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The Management of Complex Pediatric Fractures: Case Examples Demonstrating 5 Principles for Success

Flynn, John M., MD

Journal of Pediatric Orthopaedics: July 2018 - Volume 38 - Issue - p S34–S38
doi: 10.1097/BPO.0000000000001167
Cutting-Edge Pediatric Orthopaedics 2017: A Global Perspective
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Advances in imaging, surgical techniques, and surgical implants have improved pediatric fracture care, yielding results that are demanded by families who expect anatomic reductions and rapid return to activities. There are 5 principles for success in the management of complex pediatric fractures: assessing for associated injuries, optimizing imaging and precisely define the injury preoperatively, thoughtfully completing preoperative planning and operating room set up, assuring reduction/fixation is optimal before leaving the operating room and getting immobilization, observation and follow-up just right.

Division of Orthopaedic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA

The author declares no conflicts of interest.

Reprints: John M. Flynn, MD, Division of Orthopaedic Surgery, The Children’s Hospital of Philadelphia, 34th and Civic Center Boulevard, Wood Building, 2nd Floor, Philadelphia, PA 19104. E-mail: flynnj@email.chop.edu.

Pediatric fracture care has advanced dramatically over the last generation.1 An improvement in evaluation, imaging, surgical techniques, and surgical implants have yielded the results that are demanded by families who expect anatomic reductions (even when a child’s extraordinary remodeling potential obviates the need for such a reduction), excellent results and a rapid return to activities, especially high-level youth sports. In meeting these demands, it is easy for surgeons, especially young orthopaedic surgeons in training, to lose sight of the key principles which yield a good result and minimize complications. The goal of this short lecture at EPOSNA, Barcelona, 2017 is to take a high level view of modern pediatric orthopaedic fracture care. Rather than focus on a particular fracture, or a particular novel surgical technique, the aim is to provide some key, timeless principles that if followed, will yield excellent results with complex pediatric fractures, and limit complications.

There are 5 principles for success in the management of complex pediatric fractures:

  • Assess for associated injuries.
  • Optimize imaging; precisely define the injury preoperatively.
  • Thoughtful preoperative planning and operating room (OR) set up.
  • Assure reduction/fixation is optimal before leaving the OR.
  • Postop care: getting immobilization, observation and follow-up just right.

These 5 principles likely seem straightforward to the experienced pediatric fracture surgeon. Indeed, the 5 principles are easy to define, and provide a great framework for teaching pediatric fracture care to young trainees. However, it can be hard to appreciate the importance of these 5 principles until the surgeon has had a decade or 2 of experience. What follows is a description of each of the principles, illustrated by a case or cases that demonstrate the importance and utility of each principal.

  • Assess for associated injuries. The easiest injury to miss is always the “second injury.” In medical education, we teach the concept “the eye sees what the mind knows”; this certainly applies to the early teaching of pediatric fracture care, where injury recognition must be mastered. However, the next step in sophistication is to learn the discipline to look for second injury. There is the principle of “satisfaction of search”: once your eyes spot an injury, your brain stops thinking. Trauma usually causes the young skeleton to fail in one spot, but always accepting “usually” can get you in trouble. A classic example of this is seen in Figure 1, in which the ulna fracture stands out, but the associated radiocapiteller dislocation is missed. Common missed associated injuries include a second fracture, an associated joint dislocation, an adjacent physeal fracture, or associated neurovascular injury. The associated injury is sometimes obvious, as in a floating elbow (Fig. 2), or it may be very subtle, as in an adjacent physeal fracture (Fig. 3). This principle of satisfaction of search is particularly important to our radiology colleagues, who are trained to look at the edge of an image before they look at the center, where the pathology often is. We should learn from their discipline.
  • Optimize imaging: precisely define an injury before surgery. Typically, 2 good views of the injured bone and joint are enough to define the injury and plan treatment. In most cases, oblique views or comparison views of the uninjured extremity do not improve care, and simply expose the child to unnecessary additional radiation. However, there are several circumstances where additional plane radiographic views, or a computed tomographic scan, or a magnetic resonance imaging provide important additional information that might find a missed injury, better define a fracture (sometimes changing treatment) or assist with planning surgical management. A common scenario where an additional radiographic view can be valuable is in decision-making for the treatment of lateral condyle fractures. Fracture displacement is best seen on the internal oblique view. Sometimes a lateral condylar fracture that looks nondisplaced on the anteroposterior or lateral view of the distal humerus will show 3 mm or more of displacement on the internal oblique view, confirming that surgical management would be the best option. Two examples where routine use of a computed tomographic scan to define the injury and perhaps plan surgery include the triplane fracture of the distal tibia (Fig. 4) and the occult capitellar sheer fracture (Fig. 5). An example where an magnetic resonance imaging adds important information is the occult physeal fracture of the distal femur (Fig. 6).
  • Thoughtful preop planning and OR set up. For most pediatric fractures, setting up the OR and positioning the patient is quite straightforward: supine position, fluoroscopy, pin fixation. However, there are several scenarios where much more planning is needed. In some circumstances, the key is optimally positioning the patient, in other circumstances a co-surgeon should be available or special implants might be needed. The pinning of a proximal humerus fracture is a classic patient positioning challenge. The surgeon needs to access the pin entry site, hold the fracture reduced, while simultaneously achieving biplanar imaging. The posterior sternoclavicular fracture-dislocation requires very careful planning and teamwork. On rare occasions, reduction of the fracture can uncover damage to one of the great vessels, which could lead to catastrophic or even fatal bleeding. Such injuries require a thoracic surgeon on ready to assist, and a prepping and draping plan that allows wide access to the chest major vessels. Perhaps no area of pediatric fracture care has changed as much as implant selection. It was not long ago that most every pediatric fracture was managed either with the cast, or with pins. Today, there are many options for intramedullary, plate, or screw fixation. Often, careful thought and planning must be given to matching the implant to the fracture personality as well as the patient size.
  • Assuring optimal reduction/fixation before leaving the OR. The pediatric fracture surgeon has not completed her or his job until the fracture reduction is satisfactory, the implants are precisely where they need to be, and the fixation will withstand a noncompliant postop patient (it is wise to consider each young child noncompliant). An illustrative example of this principle would be the spiral femoral shaft fracture treated with elastic nails (Fig. 7). At the end of reduction and fixation of such a fracture, it is not enough just to be sure that the intraoperative radiographs show satisfactory reduction. In addition, the surgeon must assure that the child’s rotational alignment is satisfactory on examination after fixation. It is very easy to have a significant rotational malalignment despite intraoperative radiographs that look satisfactory. Perhaps the most common and important example of assuring optimal reduction fixation in the operating room is the case of the type III pediatric supracondylar humerus fracture. Obtaining a satisfactory closed reduction and placing 3 pins that appear in satisfactory position can be challenging enough, and it is easy to relax, celebrate, and apply a cast. However, the new pediatric orthopaedic surgeon will learn quickly, through cases of loss of reduction, that he should never leave the OR until he has proven that his supracondylar pinning is stable to stress. After all pins are placed and their position checked fluoroscopically, I begin with the elbow in 120 degrees of flexion and take a lateral x-ray. I then proceed to 90, 60, and then 30 degrees, shooting a lateral fluoroscopic image at each position, while staring at the distal humeral fragment. No movement should be seen in the distal fragment throughout a range of flexion and extension. Next, an anteroposterior view should be obtained in the distal humerus and gentle rotational and varus/valgus stress should be applied to assure that fixation is satisfactory. Once this is achieved, the cast can be applied and the surgeon can be confident that there is a very low risk of fracture displacement in the cast over the next 3 weeks of healing. Another common fracture that must be assessed carefully is the Monteggia fracture, after fixation of the ulna. When is the best time to discover that your radiocapitellar joint is not perfect, or that the ulna fixation is not stable enough? Of course, it is in the OR, not several weeks later when ulna has healed, the radiocapitellar joint is dislocated and a much more complicated “missed Monteggia” surgery is necessary.
  • Postoperative care: getting the immobilization, observation and follow-up just right. With experience, the pediatric fracture surgeon learns that postoperative care begins in the OR. There are several elements to consider. Supplemental casting is more valuable in pediatric fracture care than adult care, and the pediatric fracture surgeon should learn to be a craftsman with his/her cast. Any surgical wounds and exposed pins need to be protected carefully. A thoughtful decision should be made regarding the optimal time for a first postoperative visit. A paragon of these principles is shown in Figure 8, in which a Bado III Monteggia fracture is fixed in a 5-year-old. In such a case, great thought should be given to optimal surveillance of this potentially unstable fracture, implant removal, and initiation of elbow movement. Another example in which this principle is ignored at the surgeons peril is protection of the fixed femoral neck fracture. When internal fixation is used for a femoral neck fracture in a child with an open physis, and the screws are not placed across the physis, the actual fixation can be deceptively weak in the cancellous bone of the femoral neck. There may be comminution in this area that is not recognized, and the overall fixation is notoriously limited. Pediatric fracture surgeons should heed this advice: if you fix a femoral neck fracture in a child who you feel is too young to place the screws into the epiphysis, then the hip should be protected in a walking Spica cast for 4 to 6 weeks. Another example of the importance of thoughtful postoperative management is arthroscopic reduction fixation of the tibial spine fracture. These fragments are small, and fixation in the proximal tibial epiphysis can be quite limited. It is tempting to place a cast for few weeks to protect the reduction fixation. However, such a plan is a prescription for arthrofibrosis. It is essential to fix the tibial spine well enough so that it can be moved in the immediate postoperative period.
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Pediatric fracture care is often extremely satisfying, because the skilled and thoughtful surgeon can reproducibly generate outstanding outcomes and a full returned to activity, with no long-term problems. Compared with many pediatric orthopaedic congenital deformities and conditions which are hard to make “normal” even with optimal treatment, pediatric fractures can heal and yield a perfectly normally functioning limb. Although it may take years to learn the fine points of pediatric fracture management, following the 5 principles outlined here will offer the young surgeon the best chance to limit complications and produce consistent excellent results with complex fractures.

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REFERENCE

1. Flynn JM, Skaggs DL, Waters PM. Rockwood and Wilkins Fractures in Children, 8th ed. Philadelphia PA: Wolters Kluwers Health; 2015.
Keywords:

complex pediatric fractures; imaging; preop planning; fracture fixation; postoperative planning

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