Pediatric Tibia Fractures Key Points. Christopher Iobst, MD

Transcription

1 Pediatric Tibia Fractures Key Points Christopher Iobst, MD

2 Goals Bone to heal Return to full weight bearing Acceptable alignment rule of 10s 10 degrees of varus 8 degrees of valgus 12 degrees of procurvatum 6 degrees of recurvatum Dwyer AJ, John B, Krishen M, et al. Remodeling of tibial fractures in children younger than 12 years. Orthopaedics. 2007;30: % translation, and 10 mm of shortening

3 Most Commonly Missed Fracture

4 Non-Operative Management

5 Casting Long leg cast with knee bent degrees Admit for observation and elevated Incidence of compartment syndrome 11.6% Frequent, regular examinations 3 A s (analgesia, anxiety, agitation) Bi-valve cast Minimal pain medicine Can require > 3 months immobilization

6 Casting Fibula broken 1/3 of the time Valgus 3 point mold in initial cast Recurvatum deformity: foot should be placed in slight plantar-flexion Plantar aspect of the cast should come up the MTP flexion crease Do not compress/encase the small toe Careful padding of prominent areas (Achilles insertion, calcaneus)

7 Cast Wedge (Neutral)

8 Cast Wedge (Opening)

9 Cast Wedge (Opening)

10 74 patients aged Rate of closed treatment failure is approximately 40% in this patient population The presence of initial sagittal-plane displacement greater than 20% and of an associated fibula fracture represent independent risk factors for closed treatment failure Kinney et al. J Pediatr Orthop 2016

11 Toddler s Fracture Initial immobilization of a toddler s fracture in a boot resulted in faster return to weightbearing Bauer JM et al. JPO 2017

12 Surgical Indications for Pediatric Tibia Fractures Failed closed reduction Unstable fracture patterns (segmental, >10 varus with intact fibula, etc) Open fractures Fractures with neurovascular deficits Polytrauma/floating knees Severe swelling with concern for compartment syndrome Patients with spasticity Morbidly obese patients

13 Surgical Options

14 Pinning Cross pins most common Can start both from medial side (one antegrade, one retrograde) Can use threaded pins Use multiple pins Can incorporate the pins in plaster To prevent skiving start drilling perpendicular to get hole started, then drop hand

15 Pinning Brantley J et al. Iowa Orthop J 2016;36:

16 Flexible Nails Excellent for most diaphyseal fractures Choose two same size nails (each 40% width of canal) Pre-contoured so that the apex of the bend lay at the fracture site One cm incision over medial/lateral metaphysis distal to proximal tibial physis

17 Flexible Nails Orient tips posteriorly to avoid recurvatum Ensure fracture is axially compressed Avoid multiple passes Can induce a compartment syndrome 20-32% rate in the literature Leave approximately 1 cm of nail outside bone

18 Ebraheim et al. J Orthop Trauma 2016

19 Flexible Nails Non-rigid fixation Nail migration, delayed union, malunion Weight bearing delayed 4-6 weeks Watch for leg length discrepancy esp. under age 8 Lee SH et al. Factors related to leg length discrepancy after flexible intramedullary nail fixation in pediatric lower-extremity fractures. Journal of Pediatric Orthopaedics B 2015, 24:

20 6 week follow-up visit

21 One year after surgery

22 Flexible Nails for Tibia Fractures Very proximal or distal fractures are difficult to nail Length unstable fractures (long oblique, spiral, comminuted) are not well controlled Nails can create deformity (procurvatum/recurvatum)

23 Minimally Invasive (Locked) Plating Preserve soft tissues at the fracture site Remote incisions Stable fixation that allows early mobilization Masquijo 2014 JPO-B 23:

24 Plate Fixation Caution against plate fixation for Type II or III open fractures Nandra et al. Bone Joint J 2017

25 Flexible Nailing Vs. ORIF Pediatric Tibial Shaft Fractures 70 patients (44 IM nailing, 26 ORIF) Both have high union rates (Flex nails 95%, ORIF 100%) ORIF healed faster and walked faster Residual deformity: ORIF 15% Flex nails 41% Implant removal: ORIF 27% Flex nails 84% Wound complications: ORIF 23% Flex nails 9% Pennock AT et al. J Pediatr Orthop 2017

26 External Fixation

27

28 External Fixation Significantly quicker healing time, better maintenance of reduction and less complications in the hexapod group Corrected cost analysis the hexapod treatment was equivalent to uni-planar treatment An acute reduction is not needed and gradual correction can occur over time in a more soft tissue conscious manner, which may decrease the incidence of soft tissue related problems Shore B et al. Uniplanar Versus Taylor Spatial Frame External Fixation For Pediatric Diaphyseal Tibia Fractures: A Comparison of Cost and Complications JPO 2015

29 Flexible Nails Plus External Fixation Erturk et al. Orthop and Traumat 2013

30 Open Fractures Prompt intravenous antibiotics Fracture stabilization No increased risk of infection with flexible nails Pandya NK, Edmonds EW: Immediate intramedullary flexible nailing of open pediatric tibial shaft fractures. J Pediatr Orthop 2012;32(8):

31 Open Fractures Allows limb to be held in position that promotes safe wound closure Decreases need for wound VAC or flap coverage Gradually re-position the bones once the soft tissues are healed Nho SJ, Helfet DL, Rozbruch SR. J Orthop Trauma Jul;20(6): Sharma H, Nunn T Conversion of open tibial IIIb to IIIa fractures using intentional temporary deformation and the Taylor Spatial Frame. Strategies Trauma Limb Reconstr Aug;8(2):

32 Soft Tissue Control

33 Transitional Fractures

34 Tibial Tubercle Fractures 97% male Mechanisms of injury are a strong quadriceps contraction during knee extension during jumping and rapid passive flexion of the knee against the contracting quadriceps while landing

35 Pattern of Proximal Tibial Physeal Closure Pandya et al JPO 2012 Sagittal: Posterior to Anterior Coronal: Medial to Lateral Axial: Posteromedial to Anterolateral

36 Tibial Tubercle Fractures Big incision Large soft tissue injury Split patellar tendon Fasciotomy Washers

37 Pandya Classification JPO 2012 Type B = Physeal Injury where epiphysis and tubercle fracture off as a unit No intra-articular involvement because there has not been closure of the physis/apophysis

38 Type B Tibial Tubercle Fracture

39 Management of Tibial Tubercle Type B (Physeal) Fractures Highest risk of compartment syndrome/vascular injury Smooth K-wire fixation to preserve growth of the open proximal tibial physis

40 Pandya Classification JPO 2012 Type C = Intra-articular Injury extends into the intra-articular surface of the proximal tibia due to partial closure of proximal tibial physis

41 Management of Tibial Tubercle Type C (Intra-articular) Fractures Should have advanced imaging to assess intraarticular fracture pattern Should have intra-operative arthrotomy or arthroscopy to assess soft tissue/chondral injury within the joint Lateral meniscal tears Coronary ligament injury Osteochondral defects Rigid fixation with screws

42 Distal Tibial Physeal Closure Pattern Distal tibial physis closes in the following order 1. Central (first) 2. Posterior 3. Medial 4. Anterolateral (last)

43 Tillaux Fracture

44 Tillaux Named after Paul Jules Tillaux, a French Anatomist and Surgeon ( ) Reduction techniques Closed With the foot in plantarflexion, reduction is achieved with traction and internal rotation Reduction Clamp Mini-Open Open

45 Tillaux The fragment is explored through an anterolateral approach Washers Medial to lateral percutaneous screw Oblique screw orientation vs. all intra-epiphyseal

46 Thank You