Transcript Approach to Pediatric Fractures in the foot and ankle

Dan Preece MS IV
CSPM Class 2009
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Accident: the leading cause of death for pts under 14 years
of age.
Half of all emergency room admissions are for children.
In a 10 year study of 700 pediatric fractures only 6%
involved the foot and ankle with injury to the distal tibia
and fibula being the most common types.
Pediatric fractures are usually the result of major trauma
(MVA, gunshot, lawn mower, falls etc.) because of the
flexibility of the pediatric foot and its ability to adapt and
recover from abnormally large forces.
Gumann G. Fractures of the foot and ankle. Philadelphia, PA: Elsevier; 2004. Pg 335-336.
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The physis (if present) of long bones is the weakest
biomechanical link .
Physeal disruption will usually result before
ligamentous injury.
Physeal disruption that leads to the creation of a
physeal bar can result in limb length discrepancy
and angular deformities of the shaft of long bones.
Gumann G. Fractures of the Foot and Ankle. Philadelphia, PA: Elsevier; 2004. Pg 335-336.
Green Stick Fracture (radius)
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Torus/Buckle Fracture
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Cancellous Fracture: Immature bone is subject
to compressive forces that crush trabeculae.
This deformity is difficult to diagnose because
little cortical disruption can be appreciated on
x-ray. Bilateral views may help with
identification.
Plastic Deformation (Bowing): A bow in a
long bone that does not spontaneously
recover. Bowing will be noted on x-ray
with no cortical defects/breaks.
Source: Contemporary Pediatrics By: Robert L Hatch, M. Patrice. Eiff, MD Originally published: November 1, 2003
•The
Salter-Harris classification method helps
to describe fracture lines from an anatomical
but not a mechanism of action stand point.
•Useful
when planning fixation approach.
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*Due to
avulsion or
contusion.
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Types I & II – Closed reduction possible
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Types III & IV
Congruity of articular surfaces essential
 Usually require ORIF
 Accurate reduction more important than I & II
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Types I, II & III consolidate quickly
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Type V / VI – prognosis poor
 The Dias-Tachdjian combines both the concepts of Lauge-Hansen
(mechanism of action) and Salter-Harris (anatomical description)
to describe pediatric fractures of the foot and ankle.
 The supination-inversion mechanism is the most common type
encountered.
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Gumann G. Fractures of the foot and ankle. Philadelphia, PA: Elsevier; 2004. Pg 335-336.
*Fracture resulting from
external rotational forces.
*May be associated
with a high fibular
fracture due to
external rotation
forces.
 Closed Reduction is usually sufficient for the majority of
pediatric fractures.
 The Dias and Tachdjian Classification system is used to
facilitate closed reduction.
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Define the mechanism of injury.
Increase the deformity.
Apply distractive forces
Reverse the direction of the original deforming force.
 The foot and ankle should be immobilized in the opposite
position of that of the position/mechanism of injury.
Gumann G. Fractures of the foot and ankle. Philadelphia, PA: Elsevier; 2004. Pg 335-371.
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In certain cases, such as those requiring anatomic
realignment of the physis or articular surface, there
are clear indications for surgical management.
Surgical management is used to:
 maintain optimal alignment
 allow early ROM
 facilitate mobilization of children
Flynn JM, Skaggs DL. The surgical management of pediatric fractures of the lower extremity. Instructional Course
Lectures: 2003;52:647-59
 Never cause compression across the physis (unless the goal is
to close the physis).
 Only smooth hardware should cross the physis (smooth K-
wire and Steinman pins). No threaded screws, wires or pins.
 Removal of hardware once fracture healing has been
achieved to avoid further complications as pt continues to
grow.
 Pediatric pts heal very fast, don’t delay corrective procedures
(fixate within 7-10 days). Often pediatric pts will be very far
along the healing process of bone at the 4th week.
A. Burns DPM. Podiatric Trauma Lecture Series. Spring 2008 CSPM.
A. Burns DPM. Podiatric Trauma Lecture Series. Spring 2008 CSPM.
A. Burns DPM. Podiatric Trauma Lecture Series. Spring 2008 CSPM.
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Compartment syndrome
Growth arrest
Angular deformities
Avascular necrosis
Limb length discrepancy
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Following trauma, growth may cease temporarily but
mineral deposition continues creating lines visible on
x-ray. Park’s lines may eventually reabsorb. Don’t
confuse with a fracture/stress fracture later on.
→
Banks AS, Downey MS, Martin DE, Miller SJ, eds. McGlamry's Comprehensive Textbook of Foot and Ankle Surgery. 3rd edition. Philadelphia, PA: Lippincott,
Williams &Wilkins; 2001. Pg 1957-1991.
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Disruption of physis can result in central tethering and a fish tail
appearance at the physis.
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Recommendations are to follow the pt radiographically following
injury for 1-3 years or even until skeletal maturity to monitor the
possible occurrence and plan correction (if needed) of this
complication.
→
Banks AS, Downey MS, Martin DE, Miller SJ, eds. McGlamry's Comprehensive Textbook of Foot and Ankle Surgery. 3rd edition. Philadelphia, PA: Lippincott, Williams &Wilkins;
2001. Pg 1957-1991.
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Resection is called for if a bar has developed across
30-50% of the physis.
 Langenskjold A. Surgical treatment of partial closure of the growth plate. J Pediatric Orthopedics.
1981;1:3-11.
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If less than 40% of physis has developed a bar,
resection with interposition of adipose tissue or
methyl methacrylate should be attempted.
If the osseous bridge is greater than 50% of the
physis then a supramalleolar opening wedge should
be used to correct deformity.
 Gumann G. Fractures of the foot and ankle. Philadelphia, PA: Elsevier; 2004. Pg 335-367.
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Kubiak et al. in 2005 performed a retrospective review looking at
the differences in results of the treatment of pediatric tibia
fractures (in the proximal 2/3 of the tibia) with external fixation
versus flexible nails.
They reviewed 31 patients who required operative treatment for
tibia fractures. Sixteen were treated with flexible nails and 15 with
external fixation.
Major findings in this study included a significantly shorter time
to union for the patients in the flexible nail group (7 vs. 18 weeks),
and a significantly higher rate of bone-related complications in
the group treated with external fixation.
**Flexible IM nail fixation is not indicated for fractures needing
fixation across the physis.
Kubiak EN, Egol KA, Scher D, et al. Operative treatment of tibial fractures in children: are elastic nails an improvement over external fixation? J
Bone Joint Surgery Am 2005; 87A:1761–1768.
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Banks AS, Downey MS, Martin DE, Miller SJ, eds. McGlamry's Comprehensive Textbook of Foot and
Ankle Surgery. 3rd edition. Philadelphia, PA: Lippincott, Williams &Wilkins; 2001. Pg 1957-1991.
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Burns A. DPM. Podiatric Trauma Lecture Series given at CSPM. Spring 2008.

Flynn JM, Skaggs DL. The surgical management of pediatric fractures of the lower extremity.
Instructional Course Lectures: 2003;52:647-59.

Gumann G. Fractures of the foot and ankle. Philadelphia, PA: Elsevier; 2004. Pg 335-367.

Langenskjold A. Surgical treatment of partial closure of the growth plate. J Pediatric Orthopedics.
1981;1:3-11.
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Kubiak EN, Egol KA, Scher D, et al. Operative treatment of tibial fractures in children: are elastic nails
an improvement over external fixation? J Bone Joint Surgery 2005; 87A:1761–1768.
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www.e-radiography.net
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Mark 9:45 "If thy foot offend thee, cut it off."