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Principles of Treatment for Fractures in Adolescents

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Treatment of bone fractures in teenagers should not be viewed the same as for children. So say orthopedic surgeons from Cincinnati Children's Hospital Medical Center. Not only that, but they shouldn't be treated the same as adults either. The principles of treatment for fractures in adolescents requires a unique and individual approach.

In this instructional review, the management of fractures in patients between childhood and adult age is presented. The patient's bone age must be determined using X-rays. Actual age and bone age often differ. Without this piece of information, it is impossible to tell if the teen has stopped growing yet.

Concerns about damage to the physis growth plate, deformity, and leg length difference drive the need to estimate skeletal maturity as accurately as possible. Treatment varies depending on whether the growth plate is still wide open (allowing further growth), partially open, or closed. And because the anatomy is different for each bone, there are separate classification systems for each one.

Using photos of X-rays and descriptions, the authors provide a review of each classification scheme. Details are provided in how to look at each X-ray. Additional imaging studies such as CT scans and MRIs may be needed if there is any suspicion of injury to the joint or soft tissues around the bone and joint.

Two sets of principles for the treatment of fractures in teens are presented. The first are directed toward fractures affecting the physis (growth plate). The second deal with nonphyseal fractures in this age group. Specific bone fractures discussed include the clavical (collar bone), radius and ulna (bones in the forearm), femur (thigh bone), and tibia (lower leg bone or shin).

To give you an idea of the types of principles offered, the authors tell surgeons treating physeal fractures in teens:

If possible, use traction and gentle hands-on manipulation to pull the fractured ends of the bone apart in an attempt to realign the bones. This procedure is referred to as reduction of a displaced fracture. If this doesn't work easily, then open incision and surgical reduction is required.

Physeal fractures that are two millimeters apart (or less) must be reduced with a closed technique within the first 10 days after injury, otherwise surgery will be needed (open reduction). This is because most physeal fractures will be well on their way to healing by then.

When using pins or screws to hold the fracture together, the hardware must be put in parallel to the physis (not perpendicular or at an angle). When fixation devices must cross the physis, then they should be made of smooth material and taken out as soon as possible.

No matter what kind of treatment is provided, patients with physeal fractures must be followed closely for at least six months (or until skeletal maturity is reached). During this time, the surgeon will be watching carefully for any signs of growth disturbance.

That's just a partial list of the recommendations made for surgeons to follow when treating physeal fractures in teens who have not yet finished growing. What about teens with fractures of the bones named that do not affect the physis (growth plate)? What kind of principles or recommendations for treatment should be followed for fractures of the bone shaft?

Treatment is usually more like what is given to adults. The need for reduction follows an adult model.

All decisions are made based on the age and weight of the teenager.

Fixation hardware for fractures of the long bones are slightly elastic (flexible) and can be put in place through the skin (percutaneously) without making an open incision. The pin goes down through the shaft of the bone lengthwise. This is referred to as an intramedullary pin.

The end of the pin is left slightly outside the skin so that it can be pulled out easily when healing has occurred.

Most of the time, the patient who has intramedullary fixation is also placed in a cast, splint, or brace to give external support until healing takes place.

After giving general treatment guidelines for physeal and shaft fractures, the authors offered some specific details for individual fractures starting with clavicular (collarbone) fractures and working their way through all the long bones. Some changes have occurred over the years in the way various fractures are treated.

Fractures of the clavicle (shaft, not the ends) used to always be nonoperative. But studies have shown that realigning a displaced fracture and using hardware to hold it in place has a better outcome than leaving it to heal on its own where ever the broken ends might happen to be (matched up or not). Now the adolescents who are active athletes and sports participants can get back in full swing within three months rather than four. Minimally displaced fractures are still treated conservatively (without surgery).

Forearm fractures may do better when repaired surgically. X-rays and other imaging studies are needed to check the bone(s) for any sign of angulation Angulation means the bones are not healing straight but with a bend somewhere along the shaft. The amount of angulation that can be treated with a cast depends on where the fracture and angle is located in the bone (e.g., top one-third of the shaft toward the elbow, middle portion, lower third toward the wrist).

The bones of the forearm and clavicle are long but fairly thin so the placement of the pin or nail requires some care when placing it. The surgeon must avoid pushing the pin into tendons, blood vessels, nerves, or other vital soft tissues. Sometimes both bones of the forearm are broken at the same time. That creates a more complex injury to treat. There is a greater risk for delayed union, malunion, or nonunion. Other potential problems include loss of reduction, infection, injury to the physis, and migration (unintended movement) of the nail.

The authors provided a detailed discussion covering the treatment of femoral shaft, tibial fractures, and ankle fractures. Advantages and disadvantages of surgical versus nonsurgical treatment are discussed for each fracture location. There are many different treatment options for these fractures. The first concern is always for the growth plate. Age is always a factor, too. For example, in the case of femoral fractures in children 11 and older, there are more choices in terms of the kinds of hardware (metal plates, elastic nails) that can be used compared with younger children.

A few final instructions were given for the use of flexible nails for fracture fixation (especially of the femur). Two nails must be selected that are the same diameter and don't fill more than 80 per cent of the shaft. The nails are pre-bent before insertion so that once they are threaded down into the center of the bone shaft, the bend is right where the fracture is located.

A different type of nail is needed for older children who are overweight and/or who have an unstable fracture site. There are many different nail systems to choose from. Each surgeon must learn the types of nails available, when to use each one, and how to use them.

In summary, the management of fractures in teenagers can be very challenging for a number of different reasons. Skeletal age is more important than actual (chronological) age. Bone quality, location, and severity of the fracture are added variables. The surgeon must make the determination of what type of treatment is best based on principles outlined for physeal versus nonphyseal fractures.

The goals of treatment are to obtain the best fracture healing with as little deformity as possible. Preventing complications from the use of intramedullary pins used to hold the broken pieces in place until healing takes place is another goal. All management decisions are made keeping in mind the child's emotional and psychological needs with every effort to minimize time away from school and sports.

Reference: Shital N. Parikh, MD, et al. Management of Fractures in Adolescents. Om The Journal of Bone and Joint Surgery. December 15, 2010. Vol. 92-A. No. 18. Pp.2947-2958.

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