of NAT?

A
  1. No/vague explanation for significant injury.
  2. Denial of trauma in setting of significant boney injury.
  3. Mechanism of entry, not consistent with fracture type, energy associated with fracture or severity of injury.
  4. Injury inconsistent with a child’s physical and/or developmental capabilities.
  5. Inconsistent history across caregivers or changing histories provided by caregivers.
  6. Different different witnesses with different explanations.
  7. Injuries resulting from a family/domestic violence incident.
  8. Previous history of inflicted trauma.
  9. Witnessed inappropriate behaviour to a child placing them at risk of NAT
  10. Delay in seeking care for injury.
148
Q

When is a skeletal survey indicated according to the American Academy of pediatrics?

A

Indicated in the evaluation of a suspicious injury in any child younger than two years
* recommends the study be repeated in 2 to 3 weeks to assess for healing of non- or minimally displaced injuries, such as rib fractures, or better distinguished normal variance from healing injuries

149
Q

What syndrome and nutritional deficiency should be included in the differential diagnosis of NAT?

A

Osteogenesis imperfecta, menkes syndrome, juvenile idiopathic osteoporosis, osteopenia of immaturity, scurvy, copper deficiency, vitamin D deficient rickets

150
Q

What are the causes of paediatric acute compartment syndrome?

A
  1. Trauma. (Most common)
  2. Vascular insult, surgical positioning, overexertion, infection, neonatal, phenomena, or snake or insect bites.
151
Q

Who is the greatest risk of ACS?

A

Adolescent males

152
Q

What fractures are at greatest risk paediatric acute compartment syndrome?

A
  1. Tibial shaft (greatest risk)
  2. Forearm/wrist and foot (second)
  3. Combined supracondylar displaced forearm fracture = 33% risk of ACS
  4. Fractures associated with nerve palsies (delay presentation due to decrease sensation) (median n in supracondylar, peroneal n. In tibial shaft)
  5. Spica cast management of femoral shaft fractures.
  6. Crush injuries.
153
Q

What are the “three As’ in the diagnosis of pediatric ACS

A

Increasing anxiety, agitation and analgesia requirement

154
Q

What initial measures should be taken when evaluating a patient at risk of ACS

A
  1. Ensure normotensive
    • hypotension should be avoided (decreases perfusion pressure to tissue)
  2. Remove circumferential dressings
    • bivalving and splitting the cast by 0.5cm has been shown to decrease pressure by 47% in the anterior compartment and 33% in the deep posterior compartment of the leg
  3. Maintain limb at heart height
    • elevation can reduce arteriovenous pressure gradient
  4. Provide supplemental oxygen
155
Q

What is the management of pediatric ACS

A
  1. Emergent decompressive fasciotomy
  2. Myonecrosis should not be debrided at time of fasciotomy
    • muscle recovery is more robust than adults
    • myonecrosis has an 80fold increased risk of functional deficit
  3. Wound closure should be delayed
    • VAC may eliminate need for split thickness skin grafts
  4. Delayed diagnosis still warrants decompression
    • in presence of tissue and nerve damage a fasciotomy is warranted due to children’s potential for recovery
156
Q

For lateral condyle fracture, With what degree of fracture displacement is articular surface incongruence expected

A
  1. ≥4mm
  2. Type 2 fractures are typically ≥2 and <4mm of displacement (articular surface intact)
  3. Type 3 fracture are typically ≥4mm of displacement (articular surface incongruent)
157
Q

How is fracture displacement determined for a lateral condyle fracture

A

Greatest distance between the humerus and the fracture fragment on any radiographic views (AP, later, internal oblique)

158
Q

What are indications for nonop and operative treatment of lateral condyle fractures

A

Nonop indications
- ≤2mm displacement (weiss type 1)
Operative
- >2mm displacement (weiss type 2 and 3)
- Incongruent articular surface
- Progressive displacement on serial radiographs
- Failure of nonop treatment (delayed healing or inability to maintain or tolerate casting)

159
Q

What is the nonop treatment for lateral condyle fracture

A
  1. Long arm cast with elbow at 90° and forearm in neutral rotation
  2. Weekly radiographs for 3 weeks
  3. Cast continues for 4-6 weeks, remove once bridging and lack of tenderness demonstrated at fracture site
160
Q

What are features of pediatric radial neck fractures that would lead to a poor outcome

A
  1. Open reduction
  2. Age >10
  3. Greater fracture angulation
  4. Greater fracture displacement
  5. Time to surgery <2 days (suggest more severe injury)
161
Q

What is the average age of tibial shaft fractures in the pediatric population

A

8 year old (more common in males)

162
Q

What is the significance of the presence or absence of an associated fibula fracture

A

Fibula fracture present - risk of valgus alignment (due to contraction of anterior and lateral musculature)

Fibula fracture absent - risk of varus alignment (due to contraction of anterior muscles and tethering of the intact fibula)
60% will develop varus angulation in the first 2 weeks

163
Q

Which tibia fracture deformities have the greatest propensity to remodel

A

Apex anterior angulation, varus malalignment, single plane deformities have a greater ability to remodel, whereas apex posterior, valgus malalignment, and multiplanar deformities have less ability

0. Harty (30 decks)

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