Abstract
Modern concepts in paediatric fracture respect individual, social and economic needs:
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the patient’s demand for early mobility and capability to play
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the requirement to achieve an optimal end result (no posttraumatic deformity, full range of motion, no leg length discrepancy) with a minimum of total expenditure and costs: primary treatment should be the definitive treatment. Thus, redo-procedures, unnecessary irradiation, and long hospital stays are prevented.
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the spontaneous remodelling capacity should be anticipated for each specific fracture and be part of the treatment algorithm of fractures of the upper extremity. In the lower extremities a long lasting remodelling period leads to stimulation of the adjacent physis and thus to posttraumatic leg length differences.
The decision between conservative and operative treatment is based on the radiological assessment of fracture stability. Fractures with fragments in contact and at most with some angulation but no shortening may be termed stable. Conservative treatment on an outpatient basis is adequate: plaster immobilization and wedging of the plaster in case of a primary or secondary angulation. Fully displaced fractures or long oblique fractures with a strong tendency for shortening as well as comminuted fractures are unstable. Stable fixation with a child-adapted implant is required: closed reduction, minimal approach, satisfying scars, early full weight bearing, short hospital stay, and a minimal procedure for metal removal are achieved either by external fixation or elastic intramedullary nailing dependent on the fracture pattern and the surgeon’s preferences.
Humeral shaft fractures are the domain of non-operative treatment: immobilization e.g., with a U-plaster followed by functional bracing (Sarmiento) is efficient and more comfortable than a heavy hanging cast. Retrograde intramedullary nailing is indicated in open fractures, multiple injury patients, arterial injuries and compartment syndromes, or if conservative treatment does not lead to a satisfactory alignment. Concomittant radial nerve palsies: since natural history is excellent, observation instead of primary exploration is recommendable. Forearm: in case of complete fractures, closed reduction and plaster immobilisation is only justified if one of both bones is stable. If not, primary elastic intramedullary nailing prevents posttraumatic deformities and loss of function. Femur: Non-displaced fractures (less than 10° angulation in the sagital plane, no varus or valgus deformity, no malrotation) as well as displaced fractures in children younger than four years can be treated with a hip spica. In older children closed reduction followed by external fixation or elastic intramedullary nailing provides early stability and a quick return to play and school. Shortening and angulations with a subsequent high remodelling activity should be avoided in order to prevent femoral overgrowth. Lower leg: Most isolated tibial fractures (intact fibula) are managed conservatively in a long leg plaster. Radiological monitoring is recommended to detect secondary varus deformites which can be easily reduced by wedging of the plaster after 8 to 10 days. Fully displaced transverse tibia fractures and unstable fractures of the tibia and fibula – oblique fractures with shortening or fully displaced fractures – are either stabilised by external fixation or elastic intramedullary nailing.
The abstracts were prepared by David P. Davlin. Correspondence should be addressed to him at the Orthopedic Clinic Bulovka, Budínova 2, 18081 Prague 8, Czech Republic.
