Conflict of Interest. Learner Outcome. Management of Pediatric Upper and Lower Extremity Fractures. Pediatric Fractures: Unique Challenges 7/12/2016

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1 Conflict of Interest Management of Pediatric Upper and Lower Extremity Fractures I hereby certify that, to the best of my knowledge, no aspect of my current personal or professional situation might reasonably be expected to affect significantly my views on the subject on which I am presenting. Raymond Kleposki, RN, MSN, CPNP Learner Outcome As a result of this learning activity, the participant will gain confidence and apply knowledge and skills to practice in the care of the Pediatric Orthopaedic patient with an extremity fracture Pediatric Injuries Kids being Kids Annually in the U.S. : 200,000 playground related injuries 267,000 bike related injuries 200,000 trampoline related injuries 176,000 skateboard, roller skates, scooters 1.35 Million sports related injuries Pediatric Fractures Approximately 12-15% of US ER visits/yr. Significant cost and morbidity. Birth 16yrs: Girls: 27% chance of sustaining a fracture Boys: 42% chance of sustaining a fracture Despite injury prevention campaigns the overall rate of fractures is increasing. Pediatric Fractures: Unique Challenges Distinctive properties of the growing bone require special attention to recognize: Normal Variants vs Fractures Dangerous Fracture Patterns Physeal Fractures (and associated risks) Remodeling Potential Goal: Insure adequate healing while avoiding growth disturbance 1

2 Immature Bones Structurally different than adult bones! Less dense and more porous. Growth plates Point at which metaphysis connects to physis is an anatomic point of weakness Periosteum Acts like bark on a twig Can withstand greater force before breaking Often bend before breaking plastic deformation Greater potential to remodel : Thicker Periosteum Epiphysis Location in Bone Physis Metaphysis Diaphysis Fractures closer to the physis have higher remodeling potential and remodeling is better in the plane of motion A Few Must Know Common Pediatric Fractures Salter Harris Fractures Salter Harris 1-5 Supracondylar Humerus Fractures Type 1 Type 2 Type 3 Distal Tibia Transitional Fractures Triplane/Tillaux Salter Harris Fractures The Salter-Harris Classification System: Since the 1960's, the Salter-Harris classification, which divides most growth plate fractures into five categories based on the type of damage, it has been the standard for diagnosing growth plate injuries. Higher the classification ( I V) = higher the risk of physeal arrest. Salter Harris Fractures S: same level A: above L: lower T: through ER: extensive crush injury *most common: type II *type I (best prognosis) --> type V (worst prognosis) 2

3 Salter Harris Fractures Periosteum Peri = surrounding osteum = the bone Can help maintain alignment of simple fractures. Can aid in the reduction of fractures. Greater the age = thicker periosteum = greater remodeling potential. Figure from Rockwood & Wilkins Fractures in Children. 6th Edition, 2006 Stages of Fracture Healing (Timing of stages may vary based on several factors) 1) Reactive phase Fracture and Inflammatory stage/forms hematoma (with in a few hours) Granulation tissue formation (hours days) 2) Reparative phase Cartilage (soft callus/early callus) formation ( by 3 weeks) Lamellar bone deposition (4 weeks 3 months) 3) Remodeling phase Remodeling to original bone contour (may continue for several years) Acute Fracture Management Simple Immobilization Splint/Brace/Cast Sling Closed Reduction and Casting Closed Reduction and Percutaneous Pinning/Fixation Open Reduction and Internal Fixation Closed Reduction Principles Closed Reduction Principles All displaced fractures should be reduced to minimize soft tissue complications, including those that require Open reduction, internal fixation (ORIF) Use splints initially Allow for swelling Adequately pad all bony prominences Adequate analgesia and muscle relaxation are critical for success Reduction maneuver may be specific for fracture location and pattern Correct/restore length, rotation, and angulation Immobilize joint above and below 3

4 Closed Reduction Principles Reduction may require reversal of mechanism of injury, especially in children with intact periosteum When the bone breaks because of bending, the soft tissues disrupt on the convex side and remain intact on the concave side Figure from Chapman s Orthopaedic Surgery 3 rd Ed. (Redrawn from Charnley J. The Closed Treatment of Common Fractures, 3rd ed. Baltimore: Williams & Wilkins, 1963.) Closed Reduction Principles Longitudinal traction may not allow the fragments to be disimpacted and brought out to length if there is an intact soft-tissue hinge (typically seen in children who have strong perisoteum that is intact on one side) Figure from Chapman s Orthopaedic Surgery 3 rd Ed. (Redrawn from Charnley J. The Closed Treatment of Common Fractures, 3rd ed. Baltimore: Williams & Wilkins, 1963.) Closed Reduction Principles Reproduction of the mechanism of fracture to hook on the ends of the fracture Angulation beyond 90 is usually required Figure from Chapman s Orthopaedic Surgery 3 rd Ed. (Redrawn from Charnley J. The Closed Treatment of Common Fractures, 3rd ed. Baltimore: Williams & Wilkins, 1963.) - Three point mold is necessary to maintain closed reduction - Takes a good deal of practice and learning to perfect molding Closed Reduction Principles Figure from: Rockwood and Green: Fractures in Adults, 4 th ed, Lippincott, Closed Reduction Principles Casts are well-molded to resist deforming forces Crooked casts lead to straight bones Straight casts will lead to crooked bones Closed Reduction and Casting Goals: Get the bone straight and keep it there! The role of the cast! A good cast is just as important if not more important than a good reduction. Majority of acceptable reductions that are lost are due to bad casting Figure from Rockwood & Wilkins Fractures in Children. 6th Edition,

5 Evolving Roles (APP role in Orthopedic Practice) Role of the APP Early Role: Assist Surgeon with inpatient care/admit/discharge, postop care, office management, documentation, 1 st assist in OR, casting/splinting/dressing changes, education Todays Role: Assist Surgeon with inpatient care/admit/discharge, Post-Op care, 1 st Assist in OR, casting/splinting, dressing changes, education, Independent Patient Volumes Acute/Chronic conditions In Pediatric Orthopedics many major academic hospitals/institutions as well as private practices have evolved the way that APPs are utilized. Particularly when it comes to the management of high patient volumes and the treatment of acute fractures. Extension of the Surgeon Minimal Relative Value Unit $$ generating, Primarily assist with Surgeon Patient Volume Collaborative Practice Partner Significant Relative Value Unit $$ generating Assist with overall Practice Patient Volume Advanced Skills: Aspirations/injections, laceration repairs, casting, hand/fingertip repairs, closed reductions Many practices are utilizing the APP to perform moderately invasive procedures like closed reductions and complex laceration repairs that were typically preformed by a physician or resident. Pros and Cons Closed Reduction by Advanced Practice Start to Finish Average cost 50%-60% less No hardware/hardware removal No scars Decreased Risks: General Anesthesia Infection Less invasive Increased Risks: Loss of reduction Mal-reduction Multiple Cast Changes Higher # of clinic visits (3-4) Taken to the OR Start to Finish Average cost 60% higher +/-Hardware removal/2 nd OR + Scaring Decreased Risks: Loss of reduction Mal-reduction Increased Risks: General Anesthesia Complications Infection More Invasive Fewer # of clinic visits (2-3) Above All else Keys to Success Close Working Relationship with Orthopedic Surgeon: Open Communication and Availability Mutual Trust with a Collaborative Practice Established Case/Reduction Review Process Constant Feedback and Education M&M Quality Improvement Process Keys to Success Be confident in your knowledge of and ability to safely manage both the fracture and the family: Know acceptable alignment parameters Know reduction/casting techniques for specific fracture patterns Be aware of common complications with particular fracture patterns Reassure family that all reductions are reviewed and discussed with Staff Orthopedic Surgeon during rounds. Keys to Success Spend time with the family preprocedure: Review and Discuss x-rays and exam Discuss expected outcome of CR Bones don t always match up like a puzzle piece nor do they need to. (Best to know this upfront) Discuss the bone remodeling process and the role of periosteum Periosteum Acts like bark on a twig 5

6 Avoid Surprises! Keys to Success Some fractures are difficult to get with Closed Reduction the family needs to know there is a chance that acceptable alignment may not be achieved and what the plan would be should this occur. Jobs not done after the Closed Reduction. Treat closed reductions like a surgeon treats a surgical procedure: Review x-rays and reinforce all of the pre-procedure and post procedure discussions again with the family. Discuss Home Care and F/U plans in detail... Avoiding Trouble Recognize irreducible fracture patterns Follow Post Reductions weekly until stable in well fitting cast. (2-3 weeks for most) Discuss difficult fractures with Staff prior to attempting reductions. Methods Used for Anesthesia Good Cast vs Bad Cast Hematoma Block Nitrous Gas with Nasal Fentanyl Conscious Sedation Well fitting Straight ulnar border Close to 90 degrees Good Interosseous mold Not 90 degrees (banana cast) Wrinkles in cast No mold Lots of room in cast from using to much padding Bier Blocks Salter Harris II Fracture What is the Plan? Thurston Holland Fragment metaphsyeal component Can you Describe the Fracture? What needs to be considered? 6

7 Post Reduction 6 weeks Post Reduction 10 y/o Male Status Post fall from Skateboard (FOOSH) Salter Harris 2 Distal Radius What is a FOOSH? What is the Plan? Can you Describe the Fracture? What needs to be considered? Hematoma Block and closed reduction with long arm cast 11 y/o Female fall from bike 1 wk f/u 1 wk f/u 6 wk f/u 6 wk f/u 7

8 What is the plan? Closed Reduction with well molded supinatedlong arm cast Can you describe the fracture? What needs to be considered? 12 Month Follow Up Symmetrical Range of Motion : No Complaints JBJS 2012 Distal Radius Fractures Cost 5x less than Closed Reduction Cost 9x less than Fixation Equivocal Satisfaction Time/Resources saved in ER >/= 2hrs This Treatment protocol presents an alternative approach to overriding distal radius fractures in children and provides a simple, effective & cost/time-efficient method for treatment.???? 12 Months Post Distal Radius 8

9 Not a New Concept. JPO 2003 Distal Radius Fractures < 11 y/o left with1cm or less of shortening and <15 degrees of angulation will heal and remodel acceptably within months Fewer associated risks than with more aggressive treatment options Radius/Ulna Fracture Guidelines Acceptable Alignment Age < 8 yrs: Distal 1/3: 40 degrees Midshaft : degrees Proximal 1/3: 10 degrees Complete displacement 100% Translation if shortening < 1cm Malrotation (controversial) but generally < 45 degrees is acceptable Bayonette apposition/overlapping < 1cm (won t block rotation) Age > 8 yrs: Distal 1/3: < 20 degrees Midshaft: < 15 degrees Proximal 1/3: < 5 degrees < 30 degrees malrotation (again controversial) Alignment and Remodeling Principles Potential to Remodel Distal > Proximal Angular > Rotational Saggital > Frontal 80% of growth occurs distally Closer fracture is to distal physis = better remodeling Remodeling is from physeal growth & appositional new bone filling concavity Example #1- Radius/Ulna Shaft 7 y/o Female FOOSH Trampoline Closed Reduction with long arm cast Radius/Ulna Shaft Radius/Ulna Shaft Post Reduction (Fluoroscopy views) 2 weeks: Cast was changed in clinic 1 week F/U 12 weeks: Shows abundant helaing 9

10 Radius/Ulna Shaft Radius/Ulna Shaft 8 y/o Female (Fall off trampoline) Post Reduction (Fluoroscopy views) Closed Reduction & long arm cast. 1 week F/U Casted x 6wks Cast D/C with FFWB x 3wks more Healed and Released to activities at 9 weeks Radius/Ulna Shaft JBJS 2002 Both Bone Forearm Shaft Fractures Trend toward surgical treatment driven by advances in surgical techniques/instrumentation, concerns over functional outcomes and convenience Despite recent trend to treat more aggressively most literature does not support JBJS 2013 Still Fails to support Both Bone Forearm Shaft Fractures 10 y/o Male : Fall From Tree Both operative and non-operative treatments yield good results Closed reduction and Immobilization remains preferred method of treatment when able to be done safely through close follow up and appropriate interventions 10

11 What is the Plan? Closed Reduction & Cast Can you Describe the Fracture? What needs to be considered? What is wrong with this cast? What could be better? What outcomes may we expect? What dialogue do you have with parents? 3 Improvements? Complete the incomplete fracture of Ulna! Important to have cast at 90 degrees with extremely flat Ulna border! Ulnar deviation might help bring radius over 1 WK F/U: 16 degrees ulna bow Increased Room in cast Subtle shortening and increased angulation in radius 16 degree residual angulation Planned to change cast at 2 wk F/U.But family did not return until 3 wks Injury 10 days 5 weeks 12 weeks 10 months 11

12 Humeral Shaft Guidelines 3cm shortening 30 degrees varus/valgus 20 degrees A/P angulation Varus/Valgus angulation tolerated better more proximally. Injury 10 days 5 weeks 12 weeks 10 months No set values for acceptable malrotation, however compensatory shoulder motion allows for considerable tolerance of rotational deformity. Beaty, JH. Orthopedic Knowledge Update Rosemont, American Academy of Orthopedic Surgeons, 2000 Humeral Shaft 13 y/o Male fall from horse sustaining a midshaft humerus fracture Placed into Long Arm Hanging Cast Humeral Shaft Surgery needed? What is your plan? What are expected outcomes? What do you tell parents? Humeral Shaft Humeral Shaft 1 week : Post Casting 10 weeks 5 weeks : Cast discontinued and placed into sling and foot flat weight bearing 18 weeks 12

13 Humeral Shaft Supracondylar Humerus Fractures Most common elbow fractures in children and adolescents 50-70% of all elbow fractures 1 year later A A Most common between ages 3-10 years B B Figure from Rockwood & Wilkins Fractures in Children. 6th Edition, 2006 Supracondylar Humerus Fracture Treatment Type 1: Occult or Non-Displaced Posterior Fat Pad Cast elbow at 90 degrees for 3-4 weeks Type 2: Closed Reduction & LAC 3-4 weeks CRPP Type 3: CRPP ORPP if unable to reduce Know Your Ossification Centers CRITOE : Capitellum- 1 yr Radial Head- 4-5 yrs Internal 4-5 yrs Trochlea 8-9 yrs Olecranon 8-9 yrs External 10 yrs Radiographs Fat Pads Supracondylar Humerus Fractures- Gartland Classification Type I Type II Type III Non-displaced Posterior Cortex Intact Completely Displaced Figure from Rockwood & Wilkins Fractures in Children. 6th Edition, 2006 Anterior HL intersects capitellum middle 1/3 Anterior HL does not intersect capitellum Anterior & posterior cortex not intact 13

14 6 y/o Male fell from monkey bars Presented to the ER with a Type 2 supracondylar humerus fracture Plan?? JPO 2012 on Type 2 Supracondylar Humerus Fractures Some less severe T2 SCH fractures can be successfully treated without surgery if close follow up is achieved Fractures with initial rotational deformity, coronal misalignment and significant extension are likely to fail a non-operative approach JPO 2013 T2 SCH fractures Conservative treatment consisting of closed reduction and casting should be considered a valid option for the treatment of type II supracondylar humeral fractures Discussed risks and benefits of attempted closed reduction and casting versus surgery Radiological and functional results are as good as those obtained with surgical treatment Avoiding surgical complications and decreasing the hospital stay Followed closely with x-rays at week 1 and week 2 Monteggia Fractures Proximal 1/3 ulna fracture with associated anterior dislocation of the radial head. Usually presents as an obvious deformity of the proximal forearm and elbow. Healed with anatomic alignment at 3 weeks Pain free with Full Range Of Motion at 5 week Follow Up 14

15 Monteggia Fractures 5 y/o Male - fall from Swing Although some literature fails to support more conservative treatment of these challenging fracture patterns we seem to do very well treating them with closed reduction and casting. Recognize opportunity for future study.. Closed Reduction and Supinated LAC At 1 Week Closed Reduction and Supinated Long Arm Cast Healed with Acceptable Alignment and Full Range of Motion at 8 weeks 15

16 Femur Shaft-Acceptable Alignment at Union AAOS Guidelines year old child with femur fracture 2-10yrs: < 15 degrees varus/valgus < 20 degrees Anterior /Posterior angulation < 30 degrees malrotation < 2cm shortening 4 weeks after fracture: < 5yrs or 50 lbs..spica Cast >5yrs or 50 lbs..consider Fixation Lovell and Winter s Pediatric Orthopaedics, year old child with femur fracture 4 year old child with femur fracture 4 months after fracture: 18 months after fracture: Femoral Shaft 4 year old F fell from swing. Sustaining a midshaft femur shaft fracture. 16

17 Femoral Shaft Femur Shaft 7 weeks (Spica cast D/C) 2 Weeks 3 Weeks Femur Shaft Remodeling and elongation continues for 5 years 1 and ½ years later Salter Harris I Fracture No obvious Fracture on x-rays Sometimes widening Focal Tenderness to Palpation at distal Fibula physis Note improvement in ankle fracture too Localized soft tissue swelling Transitional Fractures Transitional Fractures Triplane Fractures Salter Harris II and III 3 part fracture Younger age than Tillaux > 2mm displacement after Closed Reduction = Closed Reduction with Percutaneous Pining versus Open Reduction with Internal Fixation Tillaux Fractures Salter Harris III Fragment pulled off by Anterior TaloFibular Ligament > 2mm displacement after Closed Reduction =Open Reduction with Internal Fixation Physeal Anatomy at the distal tibia Mechanism of Injury : External rotation force applied to asymmetrically closing physis Fusion of physis: mid-portion, medial, anterolateral Avg. time to fusion 18 months Physis Closes: 12 y. females, 13 y. males 17

18 Salter Harris III Fracture of Distal Tibia SH IV of Distal Tibia X-Rays SH IV of Distal Tibia CT Scan Salter Harris IV of Distal Tibia Triplane CT Scan CT Scan CT Scan Tillaux X-Ray 3D CT Scan Post-Op X-Rays Example #3- Tibia/Fibula Shaft 11 y/o Male Hit by a car. Tibia Shaft Guidelines Not Absolute < 8yrs 10 degrees varus/valgus 10 degrees sagittal plane 100% translation > 8yrs 5 degrees varus/valgus < 5 degrees sagittal plane 1cm shortening 50 % translation 18

19 Tibia Shaft X-Rays Tibia Shaft Post Closed Reduction and Long Leg Cast 6 Weeks Post Closed Reduction 8 Weeks Post Reduction 14 Weeks Post Reduction References References AAOS Guideline for the Treatment of Pediatric Thighbone Fractures AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009 AAOS Guideline for the Treatment of Pediatric Thighbone Fractures A. Shindeler, M. Mcdonald, G. Little. Cell Developmed and Biology, remodeling. Bone remodeling during fracture repair: The cellular picture. Volume 19, issue 5, October 2008, Pages Bone LB, Sucato D, Stegemann PM. Displaced isolated fractures of the tibial shaft treated with either a cast or intramedullary nailing. An outcome analysis of matched pairs of patients. J Bone Joint Surg Am 1997;79: Charnley J. The Closed Treatment of Common Fractures, 3rd ed. Baltimore: Williams & Wilkins, 1963 Court-Brown CM. Fractures of the tibia and fibula. In: Rockwood and Green's Fractures in Adults, 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006: Herring JA. Upper extremity injuries. In Tachdjian's Pediatric Orthopedics, 4 th Ed. Saunders, Philadelphia p Kellam JF, et al. Orthopaedic Knowledge Update: Trauma 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp Price, Charles. Journal of Pediatric Orthopaedics: March 2010-volume 30-issue-pp S82-S84. Acceptable Alignment of Forearm Fractures in Children. Rockwood and Green: Fractures in Adults, 4th ed, Lippincott, Rockwood & Wilkins Fractures in Children. 6th Edition, 2006 US Consumer Product Safety Commissions National Electronic Injury Surveillance System Upper Extremity Orthopeadic Trauma in Children. Presention by Lane Wimberly, MD. Childrens Medical Center Dallas Webb GR, Galpin RD, Armstrong DG. Comparison of short and long arm plaster casts for displaced fractures in the distal third of the forearm in children.j Bone Joint Surg Am2006, 88(1): THANK YOU FOR YOUR ATTENTION Questions or Comments RAYMOND.KLEPOSKI@TSRH.ORG 19