Eberl R, Singer G, Schalamon J, Hausbrandt P, Hoellwarth ME. Crush and wringer injuries are the classic causes, but more commonly, compartment syndromes are associated with fractures, severe contusion, drug overdose with limb compression, burns, and vigorous exercise. Common complications and adverse outcomes in pediatric ZMC fractures are similar to that found in the adult population: persistent hypothesia in the infraorbital nerve (V2) distribution, enophthalmos, facial widening, and flattening of the malar region despite open treatment. Elevation of the limb may increase compartment pressure and may be counterproductive if coupled with a decrease in perfusion; this combination may be the mechanism by which ischemic contractures occur after femoral fractures in children. Malunion in older patients with diaphyseal forearm fractures may be avoided with the use of intramedullary or plate fixation, and good results have been reported. Most authors prefer a lateral closing wedge to correct only the angular alignment and are not concerned about the rotation or flexionextension aspects of the deformity. Fifteen-year-old boy with a serious head injury treated with traction for a femoral shaft fracture. 7-8 ). It is mandatory that anyone who is managing trauma in children be able to determine these values. 7-2 ). SalterHarris type III and IV fractures of the distal tibia have also been identified as being especially troublesome: open, anatomic reduction and internal fixation are recommended for prevention of premature physeal closure. In contradistinction to proximal injuries, isolated single vessel injuries distal to the elbow or knee may, on occasion, be treated by vessel ligation. UpToDate. Campbell and colleagues found a brachial artery injury in 38% of patients who had severe posterior lateral displacement of their supracondylar fracture. Overgrowth occurs in the entire limb, and interestingly, overgrowth of the ipsilateral tibia often also occurs. However, clinical and experimental evidence indicates that the more common cause is an initial unsatisfactory reduction or early loss of reduction. Such delayed loss is usually caused by damage to the intima with subsequent development of thrombosis. Some resorption may occur after joint movement has begun. Bethesda, MD 20894, Web Policies However, the complication rate using elastic stable intramedullary nailing is considerably high. Absolute indications for vascular imaging are a diminished or absent pulse, a large or expanding hematoma, external bleeding, unexplained hypotension, a bruit, and peripheral nerve injury. Radiographic evidence is apparent within 3 to 4 weeks after the injury. [Complications and sequelae of talar injuries]. Proximal Femur Fractures in Children: Enigmatic Injuries. A Monteggia lesion in a 4-year-old that was undiscovered for approximately 8 months. Certain breaks may not have to be re-aligned perfectly because of this ability to remodel with growth. Similarly, displacement or angulation of the ulna and subluxation of the radial head may occur in the weeks after reduction (approximately 20%), especially when the ulnar fracture is oblique. J Orthop. Some people may be able to put weight on their leg . Many children have fat emboli after injury, but the clinical syndrome develops in very few. Attempts to excise the heterotopic bone should be delayed until the process is completely mature, usually about a year after injury. Because children are uniquely susceptible to vasospasm, the pulse may not be restored to normal, and a Doppler waveform analysis may be helpful. Late complications include malunion and stiffness. Myositis ossificans is associated with burns about the shoulder, distal end of the femur, elbow, and proximal part of the tibia, usually within 4 months after a thermal injury. In addition, calcitonin has been reported to be effective in immediately lowering serum calcium levels by inhibiting bone resorption. None of their patients exhibited signs and symptoms of compartment syndrome, which suggests that absolute pressure thresholds, no matter how great, are inadequate as indicators of impending compartment syndrome and support the concept that the absence of clinical indications alone is insufficient as an indication for fasciotomy. Complications associated with surgically treated hip fractures in children. Noonan and McCarthy have stressed the importance of recognizing the three A s of pediatric compartment syndromeagitation, anxiety, and increasing analgesic requirementwhich often precede the classic presentation by several hours. Figure 110 AP and oblique radiographs of the left foot demonstrate 2 corticated fragments at the base of the fifth metatarsal, felt to represent a non-united chronic fracture. 2005 Jan;36(1):123-30. doi: 10.1016/j.injury.2004.04.010. Similarly, closed fractures, such as femoral fractures that are treated with closed intramedullary fixation, are susceptible to compartment ischemia. Epiphyseal separation usually occurs in children 5 to 10 years of age. Risk factors associated with developing compartment syndrome include longer operating time, a high-energy injury, and associated neurologic deficit. official website and that any information you provide is encrypted Typically, the fracture is a relatively nondisplaced or easily reducible fracture of the proximal tibial metaphysis. The femoral artery can be injured at the adductor hiatus by a supracondylar femoral fracture. The ages of these children at the time of injury ranged from 1.5 to 16 years (average 11.1 years). and by Michael P. D'Alessandro, M.D. If there is significant bruising or swelling, an x-ray is the only way to know for sure if a bone is broken. Most are caused by a high-energy mechanism. Mital and colleagues found that heterotopic bone developed in 15% of head-injured children and that coma and spasticity were the most commonly related factors. Prevention from slamming their fingers in doors or putting their hand in exercise equipment or in machinery is important. Many improve spontaneously, and one should wait at least 18 months to 2 years to be confident that maximal improvement has occurred ( Fig. Growth arrest can occur after adjacent fractures in the metaphysis or, less often, the diaphysis, especially with fractures above the femur and near the knee. clinical fracture union, return to sports) treatment may take weeks to months. In this case series, posttraumatic complications after pediatric talus fractures occurred more frequently after a high-energy mechanism of injury or a displaced fracture. A residual rotational deformity can compromise pronation and supination of the forearm, although the clinical significance of this limited rotation has not been clearly established. A common misconception is that an open injury will decompress the compartment. Both high-energy mechanism and fracture displacement corresponded to a greater number of posttraumatic complications. Similarly, temporary shunting can provide a satisfactory solution to the clinical problem of whether an ischemic limb should be revascularized before fracture fixation. This finding is particularly troublesome because they account for 60% to 70% of the growth of the respective bones. Plicamycin (also known as mithramycin) also effectively lowers calcium either by direct antagonism of bone resorption or by interference with the metabolism of parathyroid hormone. The .gov means its official. In contrast, severe crushing frequently ends in early closure and the worst prognosis. The problem is caused by mechanical obstruction of the third portion of the duodenum by the superior mesenteric artery ( Fig. Ideally, if time permits, reduction and fixation of the fracture should precede vascular repair. CT scanning can be helpful in the assessment of pelvic fractures, particularly in patients who may have an osteochondral injury with a retained fragment. Toddler fractures are caused by the same twisting motions as other spiral fractures, but almost always happen to children's shin bones (tibia). The condition is more common in teenagers, but any age group is at risk. Posttraumatic complications assessed were avascular necrosis, arthrosis, nonunion or delayed union, neurapraxia, infection or wound-healing problems, and the need for further unanticipated surgery. Professor of Pediatrics, University of Iowa Childrens Hospital. Rigid fixation of long bone fractures aids in nursing care and rehabilitation efforts. Avascular necrosis occurred in 2 patients (7%), arthrosis in 5 (17%), delayed union in 1 (3%), neurapraxia in 2 (7%), infection in 0, and the need for further surgery in 3 (10%). Early complications include wound infection, below-knee amputation, deep vein thrombosis, and motor and sensory deficits. Loss of motion may be caused by soft tissue scarring that produces tension on the interosseous membrane; a few patients with complete remodeling have failed to regain motion. Deep vein thrombosis should be confirmed by appropriate noninvasive testing and perhaps venograms. In more severe fractures, surgery may be needed to reset the fracture and a metal plate, screws, pins, or rods placed in order to keep the bone in proper position while it is healing (see Figure 2b).Children heal quickly. It is not necessary to correct all the deformity of the supracondylar region. Imaging for growth arrest has evolved: initially, trispiral tomograms were preferred, then MRI, and now high-resolution helical CT scanning with coronal and sagittal reconstruction imaging is the preferred imaging modality. World J Orthop. 2012 American Society for Surgery of the Hand. 2021 Mar 10;13(3):e13801. Chaudhary S, Garg V, Mishra D, Yasam R, Barik S, Sinha SK, Singh V. Cureus. Would you like email updates of new search results? Fractures of the fifth metatarsal; diagnosis and treatment. A similar surgical recommendation could be considered to keep the fibula moving freely at the ankle joint. After fracture of long bones and or pelvic bones, or crush injuries, fat emboli may develop. A Monteggia lesion consists of a fracture of the ulna and dislocation of the ipsilateral radial head. Compartment syndromes in the foot are most commonly associated with a Lisfranc fracturedislocation but have also been reported with fractures of the metatarsals and phalanges. Complications occur at a high rate because the vascular and osseous anatomy of the child's proximal femur is vulnerable to injury. Similarly, surgical repair of nerve lacerations is facilitated by bony stabilization. Other predisposing factors include severe initial displacement, residual displacement, periosteal interposition, delayed surgery, remanipulation, and fracture at the same level of the radius and ulna. Overall, complications included osteonecrosis in 11 (48%) patients, premature physeal closure in 11 (48%), coxa vara in 3 (13%) and coxa valga in 2 (9%). Careers. Sabharwal and associates recommended that if the collateral circulation across the elbow is satisfactory, revascularization is not indicated in an otherwise well-perfused hand. With severe intercompartmental edema, the nerves show a gradual decline in action potential amplitude. The complication of supracondylar fractures can be divided into early and late. FOIA Vascular injury is reported between 2-38 % in Gartland type III. The fracture patterns are usually a combination of anterior and posterior injuries to the pelvic ring, either unilateral or bilateral. Submuscular plating has recently gained popularity as an effective treatment for length-unstable femur fractures. Younger children have greater potential for remodeling with growth. Another alternative is resection of a portion of the fibula and screw fixation of the distal end of the fibula to the tibial epiphysis. However, the fibula may slide proximally to compensate for tibial overgrowth; thus the fibular head may become more prominent at the knee. 7-7 ). In acute fractures, acute pain and inability to walk are common presentations, whereas in a stress fracture an increase in activity, or chronic repetitive forces are at play. Results: Twenty-nine children sustained a major fracture of the talar body, neck, or head. However, the problem is often not discovered until complete closure of the triradiate cartilage has occurred. Fat embolism is more often seen in teenagers and late adolescents, and the onset is usually shortly after the injury (within the first 2 to 3 days). Foot Ankle Int. An arthrogram may not always be diagnostic. Most people wear a hinged knee brace after injury or surgery. Children who have venous thromboembolic events should be screened for elevated serum Lp(a). Frequently, these patients have good capillary flow because the amount of flow required to maintain viability of the skin and subcutaneous tissue is much less than that required by muscle. However, in more recent times, it has been reported to occur in the absence of a cast, such as after traction for extended periods, after spine surgery with instrumentation, particularly after correction of kyphosis, and after a severe traumatic brain injury. FOIA To Learn More She denies any other trauma. If the projected leg-length discrepancy is less than 4.8 cm, Riseborough and colleagues advise contralateral distal femoral arrest. The double fracture indicates a force of relatively high energy. Complications of fractures fall into two categories: early and delayed. Steinmann pins can be placed antegrade down the ulnar. If this condition is not treated aggressively, the problem becomes difficult to manage, and patients are subject to progressive weight loss, hypokalemia, and life-threatening dehydration and electrolyte abnormalities. Particularly in young people, this condition can be troublesome and should be routinely evaluated during the first 6 weeks after the onset of paralysis. Spatulation of the ends of the vessels allows for a longer suture line that will accommodate a later increase in vessel size without stricture. Treatment and recovery Pandya and Edmonds reported the use of flexible intramedullary nails in the treatment of open tibial fractures and described a high union rate but increased incidence of bone healing complications. In a large study of forearm fractures, overgrowth in the radius or ulna is infrequent and averages 0.44 cm. Epub 2020 Oct 24. Barrett and associates in their review of this procedure found that patients were generally pleased with this approach. Late angulation is a common problem with fractures of the proximal tibial metaphysis in a young child. Falls are another common cause of injury. A brief period of observation (6 months) may be appropriate because of the tremendous ability to remodel. Conclusions: If the resultant bridge is of moderate size, less than 40% of the cross-sectional area, and surgically accessible, it can be excised. Most growth plate fractures heal with no complications. 7-4 ). Petechiae may develop on the skin of the chest, axilla, and base of the neck, but they may be transient and are frequently missed. Initial treatment should include splitting a tight cast and removal of occlusive dressing material and cast padding, all of which will decrease compartment pressure. Serious complications can result from a hip fracture. Children may have very good secondary capillary perfusion, which can lead to the false assumption that the vascularity is intact. Bohn and Durbin called attention to the problem of the floating knee, or ipsilateral fracture of the femur and tibia. Fracture of the radius and ulna in a 12-year-old girl. 7-5 ). The leg-length discrepancy has caused numerous problems. The number and severity of talus fractures increased in older children. Clinical follow-up averaged 24 months (range, 6 mo-5 y). Predictors of complications and poor outcome. Distal fibular growth arrest may be necessary. What are the complications of supracondylar fracture of humerus? An increasing analgesia requirement in combination with clinical symptoms was a more sensitive indicator. Malunion may also occur in children with head or spinal cord injuries. 7-9 ). Factors affecting the outcome of fractures of the femoral neck in children and adolescents: a systematic review. Your child's risk for complications may vary according to age and the extent of injury. Enter your email address to follow this blog and receive notifications of new posts by email. A rim with low signal intensity is a common finding, but no unique pattern characterizes myositis ossificans. Experimentally induced triradiate cartilage closure in rabbits further supports this paradigm. Trans-chondral fractures of the talus: a review of 64 surgical cases. In children, autogenous vein grafts are recommended rather than synthetic or bovine material. Before The available evidence suggests that such overgrowth is caused by an increase in vascularity to the bone as a result of the healing reaction. If a fasciotomy is necessary, one must adequately decompress the deep volar musculature. A complete conduction block can be obtained with a pressure as low as 50 mm Hg and, after 6 to 8 hours of sustained pressure, a pressure of 30 or 40 mm Hg. The method of fixation does not affect the healing time. Age of the child. This problem is more common in children younger than 10 years, and in this situation it can lead to incongruity of the hip joint and progressive subluxation requiring acetabular reconstruction. Initial bony fixation provides maximal skeletal stability and reduces further trauma to the soft tissues, nerves, and collateral blood vessels. Most are caused by a high-energy mechanism. Similarly, indomethacin has been reported to be helpful. We conducted a retrospective review of the complications of hip fractures (3 transepiphyseal fractures, 13 transcervical fractures, 6 cervico-trochanteric fractures, and 1 intertrochanteric fracture) in 23 patients (15 boys and 8 girls) between January 1988 and December 1997. A randomized prospective study performed by the Canadian Trauma Society demonstrated significantly improved outcome scores in adult patients treated with open reduction and internal fixation of clavicular fractures when compared with nonoperative treatment. Fractures that disrupt the surface of a joint usually need to be realigned as precisely as possible, though, and may need surgery to do so (see Figure 2a). If a clot breaks off, it can travel to a blood vessel in the lung. Risk Factors for Avascular Necrosis of the Femoral Head in Pediatric Femoral Neck Fractures. Interestingly, compartment syndrome lengthens the time for healing of closed fractures, but the healing time was approximately the same as for an open fracture. In long-term follow-up, 84% of children who were initially in deep coma (score of 5 to 7 on the Glasgow Coma Scale) were eventually able to walk freely. An x-ray after surgery for a fracture, showing normal alignment stabilized with pins, Using this search tool means you agree to the, 2022 American Society for Surgery of the Hand, from the American Society for Surgery of the Hand, Pediatric Orthopaedic Society of North America, How to Know if Your Child Has a Broken Bone. In general, midshaft fractures in children younger than 8 years tend to remodel almost completely; however, in children 11 years or older (particularly girls, who mature earlier), spontaneous correction cannot be anticipated and is unpredictable. 1/21/2014, cited 2/3/2014. When children sustain a femur fracture, the complications could be severe. If the broken bone is not lined up, the bone may need to be set or reduced with a manual manipulation by a physician. Pediatric talus fractures are rare with variable rates of posttraumatic complications reported in the literature. Download Citation | On Jan 1, 2008, R.N. MeSH Hama S, Onishi R, Yasuda M, Minato K, Miyashita M. Medicine (Baltimore). With more frequent use of fixation for supracondylar fractures, the incidence of vascular injury seems to have decreased, thus suggesting that some of the previous vascular problems were caused by the flexed position required to maintain the reduction. Thus one must assume full neurologic recovery. If the growth plate has been shifted, shattered or crushed, the risk of limb deformity is greater. Children are not just small adults. Such injury often results in delayed recognition of the physeal injury until a gross angular deformity develops. The most significant laboratory finding is a decrease in arterial oxygen tension. As in adults, massive bleeding and arterial hemorrhaging can occur in children with pelvic fractures. 2022 Aug;14(8):1907-1911. doi: 10.1111/os.13376. HHS Vulnerability Disclosure, Help Malunion is a fracture that has healed with a deformity such as rotation, angulation or an incongruent joint surface. Berson and colleagues and Hresko and Kasser recommend that all adolescents injuries be monitored expectantly so that a physeal injury can be detected early. The pulmonary changes prevent exchange of oxygen across the alveolarcapillary membrane. Children Ages 0-2; Children Ages 2-18; Men Ages 18-39; Men Ages 40-49; Men Ages 50-64; Men Ages 65+ Women Ages 18-39; Women Ages 40-49; Women Ages 50-64; Women Ages 65+ Patient Education; KidsHealth; Health Centers. Federal government websites often end in .gov or .mil. Helical computed tomography (CT) with contrast agents has recently gained popularity. Vanderbilt University, Nashville, TN. As a consequence, an acute lesion is often misdiagnosed ( Fig. Most injuries were caused by falling from a height or a motorcycle accident. Hypovolemic shock resulting from hemorrhage is more frequently noted in trauma patients with pelvic fractures and in patients with displaced or open femoral fractures. Similarly, anatomic restoration of alignment by open reduction and internal fixation does not always restore full range of motion. However, not all compartments are successfully relieved by an open injury. In the past, this syndrome was most often recognized in those treated with a hip spica or body cast, hence, the older name cast syndrome . Retrospective case series. Hip fractures account for < 1% of all pediatric fractures. Distal tibia physeal fractures are a relatively common physeal injury and are the second most common injury in children after the distal radius physis [1, 2].Distal tibia physeal fractures account for approximately 11-20% of all physeal fractures [3, 4].The stronger ligamentous attachments make the physis more vulnerable to injury and more likely to be accompanied by subsequent premature . However, a recent metaanalysis was performed reviewing the relevant observational studies concerning neurovascular injuries in supracondylar humerus fractures; it suggested that the incidence of brachial artery injuries in patients with pulseless but perfused hands is consistently underestimated by treating surgeons. J Trauma. Fixation of the osteotomy is a problem because of the small size and peculiar shape of the distal end of the humerus, which does not lend itself to standard fixation methods. Fat embolism syndrome. In a child, this may lead to disproportionate growth. Similarly, for unexplained reasons, some young patients, usually those 9 to 14 years of age, may have significantly high calcium blood levels and systemic symptoms. Fifth metatarsal fractures are a common fracture of the foot and are the most common metatarsal fracture in children > 5 years of age and adults. Physeal fractures in children younger than age 11 years have the poorest prognosis; growth problems develop in 83% of these children. Staheli noted slightly greater overgrowth in children 4 to 8 years of age. Early complications include shock, fat embolism, compartment syndrome, deep vein thrombosis, thromboembolism ( pulmonary embolism ), disseminated intravascular coagulopathy, and infection. The occurrence and severity of femoral head osteonecrosis significantly influenced the functional results (p < 0.001, and p < 0.048, respectively). The purpose of this retrospective study was to evaluate posttraumatic complications in children after talus fracture and report injury characteristics. The information contained in PediatricEducation.org is not a substitute for the medical care and advice of your physician. Donna M. DAlessandro, MD and Michael P. D'Alessandro, M.D. Persistent joint widening should arouse suspicion, even in the absence of a clear history of hip dislocation. Pulmonary angiography is still the gold standard in diagnosing pulmonary embolism. Depending on several factors (including the initial treatment) and the end point used (i.e. This phenomenon has been reported to occur in 82% of patients, and 78% of overgrowth occurs in the first 18 months after a fracture. Compartment syndrome does not seem to affect healing of the fracture, and nonunion or delayed union is seldom associated with it. All 10 of their patients who had access to patient-controlled or nurse-administered analgesia had an increasing requirement for pain medication that preceded other clinical signs or symptoms by an average of 7 hours. Sidhu GAS, Hind J, Ashwood N, Kaur H, Lacon A. Cureus. Observation of a warm pulseless leg after dislocation of the knee is insufficient. Other fractures may be displaced, which means that it is a complete fracture that has broken into two or more pieces with some shift in position so that the ends of the broken bone are not in alignment (see Figure 1a). Length discrepancy, angulation, and encroachment on the interosseous space are unpredictable indicators of loss of motion. No cookies are used. Results: If surgery is delayed too long, soft tissue contractures may preclude recovery of maximal range of pronation and supination ( Fig. Disclaimer, National Library of Medicine Methods: In adults, this condition is referred to as adult respiratory distress syndrome. J Orthop Case Rep. 2021 Oct;11(10):30-32. doi: 10.13107/jocr.2021.v11.i10.2454. Similarly, children should have frequent vascular examinations after reduction for signs of vascular insufficiency from intimal tears and brachial artery stenosis. Of all limbs, 90% can be salvaged if the circulation is reestablished within 6 hours, whereas revascularization after 8 hours from the time of injury can result in an amputation rate of 72% to 90%. Most children respond to routine treatment, similar to adults. Symptoms include anorexia, nausea, vomiting, and increased irritability; if the condition is severe, generalized seizures, pain with movement, flaccid paralysis, muscle hypertonia, and blurred vision can occur. Angulated fracture through the growth plate at the base of the little finger. Would you like email updates of new search results? Common reasons for malunion include poor blood supply, poor bone fixation (i.e. Background: This pattern is common in the intramuscular type and less so with the periosteal type. Zwitser EW, Breederveld RS. Type III fractures still showed a higher complication rate in the last follow up compared to type II (14% vs 4%, respectively), however no statistical significance was found between both types (P-value= 0.16). It may become more troublesome as more femoral shaft fractures are managed by intramedullary fixation or external fixation, which restores the fracture to length. In older children with less growth potential, this pattern is not as troublesome. However, the healing time for closed fractures associated with compartment syndrome was noted by Turen and associates to be longer, 30.2 versus 17.3 weeks. Vince and Miller recommend at least a 1-year interval before excision of a cross union. What are indications for orthopaedic consultation? The https:// ensures that you are connecting to the Most are caused by a high-energy mechanism. Disclaimer, National Library of Medicine There may be variations in treatment that your physician may recommend based on individual facts and circumstances. Complications occur at a high rate because the vascular and osseous anatomy of the child's . In their study, 16 pediatric patients with fracture displacement greater than 2 cm treated nonoperatively subsequently developed malunion but showed no meaningful loss of shoulder motion or strength. Injury to the superior gluteal artery was the most common injury associated with posterior pelvic fractures. It is likely that many cases go unrecognized. Patient records and radiographs were reviewed to determine the mechanism of injury, fracture type, associated injuries, and treatment. 8600 Rockville Pike A study by Crawford and Lee showed that completely displaced, overriding fractures of the distal radius and ulna could be treated without reduction or sedation in a short arm molded to correct only angulation. The blood volume should be restored, and fluid and electrolyte balance should be maintained. Injury to the popliteal artery or to a combination of the anterior and posterior tibial arteries is usually associated with fracture of the distal femoral ( Fig. If the deformity is present after 1 year and is posing problems, it may be managed by corrective osteotomy. An excellent example of this diagnostic dilemma is the loss of toe dorsiflexion after a metaphyseal fracture of the proximal end of the tibia, which may be caused by a direct injury to the peroneal nerve or anterior tibial artery or by an anterior compartment syndrome. This fracture involves a break in one or more of the bones that make up the ankle: the tibia (shinbone), fibula (outside ankle bone), and talus (small bone in the back part of the foot). Among the most common injuries to the hand and wrist in children are broken bones, also known as fractures. Learning Point Changes in the tibiofibular relationship because of growth disturbances after ankle fractures are frequent in children. Complications occur at a high rate because the vascular and osseous anatomy of the child's proximal femur is vulnerable to injury. 2013 Jan;95-B(1):135-42. doi: 10.1302/0301-620X.95B1.30161. This site needs JavaScript to work properly. The incidence of fat embolism syndrome is markedly decreased by immediate internal stabilization of long bone fractures as opposed to treatment by traction or late reduction. Complete resolution followed aggressive intravenous hyperalimentation. Many fractures in children heal in as little as one month. In one study, the mortality rate was 5% in children and 17% in adults. Note the contracture of the fingers, which are partially insensitive. Recently, bronchoalveolar lavage for detection of fat-containing cells and retinal examination for cotton-wool spots and retinal hemorrhages have been reported to be helpful in early diagnosis. Knee Surg Sports Traumatol Arthrosc. A severe, more crushing type of injury may be difficult to detect on initial radiographs, in which case CT scans are helpful. 2010 Jun;41(6):555-62. Several factors have been associated with femoral or tibial fracture malunion. If a definite osseous bridge can be identified, resection with fat or methyl methacrylate (Cranioplast) interposition is recommended. In . An official website of the United States government. A motor vehicle accident, a fall from a piece of playground equipment, or even a piece of furniture at home may result in a broken leg that can range in severity from a simple hairline crack to a complex injury that also involves damage to surrounding soft tissues. Fingertips are sometimes crushed in a slamming door, damaging the bone at the end of the finger. Spiral fracture surgery complications include: Acute compartment syndrome (ACS): A build-up of . Fracture complications include: Acute Injuries to adjacent structures Arterial Nerve Other organs Compartment syndrome Fracture blisters of the skin Fat embolism Open fracture Thromboembolic disease Chronic Arthritis, post-traumatic Complex regional pain syndrome Delayed union Malunion Osteomyelitis Life-threatening Hemorrhage Rhabdomyolysis Nork and colleagues and Shapiro suggested that overgrowth was independent of age, level of the fracture, or position of the fracture at the time of healing (shortened, lengthened, or distracted). Injury. Patients should be monitored in the early postoperative period for myoglobinuria or a rise in creatinine or phosphokinase levels. Fracture reduction did not have a consistent or immediate effect on reducing pressure. Angiogram or vascular ultrasound studies should be considered whenever vascular injury is suspected. Talus Fracture Dislocation Management With Crossed Kirschner Wires in Children. Mudd and colleagues found no correlation with the number or severity of fractures; rather, fat embolism syndrome was more likely to be related to the extensive nature of the soft tissue injuries. Even children with femoral shaft fractures treated by skin traction or early spica cast use may be subject to compartment syndromes. Patient Presentation Osteonecrosis is the most severe complication after hip fractures in children and is associated with poor functional results. Fingertips are sometimes crushed in a slamming door, damaging the bone at the end of the finger. Methods: This problem can be controlled by modification of the traction and by hypertension medication until the primary condition has resolved. Yeranosian M, Horneff JG, Baldwin K, Hosalkar HS. The recent popularity of closed reduction with exact anatomic alignment maintained by pin fixation has lessened the frequency of this complication. They recommended that the elbow not be flexed beyond 90, which was associated with significant (the greatest) pressure elevation. Many recent technologic improvements such as color flow duplex scanning and magnetic resonance imaging (MRI) are now available. Since the bone is softer in the area of the growth plate, it is common to see fractures in this zone. A serum lipoprotein(a) (Lp[a]) concentration greater than 30 mg/dL is an important risk factor for thromboembolism in childhood. It heals uneventfully, but over the ensuing months, progressive valgus angulation develops in the limb and can be alarming in its appearance ( Fig. As flexible intramedullary nailing of forearm and tibia fractures has become more popular, a corresponding rise has been seen in the number of patients experiencing compartment syndrome with this technique. Because the potential for growth arrest is so high, children should be monitored closely over the period of remaining growth. Traumatic disruption of the acetabular triradiate physeal cartilage occurs infrequently. Medications may impair healing of fractures. A bone scan may be useful for establishing that the healing reaction is complete and that isotope uptake has returned to the same level as that in the surrounding bone. Fractures of the forearm in children are a common cause of malunion because the reduction can easily be lost and can be difficult to regain ( Fig. They found that such a time frame preserves intrinsic hand function and sensation by removing the ischemic environment and preventing the fibrosis that may add to nerve compression and damage. Correct diagnosis and treatment are crucial to maximize the chances of a favorable outcome. Several authors suggest interposing fat, muscle, or silicone elastomer (Silastic) between the radius and ulna to prevent recurrence; however, only a few patients had a recurrence, and follow-up data are limited. Examination for fat in urine and sputum is of little value relative to more modern diagnostic measures. In this group, operative stabilization of the femoral fracture was associated with fewer complications and better results. Before Superior mesenteric artery syndrome consists of acute gastric dilatation and vomiting. Treatment consists of supportive measures for the respiratory problem, including improvement in oxygen saturation (70 mm Hg), and may require endotracheal positive-pressure breathing. All rights reserved. In a study of 74 pediatric and adolescent femur fractures followed a mean of 21 years, Palmu and associates noted a positive correlation between knee arthritis and angular deformity in children older than 10 years at the time of their fractures. Over the past 2 weeks, she began recreational league soccer practices and would have pain that initially occurred at the end of practice and now occurs when she begins running at the beginning of practice. "PediatricEducation.org", the PediatricEducation.org logo, "A Pediatric Digital Library and Learning Collaboratory intended to serve as a source of continuing pediatric education" are all Trademarks of Donna M. D'Alessandro, M.D. Since the cartilage does not have calcium, it appears as a clear band on an X-ray (see Figure 1b). Growth arrest of the distal end of the fibula and continued growth of the tibia may initially be compensated for by distal sliding of the fibula as a result of traction from the ankle ligaments. The site is secure. Most children do not have a functional deficit but may have a significant cosmetic deformity. An uncommon event is hypertension associated with traction for a long bone fracture. Compartment pressures are seldom high enough to occlude a major artery, so the peripheral pulses are often palpable, and capillary filling is routinely demonstrated in the skin of the hand or foot. Level IV. This increased urinary calcium excretion is believed to be part of the normal reparative process. The occurrence and severity of femoral head osteonecrosis significantly influenced the functional results (p < 0.001, and p < 0.048, respectively). Rev. In general, the indications for limb salvage are extended in children because of their greater capacity for healing; however, no data have established the limits of salvage. Broken fingers, wrists, and hands are mostly commonly treated in children with casting or splinting. Bae and colleagues, in their study of children with acute compartment syndrome, found that pain, pallor, paresthesia, paralysis, and pulselessness were relatively unreliable signs and symptoms. Similarly, synostosis has been reported after intramedullary fixation of fractures. Ring and colleagues found that floating elbows are associated with substantial swelling and increased potential for a compartment syndrome, particularly when they are immobilized in a circumferential cast. In children, intimal damage is often more extensive than apparent on simple inspection. Bone Joint J. PMC The function of the injured site was evaluated using Ratliff's criteria. Mital and colleagues found that, in head-injured children, salicylates can help minimize or eliminate ectopic bone, particularly after excision. In 9%, overgrowth continued throughout the period of remaining growth, although at a slower rate. In children with acute quadriplegia or paraplegia, fracture fixation decreases the incidence of skin problems and pressure sores from cast immobilization and the need for external support, which may compromise nursing and rehabilitative efforts. Appropriate hydration and diuresis can help, as can immediate weight-bearing and movement. government site. Poor outcomes were related to the development of osteonecrosis. 2002 Jul;11(3):219-28. doi: 10.1097/00009957-200207000-00005. Vascular injury is the most serious complication associated with supracondylar fractures; fortunately, it is uncommon. Fractures of the talus--differences between children and adolescents. Any time an injury is sustained in a child, an adult should provide attention to the injured child. Adolescent talus body fracture with high displacement: A case report. If not treated promptly, it results in complete death of the structures within the compartment and Volkmann ischemic contracture ( Fig. Central thoracic and abdominal vascular injuries have been associated with blunt motor vehicle trauma. The purposes of this study were to evaluate whether osteonecrosis influences the functional results and to analyze the risk factors for the development of osteonecrosis. If the child has a pulseless extremity, the fracture should be reduced immediately in an attempt to restore blood supply and avoid compartmental ischemia (see Fig. The purposes of this study were to evaluate whether osteonecrosis influences the functional results and to analyze the risk factors for the development of osteonecrosis. Diagnosis or exclusion of compartment syndrome on clinical grounds alone may be impossible. Hip fractures in children have low incidence, but osteonecrosis is the principal complication because of the hip vascular anatomy during skeletal development, and other frequently seen complications are coxa vara, premature physeal closure and nonunion. With a type II fractureseparation, internal fixation of the large metaphyseal fragment provides better results. Revascularization does not eliminate the possibility of abnormal growth (i.e., overgrowth and undergrowth). For toddlers and young children, the most common cause of femur shaft fractures is usually a low energy trauma like fall from height and direct blow trauma [, 63, 7]. The author would like to acknowledge and thank Robert N. Hensinger, MD, for his contributions to the previous versions of this chapter. She also complains that it is more painful when she is going up stairs or just at the end of a regular day. If the deformity is angulated less than 20 and the child is 9 years or younger, the forearm has excellent remodeling potential and generally leads to satisfactory function with an acceptable cosmetic result. Although many theories have been advanced, the most likely mechanism is an increased vascular response leading to stimulation of growth of the medial metaphysis of the proximal end of the tibia. Materials and methods The files of . A chest radiograph classically demonstrates interstitial edema and increased peripheral vascular markings. and Michael P. D'Alessandro, M.D. Young children can occasionally remodel the fracture dramatically; as a consequence, physicians have a tendency to depend heavily on remodeling and accept a less than adequate reduction. Overgrowth is infrequently reported in the upper extremity. If pain, swelling, or loss of movement persists, an evaluation by a physician is needed.Fractures in children may be non-displaced, which means that it is a hairline fracture, or a fracture that has not broken into two separate pieces. Results: All children should be monitored with scanograms until limb lengths stabilize. Download Citation | On Dec 31, 2015, Anthony A. Stans published Complications of Fractures in Children | Find, read and cite all the research you need on ResearchGate 7-11 ). As the pressure increases within the space, the first finding or complaint is a decrease in sensation, or paresthesia. To view pediatric review articles on this topic from the past year check PubMed. 7-2 ). has been described as the incomplete healing of a fracture where the cortices of the bone fragments do not reconnect. Some people will also use the term delayed union. A recent report suggests the potential for overgrowth resulting in length discrepancy and valgus alignment in a small percentage of patients treated with this technique. Protective gear may play a role in preventing some hand injuries in children. Ectopic bone formation is typically associated with head injuries and burns. Accessibility Fractures of the trochanteric region in children and young adolescents-a treatment algorithm for a rare injury. Signs and symptoms of renal insufficiency should also be sought because both are consistent with the diagnosis of rhabdomyolysis. Femur fracture in a child before walking age is suspicious for non-accidental trauma; Most common femur fracture type in a child is closed, transverse, and non-comminuted . Riseborough and colleagues found an alarmingly high rate of complications after femoral physeal injury: growth arrest and a limb-length discrepancy of more than 2.4 cm developed in 56%, and angular deformities greater than 5 requiring osteotomy developed in 26% (see Fig. Femur fractures are staged using the Salter-Harris system. Reduction may require osteotomy of the ulna with rigid plate fixation, reconstruction of the annular ligament, or replacement with the triceps fascia (Bell Tawse procedure). Price and colleagues suggest that the shortening resulting from fracture displacement allows for relaxation of the interosseous membrane, which preserves motion. Compartment syndromes in the thigh have been reported in teenagers after blunt trauma and because of systemic hypertension, external compression with antishock trousers, and vascular injury with or without fracture of the femur. They found no particular source of the fat, nor was evidence of bone marrow or myeloid tissue seen in the lung sections. The serum alkaline phosphatase concentration is usually normal, unlike in the case of hyperparathyroidism, in which the serum level is generally high. Fabian and colleagues found the an incidence of fat emboli in pediatric and adolescent long bone fractures to be as high as 10%. With continued ischemia, voluntary use of the muscles is decreased, and eventually complete paralysis ensues. fragments are too far away from each other), behaviors (e.g. Use of Ilizarov Device to Gain Early Range of Motion in the Treatment of Pediatric Talus Body Fractures: A Series of Four Cases and Literature Review. Volkmann ischemic contracture of the forearm after treatment of a both-bones fracture and unrecognized compartment syndrome. Does the timing of treatment affect complications of pediatric femoral neck fractures? 2020 May 6;22:207-212. doi: 10.1016/j.jor.2020.04.023. X-ray after reduction shows normal alignment. Angulation in the diaphysis is often associated with loss of motion, whereas distal metaphyseal fractures tend to correct themselves, and complete range of motion returns. An upper gastrointestinal series in a patient with superior mesenteric artery syndrome (cast syndrome) demonstrates compression of the fourth portion of the duodenum from the superior mesenteric artery. Fifty-eight percent of neurovascular injuries in children are associated with orthopaedic injuries. Pediatric fractures heal more quickly than adult fractures due to children's growth potential and a thicker, more active periosteum (the periosteum contributes the largest part of new bone formation around a fracture) As children reach their growth potential, in adolescence and early adulthood, the rate of healing slows to that of an adult. Discussion government site. Level of evidence: This lesion can be subtle; in a small child, it may be difficult to assess the relationship of the radial head to the capitellum, and associated deformation of the ulna may be subtle. Intravenous administration of fluids and corticosteroids has been reported to be successful in lowering the serum calcium level until mobilization can be accomplished. official website and that any information you provide is encrypted PediatricEducation.org is funded in whole by Donna M. D'Alessandro, M.D. The collateral circulation may be sufficient to maintain a pulse in the distal circulation but not sufficient to maintain perfusion through specific muscle groups. Understanding Asthma; Pulmonary Tests & Procedures; Controlling Asthma Triggers; Managing Your Asthma This content is written, edited and updated by hand surgeon members of the American Society for Surgery of the Hand.Find a hand surgeon near you. Objectives This article focuses on treatments and complications in patients presenting dental trauma in primary teeth. Angulation of a femoral shaft fracture in a 13-year-old head-injured patient who was treated with skeletal traction. External fixation, particularly in a severely traumatized limb, has many advantages, including a short operative time. Pain on stretching the involved muscles is a common finding but is subjective and may be the result of trauma. Fifth metatarsal fractures have various classifications. Patients who have increased compartment pressure without an associated fracture (usually a crush injury) are more likely to have muscle necrosis. Some reports have indicated that pharmacologic agents can reduce the incidence of ectopic bone formation. Help children avoid dangerous situations and protect them from falls. The site is secure. smoking, excessive alcohol ingestion, and noncompliance with treatment) and underlying medical problems. Placing the limb at approximately the same level as the heart may be optimal. Pulse oximetry is not helpful in the diagnosis of compartment syndrome because a normal reading does not imply adequate tissue perfusion. Advertising is not accepted. 7-12 ). They concluded that revascularization of a pulseless but otherwise well-perfused limb with a type III supracondylar fracture, although technically feasible and safe, has a high rate of asymptomatic reocclusion and residual stenosis of the brachial artery. too much movement) or apposition (i.e. Toddler fractures are a type of spiral fracture that usually affects children younger than three. The pain began approximately 5 months earlier after a fall on ice. 2010 Jan;68(1):126-30. doi: 10.1097/TA.0b013e3181a74667. Although angulatory deformities have a limited potential for remodeling, rotational deformities do not improve, and they should initially be treated aggressively. These techniques are noninvasive and safe for evaluation of the patency of the brachial artery, but they need further study to assess their applicability in clinical practice. Her extremity examination revealed pain over the proximal 5th metatarsal with palpation and also with supination and flexion of the foot. Some possible complications include: Septal abscess Septal hematoma Severe nosebleed Infection of the brain or tissues around the brain In some cases redisplacement in the cast did not occur until 2 weeks after the injury. Many children exhibit hypercalcemia after immobilization for a fracture. It may be caused by tension on the sciatic nerve, activation of the reninangiotensin system, or prolonged immobilization. 2021 Oct ; 11 ( 3 ): e13801 situations and protect them from falls the... Miyashita M. Medicine ( Baltimore ) of injury ranged from 1.5 to 16 years ( average years! 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