Лютц фон Лаэр - Переломы и вывихи в педиатрии (англ)

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Pediatric Fractures
and Dislocations
Lutz von Laer, M.D.
Former Director of Trauma Division
Basel Pediatric Hospital
Basel, Switzerland
1600 illustrations
5 tables
Thieme
Stuttgart · New York
IV
Library of Congress Cataloging-in-Publication
Data is available from the publisher
This book is an authorized and revised
translation of the 4th German edition
published and copyrighted 2001 by
Georg Thieme Verlag, Stuttgart, Germany.
Title of the German edition:
Frakturen und Luxationen im Wachstumsalter
Translator: John Grossman, MA, Berlin, Germany
1st German edition 1986
2nd German edition 1991
3rd German edition 1996
4th German edition 2001
䉷 2004 Georg Thieme Verlag
Rüdigerstraße 14, 70469 Stuttgart,
Germany
http://www.thieme.de
Thieme New York, 333 Seventh Avenue,
New York, NY 10001 USA
http://www.thieme.com
Cover design: Thieme Marketing
Typesetting by Druckhaus Götz GmbH,
Ludwigsburg
Printed in Germany by Druckhaus Götz GmbH,
Ludwigsburg
ISBN 3-13-135381-3 (GTV)
ISBN 1-58890-260-9 (TNY)
1 2 3 4 5
Important note: Medicine is an ever-changing
science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors,
editors, and publishers have made every effort to
ensure that such references are in accordance
with the state of knowledge at the time of production of the book.
Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part
of the publishers in respect to any dosage instructions and forms of applications stated in the book.
Every user is requested to examine carefully the
manufacturers’ leaflets accompanying each drug
and to check, if necessary in consultation with a
physician or specialist, whether the dosage schedules mentioned therein or the contraindications
stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are
either rarely used or have been newly released on
the market. Every dosage schedule or every form
of application used is entirely at the user’s own
risk and responsibility. The authors and publishers request every user to report to the publishers
any discrepancies or inaccuracies noticed.
Some of the product names, patents, and registered designs referred to in this book are in fact
registered trademarks or proprietary names even
though specific reference to this fact is not always
made in the text. Therefore, the appearance of a
name without designation as proprietary is not to
be construed as a representation by the publisher
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This book, including all parts thereof, is legally
protected by copyright. Any use, exploitation, or
commercialization outside the narrow limits set
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applies in particular to photostat reproduction,
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V
Preface to the First English Edition
I originally wrote this book for the Germanspeaking countries, where a clinical understanding of medicine has largely fallen by the wayside
since the Third Reich and the Second World War.
This process is reflected in the billing scheme of
the ill-fated itemized fee schedule introduced
after the War. In the face of economic incentives
to the contrary, I have attempted to again place
the patient in a clinical perspective and to cultivate a clinical understanding of the patient. Consequently, my field was never basic experimental
research, but primarily basic clinical research. I
have attempted to take the knowledge acquired in
clinical experience and again apply it to clinical
practice, and I have been able to evaluate this approach in several long-term studies (radial head,
lateral condyle of the humerus, transitional fractures of late adolescence, and others). I have tried
to teach clinical medicine at a German-speaking
university hospital in the narrow medical
specialty for which I was responsible, and have attempted to document that this is indeed possible
even in German-speaking countries. The established conventions of local professional culture
are what prevent the resolute implementation of
clinical medicine in these countries. Englishspeaking readers will please bear this in mind
when I employ apparently exaggerated emphasis
and an overly demanding tone in describing clinical practices that these readers may take for
granted.
Essentially, I have written a practical book
about mundane matters of everyday clinical
routine, especially for those persons who do not
treat children exclusively. For this reason, I have
placed the primary emphasis on mundane, every-
day injuries. Rare injuries such as pelvic, spinal, or
tarsal injuries are given less attention as they usually belong in the hands of specialists anyway.
My demand for the most efficient expenditure
of diagnostic effort and treatment also stems from
my concern for cultivating a clinical perspective.
Lack of clinical understanding—not only in the
German-speaking countries—expresses itself in
numerous superfluous diagnostic procedures and
equally numerous superfluous surgical interventions, secondary reductions, and changes in therapy.
Efficient medicine and the desires of the
growing patient go hand in hand: Achieving an
optimal final result with minimal total expenditure of treatment coincides with the patient’s fundamental interests, but unfortunately far less
often with those of the attending physician.
I would like to express my most heartfelt
thanks to John Grossman, who with humor and
sensitivity has rendered an excellent translation
of the book.
My thanks also to Georg Thieme Verlag for
having made the translation possible and for
generously implementing numerous revisions for
the English edition. I would not like to miss this
opportunity to thank Gabriele Kuhn for her
patience and skill in overseeing the preparation of
this edition.
Last but not least, I would like to thank all of
my patients, to whom I would also like to dedicate
this edition!
Basel, January 2004
Lutz von Laer
VI
Abridged Prefaces to the German editions
First Edition (1986):
Fractures in the growing skeleton, their treatment, and their possible late sequelae have become a topic of increasing interest in recent years
as evidenced by the great number of newly published books about pediatric fractures and their
treatment. Readers of these books will not fail to
be impressed by the profound technical transformations that the therapy of pediatric fractures
and dislocations has undergone over the last
30–40 years, due in no small measure to improvements in internal fixation and anesthesia techniques. However, it also becomes apparent that
for the most part experience and indications from
adult trauma management and orthopedics have
simply been applied to children.
Basing my work on numerous clinical studies,
I have attempted over the last 10 years to redefine
the indication for the respective treatment of a
fracture to better reflect the needs of children
than had previously been the case. One of the
most important requirements for this is
rigorously practicing efficient clinical medicine.
With children in particular, experience has repeatedly confirmed my conviction that every
medical intervention, from physical examination
to surgery, represents a violation by the physician
not only of the patient’s body but also of the
patient’s dignity and psyche. This “iatrogenic
traumatization” is not always avoidable but it
must always be considered and carefully weighed
against the possible benefit; also, critically reviewing the indication will reduce it to an astoundingly low minimum. Such traumatization
must never become a disciplinary instrument. If
we accept the importance of respecting the
patient’s dignity, then it follows that we should
recognize that the patient, like the parents, is
capable of making decisions; it is only natural that
this combined expertise be given due consideration in the process of determining which approach is indicated. One widely held notion is that
the dignity and psyche of children are only mod-
est, in proportion to their small physical size;
another is that children lack the ability and inclination to make decisions. My experience has
shown both notions to be equally false. Quite the
opposite is true. There is also the frequently
voiced complaint that patients’ unbridled appetite for consumption forces us to take medical
actions we normally would not take. I cannot confirm this at all as far as children are concerned,
and only in exceptional cases with respect to
parents. In any case, as members of a society
characterized by an appetite for consumption and
treated by a health care system equally characterized by an appetite for consumption, children can
hardly be blamed for a situation for which we
physicians ourselves are responsible. This should
give us cause to critically reflect on our own
everyday practice. The ethical imperative of
achieving optimal outcome with a minimum of
expenditure, in other words practicing efficient
medicine, is currently neutralized in the Germanspeaking countries by the customary fee
schedule. Effectively, this forces us to be increasingly less critical in utilizing all available medical
means, and there are a lot of them. At the same
time, it prevents us from realizing that today’s
medicine is significantly flawed in terms of quality in spite of its high degree of technical perfection.
Fourth Edition (2001):
It has never been my aspiration to write a
scholarly reference work that might serve to demonstrate my knowledge, my eloquence, or my
technical expertise, or even to spare readers the
effort of thinking for themselves. On the contrary,
my aspiration has always been to contribute a
clinical “cookbook” that would be a help in everyday practice and provide food for thought, even
for those experienced in dealing with children. I
wanted to attempt to portray how “doing the
right thing” is in fact, at least in the management
of pediatric trauma, extraordinarily easy. One
Abridged Prefaces to the German editions
need only ask the patient what the right thing is
for him or her and then merely think about how to
put it into practice as simply as possible. It is then
not that difficult to take the “right” action. The
problem is that each patient in each phase of life
uses his or her own “language” to convey this
message. All we have to do is to learn how to understand it. It is wrong to assume that patients do
not communicate their wishes simply because we
fail to comprehend their means of expression.
They most certainly do! We must listen to
patients, we must learn to understand their “language,” and we must respect their wishes.
Listening to the patient involves another important aspect: Pediatric and adolescent patients
are not medical consumers; they invariably want
to know how optimal functional and cosmetic results can be achieved with minimum expenditure
of treatment. This means that they have an immediate interest in clinical efficiency. Today it has
become even more important to listen to the
patient as quality has become the dominant buzzword of our age, with quality assurance systems,
evidence-based medicine, standards, and guidelines competing for priority. I myself still believe
that gauging the effectiveness and efficiency of
treatment continues to represent the best quality
assurance in pediatric trauma management, and I
feel this should be a mandatory parameter for
monitoring the quality and cost of medical care in
general. Despite widespread lip service in support
of quality, it remains an elusive goal. Here in Switzerland, we have dedicated our newly established
organization LiLa—Licht und Lachen für Kinder in
der Medizin—Effizienz in der Medizin e.V. to putting muscle behind our efforts to improve the
quality of medical care for children and adolescents.
My attitude is not one of altruistic zeal, nor a
shackle with which I attempt to bind the patient
to me. On the contrary, it represents liberation for
us both: It frees the patient from the pathology of
my benevolence, and it frees me from misusing
the patient as a means to my own ends. Accordingly, my reward does not lie in the patient’s gratitude or reverence but in the fascination of practicing individualized medicine on individuals and in
being able to find patient-friendly solutions to
practical problems. Put succinctly, my reward lies
VII
in the practical solution of doing the “right thing”
for the patient together with the patient. This is
far more than receiving the applause of the establishment, which I have never sought anyway. My
“help” thus invariably contains an element of
gratifying selfishness. This has given me and my
patients freedom and independence which I cannot live without, and which the patients should
not and must not live without. For this gift of
mutual freedom I would like to thank my patients
and their parents from the bottom of my heart.
My heart felt thanks go to all the pediatricians
in private practice in the two half cantons of
Basel-Land and Basel-Stadt. Working with them
was always a pleasure that many of my colleagues
in Switzerland and abroad were long jealous of.
Here, I would not like to miss this opportunity
to again thank my friend Ruedi Christen from
Thun, Switzerland, for his many medical and
philosophical insights.
Let me braid a wreath of gratitude for my
secretary Edith Wiggli, not because she retired
two months before I did and in a manner of speaking left me in the lurch, but for her exceptional
dedication, her good-humored patience, and the
many occasions on which we laughed together. I
am happy that our working relationship has not
ended with our retirement.
I thank the radiology department of Universitäts-Kinderspital Beider Basel for making the
radiographic images available. I also extend my
heartfelt thanks to all my colleagues outside Basel
and Switzerland who have provided me with images. These colleagues have been named in the
appropriate figure legends.
Once again, last but not least, I would like to
express my great thanks to Georg Thieme Verlag
for generously accepting all the changes and additional figures in the new edition. Heartfelt thanks
are due to Dr. Urbanowicz, Markus Pohlmann, and
Karl-Heinz Fleischmann for their inexhaustible
patience in overseeing the edition. It was Mr.
Pohlmann who finally gave the book a coherent
structure, a task that I would never have been
capable of doing myself. I thank you!
Basel 1986 and 2001
Lutz von Laer
VIII
Contents
General Science, Treatment, and Clinical Considerations
1
2
3
4
5
Growth and Growth Disturbances . . . . .
Growth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Longitudinal Growth and Possible
Growth Plate Injuries . . . . . . . . . . . . . . . . .
Physiological Closure of the Growth
Plate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Growth Disturbances . . . . . . . . . . . . . . . . .
Growth Stimulation . . . . . . . . . . . . . . . . . . .
Growth Arrest . . . . . . . . . . . . . . . . . . . . . . . .
2
2
2
3
3
4
6
Corrective Mechanisms in the Growing
Skeleton . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Correction of Side-to-Side Displacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Correction of Axial Deviations in the
Coronal and Sagittal Planes . . . . . . . . . . . .
Correction of the Shortening
Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Correction of the Lengthening
Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Correction of the Rotational Deformity .
16
16
Consolidation and Consolidation
Disturbances . . . . . . . . . . . . . . . . . . . . . . . . .
Bone Healing . . . . . . . . . . . . . . . . . . . . . . . . .
Consolidation Disturbances . . . . . . . . . . .
19
19
20
General Observations on the Nature
and Correction of Posttraumatic
Deformities . . . . . . . . . . . . . . . . . . . . . . . . . .
Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
When Is Surgical Correction of a Posttraumatic Deformity Indicated? . . . . . . .
How Can One Correct Posttraumatic
Deformities? . . . . . . . . . . . . . . . . . . . . . . . . .
Patterns of Injury and Prognosis of
Childhood Fractures . . . . . . . . . . . . . . . . . .
Forms of Injury . . . . . . . . . . . . . . . . . . . . . . .
Growth Prognosis . . . . . . . . . . . . . . . . . . . .
6
7
11
12
8
12
13
28
35
36
General Observations on Prevention of
Injuries in Growing Patients . . . . . . . . . . .
38
Classification of Pediatric Fractures . . . .
Shaft Fractures . . . . . . . . . . . . . . . . . . . . . . .
Metaphysis . . . . . . . . . . . . . . . . . . . . . . . . . . .
Articular Injuries . . . . . . . . . . . . . . . . . . . . .
Proposed Documentation System for
Pediatric Fractures and Dislocations . . . .
Diagnostic Studies . . . . . . . . . . . . . . . . . . . .
History Taking: Interviewing the
Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . .
Examining the Periphery . . . . . . . . . . . . . .
“Painful” Clinical Examination . . . . . . . . .
Radiographic Studies . . . . . . . . . . . . . . . . .
Exceptions: “Litigation Injuries” . . . . . . .
Other Imaging Systems: Computed
Tomography, Magnetic Resonance
Imaging, and Ultrasound . . . . . . . . . . . . . .
Arthrography . . . . . . . . . . . . . . . . . . . . . . . .
Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . .
Examination under Anesthesia . . . . . . . .
40
40
41
43
45
49
49
50
51
52
53
55
61
62
62
62
Measurements . . . . . . . . . . . . . . . . . . . . . . .
63
10 General Observations on Anesthesia . . .
67
11 General Observations on Treatment . . .
Therapeutic Options . . . . . . . . . . . . . . . . . .
69
69
12 Follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Radiographic Follow-up Examinations .
Clinical Follow-up Examinations . . . . . . .
78
78
85
9
27
27
Ligament Injuries . . . . . . . . . . . . . . . . . . . . .
Dislocations . . . . . . . . . . . . . . . . . . . . . . . . . .
28
30
30
32
Contents
13 Aftercare . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
87
14 Medicine and Sports . . . . . . . . . . . . . . . . . .
88
15 Hospital, Parents, and the Child . . . . . . .
89
IX
16 General Observations on Information . .
“Legal” Aspects . . . . . . . . . . . . . . . . . . . . . . .
The Most Important Information during
the Most Important Phases of Treatment of Fractures and Dislocations . . . . .
Formulating the Goal of Therapy . . . . . . .
91
91
92
93
17 “Don’t Make Such a Fuss—You’re Only
a Child.” . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
94
Specific Injuries
Upper Extremities
...................
18 Injuries to the Shoulder Girdle and
Humeral Shaft . . . . . . . . . . . . . . . . . . . . . . . .
Clavicular Fracture . . . . . . . . . . . . . . . . . . . .
Ligament Injuries and Dislocations in
the Acromioclavicular, Coracoclavicular,
and Sternoclavicular Region . . . . . . . . . . .
Overview Subcapital Humerus (1.6%) . . . . . .
Fractures in the Proximal Third of the
Humeral Shaft . . . . . . . . . . . . . . . . . . . . . . . .
Overview Humeral Diaphysis (0.6%) . . . . . . .
Fractures in the Middle Third of the
Humeral Shaft . . . . . . . . . . . . . . . . . . . . . . . .
Most Common Posttraumatic
Deformities of the Proximal and Middle
Humerus . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Shoulder Dislocation . . . . . . . . . . . . . . . . . .
Scapular Fractures . . . . . . . . . . . . . . . . . . . .
19 Elbow Injuries . . . . . . . . . . . . . . . . . . . . . . . .
Diagnostic Notes . . . . . . . . . . . . . . . . . . . . .
Overview Supracondylar Humerus (6.5%) . .
Supracondylar Humeral Fractures . . . . . .
Separated Distal Humeral Epiphyses . . .
Overview Epicondylar Humerus and Dislocations of the Elbow (1.3%) . . . . . . . . . . . . . . .
Epicondylar Fractures . . . . . . . . . . . . . . . . .
Most Common Deformities of the Distal
Humerus Secondary to Supracondylar
and Epicondylar Injuries . . . . . . . . . . . . . .
Overview Transcondylar Humerus . . . . . . . . .
Transcondylar Humeral Fractures . . . . . .
Most Common Posttraumatic
Deformities of the Distal Humerus
Secondary to Transcondylar Injuries . . .
Overview Proximal Forearm Radial Head
(1.3%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fractures of the Proximal End of the
Radius . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
96
96
96
100
102
103
116
117
119
120
121
122
122
131
132
148
149
150
150
157
158
173
179
180
Most Common Posttraumatic
Deformities of the Proximal Radius . . . . 190
Overview Proximal Forearm Olecranon
(0.4%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Isolated Fractures of the Proximal Ulna . 195
Elbow Dislocations . . . . . . . . . . . . . . . . . . . 199
Isolated Dislocation of the Radial Head . 202
Overview Elbow: “Subluxation” of the
Radial Head (3.4%) . . . . . . . . . . . . . . . . . . . . . . . 205
“Subluxation” of the Radial Head
(Nursemaid’s Elbow or Pulled Elbow) . . 206
Overview Elbow: Monteggia Fracture-Dislocations (1.35%) . . . . . . . . . . . . . . . . . . . . . . . . . 208
Monteggia Fracture-Dislocations . . . . . . . 209
Most Common Posttraumatic
Deformity Secondary to Monteggia
Fracture-Dislocation: Missed Dislocation
of the Radial Head . . . . . . . . . . . . . . . . . . . . .214
General Remarks on Arthrolysis of the
Elbow in Growing Patients . . . . . . . . . . . . 216
20 Fractures of the Radial and Ulnar
Shaft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
“Spontaneous Corrections” . . . . . . . . . . . .
Growth Disturbances . . . . . . . . . . . . . . . . .
Overview Radial and Ulnar Diaphysis:
Greenstick Fractures . . . . . . . . . . . . . . . . . . . . .
Greenstick Fractures . . . . . . . . . . . . . . . . . .
Overview Proximal Radial Shaft . . . . . . . . . . .
Overview Radial and Ulnar Diaphysis: Complete Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . .
Complete Fractures . . . . . . . . . . . . . . . . . . .
Overview Distal Radius and Ulna (19.4%) . .
Fractures in the Distal Third . . . . . . . . . . .
Most Common Deformities of the
Middle and Distal Forearm Bones . . . . . .
219
219
220
220
222
223
226
234
235
239
240
252
X
Contents
21 Injuries to the Bones of the Hand . . . . . .
Wrist Fractures . . . . . . . . . . . . . . . . . . . . . . .
Overview Metacarpals and Phalanges
(16.8%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Metacarpal Fractures . . . . . . . . . . . . . . . . .
Fractures and Dislocations of the
Phalanges of the Fingers . . . . . . . . . . . . . .
Lower Extremities
256
256
258
259
263
. . . . . . . . . . . . . . . . . . . 271
22 Injuries to the Proximal Femur and
Femoral Shaft . . . . . . . . . . . . . . . . . . . . . . . . 271
Traumatic Hip Dislocation . . . . . . . . . . . . . 271
Fractures of the Femoral Neck . . . . . . . . . 274
Peritrochanteric Fractures . . . . . . . . . . . . . 280
Avulsion Fractures of the Greater and
Lesser Trochanters . . . . . . . . . . . . . . . . . . . . 281
Overview Proximal Femoral Shaft (0.5%) . . . 285
Overview Femoral Shaft Diaphysis (1.1%) . . 286
Femoral Shaft Fractures . . . . . . . . . . . . . . . 287
Most Common Posttraumatic Deformities
of the Proximal and Middle Femur . . . . . 305
23 Knee Injuries . . . . . . . . . . . . . . . . . . . . . . . . . 310
Diagnostic Notes . . . . . . . . . . . . . . . . . . . . . 310
Overview Distal Femur (0.3%) . . . . . . . . . . . . . 314
Supracondylar Fractures of the Femur . . 315
Fractures of the Distal Femoral Epiphysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
Overview Proximal Tibia (Epiphysis and
Metaphysis 0.2%) Fractures of the Intercondylar Eminence . . . . . . . . . . . . . . . . . . . . . . . . . . 333
Overview Proximal Tibia (Epiphysis and
Metaphysis 0.2%) Epiphyseal Fractures . . . . 334
Fractures of the Proximal
Tibial Epiphysis . . . . . . . . . . . . . . . . . . . . . . 335
Overview Proximal Tibia (Epiphysis and
Metaphysis 0.2%) Metaphyseal Fractures . . . 338
Fractures of the Proximal
Tibial Metaphysis . . . . . . . . . . . . . . . . . . . . . 339
Most Common Posttraumatic Deformities
of the Distal Femur and Proximal Tibia . 348
Patella Dislocations . . . . . . . . . . . . . . . . . . . 354
Patellar Fractures . . . . . . . . . . . . . . . . . . . . . 355
Injuries to the Knee Ligaments and
Intraarticular Knee Injuries . . . . . . . . . . . . 357
Overview Tibial Diaphysis—Isolated Tibial
Fractures (10.8%) . . . . . . . . . . . . . . . . . . . . . . . . . 370
Tibial and Fibular Shaft Fractures . . . . . . 379
Most Common Deformities of
the Tibial and Fibular Shaft . . . . . . . . . . . . 381
25 Ankle Injuries . . . . . . . . . . . . . . . . . . . . . . . .
Diagnostic Notes . . . . . . . . . . . . . . . . . . . . .
Overview Distal Tibia (Epiphysis and Metaphysis 6.6%): Metaphyseal Fractures . . . . . . .
Fractures of the Distal
Tibial Metaphysis . . . . . . . . . . . . . . . . . . . . .
Overview Distal Tibia (Epiphysis and Metaphysis 6.6%) Epiphyseal Fractures (Medial
and Transitional Fractures) and Ligamental
Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medial Injuries to the Ankle . . . . . . . . . . .
Most Common Deformities of
the Middle and Distal Tibia . . . . . . . . . . . .
Overview Ankle: Talofibular Ligament
Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ankle Injuries Involving
the Lateral Ligaments . . . . . . . . . . . . . . . . .
Transitional Fractures
of the Distal Tibial Epiphysis
in Late Adolescence . . . . . . . . . . . . . . . . . . .
Most Common Posttraumatic
Deformities of the Ankle . . . . . . . . . . . . . .
26 Injuries to the Bones of the Foot . . . . . . .
Diagnostic Notes . . . . . . . . . . . . . . . . . . . . .
Overview Metatarsals and Toes (6.9%) . . . . .
Metatarsal Fractures . . . . . . . . . . . . . . . . . .
Fractures and Dislocations
of the Phalanges of the Toes . . . . . . . . . . .
Appendix
382
382
389
390
398
399
405
406
407
412
428
432
432
436
437
439
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
27 Battered Child Syndrome . . . . . . . . . . . . . 441
28 Birth Trauma . . . . . . . . . . . . . . . . . . . . . . . . . 445
29 Pelvic Fractures . . . . . . . . . . . . . . . . . . . . . . . 448
Injuries without Significant
Late Sequelae . . . . . . . . . . . . . . . . . . . . . . . . 455
Injuries with Serious
Late Sequelae . . . . . . . . . . . . . . . . . . . . . . . . 456
30 Spinal Disorders and Injuries . . . . . . . . . . 458
31 Toddler’s Fractures . . . . . . . . . . . . . . . . . . . 467
24 Fractures of the Tibial and Fibular
Shaft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Isolated Tibial Shaft Fractures . . . . . . . . . 371
Overview Tibial and Fibular Diaphysis
(2.9%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378
32 Pathological Fractures . . . . . . . . . . . . . . . . 470
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507
General Science,
Treatment, and
Clinical
Considerations
2
1
Growth and Growth Disturbances
Knowledge of skeletal growth phenomena is essential for treating pediatric fractures and dislocations. This knowledge should include an understanding of the potential of the growing skeleton
to make corrections in shape as well as an understanding of all possible reactions of skeletal
growth zones to traumatic injury.
Growth
The periosteal–endosteal regulatory system controls the circumferential growth in long bones;
the growth plates are responsible for longitudinal
growth (14, 41, 66, 72, 86, 124). Both systems function according to the law formulated by Roux (80)
and strive to achieve a bone shape that ensures
maximum load tolerance with a minimum of
material.
Disturbances in circumferential growth in the
form of partial or complete pseudarthroses are
extremely rare given the periosteal–endosteal
system’s tissue repair capabilities.
In contrast, longitudinal growth disturbances
are extremely common and may be expected to
occur in some form after any fracture in a growing
patient.
Metaphyseal vessels
Metaphysis
Perichondral
vessels
Metaphyseal part
of the physis
Epiphyseal part
Epiphyseal
vessels
Epiphysis
Fig. 1.1 Structure of a growth plate (physis). From a
clinical standpoint, two parts of the growth plate should
be distinguished: an epiphyseal part with proliferative
potential and the metaphyseal part without proliferative
potential. The growth plate is supplied by three independent vascular systems that can communicate with
each other
Longitudinal Growth and
Possible Growth Plate Injuries
(See also Chapter 7, Classification of Childhood
Fractures, p. 40, and Chapter 5, Patterns of Injury
and Prognosis of Childhood Fractures, p. 30).
The growth plate is the organ responsible for
longitudinal growth (Fig. 1.1). From a clinical
standpoint, we should distinguish between two
parts of the growth plate (86, 124, 132, 167): the
epiphyseal part with proliferative potential and
the metaphyseal part without proliferative potential. In the epiphyseal part, the proportion of
matrix is higher than that of the cellular components. In the metaphyseal part of the growth
plate, the proportion of cellular components is
higher than that of matrix because here the cells
progressively increase in volume. At the junction
with the metaphysis, the enlarged distended cartilage cells are then permanently transformed
and ossified by the actual mineralization
processes. The growth plate is surrounded by perichondrium, which is responsible for the circumferential growth of the cartilaginous growth
plate. Metaphysis, perichondrium, and epiphysis
together with their respective parts of the growth
plate are supplied by three independent vascular
systems. The metaphyseal and epiphyseal vascular systems can communicate with each other via
the perichondral system (24 a, 49, 94 a, 124, 141 a).
Growth and Growth Disturbances
The wide open growth plate is on the whole
an excellent buffer against axial trauma and protects the joint. Isolated crush injuries of parts of
the epiphyseal cartilage in the setting of axial
trauma have been repeatedly described in published literature (40, 62, 72, 85, 138, 139).
However, such injuries are improbable, and none
of the follow-up examinations in our entire study
group revealed any such cases (98, 124). In my
opinion this crush injury would appear to be an
unwarranted application of experimental results
and experience in animals to clinical findings in
humans.
The predominance of cellular material in the
metaphyseal part of the growth plate reduces its
resistance to shear and bending forces, especially
during puberty (63). This is why most separated
epiphyses involve this region. This injury has no
mechanical effect on the epiphyseal part of the
growth plate, and it remains intact and adheres to
the epiphysis.
Axial trauma acting on wide open growth
plates produces characteristic injuries to the
epiphysis according to where in the skeleton
(upper or lower extremity) they occur (see also
Chapter 5, p. 30). In an epiphyseal fracture, the
fracture gap invariably crosses the entire growth
plate. In the upper extremities, which do not bear
the body’s weight, the fracture gap in an articular
fracture usually courses through the bearing surfaces of the joint. In the lower, weight-bearing extremities, the fracture gap usually lies in a marginal location in the nonbearing portion of the
joint.
Physiological Closure
of the Growth Plate
Three fundamental stages can be identified in the
maturation of a growth plate (124):
The first is the stage of actual growth in which
the proliferation and mineralization processes are
balanced and the growth plate is wide open.
Shortly before growth is completed, there is a
brief period of inactivity during which the proliferation processes cease but the mineralization
processes do not yet aggressively spread to the
epiphyseal part of the growth plate. The proliferation potential in this phase is dormant yet still
present.
It is only in the final phase, the actual closure
phase, that proliferation ceases entirely. The mineralization processes then successively spread
from the metaphyseal border region to the
3
epiphyseal part of the growth plate, finally leading to bony fusion of the metaphysis and epiphysis.
The time at which physiological closure of the
growth plate occurs is genetically determined. It
depends on the location of the individual growth
plates and on the patient’s age and individual
maturation.
Growth plate maturation invariably begins at
an eccentric location, probably at the most important point of epiphyseal blood supply (Fig. 1.2 a).
From a functional standpoint, the growth plate
may be regarded as closed once most of the
metaphyseal part of the plate has mineralized
while most of the epiphyseal part still remains
open (Fig. 1.2 b). At best, this would only be detectable in radiographs as slight narrowing of the
growth plate. Definitive radiographic evaluation
of the maturity of the growth plate is only
possible once at least partial bony fusion of the
metaphysis and epiphysis has occurred.
The wide open growth plate largely protects
the joint, and the vulnerability of the joint increases significantly as physiological closure of
the growth plate progresses. In this phase, the late
adolescent fractures known as transitional fractures (45, 107, 109) occur instead of separated
epiphyses (see also Transitional Fractures of the
Distal Tibial Epiphysis in Late Adolescence,
p. 412 ff).
Growth Disturbances
Two basic types of growth disturbance are differentiated:
앫 Disturbances that increase growth plate function
앫 Disturbances that impair growth plate function
Both types can affect one or more growth plates in
their entirety or only parts of one growth plate.
Both growth disturbances only occur when the
growth plates are still open. Injuries to premature
growth plates that are nearly fully mature or to
growth plates that have already closed do not lead
to growth disturbances. While this may seem like
obvious and trivial information, it is disregarded
extremely often in the therapy of epiphyseal fractures and the evaluation of results (44, 139).
Therefore, the occurrence of a growth disturbance depends less on the anatomical location of
the injury than on the patient’s age at the time of
the accident.
4
General Science, Treatment, and Clinical Considerations
a
Mineralization
Metaphysis
Metaphyseal
part of the
physis
Epiphyseal
part
Epiphysis
b
The duration of the growth disturbance varies:
Growth stimulation is invariably relatively brief
as it depends on the extent and duration of the repair processes (156).
In contrast, growth arrest and its sequelae are
independent of remodeling and repair processes
and cease only when growth is completed.
Growth stimulation with its various sequelae
may be expected after any fracture in a growing
patient.
In contrast, growth arrest is facultative and its
incidence increases with the injury’s proximity to
the growth plate and the joint as well.
Fig. 1.2 Physiological closure of the growth plate.
a The distal tibial growth plate is a typical example of
the progression of physiological closure. Here, closure begins in the anterior region of the medial malleolus (1), slowly spreads posteriorly (2), and laterally
(3). The anterior, lateral quadrant is only mineralized
at the end of the maturation process
b Mineralization migrates slowly toward the growth
plate with decreasing potential for proliferation, continuing until complete bony fusion of the metaphysis
and epiphysis is achieved
Growth Stimulation
Posttraumatic stimulation of one or more growth
plates in their entirety represents the typical reaction of the growing skeleton to trauma.
Repair of any fracture leads to more or less extensive hyperemia of the adjacent growth plate
(95). However, our most recent studies of idiopathic and posttraumatic leg-length and rotational differences in the femur and lower-leg
cast doubt on the hypothesis that posttraumatic
hyperemia is responsible for posttraumatic leglength differences in children (29). Leg-length
differences during childhood may be observed
even in the absence of trauma; these differences
change with further growth. A significant physiological increase in torsion and length differences
Growth and Growth Disturbances
occurs prior to and during puberty regardless of
whether a fracture has occurred in the lower extremities. This phenomenon is more readily attributable to hormonal, local, or humoral growth
factors that could conceivably stimulate increased function in one or more growth plates adjacent to the fracture. The respective functional
state of the affected growth plates is stimulated.
The severity of the sequelae depends on the
extent of remodeling and on the time and
frequency of subsequent reductions and operations occurring later than five days after the
trauma. The severity of sequelae will increase the
more axial deviations are left to the remodeling of
further growth and the more frequently the fixation callus is disturbed (by secondary reduction
and change of therapy). However, this also means
that the side-to-side displacement that occurs in
the shortening correction repeatedly recommended in the literature involves increased remodeling; this remodeling leads to significant
lengthening of the affected portion of the skeleton in the actual growth phase despite the prophylactic shortening. This is confirmed by our
most recent studies of shaft fractures of the tibia
and fibula and our 1977 studies of femoral shaft
fractures, which have demonstrated that prophylactic shortening is unable to prevent subsequent
lengthening (29, 102).
Tractions also produce a growth stimulation
spurt (29, 102, 106). It is difficult to determine the
extent to which the femur as such is responsible
for the significantly greater extent of lengthening
itself as well as the higher incidence of posttraumatic differences.
Significantly greater lengthening and a higher
incidence of posttraumatic differences occur in
the femur than in the lower leg, and it is difficult
to determine whether the reasons for this are inherent in the femur itself. However, one undeniable fact is that traction was formerly applied in
90% of all femoral fractures, as opposed to only
20% of all fractures of the lower leg. Add to this the
fact that residual axial deviations (in the coronal
and sagittal planes) may be expected in 40% of all
cases of femoral traction and that these are left to
further remodeling (29, 104, 106). In contrast,
comparable axial deviations are only found in 10%
of patients following traction of the lower leg
(29). Leg-length differences were present after
femoral shaft fractures in 70% of all patients who
underwent traction (90, 93) but in only 35% of
patients following tibial and fibular shaft fractures, usually after immobilization in a plaster
gp
ip
5
cp
Lengthening
Compensation
Shortening
Fig. 1.3 Response of the growth plate to a fracture.
Injury during the actual growth phase (gp) produces
persistent posttraumatic lengthening. Injury during the
inactive phase (ip) prior to maturity may result in initial
lengthening, which may later be offset by premature
closure. Injury in the closure phase (cp) results in premature closure compared with the uninvolved contralateral
side, usually leading to slight shortening of the affected
part of the skeleton
cast. These differences measured 10 mm and
7 mm, respectively. In contrast, idiopathic leglength differences in growing patients have an incidence of 25% and measure 7 mm on average.
The sequelae of this growth stimulation vary
and depend on the functional state of the respective affected growth plates at the time of the accident (Fig. 1.3; 117).
Trauma sustained during the actual phase of
growth will produce a more or less extensive increase in length in the affected bone.
If trauma is sustained during the period of inactivity prior to maturity, the increase in function
will result in a transient increase in length. The
hyperemia will lead to premature closure of the
growth plate compared with the uninvolved contralateral side. This premature closure of the
6
General Science, Treatment, and Clinical Considerations
growth plate offsets the slight initial increase in
length.
However, trauma sustained during the actual
closure phase will accelerate closure. The growth
plate matures early and produces slight shortening of the affected bone. This means that whereas
the incidence of posttraumatic leg-length differences depends on instabilities, reductions, operations, and the extent of remodeling, the direction
of the posttraumatic leg-length difference depends on the patient’s age at the time of the accident. Prior to age 10 we must expect an increased
incidence of lengthening; after age 10 an increased incidence of shortening (29).
Initial therapy can only influence this growth
disturbance indirectly by shortening the repair
period. This is achieved conservatively only by reducing remodeling processes, i.e., by avoiding
axial deviations that must be “spontaneously”
corrected during the course of further growth
without resorting to reductions performed after
the fifth day (25, 33). This requirement can be
readily fulfilled by initial surgery. However, subsequent removal of metal implants can also result
in additional stimulation of the growth plate
(140).
The prophylactic shortening deformity
formerly recommended by Blount (8) is unable to
prevent subsequent lengthening as this procedure necessarily involves a varying degree of
side-to-side displacement. This side-to-side displacement translates into protracted remodeling
and therefore an extended repair (see Chapter 2,
Corrective Mechanisms in the Growing Skeleton,
p. 11).
To what extent are length differences clinically significant? The upper extremities do not
bear the body’s weight, and therefore such differences are unimportant in the usual posttraumatic
setting. However, they can produce symptoms in
the lower extremities depending on the specific
load distribution in the individual patient’s spine
and hips. In patients predisposed to hip dysplasia,
this represents a condition that could later
develop into degenerative joint disease (see also
Femoral Shaft Fractures, p. 287). Evaluations in
published literature differ greatly as to what
degree of leg-length difference requires therapy.
The practice in German-speaking countries is to
strive for symmetrical leg length, whereas in English-speaking countries length differences of up
to 2 cm are not considered important (27, 30, 59,
64, 67, 92). Additionally, most measurements are
made directly and not in a functional context and
as such do not allow conclusions as to whether
corrections of load distribution in the spine are indicated.
Treatment can influence growth stimulation
and therefore the incidence and extent of posttraumatic length changes only indirectly by
avoiding the obsolete technique of secondary reduction and changes in therapy, by avoiding increased remodeling in the lower extremities, and
by avoiding traction. This goal can be achieved
only with initial definitive stabilization of the
fracture. The methods required for doing so are
discussed under Specific Injuries.
Partial Stimulation of a Growth Plate
This is a very rare growth disturbance that is encountered only in consolidation disturbances that
cross the growth plate (Fig. 1.4) or are adjacent to
it (see Fig. 3.4; 91, 115, 119, 122, 124). It is the typical growth disturbance that occurs secondary to
articular fractures in the upper extremities (see
also Chapter 5, Patterns of Injury and Prognosis of
Childhood Fractures, p. 30).
The protracted and increased remodeling
processes occurring in the region of the consolidation disturbances, the “partial” or complete
pseudarthroses, result in partial stimulation of
the affected or adjacent growth plate and produce
secondary partially increased growth. This
growth disturbance terminates upon completion
of remodeling in the area of the consolidation disturbance.
The duration of this growth disturbance is
greatly reduced where initial therapy, regardless
of whether surgical or conservative, is successful
in compressing the fracture gap (the critical point
in consolidation). This avoids this particular consolidation disturbance and in so doing normalizes
the duration of consolidation. The consequences
in such cases are not clinically significant (156).
Growth Arrest
Complete Premature Closure
of a Growth Plate
This growth disturbance is very rare and is usually
encountered only in the setting of severe softtissue and crush injuries where complete disruption of the epiphyseal vascular system has resulted in death of the growth plate cartilage (124,
148, 149). However, this disturbance can also be
observed secondary to metaphyseal fractures in
Growth and Growth Disturbances
7
Fig. 1.4 Partial stimulation of a growth plate, the
typical growth disturbance in the upper extremities.
Six-year-old boy with a displaced fracture of the radial
condyle of the left humerus. On the day of the accident,
open reduction was achieved and the fracture stabilized
with a metaphyseal small fragment screw. The open
fracture gap in the lateral radiograph shows that the in-
ternal fixation failed to compress the fracture. The resulting delay in consolidation led to the typical growth
disturbance of transient stimulation of the radial distal
humeral growth plate. This produced a slight varus deformity of the axis of the elbow, with a difference of 15⬚
to the contralateral side
which for “unknown reasons” a transient or
chronic complete interruption of the epiphyseal
vascular supply has occurred (Fig. 1.5). The premature ossification of the entire growth plate that
results from this disturbance leads to progressive
shortening of the injured part of the skeleton until
cessation of growth. The younger the patient and
the larger the portion of the growth plate capable
of growth, the more severe the shortening deformity will be.
This growth disturbance cannot be influenced
by initial therapy. That means that it cannot be
avoided, not even with the “watertight” internal
fixation with compression that formerly received
such praise (99, 139).
8
General Science, Treatment, and Clinical Considerations
Fig. 1.5 Complete premature closure of a growth plate, a rarity in the upper
extremities. Eleven-year-old girl with a left distal forearm fracture. The radius was
completely displaced. Closed reduction of the fracture was performed on the day
of the accident. It consolidated with slight dorsoradial tilting of the distal fragment
and mild side-to-side displacement. Follow-up examination 10 years later revealed
significant shortening of the distal radius with respect to the ulna. The actual deformity was corrected “spontaneously.” Was vascular injury presumably responsible for the widespread destruction of the cartilage of the distal end of the
radius, which led to shortening of the radius?
Growth and Growth Disturbances
9
Fig. 1.6 Partial premature closure of a growth plate,
a typical growth disturbance of the lower extremities. A nine-year-old boy with a typical displaced epiphyseal fracture of the medial malleolus. The fracture was
treated conservatively in a lower-leg plaster cast for six
weeks. During the further course of healing, a metaphy-
seal–epiphyseal bridge developed with secondary abnormal varus growth. Given the extent of this banding
bridge, it must be assumed that this growth deformity is
attributable to vascular injury with a secondary “necrosis bridge”
Partial Premature Closure of a Growth Plate
As was stated before, occurrence of growth arrest with subsequent abnormal growth is facultative and is not at all dependent on the anatomical
location of the injury in the growth plate. Separated epiphyses basically have the same prognosis for growth as the “typical” epiphyseal fractures
occurring with wide open growth plates. Only the
transitional fractures of late adolescence invariably have a better prognosis for growth as in these
cases in which the physiological closure of the
growth plate has already begun; in nearly all
cases, the growth plate closes very quickly as the
fracture heals, and abnormal growth therefore
does not occur. The prognostic factors are more
varied and pose more questions than they answer; these include the patient’s age, the life expectancy of the affected growth plate, the proximity to the growth plate, the extent of displacement of the fracture during the course of the accident, and the location in the skeleton.
The patient’s age or, respectively, his or her
specific degree of skeletal maturity is highly significant. Below age 10, no significant differences
can be identified. However, this is all the more the
case above age 10: Girls mature earlier than boys,
persons of Mediterranean descent earlier than
persons of northern European descent, and darkskinned persons earlier than light-skinned persons. These fundamental and individual differ-
This is the typical growth disturbance of the lower
extremities. It is a facultative growth disturbance
that can occur in about 35% of cases secondary to
displaced metaphyseal fractures adjacent to the
epiphysis, displaced and nondisplaced separated
epiphyses, and displaced epiphyseal fractures
(Fig. 1.6). In the latter case, a “banding” bridge of
bone may form between the epiphysis and
metaphysis, filling the fracture gap that crosses
the growth plate (see Fig. 25. 21; 1, 9, 18, 20, 26, 99,
100, 145, 147, 151).
Depending on the extent of this banding
bridge, growth in this area may cease and lead to
increasingly abnormal growth, or the bridge may
be disrupted by the forces of further growth (17,
155, 166). However, banding bridges of this sort
may not be expected to occur as a matter of course
after epiphyseal fractures. These bridges can also
occur as a result of partial vascular injuries in the
form of what are known as “necrosis bridges” secondary to metaphyseal fractures including separated epiphyses and secondary to bony avulsions
of metaphyseal ligaments (54, 100, 105). In my
opinion, the often quoted “crush injury” is not
clinically significant and at best serves as a welcome excuse when such a growth disturbance
does occur secondary to internal fixation (Fig. 1.7;
99, 105, 119, 120).
10
General Science, Treatment, and Clinical Considerations
Metaphysis
Fig. 1.7 Partial closure of a
growth plate. Even compression
with “watertight” internal fixation
can lead to premature partial closure as a result of vascular injury
(see also Fig. 25.18; from: 100)
Physis
Epiphysis
ences are emphasized in the variable life expectancy of the individual growth plates. Growth
plates that produce a high percentage of growth
(proximal humerus, distal forearm, distal femur,
and proximal tibia) grow significantly longer than
growth plates that produce a lesser percentage of
growth (elbow, proximal femur, and distal tibia),
and therefore they are at greater risk with respect
to growth disturbances with abnormal growth.
The closer a fracture is to a growth plate, the
greater the risk to the plate’s vascular supply and
therefore to normal growth. There is also a clear
correlation with the extent of displacement, which
cannot always be determined precisely in the case
of separated epiphyses as they can more readily
reduce spontaneously. The time of reduction of
physeal fractures has no influence in the prognosis of growth (151). However, the most amazing
phenomenon is that there is a significant difference in growth prognosis between the upper and
lower extremities. Although we find approximately the same number of epiphyseal fractures
and about four times as many separated
epiphyses, growth arrest is observed significantly
less often in the upper extremities (see also Chapter 5, p. 30).
Initial therapy only has an effect in epiphyseal
fractures, where it can minimize the extent of a
possible banding bridge by reducing the fracture
gap by means of “watertight” internal fixation.
However, initial therapy cannot prevent “necrosis
bridges” secondary to vascular injury (see
Fig. 25.18; 99, 100, 120). This means that it cannot
reliably influence the partial premature closure of
a growth plate. According to experimental studies
by Dallek (19), we must assume that a banding
bridge will necessarily occur following any transepiphyseal injury to a growth plate. Where these
bridges are small, i.e., where the area of the injury
is small, they will be reliably disrupted “spontaneously“—at least in the experiment—by the
forces of further growth and will not lead to any
abnormal growth. However, it is far from clear
whether these results can be applied to clinical
cases (27).
11
2
Corrective Mechanisms in the Growing Skeleton
It is possible for growth to correct axial deviations
in all three dimensions (22, 28, 66, 131, 141). There
are different forms of corrective mechanisms
(Fig. 2.1; 123, 124). We differentiate between
direct and indirect corrective mechanisms. The
direct mechanisms may be further subdivided
into purely periosteal corrections, purely epiphyseal corrections, and combined periosteal–
epiphyseal corrections.
The periosteal and periosteal–epiphyseal corrective mechanisms invariably function according to Roux’s law: They attempt to restore the
original shape of the bone so as to achieve maximum strength with a minimum of material. In the
shaft, this remodeling to restore the original
shape involves periosteal bone formation on the
side subject to the greatest compressive stresses
coupled with endosteal bone resorption on the
side bearing the lesser load. In axial deviation, the
growth plate is able to restore its normal position
perpendicular to the plane of stress by unequal
longitudinal growth that occurs concurrently
with the bone remodeling processes. In this
sense, these corrections are the result of directed
processes.
The purely epiphyseal corrections are the result of nondirected processes as they occur solely
as a consequence of repair processes adjacent to
the fracture (see Growth Stimulation, p. 5).
Periostealendosteal
Directed
Axial deviation
(coronal and
sagittal plane)
Direct
Epiphyseal
Nondirected
Indirect
Fig. 2.1
Side-to-Side
displacement
Shortening +
(Lengthening)
Rotational
deformity
Corrective mechanisms in growing patients
Corrections of rotational deformities are indirect, totally nondirected corrections that have
nothing to do with the repair processes adjacent
to the fracture. They could theoretically occur in
any long bone within the scope of physiological
processes that reduce version. To date, such spontaneous corrections of rotational deformities
have been demonstrated directly and indirectly
only after fractures of the femoral and humeral
shaft (106, 112, 136). Our studies of the lower leg
have shown that spontaneous corrections of rotational deformities may not be expected, at least
not in the age range in which fractures most
frequently occur, after age five. On the contrary,
idiopathic and posttraumatic version differences
increase prior to and during puberty (29).
As is true of growth disturbances, all spontaneous corrections are dependent on the age of
the child at the time of the accident. The chance
that deformities will correct spontaneously is
greater in younger patients and lesser in older
patients. Such corrections also depend on the location of the injury, i.e., on the growth portion of
the nearest growth plate, functional stresses due
to adjacent musculature and the joints adjacent to
the fracture, and the static load.
The degree to which the growth plates are involved in the longitudinal growth of the individual bones varies (Fig. 2.2; 72, 124). In the
upper extremities, this eccentricity is more pronounced than in the lower extremities. The
growth plates that produce a high percentage of
growth close significantly later than those that
produce a low percentage of growth. Accordingly,
axial deviation adjacent to growth plates that produce a high percentage of growth will be better
corrected than deviation adjacent to growth
plates that produce a low percentage of growth.
Axial deviations in the main plane of motion
of the body, the sagittal plane, are normally better
corrected than deviations in the coronal plane.
This rule especially applies where axial deviations
lie in the vicinity of hinge joints (such as the elbows and interphalangeal joints of the fingers and
12
General Science, Treatment, and Clinical Considerations
Correction of Side-to-Side
Displacement
This is a purely periosteal correction (Fig. 2.3). Depending on the patient’s age, the original shape of
the bone is restored by periosteal remodeling.
Side-to-side displacements of one full shaft width
are reliably corrected in practically all parts of the
skeleton in children up to age 10–12. The proximal
end of the radius is an exception. Here, no side-toside displacements are corrected during the
course of further growth (127).
Correction of Axial Deviations
in the Coronal and Sagittal Planes
Fig. 2.2 Percentage of total longitudinal growth in
the respective bones accounted for by the individual
growth plates. The proportion of growth of the individual growth plates exhibits a more eccentric distribution
in the upper extremities than in the lower extremities
toes). In these cases, axial deviations that lie outside the plane of motion are not corrected at all
during further growth (111, 113). However, axial
deviations that lie in the plane of motion of these
joints are usually well corrected.
The fundamental limits of correction are
therefore defined by the patient’s age or, more
precisely, the anticipated growth in the adjacent
growth plate and by the functional load of the
axial deviation itself. Axial deviations that cannot
be compensated for by at least one of the adjacent
joints usually remain completely unchanged
during the further course of growth. They can occasionally lead to significant clinical symptoms,
such as a rotational deformity in the bones of the
hand or in the lower leg. In such a case, one cannot
wait for a spontaneous correction that may never
materialize, and the deformity will require surgical correction.
This is a combined correction by periosteal–endosteal and epiphyseal mechanisms. The axial deviation lying in the metaphysis or diaphysis is remodeled by periosteal bone formation and endosteal bone resorption, as in the case of the sideto-side displacement. The growth plate restores
its position perpendicular to the plane of stress by
unequal longitudinal growth that occurs concurrently with the bone remodeling processes
(Fig. 2.3; 53, 83, 124). Such corrections are dependent on the patient’s anticipated growth (corrections before age 10 are more reliable than after
age 10), the anticipated growth of the individual
growth plate (growth plates that produce a high
percentage of growth remain open longer than
those that produce a low percentage of growth),
and the direction of function of the adjacent joints
and the musculature adjacent to the deformity
(axial deviation in the sagittal plane is better corrected than deviation in the coronal plane, and
varus better than valgus).
Where the functional corrective stimulus is
limited (because of static load or function) or absent, the deformity will only be partially corrected or will persist unchanged (Fig. 2.4).
In the interest of minimizing leg-length
differences (see p. 6, 287 ff), we recommend not
leaving axial deviations in the lower extremities
to the “spontaneous correction” of further growth
whenever possible, even if these deviations
would be reliably corrected (101, 117).
The potential for correction is particularly
great in the upper extremities. Because posttraumatic length differences are unimportant from a
clinical standpoint, reliable corrections of deformities may more readily be incorporated into
initial therapy. These corrections are particularly
pronounced in the proximal end of the humerus
Corrective Mechanisms in the Growing Skeleton
13
Fig. 2.3 Periosteal and periosteal – epiphyseal “spontaneous corrections.” A femoral shaft fracture in a sixmonth-old boy consolidated
in a varus angle of 30⬚, with
side-to-side displacement
exceeding a full shaft width,
and with shortening. During
the further course of growth,
the varus deformity and
side-to-side displacement
were almost completely eliminated while the growth
plates have returned to their
physiological position perpendicular to the plane of
stress. The protracted remodeling led to overcompensation of the original shortening deformity. In the followup examination four years later, the leg in which the
fracture had occurred exhibited lengthening of 1 cm
(from: 124)
(Fig. 11.5) and the distal forearm (Fig. 2.5). The
proximal end of the radius is the exception to
every rule. Here, too, further growth reliably compensates for axial deviations in the coronal and
sagittal planes (Fig. 2.6). This occurs although
there is no adjacent growth plate that produces a
high percentage of growth and the growth plate
does not bear the body’s weight (see literature on
the elbow: 144, 115 and on the forearm: 40). Age
10–12 may be regarded as the age limit for these
corrections in the proximal humerus and distal
forearm, and age 9–10 for the proximal radius. Beyond this age limit, an axial deviation should not
be left untreated. Within this age limit, axial deviations in the coronal and sagittal planes of up to
60⬚ can be corrected spontaneously (39).
Correction of the Shortening
Deformity
This is a purely epiphyseal correction that occurs
by means of posttraumatic growth stimulation of
the growth plates adjacent to the fracture. Such
growth stimulation increases growth plate function, therefore usually leading to lengthening of
the affected section of the skeleton (see Growth
Stimulation, p. 5). This can “correct” an initial
shortening deformity. As such deformities are invariably associated with a side-to-side displacement of varying severity, this means protracted
remodeling and therefore an increase in length
(Fig. 2.3). This then leads to lengthening of the affected section of the skeleton despite the initial
shortening deformity, that is to overcompen-
14
General Science, Treatment, and Clinical Considerations
Fig. 2.4 The limits of periosteal – epiphyseal “spontaneous corrections.” In the
absence of sufficient functional stimulation of the periosteal–epiphyseal corrective
system, the axial deformity
will persist for years and diminish only slightly or not at
all, as is seen here in an anterior bow of 25 degrees in the
femur of the patient from
Fig. 2.3 (from: 124)
sation of the initial shortening deformity. In contrast, an initial shortening deformity in adolescent patients above age 10 would only be increased by growth plate stimulation and its
sequelae.
Because directed corrections of the length
differences invariably do not occur, a reliable
prognosis of length is not possible (124).
We have only observed directed length corrections in the forearm in exceptional cases to
date. However, these corrections do not apply to
the length relative to the contralateral side but to
the length relationship between radius and ulna.
This relationship is invariably restored symmetrically (39) in both initial shortening deformities
and posttraumatic lengthening but not in shortening of one of the two bones as a result of premature closure of the growth plate (Fig. 2.7).
Fig. 2.5 “Spontaneous correction” of axial devia- 왘
tions in the coronal and sagittal planes. The patient is
a three-year-old boy with a displaced fracture of the distal radius. The fracture consolidated with radial and posterior angulation of 30⬚ each. Within one year of the accident, further growth had nearly completely corrected
the axial deviation in both planes
Corrective Mechanisms in the Growing Skeleton
15
16
General Science, Treatment, and Clinical Considerations
Fig. 2.6 “Spontaneous correction” of axial deviations in the coronal and sagittal planes. The patient is
a 10-year-old boy with a displaced separated epiphysis
of the proximal radius, which in spite of attempted closed reduction consolidated with angulation of 65⬚. Follow-up examination seven years later revealed that furt-
Correction of the
Lengthening Deformity
This axial deviation is only found in iatrogenic
sequelae of traction therapy. It is not “spontaneously” corrected by further growth.
Correction of the
Rotational Deformity
Changes in version occur in all long bones during
growth. Such physiological changes in version can
correct posttraumatic rotational deformities
“spontaneously.” This applies in particular to rotational deformities (such as in the humerus or
femur) that are not initially measurable by clinical
her growth had nearly completely corrected the deformity despite the lack of functional stresses at this location and the fact that this growth plate produced only a
low percentage of growth. Despite the thickening of the
proximal end of the radius, there was no limitation of the
range of motion in pronation and supination
examination and therefore cannot be actively corrected by conservative therapy but which are well
compensated for after the fracture heals. Rotational deformities in the lower leg can be evaluated upon initial clinical examination and therefore lend themselves to active correction. This is
all the more important because they cannot be
functionally compensated for because of the adjacent hinge joints. This also applies to the forearm
and the phalanges of the fingers and toes (115).
To date such “spontaneous” corrections of rotational deformities have only been demonstrated in the humerus and femur (see also
Specific Injuries, p. 287 ff; 12, 69, 96, 112; Fig. 2.8).
Corrective Mechanisms in the Growing Skeleton
Fig. 2.7 Directed “spontaneous correction” of a
shortening deformity. The patient was an 11-year-old
boy with a shaft fracture of the distal forearm bones that
consolidated with significant shortening of the radius relative to the ulna. Follow-up examination six years later
17
revealed that the shortening had been corrected; the
correct length relation was restored between the radius
and ulna but not with respect to the contralateral side.
The growth plates were closed at the follow-up examination
18
General Science, Treatment, and Clinical Considerations
Abb. 2.8 “Spontaneous correction” of a rotational
deformity. The clinical significance of a posttraumatic
rotational deformity in the femur is often exaggerated,
turning an idiopathic mosquito into a predegenerative
elephant. In clinical and radiological terms, a rotational
deformity is defined as a difference in the anteversion of
the femoral necks. Retroversion of the unaffected contralateral side compensates for the most common deformity during further growth, the external rotation deformity of the distal fragment. It is also possible for version changes in the injured side to restore symmetry
with the contralateral side, as in the case of this six-yearold boy. The rotational deformity is then no longer
measurable by clinical or radiographic examination and
loses any clinical significance (obsolete Dunn view,
which today is no longer used because of the high dose
of radiation involved; see Fig. 9.4)
19
3
Consolidation and Consolidation Disturbances
Bone Healing
Bone healing in an immature skeleton nearly always occurs indirectly via callus formation (66,
72, 86, 130, 141). A callus of connective tissue initially forms around the fracture, bringing the fragments into opposition and stabilizing the fracture. The extent of this callus depends on the extent of initial axial deviations in the coronal and
sagittal planes, side-to-side displacement, and
mobility in the fracture. The greater the mobility
in the fracture and the greater the axial deviation,
the larger the callus will be. The fracture is then
further stabilized by formation of chondral tissue.
The callus becomes increasingly ossified due to
proliferation of vascular structures and migration
of chondroclasts, osteoblasts, and accompanying
mesenchymal cells (141) to the site. The periosteal bridging callus is the most important structure in stabilizing the fracture. Initially, it alone
can guarantee stability and immobility of the
fracture. Final bony repair of the fracture site and
the disappearance of a radiographically detectable fracture gap occur later, in certain cases
months after the patient resumes use of the affected part of the body.
During the course of further growth, the stabilizing eminences of the callus are broken down
by periosteal and endosteal action according to
Wolff’s law (142) until the bone resumes its original shape. Stability in the healing fracture requires that the callus form over the entire fracture. This in turn requires uniform distribution of
compression or tension stresses between the
fracture fragments over the entire fracture plane.
Only such conditions will ensure uniform callus
formation around the fracture and subsequent
uniform bony union.
Evaluation of Stable Consolidation
The radiographic sign of stable consolidation is a
dense cortical periosteal structure bridging the
fracture gap in three of four cortexes imaged in
the anteroposterior (A-P) and lateral radiographs
(Fig. 3.1; see also p. 80). The crucial clinical criterion for permitting full use is absence of pain.
From a clinical standpoint, a callus that is no
longer painful to palpation has healed with stability (often this can also be inferred by inspecting
the cast, which will usually exhibit extensive defects). Each child will then decide the appropriate
degree of use for himself or herself. The average
consolidation times (i.e., immobilization times)
with allowance made for this phenomenon are
listed in Table 3.1.
Open Fractures and Posttraumatic Defects
Luckily, posttraumatic soft-tissue infections and
ostitis are rare in children. They are primarily encountered in fractures with heavily contaminated
wounds and soft-tissue necrosis. In first or second
degree open fractures (in which internal penetration by bone fragments has caused more or less
extensive soft-tissue injuries), rapid soft-tissue
healing usually prevents infection. Accordingly,
most open fractures of this type can be converted
to closed fractures by initial treatment of the
wound and then treated conservatively where the
specific type of fracture permits such treatment.
Naturally, all appropriate surgical measures involved in primary wound care, such as wound debridement, drainage, mesh inserts, etc., should be
applied to prevent a soft-tissue infection. Prophylactic antibiotic treatment is not routinely indicated with first and second degree open fractures.
Third degree open fractures are usually associated with neurovascular injuries in addition
to the extensive soft-tissue injuries and possible
necroses. This means that in these cases immediate stable internal fixation is required to protect
the neurovascular sutures and as prophylaxis
20
General Science, Treatment, and Clinical Considerations
Fig. 3.1 Radiographic evaluation of stable consolidation of a transverse femoral fracture in a sevenyear-old boy. The fracture was treated conservatively
with traction. After five weeks (two weeks after traction
was discontinued), the A-P radiograph shows good medial and lateral bridging of the fracture gap with periosteal callus. In the lateral radiograph, good bridging of
the fracture gap is only visible on the posterior aspect.
The patient had begun to move his leg spontaneously in
the week after removal of traction. Upon clinical examination, the callus was no longer painful to palpation. Given the radiographic findings of callus bridging of the
fracture gap of at least three cortexes in two imaged planes coupled with the clinical findings of lack of pain
upon palpation, the fracture may be termed stable
against infection. Naturally, this also applies to all
replantations. The course of fracture healing
should determine the required doses of antibiotics in the case of third degree open fractures as
well.
All of these consolidation disturbances can
also occur in the same manner in adults. However,
there are also some consolidation disturbances
that characteristically occur in children (32).
Shaft
Consolidation Disturbances
Aside from consolidation disturbances in the setting of pathological fractures, secondary to infection, and due to iatrogenic causes (usually secondary to incorrect osteosynthesis), delayed consolidation of one bone is occasionally observed in
the conservative or surgical management of
paired bones (such as in the forearm). This is invariably the case where more rapid consolidation
in one bone then delays the process in the other.
Usually, the other bone ossifies in time with increased use without the need for further treatment.
Consolidation disturbances may occur secondary
to greenstick fractures. In these fractures, the cortex is completely breached on the convex side of
the deformity, whereas it is only partially disrupted on the concave side. Where such a fracture
is “straightened” or reduced leaving slight residual deformities, the concave side will promptly
heal. However, the convex side will lack the necessary interfragmentary compression, which results in delayed union or nonunion (Fig. 3.2). The
periosteal bridge over the fracture gap still fails to
form on the convex side of the axial deviation
even after protracted immobilization. Later bony
Consolidation and Consolidation Disturbances
21
Table 3.1 Rough guidelines for average consolidation periods (periods of immobilization or restricted use) for
the most common childhood injuries.
Injured structure
⬍ 5 years
5 – 10 years
⬎ 10 years
Clavicle
Humerus
—Proximal, stable
—Proximal, unstable
—Diaphysis
—Supracondylar
—Lateral condyle
—Medial condyle (Y fracture)
—Medial epicondyle (+ elbow dislocation)
Proximal end of the radius (radial head)
Olecranon
Radial head and elbow dislocation
Forearm diaphysis including greenstick
Distal radius and forearm
Separated distal radial epiphyses
Wrist
Metacarpal base and subcapital
—Diaphysis
Finger base and subcapital
—Diaphysis
Femur
—Femoral neck
—Subtrochanteric
—Diaphysis
—Condyles including separated epiphyses
Tibia and lower leg
—Intercondylar eminence
—Proximal metaphysis
—Diaphysis
—Supramalleolar and articular (ankle)
Tarsus and calcaneus
Metatarsal base and subcapital
Toes
Talofibular ligaments
—Bony avulsion
1
2
2–3
1
1
2
1–2
3
2–3
2–3
1
1
—
3
2
2
—
—
—
1–2
2–3
1–3
2–3
3–4
2–3
3–4
3
2–3
1 – (2)
2–3
3
4
3–4
2–3
4–6
2
3–4
2
3–4
2–3
3
4–6
3–4
4
3–4
1–2
(2)
3–4
3
4–6
4
3–4
6 – 12
2–3
4–6
2–3
4–8
—
3–4
1–3
2–3
4–6
4–5
4–5
3–4
6 – 12
4–6
4–6
4
—
2–3
2–3
2–3
—
2–3
1
3–4
3–4
3–5
3–4
4–8
3
1–2
4
4
4–6
4
6 – 12
3–4
2–3
—
2–3
3
앫 Metaphyseal fractures heal about twice as quickly as diaphyseal fractures.
앫 Transverse diaphyseal fractures heal more slowly than oblique diaphyseal fractures.
22
General Science, Treatment, and Clinical Considerations
Fig. 3.2 “Partial pseudarthrosis” secondary to diaphyseal greenstick fractures. The patient shown is a 10-year-old boy with displaced greenstick fracture of
the left forearm shaft. The fracture was reduced on the day of the accident and only “straightened.” The fracture quickly consolidated on the concave side of the de-
formity whereas consolidation failed to occur on the convex side. This “partial
pseudarthrosis” is still readily visible in the radiographs after 12 weeks of immobilization in a plaster cast. The resulting instability of the diaphyseal shaft led to a repeat fracture following minor trauma three weeks later
Consolidation and Consolidation Disturbances
Fig. 3.3 Consolidation disturbances—pseudarthrosis. Except for injuries in the radial elbow, posttraumatic
pseudarthroses in children and adolescents have a favorable prognosis. The images show a 10-year-old boy with
a dislocated diaphyseal fracture of the proximal phalanx
of the great toe. Closed reduction was achieved and the
fracture was stabilized by means of percutaneous wire
fixation. The wires were removed after three and a half
weeks, after which time the patient increasing regained
union detectable in radiographs appears to be inadequate. This “partial pseudarthrosis” represents a weak point in the diaphyseal cortex and
entails an increased risk of repeat fracture within
a year of the initial trauma (31; Fig. 3.2).
23
spontaneous full use. Pseudarthrosis developed but did
not at all impair the patient so that intervention was not
indicated. After a total of 8 and 12 months, respectively,
the onset of spontaneous bony union in the pseudarthrosis without any supporting therapy was observed
(my thanks to Dr. Staehelin, Bezirksspital Breitenbach,
Switzerland, for making these radiographs of his patient
available for publication)
24
General Science, Treatment, and Clinical Considerations
Metaphysis
Here consolidation disturbances also occur secondary to greenstick fractures, primarily fractures
of the proximal and distal tibia. Here, an overlooked slight initial valgus deformity in the proximal or distal tibia will also lead to rapid healing of
the fracture on the concave side of the deformity,
that is on the lateral side. Insufficient medial interfragmentary compression will then lead to the
consolidation disturbance known as “partial
pseudarthrosis.”
This triggers increased remodeling processes
that lead to partial stimulation of the adjacent
growth plate. The additional medial growth in
turn exacerbates the initial valgus deformity. This
is a particular problem in the proximal tibia as it
causes unilateral genu valgum of increasing
severity (Fig. 3.4). Such a deformity and its
sequelae in the distal tibia are better compensated for by the talocalcaneonavicular joint, in
terms of both cosmesis and function (103).
There is no increased risk of repeat fracture
here due to the broad cancellous support of
metaphyseal fractures. This growth disturbance is
transient and terminates with bony union in the
area of pseudarthrosis, which is only small to
begin with.
Fig. 3.4 “Partial pseudarthrosis” secondary to
metaphyseal greenstick
fractures. The patient is a
five-year-old girl with a typical greenstick fracture of
the right proximal tibia. The
initial valgus deformity was
not detected and not eliminated so that the fracture
quickly consolidated on the
concave side of the axial deviation whereas consolidation was delayed on the
convex side. This resulted in
a medial “partial pseudarthrosis.” The protracted remodeling processes around
these zones of delayed consolidation stimulated the
adjacent proximal tibial
growth plate, leading to increased medial growth that
exacerbated the initially
present valgus deformity,
causing unilateral genu valgum
Consolidation and Consolidation Disturbances
Articular Region
Growth disturbances almost only occur secondary to fractures of the lateral condyle of the
humerus. In conservatively treated unstable fractures of the lateral condyle, the specific compression forces acting in the radial elbow and the low
percentage of growth produced by the distal
humeral growth plate can lead to increasing dis-
25
placement and nonunion. This can produce
pseudarthrosis with increasing displacement of
the peripheral fragment (6, 32, 44, 72, 105, 110,
125, 135). This in turn results in an increasing valgus deformity of the elbow that entails an increased risk of subsequent injury to the ulnar
nerve (Fig. 3.5; see also Specific Injuries).
Fig. 3.5 Consolidation
disturbance with secondary pseudarthrosis following an articular fracture of
the distal humerus that
crossed the growth plate.
Conservative treatment of a
dislocated fracture of the lateral condyle in which adequate reduction of the
fracture was achieved by
closed manipulation will
invariably lead to pseudarthrosis with increasing
displacement of the peripheral fragment. This in
turn resulted in a valgus elbow deformity as in this
four-and-a-half-year-old boy
(see also Specific Injuries)
26
General Science, Treatment, and Clinical Considerations
Periarticular Region
Consolidation disturbances almost only occur
secondary to fractures of the medial epicondyle of
the humerus (see also Specific Injuries). The tension of the inserting tendons of the hand and finger flexors invariably leads to displacement of the
fragments and mobility in the fracture. This prevents definitive healing and leads to pseudarthrosis (Fig. 3.6) in about 50% of all conservatively
treated cases and in about 10% of all surgically
treated cases. Only about 10% of these pseudarthroses are subsequently symptomatic (32).
Fig. 3.6 Pseudarthrosis of
the medial epicondyle of
the humerus. Findings in
this seven-year-old boy include a dislocated avulsion
fracture of the medial epicondyle. The fracture was
treated conservatively in a
plaster cast for three weeks,
after which the patient began spontaneous motion
exercises. Upon follow-up
examination six years later,
the patient was free of subjective and objective symptoms and exhibited symmetrical free function on both
sides
27
4
General Observations on the Nature and Correction
of Posttraumatic Deformities
Cause
Posttraumatic deformities are caused either by
residual axial deviations or by the sequelae of
growth disturbances (23, 73, 134).
Residual axial deviations, especially in conservative treatment, involve either axial deviations
that will no longer “spontaneously” correct themselves and have been left untreated or deviations
that have been left untreated where correction is
possible yet would take too long and would be
poorly tolerated. Table 4.1 lists those axial devia-
Table 4.1
tions in which “spontaneous” correction is usually not possible or occurs only slowly.
Sequelae of growth disturbances are clinically
significant primarily in the lower extremities.
Length differences due to posttraumatic growth
plate stimulation play a significantly greater role
in the lower extremities than in the upper extremities. However, this is only true where they
augment preexisting idiopathic length differences and exceed 2 cm in length. Partial stimulation with transient abnormal growth in the form
of axial deviation, such as after proximal
Axial deviations left untreated
No “spontaneous” correction
Unreliable or only slow “spontaneous” correction
⬍ 10 years
⬎ 10 years
⬍ 10 years
Proximal humerus
X
X
Humeral diaphysis
X
X/O
Distal humerus
O
O
⬎ 10 years
O
Proximal forearm
X / O / AB / PB
⬎ 10 E
X / O / AB / PB
⬎ 10 E (⬍ age 5)
Forearm diaphysis
X / O / AB / PB
⬎ 10 E
X / O / AB / PB
⬎ 10 E (⬍ age 5)
Distal forearm
O / X / PB / AB
(⬎ age 12 – 13)
Proximal femur
X / PB / AB
O / X / PB / AB
Femoral diaphysis
X / AB (⬍ 20 E) / RD
(internal RD of distal
fragment)
X / AB (⬍ 20 E) / RD PB
(internal RD of distal
fragment)
PB / RD
Distal femur
RF (internal RD of
distal fragment)
AB / PB / RD (internal O / X
RD of distal fragment)
X/O
Proximal tibia
RD
RD
X
Tibial diaphysis
RD
RD
Distal tibia
RD
RD
Fingers and toes
RD / X / O
RD / X / O
O (⬍ age 5)
X
AB = anterior bowing, RD = rotational deformity, PB = posterior bowing, O = varus, X = valgus
28
General Science, Treatment, and Clinical Considerations
metaphyseal greenstick fractures of the tibia, is
extremely rare. Premature partial or complete
closure of the growth plate with subsequent increasingly abnormal growth occurs significantly
more often in the lower extremities than in the
upper extremities. The “conical” epiphysis is a
specific articular sequela of premature closure of
the growth plate that can produce severe articular
deformities.
When Is Surgical Correction
of a Posttraumatic Deformity
Indicated?
This depends on several factors:
앫 The nature of the deformity:
—Decreasing
—Increasing
—Constant
앫 The patient’s age,
앫 The patient’s functional symptoms,
앫 Cosmetic complaints by parents (relatives,
neighbors, teachers, kindergarten staff, etc.),
앫 Parents’ fear of possible subsequent consequences (neighbors, relatives, etc.),
앫 Tolerance by the patient and his or her
parents,
앫 The actual late prognosis: upper and lower extremities.
Regardless of whether the deformity is cosmetic
or functional, the correction should always depend on the severity of impairment as judged by
the patient himself or herself. Especially in
children, this impairment will primarily be defined by functional deficits and to a far lesser extent by cosmetic ones.
Another important factor is whether the deformity increases, decreases, or remains constant
over time. In the case of decreasing deformities
such as an anterior bow deformity in the distal
humerus secondary to a supracondylar humerus
fracture at age five or six, it is easy to convince the
parents to wait until the child regains unrestricted function or the cosmetic defect has disappeared. In the case of a constant or apparently
constant deformity, patient and parents will be
quicker to demand correction. This naturally applies to deformities that increase in severity as
well, such as growth arrest. The speed of a
possible “spontaneous” correction or the increase
in severity of a deformity naturally depends on
the patient’s age; the younger the patient, the
more rapid the growth changes will be.
Neighbors, kindergarten staff, relatives, and
co-workers represent another powerful influence
that should not be underestimated: “You can’t
just leave it like that!”; “Look at how you let your
child run around!”; “My uncle got his severe arthritis from just such a thing”; “Another person
died of it.”; and so on. People will shamelessly
voice such opinions, and it is not always easy for
parents to reject them. The physician should
make it clear that he or she is aware of such ridicule thinly disguised as “well-meant advice” and
is willing to help in the struggle to come to terms
with it and defend against it.
A significant argument for parents is their responsibility for their children’s subsequent wellbeing and the fear of permanent disabilities in the
short term or long term that could have an impact
on the child’s play, sports activities, and choice of
profession. Unfounded threatening on the part of
physicians is unfortunately common. The wildest
prognoses for degenerative joint disease are made
without any knowledge of the actual late prognosis of various injuries: early arthritis between the
ages of 20 and 30, loss of mobility in joints, etc.
Admittedly, there are few late follow-up studies
of childhood injuries that provide information
about the actual late prognosis, but one should at
least consult those studies that do. As far as any
others are concerned, the very least physicians
should do is to avoid making claims that they do
not know to be true. For example, who can really
say what the actual late prognosis for an overlooked untreated Monteggia injury is, or for congenital dislocations of the radial head?
The necessity of and time frame for a possible
correction should therefore invariably be discussed with the patient and the patient’s parents
and determined on an individual basis. Leaving a
deformity temporarily or permanently untreated
as well as correcting it must be tolerable for both
the patient and the patient’s parents. Under no
circumstances should the indication for correction become subordinate to factors such as the
physician’s business interests, an interest on the
part of the insurer or society at large to ration
care, or a hospital’s desire to amortize its assets.
How Can One Correct
Posttraumatic Deformities?
There are many possibilities for correcting or
compensating for posttraumatic deformities (11,
145, 152, 154). Conservative methods usually correspond to compensations (e.g., length compen-
General Observations on the Nature and Correction of Posttraumatic Deformities
sation), whereas surgical methods represent
definitive or temporary corrections. Ortheses that
positively reinforce growth rarely have a somatic
effect but usually a psychological effect. They give
parents the impression that something is being
done, they usually cost a lot of money, and
children wear them grudgingly or not at all.
Therefore, they should be used sparingly and for a
very specific purpose.
Table 4.2 lists all possible measures. The surgical procedures will be discussed in detail in the
respective chapters under Specific Injuries.
29
Table 4.2 Corrective measures for treating posttraumatic deformities
Method
Measures
Conservative
앫 Observation
앫 Length compensation
앫 Ortheses
앫 Corrective osteotomy in all
planes
— Single procedure
— Multiple procedures
앫 Growth plate obliteration
— Temporary
— Permanent
앫 Iatrogenic bridge disruption
앫 Bridge resection
Surgical
30
5
Patterns of Injury and Prognosis of Childhood Fractures
I have compiled the most important data for this
chapter from the monograph by Jonasch and Bertel (42), from the data supplied by Ritter (78), and
by Höllwarth and Hausbrandt (37) in Sauer’s book
on childhood injuries, from Landin’s publications
on the pattern of injury in children (51, 52), and
from observations among my own patients.
As long as the growth plates are still wide
open, all bony injuries to the extremities follow a
single stereotypical pattern of injury that depends on the degree of maturity of the growth
plates, not on the direction of trauma.
Forms of Injury
We encounter shaft fractures 50 times more often
than articular fractures, whereby separated
epiphyses should be regarded as the most peripheral form of shaft fractures (Fig. 5.1).
Metaphyseal injuries account for the greatest
number of shaft fractures by far, whereby separated epiphyses occur four times more often in
the upper extremities than in the lower extremities (Fig. 5.2). The majority of the remaining
metaphyseal fractures are impacted fractures and
only rarely bending fractures. Contusions are
rare; what would normally be contusions, i.e., the
impaction injuries in growing patients, are the
typical metaphyseal buckle fractures.
Greenstick fractures of the forearm are the
most common diaphyseal fractures in the upper
extremities. In the lower extremities, the most
common injuries in the femur are transverse fractures, and the most common injuries in the lower
leg are isolated torsion fractures of the tibia.
The pattern of articular fractures is also stereotypical: We encounter articular fractures
twice as often in the upper extremities than in the
lower extremities. The typical example of an articular fracture of the upper extremities is the
fracture of the lateral condyle of the humerus; the
typical articular fracture of the lower extremities
is the medial malleolar fracture. In the nonweight-bearing upper extremity, the fracture
Fig. 5.1 Distribution of the incidence of fractures in
growing patients. As long as the growth plates are still
wide open, shaft fractures are encountered 50 times
more often than articular fractures, whereby separated
epiphyses should be regarded as the most peripheral
form of shaft fractures
crosses the main area of stress transfer in the
joint, whereas in the weight-bearing lower extremity articular fractures in patients with wide
open growth plates always lie at the edge of the
joint outside the main area of stress transfer. Articular fractures in the main area of stress transfer,
for example in the ankle, are only observed in
fractures occurring in late adolescence (transi-
Patterns of Injury and Prognosis of Childhood Fractures
31
Abb. 5.2 Distribution of
the incidence of separated
epiphyses, the most
peripheral of all shaft fractures. Separated epiphyses
occur four times more often
in the upper extremities
than in the lower extremities
tional fractures). Yet here, too, the form of the
fracture and the location of the fracture line depend on the maturity of the growth plate (its
degree of physiological closure) and not on the
mechanism and direction of injury (Fig. 5.3; see
also Chapter 25, Ankle Injuries, p. 382).
Depending on the patient’s age, we may basically expect stereotypical patterns of bone injury.
This is significant in diagnosing the injury and
evaluating its prognosis. Before age 12, as long as
the growth plates are still wide open, we may expect far more fractures than contusions. We find
more fractures in the upper extremities than in
the lower extremities, and the shaft is more often
involved than the joint. Bony ligament avulsions
are encountered far more often than torn ligaments, and dislocations are far less common than
fractures.
Abb. 5.3 Distribution of
the incidence of articular
fractures. The typical example of an articular fracture
of the upper extremities is
the fracture of the lateral
condyle of the humerus;
typical examples of fractures in the lower extremities include the medial malleolar fracture and late adolescent fractures of the distal tibia. In patients with
open growth plates, we
encounter articular fractures twice as often in the
upper extremities than in
the lower extremities
32
General Science, Treatment, and Clinical Considerations
Growth Prognosis
The growth prognosis for bony injuries to the extremities also varies significantly between the
upper and lower extremities. The capability for
spontaneous correction of residual axial deviation is greater in the upper extremities than in the
lower extremities. This results in a more favorable
prognosis for metaphyseal shaft fractures in the
upper extremities, where they occur significantly
more often than in the lower extremities. Growth
arrest due to premature partial or complete closure of a growth plate secondary to epiphyseal
fractures, separated epiphyses, and other
metaphyseal fractures close to the growth plates
is a problem in the lower extremities that rarely
occurs in the upper extremities. This also improves the prognosis for epiphyseal fractures and
separated epiphyses in the upper extremities,
which occur more frequently (the incidence of
partial or complete premature closure of the
growth plate is less than 10% in the upper extremity as opposed to more than 20–30% in the lower
extremity). Transient partial stimulation is the
classic growth abnormality that occurs in the
upper extremity following an epiphyseal fracture
of the lateral condyle of the humerus, and it occurs after any such injury. The classic growth abnormality following an epiphyseal fracture of the
distal tibia, for example a medial malleolar fracture, is premature partial closure of the growth
plate. However, this only occurs in about 20–30%
of all cases (1, 6, 8, 11, 26, 53, 72, 76, 84, 99, 100,
124, 135).
Again, we should emphasize that growth abnormalities can only occur in the patient up to a
certain age. This phenomenon is often overlooked, especially in comparative evaluations of
the prognosis for separated epiphyses and the
prognosis for epiphyseal fractures in the literature (1, 62, 72, 85, 139). Here, authors repeatedly
claim that separated epiphyses, due to the anatomical site of the injury (the fracture does not
cross the growth plate perpendicularly), have a
significantly better growth prognosis than
epiphyseal fractures (where the fracture crosses
the growth plate perpendicularly). As we have
demonstrated in our own studies and as has been
confirmed in individual descriptions in the literature (37, 49, 100, 101, 108, 114, 119), growth abnormalities, specifically premature closure of the
growth plate, can indeed occur even secondary to
a separated epiphysis. This may be observed especially where there is involvement of a growth
plate that remains open for a long time, such as
the growth pate in the distal femur. According to
the data supplied by Jonasch and Bertel (43), there
is a significant difference between epiphyseal
fractures and separated epiphyses with respect to
the age at which peak incidence occurs (Fig. 5.4).
Epiphyseal fractures exhibit about the same peak
age as shaft fractures of the distal radius (which
are most frequent) and tibia, i.e., significantly
below age 10 (42, 61, 77). In contrast, the peak age
for all cases of separated epiphyses in the upper
and lower extremities is significantly past age 10.
As a matter of fact, growth abnormalities involving premature closure of the growth plate occur
less frequently after separated epiphyses (e.g., in
the distal tibia) than after epiphyseal fractures.
However, it is more accurate to include only those
patients with fractures who at the time of the accident are at an age in which growth abnormalities can still occur, and in this case this difference
is no longer significant. The growth prognosis for
separated epiphyses still remains slightly better
than for epiphyseal fractures. However, this is
clearly attributable to the fact that the peak incidence of separated epiphyses occurs in an age
group in which growth abnormalities with clinically significant sequelae are no longer possible.
Again, we should emphasize that the expected growth in the individual patient as a whole
is not the determining factor, rather the expected
growth in the affected or adjacent growth plate.
The longer the growth plate remains open, the
more severe will be the sequelae of premature
partial or complete closure. A typical example is
the distal femoral growth plate. Here even a nondisplaced separated epiphysis may later result in
premature partial closure of the growth plate
with clinically significant sequelae. This also applies to growth plates in other locations, such as
the proximal tibia (Fig. 5.5).
This results in a significantly different growth
prognosis for bony injuries to the extremities according to their distribution in the upper and
lower extremities. The more common diaphyseal,
metaphyseal, and epiphyseal injuries in the upper
extremities exhibit significantly better potential
for spontaneous correction and produce more
benign growth abnormalities than the fractures in
the lower extremities. Spontaneous corrections
are less common in this latter group, and given
the incidence and severity of posttraumatic
differences in leg length, one should not rely on
such corrections. Premature partial closure of the
growth plate is a growth disturbance that is
Patterns of Injury and Prognosis of Childhood Fractures
33
Shaft fractures
Isolated tibia
Distal radius
Number of
patients
n = 8353
n = 6007
13
Separated
epiphysis
13
Upper
Extremity
Number of
patients
Distal radius
n = 5433
Age
Lower
Distal tibia
n = 1723
Great toe
n = 544
Proximal humerus
n = 398
Proximal radius
n = 398
13
9 13
Age
Epiphyseal
fracture
Lateral condyle
of the humerus
n = 889
Abb. 5.4 Distribution of the incidence of the most
common shaft fractures, separated epiphyses and
epiphyseal fractures, in different age groups (according to Jonasch and Bertel). Epiphyseal fractures, shaft
fractures of the distal radius (which are most frequent),
and tibia shaft fractures exhibit a peak incidence be-
Distal tibia
(Jonasch)
n = 57
Ditto (von Laer)
n = 53
tween the ages of seven and ten. In contrast, separated
epiphyses, due to hormonal influence, exhibit their peak
incidence at age 13. The only exception is the elbow,
where the growth plates close earlier. This is the only explanation for the difference in the prognosis between
separated epiphyses and epiphyseal fractures
34
a
b
c
General Science, Treatment, and Clinical Considerations
Abb. 5.5 Growth abnormalities involving premature partial closure of the growth plate following a
separated epiphysis. The patient is a 12-year-old boy
with a slightly anteriorly displaced separated tibial epiphysis with otherwise normal axial alignment. Conservative treatment (a). During the further course of healing,
partial closure of the lateral portion of the growth plate
occurred, resulting in increasing, unilateral genu valgum
(b). The computed tomography (CT) image shows premature partial closure of the posterolateral portion of
the growth plate to which the growth deformity may be
attributed (c). Given the patient's age (13 by that time),
we decided against resection or separation of the
growth plate with the Ilizarov fixator. Upon cessation of
growth (d), surgical correction of the slight deformity
(valgus difference of 10⬚ to the contralateral side) was
deemed unnecessary, as the patient was free of symptoms. The knee exhibited its full range of motion, and
there was no difference in leg length
d
Patterns of Injury and Prognosis of Childhood Fractures
possible but not inevitable following fractures in
the lower extremities. However, where it does
occur, its clinical sequelae are also more severe
than in the upper extremities.
Ligament Injuries
Ligament injuries also exhibit a typical behavior
in growing patients. The most common ligament
injuries are injuries to the fibulotalar ligaments
and injuries to the anterior cruciate ligament.
We conducted a prospective and retrospective
study of over 300 patients with fibulotalar ligament injuries and over 60 patients with cruciate
ligament injuries (see pp. 360, 385, 407 ff). In
ankle injuries, we found that as long as the growth
plates were still wide open, the ligaments avulsed
from the fibula in 80% of all cases and only rarely
from the talus. The ligament itself remained intact. In nearly 50% of these cases, the injury occurred as a bony avulsion and was immediately
recognizable as such in the radiographs (see
Fig. 25.5). One quarter of the avulsions were chondral and another quarter periosteal. We observed
intrasubstance ruptures in only slightly less than
20% of patients with open growth plates (i.e., in
patients below age 12). After age 12 as the growth
plate increasingly closes, the situation is exactly
the opposite: In 80% of these patients, we ob-
< age 12
> age 12
80%
80%
Abb. 5.6 Types of ligament injuries in growing patients. Before age 12, we find bony, periosteal, or chondral avulsions with an intact ligament in about 80% of all
cases. After age 12, intrasubstance ruptures are observed in 80% of all cases
35
served intrasubstance ruptures; avulsions with
an intact ligament occurred in only 20% of these
patients. These avulsions again evidenced the
same distribution of bony, periosteal, and chondral injuries (Fig. 5.6).
The distribution of this pattern of injury is
even more extreme in the injuries to the anterior
cruciate ligament. Before age 12, intrasubstance
ruptures occurred in only 5% of our study group,
whereas a complete or partial bony avulsion of
the entire intercondylar eminence occurred in
95% of the patients in this age group. After age 12,
we find the typical pattern of injury that occurs in
adults, even where the growth plates are still
open. That means we find intrasubstance ruptures in 80 % of these patients, proximal or distal
periosteal or chondral avulsions in another 15% of
these patients, and bony avulsions (usually involving only portions of the intercondylar eminence) in only 5% of these patients.
The prognosis for ligament injuries is difficult
to evaluate as the issue of stability or compensation for instability cannot be evaluated on the
basis of a single factor as we are used to doing in
other situations.
In principle, both bones and ligaments can restore the stability of a joint in growing patients
following a ligament injury. That means that the
bony components of the joint can adapt to the
new situation during the course of further
growth; increasing plastic deformation of these
bony components can compensate for the loss of
the ligament and regain stability. Ligament stability can also return independently of treatment. It
is not known how this occurs and whether it may
also be partially attributable to bony changes. We
are usually inclined to attribute the restoration of
stability to our treatment while regarding the
cases in which stability does not return as the
patient’s individual fate. However, a striking finding is that the final results in both the ankle and
the knee are identical regardless of the treatment
performed: Good, stable final results are consistently reported in 80% of all cases; poor results
are reported in another 20% of all cases. These
stereotypical results suggest to me that the conservative or surgical treatment performed did not
succeed in restoring stability, rather that it was restored by spontaneous stabilizing mechanisms
which we do not fully understand.
Another phenomenon confirms our lack of
understanding of the mechanisms of joint instability and restoration of stability. This is the compensation or decompensation that occurs with
36
General Science, Treatment, and Clinical Considerations
existing instability. Instability remains after every
type of treatment in approximately 20% of all ligament injuries in the knee and in the ankle. Exactly
50% of our patients with fibulotalar ligament injuries were found to have compensated for residual instability at their first follow-up examination. These patients reported no symptoms, experienced no recurrent trauma, had no swelling,
experienced no pain, and participated in sports at
least to the extent that they had prior to the accident. However, the other half of this patient group
with instability exhibited clear signs of decompensation: They complained of swelling of the
hindfoot and the mortise of the ankle, recurrent
bouts of pain, recurrent trauma, and significant
impairment in sports activities. We were unable
to find any parameter in either group that could
have explained this phenomenon, such as body
weight, handedness, specific sport, etc. By the
next follow-up examination of the same patients,
on average three to fours years later, one third of
these patients revealed opposite findings for no
apparent reason. That means that patients who
had reported compensated instability at the first
follow-up examination were now decompensated and vice versa.
The phenomenon of joint stability and the action of muscles, ligaments, and bones in compensating for existing instability depends on multiple
factors and is more complex than we had previously thought. Surgical intervention, regardless
of the extent of treatment, can in no way correct
every factor in this equation. At best, it can stimulate existing compensation mechanisms and pro-
tect the ligaments from recurrent trauma until
the injury has developed a reliable envelope of
scar tissue after about six to eight weeks.
Naturally, both the process of compensating
for instability and the subjective evaluation of
treatment are significantly determined by psychological factors in the patient and the physician.
These factors can positively or negatively influence the results for years.
For the future, it would be more interesting to
devote our attention to analyzing the poor results
of our treatment of ligament injuries than to
shortsightedly attribute what appear to be good
results to our treatment.
Dislocations
The occurrence of dislocations should be regarded as a sign of the changing elasticity of the
ligament or the changing stability of the insertions of the ligaments during the course of further
growth. The growth plates adjacent to the elbow
are responsible for a low percentage of growth
and close earlier than all other growth plates in
the immature skeleton, between the ages of nine
and 12. Supracondylar humeral fractures are the
injuries typically encountered until about age
seven. Elbow dislocations only occur after this age
as the growth plates begin to close. The proximal
humeral growth plate remains open for a long
time. Shoulder dislocations before age 12 are accordingly rare in patients with open growth
plates. They are usually found only in adolescents
with closed growth plates (Fig. 5.7).
Patterns of Injury and Prognosis of Childhood Fractures
Abb. 5.7 Age of patients presenting with dislocations. Dislocations are far less common than fractures.
At age 7, i.e., as the elbow growth plates begin to close,
dislocations may occur instead of supracondylar fractu-
37
res (b). Dislocations of the shoulder are observed only as
the proximal humeral growth plate begins to close. This
practically occurs only after age 12 (c)
38
6
General Observations on Prevention of
Injuries in Growing Patients
When contemplating prevention, we should give
some thought to what it is we want to protect
children against. We must differentiate according
to the severity of the injury. Children profit from
minor injuries because such injuries expand the
child’s experience, increase the child’s self-confidence with respect to motor function, and make
the child increasingly self-reliant in daily life.
Such “educational” injuries include the numerous
metaphyseal impacted fractures, Chassaignac injuries, and the many harmless diaphyseal fractures (such as an isolated tibial fracture) that do
not cause complications and only briefly incapacitate the patient. Causes include falls from a
slight height or on even ground and accidents occurring during play or sports.
The situation is totally different in the case of
life-threatening injuries, multiple trauma,
craniocerebral trauma, severe accompanying injuries, complicated articular fractures, and the
like. Here, severe late sequelae may be expected
in some cases, and every effort should be made to
avoid them. Traffic accidents are most frequently
the cause, followed by falls from a great height,
accidents involving fire and electricity, drowning,
and also certain types of sports such as downhill
skiing, etc. (36, 38, 89, 144, 146, 157, 158, 159, 160,
161, 162, 165).
What should be done? “Nailing down”
children will not help because that deprives them
of every opportunity for development and for acquiring self-confidence and confidence in dealing
with their environment and the hazards it poses.
Faced with a choice between two alternatives,
one effectively must opt for both.
It is only possible to prevent life-threatening
accidents when one simultaneously employs all
contributing factors:
앫 Restrictions and rules,
앫 Passive protection,
앫 Active training in dealing with hazards,
앫 Providing a role model of self-confidence.
Restrictions and rules are passive forms of prevention. They provide immediate protection of life
and limb as long as children and adolescents have
also learned to deal self-reliantly with hazards
such as electricity, fire, falls from a great height,
traffic, skiing on slopes with an increased risk of
avalanches, etc.
Passive protection first and foremost involves
personal protection by the child’s parents. It goes
without saying that as long as children have not
yet learned to deal with their environment, they
should be strictly supervised—whether at home
in the kitchen, in the yard, while taking a walk, on
the playground, in stores, etc.
Passive protective measures according to the
age-specific patterns of injury (36, 38, 42, 77, 89)
are also essential. For example, up to age five, accidents from falls from a diaper-changing table,
down stairs, from windows, etc. should be prevented with appropriate physical safety features.
This includes common-sense measures such as
using changing tables with safety railings, placing
babies in child carriers, doing without support devices while the child is learning to walk. It also includes safety features such as protective grating
on stoves and in nature preserves; properly
equipped high chairs, bunk beds, and child car
seats; and accident-prevention features on playgrounds, etc. In the case of children beyond the
age of five to six, the hazards are less in the home
than in these children’s wider radius of action beyond the home, i.e., on playgrounds, athletic
fields, streets, etc. Helmets, shin guards, proper
settings for ski bindings, etc. play an important
role in protection. However, they cannot replace
active training in dealing with hazards.
Active training in dealing with hazards requires that parents allow their children the freedom of action that is appropriate to their age and
that they allow their children to acquire and learn
from experience on their own. This is the only way
that children will learn to treat themselves and
their bodies responsibly. They can only do so
when they become familiar with both in play and
General Observations on Prevention of Injuries in Growing Patients
in sports. Parents can be a detrimental influence
in two ways: First, by demanding performance
and by exhibiting a lack of patience they can significantly disturb and prevent the child’s individual proprioceptive development. Second,
lacking self-confidence in their own lives, they reveal this inner dependence on their parents to
their own children. Of course it is not always easy
to watch small children hold scissors for the first
time in their lives and to let them learn to use
them and acquire their own experience despite all
their apparent clumsiness. More often than not,
one is surprised to have to admit that children are
indeed well able to master such things. The more
trust one places in them, the more confidence and
self-confidence they will exhibit.
Providing a role model of self-confidence requires a great deal of self-confidence from the
parents themselves. Often they lack it and attempt to conceal that fact behind a profusion of
restrictions and rules. The danger of arbitrary
rules that are not meant seriously is that children
will quickly learn that violating unimportant
rules will not have serious life-threatening con-
39
sequences. This leads them to conclude that rules
and restrictions are merely intended to cement
the parents’ position in the family hierarchy, not
primarily to protect the child. Children are not
able to distinguish between unimportant and important restrictions and rules on their own, and
eventually this will lead to a situation in which
the child no longer observes any rules or restrictions. Such a situation is life-threatening. Parents
must possess enough self-confidence to assert
only those rules and restrictions that protect the
life of the child and to avoid expanding them to include children’s secondary activities.
Other adults aside from parents have a similar
role model function. Among these are top competitive athletes, whose behavior in daily life and
in sports sets an example and is often imitated by
children and adolescents.
!
Restrictions and rules only make sense when
they protect children, not when they hinder
them.
40
7
Classification of Pediatric Fractures
Because growth disturbances cannot be reliably
corrected by initial therapy and therefore can only
be indirectly influenced, the prognosis for growth
should not be used as a criterion for classifying
pediatric fractures. A classification system should
attempt to limit itself to describing the location
and morphology of the fracture and in so doing
provide therapeutic information (132). However,
we should not overlook the fact that a major purpose of classification systems is facilitating documentation in quality controls and multicenter
studies. With respect to the indication and technique in the setting of initial treatment, the only
fundamental difference is between articular injuries and shaft fractures.
Regardless of the classification system, one
should invariably determine whether the fracture
in question may be regarded as a “retention fracture” or a primary or secondary “reduction fracture.” This means that one should fundamentally
consider whether a purely conservative therapy
will suffice or whether manipulative “active”
therapy under some form of anesthesia will be
unavoidable, at the very least so that the parents
may be informed accordingly.
“Retention fractures” of the diaphysis and
metaphysis may be understood as transverse
fractures in which the fragments are in apposition
or oblique fractures that are stabilized by the intact paired bone (such as isolated fractures of the
tibial shaft). “Retention fractures” of a joint include nondisplaced epiphyseal fractures in which
the width of the fracture gap does not exceed
2 mm that means: just visible in the radiograph.
Treatment of “retention fractures” consists of
simply immobilizing the fracture in a plaster cast
in the case of shaft fractures with or without a
subsequent cast wedge. This means that no anesthesia is required.
“Reduction fractures” may be understood to
include all completely displaced diaphyseal and
metaphyseal transverse and oblique fractures
with respective shortening whose treatment requires anesthesia. “Reduction fractures” of the
joints include displaced epiphyseal fractures with
fracture gaps exceeding 2 mm. It is understood
that the treatment undertaken under anesthesia
should be definitive so as to avoid obsolete secondary reduction procedures and changes in
therapy.
Note that there are initial “retention fractures”
that are initially nondisplaced but can subsequently become displaced even when immobilized in a plaster cast. Examples include fractures
of the lateral condyle of the humerus or metaphyseal fractures of the distal forearm. These fractures can therefore become “reduction fractures.”
It is important to inform the patient and the
patient’s parents early about such eventualities.
The following classification system limits itself to distinguishing between shaft and articular
fractures without respect to therapy. A recently
proposed documentation system for these injuries is discussed separately at the end of this
chapter.
Shaft Fractures
Diaphysis
Especially in the case of diaphyseal fractures it is
crucial to distinguish between stable and unstable fractures. Fractures may be regarded as
stable where the fragments are in apposition and
at most exhibit axial deviation but not shortening.
Unstable fractures include all those that are
completely displaced and long oblique fractures
with significant shortening. For example, the isolated torsion fracture of the tibia, the most common shaft fracture in the lower extremities, represents a stable fracture despite its slight shortening tendency because of the varus position of the
intact fibula. In contrast, completely displaced oblique fractures of the calf and femur invariably
represent unstable fractures.
Therefore, we differentiate the oblique, torsion, and comminuted fractures also seen in adults
from the transverse fractures, and the typical pediatric shaft fractures from the diaphyseal greenstick fractures.
Classification of Pediatric Fractures
41
Fig. 7.1 Schematic diagram of a diaphyseal greenstick fracture
Fig. 7.2 Schematic diagram of a metaphyseal impacted fracture
Diaphyseal Greenstick Fractures
Metaphyseal Greenstick Fractures
These are invariably bending fractures in which
one cortex is partially broken and the opposite
cortex is completely broken (Fig. 7.1). By definition, all greenstick fractures exhibit a more or less
severe axial deviation that is often overlooked. Inadequate therapy will lead to a partial consolidation disturbance (see Chapter 3, Consolidation
and Consolidation Disturbances, p. 19) with increased risk of repeat fracture (see also diaphyseal
forearm fractures, pp. 22, 222 ff).
Here too, one cortex is intact and possibly impacted whereas the opposite cortex is broken. By
definition, the metaphyseal greenstick fractures
also exhibit a more or less severe axial deviation
that is often overlooked. This axial deviation is
often only detected because of the unilateral fracture gap. A consolidation disturbance (see pp. 24,
343) on the convex side of the deformity can result in partial stimulation of the adjacent growth
plate. This growth disturbance exacerbates the
deformity that is invariably initially present. Depending on the location, the resulting axial deviation can cause a major cosmetic and functional
impairment (Fig. 7.3). Fractures of this sort must
not be confused with the subperiosteal impacted
fractures as they present a distinct set of problems
in the form of a consolidation disturbance.
Metaphysis
Metaphyseal Impacted Fractures
These are readily treatable fractures in which the
cancellous bone of the metaphysis and the cortex,
which becomes thinner here, have become impacted (Fig. 7.2).
42
General Science, Treatment, and Clinical Considerations
Metaphyseal Ligament Avulsions (see
Articular Injuries, below)
Nondisplaced and displaced metaphyseal bony
avulsions (Fig. 7.5) can lead to premature partial
or complete closure of the adjacent growth plate
by causing vascular injury.
Apophyseal Avulsions (Muscular Avulsions)
Apophyses are the sites of tendon insertions in
the metaphyseal region, and their plates have the
same morphological structure as the growth
plates. They are not involved in the longitudinal
growth of the bone. Therefore, growth disturbances are not to be expected following apophyseal avulsions (Fig. 7.6).
Separated Epiphyses (Salter–Harris Types I
and II, Aitken Type I)
Fig. 7.3 Schematic diagram of a metaphyseal greenstick fracture
Separated epiphyses with and without a
metaphyseal bending wedge are the most peripheral shaft fractures (Fig. 7.7). The separation oc-
Supracondylar Fractures
These fractures are associated with a distinct set
of problems both in the upper arm and in the
femur. Usually, they can be readily reduced due to
the small peripheral fragment but are hard to fix
(for this reason percutaneous pinning is often indicated; Fig. 7.4).
Fig. 7.4 Schematic diagram of a supracondylar
fracture
Fig. 7.5 Schematic diagram of ligament avulsions in
the knee (distal femur and proximal tibia)
Classification of Pediatric Fractures
43
Articular Injuries
Typical Epiphyseal Fractures with Wide Open
Growth Plates (Salter–Harris Types III and IV,
Aitken Types II and III)
Fig. 7.6 Schematic diagram of muscular avulsions
(apophyseal separation of the medial epicondyle of the
humerus)
curs in the metaphyseal portion of the growth
plate where cell proliferation has ceased (132).
The epiphysis itself and the epiphyseal portion of
the growth plate remain intact. Growth disturbances including premature partial and complete
closure of the affected growth plate may occur
secondary to vascular injuries (1, 85).
These fractures are invariably articular fractures.
The fracture gap crosses the metaphyseal and
epiphyseal parts of the growth plate. Bony growth
in the fracture gap in the growth plate cartilage
can produce a banding bridge between the
epiphysis and metaphysis with subsequent abnormal growth. This may also occur as a result of
vascular injury (necrosis bridge). The articular injury in the lower extremities always lies in the
marginal part of the joint; in the upper extremities it lies in the central part of the joint (see p. 31;
Fig. 7.8; 1, 77).
Fig. 7.7 Schematic diagram of a
separated epiphysis (Salter–Harris
types I and II)
Fig. 7.8 Schematic diagram of
epiphyseal fractures (Salter–Harris
types III and IV)
44
General Science, Treatment, and Clinical Considerations
Lateral
A-P
Fig. 7.9 Schematic diagram of transitional
fractures of the distal tibia
Two-plane
Triplane I+II
Transitional Fractures of Late Adolescence
(Two-Plane and Triplane I and II)
These fractures occur in late adolescence when
physiological closure of the growth plate has
begun. Growth disturbances are not generally to
be expected because of the advanced age of the
patient. The articular injury lies in the central,
load-bearing portion of the joint in both the upper
and lower extremities (see Specific Injuries,
p. 412 ff; Fig. 7.9).
Epiphyseal Ligament Avulsions
of wide open growth plates. They do not usually
lead to growth disturbances (avulsions of the
talofibular ligament in the distal tibia and avulsions from the eminence in the proximal tibia;
Fig. 7.10).
Chondral or Osteochondral Flake Fractures
As in adults, these injuries can occur as injuries
associated with dislocations, primarily on the
talus or on the patella. Because they represent
epiphyseal fractures without involvement of the
growth plate, they do not lead to growth disturbances (Fig. 7.11).
These are most frequently encountered as chondral, periosteal, or bony avulsions in the presence
Fig. 7.10 Schematic diagram of lateral ligament
avulsion in the distal fibula
Fig. 7.11 Schematic diagram of a lateral ligament
rupture in the ankle with a flake fracture of the talus
Classification of Pediatric Fractures
Proposed Documentation System
for Pediatric Fractures and
Dislocations
The Swiss organization Li-La (Licht und Lachen für
Kinder in der Medizin—Effizienz in der Medizin e.V;
www.li-la.org) and the Institute of Evaluating Research in Orthopedic Surgery at the University of
Bern (formerly the Department of Documentation and Evaluation of the M.E. Müller Foundation; memdoc) have jointly developed a documentation system for pediatric fractures that is
suitable for international use (www.orthoglobe.com). The draft classification utilized by
this system may yet undergo slight modification
before the final version is published.
The final version of the documentation system will be available in 2004. It will essentially
comprise the elements described below.
It starts analogous the Maurice Müller’s
classification of fractures in long bones in adults
(65):
앫 The primary site is the anatomical location of
the fracture in a specific bone, defined in descending order as: upper arm 1, forearm 2,
femur 3, and lower leg 4.
앫 The secondary site is the location of the fracture within a specific bone segment, defined
in descending order as: proximal 1, middle 2,
and distal 3.
4.3.1
Epiphyseal fracture
(Salter-Harris type III)
Fig. 7.12
4.3.2
Epiphyseal metaphyseal fracture
(Salter-Harris type IV)
45
At this point, the proposed system diverges from
the adult classification (which further specifies
the injury according to its severity) and appends a
specifically pediatric morphological identifier.
This identifier includes one of a total of 15 numbers as the third number or as the fourth number
in certain fractures of paired bones, which are described below under “exceptions.”
Numbers 1–4 designate the articular region
(fractures of the epiphyseal portion of the growth
plate are articular fractures). They lie in segment 1
or 3 of each bone (see Fig. 7.12):
1. Epiphyseal fracture (Salter–Harris type III)
2. Epiphyseal–metaphyseal fracture (Salter–
Harris type IV)
3. Two-plane transitional fracture
4. Triplane transitional fracture (I and II)
Numbers 5–8 designate the periarticular region
(fractures of the metaphyseal portion of the
growth plate and the rest of the metaphysis are
periarticular fractures). They also lie in segments
1 and 3 of each bone (see Fig. 7.13):
5. Separated epiphysis without a metaphyseal
wedge (Salter–Harris type I)
6. Separated epiphysis with a metaphyseal
wedge (Salter–Harris type II)
7. Impacted and greenstick metaphyseal fracture
8. Complete metaphyseal fracture
4.3.3
Two-plane transitional
fracture
Classification of articular fractures of the distal tibia: 4.3.1–4
4.3.4
Triplane transitional
fracture (I and II)
46
General Science, Treatment, and Clinical Considerations
4.3.5
Separated epiphysis without
a metaphyseal wedge
(Salter-Harris type I)
Fig. 7.13
4.3.6
Separated epiphysis with
a metaphyseal wedge
(Salter-Harris type II)
4.3.8
Complete metaphyseal
fracture
Classification of periarticular fractures of the distal tibia: 4.3.5–8
Differentiating the metaphysis from the diaphysis
in the anteroposterior (A-P) radiograph:
앫 In the cortex, there is a transition between the
thin metaphyseal cortex and the significantly
thicker diaphyseal cortex,
앫 In the bone, the cancellous structure exhibits a
curved margin that is convex toward the shaft.
3.2.9
Transverse fracture
Fig. 7.14
4.3.7
Impacted and greenstick
metaphyseal fracture
3.2.10
Simple oblique fracture
Numbers 9–12 designate the shaft region, the diaphyseal fractures. They lie in segment 2 of each
bone (see Fig. 7.14):
9. Transverse fractures (⬍ 30⬚ to the longitudinal axis of the bone)
10. Simple oblique fractures (⬎ 30⬚ to the longitudinal axis of the bone)
3.2.11
3.12.12
Multifragmentary, torsion Diaphyseal greenstick fracture
and spiral wedge fracture
Classification of shaft fractures of the femoral shaft: 3.2.9–12
Classification of Pediatric Fractures
11. Multifragmentary, torsion, and spiral wedge
fractures
12. Diaphyseal greenstick fractures
Numbers 13 and 14 designate bony avulsions of
ligaments and muscles from the epiphysis or
metaphysis; these injuries lie in segments 1 and 3
of each bone.
13. Avulsions of ligaments (epiphyseal and
metaphyseal) (see Fig. 7.15)
14. Avulsions of muscles (apophyseal avulsions:
metaphyseal) (see Fig. 7.16)
4.1.13
Avulsion of ligament
(fracture of the eminence of the tibia)
Fig. 7.15 Classification of ligamental
fractures, eminential fracture: 4.1.13
47
Number 15 designates special forms in all segments of the long bones:
15. Special forms that do not fit into this scheme
and can only approximately be collectively
localized in segments 1, 2, and 3
3.1.14
Avulsion of muscles
(fracture of the lesser trochanter)
avulsion
Fig. 7.16 Classification of muscular avulsion fractures, avulsion of the trochanter minor: 3.1.14
48
General Science, Treatment, and Clinical Considerations
1.3.0.1
Lateral condylar fx,
hanging
1.3.0.2
Lateral condylar fx,
complete
1.3.0.3
Y-fx
1.3.0.4
Medial condylar fx
Fig. 7.17 One of the exceptions of the classification: fracture of the distal humerus epiphysis: 1.3.1–4
Exceptions: (a 0 as the third number identifies an
exception).
앫 Distal humeral metaphysis: 1.3.0. 5–8
앫 Distal humeral epiphysis: 1.3.0. 1–4 (see
Fig. 7.17)
앫 Olecranon: 2.1.0. 5–8
앫 Femoral neck: 3.1.0. 5–8
In injuries to paired bones, the radial fracture is
documented in the forearm and the tibial fracture
in the calf. Isolated injuries of the ulna or fibula
are also identified by a third number of 0 and are
classified according to the usual scheme.
앫 Epiphysis, metaphysis, shaft of ulna or fibula
(isolated injury):
—2.1/2/3.0. 1–15
—4.1/2/3/.0. 1–15
49
8
Diagnostic Studies
History Taking: Interviewing the
Patient
The mechanism of injury has less importance for
injuries to the growing skeleton than for injuries
in adults. The type of injury depends primarily on
the degree of maturity of the skeleton and less on
the mechanism of injury itself (ligament injuries,
transitional fractures, supracondylar fractures,
dislocations, etc.). Therefore, history taking does
not have to include painstaking questioning of the
patient, parents, and witnesses to precisely reconstruct the chronology of the accident. Experience has shown that this is hardly ever
possible, it has a negligible effect on further procedure, and it only makes the pain-stricken
patient increasingly impatient and frustrated. The
goal of history taking should be to ascertain
whether trauma has occurred that may have been
sufficient to produce an injury requiring diagnosis and treatment. Remember that in contrast to
injuries in adults, isolated contusions are rare but
that fractures (including hairline fractures, separated epiphyses, buckle fractures, avulsed ligaments) are encountered very frequently. History
taking after the accident should aim to localize
the possible injury and ascertain the subjective
extent and severity of pain (Fig. 8.1; see also
Chapter 16, General Observations on Information).
HISTORY TAKING
Fig. 8.1 Overly meticulous history taking will unnecessarily delay the onset of treatment
50
General Science, Treatment, and Clinical Considerations
Inspection
Inspection should primarily be a visual examination, never a palpatory examination. Obvious
swelling, deformities, missing parts, asymmetry,
etc. can be noted by inspection. These visual findings determine the further procedure (Fig. 8.2).
Observing how physicians in training “see” with
their hands, one often has the impression that
they have completed a school for the blind. It
pains to experience such an examination, especially for the patient!
INSPECTION
SURFAC
ERYTHEMA
AXIS
Fig. 8.2
only
RELAXATION
ABSENCE
LIMP
SWELLING
Inspection should be a visual assessment
Diagnostic Studies
51
Examining the Periphery
Prior to any manual examination, the examiner
should inform the patient about the procedure
and obtain his or her consent by asking “May I
touch you?” This is more than simply the polite
thing to do; it also significantly increases the
patient’s willingness to cooperate.
Evaluating the periphery is both unavoidable
and the most important “manual” examination of
the patient. In any suspected fracture, which is a
common occurrence in children, one must evaluate and document motor function, vascular
supply, and sensation. A perfunctory neurological
examination without pin pricks will suffice initially (Fig. 8.3).
Fig. 8.3 A meticulous evaluation of sensation will
only rarely fail to cause pain
52
General Science, Treatment, and Clinical Considerations
“Painful” Clinical Examination
Before the advent of radiography, a thorough and
meticulous clinical examination was necessary to
determine whether the injury was indeed a fracture and what type of fracture was present. The
positive “fracture signs” caused severe pain for
the patient and smug nods of approval on the part
of the examining physician: “Thought so!”
Why such painful clinical signs should still be
regularly cited and given priority over radiographs (46) today, long after the introduction of
diagnostic radiographic studies, regularly defies
patients’ comprehension. It should rightly defy
the physician’s comprehension as well, given the
lack of efficiency that these methods exhibit in
comparison with radiographs in two planes:
Clinical examination can neither determine
whether an injury is indeed a fracture, nor can it
identify the specific type of fracture (buckle fracture, separated epiphysis, epiphyseal fracture,
etc.). It is equally impossible to diagnose an
avulsed ligament or a torn ligament in the presence of age-related, sex-related, or idiopathic
ligament laxity by clinical examination alone
(Fig. 8.4).
!
Clinical manual diagnostic examination of a fracture or dislocation should be avoided as it is extremely painful and highly inefficient.
OP
EN
ING
AB
NO
RM
AL
M
OB
ILI
ON
TY
TI
PAC
N
PAI
IM
EXTENSION IMPAIRMEN
T
WER
DRA
CR
EPI
TU
S
Fig. 8.4 Clinical diagnostic examination with the aid
of fracture signs is inefficient and painful (from: 116)
Diagnostic Studies
Radiographic Studies
Not every fracture must be radiographed, and not
every fracture in growing patients is detectable in
a radiographic image. When asked, the patient
will be most concerned about treatment, i.e.,
elimination of pain; the diagnosis is only of secondary interest. Patient and physician should be
assured that no significant injuries have been
overlooked that could lead to late sequelae.
Radiographs are indicated for two reasons: First,
to exclude what may be called “litigation injuries”
(see p. 55) and, second, to determine the choice of
treatment. Where the choice of treatment has already been determined by clinical findings, radiographic studies may be dispensed with and the
clinical findings documented in photographs.
Basically a radiograph, even a diagnostic
image, should only be obtained where the type of
treatment will be determined by the radiographic
findings alone. This means that prudent use of
roentgen ray radiation is directly proportional to
the effectiveness and efficiency of the intended
therapy.
53
A diagnostic radiograph of a displaced clavicular fracture is fundamentally superfluous in
cases where one only intends to treat the pain
without reducing the fracture. Authors who
believe that a displaced clavicle should be treated
by closed reduction will naturally require an initial radiograph. However, it is interesting to note
that these authors dispense with radiographic
documentation of their reduction results, which
in turn casts doubt on their initial procedure (16).
With respect to radiological procedure, we
should fundamentally distinguish between fractures with and fractures without clinically visible
deformation, i.e., between displaced and nondisplaced fractures.
Depending on the severity of pain, the initial
radiographic examination is performed following
administration of pain medication or with the
patient sedated preparatory to general anesthesia. In fractures with clinically visible displacement, a radiograph in a single plane will suffice to
make the diagnosis and definitively determine
the type of treatment required (Fig. 8.5). As a matter of course, this radiograph should also visualize
Fig. 8.5 Indication for initial radiograph. Where a significant deformity is
visible upon clinical examination, a radiograph in a single plane will suffice to
determine the type of treatment required
Female,
age 9
Preop.
Day 1
54
General Science, Treatment, and Clinical Considerations
Abb. 8.6 Initial diagnostic radiographs.
a In the presence of clinically visible deformities, the initial radiographic examination must always visualize
the adjacent joints. Additional fractures and dislocations can easily be overlooked in “close-up” radiographs
b In the absence of clinically visible deformities, the initial radiographic examination must always include radiographs in two perpendicular planes
a
b
the two adjacent joints (Fig. 8.6 a). Where the fracture in question does not exhibit any clinically visible deformation, then radiographs in two planes
will naturally be required. This is because numerous fractures will only be visible in one of the two
imaging planes (Fig. 8.6 b).
Radiographs of the Contralateral Side
The literature abounds with recommendations
(44, 46, and others) for obtaining radiographs of
the contralateral side in the setting of nondisplaced fractures, and often even displaced frac-
tures, as part of the diagnostic workup of acute
fractures and dislocations (60). This is complete
nonsense. The technique is verifiably inefficient
(116), and it is also unable to visualize the initially
detectable fractures that very frequently occur in
growing patients (Fig. 8.7). Additionally, these reference radiographs are often obtained in different
planes so that they are not comparable. The fact
that many stubbornly insist on reference radiographs even today suggests that there is an economic incentive for obtaining them.
If the indication for reference radiographs is to
be determined by economic considerations, then
Diagnostic Studies
55
Fig. 8.7 Comparative radiographs
of both sides. Fractures that are not
initially visible will often occur in
growing patients. These include
nondisplaced or spontaneously reduced separated epiphyses without
a metaphyseal wedge fragment
(such as here on the left). Even comparative radiographs of both sides
will be unable to visualize these injuries
a better way to achieve the desired economic result would be to perform radiographic screening
of the family or locale in search of endemic fractures (Fig. 8.8).
Secondary Diagnostic Examinations
The patient would be happy if the initial treatment reduced pain. This is readily possible in the
case of initially undetectable or minimally displaced and easily overlooked diaphyseal and
metaphyseal fractures: Depending on pain and
swelling, the patient is fitted with a plaster cast to
immobilize the skeletal structure for about eight
days. Swelling and pain are again assessed when
the cast is initially removed, this time by direct
palpation. Where significant tenderness to palpation and pain persist, further immobilization is
continued until pain disappears. If there is any
need for them at all, the radiographs (Fig. 8.9) or,
better yet, ultrasound images obtained thereafter,
enable a diagnosis of the fracture that has occurred on the basis of the periosteal fixation callus. This procedure can be readily performed in
the case of nondisplaced diaphyseal and
metaphyseal fractures.
Exceptions: “Litigation Injuries”
The principle of “treat first, diagnose later” can
normally be followed in the case of any suspected
nondisplaced fracture, i.e., in the presence of
clinical signs of swelling and pain without deformity. However, there are five specific injuries
in which one should not blindly follow this principle. These injuries must be correctly diagnosed,
and the physician must understand their specific
issues and possible complications. If they are
overlooked, the patient can rightly hold the attending physician liable and sue for malpractice.
The injuries in question include:
앫 Nondisplaced fracture of the lateral condyle of
the humerus,
앫 Dislocation of the radial head, either an “isolated” dislocation or in the setting of Monteggia fractures,
앫 Initial or secondary rotational deformity in
the setting of a supracondylar fracture of the
humerus,
앫 Proximal greenstick fracture of the tibia,
앫 Fracture of the medial malleolus.
An initially nondisplaced fracture of the lateral
condyle of the humerus (see Specific Injuries,
p. 161) can subsequently dislocate under the constant pressure of the radial head even when
56
General Science, Treatment, and Clinical Considerations
NUMISMATIC PRAYER:
Comparative radiographs
of both sides
for diagnosting acute fractures
in growing patients
Diagnostic Studies
왗 Fig. 8.8 a, b Radiographs of the contralateral side
for diagnosing acute fractures represent a “numismatic prayer.” If radiographic examination of the contralateral side is to be justified on economic grounds,
then it would make more sense to examine not only the
patient’s contralateral side but also the persons at the
patient’s side, such as by screening kindergarten or
school classes for comparable endemic fractures and
sides for making money (below)
immobilized in a plaster cast. Sequelae such as
growth disturbances and consolidation disturbances including pseudarthrosis may result (see
Figs. 19.40, 19.41). In these fractures, it is important to distinguish between complete and incomplete articular fractures, whereby secondary
dislocations can occur only with the complete articular fractures (Fig. 8.10). Initial radiographic
studies cannot differentiate between the two because the fracture line courses through the cartilaginous portion of the trochlea, which cannot
be evaluated in a radiograph. Stress radiographs
or arthrograms such as those recommended by
57
certain authors (76, 143) are absolutely unnecessary for differentiating these injuries. The examinations are painful, and the stress radiographs are
at best suitable for transforming initially nondisplaced fractures into displaced fractures. This
would only be of interest to unemployed surgeons
seeking indications for surgical intervention. A far
simpler method is to detect this fracture initially,
which can be identified especially on the lateral
radiograph by the typical metaphyseal fracture
line that ends at the growth plate. A radiograph
out of plaster obtained four days after the accident will clearly show whether secondary dislocation of the fracture has occurred in the central
region of the joint (see also elbow fractures,
p. 157 ff.), indicating a complete articular fracture.
This would then imply a change of therapy. In the
future, ultrasound will make initial diagnosis easier and in so doing will help reduce the secondary
problems (elbow 208).
Dislocation of the radial head is a very rare injury, occurring more frequently in the setting of
Fig. 8.9 Secondary diagnostic radiography. Only
the radiographic image obtained secondary to treatment and demonstrating a
visible fixation callus is able
to confirm the initial clinical
suspicion of a separated epiphysis
58
General Science, Treatment, and Clinical Considerations
Fig. 8.10 “Litigation injury” 1: Fracture of the lateral
condyle of the humerus. In nondisplaced fractures of
the lateral condyle of the humerus, we must differentiate incomplete articular fractures (left) from complete articular fractures (right). This differentiation is not possi-
ble in the initial radiograph but can only be made during
the further course of the injury. Only complete articular
fractures entail the risk of secondary dislocation despite
immobilization in a plaster cast (see p. 161 and
Figs. 19.39, 19.40, 19.41)
Monteggia fractures than as an isolated injury
(see also Specific Injuries, pp. 202, 208 ff). Because
it is rare, the risk of overlooking it is all the greater.
Initial treatment is simple, and in growing
patients consists of closed reduction. Late results
are good. Secondary treatment of initially overlooked dislocations is complex and invariably involves an ulnar osteotomy. Despite claims occasionally made in the literature (literature on the
elbow: 94), the late results of secondary therapy
are invariably poor the longer the dislocation has
persisted. This means that there is a significant
discrepancy between initial and secondary therapy with respect to complexity and results. Therefore, elbow radiographs in two planes should be
obtained in any isolated fracture of the ulnar
shaft, and the correct position of the proximal end
of the radius with respect to the capitellum of the
humerus must be verified (Fig. 8.11).
An initial or secondary rotational deformity in
the setting of a supracondylar fracture of the
humerus invariably represents a severe instability
in which ulnar angulation of the distal fragment
can occur, producing a severe varus deformity.
This varus deviation of the axis of the elbow never
corrects itself spontaneously during the course of
further growth, making it all the more important
to avoid such a deformity in the first place. Therefore, in any supracondylar fracture one should be
alert to the possibility of an initial or secondary
rotational deformity. Such a deformity is usually
detectable by the presence of an anterior spur and
less often by the presence of a posterior spur.
Where a supracondylar humeral fracture initially
displaced only in the sagittal plane appears to be
at risk of secondary displacement, a lateral radiograph in plaster should be obtained four days
after the accident to exclude a rotational spur.
Where a secondary rotational deformity has occurred, the rotational deformity should be eliminated. This will invariably require a change of
therapy (Fig. 8.12). In reducing the fracture, every
effort should be made to avoid a rotational deformity, insofar as it can be visualized. An even
better approach is to opt for a fixation concept
that will counteract a possible rotational deformity.
A greenstick fracture of the proximal tibial
metaphysis—with a classic valgus axial deviation—
leads to a typical growth disturbance with unilateral genu valgum of increasing severity. The
underlying problem is a medial consolidation dis-
Diagnostic Studies
Fig. 8.11 “Litigation injury” 2: Dislocation of the radial head. Elbow radiographs in two planes should be
obtained in any isolated fracture of the ulnar shaft. In
each elbow radiograph, the axis of the proximal end of
the radius must be centered on the midpoint of the capitellum of the humerus. Where this is not the case (right),
a dislocation of the radial head is present
turbance that invariably occurs as a result of
failure to eliminate the initial valgus deformity
and compress the medial fracture gap. Any open
medial fracture gap in the setting of such a fracture should therefore be regarded as a sign of a
valgus deformity. The aim of treatment must be to
eliminate this open medial fracture gap (Fig. 8.13).
Only in this manner is it possible to ensure that
the sequela of the growth disturbance will remain
clinically manageable.
Fracture of the medial malleolus. As long as
the growth plates are wide open, the medial
malleolar fracture is the “typical” epiphyseal articular fracture of the distal tibia. It is important to
detect this fracture and the extent of its displacement because in the setting of displaced fractures,
growth disturbances can occur whose sequelae
can be prevented by diminution of a possible
banding bridge. Nondisplaced fractures have a
59
Fig. 8.12 “Litigation injury” 3: The secondary rotational deformity in the setting of a supracondylar humeral fracture. Where one of the two condylar pillars
(usually the ulnar one) appears separated and no rotational deformity is initially present, a second radiograph
should be obtained four days after the accident to exclude or confirm a secondary rotational deformity (see
also Fig. 19.28)
Fig. 8.13 “Litigation injury” 4: Greenstick injury of
the proximal tibia. Any open medial fracture gap in the
proximal tibia is a sign of a valgus deformity. If this persists, it will lead to transient partial stimulation of the
proximal tibial growth plate with abnormal growth producing an increasing valgus deformity
60
General Science, Treatment, and Clinical Considerations
Ossification Centers
The time at which each individual epiphyseal
ossification center initially appears in radiographs and the time at which they subsequently
fuse are genetically determined and vary according to the patient’s age, sex, and individual
development (Fig. 8.15; 15, 56, 71, 72, 79). One
should remember that the growth plate is not a
smooth plane. Because it must continuously
adapt to a wide range of functional loads, its surface as viewed from the metaphysis develops hills
and valleys like those on the surface of a walnut
shell. This should be taken into consideration in
the radiographic projections. Ossification centers
are often multifocal and should not be mistaken
for avulsion fractures or intraarticular loose bodies. Ossification centers are round with irregular
borders and are not painful. In this regard, it is
best to bear the following rule in mind:
!
Abb. 8.14 “Litigation injury” 5: Medial malleolar
fracture. Where there is the slightest clinical sign of a
medial injury in the ankle region, even where there is no
evidence of a bony injury in the standard radiograph, an
oblique radiograph must be obtained to confirm or exclude a possible fracture
good growth prognosis and should be treated
conservatively. However, this fracture will occasionally escape detection on a standard anteroposterior (A-P) radiograph. If swelling and pain
give rise to the slightest clinical suspicion of a
possible medial bony injury, whether isolated or
associated with another injury, then a second
ankle radiograph should be obtained to image the
fracture and determine the severity of displacement. An oblique projection may be required for
this second radiograph (Fig. 8.14). This is the only
way to ensure correct, specific choice of therapy.
Here, too, advocates of contralateral radiographs
should note that such superfluous comparative
radiographs merely show the contralateral side.
The fracture and the extent of its displacement
will only be visible on the injured side itself.
Articular fractures (epiphyseal fractures) are rare,
whereas shaft fractures (separated epiphyses and
metaphyseal buckle fractures) are common
(Fig. 8.16).
Stress Radiographs
Stress radiographs are used to demonstrate instability and can also be used to visualize nondisplaced fractures that are not detectable in initial
standard radiographs by means of secondary displacement. This latter use is recommended for
demonstrating the extremely rare separated
epiphysis of the distal tibia. These studies are also
recommended for demonstrating fractures of the
lateral condyle of the humerus in order to distinguish between complete and incomplete intraarticular fractures (76). In this context, it appears to
me that the stress radiograph is used first and
foremost to force an indication for surgery that
may not have been present otherwise (see p. 387).
Stress radiographs to demonstrate instability
should no longer be performed today because the
ligament suture as initial treatment has fallen
from favor. The indication for objectively demonstrating instability should be narrowly defined,
and such studies should only be performed as secondary procedures in cases where they may help
determine the choice of further treatment. Ultrasound studies should be used to objectively demonstrate instability (80).
Diagnostic Studies
61
a
b
Abb. 8.15 a, b Ossification centers. Individual ossification centers in the skeleton initially appear and disappear in radiographs at different times. The numbers to
the left of the slash indicate age in years (no label) or
months (m) at which the center initially appears. The
numbers to the right of the slash indicate the age of fusion in years
Other Imaging Systems: Computed
Tomography, Magnetic Resonance
Imaging, and Ultrasound
We see the indication for initial or subsequent CT
diagnostic studies in displaced fractures of the
calcaneus and the talus, with all posterior and
anterior Malgaigne fractures of the pelvic ring,
and in spinal fractures. It is too early to tell
whether ultrasound studies could replace initial
radiographs for demonstrating acute fractures. It
Computed tomography (CT) and magnetic resonance imaging (MRI) are basically unnecessary
for diagnosing acute fractures of the extremities.
62
General Science, Treatment, and Clinical Considerations
Shaft fracture
(separated epiphysis)
Articular fracture
(typical epiphyseal fracture)
Abb. 8.16 Differentiation of metaphyseal and epiphyseal fractures. With every fracture gap that courses
from the metaphysis toward the growth plate, the epiphysis must be carefully examined in both planes for a
possible fracture gap. An injury without a fracture in the
epiphysis is a separated epiphysis, i.e., a shaft fracture.
appears to me that nondisplaced buckle fractures
of the distal forearm, the phalanges of the fingers,
and fractures of the clavicle could be diagnosed
with ultrasound, as could nondisplaced fractures
of the lateral condyle of the humerus (elbow 208).
MRI can be very helpful in searching for intraarticular ligamental injuries, such as in the
knee. Today it should be done in all knee injuries
with hemarthrosis without a fracture visible in
the standard radiographs. However, it is unclear
whether it is actually reliable in the prognostic
evaluation of epiphyseal fractures. At least at
present, such examinations do not provide sufficient information to determine the choice of therapy (150, 153).
Arthrography
We are opposed on principle to using arthrography, an invasive method, to diagnose acute ligament injuries or, as has occasionally been recommended, to demonstrate an incomplete intraarticular fracture of the lateral condyle of the
humerus (58, 143). The method is superfluous.
Articular fracture
(transitional fracture)
An injury with a visible fracture gap in the epiphysis is an
epiphyseal fracture, i.e., an articular fracture. This applies to all sections of the joint in which the epiphysis or
its ossification center is completely imaged
Arthroscopy
This method has become the established modality in the diagnosis and therapy of intraarticular
knee injuries even in children and adolescents (7,
35). It is not clear whether the blanket indication
“every hemarthrosis requires arthroscopy” is
justified. In our opinion, differentiation is both
possible and practicable. Arthroscopic examinations of the shoulder, elbow, hip, and ankle are
possible, but are actually indicated only in extremely rare cases in the setting of acute trauma
in growing patients.
Examination under Anesthesia
Examinations under anesthesia should never be
performed without the intent of therapeutic intervention during the same session. Such an examination is invariably merely a sign of clinical
helplessness and not a sign of the clinical proficiency that we owe our patients.
63
9
Measurements
Every measuring method has a certain margin of
error, and measurements on radiographs, like
clinical measurements of function, do not provide
absolute values.
Radiographic measurements: Measurements
on the radiograph are rarely required in daily practice. Occasionally, they are unavoidable for identifying or quantifying an axial deviation. Most of the
time, they provide an objective measurement of a
reduction.
In the shaft, it is usually easy to determine an
axial deviation using the shaft axis angle (Fig. 9.1).
In small peripheral periarticular fractures, it is
easy to overlook or underestimate axial deviation.
In these cases, the recommended technique is to
use the epiphyseal axis angle to measure the axial
angle (Fig. 9.2), and in fractures of the proximal
radius, fractures of the proximal tibia, and basal
phalangeal fractures of the fingers this is often
necessary.
The side-to-side displacement should be expressed as a fraction of the shaft width (Fig. 9.3).
Rotational deformities cannot be directly
measured in anteroposterior (A-P) and lateral
radiographs, although they can be indirectly calculated. The method of semi-axial radiographic
measurement formerly used to determine the
severity of a postoperative rotational deformity in
the femur has been abandoned in favor of ultrasound because of the high dosage of ionizing
radiation and exceptionally high margin of error
associated with it (47, 48, 55, 94). This method
also visualizes the anteversion of the femoral
necks in a semi-axial projection (Fig. 9.4). For
follow-up examinations, obtaining clinical
functional measurements will suffice to evaluate
the behavior of a version difference during the
course of further growth (Fig. 22.19; 133).
Rotational deformities are clinically significant especially in locations where they cannot be
compensated for by the adjacent joints, such as in
the phalanges of the fingers and in the lower leg.
However, here they can readily be clinically evaluated and corrected in initial therapy.
Abb. 9.1 Shaft axis angle. This is used to evaluate axial deformities in the coronal and sagittal planes in the
shaft
64
General Science, Treatment, and Clinical Considerations
Abb. 9.2 Epiphyseal axis angle. Especially in metaphyseal fractures with a small fragment, an initial axial
deviation may be easily overlooked unless a measurement is taken. The axial deviation is verified using the
epiphyseal axis angle: A reference line is drawn through
the growth plate, and the angle between this perpendicular to this reference line and the shaft axis indicates
the deformity
1/2 shaft width
Abb. 9.3 Measurement of side-to-side displacement. This deformity is expressed as a fraction of the
shaft width, i.e., one half, one quarter, or one full shaft
width
Clinical evaluation of rotational deformities is
not possible in acute humeral and femoral fractures. However, these fractures are functionally
well compensated for by the adjacent shoulder
and hip joints. They can be clinically evaluated indirectly after the fracture has consolidated by the
difference in rotation between the shoulders or
hips, respectively, and documented in photographs (direct clinical measurements of the anteversion of the femoral neck can be readily obtained; see Specific Injuries). Where such documentation is not sufficient, ultrasound would be
today’s method of choice in documenting a rotational deformity (Fig. 9.4).
In evaluating shortening deformities, allowance should be made for the enlargement of
the radiographic image. An exact measurement is
only rarely possible (Fig. 9.5) because the reference points are only very rarely visualized precisely.
Even experienced practitioners should allow
for a margin of error of about 5–10⬚ in clinical
measurements of range of motion. Measurements
expressed in single degrees are invariably open to
question.
Measurements are most easily obtained by
measuring motion through the 0⬚ neutral position. Even inexperienced practitioners can obtain
“exact” measurements by comparing the results
with the contralateral side. This is facilitated by
visualizing the angle as the sum of easily estimated angles and increments of half of those angles: 90⬚, 45⬚, 135⬚, etc. (Fig. 9.6).
Circumferential measurements with a tape
measure are primarily used in the setting of
formulating expert opinions. Significant margins
of error must be expected if the same references,
on each side, are not marked prior to obtaining
the measurement (e.g., 10 cm proximal to the medial joint cavity of the knee).
Measurements
65
a
b
Abb. 9.4 a, b Diagnostic ultrasound. The anteversion
of the femoral necks is visualized with ultrasound in a semi-axial projection. The rotational deformity can be calculated from the difference between the affected side
and contralateral side with a margin of error of about 5⬚.
Reduced anteversion of what was once the fractured
side corresponds to external malrotation of the distal
fragment, and increased anteversion corresponds to internal malrotation of the distal fragment. These images
demonstrate symmetrical anteversion
Abb. 9.5 Measuring a shortening deformity. This
can only be done very imprecisely on a radiograph. The
magnification of the radiograph must be taken into account, and the visualization of the reference points is
usually very imprecise
Abb. 9.6 Measurement of joint
function. This is done by measuring
motion through the 0⬚ neutral position. The range of motion can be accurately estimated even without an
instrument by first visualizing a 90⬚
angle and then adding successive increments of half the previous angle
66
General Science, Treatment, and Clinical Considerations
Clinical leg-length measurements should only
be obtained as functional measurements using
plates inserted under the shorter leg. This is the
only method that also permits simultaneous evaluation of the structural alignment of the spine
and provides a clinical indication of the extent of
therapy that might be required (Fig. 9.7). Plates of
standardized thickness are placed under the
shortened leg until the spine is compensated.
Direct measurements with a tape measure should
be avoided because they do not provide any information about the required extent of a possible
leg-length equalization, and a significant margin
of error may be expected.
Direct measurements (measuring images)
using ultrasound do indeed provide very precise
information about length differences. However, at
best they are suitable for a preoperative examination if there is doubt as to whether a shortening or
lengthening osteotomy should be performed (in
the femur or lower leg). These studies also fail to
provide any information about the structural
alignment of the spine (50, 57, 137).
Abb. 9.7 Functional leg-length measurements. Clinical and radiographic leg-length measurements should
always be obtained as functional measurements. This is
the only method that also permits simultaneous evaluation of the structural alignment of the spine
67
10
General Observations on Anesthesia
The anesthesiologist should be equally proficient
in all anesthetic techniques that may be required
(general anesthesia, all forms of regional anesthesia, etc.) so that he or she can offer them to the
patient without reservation and adapt them as required to the patient’
!
“In an emergency” means as an actual emergency procedure within one hour after the
patient has been admitted to the hospital.
A legal argument is repeatedly presented at this
point, one that leads to a conflict between the
“pharisaical benevolence” of the anesthesiologist
and the “uncivilized insistence” of the surgeon:
the six-hour limit. Every anesthesiologist knows
that a patient who has eaten shortly before the accident will not have an empty stomach even six
hours later. The medical problem remains the
same after six hours; only the legal situation has
changed. Surprisingly, anesthesiologists either
have not yet seen fit to scientifically explain and
document the medical situation or claim to be unaware of any such studies. They could otherwise
long since have demonstrated the absurdness of
the legal argument—the entrenched doctrine of
the six-hour empty stomach limit. It may be regarded as a proven fact that the incidence of complications and the risk of anesthetization after six
hours are equivalent to those of emergency anesthesia one hour after the accident (3, 4, 5, 16 a,
26 a, 49 a, 137 a). I fail to grasp why anesthesiologists persist in offering “legal” arguments although this is an area they know nothing about.
Even in our debates, we should limit ourselves to
our own field of study and not follow pseudolegal
arguments.
Let us look at the patient and jointly contemplate what is best for him or her.
If emergency anesthesia involves even a hint
of an increased risk—with or without a six-hour
limit—then we as surgeons should define the indication for emergency intervention as restric-
tively as possible in the interest of the patient.
Professional policy considerations, for example,
that primary care and follow-up should not be entrusted to the same physician, are beside the point
here. The only relevant arguments are those that
genuinely and exclusively affect the patient.
Therefore, we have reached an agreement with
our anesthesiologists: We define “emergency”
extraordinarily narrowly and attempt wherever
possible to convert an emergency intervention
into an elective procedure. Not only does this have
the medical advantage of reducing risk; it also has
the psychological advantage of allowing the physician to deal with a patient and parents who are
not under stress. Then one can determine the necessary therapy—after initial presentation and
after informing patient and parents in a relaxed
atmosphere as opposed to an emergency setting
(see Chapter 16, General Observations on Information). We have agreed on the following definition, and both parties observe this agreement for
the most part:
The term anesthesia includes both general anesthesia and regional anesthesia. Emergency anesthesia means that no consideration is given to
whether the patient has an empty stomach but
that the patient is treated within an expedient period (i.e., in most cases within one to two hours)
after admission to the hospital.
앫 Absolute emergencies: These are understood
to include all dislocations and all completely
displaced articular and shaft fractures with
and without the threat of neurovascular injury. Naturally, these also include all open second and third degree fractures. Yet they also
include closed fractures with angulation of
the fragments (which could be immobilized
with the deformity in a plaster cast and then
reduced the following day as an elective procedure) where it is obvious that anesthesia
will be required to treat the fracture. However,
because of fear, pain, or required hospitalization, it is often unrealistic to expect the
patient to tolerate such a treatment, and the
68
General Science, Treatment, and Clinical Considerations
decision to proceed with emergency treatment can be made with the approval of the
physicians responsible (surgeons, orthopedists, and anesthesiologists). The potentially increased risk of aspiration is accepted
in the interest of overall management tailored
to the child’s needs.
앫 Elective procedures: Nonemergency procedures fundamentally include all fractures
with only slight angulation of the fragments
where the deformity can in all probability be
eliminated with a cast wedge after initial
treatment or where the severity of the deformity is tolerable in light of the patient’s age
and can be left untreated without any reduction. In the case of these patients, it is not certain whether anesthesia would be required at
all for treatment.
!
Not every displacement represents an indication
for reduction.
Not every reduction must be performed as an
emergency procedure.
Regardless of whether the injury itself represents
an emergency or a nonemergency, adequate initial pain therapy should be performed as an emergency procedure in any case. Sensitivity to pain is
subjective. The physician cannot determine
whether the patient is in pain or not; the physician must believe patients when they report pain
and must eliminate that pain. Treating pain is an
act of humane compassion. This means that there
is all the less justification for pursuing a treatment whose goal is to cause pain. This applies not
only to clinical diagnostic procedures (see p. 52)
but also to any actions prior to administration of
anesthesia: The dubious procedure of using a
thick gastric tube prior to administration of the
anesthesia to pump out the stomachs of children
requiring emergency anesthesia is sadistic, and in
my opinion it no longer has a place in the repertoire of a responsible anesthesiologist.
69
11
General Observations on Treatment
What is the purpose of a therapy? The patient’s
perspective provides definite goals of therapy
that should determine the quality of our work:
앫 The quickest possible adequate pain treatment without inducing further pain,
앫 The quickest possible restoration of the
patient’s mobility. Here, we must differentiate
between the upper and lower extremities: In
the upper extremities, we need rapid restoration of full use; in the lower extremities, we
need rapid restoration of full use and weight
bearing. This goal can only be achieved where
the shape and function of the respective portion of the skeleton have been restored,
앫 Treatment must not disturb fracture healing, a
process that in growing patients is nearly
guaranteed,
앫 Treatment should attempt to positively influence growth disturbances and their
sequelae, i.e., by prevention,
앫 Treatment must not produce any psychological or somatic early or late sequelae,
앫 Treatment must be efficient, meaning that it
must achieve maximum final results with
minimum cost and complexity. This means
that any initial treatment under anesthesia—
for social, psychological, and medical reasons—
must be definitive. Secondary reductions and
changes of therapy are obsolete techniques.
Under the criterion of efficiency, one must therefore choose from among the broad range of diagnostic and therapeutic options the treatment that
will ensure an optimum final result at minimum
cost. This choice must suit the type of injury and
the patient’s age, while allowing for all growth
phenomena.
Therapeutic Options
For the sake of clarity, we should differentiate the
following fundamental therapeutic options:
앫 Conservative without anesthesia
앫 Conservative with anesthesia
앫 Surgical with closed reduction
앫 Surgical with open reduction
Conservative Treatment Without Anesthesia
Aside from elastic bandages, plaster casts are used
as the ideal means of immobilizing injuries. Recent advances in synthetic plaster substitutes
have now become available in products such as
the hard, stable Scotchcast (manufactured by 3M)
and the soft, pliant Softcast (manufactured by
3M). These casts are very light weight and are
easily applied without creating a mess. Our initial
arguments that synthetic immobilization materials were not conducive to achieving good fracture
stabilization because they were too hard, did not
facilitate wedges, and could not be sufficiently
molded to fit body contours no longer apply since
the introduction of Softcast.
The indication to apply a plaster or synthetic
cast may be defined generously in growing
patients. There is no reason to believe that
children would seek to take advantage of this. On
the contrary, one should consider that a child who
wants a cast really needs one, whether for physical or psychological reasons.
Indications for conservative treatment
without anesthesia include all “nondisplaced”
epiphyseal, metaphyseal, and diaphyseal fractures. Note that “nondisplaced” should be defined
according to age and location of injury (132). All
diaphyseal and metaphyseal fractures with slight
angulation of the fragments (between 10⬚ and 30⬚,
depending on the patient’s age) that are later
treated with wedges also fall under this category.
With respect to plaster technique, we refer the
reader to the respective standard works (31 a,
164 a, 164 b, 168). We ourselves prefer the splint
70
General Science, Treatment, and Clinical Considerations
technique. We never apply circumferential casts
as part of initial treatment which we then later
split; we exclusively apply posterior splints, usually with lateral reinforcement. Prior to application of the plaster splint, a gauze stockinette is
pulled over the extremity, which is then padded
with thin semi-elastic cast padding. The plaster
splints are applied so that a plaster-free space of
2–3 cm remains along the entire length of the
plaster structure. This provides a window in
which the padding can be cut open along the full
length if necessary. After the plaster splints are
applied, they are molded to the contour of the
limb with an elastic paper bandage. This is removed before the elastic bandage is applied.
After soft-tissue swelling subsides on about
the fourth day, the plaster may be closed. The
splints should again be pressed closely against the
soft tissue. Closure may be dispensed with in
small children, who usually experience anxiety
before the cast is removed with the loud cast cutter. However, if treatment with a wedge is intended, then the cast will have to be closed
around its full circumference.
When applying synthetic materials, the first
step is to apply a thin cotton stockinette as padding. Where subsequent treatment with a wedge
is intended, the site of the wedge is padded with
special longitudinal pads. Otherwise, two longitudinal pads are applied, either medial and lateral
or dorsal and volar. Then a circular Softcast layer is
applied, the longitudinal padding with Scotchcast
stripes is reinforced, and then the entire bandage
in the area of the Softcast is split longitudinally
with scissors. After soft-tissue swelling has subsided, and especially if a wedge is intended, circumferential closure is then achieved with Softcast. In the case of a wedge, the area of the wedge
is first circled with a circumferential Scotchcast
bandage on the eighth day after the accident.
After it dries, the wedge can be created after a few
minutes in the same manner as with a plaster
cast. Complications are identical to those that
occur with the use of a plaster cast and are treated
identically.
Cast Windows
If the patient complains about continuous pain in
the cast, the skin below it must be inspected. This
is done by cutting a window in the cast, removing
the padding, and then inspecting the skin. If the
reported pain disappears with this procedure,
then ample additional padding is inserted in the
window area. The cast window must be closed
again to minimize the risk of a window edema.
Cast Wedges
Basically, any deformity in the shaft in the coronal
and/or sagittal plane can be wedged in a circumferential cast, Softcast, or Scotchcast. Two
items are important:
앫 Time: This should be done around the eighth
day once the swelling has completely subsided and secondary displacement after
wedging need not be feared. This eliminates
the need for secondary wedging.
앫 Location: The wedge must always be inserted
at the lowest point of the concavity of the deformity (also in combined deformities in applicable cases). This is done by cutting open
half of the plaster cast according to the
specific deformity, anteroposteriorly, posteroanteriorly, or along its first or second oblique diameter (Fig. 11.1 a,b). The farther peripheral the fracture is located, the farther
proximal the wedge must lie in order to increase leverage and ensure that the correction
acts on the peripheral fragment (Fig. 11.1 b).
Every wedge will hurt more or less, but not as
much as a reduction would hurt. The pain subsides quickly within the first few minutes. The
patient should be given pain medication before
any correction of gross deformities is attempted.
Thereafter, no more pain medication should be
given to permit evaluation of the pressure on the
opposite side.
In most cases (see Specific Injuries), radiographs are obtained immediately after wedging
to document the result of the wedge and move it if
necessary. Only when the position is tolerable is
additional padding applied to the wedge gap and
the circumferential cast closed with the wedge
firmly in place.
General Observations on Treatment
A-P
71
Lateral
Dorsal
Dorsal
Ulnar
Radial
Volar
A-P
Lateral
Radial
Ulnar
Dorsal
Volar
b
a
Fig. 11.1 Cast wedge.
a The wedge must always be inserted in the concavity
of a simple deformity (see above) or a combined deformity (see below)
b The farther peripheral the fracture is located, the farther proximal the wedge must lie to influence the position of the fracture
Cave
Conservative Treatment with Anesthesia
The risk of wedge treatment lies in the pressure on
the opposite side of the wedge. If increasing pain
from compression occurs after the wedge is placed,
a window should be opened in the cast and additional padding placed. Then the window must be
closed again. This procedure will not compromise
the position correction that has been achieved. A
pressure ulcer on the opposite side will not be attributable to the method but to lack of supervision
and to failure of the attending physician to properly
inform the patient.
In contrast to simple conservative treatment
without anesthesia, this involves closed reduction under some sort of anesthesia and subsequent immobilization in a cast. If the fracture
displaces after immobilization in a cast, secondary correction of the position can be achieved
using a cast wedge.
72
General Science, Treatment, and Clinical Considerations
Closed Reduction
Reduction is indicated in the presence of an initial
deformity that does not appear to be correctable
by secondary use of a cast wedge and cannot be
left to the corrective forces of further growth.
Every reduction should be performed under some
form of anesthesia. The common and notorious
technique of “pressing” a fracture with and
without pain medication should be avoided. It
causes far more pain, and experience has shown
that it is far less efficient than, for example, cast
wedges.
Indications for conservative treatment with
anesthesia include:
앫 All dislocations without associated bony and
ligamentous injuries,
앫 All completely displaced fractures that can be
transformed into a stable situation by reduction. These include such injuries as transverse
fractures that once reduced will no longer become completely displaced but will merely
slip into angulation and can then be corrected
with a cast wedge.
a
b
Surgical Treatment with Closed Reduction
This is understood to include all procedures that
use percutaneous internal fixation material introduced into the bone to directly or indirectly fix the
fracture in a more or less stable position after
closed reduction. In its widest sense, this includes
Kirschner wire or Steinmann pin traction treatments, external fixators (2, 10, 118), dynamic intramedullary nailing (24, 70, 75), and percutaneous pinning with crossed Kirschner wires
(Fig. 11.2 a–c).
Indications for surgical treatment with closed
reduction include all completely displaced
metaphyseal and diaphyseal fractures in which
closed reduction is unable to achieve a stable situation that is well tolerated by the patient.
A tolerable situation for the patient involves
definitive stabilization of the reduction, eliminating the need for any secondary reduction or
change of therapy. It also involves a stabilization
construct that will ensure stability of the fracture
in motion and in use. Last but not least, the overall
cost and complexity of treatment must be considered, for example, whether metal implants can
c
Fig. 11.2 Surgical treatment with closed or open reduction. The stabilization methods recommended for use in
children today include the external fixator (a), intramedullary dynamic nailing (b), and in applicable cases percutaneous pinning (c)
General Observations on Treatment
be removed with or without a second session
under general anesthesia.
Traction
Traction is a fundamentally obsolete method of
therapy. It forces the patient to endure protracted
hospitalization, which neither helps fracture
healing nor is otherwise any use to the patient.
Such therapy widely misses the actual goal of
treatment, namely to rapidly restore the patient’s
mobility. It is expensive and therefore uneconomical. However, it is often used in many hospitals
for just this reason, namely to amortize the hospital’s beds.
앫 Traction means constant mobility in the fracture, frequent radiographic examinations, and
the surgeon’s constant “fussing” allegedly to
correct the position. The fracture finally heals
with a more or less severe deformity. The upshot of all this is that we may expect an increased incidence of leg-length differences following traction: 70% compared with stable
and definitive methods such as the external
fixator (30–40%), Hackethal’s bundled nailing
(30%), intramedullary nailing (35–40%), and
even compared with initial plate fixation,
앫 Authors always report that they have had
nothing but good results with traction therapy, especially in the femur. However, this will
be true of any treatment method. If one measures the success of treatment in terms of the
final result at cessation of growth, then there
will be no poor results after any treatment,
only good ones. The quality criterion must not
be the good result at cessation of growth but
the expense and complexity of treatment required to reach that result (which is
guaranteed anyway). This means that great
expense and complexity, for example, in traction therapy, is a sign of poor quality care. This
is not the type of treatment method that we
would want to see established as quality care
within the framework of a quality assurance
law,
앫 In the case of fracture accompanied by severe
soft-tissue trauma, some argue that traction is
actually unable to provide the stability required for the healing of endangered softtissue structures. At least in growing patients,
this can only be achieved with the use of, for
example, an external fixator.
!
73
Traction is a degrading method of treatment,
one that today neither children nor adults may
rightfully be asked to tolerate.
For all of these reasons, we have not used traction
therapy since 1988. Should there be any hospitals
that feel they must continue to amortize their
beds with the aid of traction treatment in spite of
government appeals and financial incentives,
then at least the traction should be performed
correctly. In the case of femoral fractures, it
should be applied at a supracondylar location
with the growth plates protected; in fractures of
the lower leg, it should be applied on the calcaneus. Traction through the tibial tubercle is not
permissible where the growth plates are still
open.
Today, we see the indication for traction in adhesive bandages, which we apply without anesthesia but with pain medication, only in small
children up to age three with unstable fractures,
when a pelvic cast is not performable for social or
other reasons. With these patients, overhead traction is applied in the usual manner with one fifth
of body weight (101, 120, 121).
External Fixator
This device currently represents the therapy of
choice for all unstable fractures of the lower extremities (Figs. 11.2 a, 11.3; 40, 118, 164). We currently use the blue or yellow Monotube manufactured by Stryker Howmedica, depending on the
patient’s age. It allows good dynamic adjustment
and can be applied without having to use a template. The fracture is first reduced under unsterile
conditions; in the case of a femoral fracture, this is
done on a traction table. Once the fracture is reduced, the patient is prepped and draped. The locations for the first screws adjacent to the fracture
are then identified under fluoroscopic control.
These should not be more than two finger widths
from the fracture (Caution: Be alert to possible incomplete spiral wedges.). Next, the proximal
screw adjacent to the fracture and then the distal
screw adjacent to the fracture are inserted (we
use the self-threading apex pins manufactured by
Stryker Howmedica). Then the jaws of the apparatus are used as a template for the distance of the
respective second or third screw. Once these
screws have been inserted, the apparatus is applied, the position corrected if necessary, and the
screws are tightened. In many cases, the fixator
74
General Science, Treatment, and Clinical Considerations
can later be removed after consolidation of the
fracture without anesthesia.
For over a year, we have also been using external fixation to treat displaced supracondylar fractures of the humerus. This method avoids the risk
of iatrogenic injury to the ulnar nerve such as can
occur in percutaneous pinning with crossed Kirschner wires, and it is a treatment that ensures a
certain degree of functional stability (Fig. 11.3).
This fixator is removed in every case without anesthesia after consolidation of the fracture.
Indications
앫 Unstable diaphyseal fractures of the humerus,
앫 Isolated diaphyseal fractures of the distal
third of the radial shaft,
앫 Unstable fractures of the femoral shaft (ob-
lique and comminuted fractures),
앫 Unstable shaft fractures of the tibia and fibula,
앫 Completely displaced supracondylar fractures
of the humerus.
Dynamic Intramedullary Nailing
The procedure involves “dynamic” retrograde or
antegrade nailing of the medullary canal. One
curved nail per bone is used in the forearm, and
two curved nails per bone are used in the
humerus, femur and tibia. When two nails are
used, they should each brace themselves on the
opposite side of the cortex at the level of the fracture according to the dynamic three-point principle. This is most easily performed in transverse
fractures.
The approach to the bone is through the
metaphysis close to the growth plate. Access is
gained using a broach, taking care not to injure
the growth plate. A distal approach through the
metaphysis is used in the radius, a proximal
metaphyseal approach via the olecranon in the
ulna, and a metaphyseal approach proximal to the
lateral epicondyle in the humerus. The nail is
slightly curved at the tip to facilitate advancement into the medullary canal. The direction of
the tip can be changed by turning the nail’s hand
grip. The diameter of the nail should be two thirds
the diameter of the medullary canal. The nail is
advanced to a point just short of the growth plate,
taking care not to perforate it. Normally, this type
of fixation, like an external fixator, will not require
additional immobilization in a plaster cast. Interested readers will find further details in the fine
book on dynamic intramedullary nailing by Dietz
and Schmittenbecher (24, 39).
Indication
We regard intramedullary nailing (Fig. 11.2 b) as
the treatment of choice
앫 for completely displaced shaft fractures of the
forearm,
앫 for all completely displaced transverse fractures of the femur (see Fig. 22.28), and, under
certain circumstances,
앫 for transverse fractures in the lower leg and
the humerus.
Percutaneous Pinning with Kirschner Wires
Percutaneous pinning is indicated especially
when the peripheral fragment is very small and
the fracture can be easily reduced but it is difficult
to maintain the reduction. Regardless of whether
open or closed reduction was necessary, we prefer percutaneous wires as opposed to submerging
them beneath the skin. The wires are then easier
and less painful to remove. Removal only requires
an unsterile forceps without any pain medication
or local anesthesia. The wires need never be left in
place longer than three or four weeks at the most.
Fig. 11.3 External fixation in a supracondylar fracture of the humerus. Fixation at this location stabilizes
the fracture via the lateral condyle, prevents ulnar angulation of the distal fragment, and protects the ulnar soft
tissue
General Observations on Treatment
Cave
One must take care to ensure that the projecting
wires are not come into contact with any part of
the plaster cast and cannot strike against it. The risk
of infection is minimized only where there is a sufficient opening in the cast around the wires. It is only
possible for the wires to migrate deeper when they
constantly strike against the cast, causing a zone of
lysis to develop adjacent to the wires. This also promotes infection (Fig. 11.4 a, b).
Indications
앫 All completely displaced supracondylar frac-
75
that will guarantee the patient an optimum final
result and permit the free use of the operated extremities as quickly as possible (Table 11.1). Rush
pins, for example, require additional immobilization in plaster cast, do not provide rotational stability, and do not represent stable internal fixation. In effect, this treatment combines the disadvantages of surgery with those of conservative
treatment and therefore should no longer be
used. Basically, the same fixation methods may be
considered as in surgical treatment with closed
reduction (external fixator and intramedullary
nails). Screws may also be appropriate, whereas
fracture plates are only indicated in exceptional
cases.
tures of the humerus,
앫 Separated epiphyses in the distal radius and
femur,
앫 Separated epiphyses in the proximal and distal tibia.
Indications
앫 All completely displaced articular fractures
(screw fixation),
앫 All dislocations with associated bony and liga-
mentous injuries,
Surgical Treatment with Open Reduction
앫 All fractures with associated neurovascular
This section does not include a detailed discussion of technical procedures, various approaches,
etc. Interested readers may find this information
in the relevant literature (13, 25, 65, 68, 82, 82 a).
As a matter of principle, surgical treatment of pediatric fractures should only be performed by experienced surgeons who are well familiar with
this field.
When selecting the fixation method from
among the possible techniques, one should opt
for the simplest and least complicated method
앫 All open second and third degree fractures,
앫 All other fractures in which closed reduction
injuries,
within an expedient period is not possible.
Articular Fractures
Displaced fractures should be openly reduced.
Whenever possible they should be treated with
screw fixation to ensure reliable compression and
only stabilized with Kirschner wires in exceptional cases (84, 98, 109, 110). Crossing the growth
plate must be avoided as a matter of principle
b
a
Fig. 11.4 a, b Percutaneous pinning with Kirschner
wires. All percutaneously inserted Kirschner wires are
shortened to about 2–3 cm above the level of the skin
and are not submerged beneath the skin. To avoid infection, a generous opening is made in the cast around
them. This opening is closed with a sterile swab but is
not covered with plaster so as to permit inspection of
the wires. The wires are not left in place longer than
three to four week at most
76
General Science, Treatment, and Clinical Considerations
Table 11.1
Advantages and disadvantages of fixation methods adapted to children
Plate
Dynamic intramedullary nailing
External fixator
Surgical
Method
Surgical
Surgical
Material
Adapted to children
“Child-friendly”
Adapted to children
Reduction
Open
Closed
Closed
Scarring
Severe
Small
Small
Application
May be age-dependent
Fracture-dependent
Fracture-dependent
Strength (diaphysis)
Stable
Stable; allows early use
Stable; allows immediate use
Additional immobilization
Occasionally
None
None
Second intervention
Yes
Yes
No
Possible infection
Ostitis
Osteomyelitis
Ostitis
Growth prognosis
Known (literature on
femoral shaft: 56, 57)
Known (24)
Known (literature on
femoral shaft: 153)
with either implant. Distraction fractures of the
olecranon or patella represent an indication for
tension banding fixation as in adults.
!
Good results at the follow-up examination are
not always attributable to the therapy that was
performed.
The advantages and disadvantages of all therapeutic methods should be weighed when determining which treatment is indicated, and their
efficiency and how well they will be tolerated by
the patient should be considered. Therefore, the
treatment of articular fractures should assure stability in motion, and the treatment of shaft fractures should assure stability in motion and use
where possible.
However, one should remember that all therapeutic interventions can induce growth disturbances and that the corrective forces of growth
make some therapeutic interventions unnecessary (Fig. 11.5 a,b).
General Observations on Treatment
77
왖
Fig. 11.5 a Good results at the follow-up examination are not always attributable to the therapy performed. The images show a three-year-old
boy with a subcapital fracture of the humerus that initially exhibits a significant deformity. The follow-up examination reveals restoration of symmetry
with the contralateral side
Fig. 11.5 b Only the consolidation image reveals that the good result
was achieved by growth and not by the therapy performed, which consisted of attempted closed reduction
78
12
Follow-up
Follow-up examinations should only be performed when they are or could be of clinical importance.
Radiographic Follow-up
Examinations
Initial diagnoses (see p. 49 ff).
Radiographic Studies to Verify Correct
Position
In every fracture or dislocation requiring initial
reduction and fixation, the results of reduction
should be documented in radiographs obtained
while the patient is still under anesthesia. This
will allow the surgeon to perform a secondary reduction during the same session if indicated
(Fig. 12.1). However, additional radiographic
studies to verify correct position will not be required. Fixation should be stable wherever
feasible, in which case secondary axial deviation
(in the absence of sufficient trauma) is not to be
expected. Where achieving stable fixation is not
feasible, then the fixation method should at least
be sufficiently reliable to prevent secondary axial
deviation with the fracture immobilized in a
plaster cast. Performing repeated radiographic
studies to verify correct position indicates a lack
of trust in the stability of the fixation. Where this
is the case, it is better to change the method of
fixation outright than to wait for opportunities for
secondary intervention. The next radiographic
follow-up study secondary to surgical treatment
including radiographic documentation of the results of reduction and fixation should be to document consolidation of the fracture.
!
Regular radiographic studies to verify correct
position secondary to surgical treatment suggest
insufficient fixation.
Fig. 12.1 Radiographic studies to verify correct position. An x-ray in plaster on the day of the accident to
verify correct position should only be obtained with initially displaced and reduced fractures to document the
results of reduction while the patient is still under anesthesia
Follow-up
Immediate radiographic studies to verify correct
position in all other fractures initially treated with
immobilization in a plaster cast are unnecessary
as they will have no clinical consequences.
This also applies to the follow-up radiographs
in plaster often obtained on the fourth day prior to
closure of the cast. In our own efficiency studies of
follow-up examinations of fractures of the tibial
and fibular shaft (29, 102), we found that this
fourth-day follow-up examination in plaster was
of therapeutic consequence in only 20% of all
cases. However, the result of this therapeutic consequence was positive in only 20% of all cases,
negative in 40%, and findings remained unchanged in another 40%. Therefore, this follow-up
examination may be regarded as inefficient and
unnecessary. We ourselves find that radiographic
79
studies to verify correct position on the fourth day
after the accident are indicated only in the case of
nondisplaced fractures of the lateral condyle of
the humerus that are at risk of displacement (xrays out of plaster; 134) and possibly in the case of
type II a supracondylar fractures of the humerus
(x-rays in plaster). In the case of all other fractures, we do not see an indication for radiographic
studies on or about the fourth day because it is too
early to deduce any therapeutic consequences
(such as a cast wedge) from such studies.
The best time for radiographic studies to
verify correct position is the eighth day, after softtissue swelling has completely receded, the cast
has been closed, and a soft-tissue callus has
formed to partially fix the fracture. This time is
ideal for application of cast wedges (Fig. 12.2). A
Fig. 12.2 Radiographic
studies to verify correct position. The ideal time for radiographic studies to verify
correct position is the eighth
day after the accident as studies at this time are most
conducive to drawing therapeutic conclusions, such as
whether a cast wedge is indicated. In the patient shown,
the initial axial deviation was
eliminated by a cast wedge
placed on the eighth day
after the accident without
prior radiographic studies.
The results of this therapy
were only documented in
radiographs obtained after
treatment
80
General Science, Treatment, and Clinical Considerations
second radiographic study to verify correct position is only performed on about the 14th day in
patients above age 12 with diaphyseal fractures.
Radiographic studies after this point in time are
unnecessary as there is negligible risk of any
further displacement in the cast and the position
of the fragments can no longer be changed by cast
wedges or even obsolete treatments such as secondary reduction.
Secondary Diagnostic Examinations
(See also p. 55).
!
Secondary reduction and change of therapy in a
patient who has already undergone an initial
treatment under anesthesia are obsolete
methods.
Radiographic Studies to Verify Consolidation
Depending on the patient’s age and the location of
the fracture, a radiograph out of plaster should be
obtained between the fourth and fifth week after
Fig. 12.3 Radiographic studies to verify consolidation.
The time at which consolidation radiographs should be
obtained depends on the location of the fracture and
the patient’s age. From a
radiological standpoint, a
fracture is considered to
have healed with stability
where a periosteal callus of
approximately the same
density as the cortex visibly
bridges the fracture gap in
both imaging planes in at
least three of the four imaged cortexes
Follow-up
81
the accident in any fracture meeting the following
criteria:
앫 The fracture was reduced,
앫 A consolidation disturbance may be expected,
앫 An axial deviation was left untreated,
앫 The injury was an articular fracture.
From a radiological standpoint, a fracture is considered to be consolidated and stable where a periosteal callus of approximately the same density
as the cortex visibly bridges the fracture gap in
both imaging planes in at least three of the four
imaged cortexes (Fig. 12.3). Fracture consolidation in all clavicular fractures, nondisplaced
metaphyseal impacted fractures, isolated tibial
fractures, and all metaphyseal phalangeal fractures in the fingers and toes is determined clinically by the presence of a callus that is no longer
tender to palpation. Consolidation radiographs
are not required with these fractures because in
the phalanges of the fingers and toes in particular
the callus will not yet be visible on a radiograph
(Fig. 12.4).
One fundamental consideration is whether all
consolidation radiographs—including those indicated for “forensic” reasons—should be replaced
by ultrasound studies. At least ultrasound can
demonstrate the position of the metaphyseal and
diaphyseal fractures and can verify whether an
adequate callus has formed. However, our experience is not sufficient to assess ultrasound’s
suitability for evaluating the onset of bony union
in articular fractures as well. This is not merely a
question of convincing clinicians; it also raises organizational issues. Ultrasound examinations are
personnel intensive and are usually performed by
the physician. However, there is no reason why
radiological technologists familiar with radiographic examinations cannot be trained to perform a standardized ultrasound examination
technique for evaluating positions of fractures
and callus formation.
!
As a matter of course, no further radiographic
follow-up studies are required once a patient has
regained pain-free mobility.
Follow-up Studies to Evaluate Growth
Growth studies (Fig. 12.5) to document correction
of deformities and growth disturbances and their
sequelae should primarily include clinical evaluations. In case of doubt, results of clinical testing
Fig. 12.4 Consolidation radiographs of the finger.
The patient was an eight-year-old boy who injured his
finger playing ball 10 days before. The injury was left untreated and pain receded. The boy’s parents brought the
patient in for a diagnosis. There was no pain in the finger; clinical examination revealed a palpable painless
callus that was not visualized in the radiograph
(including static and functional examinations)
should be documented in photographs. This
should be done routinely in patients participating
in scientific studies. In most cases this documentation would even suffice for preoperative planning (see Fig. 19.37 c). It is not yet clear whether
ultrasound studies can detect the onset of abnormal growth before clinical symptoms appear and
so provide a basis for therapeutic decision
making. However, radiographic follow-up studies
are initially indicated where there is any clinical
suspicion of absent or insufficient correction of an
untreated axial deviation or clinical suspicion of a
82
General Science, Treatment, and Clinical Considerations
Fig. 12.5 Radiographic
studies to evaluate growth.
Even follow-up studies of deformities should be performed at long intervals. Images
should be obtained when
the examiner expects significantly altered findings or evidence of complete correction. In this eight-year-old girl,
the fracture of the distal radius healed in radiodorsal
angulation. Follow-up radiographs were obtained once a
year until two years after
consolidation
progressive increase in the severity of a posttraumatic deformity. Follow-up studies of this sort
should be obtained at long intervals and only performed where altered findings are expected or
where the results will influence therapy.
Increasing abnormal growth in the setting of a
growth disturbance due to partial premature closure of the growth plate raises the question of appropriate therapy. Should the condition be corrected by osteotomy, should the bridge be resected, or should the bridge be distracted and disrupted using an Ilizarov fixator? The decision depends on the extent and location of the bridge,
which cannot be evaluated on standard anter-
oposterior (A-P) and lateral radiographs. It has
since been shown that the extent and location of a
metaphyseal–epiphyseal bridge can be better
visualized by magnetic resonance imaging (MRI)
than computed tomography (CT; 11). According to
the patient’s age, one can then develop a specific
therapeutic plan for treating this bridge and its
sequelae (Fig. 12.6).
Follow-up
83
Fig. 12.6 Diagnosis and
treatment of partial premature closure of the
growth plate in S. P.,
a 10-year-old boy.
a Slightly displaced separated epiphysis in the
distal femur treated by
closed reduction. Four
weeks later, the fracture exhibits clinical
and radiographic consolidation in proper axial alignment. Over the
following one and a
half years, increasingly
abnormal growth occurred with anteversion
and a slight varus deformity due to a posteromedial bridge between the metaphysis
and diaphysis. The CT
image (the modality of
choice at the time) demonstrates that the
bridge is not very extensive
84
General Science, Treatment, and Clinical Considerations
Fig. 12.6 b In light of the patient’s age and the small
size of the bridge, the decision was made to apply an Ilizarov fixator to achieve closed disruption of the bridge.
The bridge was disrupted after a total of 21 days. Subse-
quent clinical and radiographic evidence indicated that
the feared premature closure of the growth plate did not
occur
Follow-up
85
d
c
Fig. 12.6 c, d There was no recurrence of a bridge before cessation of growth. The final follow-up study demonstrated symmetrical leg axes, symmetrical ranges
of motion in the joints of each of the lower extremities,
and shortening of 3 cm in the affected leg. The patient
desired neither conservative nor surgical correction of
the leg-length difference as he was completely free of
symptoms
Clinical Follow-up Examinations
longer tender to palpation and radiological signs
of consolidation are present, then the fracture
may be regarded as stable and healed. If the callus
is still tender to palpation, then the limb should
be immobilized for another two to three weeks at
the patient’s request until pain is absent.
The patient should decide when to attempt
full use entirely on his or her own according to
whether there is any remaining pain. Therefore,
there should be no rules, restrictions, or any sort
of active or passive physical therapy within the
first three weeks after the cast is removed. During
this period, the patient should be left to his or her
own devices.
Cast Examinations
Children who complain about pain in a cast
(Fig. 12.7) are invariably right!
On the first day after application of a cast, the
cast and periphery should be examined.
Further examinations of the cast, soft tissue,
and periphery are performed on about the fourth
day after closure of the cast, at every radiographic
examination to verify correct position (i.e., on
about the eighth day and, in applicable cases, on
about the 14th day), and when the fracture has
consolidated.
Consolidation Examinations—Onset of Motion
and Onset of Use
Palpation of the fixation callus to evaluate stability is more important than the radiograph out of
plaster. Before palpating the site of the fracture,
the physician should ask the patient’s permission
to do so. If the patient refuses, then the mother or
the patient may palpate the site. If the callus is no
!
The patient alone determines what type, direction, and speed of use is appropriate.
Functional Tests
As matter of course, no functional testing should
be performed after removing the cast. Limited
function in the joints must be expected merely as
a result of immobilization in a plaster cast, and
86
General Science, Treatment, and Clinical Considerations
Fig. 12.7
functional testing is painful. Despite this knowledge, functional testing after removal of the cast is
one of the most common clinical examinations
performed. It primarily serves to satisfy the examiner’s own “physiological” sadism and, as can
be expected, causes pain in the patient. Physicians
who do not want to expose themselves to this
criticism are best advised to perform the initial
functional test only two to three weeks after removal of the cast. The function of the joints adjacent to the fracture should be assessed by measuring motion through the 0⬚ neutral position,
and results should be documented in comparison
with the contralateral side.
Examining the cast
Follow-up Examinations to Evaluate Growth
Clinical examinations of growth are intended to
detect posttraumatic growth deformities due to
growth disturbances and to monitor the correction of residual deformities. As a matter of course,
these examinations should be performed at long
intervals (at intervals of one to two years). The
patient and the patient’s parents should be informed that one of the possible growth disturbances may be expected to occur secondary to
any fracture in a growing patient. They should understand that in most cases initial therapy can
only indirectly influence these growth disturbances and that therefore a precise growth prognosis cannot be made. Where growth disturbances with clinically significant sequelae are to
be expected, follow-up examinations should be
performed up to two years after the trauma. Follow-up examinations are indicated for all articular fractures up to two years after the accident. Especially in the lower extremities, these injuries
entail a risk of increasingly abnormal growth due
to growth disturbances involving partial premature closure of the growth plate, which itself may
be the result of either a banding bridge or a necrosis bridge. In contrast, transient partial stimulation of the affected growth plate invariably occurs
in the upper extremities. Here, too, there is the
possibility of abnormal growth with axial deviation.
87
13
Aftercare
Once full mobilization of the healed fracture is allowed (based on radiographic and palpatory evaluation of the fixation callus; 40, 47), the patient
may spontaneously mobilize the limb as he or she
sees fit without any rules or restrictions during
the first three weeks after removal of the cast. The
only restriction is that the patient should not participate in school sports until three weeks after
full use has been allowed.
On principle, healed acute fractures and dislocations in growing patients (8, 44, 76, 79, 116) do
not require any aftercare with medication or
physical therapy. The patient does not have to
learn a new pattern of motion but merely recover
the existing pattern of motion. This is easiest for
children in their familiar surroundings, playing as
they are used to. No regulations are required because growing children will respond far more reliably to their own pain and will pay more attention
to it than adults would (Fig. 13.1).
!
“Rationality” decreases with increasing age;
“irrationality” increases.
Fig. 13.1 No rules or restrictions during treatment
of fractures in children. As children grow older, their
“rationality” gives way to the “irrational” behavior of
adults
88
14
Medicine and Sports
Not every patient feels that sports are healthy.
Rightfully so, when one considers that sports accidents now account for about 50% of all accidents
in growing patients (33, 74, 81, 87, 89). This means
that sports are more often a burden than a boon
(126). For this reason, the physician should pay
close attention to the patient’s own attitude to
sports, which may well be skeptical. This should
be weighed carefully and given appropriate consideration when determining whether the respective therapy is indicated (Fig. 14.1).
Fig. 14.1 Rehabilitation to regain the ability to participate in sports. The individual patient’s attitude toward sports in general should be considered when deciding on measures to restore his or her ability to participate in sports
“Resuming” sports does not at all mean that
the patient must participate in sports, rather that
he or she can participate. That is to say, that
patients should initially decide for themselves
which sport they feel they are up to. Physical education teachers often find this difficult to understand, although they increasingly tolerate it when
they see that such students respond more rationally and cooperatively when allowed to decide for
themselves than they would if subjected to rules
and restrictions.
As a physician, it is best to avoid risking one’s
own credibility by ordering unrealistic restrictions that beg to be ignored and at best give the
patient a guilty conscience.
89
15
Hospital, Parents, and the Child
Treatment depends on the social and family environment, the child’s and parents’ emotional situation (21, 34), and medical necessity. A joint
decision is reached on whether treatment should
and must involve outpatient therapy only, surgery
with release on the same day, brief hospitalization for one to three days, or extended hospitalization for several days or even weeks. Neither the
hospital’s desire to amortize its investment nor
the personal wishes of the chief of medical staff
should influence this decision, and therefore they
should have no influence on the choice of therapy
(128, 129).
It has since become common practice in most
pediatric hospitals to permit 24-hour visitation
for parents. But this should not be misunderstood
as a source of prestige for medical professionals
(Fig. 15.1 a,b). Parents who are unable to supervise their children in the hospital, whether for
family reasons, because of employment, or
whatever, should not be subjected to preaching
and moralizing by physicians and health care
staff. On the contrary, the hospital should make a
concerted effort to adequately compensate the
children for the lack of parental visitation while
refraining from any form of arrogance or moral
judgement.
ENTRANCE
Visiting Hours
3:00–3:05 p.m.
Wed—Sat—Sun
Fig. 15.1 a
past
Medical moralizing: Visiting hours in the
90
General Science, Treatment, and Clinical Considerations
EXIT
Visiting Hours
24 hours
daily
Fig. 15.1 b Current visiting hours. Even with these
visiting hours, there is no justification for medical moralizing by health care staff
91
16
General Observations on Information
“Legal” Aspects
Even outside the English-speaking countries,
physicians practice their profession in constant
fear of the legal consequences their actions may
have. They are afraid of lawsuits and use this excuse to ruthlessly expand their medical agitation
of the patient. This leads to medical polypragmasy that is ostensibly justified on forensic
grounds. I dare not discuss the economic consequences of such thinking.
Physicians also feel legally bound to inform
parents and patients so comprehensively—
wherever possible in the presence of witnesses—
about every possible complication that this talk
more often resembles blatant threatening than a
supportive, informative discussion. Such harassment only discourages and incapacitates the
patients and their parents. Feeling lucky to have
escaped with their lives, they hardly care that this
treatment renders them incapable of thinking
clearly.
Throughout this process, the actual goal of
providing information is completely ignored. That
goal is to render the patients and their parents
capable of making a decision so that by virtue of
that decision they may contribute their support to
the therapy, the resolution of the disorder, and
therefore the final result. After all, the bottom line
is how to treat the patient, not how to provide
“legal” protection for the physician. A common argument is that patients often exhibit unbelievable
insolence, remain distrustful despite the physician’s best efforts to provide clarity and information, and constantly flock to their lawyers to sue.
My own work in drafting expert opinions and the
information provided by attorneys specializing in
the field have shown that—at least in the Germanspeaking countries—over half of all malpractice
lawsuits are attributable to patients confused by
inadequate information.
The “recalcitrant,” “critical,” and “distrustful”
patient should not be viewed as troublesome but
as a challenge and an opportunity for the phys-
ician to work with the patient to further develop
the medical art of communication and information and demonstrate its effectiveness.
What does this art involve?
Quite simply it involves:
앫 Taking the patient and his or her parents, their
concerns, and their questions seriously,
앫 Making sure that they have understood this,
앫 On the basis of this understanding, defining
the goal of a joint decision-making process as
a unique, individualized objective.
!
Take the patient as seriously as you yourself
would like to be.
Taking the patient seriously means:
앫 Recognizing the patient’s needs and addressing them in the medical procedure,
앫 Perceiving the patient’s verbal and nonverbal
signals and then interpreting them correctly,
앫 Letting the patient know that the physician is
the sole representative of the patient’s interests and regards any other interests as secondary (meaning those of the parents, those of the
institution, and the physician’s own interests,
including financial gain),
앫 That the physician never enters into an alliance with the parents against the child’s interest. The physician must decide as he or she
sees fit whether to make this clear to the
parents as well, and in so doing to cement the
physician’s role as sole representative in a
consensus with the parents.
!
The physician is the sole representative of the
patient’s interests.
Taking the patient seriously and focusing on the
patient necessarily excludes certain unbecoming
stereotypes of physicians’ behavior in every discussion:
92
General Science, Treatment, and Clinical Considerations
앫 Basking in the fatalism of possible complica-
tions,
앫 Showing others the wealth of knowledge the
physician has acquired,
앫 Showing others how magnificent the physician is,
앫 Letting the patient know how lucky he or she
is to have happened upon this particular physician, the great healer.
The physician should refrain from any sort of
showing off in front of the patient, regardless of
how great that urge might be.
!
Do not show off.
Taking the patient seriously invariably means
asking the patient questions and answering the
patient’s questions. The physician has the specialized knowledge. However, the patient, like the
physician, also has intelligence, which is required
for putting any knowledge to use. This means it is
advisable to inform the patient in such a way that
he or she can make his or her own decision and
work together with the physician in reaching the
necessary decisions. The physician may know
more but by no means knows it all.
!
Do not play know-it-all.
Taking the patient seriously and focusing on the
patient also excludes threatening the patient: “If
we (the majestic medical plural) do not undertake
this and that immediately without the slightest
hesitation, then your child may die or at the very
least must expect the most severe, unavoidable
complications! You need only trust the Healer
and His decisions and everything will be fine.”
!
Do not threaten or coerce.
And one more thing: Remember that the patient
and his or her parents invariably will be under
stress at first. They will initially understand little
of what is said to them, and when they are offered
no information later, they will feel misinformed
and finally will indeed sue in the hope of at least
being taken seriously at that point.
How should the physician proceed?
Let us examine the declaration of consent to
surgical treatment, a required legal formality,
along with the instruction about possible complications that it involves. Such informed consent
may be best described as an unavoidable legal foreign body in medical practice, and one should
make every effort not to demand this signature
from parents under stress on the evening prior to
surgery. Wherever possible such consent should
be obtained in the setting of an informative planning discussion outside of the emergency situation,
for example, during consultation in the hospital
after a joint decision to proceed with surgery has
been reached. It is obvious that in absolute emergencies this consent form will also have to be
processed in an emergency procedure. This
makes it all the more important to attempt to
make every surgical intervention an elective procedure.
In any case, the goal of therapy must be formulated in the “positive” section of this declaration
of consent to counterbalance the “negative” section describing the possible complications.
When providing information and formulating
this goal of therapy, the physician must bear in
mind that the patient and parents pass through
distinct phases, which must be taken into consideration:
앫 During the stress phase, the physician must
listen and answer questions,
앫 During the reassurance phase, the physician
must answer questions and provide information,
앫 During the confidence phase, the physician
must provide information and answer questions.
The Most Important Information
During the Most Important Phases
of Treatment of Fractures and
Dislocations
In an emergency immediately prior to rendering
treatment:
앫 Pain management
앫 Diagnostic workup
앫 Ask the patient about the goal of treatment
앫 Therapeutic options
앫 Agree on treatment
The physician should inform patient and parents
about the type of pain management and necessary primary diagnostic procedures, which will
usually include radiographs. One should inform
the patient, or the patient together with his or her
General Observations on Information
parents, of the fundamental technical options
available to achieve this goal and then agree on
the further therapeutic procedure with patient
and parents.
Immediately after rendering treatment:
앫 Treatment performed as planned,
앫 Possible complications and/or deviations,
앫 Outpatient treatment or hospitalization (duration, etc.),
앫 Time frame and treatment until injury heals,
앫 Returning to school.
One should inform the patient whether it was
technically possible to perform the treatment discussed together. The patient should be informed
whether complications occurred and, if so, which
ones and how the surgeon has resolved or plans to
resolve them. The physician and patient should
discuss whether outpatient treatment is possible
or hospitalization is required, how long it will
take until the fracture heals, and how long the
child will presumably be unable to attend school.
If emergency treatment was not rendered but
postprimary treatment is planned (such as with a
cast wedge, or leaving axial deviations uncorrected), then an additional information discussion with the patient is held at that time (usually
on about the eighth day after the accident). This
discussion should cover:
앫 The complexity, benefits, and complications
of the planned treatment,
앫 The growth prognosis.
The patient is again given detailed information
about the complexity, advantages, and disadvantages of the planned treatment and a consensus is
reached. This is the proper time for broaching the
subject of the growth phenomenon, especially if
physician and patient together agree to leave certain axial deviations untreated.
After the fracture has healed:
앫 Time frame for returning to school and resuming sports,
앫 Growth prognosis,
앫 Nature and frequency of required follow-up
examinations.
The time frame for returning to school and resuming sports is determined at this time in consultation with the patient. Only now should the physician inform the patient in detail about the growth
prognosis and agree with the patient on the na-
93
ture and frequency of follow-up examinations
that this will require.
!
!
“Don’t always say what you know, but always
know what you say.” Matthias Claudius
Formulate the goal of therapy.
Formulating the Goal of Therapy
All of this information is provided in the interest
of finding a way to achieve the jointly formulated
goal of treatment with the least possible expenditure of treatment, least possible damage, and
greatest possible benefit. This joint formulation
and achievement of the goal of treatment is a contractual agreement between the physician and
the patient or patient’s parents that is more sensible from a medical standpoint than simply obtaining a signature on a pseudolegal form.
This provides a yardstick for measuring the results of treatment against the initial goal. This
mutual quality control must always include two
phases:
앫 The first phase extends to consolidation of the
fracture to monitor the effect of therapy,
앫 The second phase extends from consolidation
of the fracture to completion of growth or until
follow-up examination two years after the injury to evaluate the influence of growth on the
final result and in so doing to monitor the efficiency of all initial therapeutic measures.
Once again: The most important thing for any
patient is to feel that he or she is being taken seriously. This especially applies to children. This
trust must first be established before patients will
be receptive to any necessary information and
able to use it in making decisions. An obligation to
provide information only makes sense if the person receiving that information is taken seriously.
!
The obligation to provide information is a medical necessity, not a legal one.
We physicians should never go beyond the medical context because this is the only one we know
anything about and can subject to our quality criteria. Moreover, when we sincerely undertake to
fulfil this obligation to provide information for
medical reasons, we automatically fulfil the legal
requirements as well.
94
17
“Don’t Make Such a Fuss—You’re Only a Child.”
Current conditions in doctors’ offices, hospitals,
ambulant care facilities, therapy centers, etc. are
poorly suited to treating children competently
and in a manner appropriate to their needs. We
must assume that 60–70% of the therapy providers who treat children have never been trained
or otherwise prepared to do so at any time during
their formal training. These children are essentially treated by incompetent therapists. This situation is due to both social and economic factors.
Social Factors
Generations of parents frustrated by their experience with their own parents have passed this
frustration on their own children and through this
“upbringing” have saddled these children with
their own gloom and loss of laughter. The adults
engage in petty fights among each other in daily
life and have problems accepting each other as individuals. It is no wonder that adults are unable to
take their own children seriously and accept them
as independent personalities in all their colorful
individual diversity. Children are reduced to pliable objects, even in medicine.
Economic Factors
Previous thinking has tended to focus on the
success of the system consisting of hospitals, doctors’ offices, and therapy institutes. The activities
involving the patient, which naturally can also
contribute to his or her healing, are performed on
the patient to a large extent with the aim of amortizing the institutions and bolstering the selfimage of the “helpers.” Hardly any consideration
is given to the patient’s individual wishes and
ideas, on the one hand out of fear that the patient
would refuse a profitable therapy in case of a paradigm shift and on the other as a result of the
therapist’s own social experience of growing up.
Here in Switzerland, our current health care
financing system provides incentives for the
economical use of existing patients and recruitment of new patients. We are a society that has
learned how to grow increasingly older and remain sick. It would be more appropriate to refer to
a “sickness care system.” Yet if we want an efficient “health care system,” a completely different
set of economic incentives will have to be implemented. Then it would be possible to earn the
same amount of money if not more. A paradigm
shift is indicated for this reason alone.
Appropriate to children’s needs does not
mean that we should cover doors with Mickey
Mouse stickers, put cheap toys for them in some
dark corner, and begin to speak to them in baby
talk. No, not like that! Instead we must view and
treat our children as individuals with opinions of
their own. We must show them the respect that
we wish to be shown (and often do not receive)
ourselves. We must protect them as long as they
require protection and must release them from
this protection into independence as soon as they
are able. We must preserve their laughter by
laughing with them. We must—especially when
they are sick—bring into their lives a light that can
only radiate from within us. One can only benefit
from light and love when one receives and radiates both.
When we bring light and laughter into our
children’s lives, we enrich ourselves with just as
much light and laughter as we give. This insight
would finally clear the way for a paradigm shift in
our social behavior toward each other and in
medicine as well: We would no longer practice
medicine on objects but with subjects.
Specific Injuries
96
Upper Extremities
18
Injuries to the Shoulder Girdle and Humeral Shaft
Clavicular Fracture
Midshaft
> 90%
Forms of Injury
The most common injury is the midshaft fracture,
which occurs as a greenstick fracture in half of
these cases. Proximal medial and distal lateral
clavicular fractures are extremely rare, occurring
in only about 3% and 5% of all cases, respectively
(11, 19). The proximal fractures usually occur as
separated epiphyses. These are always hard to diagnose, regardless of whether the epiphysis is detectable on radiographs (19, 20; see also Ligament
Injuries, p. 100). Remember that in patients with
wide open growth plates, separated epiphyses are
encountered far more often than ligament injuries. The distal fractures occur as pseudodislocations. The central fragment displaces superiorly
or inferiorly out of the periosteum; the ligament
system connecting the acromion, coracoid, and
clavicle remains intact (6; Fig. 18.1).
Diagnosis
When it occurs in the midshaft, this fracture is
easy to diagnose clinically and on radiographs.
However, a minimally displaced greenstick fracture is easily overlooked on a radiograph. Clinical
findings are invariably unequivocal, so that diagnostic radiographs may be dispensed with as a
matter of course. If really necessary in one or the
other case, ultrasound should be the diagnostic
option (40).
We have not observed any associated softtissue injuries among our own patients over the
last 10 years. The literature only mentions that
transient compression of the subclavian artery or
vein may occur in greenstick fractures with inward and inferior angulation, leading to symptoms of circulatory impairment in the arm (15).
This deformity is rare.
Distal
5%
Proximal
3%
Fig. 18.1 Forms of clavicular fractures. Midshaft
fractures (top) are the most common injuries. The less
frequent distal “pseudodislocations” are very often epiphyseal separations in which the proximal fragment displaces superiorly or inferiorly out of the periosteum. The
ligaments invariably remain intact (center). Proximal
clavicular fractures also usually occur as epiphyseal separations with or without a metaphyseal wedge fragment (bottom)
Growth Disturbances
Growth disturbances are possible secondary to
rare distal fractures and even proximal fractures.
These involve premature closure of the growth
plate followed by shortening of the lateral or medial portion of the clavicle. This disturbance does
not appear to cause any functional impairments.
Injuries to the Shoulder Girdle and Humeral Shaft
“Spontaneous Corrections”
Shortening deformities occurring in completely
displaced fractures are corrected during the
course of further growth (13). It is not known
whether stimulation of adjacent growth plates in
nondisplaced fractures leads to slight lengthening
of the clavicle; slight differences in length do not
appear to cause functional or cosmetic impairments.
Depending on age, side-to-side displacement
is usually well compensated for. Remodeling of
this deformity and the prominent motion callus
that nearly always occurs may take up to six
months. Only then should the patient expect
symmetry when wearing clothes with a low neckline. Side-to-side displacement can persist in adolescents whose growth plates have already closed
(Fig. 18.2).
Problems and Complications
Refractures are possible in greenstick fractures although they are extremely rare. The absence of a
97
clinically palpable and visible callus following a
greenstick fracture detectable on radiographs is
an indication of this hazard (Fig. 18.3). In rare multifragmentary fractures, a free fragment can
penetrate the skin. Surgical removal of the fragment may be necessary in such a case, depending
on the situation. In principle, however, this situation does not represent an indication for internal
fixation. Stress fractures (37) are rarely seen, as
are retrosternal dislocations of the proximal
clavicula after an epiphyseal separation (38).
Treatment
Clavicular fractures at any location are treated
conservatively as a matter of course. A few
authors (see General Science, Treatment, and
Clinical Considerations, p. 153) recommend reducing the displaced clavicular fractures with the
patient under local anesthesia. Astonishingly, no
radiographic studies are obtained to document
the results of reduction, and readers may therefore rightfully assume that such a procedure is
neither effective nor efficient. Patients them-
Fig. 18.2 Limits of “spontaneous correction” of
side-to-side displacement
in adolescents. The patient
is a 17-year-old girl with a
midshaft fracture of the clavicle. The fracture exhibits
side-to-side displacement of
nearly double the shaft
width. Following three
weeks of conservative treatment with a figure-eight
bandage, the fracture consolidated in its initial axial
deviation. Stable union with
unrestricted motion had
been achieved at the followup examination six months
later. Radiographic followup studies demonstrated a
slight persistent clavicular
deformity due to lack of
correction of the side-to-side displacement. This deformity was barely noticeable
in the clinical examination,
and the patient was completely free of any subjective symptoms
98
Specific Injuries—Upper Extremities
during the first five days, and the distal limb
should be inspected accordingly. An additional
sling is often desirable as pain treatment
(Fig. 18.4). After 10 days, the fracture will be sufficiently fixed by connective tissue to allow removal of the figure-eight bandage where the
patient’s subjective condition permits.
Utilizing existing corrective mechanisms and
even treating fractures with severe deformities
conservatively is also justified in the case of
lateral fractures (Fig. 18.5).
We see an indication for open reduction and internal fixation only in the case of severely displaced distal and proximal fractures in older adolescents. This treatment may also be considered
for all fractures resulting from direct trauma associated with significant soft-tissue injuries. In
the last 25 years, not a single one of our patients
with a clavicular fracture in the middle third required surgical treatment. Also, it is rarely recommended in the literature (41).
Immobilization and Consolidation
Fig. 18.3 The problem of greenstick fractures. The
patient is a seven-year-old boy with a greenstick fracture
in the middle third of the clavicle. Treatment was conservative. After four weeks, there was no palpable callus
over the fracture site and no pain at all. Both shoulders
exhibited unrestricted and symmetrical mobility. Six
months later, a repeat fracture occurred as a result of
slight trauma. Four weeks after that, clinical and radiographic examination revealed the presence of a distinct
spherical callus that was no longer painful. The radiograph was obtained at the parents’ request
selves will have no fun at all with such a procedure. Therefore, we dispense with any such reduction maneuvers. All the bandages we use are
applied to relieve pain, not to correct the position
of the fragments. As a result, there is no need for
radiographic studies to verify correct position. In
fractures without shortening, a sling for relief of
pain will suffice. Only where severe shortening is
present may a figure-eight bandage prove more
effective as a stabilizing splint to relieve pain. This
figure-eight bandage should be tightened daily
Immobilization lasts as long as the patient finds it
comfortable and helpful. In most cases, the fracture will have consolidated after two to three
weeks. Consolidation is evaluated by clinical examination of the palpable, increasingly painless
callus. A further sign of consolidation is increasingly normalized function of the affected
shoulder. The callus formation, which looks like a
deformity, will disappear within four to six
months.
Sports Participation and Follow-up
Examinations
The patient decides for himself or herself when to
resume sports activities. This requires symmetrical, unrestricted mobility in both shoulders.
Other follow-up examinations are not required if the patient remains free of symptoms
and the cosmetically disturbing callus has disappeared as expected (35).
Deformities
Pseudarthrosis after a clavicular fracture is not to
be expected in a growing patient. The rare cases
described (6, 29) were congenital pseudarthroses
that had been acutely traumatized. These only require treatment if they cause chronic pain or lead
to persistent dysfunction. This has never been the
Injuries to the Shoulder Girdle and Humeral Shaft
99
Fig. 18.4 Conservative treatment of clavicular
fractures. Patients find that placing the arm in a sling is
the best way to relieve pain (a). The figure-eight bandage stabilizes the fracture and reduces pain but is required only with severely displaced fractures (b)
a
b
100
Specific Injuries—Upper Extremities
Fig. 18.5 Distal “pseudodislocation.” The patient is
a nine-year-old boy. The significantly displaced “pseudodislocation” with inferior displacement of the proximal
fragment was treated conservatively with a figureeight bandage. Five weeks
later, both shoulders exhibited unrestricted and symmetrical mobility, and clinical and radiographic findings
indicated stable healing. After seven months, remodeling had largely eliminated
the side-to-side displacement
situation in the few cases that I have observed
myself. Surgical correction of these congenital
pseudarthroses is not always successful. The cost
and complexity of treatment must be carefully
weighed against the severity of the existing
symptoms and the possibility of an unsuccessful
outcome. Physicians should resist the temptation
to perform surgery at any cost. Where surgery appears to be justified, it should be postponed until
after cessation of growth (5). But in the meantime
the results of operative treatment seem to be
much better than before (34, 43, 44), so that the
operative treatment can indeed be of benefit to
the patient.
Ligament Injuries and Dislocations
in the Acromioclavicular,
Coracoclavicular, and
Sternoclavicular Region
In general, these ligament injuries are only to be
expected in adolescents with fully closed growth
plates. The anterior sternoclavicular dislocation is
often difficult to diagnose and cannot always be
distinguished from a separated epiphysis. Often a
reliable diagnosis can only be deduced from the
clinical course of the disorder: An area of hardened swelling that exhibits increasing volume
and decreasing pain during the first 10–14 days
suggests a fixation callus that forms following a
fracture. Soft swelling of progressively increasing
severity with increasing pain suggests a ligament
injury. The diagnosis should be made two weeks
after the injury at the latest. Open reduction and
surgical ligament reconstruction can still be
readily performed at this stage.
Injuries to the Shoulder Girdle and Humeral Shaft
A posterior retrosternal sternoclavicular dislocation is a rare occurrence (17, 26). However, it is
important to diagnose and treat such an injury
because of the severe complications it can involve, such as mediastinal compression syndrome. The mechanism of injury is unspecific, as
are the clinical symptoms, which include pain in
the region of the proximal clavicle. Initial swelling
can obscure the joint contour. Where there is the
slightest sign of intrathoracic compression, the
diagnosis should be confirmed immediately with
the aid of computerized axial tomography and the
proximal end of the clavicle should be reduced
with the patient under general anesthesia (this is
best performed using a holding forceps). We feel
there is no need for late reduction of an asymptomatic chronic dislocation, provided that the
patient remains free of symptoms.
101
Acromioclavicular dislocations may be
classified analogously to adult injuries using
Tossy’s system. Slight injuries of Tossy types I and
II (28) should be treated conservatively. Conservative treatment means the patient should not participate in sports and should refrain from full use
as he or she sees fit until symptoms have disappeared. We prefer to treat severe injuries surgically, in consultation with the patient, despite the
fact that the late prognosis is not quite clear (28).
As in adults, treatment consists of surgical reconstruction of the ligaments. This is best achieved by
securing the ligament suture by temporary placement of a coracoclavicular positioning screw (10).
102
Specific Injuries—Upper Extremities
Subcapital Humerus (1.6%)
Forms
앫 Separated epiphysis (Salter–Harris types I and II)
in one third of all cases.
앫 Subcapital fractures in two thirds of all cases.
Anteroposterior (A-P) and lateral radiographs
앫 Growth plate exhibits a central tent-shaped peak
in the A-P image.
앫 Growth plate appears even in the lateral image
(see Fig. 18.7).
Limits of correction
앫 Below age 12: Varus, anterior bowing, and posterior bowing deformities up to 50⬚.
앫 Above age 12: Varus, anterior bowing, and posterior bowing deformities up to a maximum of 30⬚
(depending on age and sex).
앫 In all age groups: No valgus deformity exceeding
20⬚.
Definition of “nondisplaced“
앫 Below age 10–12: Varus angulation or anterior or
posterior bowing up to 30⬚; valgus angulation up
to 10⬚; side-to-side displacement of one full shaft
width with up to 2 cm of shortening.
앫 Above age 10–12: Varus angulation or anterior or
posterior bowing up to 20⬚; valgus angulation up
to 10⬚; side-to-side displacement of one full shaft
width with up to 2 cm of shortening.
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Medical.
앫 Where indication is uncertain: Immobilization in a bandage.
Emergency
treatment
under
anesthesia:
Completely displaced fractures in patients above
age 10 with and without distal neurovascular dysfunction.
!
All other indications should first be discussed at
length with the patient and his or her parents.
Further treatment without anesthesia or delayed
treatment under anesthesia
앫 Completely displaced fractures in patients
below age 10 without distal neurovascular
dysfunction,
앫 Fractures with angulation (see Definition of
“nondisplaced“ above).
Conservative fixation technique: Depends on pain
and instability and of the fracture:
앫 Gilchrist bandage,
앫 Desault or Velpeau dressing in a plaster cast.
Internal fixation technique
앫 Intramedullary nailing.
앫 (Percutaneous pinning with Kirschner wires.)
Aftercare
Period of immobilization
앫 With conservative fixation: Two to three weeks.
앫 With internal fixation: Immediate spontaneous
motion.
Consolidation radiographs: None, except as a baseline study for follow-up examinations (at the parents’
request) where a significant axial deviation is left untreated.
Initial mobilization: Immediate spontaneous mobilization after removal of the cast and metal implants.
Physical therapy: None.
Sports: Usually possible after four to five weeks
(where free function is present).
Removal of metal implants: Percutaneous Kirschner wires are removed immediately upon consolidation; intramedullary nails are removed six to
eight weeks postoperatively.
Follow-up examinations: The first functional tests
are performed approximately three weeks after consolidation. Where visible deformities are present, follow-up examinations are performed at six-month intervals (with radiographs at the parents’ request)
until the deformity is no longer clinically visible.
Injuries to the Shoulder Girdle and Humeral Shaft
Fractures in the Proximal Third of
the Humeral Shaft
Forms of Injury
Two thirds of all cases are shaft fractures and one
third are separated epiphyses, usually occurring
with a metaphyseal wedge fragment and only
rarely without one (2, 11). Epiphyseal fractures
are so rare that they can be safely ignored (2, 31).
Diagnosis
Nondisplaced fractures can be difficult to diagnose because of the ossification centers in the
epiphysis of the proximal humerus, of which
there are initially three and later two. Conversely,
the obliquely projected growth plate, which exhibits an apex resembling the ridge of a roof, may
easily be mistaken for a fracture. For this reason,
the ossification centers are again shown in Figure
18.6.
In order to visualize comparable radiographic
planes to allow evaluation of the direction and
severity of deformities, the elbow should be included in the radiograph wherever possible. If this
is not feasible (e.g., due to the type of immobilization), then at least the two perpendicular images
should be obtained using the same radiographic
technique. In patients of the age at which the ossification centers have fused, i.e., after age four, the
growth plate of the proximal humerus will exhibit
Fig. 18.6 Development of the proximal humeral epiphysis. The actual ossification center of the proximal humeral epiphysis appears during the first year of life. Between ages two and three, the two centers of the tubercles appear. These three centers fuse by age five. Between the ages of 14 and 16, the medial portion of this
common growth plate system, the actual part responsi-
103
a tent-shaped peak in the A-P image, whereas its
projection will appear round in the lateral image
(Fig. 18.7).
“Spontaneous Corrections”
Given the proximity of growth plates that produce
a high percentage of growth and the three
functional planes of the shoulder joint, there is
great potential for spontaneous correction of residual axial deviations, especially side-to-side
displacement and axial deviations in the coronal
and sagittal planes (3, 16, 18, 22). Deviations of the
latter type up to 50–60⬚ of varus deformity can be
flawlessly corrected up to age 12 (31; see Fig. 11.5).
However, this is not the case with valgus deformities, which are only gradually and incompletely
corrected even in younger patients (see Fig. 18.9).
Beyond age 12, the maximum correction that may
be expected is usually only half of the original deformity (2). However, deformities of up to 30⬚, or
40⬚ at most, can be tolerated in the over-12 age
group as well because the residual deformity will
continue to grow out of the joint region and then
will no longer cause any functional or cosmetic
impairment (2, 23; Fig. 18.8, see also Fig. 18.13).
Growth Disturbances
Growth disturbances are rare but can occur primarily after separated epiphyses. Usually, these
disturbances occur in the form of a premature
ble for growth, fuses with the metaphysis. The apophyseal portion of the growth plate in the region of the two
tubercles only ossifies between the ages of 17 and
20. This part is no longer involved in the actual longitudinal growth of the humerus. The obliquely projected
growth plate can easily be mistaken for a fracture (right)
104
Specific Injuries—Upper Extremities
Fig. 18.7 Diagnostic radiographs of the proximal
humerus. It can often be difficult to distinguish the A-P
and lateral planes unless the image includes the elbow.
In the A-P image, the growth plate exhibits a tentshaped peak whereas it is round in the lateral image
A-P
Lateral
medial closure of the growth plate. However, this
can also extend to the entire growth plate (27).
The incidence of this growth disturbance is not related to leaving axial deviations untreated. The
sequela consists of a more or less severe varus deformity with shortening of the humerus (10, 14,
20; Fig. 18.10).
The transient stimulation of the proximal
humeral growth plate occurring as a result of the
fracture is a growth disturbance that leads to
slight lengthening of the humerus of about 1 cm
in children under 10. Beyond this age, it causes
slight shortening, also of about 1 cm. Length alterations of this sort can also correspond to idiopathic length differences.
Treatment
Management of proximal fractures and separated
epiphyses depends on the age of the patient at the
time of the injury.
In patients up to age 12, we initially leave
angulation up to a maximal 60⬚ varus displacement uncorrected after obtaining the informed
consent of the patients and their parents. These
injuries are then immobilized in a Desault dressing and a plaster cast (Fig. 18.11). Completely dis-
placed and shortened fractures can be treated by
closed reduction with the patient under general
anesthesia (Fig. 18.12). A contact area of half the
shaft width between the fragments is sufficient.
Where tolerable angulation of a maximum of 60⬚
varus displacement persists in the coronal plane
after reduction, it is also left untreated and left to
the corrective forces of further growth.
Below age 10, completely displaced fractures
with side-to-side displacement of one full shaft
width and shortening of 1–2 cm can (after con-
Fig. 18.8 Limits of “spontaneous corrections” in the 왘
proximal humerus. The patient is a 12-year-old girl with
a subcapital fracture of the humerus in the presence of
open growth plates. The fracture was immobilized for
three weeks in a Gilchrist dressing and healed with a varus axial deviation and posterior bowing of 30⬚ each. At
the follow-up examination one year later, a slight anterior bowing deformity was clinically visible. The radiograph shows complete correction of the varus component (a), whereas the anterior bowing has grown out
distally but remained unchanged at about 20⬚ (b). The
growth plates are nearly closed so that no further correction by growth may be expected
Injuries to the Shoulder Girdle and Humeral Shaft
a
b
105
106
Specific Injuries—Upper Extremities
Fig. 18.9 Limits of “spontaneous corrections” in the
proximal humerus. The patient is a four-year-old girl
with a subcapital fracture of the proximal humeral shaft.
The fracture exhibited over 50⬚ of valgus displacement.
Closed reduction was attempted, which successfully diminished the valgus deformity to 40⬚. The fracture then
healed in this position. At the follow-up examination 14
years later, the growth plates were closed. Clinical find-
ings included a significant cosmetic valgus deformity in
the middle and distal portion of the previously fractured
humerus. Radiographic examination revealed only partial “spontaneous correction” of the axial deviation from
40⬚ at reduction to 20⬚ at follow-up. Both shoulders and
elbows exhibited unrestricted and symmetrical function. (See also Fig. 11.5 a, b)
Injuries to the Shoulder Girdle and Humeral Shaft
Fig. 18.10 Growth disturbance of premature closure of
the growth plate secondary to a separated epiphysis.
The patient is a 17-year-old boy in whom premature closure of the right proximal humeral growth plate produced severe abnormal growth with a varus deformity
and shortening. The diagnosis of congenital humerus
varus was excluded by findings of an enormous callus in
107
the proximal humerus on a chest radiograph obtained
on the 42nd day of life (upper left) and by the fact that
only this child, one of two identical twins (upper photo),
exhibited this deformity. The opening valgus osteotomy
performed at age 17 to eliminate the varus deformity
improved mobility in the shoulder but was unable to restore completely normal motion
Fig. 18.11 Conservative treatment of a proximal humeral fracture
with angulation up to age 12. The initial angulation was left uncorrected without reduction in this nine-year-old boy. The fracture was initially treated conservatively without any reduction and immobilized in a
Desault dressing and plaster cast. The fracture healed with an axial deviation of 35⬚ in the coronal plane and 40⬚ in the sagittal plane. By the time of the follow-up examination 12 years later, the axial deviation had
grown out in both planes; both sides were symmetrical
108
Specific Injuries—Upper Extremities
Injuries to the Shoulder Girdle and Humeral Shaft
109
Fig. 18.12 Conservative treatment of completely
displaced subcapital fractures of the humerus up to
the age 12. The patient is a four-year-old girl with a completely displaced subcapital fracture of the humerus.
Whether this fracture should be allowed to heal in this
position or whether reduction under anesthesia should
be attempted is up to the discretion of the physician in
consultation with the parents. In the latter case, reduction should be closed and performed under general
anesthesia. In consideration of the patient’s age, the
fragments were left in correct axial alignment without
internal fixation; the fracture was immobilized for three
weeks in a Desault dressing with a plaster cast. After removal of the cast, the consolidation radiograph showed
periosteal bridging of the fracture in proper axial
alignment with side-to-side displacement of half a shaft
width. After consolidation, spontaneous motion was begun. Three weeks after consolidation, the patient was
free of symptoms, and both shoulders exhibited full,
symmetrical mobility
sulting with the parents) be treated conservatively without anesthesia with immobilization in
a Desault dressing and a plaster cast. This does not
have any negative effect on the clinical course or
prognosis (Fig. 18.13).
After age 12, primary or secondary deformities in the coronal (varus displacement) and sagittal planes of up to 30⬚ or 40⬚ at most may be left
uncorrected (Fig. 18.14). Completely displaced
fractures are reduced closed to limit the severity
of the deformity to a level that is tolerable for the
patient’s age.
We regard unstable fractures in patients over
age 12 and fractures in adolescents shortly before
closure of the proximal humeral growth plate as
an indication for eliminating any deformity and
an indication for definitive stabilization of the
fracture position, as other authors do (36). This
can be achieved with one to two Kirschner wires
inserted percutaneously from distal to proximal
(Fig. 18.15). However, this is usually far easier said
than done. It is simpler to achieve fixation with
two dynamic intramedullary nails inserted from
110
Specific Injuries—Upper Extremities
Fig. 18.13 Conservative treatment of completely
displaced subcapital fractures of the humerus up to
the age 12. The patient is a four-year-old boy with a
completely displaced transverse fracture of the humerus in proper axial alignment with a shortening deformity. After consultation with patient and his parents, it was
decided to leave the fracture as it was, and the injury was
immobilized for three weeks in a Desault dressing with a
plaster cast. Three weeks later, the fracture was clinically
and radiographically well healed (a), and the patient was
able to resume spontaneous motion. After another two
weeks, both shoulders exhibited full, symmetrical mobility. One year later, the radiographic follow-up study
showed that the side-to-side displacement had been
largely eliminated by remodeling (b). The arm exhibited
no cosmetic impairments and both shoulders and elbows exhibited symmetrical unrestricted function
the lateral epicondyle (Fig. 18.16). The nails are
then advanced through the growth plate into the
epiphysis. In open growth plates, damage to the
growth plate need not be feared. Whereas percutaneous pinning with Kirschner wires requires
additional immobilization in a Desault dressing,
the dynamic intramedullary nailing permits a regime of spontaneous motion.
We see an indication for open reduction only
where soft tissue is interposed, such as an inter-
posed biceps tendon in a separated epiphysis. The
proximal humerus is exposed through an anterior
approach in the anterior margin of the deltoid.
Once the interposed tissue has been removed and
any soft-tissue injury repaired, the fracture is
fixed with percutaneous Kirschner wires, which
we shorten—as in any percutaneous pinning with
Kirschner wires (see General Science, Treatment,
and Clinical Considerations)—to about 2 cm above
the level of the skin so that we can remove them
Fig. 18.14 Primary therapy of a proximal humeral fracture with angulation
after the age of 12. The initial angulation was left uncorrected without reduction
in this 13-year-old boy. The proximal shaft fracture was treated conservatively in a
Desault dressing with a plaster cast without reduction. The fracture healed with an
axial deviation of 45⬚ in the coronal plane with proper axial alignment in the sagit-
tal plane. During the further clinical course of the injury, the axial deviation grew
distally away from the proximal humeral epiphysis, reducing the original deformity. One year later, the radiograph showed that the deformity had been largely corrected. By this time, the clinical deformity had disappeared. Function was unrestricted
Injuries to the Shoulder Girdle and Humeral Shaft
111
112
Specific Injuries—Upper Extremities
Fig. 18.15 Treatment of an irreducible humeral
fracture sustained shortly before cessation of
growth. The patient is a 12-year-old girl with a completely displaced subcapital fracture of the humerus.
Closed reduction with the patient under general anesthesia was unsuccessful due to interposed soft tissue.
Therefore, open reduction was performed through an
anterior approach. The long biceps tendon was found to
be interposed; once the tendon was displaced, the
fracture was easily reduced and fixed by percutaneous
pinning with two crossed Kirschner wires. These wires
were removed after three weeks when the fracture healed. The patient then began spontaneous motion exercises and after four weeks was able to freely move both
shoulders symmetrically. At the follow-up examination
seven months later, the patient remained free of symptoms and the growth plates were open without any signs
of a growth disturbance. Treatment was concluded
later without any additional measures (remember to leave an opening in the cast around the
wires).
We do not use an abduction splint as it provides poor fracture stabilization and is inconvenient for the patient in public transportation
and in bed, nor do we use traction because of the
unnecessarily long hospitalization it requires.
When in doubt, we use Kirschner wires or—better
still—intramedullary nails for primary fixation.
this dressing to prevent the elastic windings from
slipping. If this bandage interferes with breathing,
then the chest side opposite the fracture can be
completely cut open without endangering the
position or fixation of the fracture.
It is also possible to immobilize stable fractures in a Gilchrist bandage alone (Fig. 18.18).
Patients usually subjectively feel that the Desault
dressing in a plaster cast provides more reliable
immobilization with better pain relief. When in
doubt, ask the patient.
Immobilization is maintained for up to a maximum of three weeks in all age groups. Radiographs in plaster to verify correct position are not
required, and there is no need whatsoever for a
radiograph out of plaster to document consolidation. We obtain consolidation radiographs in consultation with the patient and his or her parents
only in the case of reduced fractures and fractures
with uncorrected axial deviation. With nondisplaced stable fractures, we dispense with consolidation radiographs as a matter of course and
diagnose consolidation of the fracture based on
the presence of a painless fixation callus. Then the
Immobilization and Consolidation
The “hanging cast” is inconvenient for the patient,
painful, and totally inefficient from a medical
standpoint.
For this reason, we fix all conservatively
treated fractures in all age groups in Desault or
Velpeau dressings with plaster casts (Fig. 18.17).
We include padding at the axilla, elbow, and
wrist, using elastic bandages to produce the usual
windings. The bandage is also wound over the
contralateral shoulder to produce a support strap.
We then wind two or three plaster bandages over
Injuries to the Shoulder Girdle and Humeral Shaft
Fig. 18.16 Treatment of a displaced fracture of the
proximal humerus in an adolescent. The patient is a
14-year-old boy with a displaced separated proximal humeral epiphysis in the presence of premature growth
plates. Closed reduction was performed, and the fracture was stabilized with two intramedullary nails. One
nail was introduced from the epicondyle and the other
113
from the deltoid tuberosity. Both nails could just as well
have been introduced from the epicondyle. The patient
began spontaneous motion immediately postoperatively. The metal implants were removed after five weeks, at
which time the fracture had solidly healed and both
shoulders exhibited symmetrical unrestricted mobility
114
Specific Injuries—Upper Extremities
Fig. 18.17 Desault dressing in plaster cast. The
dressing is applied in the usual manner and then a plaster bandage is applied on top of it to prevent the elastic
bandages from slipping. The “strap” over the contralateral shoulder prevents the cast from slipping down over
the injured shoulder
patient begins spontaneous mobilization as
tolerated on his or her own.
Sports Participation and Follow-up
Examinations
Participation in sports can usually be resumed
about two to three weeks after mobilization has
begun if mobility is unrestricted and symmetrical.
The patient’s wishes should be respected. Where
mobility remains severely restricted four weeks
after consolidation, then this should be addressed
by aftercare in the form of physical therapy, especially in the case of older adolescents. Treatment may be concluded once the patient has resumed sports participation without any complaints, unrestricted symmetrical function has
been restored, and the injury has healed without
any clinically visible deformity. Presence of an expected minor posttraumatic length difference of
slightly less than 1 cm does not justify any further
follow-up examinations. Growth disturbances in
the form of premature closure of the growth plate
following separation of the epiphysis are rare, occurring in only 0.4% of our study group, and do not
justify systematic follow-up examinations of all of
these fractures either (31). Kirschner wires are removed once the fracture has healed; intramedullary implants are removed once free function has
been achieved, i.e., 6–10 weeks after the accident.
Birth Trauma
See Chapter 28 in the Appendix, p. 445.
Injuries to the Shoulder Girdle and Humeral Shaft
Fig. 18.18 Gilchrist bandage. The Gilchrist bandage
consists of a gauze stocking with transverse cuts at the
wrist and shoulder. The stocking is pulled over the arm,
and the ends are passed back around the neck and
around the chest to the hand and upper arm, respective-
115
ly. Patients find it more comfortable to have the sling
around the neck and arm padded with foam rubber. The
bandage provides a simple method of preventing abduction, elevation, and external rotation of the upper
arm
116
Specific Injuries—Upper Extremities
Humeral Diaphysis (0.6%)
Forms
앫 Oblique fractures.
앫 Transverse fractures.
Conservative fixation technique
앫 Initially with a Desault dressing,
앫 Sarmiento brace.
A-P and lateral radiographs
Internal fixation technique
앫 Transverse fractures: Intramedullary nailing.
앫 Oblique and comminuted fractures: External
fixator.
Limits of correction
앫 Side-to-side displacement of up to one full shaft
width with associated shortening,
앫 No varus, valgus, anterior bowing, or posterior
bowing exceeding 10⬚.
Definition of “nondisplaced”: Side-to-side displacement of over one full shaft width; varus, valgus,
anterior bowing, or posterior bowing up to 10⬚.
Aftercare
Period of immobilization
앫 With conservative fixation: Four to five weeks.
앫 With internal fixation: Immediate spontaneous
motion.
Consolidation radiographs: Yes.
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Medical.
앫 Where indication is uncertain: Immobilization in a bandage.
Emergency treatment under anesthesia: Distal
circulatory disruption.
Cave
Radial nerve palsy with motor and sensory deficits
does not per se represent an indication for primary
surgical repair.
!
All other indications should first be discussed at
length with the patient and his or her parents.
Further treatment without anesthesia or delayed
treatment under anesthesia
앫 Completely displaced and shortened fractures,
앫 Fractures with aligned fragments and fractures with angulation (varus, valgus, etc. exceeding 10⬚).
Initial mobilization: Immediate spontaneous mobilization upon clinical and radiographic consolidation
of the fracture.
Physical therapy: None.
Sports: Three to four weeks after consolidation.
Removal of metal implants: External fixator is removed immediately upon consolidation; intramedullary nails are removed 8–10 weeks postoperatively.
Follow-up examinations and conclusion of treatment
앫 When unrestricted function of shoulder and
elbow is achieved,
앫 When fracture heals without deformity,
앫 Any intervention to restore radial nerve function
is performed secondary to initial treatment after
consolidation.
Injuries to the Shoulder Girdle and Humeral Shaft
Fractures in the Middle Third of
the Humeral Shaft
Shaft fractures in the middle third of the humerus
are extremely rare, accounting for only 0.6% of all
pediatric fractures (11).
Growth disturbances are not to be expected.
Slight posttraumatic length differences are of no
clinical importance.
Side-to-side displacement is well compensated for within the usual limits during further
growth. Of the axial deviations, varus deformities
are better compensated for than valgus, as is true
in the rest of the skeleton as well. The exact limits
of correction are not known. As in the skeleton as
a whole, corrections depend significantly on age.
For this reason, no axial deviations in the coronal
and sagittal planes exceeding 10⬚ should be left
untreated.
Fig. 18.19 Treatment of a humeral shaft fracture.
The patient is a 14-year-old boy with a slightly displaced
oblique fracture of the humeral shaft with a spiral wedge. Complete sensory and motor radial nerve palsy was
present at the onset of treatment. The fracture was immobilized in a Desault dressing in plaster cast for four
weeks, and the patient was maintained on pain medication. The interim examination after two weeks revealed
117
Injuries to the radial nerve can occur in fractures at the junction of the middle and distal
thirds of the bone.
Treatment
Shaft fractures are treated conservatively as matter of course (Fig. 18.19). After the patient has received pain medication, gentle axial traction is
applied to the elbow, padding is placed under the
axilla and elbow, and a Desault or Velpeau dressing is initially applied. We have completely abandoned the use of a hanging cast. This is because
even in adolescents with transverse fractures,
side-to-side displacement of a full shaft width
and 1–2 cm of shortening may be tolerated
without any problems where the fragments are
otherwise in proper axial alignment.
slight signs of sensory regeneration. After three
months, the nerve had regained full sensory and motor
function. The patient began spontaneous motion exercises after removal of the plaster cast – 4 weeks after accident – without physical therapy. Unrestricted mobility
in the shoulder and elbow was regained within six weeks
of consolidation
118
Specific Injuries—Upper Extremities
After four to six days, we have a Sarmiento
brace manufactured, which we apply after removing the Desault dressing (14, 32; Fig. 18.20).
Then the patient may begin to spontaneously mobilize his or her shoulder and elbow. Eight to 10
days after the accident, we obtain radiographs to
evaluate the position of the fracture in the brace.
Where the position is tolerable for the patient’s
age group, we leave the brace in place until the
fracture heals.
Reduction with the patient under general anesthesia may be indicated as a primary or secondary procedure for one of these reasons:
앫 To treat additional soft-tissue injuries,
앫 Because of an intolerable axial deviation that
has occurred in the brace,
앫 Because the patient or his or her parents do
not want to tolerate side-to-side displacement of one full shaft width for cosmetic reasons.
Today, we feel that stable, definitive fixation of the
fracture must be achieved in such cases. Here, too,
we regard dynamic intramedullary nailing as the
method of choice for transverse fractures. It is
preferable to plate fixation in that it allows closed
reduction and there is less risk associated with
the removal of the metal implants. Here, as in the
nailing of the subcapital and proximal humeral
fractures, the procedure involves introducing two
nails from the lateral aspect of the bone slightly
superior to the lateral epicondyle (see Fig. 18.16).
All oblique and unstable comminuted fractures should be treated with an external fixator in
the interest of achieving rigid fixation that allows
immediate motion (1, 7, 25; Fig. 18.21).
An initial radial nerve deficit does not per se
represent an indication for open reduction and internal fixation (Fig. 18.19). If the palsy remains
completely unchanged three to four weeks after
initial treatment, then—once the fracture has consolidated—secondary intervention to restore
radial nerve function is indicated.
An x-ray out of plaster is obtained for radiographic evaluation of healing three to five weeks
after the accident. If the clinical examination confirms that the callus visible on the radiograph is
no longer tender to palpation, then the patient
may begin with spontaneous motion exercises for
the next three weeks and essentially no longer requires a bandage. Where spontaneous mobilization of the shoulder and elbow is delayed beyond
the first six weeks, which may occur especially in
older adolescents, aftercare in the form of physical therapy is indicated.
Removal of Metal Implants
Metal implants are removed immediately upon
consolidation in the case of an external fixator. Intramedullary nails are removed 8–12 weeks after
the accident with the patient anesthetized.
Sports Participation and Follow-up
Examinations
Fig. 18.20 Functional bracing of humeral shaft
fractures. Humeral shaft fractures are best managed by
functional treatment in a Sarmiento brace. Under this
treatment, the fracture will assume proper axial
alignment. The brace itself can be tightened as necessary according to muscle atrophy
In general, full mobility in the joints adjacent to the
injury may be expected to be achieved about three
to six weeks after full use is allowed, at which time
the patient will be fully able to resume sports.
Treatment may be concluded once the patient has
been able to resume unrestricted sports participation without any complaints and without any clinical or cosmetic defects, and the adjacent joints
have regained their full unrestricted function.
Injuries to the Shoulder Girdle and Humeral Shaft
Fig. 18.21 Treatment of an unstable humeral shaft
fracture with an external fixator. The patient is a 13year-old girl with an unstable shaft fracture at the junction between the middle and distal thirds of the humerus. Given the instability of the fracture, the patient, parents, and physician jointly decided that surgical stabilization with an external fixator was indicated for two reasons. First, this was an unfavorable location for conservative functional treatment, and second, the patient
Most Common Posttraumatic
Deformities of the Proximal
and Middle Humerus
As in the entire immature skeleton, we find that
growth disturbances are responsible for posttraumatic deformities adjacent to the joints, whereas
shaft deformities are attributable to uncorrected
axial deviations in which there has been only partial “spontaneous correction” or none at all.
Proximal
Visible cosmetic impairments resulting from an
untreated deformity (generally a varus deformity)
in the proximal humerus are rare and should be
clinically examined every six months until the
disorder has subjectively and objectively disap-
119
was determined not to ruin her summer vacation. During the consolidation phase, the patient spent her vacation at the seaside and even went swimming. After a total of four weeks, the fracture was consolidated and stable, and the external fixator was removed. The zones of
lysis around the proximal screws are attributable of the
patient’s vacation activity; there was no clinical evidence
of infection
peared. If a significant cosmetic deformity remains after one year (generally a valgus deformity), new radiographs may be obtained to document the slow decrease in the severity of the deformity.
Wherever possible, surgical correction of residual axial deviations should be postponed until
after growth has ceased in order to take full advantage of all natural corrective forces. Surgical
correction is only definitely indicated in the case
of functional deficits. However, this is usually only
the case where growth disturbances are present
(generally a varus deformity or shortening greater
than 3 cm).
Treatments for the sequelae of growth disturbances include valgus opening osteotomies (8)
and, in applicable cases, lengthening osteotomies.
Here too, such procedures are indicated only
120
Specific Injuries—Upper Extremities
where the deformity results in functional impairments. This is only the case with extreme varus
deformities. From the standpoint of function,
shortening that is not accompanied by axial deviation does not represent an indication for
surgery even where the length difference exceeds
3 cm. Corrective procedures should be performed
only at the patient’s request as the indication is
relative and depends solely on the patient’s subjective symptoms. Even in the case of severe
functional impairments due to a varus deformity,
individual patients’ subjective evaluations will
vary greatly. Only a few patients are willing to undergo corrective osteotomy, especially when they
are aware that a corrective osteotomy will not always be able to completely eliminate the
functional impairment (see Fig. 18.10).
Middle
Untreated axial deviations that grow distally out
of the proximal region rarely require correction,
as growth will at least significantly diminish their
severity (see Fig. 18.14). More serious are untreated axial deviations directly in the middle of
the shaft, especially varus and valgus deformities,
as these are practically not corrected at all by
further growth. Posterior and anterior bowing are
less important from a cosmetic standpoint and
are also better corrected “spontaneously.” Such
deformities do not result in functional impairments. These are invariably cosmetically unsightly deformities. The patient should always decide if and therefore when correction is indicated.
The correction technique involves a transverse
osteotomy, which is stabilized with an external
fixator from lateral. Correction of the deformity
can be performed as a shortening procedure immediately after removal of a wedge of the proper
size, or as an opening osteotomy with distraction
of the callus in case of a varus deformity (see also
Most common posttraumatic deformities of the
ankle, p. 430, see Fig. 25.44 c and 25.45). Length
differences of 1–3 cm in the humerus (whether
preexisting or created by the procedure) have essentially no clinical effect. Despite this, the
patient should be informed about iatrogenic
shortening or length increase, respectively.
Overview
Most Common Deformities of the
Proximal and Middle Humerus
앫 Varus deformity (with impaired abduction)
앫 Shortening (⬎ 3–5 cm).
앫 Valgus deformity and posterior or anterior
bowing (rare).
Causes
앫 Growth arrest: Proximal varus deformity and
shortening.
앫 Uncorrected axial deviation: Middle varus deformity (rare), posterior or anterior bowing,
proximal and middle valgus deformity.
Indication for correction
앫 Shoulder abduction deficit exceeding 30⬚,
앫 Cosmetic impairment due to shortening (unimportant from a functional standpoint),
앫 Unsightly cosmetic effect on the axis of the
elbow.
Time of correction: If possible after cessation
of growth; however, this depends on the patient’s
tolerance of the affliction.
Surgical technique
앫 Proximal: Closing or opening osteotomy and
stabilization with fracture plate, Kirschner wire,
or external fixator,
앫 Middle: Distraction osteotomy with external fixator,
앫 Middle: Opening distraction or shortening
osteotomy and fixation with external fixator.
Shoulder Dislocation
Shoulder dislocations replace fractures of the
proximal humerus after closure of the growth
plates and are therefore essentially adult injuries.
However, isolated dislocations are observed in the
presence of open growth plates (35). Note that
physiological closure of the proximal humeral
growth plate occurs between age 14 and
17. Therefore, a radiograph should invariably be
obtained prior to any initial attempt at manipulation, regardless of the patient’s age, to exclude a
fracture or associated bony injury.
Associated soft-tissue injuries in the setting of
isolated dislocations are extremely rare. These
can result in axillary nerve palsy (12).
If the injury is a dislocation, it should be reduced as soon as possible. We have found Hippocrates’ method of reduction to be best. If reduc-
Injuries to the Shoulder Girdle and Humeral Shaft
tion is not immediately successful, then we apply
Kocher’s method. The results of the reduction
must be documented in radiographs.
Where the reduction radiographs show no
visible associated bony injuries, we immobilize
the injury for three weeks in a Gilchrist bandage.
Nondisplaced associated bony injuries, such as a
fractured rim of the glenoid fossa, fracture of the
greater tubercle of the humerus, or fracture of the
coracoid process, have no effect on this procedure. Displaced injuries of this type would have
been visible on the initial radiographs, and would
have represented an indication for a surgical procedure.
In subsequent chronic recurrent dislocations,
reconstruction and refixation of the cartilaginous
glenoid labrum as described by Bankart is recommended. In applicable cases, this may be combined with tightening of the subscapularis tendon
as described by Putti-Platt (5).
Patients may resume sports participation
once unrestricted mobility has been restored.
Systematic follow-up examinations are not required if sports can be resumed without any complaints. However, treatment should only be concluded after one year, as chronic recurrent dislocations can result from injuries to the anterior
fossa and capsular regions that often escape
radiographic detection.
121
Given the good prognosis for these injuries,
scapular fractures should be managed with conservative functional treatment. The shoulder is
initially immobilized in a Gilchrist bandage (see
Fig. 18.18), which should be replaced at an early
stage by functional aftercare with spontaneous
motion, especially in the case of comminuted
fractures of the body of the scapula.
Open reduction and internal fixation are indicated only with significantly displaced subcoracoid or corporal glenoid fractures. The fracture
should be stabilized with a screw to immediately
allow functional aftercare.
Once unrestricted mobility is regained, the
patient may resume sports and play activities as
before the accident. Treatment may be concluded
when the patient has pursued his or her usual activities without any complaints for four to six
weeks. Any metal implants that may have been
placed in surgical treatment should be removed
after about 8–12 weeks.
Scapular Fractures
Scapular fractures are extremely rare (9, 24); here
we must differentiate between glenoid, acromial,
spinal, and corporal fractures (Fig. 18.22). The
subcoracoid glenoid fractures basically correspond to pseudodislocations of the lateral
clavicle, except that the fracture line lies caudal to
the coracoclavicular ligaments as opposed to
cranial to them. Acromial fractures can occasionally be distinguished from aseptic necrosis of
the multifocal acromial ossification centers only
on the basis of clinical findings. Coracoid fractures
can be mistaken for the coracoid and subcoracoid
growth plates.
Fractures of the scapula are difficult to visualize in radiographs; often this is only possible in
tangential views or in the oblique views described
by Bottom (30).
Complications secondary to such fractures are
rarely described. Occasionally, deformities of the
blade of the scapula can occur, which can conceivably lead to functional impairments if they lie on
the costal aspect of the bone.
Fig. 18.22 Forms of scapular fractures (see text). a
acromial fractures, co coracoid fractures, g1 glenoid
subcoracoid fractures, g2 glenoid corporal fractures,
cr corporal fractures
122
19
Elbow Injuries
Diagnostic Notes
We distinguish between injuries to the distal
humerus and injuries to the proximal forearm
bones. In the distal humerus, we differentiate extraarticular injuries in the form of supracondylar
and epicondylar fractures from intraarticular injuries in the form of transcondylar fractures
(Figs. 19.1, 19.2). In the forearm, we find fractures
of the proximal end of the radius and fractures of
the proximal end of the ulna or olecranon
(Fig. 19.3).
Fig. 19.1 Extraarticular fractures of the distal humerus. Supracondylar fractures (left); epicondylar fractures
(right)
Dislocations and combined injuries may also
occur. We may encounter the elbow dislocation in
the strict sense usually as a posterolateral dislocation with or without associated injuries, the isolated dislocation of the radial head (see Fig. 19.4),
and the traumatic “subluxation” of the radial head
known as “nursemaid’s elbow.” The combined injuries of the Monteggia fracture-dislocation must
not be overlooked.
These injuries appear in order of decreasing
incidence by (47, 58, 65):
Fig. 19.3 Elbow fractures of the proximal forearm
bones. Fractures of the proximal radius (left); fractures
of the proximal ulna (olecranon; right)
Fig. 19.2 Intraarticular
fractures of the distal humerus. Fracture of the lateral condyle of the humerus
(left). Fracture of the medial
condyle of the humerus
(center). Transcondylar Y
fracture (right)
Elbow Injuries
Fig. 19.4 Dislocations in the elbow region. Dislocation of the radial head (left); elbow dislocation (right)
앫 Supracondylar fractures
앫 Transcondylar fractures of the distal humerus
앫
앫
앫
앫
앫
and fractures of the proximal radius
Elbow dislocations
Epicondylar avulsions
Olecranon fractures
Monteggia fracture-dislocations
Isolated dislocations of the radial head
The age-dependent variation in the trade-off between ligament stability and bone strength in response to trauma is particularly apparent in the
elbow. During the age of actual growth up to age
7–10, we encounter frank fractures and infraction
fractures far more frequently, even if they cannot
initially be visualized on radiographs. The unequivocal clinical symptoms of swelling and the
severe pain invariably suggest a bony injury in
this age group. Elbow dislocations are extremely
rare in this age group. It is only beyond this age
bracket that elbow dislocations occur, which is indicative of increasing bone strength at the expense of ligament stability. This rule does not
apply to dislocations of the radial head (isolated
or in combination with other injuries), which can
also occur even in children with wide open
growth plates.
The numerous ossification centers, which appear at different tines and fuse with each other at
different times, are confusing in a diagnostic setting because they can often be mistakenly inter-
123
preted as fractures or intraarticular loose bodies.
For this reason, we have included images of the
ossification centers in Figure 19.5 a,b.
Especially in the case of the elbow, we again
emphasize that comparative radiographs of the
contralateral side cannot compensate for deficient knowledge of the radiological anatomy of
the elbow. The following observations, reference
lines, and measurements can help the examiner
arrive at the right diagnosis or determine correct
position from a unilateral radiograph:
앫 The correct relationship between the proximal end of the radius and the capitellum of the
humerus (Fig. 19.6 a,b),
앫 Recognizing a fracture of the lateral condyle
(Fig. 19.7) and differentiating it from supracondylar fractures (Fig. 19.8),
앫 Recognizing a gross rotational deformity in
the setting of a supracondylar fracture of the
humerus (Fig. 19.9),
앫 Recognizing a discrete rotational deformity in
the setting of a supracondylar fracture of the
humerus (Fig. 19.10),
앫 The malrotation quotient (Fig. 19.11),
앫 The Baumann angle (Fig. 19.12),
앫 The Rogers line (Fig. 19.13),
앫 The secondary diagnostic examination
(Fig. 19.14),
앫 The elbow axis angle (Fig. 19.15),
앫 The epiphyseal axis angle (Fig. 19.16).
124
Specific Injuries—Upper Extremities
Fig. 19.5 Ossification centers in the elbow region.
The time at which the different ossification centers appear and fuse with each
other varies greatly in the
elbow and depends on each
patient’s sex and individual
development.
(See Legend on the next
page)
a
b
Elbow Injuries
125
Fig. 19.6 a, b Relationship
between the proximal end
of the radius and the capitellum of the humerus.
Note: In every radiographic
study of the elbow in two
planes, the axis of the proximal end of the radius must
always (even in oblique
views) be centered on the
ossification center of the
capitellum of the humerus in
every plane (a). Where this is
not the case in one of the
two imaging planes, a dislocation of the radial head is
present (b)
a
b
왗 Abb.19.5 Continue
a Four-year-old girl (left). The ossification center of the
capitellum of the humerus is fully formed. The wide
posterior opening of the growth plate in the lateral
view between the capitellum of the humerus and the
humeral shaft is physiological. The ossification centers
of the medial epicondyle of the humerus and radial head are barely visible. These centers nearly always appear at the same time. Nine-year-old boy (center). The ossification centers of the capitellum of the humerus, the
radial head, and the medial epicondyle (projected posteriorly in the distal humerus in the lateral image) are
fully formed. A small trochlear ossification center is barely visible, projected on the capitellum of the humerus in the lateral image. Nine-year-old girl (right). The
images show the fully formed ossification centers of
the capitellum of the humerus, radial head, medial epicondyle, and here even the olecranon and trochlea.
The ossification center of the medial epicondyle is visible in the lateral image in the posterior shaft region;
the trochlear centers are projected on the growth plate
b Thirteen-year-old boy (left). In addition to the existing
ossification centers, the center of the lateral epicondyle is barely visible. In the lateral image, the trochlear
ossification centers are seen to project into the capitellum of the humerus. Fifteen-year-old boy (center).
The fully formed center of the lateral epicondyle has
now joined the other ossification centers, which still
appear completely isolated. Eleven-year-old girl
(right). The trochlear centers have completely fused
with each other and with the metaphysis. The ossification centers of the medial epicondyle and the radial
head still appear isolated (they are the last centers to
fuse). The centers of the lateral epicondyle and olecranon are also visible
126
Specific Injuries—Upper Extremities
Fig. 19.7 Diagnosing the
nondisplaced fracture of
the lateral condyle of the
humerus. Note: Where there
is any visible radiographic or
clinical swelling on the lateral (radial) aspect of the elbow, the lateral cortex of the
humerus must be carefully
inspected for subcortical disruption. Such findings suggest a nondisplaced fracture
of the lateral condyle of the
humerus. Therefore, the
examiner must inspect the
lateral image for a fracture
gap leading from the posterior metaphysis toward the
growth plate in the anterior
portion (see also Fig. 19.8,
left)
Condylar
Supracondylar
Fig. 19.8 Differentiating
supracondylar fractures
from transcondylar fractures. The course of the
fracture gap in the lateral
image plays an essential role
in differentiating nondisplaced or slightly displaced supracondylar fractures from
transcondylar fractures. The
fracture gap courses from
posterior and proximal to anterior and distal. The anterior
endpoint of the fracture gap
lies superior to the growth
plate in supracondylar extension fractures (right) and
within the growth plate gap
in transcondylar fractures
(left), especially in fractures
of the lateral condyle
Elbow Injuries
Fig. 19.9 Recognizing a gross rotational deformity
in the setting of a supracondylar fracture of the humerus. Malrotation in an acute supracondylar fracture
of the humerus is not clinically measurable. It can only
127
be identified indirectly on the lateral radiograph as a discrepancy between the widths of the proximal and distal
fragments (see also Figs. 19.23, 19.26)
Fig. 19.10 Recognizing a
discrete rotational deformity in the setting of a supracondylar fracture of the
humerus. As we have also
demonstrated in a model
(95, 135), discreet malrotation of about 20⬚ can be obscured in the ulnoradial lateral radiograph by the lateral
condyle (left). This deformity
is only visible in the radioulnar lateral view (right).
Therefore, the lateral radiograph should always be obtained as a radioulnar projection when a supracondylar fracture is to be evaluated
for possible rotational deformity
128
Specific Injuries—Upper Extremities
움
42
mm
15
mm
MQ = 15 ÷ 42 = 0.35
Fig. 19.11 The malrotation quotient (MQ; 124) is not
a measurement commonly used in daily practice.
However, it can be helpful in evaluating rotational deformity in reduction radiographs of supracondylar fractures
where the question is whether the degree of existing
malrotation is tolerable with respect to the axis of the elbow or whether the fracture should be reduced again.
Where the malrotation quotient is less than 0.1, no clinically significant alteration of the elbow axis is to be expected. Any rotational deformity with an MQ exceeding
0.1 should be rigorously eliminated
Normal
Extension
90°– 움 – 5° 앑 elbow axis
Fig. 19.12 Baumann angle. The Baumann angle (4) is
used for obtaining indirect measurements of the elbow
axis where the type of immobilization prevents extension of the elbow for evaluation of the axis. This measurement requires precise positioning with the central ray
aimed precisely at the distal end of the humerus, which
lies flat on the plate
Flexion
Fig. 19.13 The Rogers line.
Nearly nondisplaced supracondylar fractures can be easily overlooked. The Rogers
line in the lateral radiograph
(93) facilitates the diagnosis
of these injuries. Because of
the physiological tilt of the
capitellum of the humerus of
about 30–40⬚ with respect
to the shaft, the line marking
the anterior humeral cortex
normally intersects the capitellum at the junction between its middle and posterior thirds (left). In slightly
displaced extension fractures, the point of intersection lies in the anterior portion of the capitellum or anterior to it (center). In the
rare slightly displaced flexion
fractures, the line passes
through the posterior third
of the capitellum or lies posterior to it (right)
Elbow Injuries
Fig. 19.14 Secondary diagnostic radiography. The
patient is a six-year-old boy with pain in the elbow after
falling on his hand. There was no clearly identifiable
fracture on the initial radiograph. Only the point of intersection of the Rogers line would suggest a supracondylar extension fracture. Because of the clinical symptoms
present, the elbow was immobilized in an upper-arm
plaster splint. After 12 days, the elbow was no longer
tender to palpation. The follow-up radiographs obtained
at this time show slight periosteal callus formation indi-
129
cative of a consolidated supracondylar fracture. However, periosteal plates such as these can also occur physiologically as plates for muscular insertions. They may
only be interpreted as signs of a healed fracture where
they first appear on the secondary radiographs and not
in the initial images. For this reason, the examiner may
only rely on secondary diagnostic radiographs where initial studies have excluded a dislocation of the radial head
and a fracture of the lateral condyle of the humerus (in
the lateral radiograph)
130
Specific Injuries—Upper Extremities
Fig. 19.15 Elbow axis angle. The elbow axis angle is
only measurable in clinical and radiographic examinations in the absence of an extension deficit. This means
the elbow must be able to be placed in the neutral (zero)
position in maximum supination. Where this is not possible, this method of evaluating the axis may not be used
because an extension deficit invariably mimics extreme
valgus deformity of the elbow axis
Fig. 19.16 Epiphyseal axis angle and side-to-side
displacement. The severity of displacement in fractures
of the proximal end of the radius is best evaluated by
measuring the epiphyseal axis angle. Side-to-side displacement is specified in half and quarter shaft widths
1 S= 1/2 shaft width
!
The primary purpose of radiographs of the elbow
is to exclude the following disorders:
앫 A nondisplaced fracture of the lateral condyle
of the humerus,
앫 A dislocation of the radial head,
앫 Rotational deformity in the setting of a supracondylar fracture.
These injuries cannot be seen on the contralateral side. Therefore, radiographs of the child’s
contralateral elbow should not be obtained to diagnose acute fractures.
Elbow Injuries
131
Supracondylar Humerus (6.5%)
Forms
앫 Nondisplaced (stable).
앫 Displaced in one plane (anterior or posterior
bowing; stable and imminently unstable).
앫 Displaced in two planes (anterior or posterior
bowing, rotational deformity, or side-to-side displacement in the coronal plane; unstable).
앫 Displaced in three planes (anterior or posterior
bowing, rotational deformity, and side-to-side
displacement; unstable).
Anteroposterior (A-P) and lateral radiographs.
Caution: Note the rotational spur in the lateral radiograph (see text).
Limits of correction
앫 No axial displacement in the coronal plane.
앫 Up to age six: Anterior bowing (distal fragment in
extension) up to 20⬚.
Definition of “nondisplaced“
앫 Up to age five to six: Anterior bowing up to
20–30⬚; valgus up to 10⬚.
앫 Beyond age five to six: No axial deviation.
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Medical.
앫 Where indication is uncertain: Immobilization
in a Blount sling or upper-arm plaster splint.
Emergency
treatment
under
anesthesia:
Completely displaced type III and IV fractures
with and without associated injuries.
!
Further treatment without anesthesia or delayed
treatment under anesthesia
앫 Type II at the age of five to six: Anterior
bowing (distal fragment in extension) may be
left uncorrected after obtaining parents’ informed consent.
앫 Type II (imminently unstable), if eliminating
the anterior bowing (Blount sling) produces a
secondary rotational deformity (type II becomes type III).
Technique of conservative fixation
앫 Upper-arm plaster splint (type I and type II b
with slight posterior bowing [distal fragment
in flexion]),
앫 Blount sling (type I and type II a with anterior
bowing).
Technique of internal fixation
앫 Lateral external fixator (our method)
앫 Pinning with crossed Kirschner wires
앫 Lateral pinning with Kirschner wires
앫 Intramedullary nailing
Aftercare
Period of immobilization
앫 With conservative fixation: Three weeks.
앫 With internal fixation: Two to three weeks (in
posterior upper-arm splint).
Consolidation radiographs: Yes.
Initial mobilization: Spontaneous mobilization after
removal of the plaster splint.
앫 A completely displaced type III or IV fracture
does not necessarily represent an indication
for open reduction.
앫 Lack of a pulse in the radial artery is not in itself an indication for primary open reduction.
An emergency attempt at closed reduction
may be undertaken even where there is no
pulse in the radial artery. Open repair may
then be attempted in the same session from
an anterior approach.
앫 Where there is only a sensory deficit in one of
the three nerves, a careful emergency attempt
at closed reduction is justified.
앫 In the presence of a motor and sensory deficit
in one of the three nerves, immediate emergency open reduction and repair is recommended.
앫 All other indications should first be discussed
at length with the patient and his or her
parents.
Physical therapy: Never as primary treatment. As
the exception in older patients if function remains
uniformly poor 8–10 weeks after removal of the
plaster splint.
Sports: Usually possible after four to five weeks (free
function is not necessarily required).
Removal of metal implants: Immediately upon
verified consolidation without pain medication.
Follow-up examinations and conclusion
앫 Clinical follow-up examinations at three- to fourweek intervals until unrestricted function is
achieved,
앫 Treatment is concluded once the elbow axis is
symmetrical and unrestricted function has been
achieved.
132
Specific Injuries—Upper Extremities
Supracondylar Humeral Fractures
These are the most frequent injuries to the elbow
in growing patients (8, 47, 91, 171, 172).
Severity of displacement
I
Diagnosis
The diagnosis is readily made in the case of moderately and severely displaced fractures due to its
typical supracondylar course. In infraction fractures, the fracture line will often not be initially
detectable. The diagnosis can only be made indirectly with the aid of the Rogers line (Fig. 19.13)
or on the basis of clinical symptoms. In the latter
case, the diagnosis is later confirmed by the presence of a periosteal bridging callus (144).
II
Forms of Injury and Classifications
The classification of these injuries as extension
fractures (98% of all cases), and flexion fractures,
accounting for only 2% (4, 8, 21, 48, 58, 65, 157;
Fig. 19.13), is of little practical value in a clinical
setting, as are the most commonly used classification systems of Baumann (4), Gartland (154), or
Felsenreich (21). In an effort to achieve a measure
of comparability, especially in retrospective and
prospective studies, we have proposed a system
of classification based on the displacement in the
various spatial planes (143). Yet even this classification system has only limited therapeutic significance. From a therapeutic perspective, one must
differentiate in every classification system between fractures that are stable, imminently unstable, and manifestly unstable. That means one
must recognize the stable and nondisplaced fractures that account for 35% of all supracondylar
fractures. The imminently unstable fractures include those that are displaced with anterior or
posterior bowing but with intact condylar
columns. These account for 22% of all supracondylar fractures. In the unstable fractures, one or
both condylar columns are displaced and in
danger of slipping into angulation. These fractures account for a total of 43% (type III 18% and
type IV 25%) of all supracondylar fractures (143;
Fig. 19.17).
Rare, but possible are combination injuries
with ispilateral forearm fractures (197).
Growth Disturbances
Growth disturbances can occur in the form of
transient lateral stimulation of the distal humeral
III
IV
Fig. 19.17 Classification of supracondylar humeral
fractures. In contrast to the most commonly used classification systems of Felsenreich and Baumann, we identify not three but four different types according to the
degree of displacement (143) in an effort to better differentiate the individual fracture types:
Typ I Nondisplaced,
Typ II Displaced in one plane: Anterior bowing (distal
fragment in extension; left), posterior bowing
(distal fragment in flexion; right),
Typ III Displaced in two planes: Anterior or posterior
bowing combined with rotational displacement
(figure) or with varus or valgus displacement,
Typ IV Displaced in three planes: Anterior or posterior
bowing combined with rotational and varus or
valgus displacement.
However, regardless of the classification system, one
should differentiate from a therapeutic perspective between fractures that are stable (types I and II), imminently unstable (type II fractures with extreme displacement), and manifestly unstable (types III and IV). This
distinction is the only one that directly affects the choice
of treatment
Elbow Injuries
growth plate. However, they are of no clinical significance as they do not lead to any appreciable alteration of the axis of the elbow (124).
133
Growth arrest from premature closure of the
growth plate may result following repeated attempts to drill through the condyles (i.e., the
growth plate) during percutaneous placement of
Kirschner wires.
“Spontaneous Corrections“
Fig. 19.18 Late complications secondary to supracondylar fractures of the humerus. Cubitus varus is
the most common late complication following a supracondylar humeral fracture. This deformity is not spontaneously corrected during the course of further growth
but persists unchanged. It represents a cosmetic and social disability
As the elbow is a hinge joint, deformities that lie
outside this fixed plane of motion (i.e., axial deformities in the coronal plane, cubitus varus, and
cubitus valgus) are not corrected at all during the
course of further growth. These deformities
(Fig. 19.18) remain unchanged and can represent a
significant cosmetic and social impairment for
the patient.
More common is the anterior bowing deformity of the fracture caused by the distal fragment,
which is in extension. Depending on the age of the
patient, this deformity may be spontaneously
corrected during further growth as it lies in the
elbow's main axis of motion, the sagittal plane.
The deformity will initially migrate proximally
with growth. The capitellum of the humerus will
then assume an angle of 30–40⬚ to the shaft.
However, the growth plate is only responsible for
20% of the longitudinal growth of the humerus
and grows very slowly. As a result, this correction
takes a relatively long time, and one may only expect complete spontaneous correction of this deformity in younger patients (Fig. 19.19). The
threshold age is about seven (124).
We still know little about what happens to rotational deformities following supracondylar
humeral fractures. We are familiar with the con-
Fig. 19.19 “Spontaneous correction” of the anterior
bowing deformity. One-year-old girl with a supracondylar humeral fracture and an extension deformity of
the distal fragment. Four years later, the anterior bowing
deformity has grown proximally, and the capitellum of
the humerus has nearly returned to its physiological angulation with respect to the shaft of the humerus and is
nearly symmetrical with the contralateral side
134
Specific Injuries—Upper Extremities
sequences of a rotational deformity with respect
to the axis of the elbow; these deformities persist
unchanged. In contrast, the sign of a rotational deformity, the anterior or posterior rotational spur,
may be relied upon to disappear, as it is largely absorbed. The rest also grows proximally, with the
result that the deficit of flexion it initially causes
will disappear during the course of further
growth (Fig. 19.20). All indirect evidence would
suggest that the rotational deformity as such can
also be fully or partially “spontaneously” corrected as a result of physiological anteversion
processes as it is in the femur. However, in the distal region, this does not appear to be the case. We
observed cases in which it persisted unchanged
(122). Malrotation of 40–50⬚ is required to turn
the two condylar columns away from each other
and allow angulation. This is visible in the radiograph as a typical rotational spur (55, 118, 133; see
Fig. 19.20). However, of the patients with a large
anterior rotational spur examined during clinical
follow-up, none were found to have a difference
in rotation between the affected and contralateral
sides exceeding 10–15⬚ which would have been a
sign of a persistent rotational deformity. The average follow-up period in these patients was five
years (25). These findings suggest that the initial
rotational deformity, which was undeniably present, must have spontaneously corrected itself
during the course of further growth, and done so
proximally.
Problems and Complications
The most frequent complication of supracondylar
fractures of the humerus is varus displacement of
the axis of the elbow, cubitus varus. The incidence
cited in the literature varies between 10% and 50%
of all cases (4, 8, 28, 58, 59, 91, 101, 124, 172, 181,
194, 198, 205). A rotational deformity is invariably
responsible for this complication, whether
directly or indirectly. The rotational deformity
may be regarded as a precursor to instability and
therefore responsible for varus angulation and,
less frequently, valgus angulation. However, this
deformity is rarely attributable solely to severe
ulnar or radial angulation where side-to-side displacement exceeding half the width of the shaft is
present without a rotational deformity.
Malrotation is fostered by immobilization in
which the forearm is held in adduction against the
body, as in a cast. This internally rotates the distal
fragment, which means that the lateral condyle is
rotated anteriorly, creating a particularly severe
cosmetic deformity. This malrotation is not spontaneously corrected during further growth. At the
same time, the muscle tone of the rotator cuff externally rotates the proximal fragment so that the
ulnar proximal portion of the condyle rotates
anteriorly. The axis of rotation is in the center. The
area of contact decreases by more than 50% even
at a malrotation of 20⬚, and this occurs at the expense of both columns. At a malrotation of 50⬚,
there is no longer any contact between the fragments in either column (Fig. 19.21 a). These two
opposite rotational components can result in
malrotation of more than 30⬚. It follows that this
eliminates any contact between the proximal and
distal condylar columns so that the fracture is
only supported by the thin plate of the olecranon
fossa. This instability often provokes proximal
subsidence of the ulnar portion of the distal fragment, which usually leads to significant varus displacement of the axis of the elbow (Fig. 19.21). If
one artificially shifts the axis of rotation radially,
into the larger condyle (95, 118), then the loss of
contact area does not come at the expense of both
columns as it does where the point of rotation is
in the center, but only at the expense of the
smaller ulnar column. The area of contact in the
larger radial column only decreases by about a
maximum of one third even where malrotation
exceeds 30⬚, after which it remains constant
(Fig. 19.21 b,c). In oblique fractures where there is
good contact between the fragments, an axial deviation in the coronal plane can only occur as a
direct result of rotation on an oblique fracture
plane without angulation (124; Fig. 19.22).
Although it is now rare, Volkmann ischemia
with its severe late sequela of a Volkmann contracture is the worst early complication of the supracondylar fracture of the humerus. Even today
it is not fully clear what causes this complication.
However, we cannot fully exclude the possibility
that the anterior rotational spur coupled with repeated forceful and late reduction maneuvers
may figure prominently in the compression and
irritation of the neurovascular bundle. Our three
cases of a Volkmann contracture occurred in fractures with significant rotational spurs that had
been immobilized at an acute angle (124). The
decrease in these complications over the last few
years is undoubtedly attributable to the significantly prompter onset of treatment and to less
stressful forms of anesthesia and reduction
maneuvers.
Immobilization with or without a rotational
spur at an acute angle, excessively tight elastic
Elbow Injuries
135
a
Fig. 19.20 The cause of cubitus varus.
a The patient was an eight-year-old girl. A completely
displaced supracondylar fracture of the humerus was
stabilized in what was thought to be proper axial
alignment with a severe rotational deformity (note
the anterior spur) using crossed, percutaneous
Kirschner wires. The poor support of the fracture resulted in lateral angulation into a varus deformity. Clinical and radiographic examination revealed severe
cubitus varus of 20⬚ compared with the physiological
15⬚ valgus position of the contralateral side
136
Specific Injuries—Upper Extremities
Fig. 19.20 b
b A model demonstrating the severity of the rotational deformity. The
rotational deformity cannot be directly measured in clinical and
radiographic examinations. The rotational deformity is only detectable in the lateral radiograph as an
anterior spur or, rarely, as a posterior spur, formed by the proximal
fragment. In the model, a spur approximately equivalent to the one
shown in (a) corresponds to 40–60⬚
of malrotation
Elbow Injuries
Radial axis
137
Central axis
A-P
a
10 ° rotation
b
20° rotation
c
30° rotation
Fig. 19.21 The area of contact in the fracture depends on the position of the axis of rotation and the
severity of malrotation. With the axis of rotation in the
center, the area of contact between the fragments will
decrease linearly as malrotation increases; at 70⬚ of malrotation, it will decrease to zero. The loss of contact area
affects both condyles equally. At 30⬚ of malrotation, the
area of contact is only 30% (a). Where the axis of rota-
tion is peripheral to the lateral condyle, the total area of
contact will decrease linearly only to 30⬚ of malrotation,
after which it remains at a constant 40% (b) even as malrotation increases. In this case, the loss of contact occurs
solely at the expense of the medial condyle, whereas the
lateral condyle loses only 25% of its contact area and retains 75% even in more severe malrotation (c; 95, 118,
135)
bandages, or plaster casts can depress blood flow
in the distal vessels (107). The resulting edema
can increase pressure in the muscular compartments of the forearm. Depending on its duration,
this can lead to deterioration of the muscular
parenchyma. These dead muscles are replaced
with fibrous tissue, compromising function in the
hand with varying severity that can include total
disability (65). The most important early symptom is increasing pain with the onset of limited
motion and a sensation of coldness in the fingers.
Only during the further course of the disorder will
the symptoms range from loss of pulse and sensation to complete paralysis in the hand. At the
onset of symptoms, all restricting bandages must
be immediately released. If this does not bring
immediate relief, immediate intervention under
anesthesia is indicated to repair soft tissue, correct possible deformities, eliminate rotational
spurs, etc. When in doubt, an extensive fasciotomy should be performed to decompress the
region.
Early complications can also include nerve injuries, primarily to the radial and median nerves,
that occur as a result of irritation from the sharp
edges of the fragments (165, 188). Irritation of the
ulnar nerve is less a traumatic injury than an
iatrogenic injury and often results from repeated
reduction maneuvers or internal fixation with
Kirschner wires (41, 203). In our own study group
over the last 10 years, we observed irritation of
the ulnar nerve in 13% of all patients following
percutaneous pinning with crossed Kirschner
wires (55, 133). However, this irritation spontaneously disappeared in every case within one
year after the fracture at the latest.
Where there is evidence that a nerve injury
has occurred secondary to treatment, we invariably allow three weeks for the fracture to heal. If
the nerve or nerves do not significantly improve
during the further clinical course, we recommend
prompt revision of the nerve or nerves after a
prior electromyogram (EMG) study.
Where there is evidence of an initial motor
and sensory deficit of one or more nerves, we feel
that initial open reduction with simultaneous repair of the affected nerves is indicated. This avoids
additional injury to the nerve from closed reduc-
138
Specific Injuries—Upper Extremities
Fig. 19.22 Rotational deformity in oblique fractures. In oblique fractures, the rotational deformity leads directly to an axial deformity in the coronal plane
due to rotation of the fragments on an oblique plane. In
this four-year-old girl, the Kirschner wires crossed at the
level of the fracture line, which permitted a secondary
rotational deformity (this is evident from the bent wires
in the lateral radiograph and the slight anterior and posterior rotational spur). This led to a moderate varus displacement of the axis of the elbow
tion as one can verify that the nerve is not interposed between the fragments.
Where there is evidence that only a sensory
deficit of one or more nerves is initially present, it
is up to the surgeon’s discretion as to whether to
attempt closed reduction or to opt for immediate
open reduction. The respective procedure and the
options for further postoperative procedure
should be discussed in depth with the parents
(71).
Imminent or manifest instability determines
the prognosis for this fracture. The instability is
usually caused by a rotational deformity. This can
cause the lateral condylar portion of the distal
fragment to slip ulnarward into varus angulation
and to rotate anteriorly, producing an unsightly
deformity. A fundamental requirement of treatment is therefore to perfectly reduce the displaced fracture, eliminate any rotational deformity, and maintain the fracture securely in this
position until it consolidates. This means that the
physician must be able recognize a rotational deformity. As we have discussed in the previous section, the sign of a rotational deformity is the “rotational spur” in the lateral radiograph. A fracture
is completely reduced and free of a rotational deformity only if there is no longer any discernible
spur on the lateral radiograph obtained in a
radioulnar projection. The spur must not be confused with posterior side-to-side displacement
(Fig. 19.23). Where oblique radiographs have been
obtained, the contour of the olecranon fossa in the
oblique lateral radiograph will also indicate
whether malrotation is present (Fig. 19.24).
It is possible to miss a rotational deformity up
to a good 20⬚ in the intraoperative reduction images as it can be obscured by the lateral condyle.
Therefore, the goal of further treatment is to eliminate the destabilizing effect of any occult rotational deformity as well (Fig. 19.31).
Elbow Injuries
139
Treatment
!
Fig. 19.23 Rotational spur and side-to-side displacement. The rotational spur (right) should be distinguished from side-to-side displacement in the lateral radiograph (left). A proximal fragment that appears significantly wider than the distal fragment in the lateral radiograph suggests a rotational deformity
Fig. 19.24 Evaluation of a rotational deformity in
the oblique radiograph. Precise reduction with proper
rotational alignment may also be evaluated in oblique
radiographs by examining the contour of the olecranon
fossa. This should appear as an uninterrupted contour
from the proximal fragment to the distal fragment
The goal of treatment with displaced supracondylar fractures of the humerus is to prevent medial angulation and prevent lateral anterior rotation.
The decision for or against a specific treatment is
determined by the presence of imminent or existing instability.
Stable nondisplaced fractures are treated conservatively in an upper-arm plaster splint as opposed to a full cast (Fig. 19.25).
Stable and slightly displaced fractures with
anterior or posterior bowing (up to 20–30⬚) are
treated in a Blount sling (in an extension plaster).
As the swelling is rarely severe, the arm can
promptly be placed at an acute angle (Figs. 19.26,
19.27).
Imminently unstable displaced fractures with
anterior exceeding 20⬚ should also be treated in a
Blount sling as matter of course. That means they
should be placed at an acute angle. This is often
not initially feasible where there is intense swelling. In such a case, the patient should be given
pain medication and the elbow placed in the
desired position after soft-tissue swelling has
subsided on about the second to fourth day after
trauma. This manipulation can cause secondary
disruption of one condylar column, usually the
ulnar one. In order to detect this complication
promptly, a lateral radiograph of the elbow in the
definitive acute angle should be obtained on
about the fourth day after trauma (see Fig. 19.28).
If a secondary rotational deformity is present in
that image, then one should proceed as in the case
of an unstable fracture (see Figs. 19.28, 19.29,
19.30 a–c). The parents should be informed right
from the start that late reduction under general
anesthesia may become necessary.
In the extraordinarily rare cases of such a type
II injury with a posterior bowing deformity, the
injury is immobilized with a posterior upper-arm
plaster splint with the elbow nearly extended.
The further procedure is identical to that described above.
Where the fracture is unstable, i.e., where one
or both condylar columns is fractured, then emergency reduction with the patient under anesthesia and stable fixation of the fracture is definitely
indicated (164, 174, 183, 191, 199, 200, 211, 214,
217). In contrast to Leet (184) we still believe it is
140
Specific Injuries—Upper Extremities
Fig. 19.25 Treatment of a
type I stable nondisplaced
supracondylar fracture of
the humerus. The patient is
a five-year-old boy with a
nondisplaced supracondylar
fracture of the humerus.
The fracture line is directly
visible in the A-P radiograph
and anteriorly in the lateral
radiograph. The anterior
and posterior “fat-pad sign”
also provides indirect evidence. Treatment consists
of immobilization in an upper-arm plaster splint in 90⬚
of flexion for two to three
weeks until pain is absent.
No further radiographic follow-up studies will be required
an emergency reduction in the interest of the
patient. There are many ways to achieve this goal
(4, 8, 28, 48, 59, 65, 102, 124). As the reduction
must be performed with the patient under
general anesthesia, one should opt for the most
definitive method of fixation. This method must
exclude any subsequent change of treatment,
keep radiographic follow-up studies to a minimum, and keep that patient’s stay on the ward as
short as possible. These considerations exclude all
traction methods, acute-angle casts, and, to a certain extent, the Blount sling, as treatments for displaced type III and IV fractures. Only pinning with
crossed Kirschner wires or external fixation has
been able to fulfil these requirements to date (71,
117, 119, 199).
Emergency reduction of the fracture is performed as atraumatically as possible with the
patient under general anesthesia. The surgeon
“shakes hands” with the patient (whose hand is in
a neutral position, neither in pronation nor in
supination) and continuously pulls on the
patient’s extended arm. This continuous pull
should be brief, after which the forearm is pronated (or supinated, depending on the rotational
direction of the deformity) and the elbow is
brought into an acute angle. Where there is no interposed soft tissue, this maneuver will generally
result in ideal reduction with proper rotation on
the first try. Correct reduction is verified by
fluoroscopy.
We then proceed by first placing the lateral
wire percutaneously. The lateral epicondyle is
easily located even in the presence of massive
swelling with the elbow placed at an acute angle.
The wire should be placed precisely in the epicondyle and not distal to it to avoid having to drill
through the growth plate (which could otherwise
result in growth arrest). Remember that the
lateral epicondyle lies farther anterior than the
medial epicondyle. The wire should just barely
penetrate the opposite cortex, extending obliquely from posterior to anterior. If fluoroscopy
reveals that the wire is well seated, one may
briefly abandon the acute angle position to again
palpate the groove of the ulnar nerve and to better
identify the medial epicondyle that lies posterior.
After the medial wire is placed on the medial epicondyle under fluoroscopic control, the elbow is
returned to the acute angle position. By remaining on the epicondyle, which lies in front of the
groove, and inserting the wire from posterior to
Elbow Injuries
141
Fig. 19.26 Treatment of stable and imminently unstable type II supracondylar fractures of the humerus
that are displaced in one plane. The patient is a sevenyear-old boy with a supracondylar humeral fracture that
is displaced in the sagittal plane. The A-P image reveals
an impacted radial column, with slight opening of the ulnar fracture gap. The lateral image reveals significant anterior bowing exceeding 30⬚. No rotational spur is present. The fracture was treated with immobilization in a
plaster splint at an acute angle (which was applied initially after administering pain medication) for three
weeks. In order to exclude secondary displacement of
the separated ulnar column (which would cause the imminently unstable type II fracture to deteriorate into a
type III fracture), a second radiographic examination in
plaster was performed on the fourth day after the accident (the lateral plane would have been sufficient). The
image demonstrates that the anterior bowing has been
largely corrected, and secondary displacement in a second plane (rotational spur) can be excluded. This
means that conservative treatment may continue.
Following consolidation after three weeks, the radiograph demonstrates unchanged position of the fragments with good stabilization by the callus. After another four weeks, the patient had regained his full range
of motion. The final follow-up examination revealed
symmetrical cosmetic and functional findings
anterior into the opposite cortex, one can avoid
injuring the ulnar nerve or the radial nerve, which
courses posteriorly. The two wires should cross
proximal to the fracture line to prevent subsequent rotation of the fracture. The radiographs
out of plaster in two planes should confirm the
proper position of the wires and elimination of
the rotational deformity. Then a posterolateral
plaster splint is applied, which has an opening to
accommodate the projecting ends of the wires
(see Fig. 11.4 a, b).
We again reviewed and followed up our
patients with displaced supracondylar fractures
whom we had treated since 1973 with percutaneous pinning with crossed Kirschner wires. In
13% of these patients, we found iatrogenic injuries to the ulnar nerve, and in 13% cosmetic deformities involving varus displacement of the axis
of the elbow. The latter were attributable to
avulsed ulnar wires or insufficient initial reduction of the fracture. In 98% of these cases, the
ulnar nerve palsy subsided spontaneously.
Based on these results and on the experience
other authors have had with pinning with crossed
Kirschner wires (16, 26, 29, 66, 74, 89), we felt
obliged to switch to other methods. One such
method involved stabilizing the lateral percutaneous wire (133, 164, 183, 191, 200) with the aid
of an external fixator. In effect, this represents a
dynamic variation of an established method
142
Specific Injuries—Upper Extremities
Fig. 19.27 Treatment in a Blount sling of stable and
imminently unstable type II supracondylar fractures
of the humerus that are displaced with anterior bowing (distal fragment in extension). The Blount sling
functions on the principle of maintaining the elbow at an
acute angle. Pain and swelling may initially render this
positioning impossible, in which case it will suffice to
wait two to three days. When in doubt as to whether anterior bowing is present, the fracture should be immobilized in this position, which must be maintained until the
injury heals
(Figs. 19.29, 19.30). The reduction maneuver is
performed in the same manner as in pinning with
crossed Kirschner wires. The lateral wire is also
placed in the same manner via the lateral epicondyle with the elbow flexed. The wire should be
placed at as acute an angle as possible and should
engage both fragments. This achieves a broader
area of compression. A second wire crossing the
fracture plane is then inserted parallel to the first
one. Then another wire is inserted perpendicularly through the shaft two finger breadths above
that point. This wire must not be inserted too far
proximally to avoid injury to the radial nerve. The
proximal and distal wire or wires are then manually compressed toward one another and connected to a transverse rod and jaws from the small
Hofmann instrument set. The construct is then
screwed tight with compression applied to the
wires. To ensure permanent compression, the
wires used should not be less than 2 mm thick. In
the final intraoperative radiograph, the medial
fracture line will often show a slight gap indicative of the lateral compression (Fig. 19.30 a). The
lateral image should be obtained in a radioulnar
projection and should not show any spur (95, 100,
133).
These findings indicate stable fixation that allows motion. The range of motion is restricted
only because of the posterior and radial location
of the external fixator. This renders medial angulation impossible even in the case of a medial rotational deformity. As the lateral condyle is reduced and stabilized, it cannot rotate anteriorly.
This method excludes any iatrogenic injury to the
ulnar nerve. If there is a lateral zone of impaction
and the fracture slips into valgus when compressed, then one must switch to pinning with
crossed Kirschner wires, insert an additional medial wire, and remove the proximal compression
wire.
Definitive interpretation of the intraoperative
radiographs is hardly possible (135). For this reason, we always verify the results of reduction and
external fixation by clinical examination. Flexion
up to 120⬚ excludes the possibility of a gross rotational spur and significant anterior bowing.
Elbow Injuries
143
Fig. 19.28 Treatment of imminently unstable supracondylar fractures of the humerus. A.S. , a two-yearold girl with a slightly displaced supracondylar humeral
fracture without a rotational deformity. The ulnar column appeared to be separated (lateral image). There
fore, a lateral radiograph was obtained in plaster on the
fourth day after the accident. This image revealed a significant rotational deformity in the form of an anterior
spur. On the fifth day, the fracture was reduced with the
patient under general anesthesia with an empty stomach and was fixed with crossed percutaneous Kirschner
wires
With full extension, significant posterior bowing
is excluded, and the axis of the elbow can be clinically evaluated. We document function and the
axis of the elbow axis in intraoperative photographs (Fig. 19.30 b, c; 135).
In recent years, an increasing number of
authors have reported on the stabilization of su-
pracondylar humeral fractures by dynamic intramedullary nailing (143 a; literature on General
Science, Treatment, and Clinical Considerations:
24). Two nails 1.5 mm in diameter are introduced
in antegrade fashion from the deltoid tuberosity
prior to reduction. One nail each is introduced
into the ulnar and radial columns and advanced to
144
Specific Injuries—Upper Extremities
Fig. 19.29 Diagram of the lateral external fixator.
The lateral wires should always be placed at as flat an angle as possible to compress the entire area of contact in
the region of the lateral condyle. Two wires should always cross through the plane of the fracture so as to
achieve a measure of rotational stability and stability in
motion. Next, a third wire is placed perpendicular to the
shaft two finger breadths proximal to the two wires. The
proximal and distal wire or wires are then manually compressed toward one another and connected to a transverse rod and jaws and are screwed tight
just short of the fracture. Only then is the fracture
reduced, and standard procedure is to first attempt closed reduction. The results of reduction
are then verified by fluoroscopy. While the surgeon holds the reduced fracture at an acute angle,
the assistant carefully advances the two nails into
the distal fragment and takes care not to injure
the growth plate. Spontaneous motion in the
elbow is allowed postoperatively (Fig. 19.32). No
further immobilization is required. The metal implants are removed six to eight weeks after the
fracture. We ourselves have not had any experience with this method. Previous experience,
at least as reported in the literature, has been
positive. The expenditure of treatment is greater
than for a radial fixator only with respect to removal of the metal implants, as the nails must be
removed with the patient under general anesthesia (Fig. 19.32 a,b).
If the first attempt at reduction does not
succeed, then we attempt closed reduction only
once more at most. If reduction again proves impossible without resorting to forceful maneuvers,
then we conclude that open reduction in the same
session is indicated (174). We prefer a posterior
approach as it provides better cosmetic and
functional results than an anterior approach
(182). The two columns can be readily exposed in
Fig. 19.30 a Treatment of an unstable type IV supracondylar fracture of the humerus with a radial external fixator. Four-year-old girl with a completely displaced type IV supracondylar humeral fracture according to our classification system. Emergency closed reduction was performed and the fracture stabilized with
a radial external fixator. Three weeks later, clinical and
radiographic evidence indicated that the fracture had
completely healed. The fixator was removed in an outpatient procedure without any medication or anesthesia. Six weeks after removal of the meatal implants, the
range of motion of both sides was identical, the axes of
the elbows were symmetrical, and treatment was concluded
Elbow Injuries
145
Fig. 19.30 b Preoperative photographic documentation. The range of flexion and the axis of the elbow are documented in the nonfractured side with the patient under anesthesia prior to surgery
Fig. 19.30 c Intraoperative photographic documentation. After the fracture has been reduced and the external fixator assembled, the range of flexion and the
axis of the elbow are evaluated and compared to the
contralateral side. Flexion up to 120⬚ (swelling prevents
more than this) excludes both a clinically significant an-
terior bowing deformity and a rotational spur that might
impair flexion. Extension to a neutral position excludes a
clinically significant posterior bowing deformity, and
symmetrical elbow axes exclude ulnar tilting of the distal
fragment
a posterior approach while preserving the ulnar
nerve, and the vascular bundle can be easily inspected from a medial exposure. In spite of this,
open reduction is surprisingly difficult and by no
means easier than closed reduction. After any interposed tissue is removed, the two columns are
placed in apposition under direct visualization.
Here, too, the fragments are fixed with percutaneous Kirschner wires. If there is no radial zone
of impaction, then the fracture is stabilized with
the lateral external fixator, otherwise crossed medial and lateral Kirschner wires are used.
Once the radiographs demonstrate perfect
alignment, we invariably apply a posterior plaster
146
Specific Injuries—Upper Extremities
Fig. 19.31 Follow-up examination of a supracondylar fracture of the humerus treated with an external
fixator. The patient is an 11-year-old girl. Six-month follow-up of a completely displaced type IV supracondylar
humeral fracture in the right arm treated by closed reduction and stabilization with a radial external fixator.
The intraoperative radiographs had only hinted at the
presence of a rotational spur (see also Fig. 19.30 a). The
early follow-up examination revealed 20⬚ more of external rotation in the right arm than in the contralateral
arm. This deformity did not become clinically significant
due to the radial compression that prevented ulnar tilting. Both elbows exhibited nearly symmetrical function,
and the axes of the elbows were symmetrical
splint if we elect to use crossed Kirschner wires,
but apply one only, if necessary, if we elect to use a
lateral external fixator. This splint has an opening
to accommodate the projecting wires. We regard
completely displaced fractures without a palpable
pulse in the radial artery as an indication for immediate open reduction prior to diagnostic angiography. Usually, the neurovascular bundle is interposed between the fragments. The pulse invariably increases rapidly after careful reduction of the
fracture. Vascular injuries caused by the sharp
edges of the fragments are rarely observed. In the
presence of primary injuries to the radial or median nerve, an anterior approach should be preferred for open reduction and soft-tissue repair.
Immobilization and Consolidation
Following closed or open reduction, the patient
remains on the ward for one to three days at most
Elbow Injuries
147
c
a
d
b
Fig. 19.32 Treatment of unstable type IV supracondylar fractures of the humerus by dynamic intramedullary nailing. The patient is a six-year-old girl with a
completely displaced supracondylar fracture of the humerus ( a). Closed reduction was performed in an emergency procedure, and the fracture was stabilized by intramedullary nails (b) introduced in retrograde fashion.
The patient began spontaneous motion of the elbow immediately postoperatively. Mobility was nearly unrestricted by the time the fracture healed (c). At the followup examination after six months (d), both sides exhibited unrestricted and symmetrical function. The elbow
axes were symmetrical, and treatment was concluded.
(My deepest thanks to Dr. Weinberg from Graz, Austria,
for making these images available for publication.)
148
Specific Injuries—Upper Extremities
for evaluation of distal neurovascular status and
to allow soft-tissue swelling to subside. In
patients treated with crossed Kirschner wires, the
plaster splint should be extended to form a full
cast once swelling has subsided. Patients treated
with an external fixator require only a sling, or at
most a posterior plaster splint to protect the arm
when the child is in school. The wires may not
touch the plaster. Crusts should be removed and
the wire exit wounds cleaned with hydrogen peroxide. The family physician should inspect the
wounds once a week.
A follow-up radiograph out of plaster is obtained three weeks after internal fixation to evaluate consolidation (211). If the image demonstrates a good periosteal bridging callus at the
fracture (a slight amount of callus with an external fixator and abundant callus with crossed Kirschner wires) and the callus is not painful to palpation, then we remove all the wires. This is done
with an unsterile holding forceps. Patients regard
this manipulation with the same degree of apprehension as local anesthesia, general anesthesia, or
the prospect of protracted hospitalization. Our
practice of removing wires is nearly painless and
is therefore performed without pain medication
or sedation.
After removal of the wires, patients immediately have their full range of spontaneous motion
and do not have to observe any rules or restrictions. Most important, they require no physical
therapy. Within the first three months, all induced motion exercises, including physical therapy, entail the risk of progressive limitation of
function rarely as a result of calcification of the
capsule. Spontaneous motion as tolerated will
usually result in rapid normalization of the range
of motion within three to six weeks, depending
on the patient’s age and specific findings. Only
when a functional deficit persists unchanged over
a period of several weeks do we prescribe secondary physical therapy. However, we do not do so
until at least 12 weeks after we allow unrestricted
motion.
Treatment may be concluded once the patient
has resumed sports without any complaints,
function is unrestricted and nearly symmetrical
function, and the patient exhibits symmetrical
elbow axes and upon clinical examination after
resuming sports.
Separated Distal
Humeral Epiphyses
Separations of distal humeral epiphysis
(Fig. 19.33), that is of the entire trochlea with and
without a hemispherical metaphyseal fragment,
are repeatedly described in the literature yet
rarely encountered (14, 40, 51, 67, 83). Nearly always, these injuries turn out to be isolated fractures of the lateral condyle or transcondylar Y
fractures whose perpendicular fracture component through the trochlea is not displaced (40,
67). A correct diagnosis would only be possible
with the aid of arthrography, ultrasound, or magnetic resonance imaging (MRI; 31, 75), especially
if the trochlear ossification centers are not visible
and there is no significant displacement.
Where the injury is an actual epiphyseal separation with and without a metaphyseal wedge,
then it should be regarded as the most peripheral
form of a supracondylar fracture and treated accordingly. Nondisplaced fractures are immobilized in a plaster cast for about three weeks. Percutaneous pinning with crossed Kirschner wires is
indicated in severely displaced fractures, especially where a rotational deformity is present.
Follow-up examinations and aftercare are identical to the management of supracondylar fractures.
Sports Participation and
Follow-up Examinations
The patient can resume sports after he or she has
regained full motion. Generally, no further radiographic follow-up studies will be required. Where
an anterior bowing deformity persists, spontaneous correction may be clinically monitored
by observing the increase in the range of flexion.
Fig. 19.33 Separated distal humeral epiphysis. This is
a very rare injury that can only be verified by MRI or possibly ultrasound. These injuries should not be confused
with transcondylar intraarticular fractures (see p. 158 ff)
Elbow Injuries
149
Epicondylar Humerus and Dislocations of the Elbow
(1.3%)
Forms
앫 99% involve the medial epicondyle,
앫 One quarter are isolated fractures,
앫 One quarter are spontaneously reducible elbow
dislocations,
앫 One half are associated with clinical elbow dislocations.
A-P and lateral radiographs: Dislocations may involve collateral ligament injuries, requiring clinical
evaluation under analgesia.
Problems
앫 Chronic instability with recurrent dislocation,
앫 Medial epicondylar pseudarthrosis.
Definition of “nondisplaced“ in isolated epicondylar fractures.
앫 Medial epicondyle: Anterior displacement and
distal displacement of approximately 1 cm.
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Medical.
앫 Where indication is uncertain: Immobilization in a bandage.
Emergency treatment under anesthesia: Where a
dislocation is present.
!
All other indications should first be discussed at
length with the patient and his or her parents.
Further treatment without anesthesia or delayed
treatment under anesthesia
앫 Dislocation without associated bony or ligamentous injuries,
앫 Isolated fracture of the medial epicondyle
with tolerable displacement: This is a relative
indication for internal fixation and early mobilization, which should be weighed against
the disadvantage of two procedures under
general anesthesia (implant placement and
implant removal).
Technique of conservative fixation: Upper-arm
plaster cast.
Technique of internal fixation: Rigid screw fixation
that allows function.
Aftercare
Period of immobilization
앫 With conservative fixation: Two to three weeks.
앫 With internal fixation: Immediate spontaneous
motion.
Consolidation radiographs: Yes, after three weeks.
Initial mobilization: Immediately postoperatively in
the case of stable internal fixation, otherwise spontaneously after 10–14 days.
Physical therapy: Indicated in adolescents if no
progress in function is observed within three to four
weeks of initial mobilization.
Sports: Five to six weeks after consolidation.
Removal of metal implants: After 12 weeks.
Follow-up examinations and conclusion: At fourto six-week intervals until free function is restored, at
which time treatment is concluded.
150
Specific Injuries—Upper Extremities
Epicondylar Fractures
Both epicondyles represent traction epiphyses or
apophyses. This means that they are not involved
in the longitudinal growth of the humerus (43, 98,
99).
The isolated fracture or avulsion of the lateral
epicondyle is extremely rare; the study group of
Kutscha-Lissberg and Rauhs (58) and our own
study group included only a single case. Avulsion
fracture of the medial epicondyle is far more common, occurring in about one third of all cases as an
isolated injury and in two thirds as an associated
injury in an elbow dislocation. Like Bede and coworkers (5), we feel that medial and lateral epicondylar injuries are nearly always associated
with an elbow dislocation, which in about one
third of all cases will have reduced spontaneously.
This is also suggested by findings of instability,
primarily of the medial collateral ligaments in socalled isolated medial epicondylar avulsion fractures.
Growth disturbances need not be feared because these injuries involve apophyses. It is not
difficult to diagnose an isolated avulsion fracture
of the medial epicondyle where the examining
physician considers that possibility: The patient
will report specific pain in the medial elbow,
where classic swelling may be observed.
If the ossification center is not yet visible on
the radiograph, then it is pointless to attempt to
palpate a floating epicondyle given the visible
swelling; the same applies to ultrasound verification of a fracture, a bone scan, or MRI.
It will suffice to treat the pain by immobilization in a plaster cast until three weeks later when
the callus is no longer tender to palpation and can
be palpated. The radiograph will usually show
only a slight gap, which is why the fracture is
often overlooked despite (or maybe because of)
unnecessary comparative studies of the contralateral side (Fig. 19.34). Even in that case, clinical findings—without palpation—should indicate
the adequate therapy. The treatment of displaced
epicondylar avulsion fractures in the setting of an
elbow dislocation with instability of the elbow is
discussed under Elbow Dislocations (see p. 199).
Nondisplaced avulsion fractures are treated
conservatively by immobilization in an upperarm plaster splint for three weeks. The patient
should select the type of therapy in the case of
only slightly displaced avulsion fractures of the
medial epicondyle. The fracture can heal by bony
union without a cast (Fig. 19.34) just as easily as it
can heal by pseudarthrosis with a cast (Fig. 19.35).
The chances are 50 : 50. Surgical treatment can
nearly always bring about bony union (Fig. 19.36).
In that case, the incidence of pseudarthrosis is
about 10% (43, 150). Because pseudarthroses at
this location cause only 10% of all complaints,
bony union is not necessarily a prerequisite for
unrestricted function and absence of symptoms.
Additionally, symptomatic pseudarthrosis can
still be corrected by secondary surgery, either by
debriding and stabilizing the pseudarthrosis or by
excising the fragment.
It comes down to weighing the costs and
benefits of the respective treatments. The patient
will experience pain without a cast, and no pain
with a cast. However, the joint will be immobilized in a cast, which would not be the case with
internal fixation with a screw. Conversely, internal screw fixation requires the patient to tolerate
surgery, brief hospitalization, and a second surgical procedure to remove the metal implants.
The patient’s age can help in arriving at a decision. Young patients with these fractures have no
significant problems with rehabilitation of the
elbow even after immobilization in a plaster cast.
The situation is different in adolescents where
rigid internal fixation that allows motion would
be a good choice. Children, on the other hand,
would benefit more from conservative treatment
with a plaster cast. Kirschner wire fixation should
not be used for isolated avulsion fractures as it
does not provide rigid fixation that allows motion.
Under no circumstances should immobilization
last longer than three weeks. After immobilization, the elbow should be mobilized spontaneously as in any other elbow injury without
any physical therapy.
Most Common Deformities of
the Distal Humerus Secondary
to Supracondylar and Epicondylar
Injuries
Supracondylar
The most common deformity caused by supracondylar fractures is the varus deformity with resulting cosmetic impairment, which is not spontaneously corrected during the course of further
growth. Whether correction is indicated is determined almost exclusively on the basis of cosmetic
considerations. Only rarely is surgery indicated to
correct additional functional impairment of pro-
Elbow Injuries
nation and supination (see Fig. 19.37 b, c) or
functional disorder of the shoulder (166, 196) resulting from persistent distal malrotation or indicated to late instability of the elbow (194).
In attempting to determine the best time for
the operation, surgeons find themselves between
a rock and a hard place: As a basic rule, a cosmetic
deformity should be corrected only when requested by the patient, not the patient’s parents.
For most patients, this would mean that the correction would be made only later. However,
where a varus deformity with a radially rotated
condyle is present, then, in theory at least, the
osteotomy should be performed as early as
possible, as what amounts to a late reduction.
Once the rotational spur has receded and “spontaneous” correction of the proximal malrotation
has occurred, one no longer has the opportunity
to perform a generous derotation osteotomy to
improve the cosmetic result. Then the cosmetic
impairment of the rotated lateral condyle can
only be partially alleviated by an ulnar correction
(11, 73, 79).
However, in the presence of a varus deformity
without a radial rotational component, one may
readily adopt a watch and wait approach and, depending on how the patient and the patient’s
parents view the impairment, let the patient decide later. The only complications of posttraumatic cubitus varus mentioned in the literature
include isolated cases of late irritation to the ulnar
nerve (24) and even recurrent dislocations of the
radial head (1). In such a case, early intervention
with a corrective osteotomy and simultaneous revision of the nerve itself and the ulnar nerve
groove is indicated.
The simple fact that many corrective procedures have been suggested for cubitus varus
seems to indicate a general lack of satisfactory results. Results with our own patients have confirmed this (6, 15, 25, 53, 57, 139, 172, 181, 194,
198, 205). As a result, we have switched to uncovering both arms intraoperatively and stabilizing the correction itself with an external fixator
that is mobile in all three spatial planes (for older
patients the yellow Monotube, for small children
the Hoffmann compact II, both manufactured by
Stryker Howmedica).
Depending on the patient’s age (i.e., whether
the growth plates are still open), the distal screws
are placed farther proximally and distally. The
two proximal screws are always placed in the region of the deltoid tuberosity. The osteotomy is
performed 1 cm proximal to the distal screws. A
151
wedge is then removed from the proximal fragment. This wedge will have a lateral base and an
additional anterior or posterior base, depending
on the additional functional deficit in flexion or
extension. Then the osteotomy is stabilized with
the external fixator, and the functional and cosmetic results are compared to the contralateral
arm. Additional fine corrections can then be made
in all three spatial planes until satisfactory and
symmetrical cosmetic and functional results have
been achieved (Fig. 19.37).
Patients may begin spontaneous motion exercises immediately postoperatively. Children fitted
with the external fixator may take baths and go
swimming in a pool or salt water.
The external fixator is removed once the
osteotomy has consolidated, which is generally
after 10–14 weeks.
Again we emphasize: In spite of all theoretical
considerations, one should generally try to delay
the correction as long as possible until patients
may decide themselves. After all, this is a correction of a cosmetic deformity that concerns only
the patient.
Deformities involving functional impairments
most often include persistent anterior bowing
(with impaired flexion) and less frequently posterior bowing (with impaired extension). These deformities should only be corrected after the age of
seven or eight. Until this age, spontaneous correction of these deformities may occur to the extent
that no severe deficits remain. Everyday activities
only require 110–120⬚ of flexion, and an extension
deficit of 20⬚ would be tolerable. However,
patients usually regard this as a cosmetic impairment. Budding gymnasts require elbows that can
be hyperextended. Persistent functional deficits
in excess of these values should be corrected by
surgery. The technique we employ involves the
use of a mobile external fixator as in the correction of cubitus varus.
With deformities of this type, the patients
themselves will desire correction when they see
that growth fails to bring improvement and that
the functional impairment causes problems in
daily life. In such cases, their wishes should be
promptly addressed.
152
Specific Injuries—Upper Extremities
a
b
Fig. 19.34 Superfluous comparative radiographs of
the contralateral side. An overlooked, slightly displaced avulsion fracture of the medial epicondyle. The patient is a seven-year-old girl who fell directly on her left
elbow. Severe swelling and pain in the medial elbow occurred immediately. Despite the unequivocal clinical
findings, a comparative radiograph of the contralateral
side was obtained, the injury was overlooked, and the
patient was sent home without treatment with the reassuring remark that she had not broken anything (a).
Physical therapy was prescribed due to persistent pain
and restricted motion; this delayed further rehabilitation significantly. Only after five months was the patient
free of symptoms and able to move freely. The epicondyle had healed with slight displacement despite all the
efforts of physical therapy (b)
Elbow Injuries
153
Fig. 19.35 Pseudarthrosis following conservative
treatment of an avulsion fracture of the medial condyle. The patient is a seven-year-old boy with a slightly
displaced avulsion fracture of the medial condyle. The
injury was treated conservatively by immobilization in a
plaster cast for three weeks, followed by spontaneous
mobilization. At the follow-up examination after six
years, the patient was completely free of symptoms with
unrestricted mobility despite the pseudarthrosis. The
sensory and motor function of the ulnar nerve was normal
Fig. 19.36 Surgical treatment of an isolated avulsion fracture of the medial epicondyle. The patient is a
12-year-old boy, an athlete, with a slightly displaced isolated fracture of the medial epicondyle. The patient preferred surgical treatment in order to resume his sport as
quickly as possible. The fracture was stabilized with
screw fixation that allowed motion. We examined the
patient one year later (the metal implant had been removed at another facility four months postoperatively),
at which time he was free of symptoms and had unrestricted use of both elbows. Therefore, we dispensed
with any radiographic follow-up studies
154
Specific Injuries—Upper Extremities
a
b
c
Fig. 19.37 a–c Posttraumatic deformity following supracondylar humeral fracture and correction of the deformity. The
patient is a 10-year-old girl presenting for her first follow-up
examination at our hospital. Two years previously, she had
suffered a displaced supracondylar humeral fracture, which was
treated by percutaneous crossed Kirschner wire fixation. The
fracture healed in a significant varus deformity (a) and rotational
deformity (b). Atypically, this rotational deformity led to significant impairment of pronation and supination (c), whereas flexion and extension were nearly symmetrical with the contralateral
side
Elbow Injuries
155
Fig. 19.37 d–f At age 12, the
patient underwent a supracondylar corrective osteotomy, which was stabilized with
an external fixator. The surgical procedure corrected both
the varus deformity and the
rotation (indicated by the posterior spur; d) until pronation
and supination were freely possible intraoperatively. Three
weeks postoperatively, the patient again demonstrated the
full range of motion, including
pronation and supination with
symmetrical elbow axes with
the external fixator in situ (f).
After six weeks the osteotomy
evidenced onset of bony union.
Metal implants were removed
after 12 weeks. The last radiographic follow-up examination
four months postoperatively revealed strong bony union at the
osteotomy site with good position (e). Clinical examination
revealed continued good cosmetic and functional findings
d
e
Epicondylar
Epicondylar pseudarthroses on the medial aspect
are only symptomatic in about 10% of all cases.
Symptoms include a sensation of instability, medial prominence, weakness in throwing in baseball or handball, and, rarely, irritation of the ulnar
nerve. Surgical correction is indicated only in the
presence of persistent symptoms. Depending on
specific findings, the epicondyle may be removed
or reattached and fixed in place. Where fixation is
desired, the method of internal fixation chosen
should allow motion.
Epicondylar symptoms on the lateral aspect
can occur in the form of extracapsular osteochondrosis secondary to elbow dislocations or in the
form of lateral instability that can lead to recurrent dislocation.
f
156
Specific Injuries—Upper Extremities
Lateral osteochondrosis can in rare cases lead
to stubborn chronic symptoms during physical
exertion. Surgical removal of the fragment is indicated in such cases. Chronically recurrent dislocations are attributable to posterior slippage of the
lateral collateral ligaments, which are then no
longer able to stabilize the joint. This is confirmed
by all revision procedures performed to correct
recurrent dislocations. Findings include a sort of
posterolateral bursa caused by the back and forth
motion of the posteriorly displaced collateral ligaments. Debriding this pocket, shifting the collateral ligament anteriorly, and stabilizing the repair with a small fragment screw and washer stabilizes the elbow and prevents further dislocations. Aftercare consists of immediate spontaneous mobilization of the elbow. Full use should
only be begun after a total of six weeks.
Overview
Most Common Deformities of the
Extraarticular Distal Humerus
1 Cubitus varus (cosmetic deformity).
2 Anterior bowing in the elbow (deformity with
functional impairment).
3 Medial pseudarthrosis.
4 Lateral osteochondrosis and instability.
Causes
Re 1. Uncorrected axial deviation.
Re 2. Uncorrected axial deviation.
Re 3. Unstable internal fixation or conservative
treatment.
Re 4. Failure to perform radial revision in an elbow
dislocation.
Indications for Correction
Re 1. Cosmetic correction desired by parents and
patient.
Re 2. Severity of functional impairment.
Re 3. Persistent clinical symptoms.
Re 4. Recurrent dislocations or persistent clinical
symptoms.
Time of Correction
Re 1. Depends on patient.
Re 2. In children below age six watch and wait; in
older children soon (depending on functional
requirement).
Re 3. Not before six months to a year after the accident (immediately only in the case of irritation of the ulnar nerve).
Re 4. Immediately in the case of the first recurrent
dislocation, otherwise according to the duration and severity of symptoms.
Correction Technique
Re 1. Shortening osteotomy from lateral, stabilized with external fixator (see Fig. 19.37).
Re 2. Shortening osteotomy from lateral, stabilized with external fixator.
Re 3. Where accompanied by functional impairment: Resection of the epicondyle and arthrolysis. Where not accompanied by
functional impairment: Screw fixation allowing motion is possible; revision of the ulnar
nerve groove and modeling or anterior shift
in position of the ulnar nerve.
Re 4. Radial revision and reattachment of the collateral ligaments or removal of osteochondrotic fragments.
Aftercare
Re 1.–3. Functional aftercare.
Re 4. Functional aftercare, possibly from splint for
two weeks.
Elbow Injuries
157
Transcondylar Humerus (Lateral Condyle, Medial
Condyle, and Y Fracture: 1.8% Total)
Forms
앫 Nondisplaced hanging (incomplete articular).
앫 Nondisplaced complete (complete articular).
앫 Completely displaced.
Radiographs: A-P and lateral elbow.
Information for the parents: Nondisplaced fractures can displace secondarily in a cast. Therefore, a
radiograph out of plaster should be obtained after
four days.
Definition of displacement: See text.
Growth stimulation: See text.
Problem: Displaced fractures treated conservatively
can lead to pseudarthrosis.
Definition of “nondisplaced”: Fracture gap in the
central region (parameter for the joint) less than
2 mm, i.e., barely visible.
Technique of conservative fixation: Full circumferential upper-arm plaster cast.
Technique of internal fixation: Metaphyseal compression screw fixation, where possible with an
additional axial trochlear wire.
Aftercare
Period of immobilization
앫 With conservative fixation: Four weeks.
앫 With internal fixation: Immediate spontaneous
motion after two to three weeks, until that time
immobilization in an upper-arm plaster splint.
Consolidation radiographs: Yes.
Initial mobilization: Spontaneously after removal of
plaster splint or cast.
Physical therapy: None.
Sports: Four to six weeks after consolidation.
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Medical.
앫 Where indication is uncertain: Immobilization in a bandage.
Emergency treatment under anesthesia: All displaced fractures.
!
All other indications should first be discussed at
length with the patient and his or her parents.
Further treatment without anesthesia or delayed
treatment under anesthesia
앫 Fractures that remain nondisplaced are
treated conservatively.
앫 Fractures with secondary displacement are
treated surgically.
Removal of metal implants: 8–12 weeks postoperatively.
Follow-up examinations and conclusion
앫 At three- to four-week intervals until free function is restored.
앫 Then annual follow-up examinations until two
years after the accident to evaluate the axis of
the elbow: Transient stimulation of the lateral
growth plate causes a varus deformity. The more
rigid the fracture treatment is, the less severe the
abnormal varus growth will be.
158
Specific Injuries—Upper Extremities
Transcondylar Humeral Fractures
(Lateral Condyle, Medial Condyle,
and Y Fracture)
Fracture of the Lateral Condyle
of the Humerus
This second most common injury to the elbow invariably occurs as an articular fracture that
crosses the growth plate and exhibits a metaphyseal wedge (30, 61, 72, 134). Only rarely does the
fracture involve the ossification center of the
capitellum of the humerus. Usually, it courses medial to the ossification center through the cartilaginous trochlea toward the joint.
Fully displaced fractures represent the elbow
dislocation of little children (180) in contrary to
Fig. 19.38 Nondisplaced “stable” incomplete articular fracture of the lateral condyle of the humerus.
This is invariably a fracture that crosses the growth plate,
meaning that it is often barely detectable in the A-P image. The definitive finding is a fracture gap ending in the
growth plate on the lateral radiograph. Whether the injury is a stable (“hanging”) fracture or an unstable
fracture can only be determined by the further clinical
course. For this reason, an x-ray out of plaster should be
the elbow dislocation in older patients (see chapter 5, p. 36 and elbow dislocation p. 199).
Diagnosis and Forms of Injury
Displaced fractures are not difficult to diagnose.
Nondisplaced fractures are not always detectable
on the A-P radiograph. The oblique projection of
the growth plate can often simulate a fracture.
The definitive finding is a fracture gap with a typical course ending in the growth plate on the
lateral radiograph (Fig. 19.38; 83, 91, 128).
With respect to the nondisplaced fractures,
we must differentiate between incomplete fractures (Fig. 19.38) and complete fractures
(Fig. 19.39; see Exceptions: “Litigation Injuries”).
In an incomplete or “hanging” fracture, the main
portion of the trochlea remains intact. These frac-
obtained on about the fourth day after the accident to
determine on the basis of the severity of the displacement in the central region whether secondary displacement has occurred. If this is not the case, then the injury
may be treated conservatively, as it was in this 10-yearold boy. The cast was removed after four weeks. After a
total of seven weeks, the radiographic examination demonstrated a solidly healed fracture
Elbow Injuries
159
Fig. 19.39 Nondisplaced “unstable” complete articular fracture of the lateral condyle of the humerus.
In this five-year-old boy, the fracture is readily visible
even in the A-P image. In the central region, the fracture
gap does not appear to exceed 2 mm. The four-day follow-up radiograph shows significant lateral and central
expansion of the fracture gap indicative of secondary
displacement. Because of this, the fracture was reduced
and fixed with a small fragment screw on the fifth day after the accident. Four weeks later, the fracture had
healed in stable union
tures are not prone to secondary displacement
(Fig. 19.38; 170). In contrast, the complete fractures exhibit a fracture line that courses through
the entire trochlea into the joint. Here there is a
risk of secondary displacement even during immobilization in a plaster cast, resulting in late
union or nonunion (23, 134, 155, 170, 206, 207;
Figs. 19.40, 19.41). This means that these transcondylar fractures must immediately be recognized for what they are, by examining the lateral
radiograph.
However, it is not possible to distinguish
complete articular fractures from incomplete
fractures on the initial A-P and lateral radiographs
because the cartilaginous trochlea is not visualized. For this reason, some authors recommend
obtaining arthrograms or stress radiographs to
demonstrate the “instability” of the fracture (69,
91, 151). We disagree with this because a stress
radiograph is a painful method and arthrography
is both painful and invasive. We recommend initially immobilizing the nondisplaced fracture and
then obtaining a radiograph out of plaster on
about the fourth day. If no secondary displacement has occurred by this time, the injury is a
“stable” incomplete articular fracture that may
continue to be treated conservatively (see
Figs. 19.38, 19.45).
However, if secondary displacement has occurred, the injury is an “unstable” complete articular fracture. The most important area in evaluating primary or secondary displacement is the
central portion of the fracture, not the posterior or
lateral portion. Expansion of the fracture gap in
this central portion of the fracture that exceeds
2 mm indicates “instability” in the setting of a
160
Specific Injuries—Upper Extremities
Fig. 19.40 Sequelae of conservative treatment of an
“unstable” displaced fracture of the lateral condyle
of the humerus. The patient is an eight-year-old boy
with a displaced complete articular fracture of the lateral condyle of the humerus. The fracture was treated by
closed reduction and immobilized in an upper-arm plaster cast. The displacement of the peripheral fragment
and the compressive forces in the lateral elbow result in
significantly delayed union, a “transient pseudarthro-
sis.” After 12 weeks, a sufficient periosteal bridging callus had still failed to develop, and there was no bony
union in the fracture. The increased remodeling around
this area of delayed union caused lateral growth stimulation that led to increased lateral growth and varus displacement of the elbow axis. The slight fishtail deformity
is a sign of central instability. At the follow-up examination five years later, the fracture had solidly healed
complete articular fracture and should determine
the choice of therapy. With this procedure, it is
important to inform the parents that secondary
displacement can even occur when the injury is
immobilized in a cast and that removing the arm
from the cast to obtain a radiograph will not provoke displacement. This secondary diagnostic radiography will doubtless be replaced by ultrasound in the future. Ultrasound could then be used
to differentiate the two types of fractures in the
initial examination and immediately determine
the appropriate therapeutic procedure (208).
Two problems play an important role in these
fractures. One, discussed in the previous section,
is the danger of secondary dislocation with
delayed union that may progress to pseudarthro-
sis and severe articular deformities. The other is
the typical growth disturbance of the distal
humerus (12, 30, 61, 123).
Problems and Complications—Delayed Union
A risk of delayed union is present because of the
radial compressive forces in the elbow and the fact
that the distal humeral growth plate produces only
20% of the longitudinal growth in the humerus.
The annular ligament tethers the radial head
to the capitellum of the humerus via the collateral
ligament (76). Additionally, the lateral elbow is
subject to significant shear forces because of the
physiological valgus position of the elbow, which
exhibits individual and sex-dependent variation
between 5⬚ and 25⬚ (more in girls, less in boys).
Elbow Injuries
161
Fig. 19.41 Secondary displacement of a nondisplaced fracture of the lateral condyle of the humerus in a
nine-year-old girl. The initially nondisplaced fracture of
the lateral condyle was immobilized in a plaster cast and
treated conservatively. Increasing proximal and lateral
displacement of the peripheral fragment then occurred
in the cast. This was missed at the late radiographic
study to verify correct position performed on the 15th
day and only discovered on the radiograph out of plaster
obtained after four weeks. Even these findings failed to
influence the choice of treatment, with the result that
persistent pseudarthrosis developed during the further
clinical course
Under these conditions, the oblique fracture
plane of this fracture invites increasing proximal
and lateral displacement of the fragment in both
the sagittal and coronal planes (Fig. 19.41). The
displacing shear mechanism only fails to come
into play where the peripheral fragment initially
tilted and impacted into varus angulation or
where the fracture is incomplete and the fragment “hangs” medially (45). This latter case cannot be diagnosed in the initial radiographs be-
cause the trochlea is not yet visualized; at best a
secondary diagnosis can be made on the basis of
increasing or absent displacement of the peripheral fragment. Ultrasound will doubtless be able
to provide sufficient diagnostic information about
the initial situation of this fracture situation in the
very near future (208).
Increasing displacement of the fragment leads
to delayed union (10, 32, 155, 204), which may
only occur years later (Fig. 19.40). Consolidation
may also fail to occur at all (Figs. 19.41, 19.42).
162
Specific Injuries—Upper Extremities
a
Fig. 19.42 a and b Sequelae of conservative treatment of a displaced fracture of the lateral condyle of
the humerus. Severe displaced fractures of the lateral
condyle of the humerus on both sides occurred within
one year in this boy between age four and five. Both injuries were treated after attempted closed reduction by
immobilization in an upper-arm cast. During the further
clinical course, the persistent displacement resulted in
extremely severe pseudarthrosis with a slightly increa-
sing valgus deviation of the axis of the right elbow and 왘
an unchanged left elbow axis during the follow-up period 10 and 25 years later (a). As was to be expected, increasing irritation of the ulnar nerve developed on the
right side. This improved significantly after surgical anterior displacement of the ulnar nerve. Mobility was surprisingly symmetrical and unrestricted despite the severe bilateral joint deformities (b; from: 122)
Problems and Complications—Pseudarthrosis
pseudarthroses and never sequelae of growth disturbances. Where differences exceeding 10⬚ compared with the contralateral side exist, the danger
of late irritation of the ulnar nerve may only become acute 10–15 years after the accident. Additionally, very significant joint deformities will be
Where union fails entirely, the peripheral fragment will often increasingly displace proximally
and laterally. This results in a severe valgus deformity of the elbow. We should emphasize that
such valgus deformities are invariably sequelae of
Elbow Injuries
163
amination will often reveal symmetrical elbow
axes. This is because the valgus deformity of the
fragment is largely compensated for by the
growth stimulation and its sequelae (127; see
below). Where the valgus deformity is slight, the
sequelae of growth stimulation will outweigh it,
resulting in a varus elbow axis (2, 103, 121, 125,
132; Figs. 19.33, 19.43).
A fishtail deformity of varying severity may result as a sign of central instability in the setting of
conservative or surgical treatment (see
Figs. 19.40, 19.42, 19.43). This is not clinically significant because the joint does not bear the body’s
weight (45, 83, 123, 127, 141).
Delayed union itself leads to a typical posttraumatic growth disturbance, namely transient
stimulation of the lateral part of the growth plate.
This in turn produces more or less severe excess
lateral growth resulting in a corresponding varus
deviation of the elbow axis (58, 91, 123, 127, 152,
201). The extent of varus abnormal growth is
directly proportional to the duration of bony
union in the fracture gap, and this in turn depends
on the stabilization of the fracture. The more unstable the fracture is, the longer it will take to consolidate, and the more severe the varus deformity
will be (121, 123, 127, 167; Fig. 19.43).
Growth Disturbance—Closure
b
present (Figs. 19.42, 19.53). Surprisingly, mobility
in these joints is usually unrestricted. However,
they do exhibit instability. Late treatment of such
pseudarthroses is expensive and problematic (68,
126, 206, 207). At times, physicians will find themselves between a rock and a hard place: Opting to
stabilize the pseudarthrosis and in so doing stabilizing the elbow, can often lead to a significant restriction of motion. The patient may subjectively
experience this as more harmful than beneficial,
and it can represent a significant loss of well-being.
Growth Disturbance—Stimulation
Where the fracture still manages to consolidate
after increasing displacement, the follow-up ex-
Premature closure of the lateral portion of the
growth plate is possible (141), but by no means inevitable. It is invariably a sign of an overtaxed
growth plate and accordingly occurs only after repeated forceful attempts at closed and open reduction or following surgical treatment of fractures that were initially treated conservatively. It
is invariably preceded by the typical growth disturbance of partial transient stimulation, with a
corresponding varus component. Because the
share of growth of the capitellum growth plate
decreases with age compared with that of the
trochlear growth plate (83), the valgus effect of
partial closure is not sufficient to produce an excessive valgus deviation of the elbow axis. Usually, the most that happens is that an existing
varus deformity in progress is compensated for
(Fig. 19.44; 127). If the growth disturbance leads
to a dysplasia of the capitulum, a secondary radial
head dislocation can result (209).
Treatment
The most important goal of treatment is to prevent delayed union and development of pseudarthrosis and in so doing to avoid situations in
164
Specific Injuries—Upper Extremities
Fig. 19.43 The typical
growth disturbance in the
distal lateral humeral
growth plate. The patient
is a five-year-old boy with
an initially displaced fracture of the lateral condyle
of the humerus. Open reduction and Kirschner wire
pinning was performed on
the day of the accident, and
motion was allowed after
four weeks of immobilization once consolidation had
begun. During the further
clinical course, the typical
growth disturbance occurring in this region secondary to what may be termed unstable internal fixation
led to additional lateral
growth with varus deviation
of the axis of the elbow.
(My thanks to Prof. Havemann, Kiel, Germany, for
making these images available)
which the typical growth disturbances could become clinically significant. This means that initially displaced fractures must be fixed with sufficient stability to allow complete consolidation
within a maximum of four to five weeks. This in
turn means that nondisplaced “unstable”
complete intraarticular fractures must be recognized as such early and surgically stabilized at the
onset of secondary displacement. Nondisplaced
“stable” incomplete intraarticular fractures may
be treated conservatively as they will consolidate
within the normal period of time and clinically
significant sequelae of growth stimulation will
not occur. We arbitrarily define displacement as
the presence of a fracture gap exceeding 2 mm in
the central region of the joint (32, 123).
Nondisplaced fractures are treated conservatively by immobilization in a posterolateral
plaster splint with the elbow flexed 90⬚ and the
forearm in a neutral position. Four days after the
accident, we recommend obtaining a radiograph
out of plaster to exclude secondary displacement.
We regard signs of increasing displacement as an
indication for surgical fixation of the fragment,
and we perform the operation the next day.
Surgery performed longer than five days after the
accident usually proves difficult, represents renewed trauma, and exacerbates the sequelae of
the growth disturbance (213). If there are no signs
of increasing displacement on the fourth day after
the accident, we close the complete circumference of the splint to form a cast. Depending on the
patient’s age, another radiographic study to verify
correct position may be obtained eight days after
the accident. This is performed as a radiograph
out of plaster. If this study also fails to demonstrate increasing displacement, then conservative
treatment is continued (Fig. 19.45).
Immediate open reduction and internal fixation are indicated in the case of any displaced fracture. A percutaneous pinning of undisplaced incomplete articular fractures (173) is not necessary
at all. Our studies have shown that Kirschner wire
fixation cannot be relied upon to avoid pseudarthrosis and keep the sequelae of the growth disturbance from becoming clinically significant
(126; Fig. 19.43). However, internal fixation with a
small fragment screw to achieve metaphyseal
Elbow Injuries
165
Fig. 19.44 Rare growth disturbance in the distal lateral growth plate of the humerus. The patient is a sevenyear-old boy whose displaced fracture of the lateral condyle of the humerus was openly reduced on the day of the
accident and fixed with Kirschner wire pinning. Because
of delayed union, a second operation was performed six
weeks later and the fracture was compressed using a metaphyseal small fragment lag screw. The repeated trauma
led to premature closure of the growth plate of the capitellum (two-year follow-up, center). However, the expected abnormal valgus growth failed to materialize because the typical growth disturbance with additional lateral growth producing a varus deformity had occurred
first. The follow-up examination seven years later even revealed a slight varus deviation of the elbow axis compared with the uninvolved contralateral side
compression can accomplish this in nearly every
case. Therefore, we invariably attempt to stabilize
the fracture with a metaphyseal small fragment
screw. This is the only way to reliably compress
the fracture and achieve the short healing time required to minimize the typical growth disturbance and keep it from becoming clinically significant (Fig. 19.47; 33, 121, 123, 127, 167).
Access is gained through a posterolateral approach (193). A longitudinal incision is made in
the musculature to expose the metaphyseal fragment. This incision is extended to open the elbow
posteriorly. After the fracture has been carefully
reduced, the small fragment cancellous screw is
introduced at the broadest part of the metaphyseal fragment and advanced from distal and
lateral toward medial and proximal, taking care to
avoid injury to the growth plate (Fig. 19.47). If the
fragment is too small, we recommend using a
washer. The fracture must be compressed. If the
screw fails to sufficiently engage the cancellous
bone of the opposite column, then it must engage
the opposite cortex as well (Fig. 19.46). That will
invariably ensure sufficient compression.
In very small bones (such as in children below
age two), the fragment may be too small to accept
a screw. In such a case, the fracture will have to be
fixed with two Kirschner wires. However, as we
have noted, this will not guarantee reliable compression (121). Additional central intratrochlear
stabilization parallel to the distal growth plate is
recommended in every case; in small patients
this is best achieved with a Kirschner wire, and in
larger patients with a screw (Fig. 19.48; 35).
However, one should not succumb to the illusion
that this is easily accomplished, and the additional trauma should be carefully weighed against
the modest clinical benefit (avoiding a fishtail deformity).
Once anatomically flawless reduction and
good compression are achieved, they are verified
by intraoperative fluoroscopy. Postoperatively, a
posterior plaster splint may be applied for five to
eight days until swelling subsides. Where rigid internal fixation has been achieved, spontaneous
mobilization may then be allowed. Where fixation may be unstable, immobilization in a plaster
cast should continue for three to four weeks.
166
Specific Injuries—Upper Extremities
Fig. 19.45 Treatment of initial and secondary undisplaced fracture of the lateral condyle of the humerus.
Nondisplaced fractures can be treated conservatively.
However, the radiographic examination must exclude
any secondary displacement of the fracture in the cast.
In the case of a nine-year-old boy shown here, the radiograph out of plaster on the fourth day revealed no displacement in the central region. This was interpreted as
a sign of a nondisplaced, incomplete articular fracture (a
“hanging” fracture) and conservative treatment was
continued. After three weeks, the onset of periosteal
callus formation was observed without any change in
position. Later clinical follow-up examinations up to two
years after the accident failed to reveal any deviation in
the axis of the elbow. The two-year follow-up examination revealed symmetrical elbow axes and unrestricted
symmetrical function. Treatment was concluded on the
basis of these findings
Immobilization and Consolidation
the child’s age. Radiographs are again obtained at
this time. Unrestricted mobility usually returns
within four to six weeks after spontaneous motion is allowed. Once that occurs, the child may
resume sports activities without any restrictions.
Generally, follow-up may be limited to clinical
examinations at six-month intervals until two
years after the accident. Further radiographic
studies are indicated only when an alteration of
the elbow axis manifests itself, functional impairments appear, or the patient reports sudden pain.
Treatment may be concluded where the twoyear clinical examination demonstrates unrestricted function, elbow axes that are symmetrical or have remained unchanged for one year, absent or painless scarring, and no abnormal distal
neurovascular findings.
Nondisplaced fractures and displaced unstable
fractures are immobilized for a total of four weeks
in an upper-arm plaster cast. Where the radiograph out of plaster shows the onset of bony
union and a good periosteal bridging callus (the
latter can fail to develop even where ideal compression and ideal anatomical reduction have
been achieved) and the callus is no longer tender
to palpation, the patient is allowed to begin spontaneous mobilization.
Sports Participation and Follow-up Examinations
After another three weeks, the screw is removed.
This is done in an outpatient procedure if the scar
is otherwise painless, under general anesthesia
or, rarely, under local anesthesia, depending on
Elbow Injuries
167
a
b
Fig. 19.46 Treatment of secondary displacement in
a fracture of the lateral condyle of the humerus. The
patient is a three-year-old boy with a fracture of the lateral condyle of the right humerus. The fracture had been
deemed nondisplaced and immobilized in a plaster cast
because the central region could not be precisely evaluated. The radiograph obtained on the fourth day demonstrated significant displacement of the entire fragment in the central region on both the A-P and lateral radiographs. The entire fragment had not only slipped in
distal angulation but also exhibited anterior displacement. The fracture was therefore interpreted as a complete intraarticular fracture (an unstable fracture), and
was treated by internal fixation with metaphyseal compression. After four weeks, the fracture was healed and
stable (a). The metal implants were removed four weeks
postoperatively. At the final follow-up examination two
years later (b), both elbows exhibited unrestricted motion, and the right elbow axis exhibited a 5⬚ varus deviation compared with the left side. Radiographic findings
included a thickened right lateral condyle indicative of
the growth stimulation that had occurred
168
Specific Injuries—Upper Extremities
Fig. 19.47 Treatment of
an initially displaced
fracture of the lateral condyle of the humerus. Primary treatment of displaced fractures is invariably
surgical. Insofar as the size
of the metaphyseal fragment permits, every attempt should be made to
use a small fragment screw
to achieve metaphyseal
compression. In the absence of clinical evidence of
a growth disturbance, no
further radiographic studies
will be required after the
metal implants are removed. In the case of this
three-year-old girl, treatment was concluded two
years after the accident after clinical examination demonstrated unrestricted
function and symmetrical
elbow axes
Fracture of the Medial Condyle
of the Humerus
This fracture is extremely rarely encountered as
an isolated injury (185). It occurs more often in
older adolescents shortly before the growth
plates of the elbow close. Here, too, the injury is
an epiphyseal fracture with a metaphyseal wedge.
The diagnosis is easily made even in the case
of nondisplaced fractures because the metaphyseal fragment is invariably larger than on the
lateral side.
The risk of a growth disturbance is relatively
slight (Fig. 19.49). Here, too, a slight stimulation of
the medial portion of the growth plate with additional medial growth may be observed. This can
lead to a more or less severe valgus deviation of
the elbow axis. However, this has nearly no clini-
cal consequences because the valgus deformity
rarely differs more than 10⬚ from the contralateral
side (127). There is no danger of secondary displacement in these injuries because the continugous pressure of the radial head on the fragment is absent.
As in lateral fractures, we differentiate between nondisplaced and displaced fractures according to the severity of displacement in the
joint.
Nondisplaced fractures are treated conservatively in an upper-arm plaster cast. Here, a radiograph in plaster to verify correct position of the
fragments should be obtained after about eight
days.
Displaced fractures are treated by primary internal fixation and stabilized with one to two
compression screws depending on the size of the
Elbow Injuries
169
Fig. 19.48 Treatment of
initial and secondary displacement in a fracture of
the lateral condyle of the
humerus. Central stabilization of the fracture may be
improved by placing an epiphyseal lag screw or epiphyseal Kirschner wire in
addition to the metaphyseal compression screw. The
patient is a seven-year-old
boy with a completely displaced “unstable” fracture
of the lateral condyle of the
humerus. The fracture was
treated in an emergency
procedure by open reduction and internal fixation
with a metaphyseal lag
screw. To improve stabilization, a trochlear wire was
placed parallel to the
growth plate. After three
weeks, the fracture exhibited stable clinical and radiographic healing. The metal
implants were removed
after seven weeks. No
further radiographs were
obtained
fragments (Fig. 19.50). Internal fixation should be
rigid and allow motion so that there is no need for
immobilization. The duration of immobilization
for conservatively treated fractures is four weeks.
After this, assuming there is stable union and
good callus formation, the patient may begin
spontaneous mobilization without physical therapy.
Once unrestricted motion has been achieved
four to six weeks after spontaneous mobilization
has been allowed, the child may resume sports activities. The metal implants are removed between
six and 12 weeks postoperatively.
Because of the possible growth disturbance,
although its sequela is mild, treatment should
continue until two years after the accident or
until the growth plates have closed. Where
functional and cosmetic findings are normal upon
clinical examination at that time, treatment may
be concluded.
170
Specific Injuries—Upper Extremities
Fig. 19.49 Nondisplaced fracture of the medial condyle of the humerus. The patient is a nine-year-old boy
with a nondisplaced fracture of the medial condyle of
the humerus that had healed clinically and radiographically following three weeks of immobilization. Slight ad-
ditional medial growth occurred during the further clinical course. The follow-up examination after four years
accordingly demonstrated a slight valgus deformity
compared with the contralateral side, whereas motion
was unrestricted and symmetrical
Elbow Injuries
171
Fig. 19.50 Displaced fracture of the medial condyle
of the humerus. The patient is a 16-year-old boy with a
displaced fracture of the medial condyle of the humerus, a typical fracture in adolescents and adults. Internal
fixation allowing motion was indicated due to the severity of the displacement. This was achieved with three lag
screws. The metal implants were removed five months
postoperatively. Within six months of initial treatment,
the patient was subjectively asymptomatic and exhibited unrestricted and symmetrical function in both
elbows
Transcondylar Y Fractures of the Distal
Humerus
The injury is immobilized in a plaster cast for
four weeks postoperatively. The metal implants
should be removed 6–12 weeks postoperatively,
after which another radiographic examination is
performed. Once radiographic and clinical findings verify healing, the patient may spontaneously mobilize the arm until unrestricted
function is achieved. Treatment should continue—
These are very rare fractures and when only
slightly displaced are often indistinguishable
from supracondylar fractures of the humerus.
Here, too, the diagnosis is confirmed by the
course of the fracture gap on the lateral radiograph (Fig. 19.51).
Depending on the severity and location of displacement, lateral or medial growth disturbances
may occur. Usually, lateral stimulation outweighs
the medial disturbance, resulting in abnormal
varus growth (Fig. 19.52).
Here, too, the indicated treatment depends on
the severity of displacement.
Nondisplaced fractures are treated conservatively and immobilized in an upper-arm cast for
four weeks.
Primary treatment of displaced fractures is
surgical. Depending on the severity of the displacement, the posterior approach may be recommended. Otherwise, the respective displaced
condylar column can be reduced and fixed separately. Where only one column is displaced, the
nondisplaced column can be stabilized with only
a percutaneous Kirschner wire while the displaced column is openly reduced and stabilized
by internal fixation.
Fig. 19.51 Y fracture of the distal humerus. This fracture can easily be confused with supracondylar fractures
because the fracture component that enters the joint is
not always visualized on a radiograph. A fracture gap in
the A-P image coursing both from lateral and from medial toward the growth plate suggests a transcondylar Y
fracture
172
Specific Injuries—Upper Extremities
Fig. 19.52 Transcondylar Y fracture of the distal humerus. The patient is a seven-year-old boy with a nearly
nondisplaced transcondylar Y fracture. The articular involvement can only be detected on the lateral radiograph, where the fracture gap is seen to end anteriorly in
the growth plate. The injury was treated conservatively
as in all transcondylar fractures—until two years
after the accident or until cessation of growth.
Final follow-up may then include only a clinical
examination as with the other fractures, assuming that functional and cosmetic findings are normal.
by immobilization in a plaster cast. One year after the accident, significant varus deviation of the elbow axis was
observed as a sequela of additional lateral growth. Motion was symmetrical and unrestricted, and the patient
was free of symptoms
Elbow Injuries
Most Common Posttraumatic
Deformities of the Distal Humerus
Secondary to Transcondylar
Injuries
Valgus deformity and pseudarthrosis: Most
pseudarthroses increasingly migrate into the valgus deformity, which sooner or later causes irritation of the ulnar nerve. Function is rarely affected
(see Figs. 19.42 a,b). The pseudarthrosis should be
corrected as early as possible, effectively as soon
as it is diagnosed (68, 206, 207). The earlier this is
done, the greater the chances that joint reconstruction will be successful. I have since been
forced to revise the opinion that a large share of
function, which is usually good, occurs in the
pseudarthrosis. There are good reasons for stabilizing even severe pseudarthroses, and this will
not necessarily entail a significant loss of function
(see Fig. 19.53). The recommended method is to
provisionally stabilize the pseudarthrosis intraoperatively with two Kirschner wires and then
to evaluate function. If this test reveals that a large
share of function would be lost, then the attempt
to stabilize the pseudarthrosis is abandoned and a
varus supracondylar osteotomy is performed to
provide a stable base for the pseudarthrosis.
Otherwise, the pseudarthrosis is debrided and
compressed with an iliac bone graft and one to
two lag screws, better a reconstruction plate. Usually, there is no point in attempting reconstruction
of the joint itself. A varus stabilization will be sufficient to prevent the increasing valgus deformity.
There is a lack of consensus among the experts as
to whether a correction of the ulnar nerve should
be performed at the same time. There is no doubt
that it is more important to permanently eliminate the valgus deviation (Fig. 19.53).
Varus deformities secondary to fractures of
the lateral condyle are so rare that surgical correction is requested for cosmetic reasons. Usually, all
that occurs is that the physiological valgus position of the elbow is neutralized without the presence of an actual cubitus varus. A varus that
creates a cosmetic impairment may only be expected secondary to the extremely rare medial
growth disturbances involving partial premature
closure of the growth plate.
Medial premature closure of the growth plate
is a growth disturbance that we have observed in
only three patients to date. All three of these cases
were supracondylar fractures, possibly with involvement of the central portion, that were initially displaced and had been treated by percu-
173
taneous pinning with Kirschner wires. Medial
necrosis occurred in all three patients, which was
presumably iatrogenic. Strangely, this abnormal
growth ceased after about two to three years. In
one patient (Fig. 19.54 a–e), we then performed
surgical correction of the varus deformity without
recurrence of the abnormal growth. In all three
patients, the medial condyle had recovered and
the medial growth plate had “reopened.” Unfortunately, none of the patients had undergone an
initial MRI examination which could have been
used to evaluate the injury.
In the event that a correction becomes necessary, we perform it as previously described in the
section on supracondylar fractures of the
humerus (see also Figs. 19.37 a–f, 19.54 a–e). The
correction should be made either at a time determined by the patient or when the abnormal
growth has ceased to increase.
Malunion of fragments of the lateral condyle,
usually after initial attempts at internal fixation,
nearly always results in significant functional impairments. Usually, these cases manifest themselves too late, after the fracture has healed and
both the joint and the growth plate have adapted
to the new situation. An osteotomy to separate
the fragment again and reattach it correctly disrupts the adaptation, is certain to significantly
strain the growth plate, and forces a new situation
upon the joint to which it may not be able to
adapt, depending on the patient’s age. It is better
to wait until cessation of growth and, in the case
of severe functional impairments, to attempt to
mobilize the joint (87) or possibly venture a corrective osteotomy none the less. The fishtail deformity is not a deformity that requires correction. It verifiably does not lead to functional or
cosmetic impairments.
In this context, I will briefly mention the rare
peculiar complex growth disturbances and their
sequelae, which can lead to transient and occasionally even persistent deformities. Initial premature closure of the central part of the growth
plate and possible subsequent premature closure
of the lateral and medial parts leads to complex
abnormal growth with sequelae that usually persist. When dysplasia of the capitellum of the
humerus occurs in the setting of such a complex
process (whose exact causes remain unknown),
the radial head attempts to compensate for the
diminishing area of the opposite articular surface
by expanding in size and circumference. Finally, it
can dislocate (209). Treatment of such complex
situations can only be palliative according to the
loss of function (Fig. 19.55 a–c).
174
a
b
Specific Injuries—Upper Extremities
Fig. 19.53 Pseudarthrosis
following conservative
treatment of a fracture of
the lateral condyle of the
humerus. The patient is a
17-year-old boy with pseudarthrosis of an unstable
lateral condylar fracture (a).
Mobility was good with intermittent attacks of pain in
the ulnar nerve. As the EMG
study failed to detect any
significant nerve injuries,
stabilization of the condyle
without additional anterior
displacement of the nerve
appeared indicated. Intraoperative findings showed
that stabilization would not
result in any loss of function.
Therefore, the pseudarthrosis was debrided, an iliac
bone graft was interposed,
and the fracture was stabilized with two screws (b).
The ulnar nerve symptoms
promptly disappeared postoperatively, and the patient
remained completely free of
symptoms after consolidation of the pseudarthrosis (b).
However, the screws fractured during the course of
healing, necessitating secondary stabilization with
a reconstruction plate. The
pseudarthrosis then healed
under this treatment.
(my thanks to Dr. med.
T. Slongo, Inselspital Bern,
Switzerland, for these
images)
Elbow Injuries
175
a
c
b
Fig. 19.54 a – c Growth disturbance involving premature closure of the medial portion of the distal humeral growth plate. The patient is a two-year-old girl
with a “complicated” fracture of the distal humerus
(photographs on the day of the accident were not available) that was openly reduced and fixed with Kirschner
wires. During the further clinical course, a defect developed in the medial portion of the condyle with increa-
sing abnormal varus growth (a). The increase in abnormal growth ceased clinically (b) and radiographically
between three and four years after the accident. Therefore, we decided that a corrective osteotomy was indicated at that time. The valgus supracondylar humeral osteotomy was stabilized with an external fixator (c; my
thanks to Dr. med. M. Bittel, formerly of Bruderholzspital, Basel, Switzerland, for these images)
176
Specific Injuries—Upper Extremities
Fig. 19.54 d, e No further abnormal growth had occurred by the time of radiographic follow-up examination
after six years (e), confirming the clinical findings of a
corrected elbow axis (d). The ulnar condylar column was
completely restored by this time
d
e
Fig. 19.55 “Chance” complex posttraumatic deformity following a supracondylar fracture of the humerus.
This six-year-old boy suffered a completely displaced supracondylar fracture of the right humerus, which was
treated by emergency closed reduction and stabilized
with crossed Kirschner wires. The last radiograph, obtained two months after the accident, showed good union in an acceptable position with a slight rotational spur
(a). Four years later, the patient presented at our hospital complaining of a slowly increasing extension deficit
in the right elbow. The patient reported having suffered
no additional trauma nor had any inflammations occurred. The radiographs demonstrated a severe fishtail deformity; the capitellum of the humerus could not be correctly evaluated on the oblique radiograph. A clinical extension deficit of about 30⬚ was present, pronation and
supination were unrestricted, and the elbow itself was 왘
without irritation or other abnormal findings. After
another three years, the functional impairment had increased significantly with flexion and extension of
100–50–0⬚ with significantly restricted pronation and
supination. On the radiograph, the radial head exhibited
massive thickening with anterior subluxation (b). In light
of these findings, the decision was made to resect the
radial head, which improved mobility. Three years later
an extending supracondylar osteotomy was performed
to correct a persisting extension deficit of 50–60⬚, which
was a significant impairment for the patient. Complex
deformities of this sort cannot be initially predicted or
prevented. They can only be treated “palliatively” (c;
from: 122)
Elbow Injuries
177
a
b
c
178
Specific Injuries—Upper Extremities
Overview
Most Common Extraarticular and
Intraarticular Posttraumatic Deformities of
the Distal Humerus
앫 Cubitus varus
앫 Extreme valgus deformity with or without irritation of the ulnar nerve
앫 Persistent anterior bowing deformity (with flexion deficit)
앫 Persistent posterior bowing deformity (with extension deficit)
앫 Lateral pseudarthrosis
앫 Medial pseudarthrosis
앫 Fishtail deformity (radiographic finding)
Causes
앫 Cubitus varus:
— Untreated valgus deformity usually combined
with a rotational deformity following supracondylar fractures (Fig. 19.37),
— Medial growth arrest with transient partial
closure of the growth plate (Fig. 19.54),
— Transient lateral growth stimulation following
unstable internal fixation of fractures of the
lateral condyle (see Fig. 19.43).
앫 Extreme valgus deformity:
— Lateral pseudarthrosis following conservative
treatment of displaced fractures of the lateral
condyle,
— Transient medial growth stimulation following fractures of the medial condyle in the
presence of open growth plates.
앫 Pseudarthrosis:
— Conservatively treated displaced fractures of
the lateral condyle,
— Conservatively treated fractures of the medial epicondyle (in 50% of all cases),
— Surgically treated fractures of the medial epicondyle (in slightly less than 10% of all cases).
앫 Fishtail deformity: Partial premature closure of
the central portion of the growth plate, combined with additional lateral and medial growth
following displaced, conservatively treated, and
healed fractures of the lateral condyle and Y
fractures.
Indications for Correction
앫 Cubitus varus: Cosmetic (rare functional impairment or irritation of the ulnar nerve).
앫 Extreme valgus deformity: Where difference
exceeds 10⬚ to preserve the ulnar nerve.
앫 Persistent anterior bowing deformity:
Functional impairment.
앫 Persistent posterior bowing deformity:
Functional impairment.
앫 Lateral pseudarthrosis: Increasing cubitus valgus, ulnar nerve pain, instability.
앫 Medial pseudarthrosis: Pain with exercise, irritation of the ulnar nerve.
앫 Fishtail deformity: None.
Correction Technique
— Cubitus varus and extreme valgus deformity,
persistent anterior or posterior bowing deformity: External fixator (Compact II or yellow
Monotube from Stryker Howmedica, see
Figs. 19.37, 19.54).
— Lateral pseudarthrosis: Debridement and reconstruction of the joint, stabilization with
screws and plates if necessary.
— Medial pseudarthrosis: Debridement and stabilization with screws; simultaneous displacement of the ulnar nerve if indicated by findings.
Elbow Injuries
179
Proximal Forearm
Radial Head (1.3%)
Forms
앫 Subcapital fractures in 75% of all cases.
앫 Separated epiphyses (Salter–Harris types I and II)
in 25% of all cases.
A-P and lateral radiographs.
Limits of correction
앫 Below the age of nine or ten, 50⬚ of lateral angulation.
앫 Above the age of nine or ten, 10⬚ of lateral angulation.
Problem: Each trauma (including reduction and
surgery) leads to partial necrosis and thickening of
the radial head and neck.
Definition of “nondisplaced“
앫 Up to the age of nine or ten, up to a maximum of
50⬚.
앫 Above the age of nine or ten, up to a maximum
of 10⬚.
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Medical.
앫 Where indication is uncertain: Immobilization in an upper-arm plaster splint.
Emergency
treatment
under
anesthesia:
Completely displaced fragments (e.g., in a dislocation).
!
All other indications should first be discussed at
length with the patient and his or her parents.
Further treatment without anesthesia or delayed
treatment under anesthesia
앫 “Nondisplaced” fractures are treated conservatively.
앫 Displaced fractures are treated with closed reduction.
Technique of conservative fixation: Upper-arm
plaster splint.
Technique of internal fixation
앫 Closed reduction with the aid of an intramedullary Kirschner wire.
앫 Where closed reduction is unsuccessful or
fragments are completely displaced, the fracture is carefully reduced openly without
further stabilization.
앫 Lateral Kirschner wires or absorbable pins are
used only in absolutely unstable fractures.
앫 The indication for open reduction should be
defined as restrictively as possible.
Cave
앫 Avoid late reduction or a change in therapy.
앫 Do not perform Witt transarticular wire fixation
(this obsolete treatment leads to severe avascular necrosis, chronic separated epiphyses, and
wire fractures).
앫 Do not resect the radial head where growth
plates are open.
앫 Do not use pledgets or screws where growth
plates are open.
앫 Avoid protracted immobilization.
앫 Avoid physical therapy.
Aftercare
Period of immobilization
앫 With conservative and internal fixation: 10–14
days at maximum.
Consolidation radiographs: Two to three weeks
after the accident.
Initial mobilization: Spontaneous mobilization immediately after removal of the plaster splint prior to
obtaining consolidation radiographs.
Physical therapy: None!
Sports: Four to five weeks after consolidation.
Removal of metal implants: The intramedular nail is
removed intraoperatively immediately after reduction, percutaneous Kirschner wires after 10–14 days.
Follow-up examinations and conclusion: At threeto four-week intervals until unrestricted function has
been restored. In the case of fractures with angulation that has been left untreated, clinical and radiographic follow-up examinations are performed every
six months until the angulation has disappeared.
Treatment is concluded only when unrestricted function has been restored.
180
Specific Injuries—Upper Extremities
Fractures of the Proximal End
of the Radius
Forms of Injury
These fractures are about as common as fractures
of the lateral condyle of the humerus. One third of
them occur as separated epiphyses (with or
without a metaphyseal wedge) and two thirds as
subcapital fractures of the radial neck (Fig. 19.56).
Epiphyseal fractures have occasionally been described in the literature (83, 186).
Fig. 19.57 Diagnostic radiography of the distal end
of the radius. Displaced fractures are easily diagnosed.
Fractures with slight angulation are often difficult to detect. Here a metaphyseal (usually lateral) zone of impaction helps identify the injury
Diagnosis
Fractures with significant angulation are easily
diagnosed. However, slightly displaced fractures
can be overlooked, especially if the proximal end
of the radius has not been visualized in exactly the
right projection on the radiograph or if the
epiphyseal growth center of the radius is not yet
visible. A metaphyseal disruption of the cortex or
a metaphyseal zone of impaction is a sign of a
fracture (Fig. 19.57). Angulation can be measured
with the aid of the epiphyseal axis angle.
Problems and Complications
The most important set of problems that can
occur in this fracture involves the blood supply to
the radial head. The radial head is supplied by periosteal vessels in the neck. As a result, any trauma
to the proximal end of the radius (with or without
a fracture) will produce an aseptic necrosis of the
radial neck and head of varying severity (54, 116,
Shaft
Articular
Fig. 19.56 Fracture of the proximal end of the radius. These are nearly exclusively metaphyseal fractures,
two thirds are subcapital neck fractures, and one third
are separated epiphyses with or without a metaphyseal
wedge (left). Articular fractures with or without metaphyseal involvement (right) are rare in the presence of
open growth plates
216). This can lead to slight shortening of the
proximal end of the radius with a tendency
toward slight valgus deviation of the elbow axis.
However, the simultaneous widening and thickening of the radial head and neck are more significant; in extreme cases, this can restrict pronation
and supination. Notwithstanding this causative
mechanism, the results of our late studies of these
fractures indicate that functional impairment is
less likely to be attributable to such deformities
than to additional soft-tissue injuries from prior
trauma. Such prior trauma also includes iatrogenic trauma such as closed and open reduction
(54, 116).
The severity of this thickening appears to depend largely on the severity of the primary and
secondary trauma. The thickening is less pronounced following contusions such as can occur
in elbow dislocations (125) and more pronounced
following fractures of the proximal end of the
radius. Additionally, the thickening of the radial
head and neck is more severe following closed or
open reduction of displaced fragments than in
cases where the fracture was not reduced (131;
Fig. 19.58).
This means that the proximal end of the radius
essentially reacts to any trauma with deformation
of varying severity. Trauma includes not only the
accident but also iatrogenic trauma. Iatrogenic
trauma includes the transarticular Kirschner wire
fixation described by Witt (148, 149), which often
leads to wire fractures and invariably represents
chronic traumatization of the radial growth plate,
head, and neck. This is an absolutely obsolete
treatment and should no longer be used at all (22,
27, 38, 64, 77, 78, 82, 108, 140). Iatrogenic trauma
also includes the “triad of errors” applied by most
nonpediatric surgeons: incorrect indication, incorrect technique, and incorrect aftercare. Partic-
Elbow Injuries
181
Fig. 19.58 Posttraumatic deformities of the proximal end of the humerus. This 11-year-old girl suffered a
completely displaced subcapital fracture, which was
openly reduced and stabilized with a Kirschner wire. The
combination of healing with an uncorrected side-to-side
deformity and the severe aseptic necrosis in the radial
head led to significant deformation of the entire proximal radius with greatly restricted pronation and supination
ularly this last error in the form of excessive
physical therapy coupled with excessive prior immobilization, is one of the harshest sorts of
trauma to which the radial head can be subjected
(137, 212; Fig. 19.59).
We are unable to say whether subsequent
radioulnar synostosis may be attributable to reduction maneuvers or solely to the type of injury,
for example, an injury involving avulsion of the
annular ligament from its ulnar insertion (83). At
least such synostoses are not only encountered
secondary to severely displaced fractures (130).
However, significant traumatization of the
soft-tissue envelope with its sequelae can in itself
play a crucial role in the development of a pronation and supination impairment. This is confirmed by the poor results usually reported after
open reduction (46, 81, 91, 101, 131, 138).
182
Specific Injuries—Upper Extremities
a
b
Fig. 19.59 Iatrogenic traumatization of the proximal end of the radius. 왘
The patient is a 15-year-old boy with a separated distal radial epiphysis with angulation and a proximal radial epiphysis with 80⬚ of angulation. The fracture of
the proximal radius had been openly reduced and fixed with a transarticular
Kirschner wire (a). The fracture was then immobilized for six weeks. Immediately after this, the wire was removed and intensive physical therapy was begun. The consolidation radiograph showed a healed proximal fracture in good
position with an extensive periosteal bridging callus (b). In the 11 weeks that
followed, physical therapy succeeded in creating a chronic separated epiphysis
(c). Despite cessation of physical therapy, the injury finally healed with great
difficulty and produced a severe deformity of the proximal end of the radius
(d). As the five-year follow-up image shows, this deformity resulted in near total impairment of pronation and supination (my thanks to Prof. P. Ochser, head
of the orthopedic and trauma clinic at Kantonspital Liestal in Liestal, Switzerland, for these images)
Elbow Injuries
183
d
c
184
Specific Injuries—Upper Extremities
“Spontaneous Corrections”
Severe side-to-side displacement exceeding half a
shaft width can exacerbate the thickening of the
proximal end of the radius. This is the only location in the immature skeleton where such displacements are not corrected by further growth
(129; Fig. 19.60).
In contrast, there is enormous potential for
correction of axial deviation in the coronal and
sagittal planes (36, 50, 56, 116, 152). Given that
this region of the body bears no weight and the
growth plate accounts for only 20% of longitudinal growth, one would hardly expect these corrections. In spite of this, they reliably occur and
can eliminate, depending on the patient’s age and
sex, up to 60⬚ of angulation in the coronal and/or
sagittal planes in patients under age 9–10 (131).
Normally, only a very short time is required for
the correction, which suggests that the realignment of the peripheral fragment is more the result of mechanical forces than of further growth
(Fig. 19.62).
Growth Disturbances
The transient stimulation of the proximal radial
growth plate or its sequela that may be expected
after shaft fractures is largely compensated for by
the shortening effect of the radial head aseptic
necrosis (127).
Fig. 19.60 Limits of “spontaneous correction” in the
proximal end of the radius. This is the only location in
the skeleton in which side-to-side displacement is not
corrected but persists unchanged. In this 10-year-old
The growth disturbance of partial premature
closure of the growth plate is possible, but extremely rare (36, 131, 142, 152). It does not occur
as a result of an epiphyseal fracture. It results from
disruption of epiphyseal vascular supply, usually
in the medial region, and also occurs secondary to
separated epiphyses and subcapital fractures. The
physeal bridge that then occurs leads to increasing medial shortening with a corresponding deformity of the radial head. The result is a
functional impairment of pronation and supination (Fig. 19.61 and 19.65).
Treatment
The goal of therapy should be to protect the radial
head against all unnecessary traumatization in
the interest of preserving function yet also to
avoid leaving intolerable deformities uncorrected.
For these reasons, we initially leave angulation of a maximum of 60⬚ untreated without any
attempt at reduction in patients up to age
9–10. All we do is immobilize the injury in a posterolateral plaster splint (Fig. 19.62 ). After 10–14
days, we remove the splint, and the patient begins
spontaneous motion exercises. After three to four
months, unrestricted and symmetrical motion in
pronation and supination has usually returned.
Side-to-side displacement exceeding half a
shaft width should be treated by closed reduction
where a cautious attempt at pronation and supi-
boy, side-to-side displacement of one third shaft width
remained uncorrected at the four-year follow-up examination. This examination revealed unimpaired pronation
and supination
Elbow Injuries
185
Fig. 19.61 Growth disturbance in the proximal radius. Premature partial closure of the proximal radial
growth plate can occur secondary to subcapital fractures or secondary to separated epiphyses and epiphyseal fractures. In this nine-year-old girl who suffered a
Mongteggia fracture-dislocation involving a separated
proximal radial epiphysis with a metaphyseal wedge, the
medial side of the proximal radial growth plate closed
prematurely. This resulted in an increasing deformity
with restricted motion in pronation and supination
nation indicates a near total blockade of this function. Where this is not case, the side-to-side displacement may be left uncorrected.
Angulation exceeding 60⬚ in patients up to age
10 and angulation exceeding 20⬚ in patients above
age 10–12 should be treated by closed reduction.
This is best done using the technique described by
Maitezeau (see literature for General Science,
Treatment, and Clinical Considerations: 24; 161,
168, 190, 202). A Kirschner wire slightly angled at
the tip is introduced from the distal radial
metaphysis and advanced through the medullary
canal. Just short of the angulated fragment, the
wire is rotated so that its angled tip points toward
the peripheral fragment. Then the wire is advanced to slightly beneath the fragment and rotated 180⬚. This usually causes the fragment to reduce into correct axial alignment without any additional manual manipulation. We recommend
then withdrawing the wire slightly and evaluating pronation and supination under fluoroscopy
(Fig. 19.63). If this motion is unrestricted and the
fragment is stable, then the wire can be withdrawn again, sparing the patient a second operation to remove the metal implant. The assumption
that this single Kirschner wire represents rigid in-
186
Specific Injuries—Upper Extremities
Fig. 19.62 Treatment of fractures of the proximal
end of the radius. Angulation in the coronal and sagittal
planes up to 50–60⬚ maximum can be treated by initial
immobilization without reduction in patients up to age
9–10. In this 10-year-old boy, the proximal radial fracture
with 50⬚ of angulation was initially left uncorrected and
immobilized in an upper-arm plaster splint for two
weeks. The consolidation radiograph obtained after two
weeks showed that angulation had been reduced by
about 15⬚. Functional aftercare was then begun. The follow-up radiograph obtained after eight months showed
a residual deformity of only 10⬚. Motion was unrestricted
and symmetrical. The two-year follow-up examination
revealed slight deformation of the radial head and 5⬚ of
residual angulation with unrestricted and symmetrical
function. There was no clinical evidence of a valgus deviation of the elbow axis compared with the contralateral side
ternal fixation that allows motion has yet to be
proved. This procedure also appears to succeed
with fragments angulated 90⬚ if the surgeon
presses the fragment directly upward manually.
We ourselves have not yet had any experience
with this specific technique. Where the fragment
is displaced into the joint (Fig. 19.64), the only option is primary open reduction, which should be
performed as atraumatically as possible.
A posterolateral approach is made through a
longitudinal incision between the radial head and
the olecranon to avoid injury to the deep branch
of the radial nerve. Generally, it will not be necessary to fix the radial head once it has been reduced. Fixation will be required only in adolescents shortly before cessation of growth or in absolutely instable situations. In these patients, the
fracture is stabilized with a fine Kirschner wire introduced from lateral (Fig. 19.65).
In patients above age 10, we feel that closed
reduction is indicated in the presence of angulation exceeding 20⬚, while open reduction is indicated for completely displaced fractures.
Elbow Injuries
187
Fig. 19.63 a Closed reduction of fractures of
the proximal end of the radius with slight
angulation in patients beyond age 10. This
11-year-old girl suffered a separated proximal
radial epiphysis with 40⬚ of lateral angulation
and 30⬚ of posterior angulation. Because of the
patient’s age and the severity of displacement,
atraumatic closed reduction was indicated. This
was achieved using a distally introduced intramedullary nail instead of the Kirschner wire
used by Maitezeau. The nail was withdrawn intraoperatively and passive pronation and supination were evaluated under fluoroscopic control. This motion was unrestricted despite the
10⬚ of residual angulation, and the position of
the fragments remained completely unchanged
and stable. The nail was therefore removed, unrestricted pronation and supination were again
evaluated and the position of the fragments
was verified by fluoroscopy. The elbow was
then immobilized for 10 days in an upper-arm
plaster splint. This was followed by spontaneous motion exercises without physical therapy
a
188
Specific Injuries—Upper Extremities
c
b
Fig. 19.63 b, c The radiographic follow-up study after two weeks verified unchanged position with the
beginning of a periosteal bridging callus (b); the
fracture was clinically healed, and the range of motion in
pronation and supination at the time was 60–0–70⬚.
Functional tests six weeks after the accident revealed
unrestricted symmetrical function and symmetrical elbow axes (c)
Elbow Injuries
189
Fig. 19.64 Treatment of fractures of the proximal
end of the radius. This 10-year-old boy suffered a completely displaced separated proximal radial epiphysis.
Careful open reduction was initially performed because
of the severity of the displacement. Reduction was stable despite the slight side-to-side displacement of the
fragment, and intraoperative evaluation of motion revealed unrestricted pronation and supination. Therefore, no additional fixation was performed. At the time,
the fracture was immobilized in an upper-arm plaster
splint for slightly less than three weeks, after which the
patient began spontaneous motion without any physical
therapy. After five months, the fracture was found to
have healed in correct alignment, and motion in both elbows was unrestricted and symmetrical. The 10-year follow-up examination verified good early functional and
cosmetic results without the occurrence of any deformation
Immobilization and Consolidation
In principle, it will be sufficient to perform
clinical follow-up examinations until two years
after the accident. Radiographic studies are indicated where function remains impaired beyond
the first five months or where motion becomes
increasingly restricted. These studies are indicated to exclude growth disturbances and to
document and evaluate the extent to which the
deformity is corrected. Where the elbow axes are
symmetrical and the patient exhibits unrestricted
and symmetrical function, treatment can be concluded two years after the accident based on clinical findings.
In every case, we feel that early use is important
for revascularization of the radial head and not
long immobilization. The fracture has basically
healed within two weeks. No physical therapy
should be prescribed.
Sports Participation and
Follow-up Examinations
Patients will be able to participate in sports once
the fracture has consolidated, i.e., when it is no
longer painful, which is usually about four to five
weeks after the accident. Note that the patient
may not yet have regained the full range of pronation and supination at this time and accordingly
may initially have to refrain from certain sports.
190
Specific Injuries—Upper Extremities
Fig. 19.65 Treatment of
fractures of the proximal
end of the radius. Primary
treatment of completely
displaced fractures must be
surgical. In this 13-year-old
boy, the radial fracture was
initially reduced openly and
stabilized with a thin Kirschner wire. During the further
clinical course, remodeling
that caused significant deformation of the radial head
was accompanied by premature closure of the
growth plate on the medial
side, which in turn resulted
in abnormal growth until
growth ceased. Pronation
and supination were obstructed in the neutral position. Three years postoperatively, it was not yet possible to perform a resection
of the radial head because
the distal radial growth
plate was still open
Most Common Posttraumatic
Deformities of the Proximal Radius
Where angulation of the radial head has not been
“spontaneously” corrected in patients beyond age
10–12 and a functional impairment has resulted, a
subcapital osteotomy should be attempted to restore correct position as early as possible.
However, the physician and the patient must both
understand that this is experimental surgery: All
fixation techniques that spare the growth plate do
not provide rigid fixation that allows motion. This
effectively dictates that one proceed as in the
treatment of an acute fracture. One possible compromise is to use absorbable pins to stabilize the
osteotomy and to immobilize it in a splint for only
a short period (about five to eight days), after
which spontaneous motion may be allowed
without any physical therapy. The result will be a
matter of luck. Postponing the operation until
growth has ceased so as to use rigid internal fixation that allows motion poses a different problem.
By that time the functional impairment will have
become so entrenched by the adaptation of soft-
Elbow Injuries
tissue structures that an improvement in motion
cannot be achieved without arthrolysis. The intensive aftercare required by that treatment
would in turn put the internal fixation at risk. The
situation is similar in a deformity resulting from
the growth disturbance due to premature closure
of the growth plate (see Fig. 19.65) where correction is obviously indicated only after cessation of
growth.
Where thickening of the radial head is responsible for a restricted range of motion, the
radial head may be resected after cessation of
growth to correct severe cases of restricted motion (52). However, care must be taken to ensure
that the distal radial growth plate is also definitely
closed. Otherwise, even a resection performed on
the proximal end of the radius could lead to
severe abnormal growth in the stump of the
radius with damage to the elbow joint, such as
would occur with an open proximal growth plate
(Fig. 19.66). Therefore, it is crucial to obtain radiographs that include the distal radial growth plate
prior to any resection of the radial head (note that
the distal growth plate only closes between age 16
and 18).
191
Chronic separated epiphyses with secondary
displacement or enormous secondary thickening
with corresponding functional impairments
(Fig. 19.67) are invariably attributable to errors on
the part of the physician in planning and performing treatment and aftercare (incorrect indication,
incorrect technique, and incorrect aftercare), in
other words, to severe iatrogenic traumatization
(such as physical therapy). In the case of thickening, surgical remodeling may be attempted in an
effort to improve function. In the case of persistent pseudarthrosis, the only option is resection of the radial head.
To prevent a constant or increasing valgus deformity of the elbow axis and instability following
resection of the radial head, the resected head
may be replaced with a prosthesis. However, secondary fractures, angulations, and dislocations of
these prostheses should not come as a surprise in
young and very active patients. For this reason,
this type of treatment in young patients has
largely fallen from favor (50).
The surgical elimination of radioulnar synostoses in this region is among the most thankless
tasks imaginable (20). With a lot of luck, it may be
Fig. 19.66 Sequelae of a
premature resection of
the radial head. In this
nearly 15-year-old boy with
a closed proximal radial
growth plate, the radial
head was resected to correct posttraumatic deformation with restricted motion of the head. However,
the still open distal growth
plate triggered unexpected
deformative growth that
initially went unnoticed in
the region of what was
once the radial head. This
eventually led to severe destruction of the lateral portion of the joint
192
a
b
Specific Injuries—Upper Extremities
Fig. 19.67 Posttraumatic 왘
deformities of the radial
head. The patient is a 10year-old boy with a dislocated elbow accompanied by a
separated proximal radial
epiphysis. As the epiphysis
was completely displaced into the joint, it was correctly
deduced that open reduction
was indicated. However, the
type of internal fixation used
with open growth plates
must be characterized as incorrect (a) as was the case
with the aftercare, which
consisted of four weeks of
immobilization. Then the
metal implants were removed and intensive physical
therapy was performed. This
led to a chronically separated
epiphysis with increasing displacement of the fragment
until the six-month follow-up
examination (b). Clinical
examination demonstrated a
significant extension deficit
with unrestricted pronation
and supination (c). The ulnar
advancement due to
shortening of the radius (b)
is readily visible in the wrist
Elbow Injuries
193
With the radial head in particular, we must
subject our primary treatment to close critical
scrutiny: Our previous experience has shown that
90% of all posttraumatic deformities in this region
are iatrogenic and avoidable (137). We were only
able to classify 10% of these cases as unavoidable
misfortunes. There is no sound treatment for any
of these deformities; in many cases, the only option is the mutilating resection of the radial head.
This makes it all the more important to devote our
full attention to atraumatic primary treatment.
Overview
Most Common Deformities of the
Proximal Radius
1. Persistent or increasing axial deviation
2. Thickening of the radial head and neck
3. Chronically separated epiphyses
4. Radioulnar synostoses
Causes
Re 1. Iatrogenic: Angulation improperly left uncorrected, rarely growth disturbance.
Re 2. Iatrogenic: Incorrect indication, incorrect
technique, and incorrect aftercare.
Re 3. Iatrogenic: Incorrect indication, incorrect
technique, and incorrect aftercare.
Re 4. Chance occurrence or iatrogenic: Incorrect
indication, incorrect technique, and incorrect
aftercare.
Indications for correction: Functional impairment.
Time of correction: As soon as possible.
Correction technique
c
possible to prevent recurrence of the synostosis
with a Silastic membrane. However, the thickening of the radial head and the changes in the
capsular ligaments that usually follow the trauma
of surgery will in turn negate any functional improvement. But new reports about new methods
of eliminating radioulnar synostosis are a hopeful
sign (175, 187). Occasionally, it may be a better
idea to perform an osteotomy in the synostosis to
improve the position of the hand according to the
patient’s specific occupational needs (215). Slight
pronation of about 20⬚ or a neutral position is
most suitable for the requirements of daily life.
Re 1. Osteotomy to attempt to correct alignment
(stabilized with absorbable pins where
growth plates are still open, rigid internal
fixation that allows motion where growth
plates are closed).
Re 2. Remodeling of the radial head with arthrolysis or resection of radial head.
Re 3. Resection.
Re 4. Possible corrective osteotomy in the synostosis.
Aftercare: Functional aftercare.
194
Specific Injuries—Upper Extremities
Proximal Forearm
Olecranon (0.4%)
Isolated fractures of the olecranon are rare; usually
they occur in combination with dislocations or fractures of the radial head.
Forms
앫 Intraarticular
앫 Extraarticular
A-P and lateral radiographs.
Definition of dislocation
앫 Presence of a fracture gap wider than 2–3 mm
(risk of increasing displacement due to traction
of the triceps).
Limits of correction: Ideal position.
Definition of “nondisplaced“
앫 For intraarticular and extraarticular fractures: No
axial deviation.
앫 For intraarticular fractures: Fracture gap is barely
visible (⬎ 2 mm).
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Medical.
앫 Where indication is uncertain: Immobilization in an upper-arm plaster splint.
Emergency treatment under anesthesia
앫 Completely displaced fractures with a significant gap between the fragments.
앫 Where there is an associated dislocation of
the radial head or fracture-dislocation.
!
All other indications should first be discussed at
length with the patient and his or her parents.
Further treatment without anesthesia or delayed
treatment under anesthesia
앫 Impacted transverse and oblique fractures are
treated conservatively.
앫 Secondarily displaced fractures are treated
surgically.
Technique of conservative fixation: Upper-arm
plaster splint with the elbow flexed 90⬚.
Technique of internal fixation
앫 Transverse fractures are treated with classic
tension banding internal fixation.
앫 Oblique fractures are treated with plate or
possibly screw fixation.
Aftercare
Period of immobilization
앫 With conservative fixation: Three weeks.
앫 With internal fixation: Immediate spontaneous
motion.
Consolidation radiographs: Yes.
Initial mobilization: Immediately postoperatively
after stable internal fixation, otherwise spontaneously after removal of the plaster splint.
Physical therapy: None.
Sports: Four to six weeks after consolidation.
Removal of metal implants: 12 weeks postoperatively.
Follow-up examinations and conclusion: At threeto four-week intervals until unrestricted function has
been restored, at which time treatment is concluded.
Elbow Injuries
195
Isolated Fractures of
the Proximal Ulna
Forms of Injury
앫 Fractures of the olecranon
앫 Fracture of the coronoid process of the ulna
Fractures of the olecranon are rare injuries that
usually occur as oblique and transverse intraarticular or extraarticular fractures (7, 90, 156, 160,
162, 163, 176, 192, 218; Fig. 19.68). More often
they occur in combination with other injuries,
primarily in the setting of a dislocation of the
radial head or a proximal radial fracture (70), in a
Monteggia fracture-dislocation.
Diagnosis
Diagnostic problems arise particularly in younger
patients in whom the normally multicentric ossification centers of the olecranon are not visible on
radiographs (160). Aside from clinical symptoms,
the only radiographic signs of these injuries may
be a fine flake at the tip of the proximal ulnar
metaphysis (Fig. 19.69).
There are no known growth disturbances.
Problems and Complications
Transverse intraarticular fractures in particular
can increasingly displace under traction from the
triceps whereas oblique fractures, which are generally extraarticular, do not exhibit this tendency.
Extraarticular oblique fractures often exhibit
varus displacement, rarely valgus displacement.
These deformities are hardly corrected at all
during the course of further growth (Fig. 19.70).
Fig. 19.69 Diagnosis of nondisplaced fractures of the
olecranon. Displaced fractures are no problem to diagnose. Nondisplaced fractures, as in this patient, are often
detectable only as a fine gap in the metaphyseal region.
Nondisplaced fractures are invariably treated conservatively in an upper-arm plaster cast for two to three weeks
Fig. 19.68 Fractures of the olecranon. Intraarticular transverse or oblique fractures (left); extraarticular
transverse or oblique fractures
(right)
196
Specific Injuries—Upper Extremities
a
Fig. 19.70 The limits of “spontaneous corrections” 왘
in the proximal ulna. Axial deviations in the coronal
plane persist uncorrected during the course of further
growth. Extraarticular transverse and oblique fractures
are treated conservatively. Note, however, that axial deviations in the coronal plane in particular must be precisely eliminated. In this seven-year-old girl, an extraarticular fracture of the olecranon consolidated in a varus
axial deviation of 25⬚ (without dislocation of the radial
head). This deformity persisted unchanged until the follow-up examination five years later (a). However, the follow-up examination after 15 years suggested that a
slight “spontaneous correction” had indeed occurred
(insofar as the detail radiograph allowed evaluation).
The residual varus deformity had been reduced to about
15⬚ and was no longer clinically detectable (b). Motion in
both elbows was symmetrical and unrestricted, and the
elbow axes were symmetrical (c)
The degree of displacement that may be tolerated
is determined by the possible functional impairment in pronation and supination and far less so
by cosmetic considerations.
Treatment
b
Nondisplaced intraarticular and extraarticular
transverse and oblique fractures are treated conservatively in an upper-arm plaster splint
Elbow Injuries
197
age five, rapid healing makes it is possible to dispense with tension banding in transverse fractures, which may simply be fixed with two Kirschner wires (162). However, this will then invariably require three weeks of immobilization in a
plaster cast. This also applies to oblique fractures,
which may be treated with minimal internal fixation in the form of one to two lag screws. Older
patients receiving rigid internal fixation with tension banding will of course not require additional
immobilization in a cast.
A posterior surgical approach is made through
an S-shaped skin incision over the olecranon.
After the ulnar nerve has been identified, the fracture is reduced and fixed. Transverse fractures are
fixed by the standard tension banding method,
with which the reader is presumably familiar. Oblique fractures are fixed with one to two screws; a
one-third tubular plate may also be used if necessary (see Fig. 19.82). In children treated only with
Kirschner wire fixation, we let the wires project
percutaneously in the usual manner to facilitate
subsequent removal. In tension banding fixation,
we bend the ends of the wires over and submerge
them.
Immobilization and Consolidation
The fracture is immobilized for four weeks until
consolidation. Then the patient may begin spontaneous motion exercises.
X-rays in plaster are required only for fractures treated by closed reduction and are obtained eight days after reduction. Fractures
treated by surgical reduction and initially nondisplaced fractures do not require any additional
radiographs to verify correct position.
Sports Participation and
Follow-up Examinations
c
(Fig. 19.69). Displaced intraarticular and extraarticular transverse and oblique fractures are
openly reduced and stabilized either by tension
banding (Fig. 19.71) or screw fixation in the case
of transverse fractures or by screw fixation in the
case of simple oblique fractures (see Fig. 19.82).
The rare comminuted fractures can usually only
be stabilized with a reconstruction plate or a onethird tubular plate. In young patients up to about
Unrestricted motion is achieved about four to six
weeks after spontaneous motion is allowed. At
that time, the patient may resume sports participation without any restrictions. Metal implants
should generally be removed between 12 and 14
weeks after the accident.
Radiographic follow-up studies are no longer
required once the patient is asymptomatic with
unrestricted function. A clinical follow-up examination is performed after the patient has resumed
sports. Fracture treatment may be concluded
where this has not presented any problems and
the patient is asymptomatic with unrestricted
function.
198
Specific Injuries—Upper Extremities
Fig. 19.71 Treatment of
fractures of the olecranon.
Displaced intraarticular fractures are stabilized with tension banding. In this 12-year-old
girl, the olecranon fracture
was openly reduced on the
day of the accident and fixed
with tension banding. Although the position of the
wires was not optimal according to current criteria, the
fracture quickly healed within
four weeks, and the metal implants were removed after 12
weeks. Clinical and radiographic follow-up examinations
after two years demonstrated
a normal symmetrical situation in both elbows
Fracture of the Coronoid Process of the Ulna
Avulsion of the coronoid process of the ulna (192)
is extremely rare but easy to diagnose if the examiner is alert to that possibility (Fig. 19.72). It
often occurs as an associated injury in a dislocation of the elbow (7). In the absence of an elbow
dislocation, pain in the cubital fossa may be a sign
of this injury.
Nondisplaced fractures are immobilized in an
upper-arm plaster cast for two to three weeks.
In severely displaced fractures such as can
occur in elbow dislocations, primary open reduction is indicated. Fixation with a Kirschner wire
will suffice; an anterior or medial approach may
be used. Neglecting to stabilize displaced fractures entails a risk of instability in the elbow with
a tendency to displace anteriorly.
Patients may resume sports once unrestricted
motion has been regained, usually four to six
weeks after spontaneous motion has been resumed. Follow-up examinations are no longer required after sport has been resumed without any
problems. Growth disturbances need not be
feared.
Elbow Injuries
Fig. 19.72 Fracture of the coronoid process of the
ulna. This usually occurs as an associated injury in an elbow dislocation
Elbow Dislocations
Beyond age seven, elbow dislocations supersede
supracondylar fractures of the humerus due to
the change in the stability of the ligaments.
The diagnosis is easy to make; most injuries
are posterolateral dislocations. Where the injury
has spontaneously reduced, the diagnosis of an
elbow dislocation is often made solely on the
basis of the associated injury, avulsion of the medial epicondyle, or on the basis of instability of the
collateral ligaments, usually the lateral collateral
ligaments and less often the medial ones.
199
The lateral shear mechanisms can produce
marginal osteochondrotic fragments on the
lateral aspect of the joint, which in rare cases can
become symptomatic (25; Fig. 19.74). A more
common injury is periosteal avulsion and posterior displacement of the entire lateral collateral
ligament complex. Failure to reattach the complex will result in chronic instability with recurrent dislocation (34, 106). Chronic recurrent dislocations of the elbow like those that occur in
adults are described in the literature in older adolescents with closed growth plates, and occasionally in younger patients, secondary to conservative treatment. This may be attributed to lateral
instability (7, 14, 49, 53, 67). Pseudarthrosis of the
medial epicondyle is possible following conservative treatment or Kirschner wire fixation.
However, such a complication is only rarely symptomatic (8, 70, 77), in which case the epicondyle
can be debrided and reattached or simply removed (67; Fig. 19.75; see also Epicondylar
Humerus and Dislocations of the Elbow, p. 149 ff).
Late
she ral
a
inju r
ries
Problems and Complications
By far the most common associated injury is avulsion of the medial epicondyle. Less often, periosteal, chondral, or bony shear injuries may occur
on the lateral aspect on the radial head, capitellum, or the lateral condyle of the humerus
(Fig. 19.73). Rarely, additional fractures are observed in the proximal end of the radius, the
lateral condyle of the humerus, or the coronoid
process of the ulna (7, 43, 125). In severely displaced dislocations, the avulsed medial epicondyle can easily become interposed in the joint.
This can prevent reduction, as can interposition of
the ulnar or median nerves (5, 18, 105, 110, 125).
Growth disturbances with clinically significant sequelae need not be feared, given the
patient’s age and the minimal traumatization of
the growth plate (125).
Fig. 19.73 Associated injuries in elbow dislocations.
The direction of the dislocation is usually posterolateral
and most often accompanied by avulsion of the medial
epicondyle, which can occasionally displace into the
joint. Bony, chondral, periosteal, and ligamentous shear
injuries can also occur simultaneously on the lateral
aspect
200
Specific Injuries—Upper Extremities
Fig. 19.74 Late sequelae of elbow dislocations. This
11-year-old girl suffered avulsion of the medial epicondyle and a shear injury of the lateral aspect with a hemispherical fragment in an elbow dislocation. Following
closed reduction on the day of the accident, the injury
was treated conservatively by immobilization in an upper-arm plaster cast. The epicondyle subsequently heal-
ed to form a pseudarthrosis at the ulna, and a marginal
osteochondrotic fragment developed on the lateral
aspect of the joint. At the four-year follow-up examination, the patient was free of any symptoms, and function
was unrestricted and symmetrical in spite of the fragment healed at the ulna. Stability of the collateral ligaments was also symmetrical on both sides
Fig. 19.75 Secondary therapy following conservative treatment of an elbow dislocation. This gymnast
suffered an elbow dislocation with avulsion of the medial epicondyle and the lateral collateral ligament at the
age of 12. Her injuries were treated by closed reduction
and immobilization for five weeks in a plaster cast (a).
During the further clinical course, a persistent extension
deficit of a good 30⬚ developed despite intensive physical therapy (c, left) with increasing symptoms in the region of a medial epicondylar pseudarthrosis and a few
osteochondrotic fragments on the lateral aspect (b, 왘
left). The patient was severely impaired as a gymnast
and requested surgical revision one year after the accident. Arthrolysis was performed with removal of the
medial epicondylar fragment and bony plates from the
lateral aspect (b, right). Intensive passive and active motion therapy begun immediately postoperatively helped
to restore unrestricted elbow motion within six weeks.
Four months after the arthrolysis, the patient won first
prize in a gymnastics competition (c, right)
Elbow Injuries
a
c
201
b
202
Specific Injuries—Upper Extremities
Treatment
The obvious goal of primary treatment is to reduce the dislocation and eliminate any possible
instability. Where the injury is a spontaneously
reduced dislocation with a nearly nondisplaced
epicondylar avulsion, we evaluate the lateral and
medial collateral ligaments with the patient
under pain medication. In the absence of clear
signs of instability, we treat the dislocation conservatively by immobilizing it in an upper-arm
plaster cast.
We regard instability of the collateral ligaments as an indication for surgical repair. The
same applies to significantly displaced fractures
of the medial or lateral epicondyle.
We primarily choose a medial approach to
make the repair. After identifying the ulnar nerve
and reducing the medial epicondyle, we fix the
epicondyle with either a small fragment screw or
two Kirschner wires, depending on the size of the
fragment. We then inspect the collateral ligament
complex, which inserts distally to this site. Usually, it is reflected posteriorly with the periosteum
at that site and can be easily shifted anteriorly and
reattached to the distal portion of the medial epicondyle. Where this cannot be accomplished with
retention sutures, it may be necessary to fix the
complex with an additional screw and washer.
After repairing the medial joint, the lateral
portion of the joint is inspected by palpating
through the joint, and lateral stability is evaluated
with the elbow extended. If the elbow dislocates
again as a result of this examination (often simulating medial instability) and the lateral fragments can be palpated, then the lateral aspect of
the joint should be inspected through a small
lateral longitudinal incision. This should be done
in any case in older adolescents with closed
growth plates. Usually, there will be a periosteal
avulsion of the lateral collateral ligament complex
with posterior displacement. Where there are
larger avulsed fragments, the complex can be reattached to its original location with a screw
(Fig. 19.76) or two to three bone sutures as described by Osborne and Cotterill (17, 30, 80, 85,
106). Smaller osteochondral free fragments are
removed.
Immobilization, Sports Participation,
and Follow-up Examinations
The immediate results of reduction are documented in radiographs as a matter of course.
Whenever possible, surgical repair should permit
subsequent functional treatment. Dislocations
treated by closed reduction with stable joints
should only be briefly immobilized in a plaster
cast for about 8–10 days. Then functional aftercare should begin. The older the patient, the more
this should be done under the guidance of a physical therapist. Younger patients should first begin
spontaneous motion exercises without therapy. A
radiographic follow-up examination should be
performed three weeks postoperatively to document consolidation of bony injuries and to exclude the presence of osteochondrotic fragments.
The patient will usually regain unrestricted
motion within 10–14 weeks of the accident.
Patients may resume sports participation as early
as four to six weeks after spontaneous motion has
been allowed. Once sport has been resumed
without any problems and the patient exhibits
unrestricted function and stability in the joint,
treatment may be concluded. No further clinical
or radiographic follow-up examination will be required.
Isolated Dislocation
of the Radial Head
This is an extremely rare injury that is easily overlooked (see Monteggia Fracture-Dislocations,
p. 208 ff). In the literature (19, 37, 39, 60, 62, 84, 91,
92, 104, 111), most authors maintain that isolated
dislocations of the radial head cannot occur
without simultaneous ulnar pathology in the
form of “bowing deformations” or fractures.
However, this can be difficult to prove because
usually only detail radiographs of the elbow are
obtained. In any radiograph of the elbow, one
must be alert to whether the continuation of the
axis of the proximal radius is correctly centered
on the capitellum of the humerus in every plane.
Where this is not the case, an “isolated” dislocation is present.
It is extremely important that this injury be
diagnosed and treated immediately because primary reduction generally poses no problems
(Fig. 19.77). However, secondary reduction can
usually be performed only with difficulty, and
permanent stabilization can only rarely be
guaranteed. Primary reduction can be performed
by simply exerting pressure on the radial head
while moving the joint through pronation and
supination (146). Depending on the patient’s age,
this may be done with the patient under regional
or general anesthesia. Where this does not
Elbow Injuries
203
Fig. 19.76 Treatment of elbow dislocations. In this 12-year-old girl, open reduction
was indicated because the avulsed medial
epicondyle had become interposed in the
joint. The epicondyle was reattached and
fixed with Kirschner wires. A second lateral
incision was made because of the presence
of a bony flake on the lateral aspect and intraoperative findings of instability of the lateral collateral ligaments. The lateral collateral
ligament complex was found to be avulsed
with an osteochondral fragment and posteriorly displaced. It was reattached with a small
fragment screw. Six months postoperatively,
function was unrestricted and symmetrical
on both sides, and the elbow exhibited the
same stability as the contralateral side
succeed immediately, a deformation of the ulna
should be identified and eliminated. Open reduction is practically never indicated in growing
patients. Using a transarticular wire to maintain
the reduction is an obsolete technique and wishful thinking at best: Dislocation will recur as soon
as the wire is removed. It is important not to confuse this situation with a traumatized congenital
condition. Prior to any surgical intervention, the
physician should consider that a congenital dislocation is often bilateral, it is often a posterior dislocation, the radius is invariably excessively long
in relation to the ulna, and the radial head exhibits
a convex deformation of the articular surface. In
any case, it will obviously be necessary to document the results of reduction with a radiograph in
plaster and with the patient still under anesthesia.
The injury is immobilized for three weeks in
an upper-arm plaster cast, after which the elbow
is spontaneously mobilized without therapy. The
full range of motion is usually regained within
two weeks, at which time the patient may resume
sports. Treatment can be concluded once the
patient has resumed sports without any symptoms. Growth disturbances and other late complications need not be feared where the injury is
treated immediately.
204
Specific Injuries—Upper Extremities
Fig. 19.77 Diagnosis and treatment of a dislocation
of the radial head. The axis of the proximal radius must
be centered on the capitellum of the humerus in every
plane. Where this is not the case, an isolated dislocation
of the radial head is present. The injury is easily reduced
immediately, as in this eight-year-old boy, despite a
slight anterior bow in the ulnar shaft. The associated
avulsion of the medial epicondyle was overlooked. The
seven-year follow-up examination revealed symmetrical
unrestricted function in both elbows, and the patient
was subjectively asymptomatic despite radiographic
evidence of pseudarthrosis of the medial epicondyle.
The significant widening of the radial head in both
planes is indicative of the radial trauma that had been
sustained
Elbow Injuries
205
Elbow: “Subluxation” of the Radial Head (3.4%)
Definition: Painful, blocked pronation of the forearm in the elbow.
Age: Typically occurs at age three to four, occasionally in older patients.
Mechanism: Child is suddenly pulled up by the arm;
rarely following a fall.
Diagnosis: Made on the basis of the history and the
pronation.
Radiographs are not necessary, only where the history is unclear or a direct fall occurred: A-P and lateral
views of the elbow.
Primary pain treatment
앫 Reduction,
앫 Where this is not promptly successful: Immobilization in an upper-arm plaster splint in supination for three days.
Aftercare
In case of recurrence
앫 Warn parents to exercise greater care in dealing
with children (this is a form of abuse).
앫 Instruct parents that by first warning the child
that they are about to pull, the blockage in pronation can be avoided (this gives the child time
to tense his or her muscles in anticipation).
206
Specific Injuries—Upper Extremities
“Subluxation” of the Radial Head
(Nursemaid’s Elbow or Pulled
Elbow)
This is an extremely common injury in children
up to age four (88) because of the mechanism of
injury. It involves sudden unexpected traction on
the child’s hand and most often occurs when the
child is held by the hand and is unexpectedly and
abruptly pulled upward (8), as may occur in the
face of an obstacle. This subluxation can occur in
older children in sports like judo or as a result of
direct trauma.
The patient is usually not expecting the sudden traction on his or her arm and does not have
time to tense the elbow muscles in response. The
radial head is then thought to subluxate beneath
the annular ligament. However, nobody has yet
observed this. In my opinion, this is nothing more
than a blockade of the radioulnar joint in the
physiological motion of extreme pronation,
analogous to the rotational blockade in the cervical spine that leads to acute torticollis (see that
section, p. 459). Understandably, this injury becomes less common as children get older for the
simple reason that they are then too big to be
abruptly pulled up by the hand. The initially cartilaginous radial head resembles the adult bone
and does not significantly change its shape during
further growth. Therefore, the decrease in the incidence of this injury with increasing age is more
likely attributable to the mechanism of injury
rather than the shape of the head (Fig. 19.78).
Given a typical patient history, the diagnosis is
readily made on the basis of clinical findings and
requires neither a radiograph nor neurological diagnostic examination. The patient spontaneously
holds the arm in pronation and is unable to grasp
any object with the affected hand, not even when
offered a piece of candy. This condition often resembles paralysis (Fig. 19.79). Patients report
spontaneous pain both over the distal radius and
over the proximal end of the radius. Where the
history is atypical, for example, when the patient
has fallen directly on the elbow, it is advisable to
obtain radiographs because a fracture may be responsible for the protective posture of the arm.
Several different reduction techniques are described for treating the “subluxation” (88). Regardless of the specific technique employed, the
important thing is to extend the elbow out of its
right angle flexed position with a quick supination motion while applying traction. Usually, the
radial head will slip back into its normal position
with a slight snap that is readily palpable and usually audible as well. Shortly thereafter, the patient
will begin to move his or her arm freely and use
the hand normally when playing.
Reduction can also be readily achieved where
the subluxation has persisted for a longer period
of time. However, such a “subluxation” will often
recur spontaneously when the child is asleep or
first attempts to move. In such cases or where reduction is not immediately successful, it is advisable to immobilize the arm in an upper-arm
plaster splint in maximum supination for three
days. Once the splint is removed, the child will be
free of symptoms. Recurrent “subluxation” need
not be feared unless of course the parents
abruptly pull on the child’s arm again.
Fig. 19.78 Shape of the radial
head during growth. The essential
shape is already present as cartilage
during the first year of life. The epiphyseal ossification center only appears at about age five and expands
in the following years, as does the
metaphysis. This means that the
characteristic shape of the radial
head will only be visible on radiographs after the age of 10
0–4y
5y
8y
11y
Elbow Injuries
207
Fig. 19.79 “Pulled elbow.” The affected arm appears paralyzed and is
painful in the elbow and wrist. The
child will not use it even to grasp a
piece of candy
208
Specific Injuries—Upper Extremities
Elbow: Monteggia Fracture-Dislocations (1.35%)
Forms
앫 Classic: Ulnar shaft fracture with dislocation of
the radial head
앫 Ulnar shaft fracture with fracture-dislocation of
the radial head
앫 Olecranon fracture with dislocation of the radial
head
앫 “Bowing fracture” of the ulna with dislocation of
the radial head
앫 “Isolated” dislocation of the radial head
A-P and lateral radiographs: Radiographs of the
elbow in two planes must be obtained in any isolated
fracture of the ulna.
Problems: Overlooking the dislocation of the radial
head.
Primary pain treatment: Where emergency treatment under anesthesia is clearly indicated: Medical.
Emergency treatment under anesthesia: Any
Monteggia fracture-dislocation as such (the examiner must recognize the dislocation of the
radial head).
Technique of conservative fixation: Upper-arm
plaster splint.
Technique of internal fixation
앫 Diaphyseal greenstick fracture of the ulna:
Closed reduction with interruption of the opposite cortex.
앫 Displaced oblique ulnar shaft fracture: Intramedullary nail, external fixator, or plate.
앫 Displaced transverse ulnar shaft fracture: In-
tramedullary nail.
앫 Displaced metaphyseal fractures: Internal
fixation with plate or screws.
!
Open reduction of the radial head is almost never
necessary in growing patients immediately after
trauma. Closed reduction is invariably successful.
Aftercare
Period of immobilization
앫 With conservative fixation: Three to four weeks.
앫 With internal fixation: Immediate spontaneous
motion.
Consolidation radiographs: Yes.
Initial mobilization: Immediately postoperatively
after stable internal fixation, otherwise spontaneously after removal of the plaster splint.
Physical therapy: None.
Sports: Five to eight weeks after consolidation.
Removal of metal implants: 8–12 weeks postoperatively.
Follow-up examinations and conclusion: At threeto four-week intervals until unrestricted function has
been restored, at which time treatment is concluded.
Elbow Injuries
Monteggia Fracture-Dislocations
Forms of Injury
The classic Monteggia fracture consists of an ulnar
shaft fracture combined with a dislocation of the
radial head. However, the same accident can also
result in a fracture-dislocation of the proximal
end of the radius in addition to the ulnar fracture.
The location of the ulnar fracture may be anywhere from the middle third to the far proximal
end of the bone, where it will appear as an
olecranon fracture (Fig. 19.80). Bowing fractures
of the ulna are possible and should not be overlooked (177). Combinations with Galeazzi injuries
are possible (189, 195). The proximal radius dislocates anteriorly or laterally, rarely posteriorly. We
will dispense with the customary classifications
of Monteggia fractures described in the literature
(3, 60, 62, 86, 92, 109, 153), as they do not significantly influence the choice of treatment.
Problems and Complications
What remains is one very fundamental requirement: The examiner must not overlook the injury
to the proximal end of the radius, especially a dislocation. This in turn requires that the elbow be
visualized on any radiographs of forearm shaft
fractures. The axis of the proximal end of the
radius should always be checked for correct alignment with the capitellum of the humerus. The
prognosis for missed radial head dislocations in
209
injuries where only the ulnar fracture was treated
(which is usually only slightly displaced) is essentially poor with respect to secondary reduction
(96, 112, 113, 145, 158, 159, 169, 178, 179) despite
the occasional reports to the contrary (63). Left
untreated, this injury can lead to restricted motion, instability, and valgus deformities of the
elbow. The cost and complexity of secondary surgical treatment of chronic dislocations of the
radial head is far greater (Figs. 19.81, 19.83) than
primary therapy, and the older the dislocation,
the less certain will be the results of secondary
treatment. This is in stark contrast to the results of
timely, conservative primary treatment.
Radial head remodeling disturbances with
more or less severe thickening of the proximal
end of the radius can occur secondary to dislocations and fracture-dislocations. However, this will
lead to restricted pronation and supination only
after severe fracture-dislocations (see Fractures of
the Proximal End of the Radius, Problems and
Complications, p. 180).
Growth disturbances of the distal humeral
growth plate and the proximal end of the radius
may occur as a result of traumatization of the
radial growth plate. However, their sequelae with
respect to the alignment of the elbow axis largely
cancel each other out so that they are not clinically significant (127, 130, 131).
With the exception of side-to-side displacement, deformities resulting from ulnar shaft fractures are slowly but continuously corrected by
further growth.
Fig. 19.80 Forms of Monteggia fracture-dislocations. Fracture of the middle
third of the ulna combined
with a dislocation of the radial head (left). Fracture of the
proximal or middle third of
the ulna combined with a
fracture of the proximal end
of the radius (center). Proximal ulnar fracture (olecranon
fracture) combined with a
dislocation of the radial head
(right)
210
Specific Injuries—Upper Extremities
Fig. 19.81 a–c
a
b
왘
Elbow Injuries
211
Fig. 19.81 a–c Missed dislocation of the radial head
in a Monteggia fracture-dislocation. The patient is a
five-year-old girl with a bowing fracture of the ulna and
dislocation of the radial head, which was overlooked despite (or precisely because of) the superfluous comparative radiograph of the contralateral side (a). Three weeks
after the accident, closed reduction of the radial head
was no longer possible. The radial notch of the ulna was
freed of the impinged annular ligament by resection of
that ligament, and an ulnar osteotomy was performed
to eliminate the initial ulnar deformity. An intramedullary nail was introduced to stabilize the osteotomy and
correction (b). The capsular calcification was left untreated. The follow-up examination after 12 weeks demonstrated a good periosteal bridging callus at the osteotomy site and correct position of the radial head (c).
The patient was free of subjective symptoms, and motion in both elbows was symmetrical and unrestricted
c
Treatment
The first goal of treatment is to eliminate the dislocation of the radial head. This can be done only
by correcting the ulnar deformity. In greenstick
fractures of the ulna associated with dislocation
of the radial head, closed reduction is usually
readily achieved (Fig. 19.84). Open reduction of
the radial head is practically never indicated in
growing patients.
Where there is an additional fracture-dislocation of the proximal end of the radius, this injury
is treated like an isolated fracture of the proximal
end of the radius after the greenstick fracture of
the ulna is first converted into a complete fracture. Correction of the existing ulnar deformity
automatically corrects the dislocation of the prox-
imal end of the radius. In the treatment of
completely displaced oblique fractures of the
ulna, we previously recommended plate fixation
to maintain the reduction of the radial head.
Today, we use dynamic intramedullary nailing for
stabilization. Radiographic studies to verify correct position should be obtained on about the
eighth day in every conservatively treated Monteggia fracture-dislocation. This will allow correction of possible axial deviations in the ulna with a
cast wedge.
Immobilization, Consolidation,
and Follow-up Examinations
The injury is immobilized for four weeks. The
radiograph out of plaster will then usually dem-
212
Specific Injuries—Upper Extremities
Fig. 19.82 Treatment of the proximal Monteggia
fracture-dislocation. The patient is a nine-year-old boy
with a proximal extraarticular ulnar fracture that is completely displaced with dislocation of the radial head. The
fracture was reduced in an emergency procedure and
stabilized by internal fixation with a fracture plate (a).
The dislocated radial head reduced spontaneously; the
periosteal avulsion from the ulna of the radioulnar ligamentous structure was not fixed as it remained in contact with the bone at the site. The resulting callus formation did not interfere with spontaneous mobilization in
any way. After five weeks, the fracture had clinically and
radiographically healed, and the radial head was in correct position (b). The range of motion was unrestricted
except for a slight pronation and supination deficit,
allowing removal of the metal implants. The accompanying separated distal radial epiphysis was treated by
closed reduction and healed in a satisfactory position in
spite of the insufficient Kirschner wire fixation
a
b
Elbow Injuries
213
a
b
Fig. 19.83 a–c Treatment of a chronic dislocation of
the radial head. The patient is a seven-year-old boy who
had suffered a Monteggia fracture-dislocation one year
previously with a dislocation of the radial head that had
gone unrecognized. Initial treatment consisted of a corrective osteotomy and stabilization with a fracture plate.
The injury was then immobilized in a plaster cast for two
weeks due to intraoperative findings of “instability” of
the radial head. During the further clinical course, the
plate fractured without trauma. This was accompanied
by renewed dislocation of the radial head. Having obtained the consent of the patient and his parents, we
then attempted another form of treatment, this time
using an external fixator (see text; a). This was followed
by functional aftercare with immediate spontaneous
motion without physical therapy (c). The metal implants
were removed after eight weeks. By that time regression
of the initial angulation had occurred without renewed
dislocation of the radial head. The eight-month followup examination demonstrated stable bony union at the
osteotomy site and physiological position of the radial
head (b). At the clinical follow-up examination two years
after the second reconstruction, the patient was free of
subjective symptoms and motion in both elbows was
unrestricted and symmetrical in every plane; as the radial head was palpable in its physiological position, the
was no need for an additional radiographic examination
(from: 120)
Fig. 19.83 c 왘
214
Specific Injuries—Upper Extremities
Fig. 19.83 c
onstrate satisfactory consolidation of the ulnar
fracture. A callus that is no longer tender to palpation is an indication for allowing spontaneous
motion as tolerated without physical therapy.
Patients are usually able to resume sports once
unrestricted motion has been restored, about four
to six weeks after spontaneous motion has been
allowed. Once the patient has been able to resume
sports without any problems, we conclude treatment if function is unrestricted and the elbow
axes are symmetrical.
In the case of additional fractures of the proximal end of the radius, we perform clinical followup examinations up to two years after the accident in order to exclude possible growth disturbances due to remodeling of the radial head.
Most Common Posttraumatic
Deformity Secondary to Monteggia
Fracture-Dislocation: Missed
Dislocation of the Radial Head
The actual prognosis for a chronic Monteggia fracture-dislocation, or rather a missed dislocation of
the radial head, is not really known. Lateral insta-
bility can occur with corresponding symptoms.
However, we also know that this is not the case
with every chronic dislocation of the radial head,
just as patients with congenital dislocations are
usually asymptomatic. On the other hand, the results of reconstructions described in the literature
and among our own study group (9, 10, 13, 19, 37,
39, 42, 84, 97, 104, 111, 120) have not yet been encouraging enough to allow us to recommend such
a procedure to our patients with a clear conscience. Our own results improved only after we
reconsidered the situation and changed our correction technique accordingly.
All authors agree that an initially overlooked
axial deviation of the ulna that has largely been
“spontaneously” corrected during further growth
must again be eliminated in an ulnar osteotomy to
treat a chronic dislocation of the radial head. The
correction must also address the length discrepancy between the radius and ulna that has
developed over the years.
The main problem is to ensure that the ulnar
osteotomy lies in the right direction (to eliminate
the previous deformity) and has the right length
so that the radial head will reliably remain within
the radial notch in every motion without any additional fixation. The difficulty is that we cannot
evaluate the exact position of the axial deviation
even on the initial radiographs obtained in two
planes at the time of the accident. This is all the
more difficult two to three years later when the
previous deformity has “grown in.” Our attempts
at finding the proper correction plane from posterior and fixing the correction with a plate or intramedullary nail, or performing a simple distraction osteotomy as recommended by Exner (19)
have not led to satisfactory results that the patient
may be expected to tolerate. The quintessence of
all our deliberations was then that only the reduced radial head can and should seek the correct
position of the ulna by itself.
For this reason, we now proceed as follows:
We attach an external fixator that allows motion
in every plane (Hofmann Compact II manufactured by Stryker Howmedica) to the ulna as far
proximally as possible and perform the
osteotomy. Then we perform an open reduction of
the radial head after removing all soft tissue from
the radial notch of the ulna (remnants of the
annular ligament). Using a blunt Hohman retractor to maintain the reduction of the radial head in
the radial notch, we then move the arm into full
pronation.
Elbow Injuries
215
Fig. 19.84 Treatment of Monteggia fracture-dislocations. The most important goal in the treatment of
this combined injury is to eliminate the dislocation of
the radial head. This can usually be done without any
problems where closed or open reduction of the ulnar
deformity has been performed. This five-year-old boy
suffered a classic Monteggia fracture-dislocation.
Closed reduction was performed on the day of the accident. Correcting the ulnar deformity promptly restored
the radial head to its correct position. The follow-up
examination 10 years later demonstrated symmetrical
clinical and radiographic findings
After fastening the fixator in this position, we
move the arm into supination. If the head exhibits
a tendency to subluxate in this motion, we reopen
the fixator (now in maximum supination), again
press the radial head firmly into the notch, and
close the fixator again. The same technique is
used for flexion and extension. This method will
invariably identify a position of the osteotomy,
usually an oblique position with a rotational component, in which the radial head will remain securely in the radial notch in every motion. We
then dispense with reconstruction of the annular
ligament and allow the patient to spontaneously
mobilize the limb immediately postoperatively.
Patients soon regain full mobility and resume
their normal daily activities with the fixator in
place, where it remains until definitive consolidation has occurred after 10–14 weeks. We have employed this method in 14 patients to date with
good short-term results after two years (136, 210).
Primary treatment is undoubtedly simplest.
However, where such an injury has been overlooked, secondary treatment must be initiated as
quickly as possible to achieve good results.
216
Specific Injuries—Upper Extremities
Overview
Most Common Posttraumatic Deformities
of the Elbow: Proximal Forearm
1. Chronic dislocations of the radial head
2. Deformations of the radial head (deformities of
the head and neck, chronically separated
epiphyses, etc.) with functional impairments
3. Varus deformity of the ulna
Causes
Re 1. Overlooked and untreated dislocation of the
radial head and ulnar deformity.
Re 2. Incorrect indication for open reduction of
radial head fractures, incorrect surgical technique, incorrect aftercare. Premature partial
closure of the growth plate is rare.
Re 3. Axial deviation left uncorrected with only
slight “spontaneous correction.”
Indications for Correction
Re 1. As the late prognosis in not known, correction is indicated due to imminent instability
and increasing valgus displacement of the
elbow axis.
Re 2. Severe functional impairments especially in
pronation (less so in supination) and in flexion.
Re 3. Cosmesis.
Time of Correction
Re 1. As soon as possible; beyond three years after
the accident, only in the presence of significant symptoms and only at the patient’s request.
Re 2. Wherever possible, only after cessation of
growth depending on patient's tolerance of
the affliction.
Re 3. Wherever possible, only after cessation of
growth or when specifically requested by the
patient.
Correction Technique
Re: 1. Ulnar osteotomy, open reduction of the
radial head after debriding the radial notch of the
remnants of the annular ligament, and maintenance of reduction with external fixator (Compact II manufactured by Stryker Howmedica).
Direction of the osteotomy is determined by intraoperative functional testing of the reduced
radial head.
Plastic reconstruction of the annular ligament is not
performed, nor is temporary wire fixation (to the
humerus or the ulna).
Re 2. Remodeling of the radial head, possibly resection in the presence of closed radial
growth plates (including distal plate),
possibly in combination with arthrolysis.
Re 3. Shortening or opening osteotomy and fixation with external fixator (Compact II manufactured by Stryker Howmedica).
General Remarks on Arthrolysis of
the Elbow in Growing Patients
The approach is made through a generous posterolateral incision that allows exposure of all
parts of the elbow. Arthrolysis of the elbow includes a repair of the entire elbow with lysis of all
visible adhesions, especially in the region of the
radial head. The significance of the olecranon
fossa, which is usually filled with connective
tissue, is often overestimated. Even after meticulous debridement of the fossa, extension will be
no means be improved and even shortening and
sculpting the tip of the olecranon will not change
anything. Only the crucial anterior and lateral
capsulotomy performed close to the bone will
help improve mobility. This effort is enhanced by
aggressively correcting mobility intraoperatively,
in which previously hidden adhesions tear with a
loud popping sound.
It is no surprise that the aftercare of a joint
traumatized in this manner—and the elbow is particularly sensitive—must be extraordinarily painful. This means that reliable analgesia by means of
an axillary nerve block must be ensured during the
first eight days. During this period, elbow mobility
is maintained day and night on a continuous passive motion device. This treatment is interrupted
only for active motion exercises, which should be
performed twice daily. Depending on the individual patient’s sensitivity to pain, oral pain
medication alone will be sufficient to ensure analgesia after 8–14 days. At the same time, an effort
should be made to replace passive motion exercises with active motion training. This must be ensured before the patient is released into outpatient
care. There is a chance of permanent improvement
only if the patient engages in active motion training several times a day over a period of at least
three to four months. If the patient does not diligently adhere to this regime over a period of
months under pain medication (the painful capsular swelling persists for about four to five months),
then the initial gain in functional improvement
will decline again within a few weeks.
It is clear that patient compliance is the only
guarantee of lasting success. This is never present
in children under age 10, and adolescents exhibit it
only where they themselves are interested in improvement. Where only the parents have this interest, a conflict situation will arise that can never
be conducive to improving elbow mobility, especially where the child is near the age of puberty.
Therefore, one should carefully consider whether
arthrolysis is indicated in a growing or nearly ma-
Elbow Injuries
ture patient, and treatment should be performed
only when directly requested by the patient
(Fig. 19.85).
I feel that mobilization with the articular fixator described by Pennig (87) is a more promising
method for growing patients due to the significantly shorter duration of pain as a result of the
shorter duration of capsular swelling. Yet even
this option should tempt the surgeon to undertake mobilization at the request of the parents. If
the request for treatment does not come from a
well-informed and well-prepared patient of his or
her own volition, then the surgeon should refrain
from performing such an operation.
Overview
Most Common Cause of Posttraumatic
Functional Impairment in the
Elbow—Arthrolysis of the Elbow
Most Common Causes of Functional
Impairments
1. Capsular adhesions
2. Capsular calcifications
3. Thickening of the radial head and neck
4. Radioulnar synostosis
5. Radioulnar osteophytes
6. Ankylosis
Causes
앫 Excessively painful physical therapy after any
elbow injury in a growing patient,
앫 Incorrect indication, incorrect technique, and
incorrect aftercare following fractures of the
radial head (isolated, but usually in combination),
앫 Conservative treatment of elbow dislocations in
adolescents with ligamentous and bony associated injuries with excessively long immobilization followed by physical therapy.
Indications for Correction
앫 Isolated flexion deficit exceeding 40–50⬚,
앫 Isolated extension deficit exceeding 40⬚
(especially in gymnasts),
앫 Combined flexion and extension deficit exceeding 40⬚ (ankylosis),
앫 Isolated pronation deficit exceeding 40⬚,
앫 Isolated supination deficit exceeding 60⬚.
Time of Correction
앫 About one year after trauma and after completion of causative primary therapy.
앫 Depends on patient's tolerance of the affliction:
Unmotivated patients should not receive arthrolysis (age limit: Arthrolysis cannot be
successfully performed in patients below the
age of 10).
217
Correction Technique
Re 1. Capsular adhesions: Broad exposure through
posterior approach; anterior and posterior
capsulotomy with lysis of all adhesions
around the radial head and, if indicated, remodeling of the radial head. An additional
osteotomy is not performed because intensive aftercare on a continuous passive motion device in combination with therapy are
required.
Re 2. As in item 1, including removal of all capsular
fragments and calcifications.
Re 3. As in item 1, including remodeling of the
radial head.
Re 4. No arthrolysis, no attempt at separation; improvement in position achieved by rotational
osteotomy in the synostosis.
Re 5. Resection of the osteophyte; depending on
findings, continue with item 1.
Re 6. Closed mobilization of the joint following distraction of the joint with external fixator
(87).
Aftercare
앫 1.–5.: Every elbow that has undergone arthrolysis is placed on a continuous passive motion device day and night for the first five to eight
days. This requires copious pain treatment, initially with an axillary nerve block, later with intravenous morphine, and finally with oral medication. The elbow is put through active motion
two to three times daily with the aid of physical
therapy. Once the most aggressive pain treatment has been discontinued, the physical therapy increasingly assumes the form of active motion therapy. The patient remains on the ward
for two to three weeks. Physical therapy continues for three to four months and includes
exercises to be performed by the patient alone;
later it continues solely in the form of exercises
performed by the patient alone for up to six
months. Treatment is only concluded after two
years (only then will a truly stable result be
present).
앫 External fixator allowing motion. We have
not yet had any experience ourselves with this
device. The results published by these authors,
especially Prof. Pennig from Cologne, Germany,
appear extremely promising. As this method
does not require the same high degree of compliance that arthrolysis does, it can be employed successfully in children as well.
218
Specific Injuries—Upper Extremities
a
b
Fig. 19.85 Overlooked condylar fracture of the distal humerus and arthrolysis. This 13-year-old girl had
fallen on her right elbow. Because of severe swelling and
pain, initial radiographs were obtained only in one
plane. The diagnosis of “no fracture” was based on the
lateral radiograph. The injury was immobilized in a zinc
adhesive bandage, and after eight days intensive physical therapy was begun. As a result of severe pain during
this therapy, another radiographic study was performed
after three weeks, this time in two planes (a). This revealed a displaced fracture of the lateral condyle with a
periosteal callus. Presumably because of the onset of
consolidation, conservative treatment with physical
therapy was continued until the elbow had lost nearly all
mobility. A good six months later, open arthrolysis was
performed at another hospital with correspondingly intensive motion treatment on the ward. After initially favorable results, complete ankylosis of the joint in 70–80⬚
of flexion developed during the further clinical course
(b). Fear of pain prevented the necessary patient compliance, which would have been necessary for the extraordinarily active participation in aftercare of arthrolysis.
Understandably, the patient rejected the suggestion of
a renewed attempt at arthrolysis one year later. We have
no information at present as to whether treatment with
an external fixator allowing motion as described by Prof.
Pennig from Cologne, Germany, was successfully performed
219
20
Fractures of the Radial and Ulnar Shaft
Forms
앫 Incomplete fractures (greenstick fractures)
앫 Complete fractures
Remember that the proximal growth plates of the
forearm bones only account for about 20% of the
longitudinal growth in the two bones, whereas
the distal plates account for about 80%. The proximal growth plates in the elbow region close at
about age 12; the distal plates only close between
age 15 and 18 (Fig. 20.1).
Let us recall the definition of a greenstick fracture. This injury is best understood as a bending
fracture that involves a unique set of problems. It
is important to differentiate it from the easily
treated metaphyseal, cancellous impacted fractures (6, 5; Fig. 20.1).
About two thirds of all diaphyseal fractures of
the forearm bones are greenstick fractures. About
one third are complete fractures such as occur in
adults and are limited to adolescents above age
10–12.
As we have said, greenstick fractures involve a
unique set of problems. These include not only
cosmetic and functional impairments due to
delayed spontaneous correction but also an increased risk of repeat fracture due to a consolidation disturbance. This is due in no small part to the
fact that these are invariably stable fractures that
by definition include axial deviation. They exhibit
a resilient stability coupled with a tendency to
displace secondarily. One would expect that this
would dictate certain fundamental differences in
the therapeutic concept of these injuries.
However, these considerations are given surprisingly little attention in the literature and at current congresses (5, 7, 12, 18, 28, 32, 34, 43).
Proportion of growth
80%
20%
Fig. 20.1 Greenstick fracture, impacted fracture,
and proportion of growth accounted for by the individual growth plates. The greenstick fracture (left) is
best understood as a bending fracture that must be
differentiated from an impacted fracture (right). The
distal radial and ulnar growth plates account for about
80% of longitudinal growth; the proximal growth plates
only account for about 20%
220
Specific Injuries—Upper Extremities
“Spontaneous Corrections”
Axial deviations in this region are only corrected
to a certain extent (5, 16, 18, 26, 31, 38, 40): Sideto-side displacement is almost completely eliminated. Residual deformities in adolescents may
represent cosmetic impairments. Axial deviations
in the coronal and sagittal planes are only slowly
corrected spontaneously and only to a certain
degree. This greatly depends on the patient’s age.
Age five should be regarded as the age limit
(Fig. 20.3; 40). Residual deformities of 10–15⬚
usually remain unchanged during the course of
further growth. Depending on their specific location and direction, they can lead to significantly
Fig. 20.2 Lack of spontaneous correction of shaft
deformities. The patient is an 11-year-old boy. The shaft
fracture of the forearm bones consolidated with an axial
deviation in the coronal and sagittal planes in both
bones. This axial deviation was partially corrected in the
impaired pronation and supination (Fig. 20.2).
This region provides a particularly striking example of the limiting principle defined by the apparent relationship between the corrective mechanisms and the functional load on the adjacent
joints and musculature (14, 19, 20, 29, 42). In the
absence of this stimulus, no correction will take
place.
Growth Disturbances
The usual growth disturbance, transient posttraumatic stimulation of the growth plates adjacent to
the fracture, does not become clinically significant in diaphyseal shaft fractures. Occasionally,
coronal plane during the further clinical course. The
ulnar axial deformity remained unchanged. Pronation
and supination were found to be severely restricted at
the 11-year follow-up examination as a result of the
proximal remaining axial deviation
Fractures of the Radial and Ulnar Shaft
slight lengthening of one of the two bones, usually the radius, may occur. However, this deformity is corrected during the course of further
growth, restoring the physiological length rela-
221
tionship between the two bones. This also applies
to fractures that heal with shortening deformities
(see General Science, Treatment, and Clinical Considerations).
a
b
Fig. 20.3 a, b “Spontaneous correction” in diaphyseal fractures of the forearm bones up to age five. The
patient is a two-year-old girl with a midshaft greenstick
fracture of the radius and ulna with only slight angulation of the fragments. The injury was immobilized in an
upper-arm plaster cast. After four weeks, clinical and
radiographic examination revealed over 30⬚ of secondary angulation in the ulna and over 20⬚ in the radius (a).
The fracture exhibited good clinical and radiographic
healing. Trusting in the corrective forces of further
growth in such a young patient, we recommended no
further treatment and left the situation as it was. Clinical
and radiographic follow-up examinations seven years
later (b ) revealed nearly fully normalized anatomy. Both
arms exhibited unrestricted and symmetrical mobility.
This approach to treatment should be restricted to
patients up to age five at most
222
Specific Injuries—Upper Extremities
Radial and Ulnar Diaphysis: Greenstick Fractures
(Invariably “stable” fractures. All diaphyseal fractures of the forearm bones
account for about 6% of all injuries; one quarter of these are greenstick
fractures).
Forms
앫 Typical greenstick fractures: Cortex is completely
disrupted on the convex aspect and incompletely
fractured on the concave aspect.
앫 Impacted greenstick fractures: Cortex is continuous on both the convex and concave aspects.
앫 Bowed greenstick fracture (bowing fracture): No
visible fracture gap is present.
Problems associated with a greenstick fracture:
Straightening the fracture results in insufficient periosteal bridging with a 25–30% risk of repeat fracture.
An uncorrected deformity will be stable but will not
be spontaneously corrected.
Anteroposterior (A-P) and lateral radiographs:
Additional A-P and lateral views of the elbow should
be obtained in an isolated ulnar fracture to exclude a
possible Monteggia fracture-dislocation.
Definition of “nondisplaced”: Not known.
Every greenstick fracture exhibits axial deviation by
definition. However, it has not yet been possible to
define a “tolerable” degree of severity based on the
aspects of risk of a repeat fracture, “spontaneous
correction,” and cosmesis that may be regarded as
tantamount to nondisplaced.
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Medical.
앫 Where indication is uncertain: Immobilization in an upper-arm plaster splint.
Emergency treatment under anesthesia: Where
angulation of one or both of the forearm bones
exceeds 30–40⬚.
!
앫 Where angulation increases or cast wedge
treatment is unsuccessful, the opposite cortex
should be broken and the injury reduced
closed.
앫 Where one or both bones are completely displaced, intramedullary nails are placed during
closed reduction.
!
The goal of treatment in diaphyseal greenstick
fractures is not only to correct position but also
to achieve compression of the completely fractured cortex.
Technique of conservative fixation: Upper-arm
plaster splint in a neutral position.
Technique of internal fixation: Intramedullary
nailing of the completely fractured and displaced
bones.
Aftercare
Period of immobilization
앫 With conservative fixation: Three to four weeks.
앫 With internal fixation: Immediate spontaneous
motion.
Consolidation radiographs: Yes; parents should be
informed where consolidation is inadequate (increased risk of repeat fracture).
Initial mobilization: Spontaneous mobilization after
removal of the plaster splint or immediately postoperatively, respectively.
Physical therapy: None.
Sports: Four to six weeks after consolidation.
All other indications should first be discussed at
length with the patient and his or her parents.
Further treatment without anesthesia or delayed
treatment under anesthesia
앫 Treatment of angulation of up to 20⬚ with a cast
wedge on the eighth day after the accident.
Removal of metal implants: Intramedullary implants are removed 8–12 weeks postoperatively.
Follow-up examinations and conclusion: Examinations with functional testing are performed at threeto four-week intervals. Treatment is concluded three
to four weeks after the metal implants have been removed.
Fractures of the Radial and Ulnar Shaft
Greenstick Fractures
Forms
With respect to prognosis, we must distinguish
between two forms of greenstick fractures:
bowing fractures and “genuine” greenstick fractures.
Bowing fractures are understood to include
bowed and impacted greenstick fractures
(Fig. 20.4).
The peak incidence of bowing fractures occurs
above age 10. These injuries are characterized by
small fissures occurring at numerous sites along
the bowed cortex that are rarely detectable on
radiographs (12). Primary fracture healing almost
invariably occurs without formation of a visible
callus. There is no increased risk of repeat fracture
in these injuries.
Fig. 20.4 Forms of greenstick fractures: Bowing
fractures. Fractures with a visible fracture line (cortex is
impacted without a gap between the fragments on the
side opposite the zone of impaction; left). Fracture without a visible fracture line (cortex on both sides is bowed
without any visible signs of fracture; right)
223
Impacted greenstick fractures are primarily
observed in small children up to age five. Here the
cortex on the convex aspect is only incompletely
fractured and remains otherwise intact because it
is the concave aspect that is impacted. These injuries also involve no increased risk of repeat fracture in these injuries.
Problems and Complications
In the “genuine” greenstick fractures, the cortex
on the convex aspect of the deformity is
completely fractured, whereas on the concave
aspect it is usually only incompletely fractured or
the fragments at this location are in ideal position
without any side-to-side displacement and good
cortical contact (Fig. 20.5). The prognosis for these
injuries reflects the risk of repeat fracture. This is
not attributable to the duration of immobilization
Fig. 20.5 Forms of greenstick fractures: “Genuine”
greenstick fractures. The cortex on the concave aspect
of the axial deviation is usually only partially disrupted.
A complete fracture occurs on the convex aspect, and
there is a gap between the fragments that varies with
severity of displacement. Eliminating the deformity
without breaking the intact cortex will invariably result
in a partial consolidation disturbance with an increased
risk of repeat fracture
Fig. 20.6 Problem associated with greenstick fractures. The patient is a sixyear-old boy with greenstick fractures of both forearm bones. The fracture was
only straightened without breaking the intact cortex. This resulted in the typical
partial consolidation disturbance: On the concave aspect of what was once the de-
formity, the fracture consolidated with a strong periosteal bridging callus.
However, on the convex aspect, no such periosteal bridging callus developed.
Thirty-one weeks after the initial trauma, a refracture occurred following a minor
accident
224
Specific Injuries—Upper Extremities
Fractures of the Radial and Ulnar Shaft
as some authors maintain (38) but to a partial
consolidation disturbance (10, 41). If the fracture
is “straightened,” a partial consolidation disturbance will occur on the convex aspect of what was
once the bow (see General Science, Treatment,
and Clinical Considerations). This entails a risk of
repeat fracture, which occurs in 20–35% of these
injuries (Fig. 20.6). The greater the initial displacement, the lower the incidence of repeat fracture will be; the lesser the displacement, the
higher the incidence of repeat fracture. Where the
fracture heals in a deformity with a broad periosteal bridging callus on the concave side, the
broad callus will be sufficient to prevent a repeat
fracture. However, such deformities cannot usually be tolerated in the middle of the shaft because
there they are hardly corrected at all and can lead
to persistent functional impairments.
225
In determining which specific treatment is indicated, we must differentiate between greenstick fractures and complete fractures. Greenstick
fractures may be regarded as stable because one
cortex is only partially disrupted and the periosteum on that aspect presumably remains intact,
even after breaking the intact cortex. Most of
these injuries can then be treated conservatively.
When one or both bones are completely fractured
and displaced, closed reduction of the fragments
will often be successful, but it will hardly be
possible to maintain the reduction by conservative means. The high incidence of secondary displacements, secondary reductions, and changes
in therapy are evidence of this instability (18, 32,
37). Such unstable fractures may therefore categorically be regarded as a poor indication for conservative treatment. These injures require primary definitive stabilization (see p. 235).
226
Specific Injuries—Upper Extremities
Proximal Radial Shaft
Forms
앫 Greenstick fractures
앫 Complete fractures
Problems: Persistent axial deviation exceeding 10⬚
may be expected to cause functional impairment in
pronation and supination.
A-P and lateral radiographs
Limits of correction: Axial deviation of less than 10⬚.
Definition of “nondisplaced”: Axial deviation of up
to 10⬚.
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Medical.
앫 Where indication is uncertain: Upper-arm
plaster splint.
Emergency treatment under anesthesia: Where
associated complete, dislocated ulnar fractures
are present.
!
All other indications should first be discussed at
length with the patient and his or her parents.
Further treatment without anesthesia or delayed
treatment under anesthesia
앫 Radiographs in plaster should be obtained on
the eighth day after the accident. Conservative treatment is indicated where angulation
of the proximal radius up to 10⬚ in both planes
persists (assuming any possible ulnar fracture
is in correct position).
앫 A cast wedge is justified in the presence of initial or secondary angulation exceeding 10⬚.
Where this is unsuccessful, the procedure described in the previous section is indicated.
앫 Angulation exceeding 20⬚ requires closed re-
duction with the patient under anesthesia. In
greenstick fractures, the intact opposite cortex should be broken and the reduced fracture
stabilized with an intramedullary nail (the
nail should be bent prior to insertion so that
stable retention of the fragments can be
achieved by rotating the nail).
Technique of conservative fixation: Upper-arm
plaster splint.
Technique of internal fixation: Intramedullary
nail.
Aftercare
Period of immobilization
앫 With conservative fixation: Three to four weeks.
앫 With internal fixation: Immediate spontaneous
motion.
Consolidation radiographs: Yes.
Initial mobilization: Spontaneous mobilization after
removal of the plaster splint.
Physical therapy: None.
Sports: Five to six weeks after consolidation.
Removal of metal implants: 8–12 weeks postoperatively.
Follow-up examinations and conclusion: Examinations to evaluate function are performed at three-to
four-week intervals. Treatment is concluded once
unrestricted function has been regained.
Fractures of the Radial and Ulnar Shaft
227
Isolated fractures occurring in the proximal third of
the radial diaphysis or at the junction between the
proximal and middle thirds of the bone warrant
special attention, whether they occur as greenstick or as complete fractures. Any axial deviation
exceeding 10⬚ can be expected to produce
functional impairment in pronation and supination. Therefore, the goal of treatment must be to
reduce an axial deviation at this location to less
than 10⬚. If a cast wedge is unsuccessful in achieving this, reduction (i.e., correction of the axial deviation and breaking of the intact cortex) must be
performed with the patient under anesthesia.
Maintaining reduction with a plaster cast alone is
nearly impossible because of the surrounding
musculature. Therefore, internal fixation with an
intramedullary nail is recommended during the
same session. The nail should be bent slightly
prior to insertion so that the curvature can be
Presumably the “bow” in bowing fractures is not
spontaneously corrected. However, it is clinically
not very severe, nor is it accompanied by any
functional impairment in pronation and supination. This means that the fracture can be treated
conservatively without reduction (Fig. 20.8). The
injury is immobilized in a neutral position in an
upper-arm plaster splint for three weeks.
However, where function is initially restricted
(which experience has shown occurs with bends
exceeding 20⬚), one can attempt to eliminate the
axial deviation with a cast wedge. Should this fail,
then the axial deviation must be reduced with the
patient under anesthesia and the reduction main-
Fig. 20.7 a Isolated fracture of the proximal third of
the radius. The patient is an 11-year-old boy with an isolated fracture at the junction between the proximal and
middle thirds of the radius. Initial axial deviation of
slightly less than 20⬚ was present. The decision was
made to treat the injury by immobilization in an upper-
arm plaster splint and attempt correction of the angulation with a cast wedge eight days after the accident. This
treatment was unsuccessful and 20⬚ of axial deviation
remained. No further attempt to correct the deformity
was undertaken, which was inconsistent with previous
therapy
used to better correct and maintain the position
of the fragments (Fig. 20.7).
Treatment (Greenstick Fractures)
228
Specific Injuries—Upper Extremities
Fig. 20.7 b The cast was removed after a total of four
weeks. A consolidation radiograph was not obtained. As
was to be expected, the patient exhibited significantly
restricted pronation and supination of 20–0 – 30 ⬚ as opposed to 90–0 – 0⬚ in the contralateral arm after another
two weeks. Finally, it was decided that an axial correction was indicated, which was stabilized by intramedullary nailing. After another four weeks, the fracture had
healed stably. In initial functional testing after another
three weeks, the patient had a range of motion in pronation and supination of 70–0 – 80⬚. Occasionally, the use
of a cast wedge will successfully eliminate the deformity
in isolated radial shaft fractures of this type. However,
active reduction and stabilization of the fracture is indicated whenever it is not possible to reliably maintain a
deformity of less than 10⬚. This can be achieved very well
with intramedullary nailing
tained by stabilizing it with an intramedullary
nail (Fig. 20.9). Where the bowing fracture of one
forearm bone is accompanied by a completely
displaced fracture of the other bone, stabilization
with an intramedullary nail is often not strong
enough to counteract the tendency of the reduced
fragments to spring back into the deformity. This
means that the completely fractured bone must
be stabilized with a fracture plate (Fig. 20.10).
An injury involving a “genuine” greenstick
fracture of only one of the paired bones will rarely
exhibit angulation exceeding 20⬚. We initially
leave a deformity of this severity uncorrected and
apply an upper-arm plaster splint that we close to
form a complete cast on the fourth or fifth day
after trauma. We then place a cast wedge on about
the eighth day without any prior radiographs.
Fig. 20.9 Treatment of bowing fractures. The
patient is a 10-year-old girl with a bowing fracture of
both forearm bones; the radius is bowed and the ulna
impacted. The initial axial deviation of slightly less than
20⬚ was associated with significantly impaired pronation
and supination. Treatment with a cast wedge on the
eighth day after the accident failed to eliminate the axial
deviation (a). Therefore, the radius was realigned the
next day with the patient under anesthesia, and the re- 왘
duction was stabilized with an intramedullary nail. A regime of functional aftercare was prescribed. After nine
weeks, the fracture exhibited clinical and radiographic
evidence of solid healing (b). Both arms exhibited unrestricted and symmetrical function and the metal implants were removed
Fractures of the Radial and Ulnar Shaft
229
Fig. 20.8 Treatment of
greenstick fractures. Where
pronation and supination
are not initially restricted in
a bowing fracture of the
radius, as in the case of this
seven-year-old boy, then the
injury can be treated by immobilization in a plaster
cast without reduction. A
periosteal reaction like the
one here, which is indicative
of consolidation of the bowing fracture, is only rarely
observed
a
b
230
Specific Injuries—Upper Extremities
Radiographs are then obtained to evaluate the results of the cast wedge treatment. Where the
position of the fracture is ideal and what was once
the convex side is well compressed, the site of the
wedge is padded and closed (Fig. 20.11).
The wedge treatment may fail to achieve its
goal (eliminating the axial deviation and compressing the fracture gap on the convex aspect of
the injury). In such a case, the physician, parents,
and patient should jointly decide whether to attempt to place a broader wedge or to reduce the
injury the next day with the patient under anesthesia. This involves completely breaking the
fractured cortex. In reaching this decision, due
consideration should be given to the patient’s age,
temperament, and the severity of the axial deviation. Where ideal position cannot be achieved and
maintained—and this applies especially to isolated fractures at the junction between the proximal and middle thirds of the radius—then dynamic intramedullary nailing should be performed during the same session.
We treat “genuine” greenstick fractures of both
forearm bones with up to 20⬚ of displacement with
a cast wedge placed on the eighth day after the injury. Where the wedge treatment fails to
completely eliminate the axial deviation and
compress the cortex of what was once the convex
aspect of the deformity, the injury should then be
treated like any greenstick fracture with initial
displacement exceeding 20⬚: The intact cortex is
broken and the injury reduced with the patient
under anesthesia (Fig. 20.12). One should strive to
achieve slight side-to-side displacement as this
would provide ideal conditions for reliable fracture healing without complications. Here too, the
injury is initially immobilized in an upper-arm
plaster splint reinforced on its volar aspect with
the forearm in a neutral position. It is crucial to
mold the splint for an intimate fit along the dorsovolar aspect of the forearm. Using this method,
we have never observed any subsequent displacement of the fragments that would require secondary reduction, a potential complication that has
occasionally been discussed in the literature (7).
Intraoperative evaluation of a completely disrupted greenstick fracture may reveal it to be unstable in that the fragments are not only
completely separated but also tend to displace
completely. In such cases, we stabilize the fracture with an intramedullary nail during the same
session. We close the circumference of the splint
to form a cast on about the fourth day after
trauma as usual.
Fig. 20.10 Treatment of bowing fractures. The 왘
patient is a 14-year-old boy with a bowing fracture of the
radius and a complete fracture of the ulna. Because the
severity of the axial deviation exceeded 20⬚, reduction
with the patient under anesthesia was indicated (a). The
radius was straightened but then displayed such a
strong tendency to spring back into the previous axial
deviation that the ulna had to be stabilized with a fracture plate. Even then, the radius still sprang back into a
slight axial deviation (b). However, this residual deviation did not produce a cosmetic or functional impairment. The plate was removed after seven months, at
which time the patient exhibited unrestricted and symmetrical mobility in both arms
Fig. 20.11 Treatment of greenstick fractures. Mod- 왘
erate axial deviation of one or both forearm bones that
does not exceed 20⬚ is initially left untreated. Then, on
about the eighth day, it is eliminated with a cast wedge
without any prior radiographic studies. The goal of the
cast wedge must be to apply compression to what was
once the convex aspect of the deformity. Where the
consolidation radiograph shows a well-developed periosteal bridging callus on every aspect of the bone like in
this nine-year-old boy five weeks after the accident,
there will be no danger of refracture
Fractures of the Radial and Ulnar Shaft
a
b
231
232
Specific Injuries—Upper Extremities
Fig. 20.12 Treatment of a typical greenstick fracture. This 12-year-old girl suffered a typical greenstick
fracture of both forearm bones with initial axial deviation of 20⬚. The cast wedge placed on the seventh day
after the accident failed even to improve the axial deviation, let alone compress the opposite cortex. Therefore,
the injury was reduced the next day after breaking the
intact cortex with the patient under anesthesia. After
four weeks of immobilization in a plaster cast, the injury
had healed with a well-developed periosteal callus that
was no longer tender to palpation. The patient was
monitored for one year, during which time no repeat
fracture occurred
An x-ray in plaster is obtained on the eighth
day. A cast wedge is placed at this time if findings
so indicate. If findings are satisfactory in the
radiograph obtained after wedging, then subsequent follow-up radiographs will only be re-
quired in the case of older adolescents about two
weeks after the injury (Fig. 20.13). Note that diaphyseal fractures heal far more slowly than
metaphyseal fractures.
Fig. 20.13 Treatment of greenstick fractures. The initial axial deviation may be
too great for a cast wedge to eliminate the deformity and apply compression to
the opposite cortex. In these cases, the intact cortex must be broken to allow adequate healing. One should strive to achieve slight side-to-side displacement. Usually, the fracture will have healed after four weeks without the danger of repeat
fracture. In this 11-year-old boy with greenstick shaft fractures of both forearm
bones, the intact cortexes were broken and the injury treated conservatively by
immobilization in an upper-arm plaster cast. After four weeks, the fracture exhibited good clinical and radiographic healing in proper alignment as evidenced by
the good periosteal bridging of the fracture gap. No refracture occurred during the
further clinical course. Because diaphyseal greenstick fractures are stable even
after reduction, they are treated conservatively as a matter of course
Fractures of the Radial and Ulnar Shaft
233
234
Specific Injuries—Upper Extremities
Radial and Ulnar Diaphysis: Complete Fractures
(Invariably “instable” fractures. All diaphyseal fractures of the forearm
bones account for about 6% of all injuries; one quarter of these are
greenstick fractures).
Usually the radius and/or ulna are completely displaced.
Technique of conservative fixation: Upper-arm
plaster splint.
Limits of correction
앫 Below age five: Axial deviation of up to 20⬚.
Radius and ulna must not exhibit any axial deviation in opposite directions.
앫 Above age five: Axial deviation of up to 10⬚. The
farther proximal the injury, the less axial deviation is allowed.
Technique of internal fixation: Intramedullary
nailing.
A-P and lateral radiographs are indicated. (Caution:
Care should be taken to exclude a possible Monteggia fracture-dislocation in an isolated ulnar fracture.)
Definition of “nondisplaced“
앫 Below age five: Axial deviation up to 20⬚.
앫 Above age five: Axial deviation up to 10⬚.
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Medical.
앫 Where indication is uncertain: Immobilization in an upper-arm plaster splint.
Aftercare
Period of immobilization
앫 With conservative fixation: Three to four weeks
initially and in applicable cases with secondary
immobilization in a removable forearm plaster
splint for two to three weeks.
앫 With internal fixation: Immediate spontaneous
motion.
Consolidation radiographs: Yes, after four weeks
and in applicable cases after seven weeks, depending
on consolidation.
Initial mobilization: Spontaneous mobilization immediately postoperatively.
Physical therapy: None.
Sports: Four to six weeks after consolidation.
Emergency
treatment
under
anesthesia:
Completely displaced fractures of one or both
forearm bones with a shortening deformity.
!
All other indications should first be discussed at
length with the patient and his or her parents.
Further treatment without anesthesia or delayed
treatment under anesthesia
앫 Complete “nondisplaced” transverse fractures with the fragments in contact and slight
angulation (rare): Conservative.
앫 Fractures with secondary displacement exceeding the age-related tolerance range: Surgical.
Removal of metal implants: Intramedullary implants are removed 8–12 weeks postoperatively;
fracture plates one year postoperatively.
Follow-up examinations and conclusion
앫 Examinations are performed at three- to fourweek intervals until function is unrestricted.
앫 Treatment is concluded three to four weeks after
the metal implants have been removed.
Fractures of the Radial and Ulnar Shaft
235
In complete shaft fractures of the forearm bones,
the cortex of at least one of the two bones is
completely fractured around its entire circumference, the fragments are displaced, and a shortening deformity is present. Combined greenstick
and complete fractures may be treated in the
same manner as greenstick fractures. A cast
wedge will be effective in treating even slight
shortening deformities because the greenstick
fracture in the other bone against which the
wedge acts is relatively stable.
With respect to all other complete fractures of
the radius and ulna, we have changed our tactics
and technique in light of the numerous complications that can occur following conservative treatment. Published studies have reported that as
many as 50 % of all cases have required secondary
reduction and change of therapy or have resulted
in persistent functional impairment (7, 12, 18, 26,
32, 37, 40). We now feel that attempting conservative reduction is only justified where one of the
two bones is stable. Unstable fractures of both
bones represent a clear indication for primary internal fixation (46, 50, 51, 54, 55). Bear in mind
that while posttraumatic forearm deformities do
not lend themselves to secondary correction, they
usually do not lead to functional impairments.
This is because loss of function does not occur due
to bony injury alone; it can result solely from softtissue damage. These indications are not defined
by the patient’s age but by the stability of the fracture.
In injuries involving a combination of greenstick and completely displaced fractures such as
in Figure 20.14, we reduce the injury with the
patient under general anesthesia and attempt to
bring the displaced fragments into apposition.
This is easiest where the bones are at an acute
angle and the surgeon can reduce the fragments
by applying pressure with a finger. The danger in
this maneuver is that it may completely break the
partially fractured opposite bone, turning an initially partially stable injury into a completely unstable injury. Yet if the injury can be reduced
without rendering the forearm unstable, this will
create a stable situation. For this reason, we continue to treat these injuries conservatively.
However, in situations where it is apparent
that a stable situation cannot be achieved (e.g., in
short oblique fractures) or where both bones are
completely displaced from the start, we feel that
definitive retention with rigid internal fixation is
indicated (Fig. 20.15).
We no longer favor plate fixation, which we
once performed as a matter of course. Veterinary
plates are too rigid, and one-third tubular plates
do not provide sufficient stability. A plate can impair pronation and supination, and its rigid axis
Fig. 20.14 Treatment of complete shaft fractures of the
forearm bones. Closed reduction and conservative treatment are only indicated where one of the paired bones exhibits a stable fracture. Only then, as in this nine-year-old
boy, will reducing the injury produce a stable situation.
Clinical and radiographical examination after four weeks
revealed solid healing in correct position so that no
further immobilization was required
Complete Fractures
236
Specific Injuries—Upper Extremities
Fig. 20.15 Treatment of complete shaft fractures of
the forearm bones. Complete fractures of both bones
represent an unstable situation that cannot be eliminated by conservative treatment alone. Therefore, primary internal fixation of these fractures is indicated as a
matter of course. In the case of this nine-year-old boy, it
was decided that primary internal fixation was indicated
without attempting conservative closed reduction. Fixation was achieved by means of intramedullary nailing.
After four weeks of functional aftercare, clinical and
radiographic examination revealed that the fracture had
healed solidly. The metal implants were removed after
12 weeks
promotes the persistence of slight axial deviations that in turn can cause functional impairments or even consolidation disturbances and repeat fractures (6, 21). We ourselves have never
observed any radioulnar synostoses developing
secondary to plate fixation (1). Plate fixation invariably produces ugly permanent scars in the
forearm. This, coupled with the fact that the second operation to remove the metal implants is
significantly more difficult, has led us to favor dynamic intramedullary nailing as the standard solution for all age groups (27, 33, 43, 44). Fractures
at the junction between the middle and distal
thirds of the radius are in a very unfavorable location for an intramedullary nail, which stabilizes
the middle portion of the medullary canal but not
the distal fragment. The distal fragment remains
mobile around the nail and requires additional
immobilization. We regard these fractures as a
legitimate indication for plate fixation. However,
an external fixator could do the job just as well,
especially in an isolated fracture of the radius
(Fig. 20.16). An associated ulnar fracture can be
stabilized with an intramedullary nail. With all
Fractures of the Radial and Ulnar Shaft
237
other complete fractures and completely displaced fractures, intramedullary nailing offers the
distinct advantages of minimal scarring, closed
reduction, and easy implant removal. Nailing requires no additional immobilization in a plaster
cast but should be followed by functional aftercare. One nail is required for each bone. Forearm
nails are available in sizes ranging between 2–2.5
mm and 3 mm. The radial nail is inserted through
the distal metaphysis, taking care to preserve the
distal radial growth plate. The site is marked
under fluoroscopic control. The distal radial
metaphysis is exposed through a skin incision
measuring about 2 cm, and a hole rising obliquely
into the bone is drilled with a broach. Attached to
the hand grip, the nail can now be easily inserted
and advanced as far as the fracture. The surgeon
reduces the fracture while simultaneously advancing the nail into the proximal fragment under
fluoroscopic control. Turning the hand grip alters
the direction in which the nail advances. The nail
is advanced until it is immediately distal to the
proximal radial growth plate and then clipped off
at the end beneath the skin. The ulnar nail is inserted into the proximal metaphysis and advanced in the same manner. Functional aftercare
in the form of spontaneous motion as tolerated
begins immediately postoperatively (27, 33;
General Science, Treatment, and Clinical Considerations: 24).
Fig. 20.16 Treatment of a complete fracture of the
radius at the junction of the middle and proximal
thirds of the bone in an adolescent. The patient is a 15year-old boy with a Galeazzi fracture. The fracture was
located at the junction of the middle and distal thirds of
the radius; the patient’s growth plate were open. Closed
reduction was performed and the fracture stabilized
with an external fixator (yellow Monotube manufactured by Stryker Howmedica) because of the patient’s
age and the location of the fracture. The postoperative
clinical course was initially complicated by accumulations of secretions around the distal screw which were
managed by local application of moist compresses with
1% chloramine. After seven weeks, the fracture exhibited good clinical and radiographic healing, allowing
the fixator to be removed without anesthesia. Treatment was concluded 16 weeks after the accident, at
which time the patient was free of subjective symptoms
and both elbows and wrists exhibited unrestricted and
symmetrical mobility
238
Specific Injuries—Upper Extremities
Immobilization and Consolidation
We always remove a plaster cast after four weeks
for reasons of hygiene alone. Fractures stabilized
by internal fixation do not require additional immobilization in plaster, and the patient can begin
spontaneous motion exercises immediately postoperatively. Some patients desire a “protective
shield,” especially for school. These patients receive a removable dorsal forearm plaster splint for
two to three weeks.
The radiograph out of plaster obtained after
four weeks usually shows a solid periosteal bridging callus on all sides in conservatively treated
patients and surgically treated patients alike.
Where the callus is no longer tender to palpation,
we allow patients unrestricted spontaneous motion. Regardless of the radiographic findings, we
again immobilize a fractured arm with a callus
that is tender to palpation in a removable forearm
splint. This additional immobilization is maintained for two to four weeks until the pain disappears. In any case, the patient begins spontaneous
motion and strength exercises as soon as the injury site is no longer painful. Additional radiographs will not be required where the first consolidation radiograph demonstrates a bridging
callus across the fracture gap on at least three
sides of the cortex. Where this is not the case,
another radiographic study to verify consolidation should be performed after four to six weeks.
Nails should be removed about 8–12 weeks
postoperatively once the fracture has definitively
healed. Occasionally, a longer incision will have to
be made to bend the end of the nail so that it can
be engaged with a grasping forceps. Removing the
nail is a simple procedure. A fixator should be removed without anesthesia immediately after the
fracture has healed. Fracture plates are normally
removed after six to eight months.
Sports Participation and Follow-up
Examinations
Patients should refrain from sports for the first
three weeks after consolidation. Where motion is
unrestricted after this period and the patient is
asymptomatic, he or she may then gradually resume sports activities. Treatment is concluded
three to four weeks after the patient has resumed
sports if there are still no subjective symptoms,
the scars are not tender, and distal neurovascular
function is normal.
Fractures of the Radial and Ulnar Shaft
239
Distal Radius and Ulna (19.4%)
Forms
앫 Diaphyseal greenstick fractures
앫 Metaphyseal greenstick fractures
앫 Metaphyseal impacted fractures
앫 Separated epiphyses
Limits of correction: There is immense potential for
correction.
앫 Below age 10–12: Deviation of up to 50⬚ in the
coronal and sagittal planes can be corrected.
앫 Above age 10–12: Corrective potential is limited
(treatment should strive for ideal position).
A-P and lateral radiographs are indicated.
Definition of “nondisplaced”:
앫 Below age 12: Angulation of up to 30–40⬚ in the
sagittal plane and 10–20⬚ in the coronal plane.
앫 Above age 12 (depending on sex and maturity of
the growth plates): Angulation between 0 and
10–20⬚ in both planes.
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Medical.
앫 Where indication is uncertain: Immobilization in an upper-arm and/or forearm plaster
splint.
Emergency
treatment
under
anesthesia:
Completely displaced fractures of one or both
forearm bones with a shortening deformity.
!
All other indications should first be discussed at
length with the patient and his or her parents.
Further treatment without anesthesia or delayed
treatment under anesthesia
앫 Nondisplaced impacted fractures with the
anterior or posterior cortex in physiological
alignment: Conservative treatment without
any further radiographic examinations.
앫 Fractures with angulation in all age groups:
Conservative treatment with a cast wedge on
about the eighth day after the accident.
—Below age 12, “nondisplaced” fractures can
be left uncorrected after the patient and his or
her parents have been properly informed (additional radiographic studies may not be required).
—Above age 12—depending on the maturity of
the distal radial growth plate—treatment
should strive for ideal position (verified by
radiographic examination after placing the
wedge). Where it is not possible to achieve a
tolerable position for the patient’s age, closed
reduction the next day is indicated.
앫 Following closed reduction—whether late or
emergency reduction—treatment should
strive for definitive stabilization with one to
two Kirschner wires.
—Below age 12, wire fixation is optional.
—Above age 12, wire fixation is mandatory.
Technique of conservative fixation
앫 Small children up to age eight receive an
upper-arm cast.
앫 Older children and adolescents receive a forearm cast.
Technique of internal fixation: Percutaneous pinning with one to two Kirschner wires with additional immobilization in a forearm cast.
Aftercare
Period of immobilization: Three to four weeks with
conservative or internal fixation.
Consolidation radiographs: None except in the
case of Kirschner wire fixation prior to removal of the
wires and at the parents’ request as a baseline study
for follow-up in cases where a gross deformity has
been left untreated.
Initial mobilization: Spontaneous mobilization immediately after removal of the cast.
Physical therapy: None.
Sports: Two to three weeks after consolidation.
Removal of metal implants: Implants are removed
upon consolidation.
Follow-up examinations and conclusion: Examinations are performed at two- to three-week intervals
until function is unrestricted. Treatment is concluded
once unrestricted function has been achieved and no
visible clinical deformities are present.
240
Specific Injuries—Upper Extremities
Fractures in the Distal Third
Forms of Injury
앫 Greenstick
앫
앫
앫
앫
Fig. 20.17 Distal forearm fractures: Greenstick fractures in the diaphyseal–metaphyseal junction
앫
a
b
c
fractures of the diaphyseal—
metaphyseal junction of one or both bones
(Fig. 20.17)
Metaphyseal impacted fractures (Fig. 20.18 a)
Metaphyseal bending fractures (Fig. 20.18 b)
Metaphyseal complete fractures
Separated distal radial epiphysis with or
without a metaphyseal wedge, either isolated
or in combination with impacted ulnar fractures, a separated ulnar epiphysis, or avulsion
of the ulnar styloid (Fig. 20.18 c)
(Galeazzi injuries or their equivalent [52] are
extremely rare)
Fig. 20.18 Metaphyseal fractures
in the distal forearm.
a Metaphyseal impacted fractures
of one or both bones with impaction of the posterior cortex or
posterior and anterior cortexes
b Metaphyseal bending fractures or
one or both bones
c Loosening and separation of the
epiphysis with or without an additional metaphyseal wedge and/or
additional injury to the ulna (fracture of the ulnar styloid, separated epiphysis, or fracture with
avulsion of a metaphyseal wedge)
Fractures of the Radial and Ulnar Shaft
Diaphyseal greenstick fractures with the specific
problems they involve can occur even at the distal
diaphyseal–metaphyseal junction (see Greenstick
Fractures, p. 223). However, most injuries are impacted fractures with or without angulation of the
fragments or, less often, completely displaced
fractures. Metaphyseal bending fractures only
rarely occur at this site, and they are not clinically
significant when they do. The most distal
metaphyseal fracture is the separated epiphysis.
These injuries usually involve the distal radius,
which is the most common site in the entire body
for separated epiphyses.
Only the separated radial epiphysis corresponds to the classic example of a radial fracture
in adults.
Distal forearm fractures are the most common
injuries to the extremities.
Epiphyseal fractures of the distal radius are so
rare as not to warrant further mention (15, 18, 19,
23, 40).
Diagnosis
Injuries that present diagnostic problems include
minimally impacted cancellous fractures,
loosened epiphyses, and nondisplaced separated
epiphyses or separated epiphyses that have spontaneously reduced in ideal alignment. Secondary
diagnostic examinations are not always reliable
because a periosteal callus may fail to develop
where the fragments are in ideal alignment
Fig. 20.19 Diagnosis of a nondisplaced separated
epiphysis. Often a metaphyseal fracture (arrow) is the
only sign of a separated epiphysis other than clinical
symptoms. Where the fragments are in ideal alignment,
a periosteal callus will not develop and secondary radio-
241
(Fig. 20.19). It is best to rely solely on clinical findings in all of these cases.
Growth Disturbances
The most common growth disturbances include
transitory stimulation of the distal radial growth
plate, producing a transitory growth spurt in the
radius. This results in significant longitudinal
growth in the radius with respect to the ulna, particularly after multiple fractures or repeated attempts at reduction. However, the actual length
difference is slight and does not become clinically
significant. This is because the length increase is
spontaneously corrected around the time of cessation of growth and the deformity is reduced to a
tolerable degree that remains clinically insignificant. This specific length correction only occurs
with respect to the ipsilateral paired bone; it is
completely independent of the length relationship in the contralateral forearm (42).
Growth disturbances such as premature
complete or partial closure of the distal growth
plate are extremely rare. However, they can occur
in both the ulna and the radius following nondisplaced and displaced impacted fractures or separated epiphyses (17, 18, 19, 25, 42, 47, 56). The
cause of these disturbances is not known, although most likely they are attributable to traumatic disruption of the epiphyseal vascular system (42). The result is an age-related deformity
with increasing shortening of the respective bone
graphs will be inconclusive. The examiner must rely on
clinical findings in such cases. In this 14-year-old boy, the
fracture had clinically healed without a visible callus on
the radiograph after four weeks of immobilization
closure of the ulnar aspect of the distal radial growth plate occurred after a
metaphyseal fracture had healed in malalignment. This resulted in abnormal
growth
Specific Injuries—Upper Extremities
Fig. 20.20 Rare growth disturbance following distal forearm fractures. Premature partial or complete closure of the distal radial or ulnar growth plate can
occur after any metaphyseal or epiphyseal fracture. In this 13-year-old boy, partial
242
(Fig. 20.20). No initial parameter can be identified
that would indicate when such a growth disturbance might occur. Neither the displacement, nor
the type of axial deviation, nor the type of injury
correlate with the occurrence of these growth disturbances (Fig. 20.21).
“Spontaneous Corrections”
Because the distal forearm growth plates account
for a high percentage of growth and the wrist articulations are highly mobile, the distal forearm
provides excellent spontaneous correction of
both side-to-side displacement and axial deviations in the coronal and sagittal planes (8, 9, 11, 16,
18, 19, 34, 37, 38, 49). Side-to-side displacement of
up to one full shaft width is completely compensated for (11). However, displacement exceeding
one-quarter shaft width will continue to restrict
pronation and supination for a long time and
therefore should not be left uncorrected. Angulation of up to 40–50⬚ in the coronal and sagittal
planes may be found in this region. These deformities are reliably spontaneously corrected in
fractures occurring up to age 10–12; growth
causes the deformity to migrate into the shaft,
where it is largely compensated for by the periosteum. At the same time, further growth restores
the physiological alignment of the epiphysis perpendicular to the plane of motion. Such corrections can occur very rapidly within just a few
months. This would suggest that these corrections may be primarily attributable to mechanical
forces rather than to further growth. Spontaneous
correction of deformities following impacted
fractures and separated epiphyses (Figs. 20.22,
20.23) is equally reliable. Volar angulation is rare
and is corrected more slowly than dorsal angulation, which is significantly more common. Shortening deformities usually occur in combination
with radial or dorsal angulation. As we mentioned, this is the only region of the skeleton in
which such deformities are spontaneously corrected during the course of further growth (42;
Fig. 20.23). Spontaneous correction is also
possible where these injuries are associated with
side-to-side displacement (as completely displaced fractures) although it will take longer in
such cases (11).
Fractures of the Radial and Ulnar Shaft
243
Fig. 20.21 Growth disturbance involving premature
partial closure of the distal
radial growth plate. The
patient is a 12-year-old girl
of Mediterranean descent
with a nearly nondisplaced
separated distal radial
epiphysis (a). The fracture
was treated conservatively
with a dorsovolar plaster
splint. A consolidation radiograph was not obtained, and
after six weeks the fracture
had clinically healed without
a visible deformity. During
the following year, the
patient developed a clinically visible deformity of the
distal wrist characterized by
relative ulnar advancement
and increasing pain. Radiographic examination revealed premature partial
closure of the ulnovolar
aspect of the growth plate
with corresponding abnormal growth (b)
a
b
244
Specific Injuries—Upper Extremities
Fig. 20.22 “Spontaneous corrections” in the distal
forearm. The anatomy of the distal forearm is not conducive to angulation exceeding 40–50⬚, and such deformities are accordingly rare. The usual angulation deformities in the coronal or sagittal planes occurring secondary to a fracture suffered up to age 10–12 are
completely corrected by further growth. In this sevenyear-old boy, the metaphyseal bending fracture healed
in dorsal and radial angulation of 35⬚ each. Within one
year of the accident, the deformity had been largely
compensated for. At no time did the patient experience
any restriction of pronation or supination
Fig. 20.23 “Spontaneous
corrections” in the distal
forearm. Shortening deformities (such as in this
10-year-old girl 12 months
after a separated epiphysis)
are spontaneously corrected during further
growth, which restores the
physiological length relationship between the paired
bones
Fractures of the Radial and Ulnar Shaft
Treatment
Up to age 10, “spontaneous corrections” at this
site can be readily integrated into primary treatment. This means that untreated deformities such
as dorsal and radial angulation can be left to the
corrective forces of further growth. However, the
physician and parents should contemplate to
what extent the patient may be expected to
tolerate such an approach. Unfortunately, one
must also consider that neighbors and the physician’s colleagues may be only too happy to offer
“well-meant advice” and will never miss an opportunity to maliciously predict how such an approach is doomed to failure, especially as they
themselves have nothing at stake. Children are
usually able to take this in their stride. Yet such
criticism is all the more unsettling for their
parents and it is important to avoid overtaxing
them, even where “spontaneous corrections” may
be relied upon. To avoid unnecessarily increasing
the burden of primary treatment, one should initially immobilize fractures with angulation in a
cast regardless of the age group and leave the deformity untreated: The cast will hide the deformity from nosy neighbors. Treatment with a cast
wedge or by reduction (depending on the
patient’s age) to diminish the visible deformity
that neighbors may perceive should only be attempted later.
For the purposes of treatment, we differentiate between three categories of metaphyseal
impacted and bending fractures, including sepa-
Table 20.1
245
rated epiphyses. These injuries are either nondisplaced fractures, fractures with angulation, or
completely displaced fractures. All of these fractures are treated on an outpatient basis as a matter of course (Table 20.1). However, wherever
general anesthesia or a nerve block is indicated to
reduce the fracture, the reduction should invariably be definitively maintained (if need be with
percutaneous Kirschner wires) so as to render any
additional radiographs and cast wedges unnecessary. The likelihood that such pinning will be required increases with the age of the patient.
However, one should carefully consider whether
initial treatment under general anesthesia is truly
necessary in such a patient, especially as the
patient may not have an empty stomach. In particular, the surgeon should consider whether the
expected benefits of reduction under general anesthesia could not be achieved equally well with a
cast wedge, which requires no anesthesia at all.
The only situation in which stable fractures (fractures with the fragments in apposition and incompletely displaced fractures) might require reduction is in adolescents where a cast wedge has
failed.
Greenstick fractures at the diaphyseal –
metaphyseal junction represent a combination of
impacted and greenstick fractures. They invariably involve slight angulation as a result of the
bending trauma. Here, too, consolidation disturbances can occur on what was once the convex
aspect of the fracture. Deformities associated
with these injuries may safely be left untreated
Treatment of metaphyseal fractures of the forearm
Nondisplaced metaphyseal impacted
fractures
Day of injury Plaster splint
Complete fractures
“Nondisplaced”
metaphyseal bending with angulation
fractures
Completely displaced fractures
Plaster splint
Reduction, plaster
splint (dorsovolar),
and XR
Plaster splint
Day 4
—
Close cast
Close cast
Close cast
Day 8 – 10
—
⬍ age 10, XR,
(cast wedge)
⬎ age 10, XR,
(cast wedge),
(XR)
⬍ age 10, cast wedge
⬎ age 10, cast wedge,
XR
(reduction)
⬍ age 10, cast wedge
⬎ age 10, (cast wedge)
(XR)
Week 4
Remove cast,
clinical exam
Remove cast,
clinical exam
(XR)
Remove cast, clinical
exam, and XR
(XR)
Remove cast, XR
XR = radiographic follow-up study, () = optional
246
Specific Injuries—Upper Extremities
Fig. 20.24 Treatment of
distal forearm fractures.
The patient is a six-year-old
boy with greenstick fracture
at the diaphyseal–metaphyseal junction with angulation. A cast wedge
diminished the severity of
the deformity. However, it
did not place the convex
aspect of the deformity
under compression, which
resulted in a partial consolidation disturbance at
this site. The broad periosteal bridging callus on the
concave aspect prevented a
refracture (treatment was
concluded upon clinical follow-up examination one
year later)
within the age limits mentioned above. The
broader support provided by the resulting periosteal fracture callus will reliably prevent repeat
fracture (Fig. 20.24).
Nondisplaced metaphyseal impacted fractures
with impaction of only the dorsal cortex or the
dorsal and volar cortex are initially immobilized
in a dorsolateral plaster forearm splint to relieve
Fig. 20.25 Treatment of distal forearm fractures.
Impacted cancellous fractures require only pain relief in
the form of a plaster cast
pain. It is not necessary to close the splint to form
a cast (48). Usually, no further radiographs will be
required. The period of immobilization is two to
three weeks, depending on the patient's age.
Treatment may then be concluded if the patient is
free of pain (Fig. 20.25).
“Nondisplaced” metaphyseal bending fractures (Fig. 20.26) and separated epiphyses involve
a risk of secondary displacement. Therefore, an
x-ray in plaster must be obtained on about the
eighth day in patients above age 10 and may optionally be obtained in patients younger than age
10. Treatment with a cast wedge is indicated
wherever angulation is seen to increase. Results
of this cast wedge treatment should be documented in radiographs in patients above age
10. The injury is immobilized for a total of three to
four weeks in a plaster splint with a volar forearm
reinforcement. Radiographic documentation
should be obtained in addition to clinical examination after the splint is removed in all injuries involving a separated epiphysis or fractures treated
with a cast wedge.
After obtaining the informed consent of the
patient and his or her parents, we initially leave
metaphyseal bending fractures or separated
epiphyses of one or both bones with up to 40⬚ of
initial angulation in the coronal and/or sagittal
planes uncorrected (49), and we do not attempt to
reduce these injuries. We then immobilize the injury in a forearm plaster splint with volar reinforcement, using a forearm splint only in adolescents with far distal fractures. On about the fourth
Fractures of the Radial and Ulnar Shaft
247
Fig. 20.26 Treatment of distal forearm fractures.
Metaphyseal bending fractures involve a risk of secondary displacement, which can be confirmed by radiographic examination on about day eight. This eightyear-old boy received a cast wedge after a radiograph
was obtained to verify correct position. In consideration
of the patient’s age, it was decided not to document the
results of the wedge treatment in additional radiographic studies. The fracture healed with a slight deformity. Within six months, the deformity was no longer
clinically visible. Mobility was unrestricted during the entire clinical course
day, we close the splint to form a cast in every
case. The initial wedge is placed on the eighth day
once the soft-tissue swelling has completely
abated (Fig. 20.26).
Radiographs are then obtained to evaluate the
results of the cast wedge treatment, primarily in
patients above age 10. If necessary, the wedge is
moved before the cast is closed again. Radiographs after placement of a wedge may be dispensed with in patients below the threshold age
of 10–12, as angulation of up to 40⬚ in one or two
planes is acceptable in these patients. However,
one should strive to achieve an ideal position in
adolescents. Where an ideal position or, in
children below age 10, a tolerable position cannot
be achieved with a cast wedge, then the injury is
reduced the next day. The patient receives either
general anesthesia on an empty stomach or a
nerve block. In patients aged 10–12, in the transitional age between childhood and adolescence,
every effort should be made to achieve an ideal
position. In cases where a fracture heals in angulation despite these efforts (Fig. 20.27), then one
should consider on a case-to-case basis specific
factors such as the maturity of the growth plate,
individual development, phenotype, etc. in evaluating whether to leave the axial deviation to subsequent “spontaneous correction” or whether to
perform a refracture (Fig. 20.28) or corrective
osteotomy at a later date.
We employ percutaneous fixation with a Kirschner wire to immobilize separated epiphyses
and certain impacted fractures in older adolescents in whom closure of the growth plates is imminent (Fig. 20.29). This is done to prevent secondary displacement (53). All of these cases require intraoperative radiographic verification of
correct position after the fracture has been reduced.
After three to four weeks of immobilization,
we verify healing by clinical examination only as a
matter of course. We dispense with any initial
consolidation radiographs in patients without a
clinical deformity whose callus is no longer
tender to palpation. However, there are several
exceptions to this rule:
248
Specific Injuries—Upper Extremities
Fig. 20.27 Chronic forearm fracture with angulation in
the transitional age between childhood and adolescence.
The patient is a 12-year-old girl with a four-week-old fracture
of the distal radius that healed with 25⬚ of dorsal angulation.
The fracture exhibited good clinical and radiographic healing. An appointment for open reduction had been made at
another hospital. Asked for a second opinion, we recommended waiting to see what further growth would correct,
considering that the growth plates were still wide open in a
patient who had neither experienced menarche nor the
onset of breast development. Parents and patient followed
this suggestion. A year and half later there was no clinical evidence of a deformity, only slight radiographic evidence of
one, and the patient exhibited unrestricted and symmetrical
mobility
앫 All fractures treated with internal fixation,
앫 Where a clinical deformity is present and the
parents are worried, we also obtain radiographs to be able to document the “spontaneous correction” of the deformity if need
be,
앫 Where a functional impairment in pronation
and supination persists beyond the first four
to six weeks, we also obtain radiographs to
provide objective baseline studies for subsequent follow-up.
Completely displaced and shortened fractures are
reduced in emergency procedures. The forearm is
placed in a neutral position and the arm is immobilized in an upper-arm plaster splint with a volar
forearm reinforcement. In older adolescents, the
fracture is simultaneously stabilized by pinning
with Kirschner wires. Pinning is not required in
younger patients.
The splint is closed to form a cast on about the
fourth or fifth day. An initial radiographic examination to verify correct position is performed on
about the eighth day. Where there are signs of a
beginning deformity, we proceed as in the case of
initial angulation (Fig. 20.30). A second radiographic examination to verify correct position is
only required in older children on about day 14. In
every case, we remove the cast and obtain a consolidation radiograph after four weeks.
Technique of percutaneous Kirschner wire fixation: The wire should be inserted via the radial styloid and may cross the growth plate, especially in
adolescents. It should not lie at too acute an angle
because otherwise the fracture could rotate
around the wire and slip into angulation. For this
reason, the wire should be placed at a steep angle
and engage the cortex well (see Fig. 20.29). When
Fractures of the Radial and Ulnar Shaft
249
Fig. 20.28 Treatment of a chronic fracture of the
distal radius in an adolescent. The patient is a 13-yearold boy of Mediterranean descent with a three-week-old
fracture of the distal radius with 35⬚ of angulation. The
growth plate appeared to be approaching maturity, and
the boy was already in puberty. Therefore, we felt that
refracture was indicated. This was performed closed by
increasing the dorsal angulation. Then the angulation
was corrected against the resilient resistance of the callus, and the reduction was stabilized with two crossed
Kirschner wires. After four weeks, the fracture exhibited
good clinical and radiographic healing, and the wires
were removed. After another four weeks, both sides exhibited unrestricted and symmetrical mobility in pronation and supination
in doubt, percutaneous pinning with crossed Kirschner wires is recommended (see Fig. 20.28). The
wires should project beyond the skin to facilitate
later removal without local anesthesia. As in the
elbow, an opening in the cast is left around the
ends of the wires. If the radial wire is correctly inserted at the proper steep angle, it can press
against the skin and cause ulceration. This complication can be avoided by bending the wire radially
and placing the hand in slight ulnar deviation
when applying the plaster. After pinning, the injury is immobilized in a dorsovolar forearm splint.
nation and supination. However, these can be
well compensated for by the shoulder.
Immobilization and Consolidation
All patients begin with spontaneous motion exercises as soon as the callus is no longer tender to
palpation. Where motion is unrestricted, they will
usually be able to fully resume sports activities
within two to three weeks.
In children, uncorrected axial deviations of
the radius alone do not usually lead to any significant functional impairment. This also applies to
angulation of around 40⬚. Deformities in both
bones can cause functional impairments in pro-
Sports Participation and Follow-up
Motion impairments of this sort usually disappear after three to four months. An uncorrected
deformity will not interfere with sports participation. Late sequelae such as length differences
need not be feared (19). Children are not generally
disturbed by uncorrected deformities at all,
neither by the transient cosmetic deformities nor
by transient functional impairments. It is the
parents who feel disturbed, deeply worried as
they are by the advice of their family physician
and the expert paramedical opinions of friends
and relatives.
In the further clinical course, radiographic follow-up studies can reassure worried parents by
demonstrating the extent of correction that has
occurred. Parents who have not been negatively
influenced will be satisfied with clinical followup examinations at six-month intervals (possibly
with photographic documentation) until the cosmetic and functional impairment has completely
250
Specific Injuries—Upper Extremities
Fig. 20.29 Treatment of
an acute fracture of the
distal radius in an adolescent. The patient is a 15year-old boy with a separated distal radial epiphysis
with angulation. In light of
the patient’s age, it was felt
that reduction was indicated.
This was performed the day
after the accident after the
patient received an axillary
nerve block. The fracture
was stabilized with a single
percutaneous Kirschner wire
crossing the growth plate
that projected above the
skin. The wire was removed
once clinical and radiographic examination demonstrated solid healing. Three
weeks after healing, the
patient was free of subjective symptoms, both sides
exhibited unrestricted and
symmetrical mobility, and
the wire puncture site had
healed without irritation
disappeared. Treatment may then be concluded
solely on the basis of clinical findings.
The possible growth disturbance of premature partial closure of the growth plate does not
justify any long-term follow-up that could conceivably extend to cessation of growth. The infrequency of this growth disturbance coupled
with the high incidence of these injuries in the
distal forearm make such monitoring superfluous. Nor should an exception be made for separated epiphyses: Premature closure of the growth
plate is equally rare following separation of the
epiphysis with or without metaphyseal involvement, as is also the case following displaced and
nondisplaced metaphyseal impacted and bending
fractures.
Shortening deformities following such
growth disturbances require secondary correction. Such corrections can conceivably require
several operations in order to restore the symmetrical length relationships between the radius
and ulna on both sides.
Combinations of radial fractures and avulsions of the ulnar styloid are rare and tend to
occur only in adolescents. However, such an injury may be overlooked especially where the
ulnar styloid is not yet visible on a radiograph. The
avulsed fragment does not always heal with bony
Fractures of the Radial and Ulnar Shaft
251
Fig. 20.30 Treatment of
fractures in the distal
forearm. Completely displaced fractures are reduced in an emergency
procedure regardless of the
patient’s age, and the results of reduction are documented in radiographs.
Radiographs to verify correct position obtained on
about the eighth day
should detect any beginning axial deviation if present. This deviation may
then be eliminated with a
cast wedge. Tolerable deformities may be left
treated in children up to
age 10. Beyond age 10, as
in the case of this 11-yearold girl, every effort should
be made to achieve an ideal
axial position
union. Persistent pseudarthroses can occur and
produce chronic symptoms (23). Removal of the
fragment is indicated in such cases.
As was mentioned above, epiphyseal fractures
are rare in the distal radius because the growth
plate provides exceptionally good protection for
the joint and therefore for the epiphysis as well.
Nondisplaced fractures with a fracture gap of up
to 2 mm should be treated conservatively; surgical reduction and fixation with Kirschner wires or
with mini fragment screws would be indicated for
any greater displacement.
252
Specific Injuries—Upper Extremities
Fig. 20.31 Correction of a
deformity following a
forearm fracture. The
patient is a 13-year-old boy
with a healed forearm shaft
fracture in the middle third
sustained slightly less than
six months previously. The
injury healed with massive
deformities in the radius
and ulna. Although the deformities are in the same
direction, pronation and
supination are significantly
impaired. An osteotomy
was performed for
functional and cosmetic
reasons and was stabilized
with two fracture plates.
The osteotomies had definitively healed after 12 weeks,
and the metal implants
were removed after six
months. At this time, both
sides exhibited unrestricted
and symmetrical mobility
Most Common Deformities of the
Middle and Distal Forearm Bones
As in the upper arm, posttraumatic deformities in
the middle of the shaft are caused by uncorrected
axial deformities in which “spontaneous correction” occurred only partially or not at all (30, 35,
39, 40, 43). In contrast, clinically significant deformities and symptoms (36) in the vicinity of the
wrist are usually attributable to growth disturbances due to premature closure of the growth
plate (3, 4, 22, 24, 40, 45).
Shaft
In contrast to experimental studies (43), our own
clinical experience has led us to conclude that the
farther proximal an uncorrected axial deviation is
located, the greater the restriction of pronation
and supination will be. Another significant factor
impairing function is the direction of the deformities. If they lie in opposite directions in the shaft,
this will exacerbate the functional impairment.
Many unknown factors influence function: We
only partially understand the role of malrotation
in the respective bone in experiments (35, 43),
and we know how unreliable experimental experience is when applied to a clinical setting.
Fractures of the Radial and Ulnar Shaft
253
a
b
Fig. 20.32 Correction of a deformity close to the
wrist following a metaphyseal fracture. The patient is
a 15-year-old boy with a nondisplaced metaphyseal fracture of the radius accompanied by avulsion of the right
ulnar styloid. The injury was treated conservatively with
a forearm plaster cast. After four weeks, the radial fracture had healed with slightly less than 20⬚ of volar angu-
lation (a). At cessation of growth the angulation had increased by a further 10⬚, presumably due to premature
partial closure of the growth plate. Because the patient
experienced persistent pain on exertion, it was felt that
an opening osteotomy was indicated to correct the deformity. The defect was filled with an iliac bone graft and
fixed with an AO T-plate (b)
Another factor that is highly obscure (and consequently the subject of vehement discussion)
and whose impact on function we do not at all understand is the interosseous membrane (2, 43).
And last but not least, we do not know what influence further growth has on all these known
and unknown factors with respect to function. To
date, we have only been able to observe that the
uncorrected axial deviation changes over the
course of further growth: It flattens out and the
distance to the two adjacent joints changes. Any
attempt, after months or years, to eliminate the
bony deformity (e.g., with a two-level osteotomy)
will produce very good cosmetic and radiographic
results. However, in many cases function will remain impaired or will only improve slowly in
younger patients during the course of further
growth. Up to now we have failed to discern any
254
Specific Injuries—Upper Extremities
definite pattern to this phenomenon. Weinberg’s
studies (43) may conceivably help us to better
recognize the problems involved and draw appropriate conclusions for clinical management.
Today it is common practice to treat forearm
shaft fractures by intramedullary nailing, with the
result that the problem of uncorrected deformities has become increasingly rare. Where we encounter uncorrected axial deviations with corresponding functional impairments in spite of this,
we advocate intervention to correct the bony deformity as quickly as possible. The earlier this is
done, the greater the chance that normal mobility
will be regained. At this point, we warn the reader
against relying on the corrective forces of further
growth. Even six months after the injury can already be too late for attempting corrective
surgery. However, as was mentioned, this recommendation to perform the correction as early as
possible is based not on knowledge but on fear. In
light of these uncertain aspects, the patient
should decide himself or herself whether correction is indicated after being comprehensively informed. Where it is certain that no functional rehabilitation may be expected, one can at best offer
the patient a corrective rotational osteotomy to
bring the hand into a more favorable position
without improving the existing range of motion.
As in the management of a radioulnar synostosis,
the physician should discuss with the patient
which position would be best for him or her. In
most cases, this would be somewhere between
slight pronation and a neutral position.
The technique for this sort of early correction
is very simple: The bone is refractured or a transverse osteotomy is performed at the apex of the
current deformity. If the correction involves refracture, the reduction is stabilized by elastic
stable intramedullary nailing (ESIN). This requires
reaming the medullary canal with a broach or
better yet with a drill. In older fractures, at least
one of the two bones (preferably both) should be
treated with plate fixation that ensures rotational
stability (Fig. 20.31). Pseudarthrosis can result
where there is pronation and supination in the
osteotomy around a nail.
Aftercare should invariably consist of spontaneous motion immediately postoperatively.
Only rarely will good physical therapy be helpful
in the early stage of healing.
Pseudarthrosis nearly always occurs secondary to motion-impairing plate fixation, rarely
with nails of overly large diameter, and only in exceptional cases following infection. Hypertrophic
pseudarthrosis of the ulna is most common and is
usually asymptomatic so that surgical repair may
safely be postponed. This type of pseudarthrosis
has the greatest chances of resolving spontaneously. However, the process may take one to
two years. During this time, the patient need not
take any special precautions but may use the arm
completely normally. However, if the patient reports any symptoms such as pain or increasingly
restricted motion, the surgeon should not hesitate
to debride the pseudarthrosis, achieve reliable
compression with a plate or external fixator, and
insert cancellous graft material. Atrophic
pseudarthrosis of the ulna is rare. In such cases,
one should not wait for spontaneous healing because the situation will steadily worsen. Prompt
surgical repair with a cancellous graft and stabilization is indicated instead.
Pseudarthrosis of the radius represents a
greater handicap for the patient as the radius is
the primary load-bearing structure in the forearm. Here, there will usually be no choice but to
intervene surgically at an early stage.
Distal
Distal forearm deformities are invariably attributable to the growth disturbance of premature partial or complete closure of one or both growth
plates following metaphyseal fractures. Epiphyseal fractures at this site are rare. Compared with
the high incidence of separated epiphyses and
other metaphyseal fractures, these growth disturbances are extraordinarily rare (see chapter Patterns of Injury and Prognosis of Childhood Fractures p. 32). The sequelae are extraordinarily distinctive and varied:
Increasing shortening of the radius with or
without axial deviation may occur in conjunction
with normal ulnar length, producing a pseudo
Madelung deformity (Fig. 20.21 and 20.32). A
conical epiphysis can develop in which the abnormal growth ceases after a while and the radius
then continues to grow normally. If ulnar growth
is normal, the ulna will then be too long. This is
rarely associated with severe motion impairment; depending on the severity of the condition,
it will usually involve only an obvious cosmetic
deformity.
Correction is indicated when the deformity
leads to a functional impairment and interferes
with the patient’s daily life (22, 24). The presence
of such an impairment also dictates the time at
which the correction should be performed.
Fractures of the Radial and Ulnar Shaft
However, patients with open growth plates
should understand that further abnormal growth
will occur, which will necessitate a second correction at a later date. Another aspect to consider in
this regard is whether the patient’s age will allow
obliteration of the remaining radial growth plate
and the ulnar growth plate in the interest of
avoiding a second intervention which could lead
to shortening of the entire forearm although it
would remain clinically irrelevant. However, particularly in patients with a purely cosmetic impairment, it is best to try to postpone the corrective intervention until after cessation of growth
and then perform a definitive correction at that
time.
In most cases the shape of the joint is preserved but its position is altered: The joint plateau
usually drops off anteriorly and ulnarward and is
shortened with respect to the ulna. Our experience has shown that correction is best
achieved with rigid plate fixation, which is superior to an external fixator. An anterior approach is
used, and the correction is stabilized with an
AO small fragment T plate. Where an opening
osteotomy is performed to correct the length with
respect to the ulna, the resulting defect will have
to be filled with an iliac bone graft (Fig. 20.32 a,b).
If this is not possible, a closing and shortening
osteotomy may be performed and the proper
length of the ulna achieved with a Z-shaped
shortening osteotomy. Both osteotomies should
then be stabilized with a plate. The patient’s age
permitting, the remaining radial growth plate and
the ulnar growth plate are then obliterated. The
ulnar growth plate must be rigorously obliterated
as it can exhibit remarkably tenacious growth.
Complex situations such as, for example, the formation of a conical epiphysis will require a complex palliative procedure for which no recommendations or guidelines may be formulated.
Shortening of the ulna due to premature closure of the distal ulnar growth plate should also
be corrected toward the end of growth wherever
possible. A callus distraction osteotomy with an
external fixator is the best recommendation for
such cases.
255
Overview
Most Common Posttraumatic Deformities
of the Middle and Distal Forearm Bones
1. Axial deviation of the proximal radial shaft exceeding 10⬚ (with functional impairment in pronation and supination)
2. Simultaneous midshaft axial deviations in the
radius and ulna (occasionally without functional
impairment in pronation and supination but
with a visible cosmetic deformity)
3. Midshaft axial deviations in the radius and ulna
in opposite directions (invariably with functional
impairment in pronation and supination)
4. Ulnar and radial pseudarthrosis
5. Pseudo-Madelung deformity with shortening
and angulation of the radius (usually volar angulation) accompanied by relative excessive
length of the ulna
6. Shortening of the ulna
Causes
Re 1.–3. Uncorrected axial deviations.
Re 4. Rigid internal fixation and infections.
Re 5.–6. Growth disturbances involving premature
partial or complete closure of the growth plate.
Indication for correction
앫 Functional impairment (especially in pronation),
앫 Possible pain in pseudarthrosis,
앫 Rarely: Cosmetic deformities.
Time of correction
Re 1.–3. As quickly as possible.
Re 4. Soon in radial pseudarthrosis and atrophic
pseudarthrosis of the ulna; ulnar hypertrophic
pseudarthrosis, postpone and observe over
clinical course depending on symptoms.
Re 5.–6. If possible, perform definitive correction
only upon cessation of growth; otherwise as
functional impairment increases or upon cessation of abnormal growth.
Surgical technique
Re 1.–3. Transverse osteotomy at the apex of the
deformity, if indicated at two levels; stabilize
with intramedullary nails or fracture plates.
Re 4. Debride and stabilize with fracture plate or
external fixator; pack with cancellous graft.
Re 5. Distal radial opening or closing osteotomy
(depending on ulnar situation; pack with iliac
graft if indicated). Stabilize with T-plate. (Depending on patient’s age, the remaining radial
growth plate and possibly the ulnar growth plate
should be obliterated, possibly after performing
a Z-shaped shortening osteotomy of the ulna).
Re 6. Callus distraction osteotomy with external
fixator.
Aftercare: Spontaneous motion without physical
therapy immediately postoperatively.
256
Specific Injuries—Upper Extremities
21
Injuries to the Bones of the Hand
Wrist Fractures
Wrist fractures are extraordinarily rare and most
likely occur only in adolescents. Usually, the scaphoid is involved, most often as an isolated injury
and rarely in combination with a distal radial fracture (7, 8, 9, 18, 19).
We have never observed any wrist dislocations among our patients over the last 20 years.
Nor did Jonasch and Bartel (20) observe any such
injuries among children below age 14. In the last
25 years, we have encountered a genuine Galeazzi
Fig. 21.1 Scaphoid fractures.
The risk of pseudarthrosis is negligible in the presence of open distal radial growth plates. Even
chronic fractures like this six-weekold fracture in a 14-year-old boy
will reliably heal under conservative treatment, as is demonstrated
by the two-week consolidation
radiograph and the two-year follow-up study
fracture in the presence of open growth plates in
only two cases.
As in adults, scaphoid fractures may not show
up on initial radiographs (4) and may only become visible after 10–14 days. Where clinical
signs suggest a scaphoid fracture but none is visible on the anteroposterior (A-P) and lateral
radiographs, we initially forego specific scaphoid
views and immobilize the hand for two weeks in a
scaphoid forearm plaster splint that includes the
thumb. In cases where the site is painful to palpation after the splint has been removed, the appro-
Injuries to the Bones of the Hand
priate spot images will usually clearly confirm a
fracture. We dispense with any further radiographs if there is no pain over the scaphoid. Spot
images in particular can clearly visualize the ossification centers in the scaphoid tuberosity. These
findings may easily be misinterpreted as fractures, leading to unnecessary treatments. The
procedure described above minimizes the risk of
such misinterpretation.
Acute and chronic fractures are initially
treated conservatively as a matter of course. For
the first four weeks, we immobilize the injury in
257
an upper-arm plaster splint. Usually, the fractures
will heal completely within six to eight weeks. We
obtain a radiograph out of plaster after four
weeks. Where indicated by clinical findings, we
then immobilize the injury in a scaphoid cast for
another two to four weeks, after which we obtain
another radiograph to verify consolidation. Usually, the risk of pseudarthrosis will be negligible if
the adjacent growth plates are still open
(Fig. 21.1).
Fracture of the other wrist bones are so rare as
not to warrant further mention (8).
258
Specific Injuries—Upper Extremities
Metacarpals and Phalanges (16.8%)
Forms
앫 Separated epiphyses (Salter–Harris I and II)
앫 Metaphyseal impacted fractures
앫 “Volar lip” fractures
앫 Subcapital and diaphyseal fractures (rare)
Radiographs: A-P and lateral.
Limits of correction
앫 No rotational deformity,
앫 No axial deviations in the coronal plane,
앫 Good corrective potential in the sagittal plane.
Note: The phalanges and metacarpal of the thumb
have only one basal growth plate; the metacarpals of
the other fingers have only one subcapital growth plate.
Definition of “nondisplaced”: Axial deviations in
the sagittal plane up to about 20⬚ in all age groups.
Technique of conservative fixation: Finger splint.
Technique of internal fixation
앫 Percutaneous pinning with crossed Kirschner
wires in subcapital and unstable basal fractures.
앫 Intramedullary nailing with a Kirschner wire
in diaphyseal fractures.
Aftercare
Period of immobilization
앫 With conservative fixation: Five days for “volar
lip” injuries; 10–14 days for metaphyseal fractures; three to six weeks for diaphyseal fractures.
앫 With internal fixation: Immediate spontaneous
motion with intramedullary nailing, otherwise
additional immobilization for 10–14 days.
Consolidation radiographs: None.
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Digital block.
앫 Where indication is uncertain or conservative
treatment is indicated: Immobilization in a
finger splint.
Emergency treatment under nerve block
앫 All fractures with a rotational deformity.
앫 All fractures with an axial deviation in the
coronal plane that cannot be functionally
compensated,
앫 All fractures with an axial deviation in the
sagittal plane exceeding 20⬚.
Initial mobilization: Immediate spontaneous mobilization after removal of the plaster splint.
Physical therapy: None.
Sports: Two to three weeks after consolidation.
Removal of metal implants: Upon consolidation.
Follow-up examinations and conclusion: Examinations are performed at one- to two-week intervals
until unrestricted function is regained. In the absence of visible clinical deformities, treatment is concluded once unrestricted function has been regained.
Injuries to the Bones of the Hand
Metacarpal Fractures
All the metacarpals, like the phalanges of the fingers, have only one growth plate. The metacarpal
of the thumb, like the phalanges, has a growth
plate at its base, whereas all other metacarpals
exhibit distal subcapital growth plates (Fig. 21.2).
Pseudo growth plates are often present at the
metacarpal bases of the fingers excluding the
thumb, and a subcapital pseudo growth plate may
occur in the thumb. It is important not to misinterpret these physiological structures as fractures.
The most common injuries in the metacarpals
and phalanges are metaphyseal impacted fractures or separated epiphyses, usually occurring
with a metaphyseal wedge fragment. Accordingly,
the injuries we encounter in the metacarpal of the
thumb are often proximal fractures, occurring
either as metaphyseal impacted fractures or separated epiphyses. As in a separated radial
epiphyses, the metaphyseal wedge fragment may
be impacted as in an impacted fracture. Genuine
Bennett or Rolando fractures do not occur in the
presence of open growth plates.
In contrast, fractures of the metacarpal base
are rarely observed in the other metacarpals. Far
more often we encounter distal subcapital
Fig. 21.2 Injuries to the metacarpals. The growth
plates in the fingers other than the thumb are located
distally in the subcapital region. Only in the thumb is the
growth plate located proximally at the base. Separated
epiphyses are most common, usually occurring with a
metaphyseal wedge fragment (thumb and ring finger).
Less common injuries include subcapital or metaphyseal
fractures (little finger), oblique fractures (middle finger),
or transverse fractures (index finger) of the shaft
259
metaphyseal fractures or separated epiphyses
with a metaphyseal wedge. The metacarpal of the
little finger is most often involved (2, 5, 10).
Shaft fractures of the metacarpals are as rare
as fractures of the metacarpal base in the presence of open growth plates.
Growth disturbances are extremely rare in the
entire skeleton of the hand, and accordingly in the
metacarpals as well. Occasionally, severe complex
injuries can cause premature closure of a growth
plate, with a resulting shortening deformity in the
affected bone.
Angulation in the sagittal plane, the main
plane of motion of the hand, is well corrected
during the course of further growth even in adolescents. In contrast, angulation in the coronal
plane is not corrected. Side-to-side displacement
is corrected completely; shortening deformities
in shaft fractures can persist (5, 14).
Metacarpal of the Thumb
Nondisplaced proximal fractures of the metacarpal of the thumb are treated by simple immobilization in plaster for 10–14 days. Displaced fractures usually involve volar angulation of the fragments. These are not difficult to reduce, but maintaining the reduction often proves difficult.
Where reduction has been readily achieved, the
injury is immobilized in abduction in a thumb
spica cast. Axial deviations in the coronal plane
must be avoided. Axial deviations of up to 20⬚ in
the sagittal plane can be tolerated where the
growth plates are still open. Unstable fractures are
best treated with percutaneous axial pinning
with Kirschner wires, especially in adolescents
(Fig. 21.3).
Except for fractures stabilized with Kirschner
wires, a radiograph in plaster is best obtained on
the fourth day after the accident to verify correct
position.
After two weeks of immobilization, healing is
evaluated by clinical examination. If the callus is
no longer tender to palpation, the patient may
begin spontaneous motion exercises. The patient
will usually regain unrestricted motion within the
next two weeks and will then be able to resume
sports participation.
Nondisplaced shaft fractures of the metacarpal of the thumb are also treated conservatively
by immobilization in a plaster cast. Displaced
fractures can usually be readily reduced closed in
proper axial alignment. Slight shortening deformities are tolerable, but any malrotation must
260
Specific Injuries—Upper Extremities
Fig. 21.3 Treatment of a separated epiphysis of the
metacarpal of the thumb. Usually, the injury is easily
reduced, but reduction is difficult to maintain in a
plaster cast. Secondary displacement of the fracture
may occur especially in the coronal plane, as in this 11-
year-old girl. Axial deviation in the coronal plane is not
corrected by further growth in this region. Therefore,
this axial deviation was eliminated and the fracture was
stabilized with percutaneous Kirschner wire fixation
be rigorously eliminated. Kirschner wires, tension
banding, or plate fixation will not generally be required.
The injury is immobilized for four weeks, after
which healing is evaluated by clinical examination. A callus that is still tender to palpation will
require an additional two to four weeks of immobilization in a plaster cast.
Metacarpals of the Fingers Excluding
the Thumb
Fig. 21.4 Treatment of subcapital fractures of the
metacarpal of the little finger. Where axial deviation is
present only in the sagittal plan, the main plane of motion, then the injury may be treated conservatively in a
cast without reduction, even in adolescents like this 14year-old boy. This is because further growth may be expected to correct the deformity (from: 14)
Fractures of the metacarpal bases of the fingers
excluding the thumb are rarely displaced. These
injuries invariably only require immobilization in
a plaster cast for 10 days.
The most common subcapital fractures—
whether separated epiphyses or cancellous impacted fractures—almost always involve more or
Injuries to the Bones of the Hand
less severe volar angulation of the metacarpal
head (Fig. 21.4). The metacarpal of the little finger
is most often involved. Occasionally, we observe
additional ulnar displacement or, rarely, radial
displacement.
Fractures with additional radial or ulnar displacement require reduction and immobilization,
either in a plaster gutter splint (little and ring fingers) or an Iselin splint (index and middle fingers). Injuries exhibiting only 30⬚ or less of volar
angulation without any radial or ulnar axial deviation or malrotation do not require reduction.
While these angulated injuries are usually easy to
reduce, the reduction is invariably difficult to
maintain. Injuries in adolescents with nearly
closed growth plates require precisely corrected
positioning. These reductions should be stabilized with an axial Kirschner wire. Where a reduced fracture is immobilized in an Iselin splint,
the bend in the splint must not lie in the distal
transverse palmar crease as usual. Instead, it must
lie distal to the crease at the level of the interdigital folds so as to exert pressure on the volar aspect
of the metacarpal head and help prevent secondary displacement.
Two weeks of immobilization are generally
sufficient for separated epiphyses and subcapital
fractures. Consolidation is evaluated by clinical
examination. Once the callus is no longer tender
to palpation, the patient may begin spontaneous
motion exercises. The full range of motion is usually regained within the next eight days, at which
time sports activities may be resumed.
261
Follow-up of uncorrected or persistent deformities—usually the contour of the injured
metacarpal head will be visibly depressed volarward—should include clinical examinations at
six-month intervals until normal symmetrical
contour of the knuckles is restored. This follow-up
may also include photographic documentation. In
the absence of pain, there will be no need for additional radiographic studies.
Nondisplaced or only slightly displaced shaft
fractures (Fig. 21.5) can be immobilized in an
Iselin splint or a volar forearm plaster splint extending to the fingertips. Displaced and shortened shaft fractures are reduced with the aid of an
Iselin splint (Fig. 21.6). Here a volar plaster splint
is applied over the usual padding. The prepared
aluminum splint is then applied over the volar
plaster splint and covered with a second, thinner
plaster bandage. Then the splint is closed to form
a circular cast. Preparing the splint means bending it into the proper longitudinal shape and
twisting it to fit the affected finger so as to prevent
malrotation (see also Fig. 21.12). The farther ulnar
the finger is, the greater the radial twist must be.
This twist should take into account that the axis of
every finger points toward the scaphoid when the
metacarpophalangeal and proximal interphalangeal joints are in flexion (Fig. 21.7). When
the first plaster bandage is applied, one should
take care to ensure that the plasters cast ends at
the proximal transverse palmar crease. Once the
plaster has set, the extended finger is tethered to
the splint with strips of plaster bandage, and the
Fig. 21.5 Treatment of
metacarpal shaft fractures. In a transverse fracture without a shortening
deformity as in this 14-yearold boy, an axial deviation
of up to 20–30⬚ may be left
uncorrected. However, any
axial deviation in the
coronal plane and any
malrotation must be precisely eliminated (from: 14)
262
Specific Injuries—Upper Extremities
Fig. 21.6 Reduction of a metacarpal fracture with
the aid of an Iselin splint. After the finger has been
taped to the extended and pretwisted metal splint, the
splint is bent volarward at the distal transverse palmar
crease to an angle of 70⬚. The traction this creates elimi-
nates the shortening deformity in the fracture. The
splint is then bent back at the fingertip and the free end
is wrapped in plaster to prevent the splint from fracturing
splint with the finger is then bent volarward at
the distal transverse palmar crease, flexing the
finger at the metacarpophalangeal joint. This
gives the fracture the proper axial alignment, and
corrects the shortening deformity by placing traction on the fragments. To prevent the metal splint
from later fracturing, we bend its distal end back
at the fingertip so that it rests against the proximal portion of the splint. There we wrap a plaster
bandage around it. Remember to clinically examine the splint and assess vascular status the
next day.
Multiple nondisplaced shaft fractures in
patients with open growth plates can generally be
managed conservatively.
Fig. 21.7 Centering of the phalangeal axes on the
scaphoid. With the proximal interphalangeal joint in
flexion, the axes of the middle and distal phalanges of
the fingers other than the thumb are always centered on
the scaphoid. The Iselin splint must be twisted accordingly to avoid or eliminate malrotation. The farther ulnar
the splint is applied, the greater the radial twist must be
Injuries to the Bones of the Hand
263
b
a
Fig. 21.8 Injuries to the phalanges and joints of the
fingers. The growth plates of the phalanges always lie at
the phalangeal base. a The most common injuries are
impacted fractures of the phalangeal base (proximal
phalanx of the ring finger) and separated epiphyses
(little finger). Less frequent are oblique shaft fractures
(index finger) or transverse fractures (thumb) and subcapital fractures (middle finger and middle phalanx of
the ring finger). b Bony avulsions of the extensor tendons may occur as separated epiphyses (1) or as epiphyseal fractures (2). Bony avulsions of an extensor tendon
from the epiphysis (2), like fibrocartilaginous avulsions
(3) and avulsion of the ulnar collateral ligament of the
thumb (4), should be regarded as epiphyseal fractures
and therefore as articular injuries. Dislocations in the interphalangeal joints are extremely rare (5)
Multiple nondisplaced fractures in patients
whose growth plates have closed or multiple displaced fractures in patients with open growth
plates are treated by internal fixation as in adults.
All shaft fractures are immobilized for four
weeks. Healing of these injuries is also assessed
by clinical examination. Depending on findings,
patients may either begin spontaneous motion
immediately or the injury will require a brief additional period of immobilization.
Patients may resume sports activities once
unrestricted mobility has returned. This includes
the ability to make a complete fist, which will
usually be about three weeks after spontaneous
mobilization is allowed. Treatment is concluded
in the absence of deformity once unrestricted
function has been regained and sport has been resumed without any problems.
Fractures and Dislocations of the
Phalanges of the Fingers
The most common injuries are separated
epiphyses with and without a metaphyseal wedge
fragment. Shaft fractures or distal subcapital fractures (Fig. 21.8 a) are far rarer (1, 3, 5, 6, 8, 10, 11,
13). Epiphyseal fractures are rare and usually
manifest themselves as bony avulsions of the collateral ligaments, extensor tendon avulsions, or
an injury to the “volar lip” (Fig. 21.8 b, 1–5).
The growth plates are always located at the respective phalangeal base. Growth disturbances
usually need not be feared. Premature closure of
the growth plate leading to shortening of the affected phalanx can occasionally occur following
severe crush injuries.
264
Specific Injuries—Upper Extremities
Axial deviations in the sagittal plane are corrected entirely, as is side-to-side displacement
(Fig. 21.9).
Axial deviations in the coronal plane are not
corrected at all during the course of further
growth. Deformities of up to 10⬚ in the coronal
plane may only be tolerated in fractures of the
proximal phalangeal base because here the adjacent metacarpophalangeal joint provides a
limited measure of functional compensation.
However, no such compensation is possible in the
middle and distal phalanges. Here, axial deviations of even 10⬚ in the coronal plane produce significant symptoms and impairments (Fig. 21.10).
“Spontaneous” corrections of malrotation at
this site have yet to be described in the literature.
If they were to indeed occur, such processes
would take extraordinarily long, and patients
would not tolerate the associated impairments
(superduction or subduction of the finger when
making a fist; see Fig. 21.12) for the long time required until “spontaneous correction.” Therefore,
these deformities must be carefully eliminated.
In the absence of displacement, treatment of
separated epiphyses or metaphyseal impacted
fractures of all digits involves immobilization in
plaster for 8–10 days (Fig. 21.11). Displaced fractures are reduced after administering a digital
block. Here, the primary goal is to eliminate
malrotation and/or an axial deviation in the
coronal plane. To evaluate whether the malrotation has been eliminated, the hand must be carefully passively closed into a fist. Malrotation has
been eliminated where this can be done without
the phalanges distal to the injury deviating in the
form of superduction or subduction (Figs. 21.7,
21.12).
Slight axial deviations in the sagittal plane
and side-to-side displacement are tolerable (20).
Axial deviations in the coronal plane may only be
tolerated in the proximal phalanx where they do
not exceed 10⬚ or 15⬚ at maximum (Fig. 21.13). Reduced fractures are best immobilized on an Iselin
splint for 8–10 days.
Healing of all finger fractures is assessed by
clinical examination because a radiographically
Fig. 21.9 Reliable “spontaneous corrections.” Axial
deviations in the sagittal
plane, the main plane of
motion of the bones of the
hand, are spontaneously
corrected during the course
of further growth. In this
nine-year-old boy with a diaphyseal shaft fracture, the
Kirschner wire introduced
initially was removed after
three weeks and the spontaneous motion was allowed after four weeks,
which was too early. The
fracture slipped into angulation in the sagittal plane of
approximately 30 ⬚. Over
the next three years, the
axial deviation in the shaft
region “spontaneously” corrected itself
Injuries to the Bones of the Hand
265
Fig. 21.10 Lack of “spontaneous corrections.” The
axial deviation in the coronal plane will remain unchanged and will cause significant symptoms during the
course of further growth unless compensated for by the
adjacent joint. In this 10-year-old girl, 10⬚ of radial angulation remained following a subcapital fracture. This deformity persisted unchanged until the follow-up examination seven years later (from: 14)
detectable callus will only be visible long after the
fracture has consolidated. The patient may begin
spontaneous motion exercises once the callus is
no longer tender to palpation. Full range of motion usually returns one to two weeks after consolidation, at which time sports activities may be
resumed. Treatment is concluded once the
patient has regained unrestricted function in the
presence of symmetrical finger axes.
Nondisplaced shaft fractures of the phalanges
are treated conservatively.
Displaced shaft fractures may require Kirschner wire fixation to maintain reduction, especially in the coronal plane. Injuries involving
malrotation should invariably be stabilized with
two Kirschner wires. Percutaneous pinning with
two crossed Kirschner wires is also recommended
for stabilizing the reduction in unstable transverse fractures (Fig. 21.14).
Immobilization of phalangeal shaft fractures
lasts between five and seven weeks, depending on
the patient’s age. Here, too, tenderness to palpation after four weeks serves as an indicator as to
whether further immobilization is required.
Treatment is concluded once the patient is
able to resume sports without problems, function
is unrestricted, and the finger axes are symmetrical.
Remaining deformities should be monitored
until they are no longer clinically visible or until
secondary correction. Subcapital fractures
(Fig. 21.15) are usually unstable fractures. Where
there is no axial deviation in the coronal plane,
side-to-side displacement and axial deviation in
the sagittal plane may be tolerated and the injury
treated conservatively by immobilization for two
weeks in a plaster splint. Where this is not the case,
the injury must be stabilized by percutaneous pinning with one or two Kirschner wires (16, 17).
Injuries in older patients are often subcapital
oblique fractures, some of which may radiate into
the joint. These injuries involve an increased risk
of secondary displacement resulting in axial deviation in the coronal plane. When treated conservatively with a plaster cast or an Iselin splint,
another radiograph should be obtained about
four days after the accident to allow prompt detection of any secondary displacement. Immediate percutaneous fixation with a Kirschner wire is
recommended to stabilize the injury in cases
where initial reduction was required to address
axial deviation in the coronal plane.
266
Specific Injuries—Upper Extremities
Fig. 21.11 Most common fractures in the phalanges
of the fingers. Nondisplaced separated epiphyses or
metaphyseal impacted fractures (ring and little fingers)
are often overlooked. Immobilization in a plaster splint
for 8–10 days is recommended to treat pain. No additional radiographs will then be required
Fig. 21.12 Sign of malrotation following metacarpal
and phalangeal fractures in the fingers. Superduction
of one finger over the other when making a fist is a sign
of malrotation (above), as is deviation of the plane of
one fingernail with respect to the others (below)
In every case, the injury is immobilized in a
plaster cast or Iselin splint for two weeks. Healing
is assessed by clinical examination. Further procedure is the same as for all other fractures of the
bones of the hand.
Epiphyseal fractures, especially bony avulsions
of the ulnar collateral ligament of the thumb, are
usually transitional fractures of late adolescence.
This means that physiological closure of the
growth plate in the nondisplaced portion of the
epiphysis has already begun and growth disturbances no longer need be feared. The nondis-
placed portion of the growth plate may already be
solidly ossified or beginning to ossify (Fig. 21.16).
Nondisplaced fractures are treated conservatively in a plaster cast for two weeks. Displaced
fractures must be reduced (12). If closed reduction is not feasible, open reduction is indicated.
The reduced fragment is fixed with a Lengemann
suture, Kirschner wire, or small cannula. The Kirschner wire or cannula projects through the skin
next to the wound as usual, and an opening is left
in the cast to accommodate it.
Injuries to the Bones of the Hand
267
Fig. 21.13 Treatment of
the most common
phalangeal fractures.
Malrotation and axial deviation in the coronal plane
must be strictly avoided in
the bones of the hand. Axial
deviation of up to 10⬚ in the
coronal plane is only tolerable in fractures of the proximal phalangeal base, such as
in this 13-year-old boy with a
separated proximal
phalangeal epiphysis of the
little finger. This is because
these deviations can be well
compensated for by the
metacarpophalangeal joint
Fig. 21.14 Treatment of
phalangeal shaft fractures.
The shaft fracture of the
middle phalanx of the index
finger in this 17-year-old boy
exhibited malrotation.
Therefore, the reduction was
stabilized by percutaneous
pinning with crossed Kirschner wires. The wires were
left in situ for three weeks
and the fracture immobilized
for five weeks. Healing was
evaluated by clinical examination. Eight weeks after the
accident, the finger exhibited unrestricted function
with proper axial alignment
and symmetry
The injury is immobilized in a plaster cast for
two weeks. After that, the metal implants may be
removed and the patient may begin with spontaneous motion exercises.
Where the injury is a rupture or periosteal
avulsion of a collateral ligament in an older adolescent with closed growth plates, the nature of
the injury is verified by clinical examination. Stability is then restored by surgical reconstruction
of the collateral ligament structures. Immobilization is continued for three weeks.
A common injury of the proximal interphalangeal joint is the fibrocartilaginous avulsion,
the volar lip injury to the proximal interphalangeal joint. The typical mechanism of injury
of hyperextension in volleyball or handball initially suggests just this injury. A radiographic sign
of this injury is a small, only slightly displaced
volar fragment (Fig. 21.17).
Significant swelling of the joint is invariably
noted upon clinical examination. Because the
bony fragment is avulsed from the epiphysis, this
injury must be regarded as an epiphyseal injury.
However, no growth disturbances need be feared.
268
Specific Injuries—Upper Extremities
Fig. 21.15 Treatment of subcapital fractures. Treatment may generally be conservative, as in this eightyear-old boy. Axial deviation in the coronal plane, like
malrotation, must be carefully eliminated and the reduction documented clinically and in radiographs. Healing is evaluated by clinical examination after removal of
the plaster splint
Fig. 21.16 Treatment of bony avulsions of the collateral ligaments. These avulsion injuries are usually
transitional fractures of late adolescence. Where there is
slight displacement as in this 14-year-old boy, the injury
may be managed conservatively by immobilization in a
plaster splint. More serious displacement should be
treated by open reduction. Growth disturbances need
not be feared (from: 14)
In contrast to the situation in adults, treatment of these injuries in growing patients is not a
problem. Specific physical therapy aftercare is not
required except in older adolescents with closed
growth plates. Usually, all that is needed is temporary immobilization on an aluminum splint for
four to five days until soft-tissue swelling subsides. Then the patient should begin spontaneous
motion exercises, primarily flexion. If there is unrestricted mobility in the proximal inter-
phalangeal joint after two weeks as is to be expected, then the patient may gradually resume
sports activities. Treatment is concluded once the
patient is free of pain and motion is unrestricted.
Rehabilitation of the joint will take longer, the
older the patient is.
A further finger injury is the avulsion of the extensor tendon from the distal phalanx. The avulsion may be periosteal or bony, and bony avulsion
may in turn involve a separated epiphysis or an
Injuries to the Bones of the Hand
Fig. 21.17 Fibrocartilaginous avulsion. The patient’s
history and significant swelling provide clinical evidence
of the injury. Radiographic findings often include only a
slightly displaced, narrow avulsed bony flake in the
volar epiphyseal region of the middle phalanx
epiphyseal fracture. Most cases involving no displacement or only slight displacement can be
managed simply by immobilization with the distal phalanx in hyperextension on a metal splint
for two weeks. In the presence of severe swelling,
this immobilization in hyperextension can be
maintained by temporary arthrodesis of the distal
269
interphalangeal joint with a Kirschner wire or
cannula until soft-tissue swelling subsides.
Where the avulsed fragment is severely displaced,
it may not be possible to reduce the injury by
simple hyperextension. In this case, the injury
should be reduced and the reduction stabilized
with a Kirschner wire or Lengemann suture. Here,
too, two weeks of immobilization will suffice.
Where the injury is a closed or open avulsion
without bony involvement, it is immobilized in a
mallet splint for four to six weeks, as in adults.
Chronic closed periosteal avulsions can also be
treated successfully with a mallet splint even
weeks later. The splint must then be worn for six
to eight weeks.
A fracture of the tuft of the distal phalanx usually occurs as an associated injury in a nail dislocation. Where repair and reduction of the nail
with simultaneous suturing of the soft tissue are
indicated, one can also remove small fragments
and fix larger ones in place with a fine cannula. A
fine cannula is also helpful in providing a splint
for a soft-tissue repair. Other than that, this fracture does not require any further treatment other
than immobilization in a metal splint for two to
three weeks until pain subsides. Unstable fingertips due to pseudarthrosis following such an injury in growing patients need not be feared.
Interphalangeal and metacarpophalangeal
dislocations are very rare. They almost always can
be reduced by carefully applying traction to the
affected finger. Only rarely will interposed injured
soft tissue from a ruptured capsular ligament prevent reduction. In such a case, open reduction and
repair of the capsular ligaments is indicated (3, 5,
15).
The reduction should in every case be documented in radiographs. Generally, the injury is
immobilized in a plaster cast or splint for two
weeks. Treatment may usually be concluded two
to three weeks later once unrestricted function
has been regained (Fig. 21.18).
270
Specific Injuries—Upper Extremities
Fig. 21.18 Metacarpophalangeal dislocations. Usually, the dislocation can be reduced by placing strong
traction on the finger without anesthesia. The reduction
should then be documented in radiographs, as in this
seven-year-old girl
271
Lower Extremities
22
Injuries to the Proximal Femur and Femoral Shaft
Traumatic Hip Dislocation
With an incidence of far less than 1% of all injuries
to the lower extremities (Höllwart and Hausbrandt [55] cite 0.2%), this is the rarest of all injuries encountered in growing patients (20, 29, 58,
61, 77, 93, 184). This injury usually occurs as a
posterosuperior dislocation, rarely as an anterior
or central dislocation. According to the literature,
dislocation can occur in patients up to age five
(92) even in moderate trauma; in older patients,
dislocation invariably occurs in high-energy
trauma, most frequently in traffic accidents (20,
61, 68, 91, 124, 146). Associated injuries such as
damage to the isciatic nerve are rare. Central dislocations are usually associated with rupture of
the triradiate cartilage (8, 10).
Diagnosis
The diagnosis is readily made on the basis of clinical and radiographic findings. In a posterior dislocation, the thigh will be in slight adduction, internal rotation, and flexion. In an anterior dislocation, it will be external rotation, extension, and
abduction. The radiograph must visualize the entire femoral shaft as additional shaft fractures
may accompany the dislocation.
Problems and Complications
The risk of posttraumatic avascular necrosis of the
femoral head due to vascular injury appears to be
the main problem associated with this injury.
Even in children, the occurrence of this sequela
appears to depend on the time elapsed between
the accident and the onset of treatment. Necrosis
is not to be expected in children in whom the dislocation is reduced within the first 12 hours after
trauma. Reduction later than 24 hours after
trauma invariably results in necrosis of the
femoral head (91, 97, 146). Here, one should remember that late reduction must usually be per-
formed as an open procedure. Logic dictates that
late open reductions of traumatic dislocations
will necessarily have a poorer prognosis than immediate closed reductions in the hip as in other
joints. However, this is contradicted by Ganzen’s
recent experience in Bern, Switzerland, in the
treatment of slipped capital femoral epiphyses by
open reduction (77 a, 89 a). Additionally, initial
closed reduction maneuvers can just as easily
cause iatrogenic injury (such as a separated
epiphysis) that may lead to subsequent avascular
necrosis of the femoral head. In follow-up examinations of 20 of our own patients with traumatic
hip dislocations, we found two cases in 20 of
avascular necrosis of the femoral head. In one
patient, the trauma included an associated
slipped capital femoral epiphysis that received inadequate surgical treatment. Poor to begin with,
the prognosis worsened further and was finally
confirmed by subsequent findings of posttraumatic avascular necrosis of the femoral head. The
other case involved an overlooked dislocation
that was only reduced in an open procedure on
the fifth day after the accident. Other late
sequelae include repeat dislocations and posttraumatic osteochondritis (34, 93).
Growth Disturbances
Transient stimulation of the growth plate can result in slight coxa magna (91). However, the
severity described is not clinically significant.
Growth disturbances from premature complete
closure of the growth plate have been described
but may not be expected to occur invariably. The
sequela would involve shortening and thickening
of the femoral neck (99, 142). Rare growth disturbances of this sort are probably always associated
with avascular necrosis of the femoral head and
both are probably attributable to vascular injury.
The fact that trauma and posttraumatic hyperemia result in somewhat premature closure of
the growth plate in adolescents may be under-
272
Fig. 22.1
Specific Injuries—Lower Extremities
Treatment of traumatic hip dislocation.
a The patient is a 13-year-old boy who suffered a dislocation of the left hip in a traffic accident. Closed reduction of the dislocation was performed three hours
after the accident. The A-P and axial radiographs confirmed that precise reduction had been achieved. A
comparative radiograph including the contralateral
side excluded interposition of soft tissue. The patient
was then placed on forearm crutches for six weeks to
protect the injured hip against excessive weight bearing. Further follow-up continuing up to two years
after the accident revealed no further complications
and specifically excluded avascular necrosis
stood as a nearly physiological consequence of
trauma and not as a growth disturbance in the
strict sense (139).
A posterior dislocation is reduced with the
patient under general anesthesia. With the
patient’s hip and knee flexed, the surgeon pulls
the leg anteriorly until the femoral head slips into
the acetabulum with an audible snap when external rotation is attempted. An anterior dislocation
is reduced by applying longitudinal traction to the
extended leg; the actual reduction occurs as the
hip is internally rotated. Hemarthrosis is repeatedly cited as a cause of posttraumatic remodeling. Therefore, care should be taken to
aspirate the hemarthrosis that invariably accompanies dislocation immediately after reduction.
Astonishingly, the literature regards this pro-
Treatment
Treatment of traumatic hip dislocation consists of
reducing the relaxed hip as quickly and
atraumatically as possible in the hope of minimizing the risk of avascular necrosis of the femoral
head. This requires that a positive diagnosis be
made as soon as possible after trauma
(Fig. 22.1 a,b).
Injuries to the Proximal Femur and Femoral Shaft
273
Fig. 22.1 b Both sides exhibited normal symmetrical
anatomy at the two-year
clinical and radiographic
follow-up examination
cedure as unnecessary, in contrast to fractures of
the femoral neck (20, 61, 68, 91, 124, 146). The
comparative radiograph of both hips obtained
after reduction must show symmetrical articular
anatomy. The axial image of the affected hip must
also show a normal joint cavity and exclude additional posterior injuries to the bony acetabular labrum. A difference between the joint cavities on
the anteroposterior (A-P) radiograph obtained
after aspiration suggests the presence of interposed soft tissue (116). In such a case, the interposed tissue will usually be capsular tissue or the
cartilaginous portion of the acetabular labrum;
magnetic resonance imaging (MRI) can verify this
suspicion. The presence of interposed soft tissue
represents an indication for open reduction. A
posterior approach is used to expose and eliminate the interposed tissue in a posterior dislocation, and an anterior approach is used in an anterior dislocation.
Brief longitudinal traction is sufficient to reduce a central dislocation without significant displacement. Severely displaced central dislocations in which the triradiate cartilage is disrupted
require primary surgical treatment (8).
Following open or closed reduction, we have
the patient remain in bed for a few days until the
hip is free of pain and unrestricted mobility has
274
Specific Injuries—Lower Extremities
returned. This usually takes three to five days. We
no longer use traction. Studies by Kallio and Ryöppy (64) and Wingstrand and co-workers (151)
have shown that the position of the hip in traction, i.e., a neutral position, tends to increase pressure and therefore pain. We allow small patients
to bear weight as soon as unrestricted function is
restored. We have adolescents use forearm
crutches for about four weeks to protect the hip
against excessive weight bearing and especially to
prevent them from engaging in sports. After this
period, i.e., four to six weeks after the accident, we
obtain an MRI scan (we no longer obtain bone
scans) to exclude beginning avascular necrosis of
the femoral head. Where there are no signs of
avascular necrosis of the femoral head, the
patient may begin full weight bearing and resume
sports.
Sports Participation and Follow-up
Examinations
Additional follow-up examinations are performed at six-month intervals until two years
after the trauma. At that time, radiographic follow-up studies are obtained to exclude late
avascular necrosis of the femoral head and
possible growth disturbances. We then conclude
treatment in the absence of any abnormal clinical
or radiographic findings.
Where beginning avascular necrosis is present, further therapy will depend on MRI findings
or the severity of the deformity, respectively.
Treatment options include reduced weight bearing with forearm crutches, or corrective
osteotomy. Full weight bearing is only possible
where MRI findings are negative.
In all cases in which MRI has demonstrated
severe avascular necrosis of the femoral head, we
perform clinical follow-up examinations every six
months after the beginning of weight bearing and
obtain radiographic follow-up studies every year
or two until cessation of growth and only conclude treatment at that time. The final follow-up
examination naturally includes functional evaluation of the hips and knees, evaluation of gait,
functional leg-length measurement, and a radiograph of both hips.
Fractures of the Femoral Neck
Forms of Injury
Because of the solid substance of the cancellous
bone, these fractures are among the rarest injuries in growing patients. Like traumatic hip dislo-
Fig. 22.2 Possible injuries to the femoral neck. Traumatic slipped capital femoral epiphysis (left); transcervical
fracture (center); cervicotrochanteric fracture (right)
Injuries to the Proximal Femur and Femoral Shaft
275
cations, they account for less than 1% of all fractures of the lower extremities (55, 58, 61).
The usual classification of fractures as traumatic slipped capital femoral epiphyses, transcervical fractures, or cervicotrochanteric fractures
based on their prognosis (44, 74, 110, 150) has no
bearing on treatment (Fig. 22.2).
Transcervical and cervicotrochanteric fractures each account for about 45% of all such injuries; slightly less than 10% are traumatic slipped
capital femoral epiphyses (89). However, the literature does not examine the respective incidence of fractures in specific age groups; this incidence could just as easily reflect an acute hormonally induced slipped capital epiphysis in the
adolescent age group.
Diagnosis
Even nondisplaced fractures and slipped capital
femoral epiphyses are easily diagnosed where
radiographs have been obtained in two planes (AP and axial).
Problems and Complications
The pattern of vascular supply to the proximal
femur and the course of growth zones through
this region determine the specific prognosis of
femoral neck fractures.
The literature cites varus deformities of the
hip, pseudarthrosis, growth disturbances, and
necrosis of the head and neck in particular as main
problems associated with these injuries (4, 16, 24,
41, 118, 150, 155, 160, 162, 164, 175, 178, 188).
The blood supply to the femoral head and
neck explains the risk of posttraumatic avascular
necrosis (Fig. 22.3). According to Chung (16, 17),
the femoral head and neck are supplied by extracapsular and intracapsular anastomotic rings
(Fig. 22.4 a). The extracapsular ring is primarily
supplied by the ascending branches of the medial
circumflex femoral artery and only to a slight extent by the vessels of the lateral circumflex
femoral artery. The greater part of the head, neck,
and greater trochanter is supplied by the lateral
ascending arteries of the medial circumflex
femoral artery of this extracapsular ring. The
inner subsynovial ring is supplied more or less
equally by four ascending branches of the two circumflex femoral arteries. This inner ring supplies
the metaphysis adjacent to the growth plate and
crosses the growth plate to supply the epiphyseal
ossification center. Both this intracapsular ring
Fig. 22.3 Blood supply to the femoral neck. The neck
and head receive their primary vascular supply from intracapsular and extracapsular arteries, some of which
cross the growth plate. These vessels are branches of
lateral arteries arising from the medial circumflex
femoral artery (3) and of anterior arteries arising from
the lateral circumflex femoral artery (2). The artery of
the capitis femoris ligament (1) contributes only slightly
to the vascular supply
and the single terminal artery of the medial circumflex femoral artery (which gives rise to the ascending lateral arteries that supply the head) are
particularly vulnerable to increased intraarticular
compression.
Age-related variants are also observed (130).
Up to about age four, the head and neck are jointly
supplied by the medial and lateral arteries
(Fig. 22.4 b); whereas between age four and eight,
the medial circumflex femoral artery is primarily
responsible for vascular supply (Fig. 22.4 c). After
age eight, the contributions of the arteries arising
from the lateral circumflex femoral artery and the
arteries from the capitis femoris ligament increase in importance.
This situation explains the good prognosis in
children up to age five (4, 24, 97, 98, 99). It also ex-
276
Specific Injuries—Lower Extremities
Extracapsular ring
Greater trochanter
Subsynovial ring
a
Arteries from the
medial femoral
circumflex artery
b
Arteries from the
lateral femoral
circumflex artery
c
Fig. 22.4 Vascular supply to the femoral neck and head.
a Chung identifies an extracapsular ring (from the medial femoral circumflex artery) and a subsynovial ring
(from the lateral femoral circumflex artery)
b Up to age four, the medial and lateral femoral circumflex arteries contribute equally to the vascular supply
of the femoral neck
c Beyond age four, the lateral femoral circumflex artery
becomes less important for the supply of the femoral
head, i.e., the medial femoral circumflex artery increasingly becomes the sole source of blood supply to
the head. Its terminal artery between the femoral
neck and greater trochanter that gives rise to the
lateral arteries supplying the head is particularly
vulnerable
Fig. 22.5 Posttraumatic avascular necrosis of the femoral head according to Ratcliff. Type I: complete necrosis,
type II: epiphyseal necrosis, type III: neck necrosis
Injuries to the Proximal Femur and Femoral Shaft
plains why not every femoral neck fracture necessarily leads to avascular necrosis of the femoral
head. This means that the prognosis for avascular
necrosis of the femoral head depends less on factors such as the onset and type of treatment or location and displacement of the femoral neck fracture than it does on the patient’s specific vascular
anatomy.
Ratcliff (103, 104) identifies three different
patterns of avascular necrosis with varying prognosis (Fig. 22.5). Of these, complete necrosis or
type I understandably has the poorest prognosis
compared with physeal necrosis (type II) or neck
necrosis (type III), whose prognosis is more
favorable.
Pseudarthroses are no longer described in recent literature since early surgical treatment of
displaced fractures have become common practice (1, 10, 15, 76, 106).
Growth Disturbances
The growth plates of the femoral head, the lateral
femoral neck, and the greater trochanter form a
Fig. 22.6 Development of the proximal femoral
growth plate. Beyond age eight, the growth plate of
the greater trochanter separates from the proximal
femoral growth plate. It then becomes a traction
277
functional unit until about the age of 8–10
(Fig. 22.6). At that time, the two systems separate.
The trochanteric epiphysis becomes a traction
epiphysis or apophysis and ceases to contribute to
the longitudinal growth in the femur, specifically
in the femoral neck. Growth disturbances that result from injury to the neck portion of the growth
plate and can lead to valgus displacement of the
femoral neck are not to be expected after this age.
Only occasionally are sequelae of growth disturbances described separately from those of necrosis (89). Partial closure of each part of the growth
plate is theoretically possible, which in turn would
lead to coxa valga, coxa vara, femoral anteversion,
or femoral retroversion. Varus deformities are described in the literature. However, these should be
regarded more as sequelae of primary displacement and less as sequelae of a growth disturbance.
Complete closure of the entire growth plate
system would lead to shortening of the femoral
neck (see Fig. 22.11 a–c). However, complete
necrosis would produce the same deformity,
which would be indistinguishable from the
sequelae of growth disturbance. It makes no
epiphysis, an apophysis. Like the portion of the growth
plate along the femoral neck, it then no longer contributes to the actual longitudinal growth of the femur
278
Specific Injuries—Lower Extremities
difference from a practical standpoint. Initial
treatment cannot address the cause in either case,
which is primary or secondary vascular injury. It
does not make sense to attribute premature closure of the growth plate to a “crush” injury when
the vascular injury identified as the cause of
avascular necrosis of the femoral head can involve
damage to the epiphyseal vessels. Were a crush
injury is indeed responsible for closure, then in
light of the massive traumatization resulting from
this injury we should expect to encounter such a
growth disturbance in every patient with a
femoral neck fracture. However, this is not the
case.
“Spontaneous Corrections”
Fig. 22.7 Treatment of femoral neck fractures. M.C.,
an 11-year-old girl, suffered a transcervical fracture of
the left femoral neck. Immediate emergency reduction
was performed and stabilized by internal fixation with
two cancellous screws. Six weeks later, the fracture exhibited good clinical and radiographic healing. The
metal implants were removed 12 months after the acci- 왘
dent (a). Both the radiograph obtained afterward and
the MRI studies (b) excluded avascular necrosis of the
femoral head. (My thanks to the radiographic institute
Nidecker and Benz for performing the MRI and making
this documentation available for publication)
Most authors explicitly state that no “spontaneous corrections” of deformities occur in the
proximal femur during the course of further
growth. However, as this is a weight-bearing extremity, it is indeed possible that the stimulus of
weight bearing will induce the growth plate and
with it the epiphysis to return to a position perpendicular to the plane of stress. Even axial deviations in the coronal plane may conceivably be corrected (65, 75, 95, 139). However, this growth
plate is slow and accounts for only 30% of growth.
a
Injuries to the Proximal Femur and Femoral Shaft
As a result, such corrections are only possible in
young patients (65). Yet, varus deformities should
not be left uncorrected even in small children.
They can involve significant shortening of the leg,
and the relative shortening of the medial gluteal
musculature can produce a Trendelenburg gait
that persists for years.
Treatment
The goal of treatment in a femoral neck fracture,
regardless of its location, must be to eliminate
axial deviation and prevent pseudarthrosis while
at the same time creating the best possible conditions for vascular supply to the femoral head.
Pseudarthrosis and deformity can be addressed
directly. However, vascular injuries and avascular
necrosis or growth disturbance as possible
sequelae can only be influenced indirectly.
To avoid further disruption of the already
compromised vascular supply to this region, we
suggest treating nondisplaced fractures conservatively in a plaster hip spica as a matter of course.
This should be left in place for four to six weeks,
b
279
depending on the patient’s age. We obtain radiographs after one week to definitively exclude secondary displacement, especially in the coronal
plane. However, the risk of secondary displacement appears to be small. We aspirate the hip in
every case under local or general anesthesia, depending on the patient’s age. We perform this
procedure to eliminate possible vascular compression due to hemarthrosis. Although it is not
very probable, such vascular compression remains a theoretical possibility, and aspiration
may be regarded as prophylaxis against avascular
necrosis of the femoral head.
Primarily displaced fractures should be
treated surgically in an emergency procedure. The
anterolateral approach popularized by WatsonJones is the best choice as the anterior capsulotomy will directly expose the fracture and
permit reduction under direct visualization (182).
Depending on the patient’s age and the location of
the fracture, the reduction is stabilized with Kirschner wires, Steinmann pins, or one to two cancellous screws (Fig. 22.7). The implants should not
penetrate the growth plate except in the case of a
280
Specific Injuries—Lower Extremities
Fig. 22.8 Peritrochanteric fractures. Peritrochanteric
fracture of the femur (left); intertrochanteric fracture of
the femur (right)
slipped capital femoral epiphysis. Depending on
the patient’s age, the epiphysis is fixed with Kirschner wires or Steinmann pins that cross the
growth plate. Intraoperative radiographs to verify
proper implant seating and correct position are
obtained in two planes (A-P and axial).
Immobilization and Consolidation
The x-ray out of plaster obtained after four to six
weeks should confirm that the fracture has
healed. The patient may then begin with increasingly spontaneous weight bearing but should
continue to refrain from sports. Approximately
six weeks after the radiographs to verify consolidation, we recommend an MRI study to exclude avascular necrosis of the femoral head.
Where MRI findings exclude beginning necrosis,
the patient may resume sports activities. Metal
implants should be removed about one year after
surgery—depending on the kind of metal. At this
time, we recommend another MRI study
(Fig. 22.7) to definitively exclude avascular necrosis of the femoral head.
Follow-up Examinations
In patients who remain free of symptoms under
normal levels of exertion, treatment can be concluded two years after trauma. The final examination includes gait evaluation, clinical measurement of hip and knee function, functional
measurement of leg length, and a plain pelvis
radiograph to evaluate the situation of the hips
and femoral necks. Treatment may be concluded
where all findings are normal.
Peritrochanteric Fractures
Peritrochanteric and intertrochanteric fractures
account for only about 8% of proximal femoral
fractures (55, 58, 61), which as a whole are rare
themselves (Fig. 22.8). Most of these fractures
occur as pathological fractures (see Chapter 32).
In contrast to the fractures of the femoral neck,
the injuries involve minimal risk of avascular
necrosis of the femoral head or neck (89).
Growth disturbances are also not to be expected after such fractures. Deformities are corrected only slowly, as is typical of the entire region
of the proximal femur. The diagnosis is easy to
make.
Nondisplaced fractures are immobilized in a
one-and-a half hip spica. A radiograph in plaster
should be obtained 8–10 days after trauma. Fractures with angulation and completely displaced
fractures are reduced open and stabilized with an
angled plate (see Fig. 31.5).
Immobilization or the period of nonweight
bearing should continue for four to six weeks.
Then, in the presence of clinical and radiographic
healing the patient may begin with spontaneous
motion exercises. Weight bearing should be allowed only gradually once unrestricted motion
has been regained. The patient may gradually resume sports activities about four to six weeks
Injuries to the Proximal Femur and Femoral Shaft
281
Fig. 22.9 Avulsion fractures of the greater and
lesser trochanters. The traction of the iliopsoas usually
causes more or less severe displacement of the avulsed
lesser trochanter (left). The traction of the medial
gluteal musculature can cause displacement in an avulsion of the greater trochanter (right)
after definitive healing has been confirmed. If
sports do not present any problems, further radiographic studies may be dispensed with. Any metal
implants may be removed six months to one year
postoperatively, depending on the child’s age.
Functional leg-length measurements are obtained every year until two years after the accident. Treatment may be concluded where gait is
normal, hip and knee function is normal, leg axes
are symmetrical, and leg length is symmetrical in
functional measurements.
We clinically monitor verifiable leg-length
differences at two-year intervals until cessation
of growth.
Avulsion Fractures of the Greater
and Lesser Trochanters
These injuries primarily occur in prepubescent
patients in whom the tissue of the epiphyseal and
apophyseal growth plates is sparse from hormonal influence. In these patients, sudden muscle
contractions can lead to separation of the
apophyses of the greater and lesser trochanters
(Fig. 22.9; 51, 56, 79, 154, 187). Avulsion of the
greater trochanter may also result from direct
trauma. The diagnosis is easily made on the basis
of radiographic findings obtained in patients
presenting with a typical history of sudden pain
after extreme muscular contraction.
Traction from the muscular insertions of the
gluteus medius or iliopsoas, respectively, invariably causes limited distraction of the fragments.
Avulsion of the lesser trochanter can be
treated conservatively, as can “nondisplaced”
avulsions of the greater trochanter. More severely
displaced avulsions of the greater trochanter are
treated surgically because this allows quicker rehabilitation; the fracture is stabilized with tension banding fixation. The prognosis for trochanteric avulsions varies greatly. The growth prognosis is essentially good for the reasons discussed
earlier: at about age eight, the growth plate of the
greater trochanter ceases to contribute to the
longitudinal, epiphyseal growth in the proximal
femur and thereafter produces only apophyseal
growth. The growth plate of the lesser trochanter
is an apophyseal growth plate right from the
beginning. However, both displaced and nondisplaced avulsions of the greater trochanter can be
associated with lacerations of the femoral circumflex artery, which involves the risk of partial
or total avascular necrosis of the femoral head (31,
56, 79; Fig. 22.10 a–c).
Conservative treatment of avulsions of the
lesser trochanter consists of placing the patient
on forearm crutches for five to six weeks to reduce
weight bearing. Nondisplaced avulsions of the
greater trochanter are immobilized in a one-anda-half hip spica, and the patient is mobilized on
forearm crutches in this cast. This makes it
possible to treat these cases on an outpatient
basis.
Displaced avulsions of the greater trochanter
are openly reduced and stabilized with tension
banding fixation. This allows the patients to continue treatment with functional aftercare.
After five to six weeks of immobilization or reduced weight bearing, avulsion fractures of the
lesser trochanter will not require radiographic
studies to verify consolidation. Spontaneous mobilization may be begun at this time. In the case of
282
Specific Injuries—Lower Extremities
a
b
Fig. 22.10 Avascular necrosis of the femoral head
secondary to a nearly nondisplaced avulsion fracture
of the greater trochanter. The patient is a 13-year-old
girl with an only slightly displaced avulsion fracture of
the greater trochanter. Treatment was conservative: The
injury was immobilized in a one-and-a-half hip spica and
the patient was mobilized on forearm crutches in the
cast for five weeks. After that, spontaneous mobilization
of the hip was allowed with increasing weight bearing.
After another five weeks, full weight bearing was
possible without any problems, and both hips exhibited
unrestricted and symmetrical mobility. The follow-up
radiographs obtained three months after the injury
showed stable healing and normal hip anatomy. The
growth plates of the greater trochanter and of the
femoral head are closed (a). After a total of six months,
the patient presented with increasing pain in the left hip.
The radiographs showed beginning avascular necrosis of
the femoral head, which later developed into complete
necrosis with subluxation (b) despite reduced weight
bearing and core decompression of the femoral neck.
The Beck drilling technique was performed but failed to
improve vascular supply (center)
Injuries to the Proximal Femur and Femoral Shaft
283
Fig. 22.10 c Only a triple osteotomy succeeded in
achieving sufficient acetabular coverage of the femoral
head. This significantly improved mobility and gait
during the further course of the disorder, and pain on
weight bearing disappeared
c
avulsion fractures of the greater trochanter, consolidation should first be documented in radiographs before the patient begins with spontaneous mobilization. Patients with avulsions of
the lesser trochanter may usually resume sports
activities two to three weeks after consolidation;
those with avulsions of the greater trochanter,
four to six after consolidation.
Treatment is concluded once sport has been
resumed without problems, gait is normal, and
hip function is unrestricted.
284
a
b
c
Specific Injuries—Lower Extremities
Fig. 22.11 Posttraumatic deformities in the proximal femur. Partial pseudarthrosis of the femoral neck
and growth disturbance with shortening of the femoral
neck. The patient is a 13-year-old boy with a cervicotrochanteric fracture of the femoral neck that was reduced
in an emergency procedure. An attempt to stabilize the
fracture with a screw destroyed the lateral column, and
the surgeon then decided to fall back on unstable internal fixation with Kirschner wires with additional immobilization in a plaster hip spica (a). Avascular necrosis of
the femoral head was feared but failed to occur during
the further course of healing. However, partial pseudarthrosis developed and was stabilized by internal fixation
with an angled plate after 14 weeks. This finally allowed
the fracture to heal in the correct position, which it did
without any signs of avascular necrosis (b). Radiographic
follow-up studies after removal of the metal implants
(two years after the accident) showed normal length of
the femoral neck, However, follow-up studies after cessation growth (five years after the accident) showed significant shortening of the femoral neck. These studies
also failed to show any signs of past avascular necrosis
(c). As the patient was free of subjective symptoms and
exhibited only a slight Trendelenburg gait, we decided
not to suggest an osteotomy to lengthen the femoral
neck
Injuries to the Proximal Femur and Femoral Shaft
285
Proximal Femoral Shaft (0.5%)
Forms
1. Nondisplaced subtrochanteric
2. Displaced subtrochanteric
A-P and lateral radiographs: One plane will suffice
in grossly displaced fractures.
Limits of correction: No axial deviations should be
left uncorrected; spontaneous correction does not
occur.
Definition of “nondisplaced”: No axial deviations
may be tolerated.
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Medical.
앫 Where indication is uncertain or conservative
treatment is indicated: Medical, i.e., sedation
to apply a plaster cast.
Emergency treatment under anesthesia: All displaced fractures.
Technique of conservative fixation: Plaster hip
spica for nondisplaced fractures.
Technique of internal fixation
앫 Intramedullary nailing,
앫 Internal fixation with an angled plate may be
an option.
Aftercare
Period of immobilization
앫 With conservative fixation: Three to four weeks.
앫 With internal fixation: Immediate spontaneous
motion.
Consolidation radiographs: Yes.
Initial mobilization: Immediate spontaneous mobilization after removal of the plaster splint.
Postoperatively
앫 In patients below age six, either after three
weeks or immediately on crutches.
앫 In patients above age six, postoperative mobilization may begin on forearm crutches without
weight bearing; patients may sit once hip flexion
of 90⬚ has been achieved.
Physical therapy: Only in the case of immediate
postoperative mobilization, otherwise none.
Sports: Three to four weeks after consolidation.
Removal of metal implants
앫 Intramedullary nails after four to six weeks,
앫 Fracture plate after four to six months.
Follow-up examinations and conclusion: Examinations are performed at three- to four-week intervals
until normal gait is regained (even after removal of
metal implants). Thereafter, clinical follow-up examinations are performed at six-month intervals and include functional leg-length measurements and clinical measurement of anteversion until two years after
the accident. Where there is a difference in leg
length, follow-up examinations are continued at
two- to three-year intervals until cessation of growth.
286
Specific Injuries—Lower Extremities
Femoral Shaft Diaphysis (1.1%)
Forms
앫 Transverse fractures
앫 Oblique fractures with or without a spiral wedge
A-P and lateral radiographs: One plane will suffice
in grossly displaced fractures.
Limits of correction
앫 No axial deviation,
앫 Malrotation: 20⬚,
앫 Side-to-side displacement of one half shaft
width.
Growth stimulation: A lengthening deformity occurs below age 10; a shortening deformity above age
10. The more remodeling occurs and the longer it
lasts, the greater the difference in leg length. Prophylactic shortening is ineffective.
Definition of “nondisplaced”
앫 Side-to-side displacement up to age three: Up to
one full shaft width; above age three, up to one
half shaft width at maximum.
앫 Shortening of 1–2 cm below age three; none
above age three.
앫 Varus deformity up to 20⬚ below age three; up to
10⬚ above age three.
앫 Valgus deformity up to 10⬚.
앫 Anterior bowing up to 10⬚; no posterior bowing.
앫 Rotational deformity up to 20⬚ below age three;
up to 10⬚ above age three.
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Medical.
앫 Where indication is uncertain: Same, i.e.,
sedation to apply cast.
Emergency treatment under anesthesia
앫 Every displaced fracture in multiple trauma,
앫 Every individual displaced fracture above age
three to four (up to about 25 kg of body
weight).
!
All other indications should first be discussed at
length with the patient and his or her parents.
Further treatment without anesthesia or delayed
treatment under anesthesia: Delayed treatment
under anesthesia where position in the pelvic cast
is not tolerable (x-ray in plaster on about day
four).
Technique of conservative fixation
앫 Plaster hip spica (extending to the malleoli on
the fractured side and to the knee on the contralateral side),
앫 One-and-a-half hip spica for nondisplaced
fractures in all age groups (extending to the
malleoli on the fractured side).
Technique of internal fixation
앫 Oblique, spiral, and comminuted fractures are
treated with an external fixator.
앫 Transverse fractures are treated with dynamic
intramedullary nailing.
앫 Interlocked nail is used where growth plates
are closed.
Aftercare
Period of immobilization
1. With conservative fixation: Two to three weeks.
2. With internal fixation: Immediate spontaneous
motion.
Consolidation radiographs are obtained in patients
above age three to four and in those treated with an
external fixator, intramedullary nail, or AO intramedullary nail.
Initial mobilization
앫 Spontaneously after removal of the plaster cast,
앫 Immediately postoperatively with full or partial
weight bearing as allowed.
Physical therapy: Only in the case of immediate
postoperative mobilization, otherwise none.
Sports: Four to six weeks after consolidation.
Removal of metal implants: External fixator or intramedullary nail, 6–12 weeks postoperatively; AO
intramedullary nail, one year postoperatively.
Follow-up examinations and conclusion: Patients
with external fixators are to receive weekly clinical
examinations and monthly radiographic examinations until the fracture has healed. Thereafter, followup examinations are performed at three-week intervals until normal gait is regained. Once the patient
has resumed sports activities, annual clinical followup examinations are performed until two years after
the accident. In the absence of a difference in leg
length, treatment may be concluded. Otherwise, follow-up examinations are continued every two years
until cessation of growth.
Injuries to the Proximal Femur and Femoral Shaft
Femoral Shaft Fractures
앫 Subtrochanteric and proximal fractures
앫 Fractures of the proximal, middle, and distal
diaphysis
Following fractures of the lower leg, femoral fractures are among the most frequent injuries to the
lower extremities (58, 61, 77, 158, 172, 185), yet on
the whole they are rare. The usual cause is severe
direct trauma. Accordingly, they may be associated with severe soft-tissue injuries (it is especially important to evaluate distal neurovascular function). Radiographs must always include
the adjacent joints.
Posttraumatic Leg-Length Alterations
As after every shaft fracture in a growing patient,
growth disturbances in the form of transient
stimulation of the growth plates adjacent to the
fracture may be expected along with their various
sequelae (see General Science, Treatment, and
Clinical Considerations). In every case, the severity of the sequelae of stimulation is determined by
the scope and therefore the duration of remodeling, and by late reduction and surgery later than
five days after the accident. Every axial deviation
that is left up to the corrective forces of further
growth (except for malrotation) and every
manipulation of the fixation callus will lead to
protracted stimulation of the growth plates.
However, as we found in examining our patients
with lower-leg fractures, even traction per se
negatively influences posttraumatic changes in
leg length (35). To restore the status quo ante as
far as possible, one should ideally leave no axial
deviation (varus, valgus, anterior bowing, posterior bowing, side-to-side displacement) to the
corrective forces of further growth, avoid performing closed or open reduction later than five
days after the accident, and use no traction.
The significance of a posttraumatic leg-length
alteration can vary greatly. It depends on the
patient’s age at the time of the accident, existing
idiopathic differences in leg length, and the
specific load distribution in the patient’s spine.
Where trauma occurs during the actual
growth phase, there will usually be an increase in
length, which can intensify within a maximum of
two years depending on the scope of remodeling.
Notwithstanding isolated arguments to the contrary (154), the resulting difference in leg length
will most probably persist unchanged until cessation of growth and of course beyond that point
287
(18, 37, 85, 119, 127, 181). There is no regulating
organ for achieving symmetrical length on both
sides in the growing skeleton. Only after age 10
may a primary posttraumatic leg-length difference be reduced or disappear as a result of accelerated physiological closure of the growth plates
on the affected side (see General Science, Treatment, and Clinical Considerations). However, this
will not follow a predictable pattern in the individual patient and can only be documented by
leg-length examinations until cessation of
growth. We ourselves have not observed femoral
fractures to have any influence on tibial length
(158) or vice versa (35).
The incidence of idiopathic differences in leg
length cited in the literature fluctuates between
25% and 70% (35, 38, 149). The magnitude lies between 0.5 and 3 cm. The existence and magnitude
of an idiopathic difference in leg length is usually
not known prior to trauma. Posttraumatic alterations in leg length can often reduce or eliminate
such an idiopathic difference in leg length, but can
also exacerbate it. This, too, can only be detected
by specific examination.
A posttraumatic difference in leg length will
typically lead to secondary lumbar scoliosis
toward the shortened side (Fig. 22.12). However,
existing disorders of the lumbosacral junction (a
hemivertebra, lumbarization of the first sacral
vertebra, or sacralization of the fifth lumbar
vertebra) can produce an unusual scoliosis that
may require a leg-length difference to maintain
the spine in a vertical position (Fig. 22.13). Because the specific load distribution in the spine
varies with every patient, clinical and radiographic leg-length measurements should always
be restricted to the functional method using
shims placed under the patient’s foot
(Fig. 22.14 a,b; see General Science, Treatment,
and Clinical Considerations). The clinical significance of differences in leg length of the magnitude present in both idiopathic cases and posttraumatic cases is largely unknown (35, 38); it depends on the load distribution in the spine and on
the function of this load distribution (containment of scoliosis). In the patient group we studied, which included a total of 1400 persons (35,
132, 133), we found that not every difference in
leg length leads to scoliosis (about 30% of these
patients were found to have compensated for a
difference in leg length while maintaining a
straight spine) and that cases of scoliosis can
occur without differences in leg length (nearly
10% of the patients without a difference in leg
288
Specific Injuries—Lower Extremities
Fig. 22.12 Clinical significance of differences in leg
length. The patient is a 15-year-old girl with status post
right femoral shaft fracture. The injury increased what
was probably an existing idiopathic difference in leg
length. The pelvic obliquity produced left convex scoliosis of the lumbar spine. After correction of the pelvic obliquity, the spine assumed a largely normal position
length were found to have scoliosis). However,
back pain was found to be significantly more common in patients with scoliosis than in those
without it (15% as opposed to 5%), and patients
with a difference in leg length also complained of
back pain more often. We found that the magnitude of the difference was not a significant factor
in whether the patient complained of back pain.
In light of these three prognostic aspects, one
can only reliably predict that a femoral shaft fracture in a growing patient will result in an alteration of leg length, but not whether the leg will be
lengthened or shortened. Treatment of the difference in leg length depends primarily on the load
distribution in the spine and only to a lesser extent on the load distribution in the hip (in hips
predisposed to dysplasia where there is an ex-
isting difference in leg length, there may be a relative coxa valga on the lengthened side in which
acetabular coverage of the femoral head is compromised; this can represent a predisposition to
arthrosis).
Whether every difference in leg length actually requires correction is a separate issue (see the
section on deformities, p. 27). In children at least,
there is no cause to fear that a fixed spinal deformity will quickly develop, and one can wait
before prescribing an orthosis. We also have to
take patient compliance into account when we
consider prescribing an orthosis to compensate
for leg length. Most children wear the orthosis as
long as their parents ensure they do. Most adolescents no longer wear any orthosis or only when
their parents still have enough influence to verify
Injuries to the Proximal Femur and Femoral Shaft
289
Fig. 22.13 Clinical significance of differences in leg
length. The patient is a 13-year-old girl with status post
left femoral shaft fracture with an obvious right pelvic
obliquity. The spine is well compensated without a shim
despite the pelvic obliquity. This is due to the presence
of an abnormality of the lumbosacral junction. Addition
of a shim to correct the obliquity resulted in a slight left
convex scoliosis of the lumbar spine with the usual clinical symptoms (unfortunately, gonad protection had
been forgotten)
that they are wearing one. Most young adults do
not wear an orthosis if they are asymptomatic. As
a result, one can often only advise the patient
with beginning back pain to consider that this
pain may be due to the existing difference in leg
length and that it can often be eliminated by a
heel pad.
will take a long time to return to the proper plane
of stress transfer.
Posterior bowing deformities in the diaphyseal region are almost never encountered. Anterior bowing deformities are encountered far more
frequently. These deformities are only gradually
reduced within certain limits during the course of
further growth. In each third, they are only reduced to 10–15⬚ of increased anterior bowing
compared with the unaffected contralateral side
(Fig. 22.16). It is apparent then that with this
severity of deformity no additional functional
stimulus acts on the periosteum to initiate further
correction.
Side-to-side displacement may be regarded as
completely harmless even in adolescence.
However, it involves significantly prolonged remodeling, which may only be completed years
after the accident (138; Figs. 22.15, 22.16).
Traumatic shortening deformities can be compensated for in patients up to age 10 at the time of
the accident. However, they always involve a vary-
“Spontaneous Corrections”
Spontaneous correction of all axial deviations in
all three spatial planes is always possible during
the course of further growth.
Due to the distribution of muscles in the thigh,
valgus deformities are only slowly corrected and
may occasionally persist. Varus deformities are
readily corrected. However, the farther proximal
they lie, the longer the correction will take (139;
Figs. 22.15, 22.16). Therefore, one should not
leave varus and valgus deformities untreated in
peritrochanteric and subtrochanteric fractures as
they directly influence the load distribution in the
femoral neck and the proximal end of the femur
290
Specific Injuries—Lower Extremities
b
a
Fig. 22.14 a, b Function clinical measurement of
posttraumatic differences in leg length. Leg-length
measurements should always be obtained by the
functional method using shims. This is the only way to
evaluate the spine and a possible compensated difference in leg length. The absolute magnitude of the difference is less important than the size of a therapeutic heel
pad that may be required. To determine the size of the
pad, one must evaluate the triangles of the waist, the
direction of the anal fold, the position of the gluteal folds
of the buttocks, and the lumbar spine itself before and
after placing shims under the foot of the shorter leg. The
level of the iliac crests is only of secondary importance.
For this evaluation to yield reliable results, both knees
should be extended and the joints of the lower extremities should be free of any contractures
ing degree of side-to-side displacement, and the
resulting remodeling usually leads to overcompensation. This in turn causes leg lengthening,
despite the widespread yet erroneous opinion to
the contrary. An initial shortening deformity will
not prevent development of a secondary posttraumatic lengthening deformity.
Initial lengthening deformities are not compensated for at all.
Malrotation following a femoral fracture in a
growing patient is portrayed in the literature as a
key problem. One is repeatedly warned about the
severe consequences of malrotation, although
these consequences have yet to be documented in
a clinical study group. Most authors are content to
warn about this deformity and deny the possi-
bility of spontaneous correction (9, 62, 93, 102,
109, 117, 144). However, we first documented
such “spontaneous corrections” in 1976, and our
findings have since been confirmed by other
authors (13, 90, 131, 134, 135).
Malrotation of the femur manifests itself in
clinical and radiographic examinations as a difference in the anteversion of the femoral necks,
which is evidenced by a difference in the hips in
internal rotation (Figs. 22.17, 22.18). Radiographic
studies should no longer be used to demonstrate
this condition; instead it should only be diagnosed by clinical examination (107) or with the
aid of ultrasound studies (Figs. 22.19, 9.4 a,b).
The external rotation deformity of the distal
fragment leads to decreased anteversion of the af-
Injuries to the Proximal Femur and Femoral Shaft
291
Fig. 22.15 Reliable “spontaneous corrections” in
the femoral shaft. The patient is a four-year-old girl
with a femoral shaft fracture that healed in a 15⬚ varus
deformity and with one full shaft width of side-to-side
displacement. As early as two years after the accident,
the varus deformity had improved significantly and the
side-to-side displacement was completely remodeled.
The distal femoral epiphysis had regained its physiological position perpendicular to the plane of stress transfer
fected side. The internal rotation deformity of the
distal fragment exhibits increased anteversion of
the affected side (Fig. 22.17).
The anteversion of the femoral necks changes
during the course of growth; changes in version
occur in all long bones of the growing skeleton.
Physiological retroversion processes diminish the
angle of anteversion from 40–50⬚ at birth to
10–15⬚ at the cessation of growth. The posttraumatic reduced anteversion of the external rotation deformity essentially approximates the final
effect of physiological retroversion of this side
prematurely. As retroversion of the unaffected
contralateral side takes place during the course of
further growth, the difference in anteversion
gradually disappears. The malrotation is then no
longer measurable, neither by clinical examination nor in ultrasound studies, and loses its clinical significance. Internal rotation deformities involve increased anteversion of the affected side
and are encountered significantly less frequently.
Here, the deformity can be eliminated or at least
diminished by increased retroversion during the
course of further growth. The physiological retroversion of the femoral necks primarily occurs in
two major episodes, once between age five and
eight, and again prior to puberty. This means that
one may expect malrotation to diminish even
shortly before the cessation of growth. At least in
my opinion, this “spontaneous correction” does
not have any influence on the posttraumatic alteration in leg length as it represents an indirect,
nondirected correction (134).
292
Specific Injuries—Lower Extremities
Fig. 22.16 The limits of “spontaneous corrections”
in the femoral shaft. The patient is a five-year-old boy
with a femoral shaft fracture that healed in 20⬚ of anterior bowing and 10⬚ valgus. Three years later, the valgus
and anterior bowing deformity was still unchanged. The
distal epiphysis was again perpendicular to the plane of
stress transfer. The side-to-side displacement corrected
itself without any problems
In acute femoral fractures, the malrotation
cannot be directly evaluated in a clinical setting
and therefore cannot be directly corrected by conservative treatment.
Clinical measurements can only be obtained
after open stabilization of the fracture or after it
has consolidated and both hips exhibit their full
range of motion. The reduced internal rotation of
the hip on the affected side results from a
decrease in anteversion, i.e., an external rotation
deformity, whereas increased internal rotation of
the hip compared with the contralateral side results from an increase in anteversion, i.e., an internal rotation deformity. The deformity is measured
clinically, and these measurements are best ob-
tained with the patient prone (the patient’s pelvis
and legs must be parallel to the examining table).
The examiner flexes the patient’s knee 90⬚, palpates the greater trochanter, and rotates the thigh
outward from the body until the greater trochanter is parallel to the examining table. The
angle between a vertical line and the lower leg in
internal rotation (rotated outward from the body)
specifies the angle of anteversion within a margin
of error of slightly less than 10⬚ (100). The difference to the contralateral side specifies the severity of the malrotation (Fig. 22.19).
Malrotation has been measured radiographically in the semi-axial projection described by
Schulz (115). The measurements can be obtained
Injuries to the Proximal Femur and Femoral Shaft
> 30 °
293
At birth
15 °–30 °
Age five to seven
10 °–15 °
Cessation of growth
External rotation
deformity of distal
fragment
Internal rotation
deformity of distal
fragment
Fig. 22.17 Development of anteversion of the
femoral necks and spontaneous correction of malrotation during further growth. During the course of
further growth, the anteversion of the femoral neck
diminishes from 30–40⬚at birth to 10–15⬚ at the cessation of growth. An external rotation deformity of the dis-
tal fragment prematurely approximates the final effect
of physiological retroversion. This deformity is “corrected” by the physiological retroversion of the unaffected contralateral side. The internal rotation deformity of the distal fragment can be “corrected” by increased retroversion of the affected side
on a Rippstein frame (25, 105) only after the fracture has consolidated. Even with the patient correctly positioned on the frame, one must expect a
margin of error of a good 10⬚ due to projection errors and the need for individualized interpretation of every radiograph (39, 45, 135, 141). The
margin of error increases accordingly in radiographs obtained with the patient in bed, a method
that is still sporadically recommended (e.g., in
traction treatment on a Weber table). Measure-
ments purported to specify differences within a
single degree (55, 109, 145) border on medical
clairvoyance. For this reason, radiographic studies
of a malrotation in the femur should no longer be
obtained, neither as semi-axial projections nor as
computed tomography (CT) images. We feel that
clinical documentation with photographs will
suffice. If this does not satisfy the often exaggerated documentation demands of large facilities such as university hospitals, then one should
294
Specific Injuries—Lower Extremities
Fig. 22.18 Clinical measurement of posttraumatic
malrotation and idiopathic differences in anteversion by evaluating the range of motion of the hips in internal rotation. This girl suffered a right femoral shaft
fracture, which was treated conservatively with traction.
This led to an internal rotation deformity of the distal
fragment in which the affected hip exhibited increased
internal rotation of 25⬚ compared with the contralateral
side. This method of measurement and documentation
is excellently suited for use in follow-up examinations.
Such documentation would even suffice as a preoperative evaluation because the extent of any intraoperative
correction would invariably depend on comparing the
range of motion of the affected hip in internal rotation
with that of the contralateral side
Fig. 22.19 Clinical measurement of anteversion of
the femoral neck and posttraumatic malrotation of
the femur (107). With the patient prone and the knees
flexed 90⬚, the examiner palpates the greater trochanter
and rotates it parallel to the examining table. The angle
between a vertical line and the lower leg indicates the
angle of anteversion. The severity of the malrotation is
the difference to the contralateral side. If the anteversion of the fractured side is decreased compared with
the contralateral side, then an external rotation deformity of the distal fragment is present. If it is increased
compared with the normal contralateral side, then an internal rotation deformity is present
document the deformity with ultrasound studies
only (28; Fig. 9.4 a,b).
A review of the literature reveals a persistent
discrepancy. On the one hand, conservative treatment of femoral fractures is recommended because of the favorable healing tendencies in growing patients. On the other hand, one is warned
about the sequelae of malrotation despite the fact
that to date an indirect conservative correction of
malrotation has only been proposed in theory,
and only for a certain age group: Weber (145) first
presented his method of active correction of a
malrotation in 1963. The Weber table can accommodate only children between age three and 10.
Injuries to the Proximal Femur and Femoral Shaft
This means that children beyond this age range
who undergo the conservative treatment recommended in the literature must tolerate persistent
rotational deformities and their “grave” sequelae.
No objection to this has been raised in the literature.
Yet regardless of the method of treatment and
the patient’s age at the time of the accident, once
growth has ceased one invariably encounters approximately the same incidence of malrotation
secondary to femoral shaft fractures. And with
few exceptions, one encounters these deformities
in the same severity: 10–20% of patients had a
difference in anteversion of up to 25⬚ (13, 134, 135,
141, 143). We attribute the comparability of these
final results to spontaneous correction and to the
presence of idiopathic differences in anteversion,
which themselves are encountered with an incidence of nearly 20% and in a magnitude exceeding 20⬚ (13, 59, 60, 13). This suggests that these
“persistent malrotation deformities” may in fact
simply represent idiopathic differences in anteversion.
The significant margin of measurement error
in conservative treatment on the Weber table,
“spontaneous corrections,” idiopathic differences
in version, and the fact that hips can provide good
functional compensation, combine to reduce the
clinical significance of posttraumatic malrotation
in the femur. Only persisting differences in anteversion exceeding 25⬚ should be regarded as
malrotation (13, 135). Only they can produce significant long-term symptoms and lead to the late
sequelae described in the literature (144). Accordingly, initial treatment should strive to avoid
them.
Treatment
Here we again emphasize the goal of treatment:
앫 To rapidly restore patient mobility to permit
rapid weight bearing and full function,
앫 To avoid impairment of fracture healing,
앫 To avoid additional injuries,
앫 To ensure good functional and cosmetic results initially and in the long term,
앫 To achieve these goals by the simplest means
possible.
Therefore, in the interest of minimizing the effect
of posttraumatic alteration of leg length, treatment of femoral shaft fractures in growing
patients must aim to achieve proper axial alignment. This means that no axial deviations exceed-
295
ing 10⬚ in the coronal and sagittal plane, no malrotation exceeding 20⬚, and no side-to-side displacement exceeding half the width of the shaft
may be tolerated. At the same time, the goal is to
restore the child’s natural vitality as quickly as
possible. This means achieving efficiency in treatment by using the simplest means possible. As the
initial treatment cannot directly influence differences in leg length, any surgical procedures intended solely to rectify the difference in leg
length are not justified (53, 117). This means that
even side-to-side displacement exceeding half of
the width of the shaft would not represent an indication for surgical treatment.
We now know that this goal cannot be
achieved by conservative means, that is to say by
the semi-conservative method of traction. The
patient is by no means rapidly mobilized. Even
when traction brings rapid healing, we must still
expect posttraumatic differences in leg length in
about 70% of all patients. The goal of treatment is
not achieved by the simplest means possible and
certainly not by the least expensive means: In
Switzerland, the costs of traction amount to approximately 20,000 Swiss francs (US $14,600).
Compare this to internal fixation with a fracture
plate (eight days of initial hospitalization and
three days for removal of the metal implants) at
9,000 Swiss francs (US $6,570), intramedullary
nailing (eight days of initial hospitalization and
three days for removal of the metal implants) at
around 5,000–7,000 Swiss francs (US $3,650–
5,110), and even less for treatment with an external fixator, which requires eight days of initial
hospitalization with the fixator removed in an
outpatient procedure (19, 132).
When asked for their own opinion, patients
show a striking lack of interest in an extended period of hospitalization with the indignity that
such treatment entails. Patients invariably opt for
the method that is least elaborate and easiest for
them to accept. Viewed from this perspective,
they would prefer methods that unfortunately are
not yet available: Definitive treatment methods
that do not require a second surgical procedure
and that permit immediate full use, do not require
any special care, do not impair healing, and do not
cause growth disturbances. We should be working on developing just such methods instead of
complacently extolling the virtues of the existing
ones.
If we consider all the medical and social factors, we find that traction treatment is no longer
justified in children, especially in light of the tech-
296
Specific Injuries—Lower Extremities
nical alternatives available today. The goal of
treatment in adults is to ensure that the patient
can return to work as quickly as possible. In
children, the goal of treatment is to restore the
child’s natural vitality as quickly as possible even
if this might not appear to be of paramount social
and economic importance. This means that we
should offer them a mobility that rapidly enables
them to regain their freedom of movement and
ability to play. Wherever general anesthesia is
deemed necessary for initial treatment of the
fracture, the patient should also have a right to
definitive treatment. Traction treatment, whether
on a Weber table, a traction table, or a Braun
frame (80, 120, 125), cannot claim to be a definitive treatment. In the literature, conservative
treatment (157, 159, 166, 168, 173, 190) is still
compared to operative treatment (16, 161, 165,
167, 171, 174, 176, 177, 179, 180, 183). However,
due to the lesser costs involved as well as social
arguments, operative treatment is increasingly
becoming the treatment of choice (158, 163, 170).
For all of these reasons, we no longer perform
any traction treatment in cases where we feel
general anesthesia is indicated to treat the fracture, and this includes femoral fractures. We immobilize nondisplaced subtrochanteric fractures
in a hip spica. Dislocated subtrochanteric fractures are treated by closed reduction under anesthesia where possible and stabilized with intramedullary nails (Figs. 22.20, 22.21). If this is not
successful, we perform open reduction in the
same session and stabilize the fracture with an
angled plate (186; Fig. 22.22). Intramedullary
nailing and plate fixation are fixation techniques
that permit stable motion and require no additional immobilization. The fracture will consolidate within two to five weeks depending on the
patient’s age. By this time at the latest, it will permit weight bearing.
Rare, completely nondisplaced diaphyseal
fractures, i.e., incomplete fractures, are treated
conservatively in every age group by immobilization in a hip spica (40, 46, 47, 108, 111). Where
possible, a one-and-a-half hip spica is used to
allow children to walk and attend school where
necessary.
We discuss the planned procedure with the
parents as a matter of course. This also applies to
children with displaced femoral shaft fractures up
to age three to four. In this age group, we do not
feel that general anesthesia is indicated in every
case, and we recommend a hip spica or traction
with an adhesive bandage. Traction with an adhe-
sive bandage has the advantage of being easier to
care for than a hip spica. However, both treatments permit the patient to be cared for at home
(81, 82, 88, 129; Fig. 22.23).
Traction with an adhesive bandage and the
hip spica are applied with the patient sedated but
without general anesthesia. We extend the hip
spica to the foot on the injured side but leave the
foot free. On the contralateral side, the spica extends to the knee, and we leave the knee and foot
free. For better stabilization, we mold a bar into
the cast, which can also be used as a grip
(Fig. 22.24).
In the case of every other child or adolescent
requiring general anesthesia for initial treatment
of a femoral fracture, the goals we have outlined
permit only three treatment options. These include intramedullary nails (Küntscher, AO), dynamic intramedullary nailing, and the dynamic
external fixator (see also Table 11.1).
The Küntscher nail is only an option for adolescents with closed growth plates. The indication
and technique are identical to those in adult
trauma cases (Fig. 22.25). But the danger of head
necrosis is described in adolescents (189).
Plate fixation (with AO fracture plates), which
we formerly advocated (86), is a surgical method
involving open reduction. It leaves a scar of varying size that is always a cosmetic disadvantage in
growing patients. For this reason, many authors
only treat transverse fractures by plate fixation
(54), whereas they do not use this form of internal
fixation to treat long oblique fractures.
Plate fixation ensures stability in motion but
does not permit immediate weight bearing.
Therefore, some authors advocate additional immobilization in a cast in children. This negates the
advantage of rigid internal fixation that allows
motion. Although the incidence and magnitude of
differences in leg length following initial plate
fixation have significantly decreased in relation to
traction treatment (50, 54, 73), the cost and complexity of the procedure (two operations), the
cosmetic disadvantage of the scar, and the lack of
rigid fixation that allows motion speak against
this method. It is not compatible with children’s
needs. For this reason, we have ceased to use it entirely.
Dynamic intramedullary nailing is a surgical
method involving closed reduction. The skin incisions for placing the metal implant are significantly smaller those required for plate fixation
and accordingly represent less of a cosmetic disadvantage. The method can be used to treat all
Injuries to the Proximal Femur and Femoral Shaft
297
Fig. 22.20 Treatment of subtrochanteric femoral
fractures. The patient is a four-week-old boy with a displaced subtrochanteric right femoral fracture with a valgus and anterior bowing deformity. An unsuccessful attempt at conservative treatment without anesthesia
was undertaken. Open reduction and internal fixation
were indicated by the persistent direction and severity
of the deformity. The presence of interposed muscle al-
lowed only open reduction. The fracture was stabilized
with an intramedullary Kirschner wire bent at the blunt
end. After two weeks, clinical and radiographic evidence
indicated that the fracture had sufficiently consolidated
with abundant formation of callus. After six months,
clinical signs of callus had completely disappeared, and
the patient was free of symptoms
forms of fractures (including peripheral fractures
in particular, but most importantly stable transverse fractures). Due to the weaker internal fixation material, stability in motion and stability in
early weight bearing is not always ensured in unstable fractures and in older adolescents. Applied
correctly, this technique provides internal fixation that ensures stability in motion and probably
allows early weight bearing. The data in the literature vary (5, 11, 13, 23, 52, 69, 78, 83, 100, 101, 112,
113, 123, 152). Oblique and transverse fractures
are compared with one another, and most authors
only mention the “prompt” mobilization of the
patients within the first two weeks postoperatively as opposed to the actual time of weight
bearing. The relatively long periods of hospitalization ranging between two and three weeks for
isolated fractures are also conspicuous. However,
these may still be related to nonmedical factors
such as amortization of hospital assets.
Additional immobilization should not be prescribed. The metal implants must also be removed
in a second procedure under general anesthesia.
The rare cases of infection with this type of internal fixation involve osteomyelitis as the intramedullary canal is completely opened from one
metaphysis to the other. The growth prognosis is
more favorable than with traction treatment, with
posttraumatic alterations in leg length occurring
in between 25% and 35% of all patients (22).
298
Specific Injuries—Lower Extremities
Fig. 22.21 Treatment of
subtrochanteric femoral
fractures. The patient is a
four-year-old girl with a displaced subtrochanteric right
femoral fracture. Reduction
under general anesthesia was
indicated because of the displacement. Closed reduction
was successful, and the fracture was stabilized with two
intramedullary nails. After
four weeks, clinical and radiographic evidence indicated
that the fracture had consolidated. The metal implants
were removed after 10
weeks. At the follow-up examination one year later, the
patient was subjectively
completely free of symptoms. To the extent that this
could be ascertained in a
patient of this age, the legs
were of equal length, and
both hips and knees on both
sides exhibited unrestricted
and symmetrical mobility
The dynamic external fixator is also a surgical
method involving closed reduction (2, 7, 21, 63,
72, 147, 148). It can be used to treat practically all
forms of fractures, and in theory it can be used in
any age group. The only drawback is the cosmetic
aspect, as adolescent patients often find the external frame intolerable and they or their parents
have to assume responsibility for caring for the
pin exit wounds. This method ensures rigid fixation that allows motion, it allows early weight
bearing, and does not require any additional immobilization. The metal can be removed without
a second surgical procedure and without general
anesthesia. Where infection occurs, it will be localized ostitis. The prognosis for growth is more
favorable here than for traction treatment, with
posttraumatic differences in leg length occurring
in between 25% and 40% of all patients.
Since 1988, we have used the external fixator
with fractures in the lower extremities and have
employed a variety of systems. Our experience
largely confirms that of other hospitals (3, 6, 7, 30,
70, 72, 126, 148). Whereas oblique fractures did
not represent a problem with any of the systems
used (Fig. 22.26 a,b), the transverse fractures
(Fig. 22.27 a,b) proved difficult, with relatively
long consolidation periods. Eighty-five percent of
all other complications such as infections,
delayed union, and refractures occurred with the
transverse fractures (147). In order to achieve
nearly normal consolidation periods of five to six
weeks in transverse fractures, the systems may
not be too rigid and must allow reliable dynamic
adjustment. Our previous experience has shown
that the Monotube series (manufactured by Stryker Howmedica) currently best meets these requirements.
Based on our own experience with the external fixator (136) and others’ experience with dynamic intramedullary nailing as described in the
literature (22, 113), we feel that the problem is
best managed with this flexible approach: We
treat “unstable” oblique, comminuted, and torsion fractures with the external fixator because of
their short healing time and the fixator’s precise
retention of the proper length. For all “stable”
transverse and short oblique fractures, we recommend dynamic intramedullary nailing.
We currently prefer the Monotube (see also
Fig. 24.5 b) as it is simpler to apply and does not
have to be adjusted with a template but is aligned
according to the fracture. We use a traction table
Fig. 22.22 Treatment of subtrochanteric femoral fractures. The patient is an
eight-year-old girl with a displaced subtrochanteric left femoral fracture. Reduction under general anesthesia and definitive fixation was indicated because of the
displacement. As a satisfactory position could not be achieved with closed reduc-
tion, we converted to open reduction and stabilized the fracture with an angled
plate. The fracture had completely healed after four weeks, and the metal implants
were removed after eight months
Injuries to the Proximal Femur and Femoral Shaft
299
300
Specific Injuries—Lower Extremities
Fig. 22.23 Treatment of
femoral shaft fractures. Up
to the age of three to four,
patients may be treated with
overhead traction in a plaster
cast, initially with up to one
fifth of body weight (from:
136)
Fig. 22.24 Treatment of femoral shaft fractures in
patients up to age three to four. The patient is a fouryear-old boy with an oblique fracture of the left femur.
The cast was applied with the patient under pain medication. The patient lies on a table without foot supports
but with a frame that leaves the buttocks and both legs
free and only provides a bar to support the perineal region. One person holds both legs slightly abducted and
applies uniform traction, while the other applies padding and plaster. The cast extends just past the malleoli
on the fractured leg, and to the knee on the contralateral leg. A wooden bar is molded into the cast to
improve stability and handling. The treatment may be
performed on an outpatient basis
when the child’s size permits. We place the child
on the table, adjust the C-arm, and reduce the
fracture with the aid of the table before sterilizing
the fracture site. Once the fracture has been reduced in proper alignment, then the fixator is applied under sterile conditions. The first screws are
inserted blindly, the first two finger breadths
proximal to the fracture and the second two finger
breadths distal to it. We use the self-threading
Apex screws manufactured by Stryker Howmedica. It is important to make a generous skin inci-
sion and to divide the subcutaneous fascia even
more generously. The screws should be inserted
in a posterolateral location along the intermuscular septum to minimize trauma to the musculature and facilitate subsequent mobilization. Then
the apparatus is applied and the two other screws
are inserted through the jaws, which are already
in place. Proper seating, proper screw length, and
the correct position of the fracture are verified by
fluoroscopy. Then all the nuts are tightened. After
that, the patient is removed from the traction
Injuries to the Proximal Femur and Femoral Shaft
301
Fig. 22.25 Treatment of femoral shaft fractures in
an adolescent with closed growth plates. The patient
is a 15-year-old boy with a distal femoral shaft fracture
and closed growth plates. The fracture was treated with
an interlocked nail. The patient was mobilized immedi-
ately postoperatively, and began full weight bearing
after eight days. After four weeks, he resumed his work
as an apprentice mechanic. The metal implants were removed two years postoperatively at another hospital
table. The knee and hip are moved through their
full range of motion to ensure mobility in the
knee, and symmetrical hip rotation is verified. If
there is a significant malrotation exceeding 20⬚,
the apparatus must be released and adjusted to
ensure symmetrical hip rotation. The dynamic adjustment is made as quickly as possible, within
the first five to eight days.
The duration of fluoroscopy in closed reduction has occasionally been cited as an argument
against the use of the fixator as well. Our average
duration of fluoroscopy when applying the fixator
in recent years was 2.1 minutes (minimum of
0.4 minutes and maximum of 4.7 minutes), which
we feel is tolerable (147, 148). It is certainly more
tolerable than the uncontrolled radiographic
studies used in traction treatment to verify position, which one could almost measure in kilograms. Curiously enough, no mention is made of
this exposure in the literature, nor of the duration
of fluoroscopy in intramedullary nailing.
We also use the traction table for “dynamic”
intramedullary nailing. The two nails should each
be as thick as one third of the intramedullary
canal at its narrowest point. In midshaft fractures,
the nails are impacted using a retrograde technique from medial and lateral through a small
longitudinal incision. The same technique is used
302
Specific Injuries—Lower Extremities
a
b
Fig. 22.26 Treatment of unstable fractures of the femur with the external fixator. The patient is an 11-year-old girl
with a displaced oblique fracture with a
free spiral wedge at the junction of the
proximal and middle thirds. The fracture
was treated with an AO tube-to-tube configuration (b), which was dynamically adjusted three weeks after the accident by
inserting a rolling rod element. Today, we
would use a Monotube (possibly assembled in combination with a Hofmann
fixator if required) and make a dynamic
adjustment after eight days. Especially in
patients of this age with oblique fractures,
it is important to maintain the correct
length (which is readily achieved with an
external fixator) as growth stimulation can
produce a shortening deformity. After five
weeks, a strong periosteal bridging callus
had developed (a), and after seven weeks,
the external fixator was removed in an
outpatient procedure without general anesthesia or pain medication. The patient
was able to bear full weight at once, but
did it after three weeks with the external
fixator in situ. Oblique fractures are
“benign” fractures; they heal reliably and
quickly with every system
Injuries to the Proximal Femur and Femoral Shaft
303
a
Fig. 22.27 Treatment of femoral shaft fractures in an adolescent
with closed growth plates. The patient is a 16-year-old girl with a displaced transverse fracture of the left femur. For cosmetic reasons, the
patient insisted on a stabilization method that would produce minimal
scarring. We then jointly arrived at the decision to use an external fixator. A red Monotube was used and a dynamic adjustment was made immediately intraoperatively. The fixator was removed after 14 weeks, at
which time the fracture exhibited stable healing (a). The patient had
engaged in full weight bearing after three weeks with the fixator in situ.
She was perfectly satisfied with the cosmetic results after the pin
wounds had healed (b)
b
304
Specific Injuries—Lower Extremities
with subtrochanteric fractures. With supracondylar fractures, the nails are impacted using an antegrade technique from lateral via two small bone
windows. One should avoid making the subtrochanteric bone window too large or repeatedly
perforating the cortex. Otherwise, this might
weaken the lateral shaft of the femur in the subtrochanteric region and provoke spontaneous
fractures at these perforation sites. The principle
of dynamic nailing is to achieve three-point support for both nails: the point of impaction, the opposite cortex at the level of the fracture, and the
cortex on the same side at the other end of the
bone or the cancellous bone of the femoral neck,
which in children is very strong (Fig. 22.28). Once
this has been successfully achieved with both
nails, the child is removed from the traction table
as when applying an external fixator. The knee
and hip are then moved through their entire
ranges of motion to ensure mobility in the knee,
and hip rotation is evaluated. Where there is
malrotation, then at least one nail must be removed, rotation corrected, and the nail implanted
again.
Postoperatively, we place every patient in 90⬚
of knee and hip flexion on a graduated frame for
four to five days. This is because our experience
has shown that patients then find it easier to mobilize the knee and to walk with forearm crutches.
From this position, the patient is then mobilized
on shoulder crutches or forearm crutches, depending on his or her age, starting on postoperative day one.
In the case of the external fixator, the care of
the pin exit wounds naturally warrants special attention. Particularly in the thigh, increased secretion may be encountered around the proximal
screws. This secretion should be regarded as pin
irritation and does not represent a pin infection.
The goal of care is to prevent any formation of a
crust. That would result in retention of the secretion, which is invariably contaminated. As long as
secretion flows, the wound should be cleaned and
the crust removed two to three times daily with
moist cotton swabs saturated with hydrogen peroxide. Then bandages moistened with a 1-ppm
chloramine solution or a physiological saline solution are applied. Not only may patients with the
external fixator take showers with the external
fixator in place, they may also take baths to prevent crust formation. A towel should be used to
protect the bathtub from being scratched. When
the children have learned how to perform this
care themselves and can maneuver well with
Fig. 22.28 Treatment of transverse femoral fractures with dynamic intramedullary nailing. To provide fixation that allows motion and allow weight bearing where possible, both nails must be supported at
three points: 1) the point of entry, 2) the opposite cortex
at the level of the fracture, and 3) the cortex or proximal
cancellous bone of the femoral neck on the same side as
the point of entry. The patient is a nine-year-old girl with
a short oblique midshaft femoral fracture. The injury
was treated by internal fixation with dynamic intramedullary nailing. The fracture healed in stable union
within six weeks. The patient increasingly resumed
weight bearing after three weeks. The metal implants
were removed after three months
forearm crutches, they may be released from the
hospital. This will be after an average period of
eight days.
In all patients, those with an external fixator
and those with nails (transverse fractures), the
fracture may bear full weight from postoperative
day one on. Patients will rarely do this at first because of the pain and uncertainty. On average they
only subject the injury to full weight bearing after
two weeks. There are significant differences from
patient to patient, and these differences usually
depend on the response of the patient’s immediate environment. Some patients will play soccer
after three weeks with an external fixator in situ,
whereas others stay home in bed until the metal
Injuries to the Proximal Femur and Femoral Shaft
implants are removed after six to seven weeks. It
would be easier if one could discuss the issues involved with the external fixator with the patient
and his or her parents prior to the fracture as in
the case of lengthening osteotomies, but unfortunately this is not possible. One thing we do
know now is that the patient alone decides when
the fracture is ready to bear weight.
Depending on the patient’s age, we obtain
radiographic follow-up studies every three to four
weeks to demonstrate callus formation. As soon
as there is clinical and radiographic evidence that
the fracture has sufficiently consolidated, the external fixator is removed or an appointment is
made to remove the nails. This should be possible
without anesthesia or sedation. Children who are
very fearful are requested to report for the procedure with an empty stomach. We begin in
“stand-by mode” and anesthetize them if we find
they cannot tolerate the procedure. This was necessary in about one third of our patients. One
should not regard it as a matter of personal pride
to attempt to remove the metal implants from
every patient without anesthesia.
Immobilization and Consolidation
Three to six weeks after the accident, or six to
eight weeks in the case of transverse fractures, the
x-ray out of plaster will demonstrate consolidation of the fracture. Where the fracture is no
longer tender to palpation, we remove the external fixator. This is usually done with the patient
under pain medication and only rarely under
general anesthesia. In intramedullary nailing, the
implants are removed under general anesthesia.
The incisions are usually longer than those required during implantation. Further mobilization
takes places spontaneously, initially with the
patient still using forearm crutches. Even where
knee mobility is restricted, as frequently occurs
following treatment with an external fixator, we
do not allow any physical therapy during the first
three weeks after removal of the fixator. Usually,
the knee will have regained nearly its full range of
motion by the next follow-up examination. If this
is not the case, then increasing active mobilization with the aid of physical therapy is indicated.
Sports Participation
and Follow-up Examinations
Three weeks after the patient has begun weight
bearing (in patients up to age 10, this will be when
305
the patient spontaneously decides to do so; after
age 10, within three weeks after beginning mobilization), the patient can usually walk freely and
can gradually resume sports. Where the patient is
able to resume sports without any problems, we
examine leg length, hip, knee, and spine function,
axial alignment in the legs, and gait in functional
clinical tests once a year until two years after the
trauma.
Two years after the accident, if leg length is
normal and there is no malrotation exceeding 10⬚
in a patient who was below age 10 at the time of
the fracture, we conclude treatment in the absence of late sequelae. Where we observe a difference in leg length requiring treatment or a malrotation exceeding 10⬚, we continue follow-up examinations at two-year intervals until growth has
ceased. In patients who were older than 10 at the
time of the fracture, we always clinically monitor
leg length and any malrotation at intervals of one
to two years until growth has ceased. Rotational
deformities occur practically only in traction
treatment with an adhesive bandage or in a hip
spica. However, in this age group the chances of
spontaneous correction are good. In the clinical
follow-up examinations, differences in internal
rotation of the hips indicate the presence of a
difference in anteversion, which in turn is indicative of residual malrotation. This conservative
treatment nearly always involves external rotation deformities of the distal fragment, which essentially approximate the final effect of physiological retroversion.
Most Common Posttraumatic
Deformities of the Proximal
and Middle Femur
As in all other regions of the growing skeleton,
growth disturbances (4, 31, 32, 44, 74, 122, 137)
are also responsible for posttraumatic deformities
in the proximal femur (which is adjacent to the
joint), whereas uncorrected axial deviations that
resist “spontaneous correction” (49, 121, 128, 140)
are the cause of shaft deformities. It is best to remain calm when a posttraumatic deformity
arises, despite these different causes. It is important to first wait and to monitor and document
the deformity before planning a definitive therapy (27, 42, 43, 87).
The duration of this watch and wait approach
will naturally depend on any symptoms the
patient may exhibit. Watching and waiting is easy
in a patient with no functional impairments.
306
Specific Injuries—Lower Extremities
Fig. 22.29 Posttraumatic deformities in the femoral
shaft. The patient is a nine-year-old girl with a transverse midshaft femoral fracture. Primary treatment included stabilization with an external fixator placed with
slightly increased anterior bowing. According to initial
information, the fixator was to have been removed after
six to eight weeks at the latest and that no problems
were to be expected. After two months, the fracture had
still failed to consolidate, the position of the fragments
reflected the increased anterior bowing mentioned
above, and the distal screws had loosened significantly.
Clinical examination revealed that proper care of the pin
wounds had been neglected, and significant crusting
was observed. No fever or soft-tissue swelling was present. Three months later, the anterior bowing had increased, healing remained sluggish, and the proximal
pins had also begun to loosen (a).
a
b
The patient and her parents became impatient. Citing
the initial information, they demanded the removal of
the fixator. The metal implants were then removed as requested. One month later, the patient presented with
clinical and radiographic evidence of grossly increased
anterior bowing (b), shortening, and a corresponding
gait impairment. The deformity was then corrected, and
the injury was stabilized with two intramedullary nails
(c). The fracture then promptly healed in the correct
position
Injuries to the Proximal Femur and Femoral Shaft
Where the patient has functional complaints or
the parents have cosmetic complaints, their tolerance of these complaints and the further development of the patient’s condition should determine
how long to continue with this observation phase.
Where the situation worsens during the
course of further observation, for example, as the
result of a growth disturbance involving premature closure of the growth plate, then the further
procedure will have to be planned in relatively
short order. Where findings remain unchanged or
even improve, for example, after leaving an axial
deviation uncorrected, then the corrective forces
of further growth should be given every opportunity to correct the deformity, and possible surgical intervention should only be planned for after
the cessation of growth. The added advantage of
this approach is that definitive corrections can be
made at that time.
During the observation phase, the development of all findings should be documented. In
doing so, it is crucial to bear in mind the quality
criteria of efficiency. It is not necessary to radiograph the patient from head to toe every six
months and to document every presumed or visible deformity with computerized axial tomography (CAT) scans, MRI, and the like (66) as part of
the follow-up. Remember that a meticulous preoperative measurement can neither be put to use
nor verified intraoperatively. Add to this the fact
that diagnostic radiography now represents a recognized source of exposure to harmful ionizing
radiation. This means that these studies require
the same degree of justification to the patient as
do surgical or medical treatments. Photography is
perfectly suitable for follow-up documentation of
both functional and cosmetic deformities, and ultrasound studies (67, 71) may be used as a supplementary modality when in doubt (see General
Science, Treatment, and Clinical Considerations).
Where surgeon and patient jointly decide to
attempt surgical correction of an existing deformity, the deformity must be carefully analyzed and
the correction planned equally carefully (26, 96).
This is no place for experimental surgery based on
assumptions and on faith in theoretical doctrines.
Proximal
Complete avascular necrosis is the most feared
complication in the proximal femur. It cannot be
reliably prevented by therapy, as is the case with
all growth disturbances. Whether it represents a
genuine growth disturbance in the strict sense is
307
an academic question. In any case, it may be attributed to defective vascular supply.
Once avascular necrosis of the femoral head or
a growth disturbance has occurred, further therapy will necessarily depend on the severity, location, and direction of the deformity. The best option may be to attempt to improve acetabular
coverage of the femoral head (see Fig. 22.10 c) by
means of subcapital, intertrochanteric, or pelvic
osteotomies. These may include simple intertrochanteric osteotomies, an Imhäuser corrective
osteotomy in three planes (14, 57, 96, 84), a triple
osteotomy, or other such techniques. Arthrodesis
(114) should be employed sparingly in growing
patients in light of the remodeling and adaptive
forces of the immature skeleton. Growth disturbances can result in coxa valga as was observed
earlier after treating femoral fractures in children
with wide open growth plates by intramedullary
Küntscher nailing through the growth plate of the
femoral neck. In contrast, coxa vara may be regarded more as an iatrogenic deformity and less
as the sequela of a growth disturbance. It occurs
as either a primary or secondary axial deviation in
unstable internal fixation, secondary to partial or
total pseudarthrosis, or as a deformity left uncorrected right from the start.
Shortening of the femoral neck is a rare
sequela of a growth disturbance involving premature closure of the proximal growth plate.
Whether a lengthening osteotomy of the femoral
neck (14, 48, 84) is indicated will depend on the
severity of shortening (measured by the level of
the apex of the greater trochanter relative to the
midpoint of the femoral head) and the varying
severity of Trendelenburg gait associated with it.
Partial or total pseudarthrosis is a sequela of
unstable internal fixation or conservative treatment of displaced fractures. These injuries should
be promptly debrided, the position of the fragments corrected, and the reduction maintained
by fixation with an angled plate to allow motion
(see Fig. 22.11 a–c).
Functional aftercare should follow correction
of any deformity. Follow-up examinations, resumption of sports participation, etc. will depend
on the specific, usually complex situation of the
deformity and the necessary correction.
Shaft
One will rarely encounter untreated varus deformities requiring correction in the femoral
shaft. The growth prognosis for varus axial devia-
308
Specific Injuries—Lower Extremities
tion is exceptionally good. In contrast, “spontaneous” correction of valgus axial deviations is
far poorer. However, such axial deviations are
hardly encountered at all in the femur—even in
conservative treatment. Such deformities would
influence the axis of the knee and could indeed
represent a functional impairment if they were to
exceed 20⬚. In patients below age 10, we recommend waiting and giving the corrective forces of
further growth every opportunity to correct the
deformity. Beyond age 10, correction may well be
required to eliminate a functional impairment—
not merely for cosmetic reasons.
Similar considerations apply to initial anterior
bowing deformities exceeding 20⬚. These are primarily cosmetic deformities, although they can
also lead to functional impairments due to significant shortening of the leg. The growth prognosis
is invariably good when the deformity is reduced
to 20⬚. This means that these deformities can
readily be left up to the corrective forces of further
growth in small children up to age five to six. Beyond that age and especially above age 10, a watch
and wait approach is usually not tolerable, given
that the duration of the “spontaneous” correction
is significantly longer. These patients will require
a corrective osteotomy within a short time
(Fig. 22.29 a–c).
Malrotation deformities requiring correction
have always been rare. First, the hip provides good
functional compensation for malrotation, and
these deformities are not clinically significant
during the growth phase. Second, well over 70 %
of all cases with residual malrotation involve an
external rotation deformity of the distal fragment,
which is “spontaneously” corrected or at least reduced to a tolerable degree by physiological retroversion of the unaffected contralateral side. This
leaves the rare malrotation deformities involving
internal rotation of the distal fragment, which can
lead to increased anteversion of the femoral neck.
This increased anteversion can also be
diminished or “corrected” in the second episode
of physiological retroversion. Assuming that the
hip can still compensate well for the deformity,
one is best advised to wait until the cessation of
growth before attempting surgical correction.
However, earlier intervention may prove necessary where chronic compensation causes persistent hip symptoms, for example, with deformities exceeding 25⬚.
Leg-length differences resulting from femoral
shaft fractures rarely exceed a magnitude of 2 cm.
Differences of 3–4 cm are observed only when a
posttraumatic increase in leg length exacerbates
an existing length difference.
It is not the absolute magnitude of the length
difference (36, 38, 71) that determines the size of
the required correction but the specific load distribution in the patient's spine. Leg-length differences of up to 2 cm are usually compensated for
with a heel shim with or without a corresponding
sole shim and with heel pads in the form of inserts. Young ladies rarely tolerate shoes with heel
shims thicker than 0.5 cm for cosmetic reasons.
Here, a workable compromise is to achieve the required 1-cm correction with a 0.5-cm heel shim in
combination with a 0.5-cm heel insert.
The decision as to whether a difference of
2–4 cm should be eliminated with an intertrochanteric shortening osteotomy or epiphysiodesis performed at the proper time in the longer leg
or with callus distraction in the shorter leg is best
left to the patient. Not every patient wants to be
shorter, and not every patient wants to undergo
surgery. However, the length calculations involved in epiphysiodesis are not always reliable,
and one must be prepared to accept a possible
leg-length difference of 1 cm in the other leg.
Lengthening osteotomies are an option especially for differences exceeding 4 cm. The
patient should be well aware of the total duration
of procedure (corticotomy and callus distraction
will require an external fixator in situ for about
two months per 1 cm of length increase). The
patient should also understand the number of interventions required, and the possible risks.
Under no circumstances should conservative
or surgical leg-length correction be made in the
presence of a fixed scoliosis. In secondary scoliosis resulting from leg-length differences, such
fixations are never encountered in children and
only rarely in adolescents. Physical therapy usually succeeds in eliminating the fixation and
creating conditions conducive to leg-length compensation.
The technique of all corrections in the femoral
shaft involves transverse osteotomies in the distal
third. This will be an opening or closing
osteotomy depending on the respective lengths.
We invariably use an external fixator to stabilize
the correction because it allows immediate mobilization and weight bearing as tolerated by the
patient. We perform a Z-shaped intertrochanteric
osteotomy only where a shortening osteotomy is
required to achieve a correction of 2 cm.
Lengthening axial corrections with a callus
distraction can be performed very well with the
Injuries to the Proximal Femur and Femoral Shaft
Monotube if one opens the two rotation jaws
while simultaneously lengthening the frame by
1 mm every 24 hours after postoperative day
eight (see Figs. 25.44 a–c, 25.45, 25.46). The correct position is achieved when there is symmetry
in the length relationship upon clinical evaluation.
Additional information about lengthening
osteotomy will be provided in later sections.
Growth plate obliteration may be transient
using Blount staples or a definitive percutaneous
procedure in which the growth plate is destroyed
with an oscillating drill. Full weight bearing on
forearm crutches is then possible, and the
epiphysiodeses will usually heal within two to
three weeks.
309
Overview
Most common deformities
1. Avascular necrosis in the femoral head and neck
of varying severity
2. Coxa vara or coxa valga
3. Shortening of the femoral neck
4. Pseudarthrosis
5. Valgus and anterior bowing deformities in the
shaft
6. Malrotation
7. Leg-length differences
Causes
Re 1. Fractures of the femoral neck and greater
trochanter.
Re 2. Fractures of the femoral neck with uncorrected axial deviations or growth disturbances.
Re 3. Growth disturbance.
Re 4. Unstable internal fixation.
Re 5. Uncorrected axial deviations.
Re 6. Uncorrected axial deviations.
Re 7. Growth disturbances (usually growth stimulation, rarely growth arrest).
Indications for and time of correction
Re 1. As soon as possible depending on symptoms.
Re 2. As soon as possible depending on symptoms.
Re 3. Depending on severity and symptoms at cessation of growth.
Re 4. As soon as possible.
Re 5. In the presence of functional impairments
and when persisting longer than six months.
Re 6. At cessation of growth only with prior gait
disturbances.
Re 7. Possibly at cessation of growth, depending
on severity.
Correction technique
Re 1. Complex corrections; intertrochanteric or
triple osteotomy where indicated.
Re 2. Intertrochanteric corrective osteotomy.
Re 3. Lengthening of femoral neck (Morscher technique; 14, 48, 84).
Re 4. Fixation with angled plate, with debridement
and bone graft where indicated.
Re 5. Opening or closing osteotomy with external
fixator depending on length relationships.
Re 6. Derotation osteotomy.
Re 7. Distraction osteotomy where differences
exceed 3 cm; conservative treatment or
shortening osteotomy with differences of
2–3 cm.
Aftercare
Functional aftercare is indicated in every case, with
the aid of physical therapy where required.
310
23
Knee Injuries
Diagnostic Notes
Diagnostic radiography of the knee involves fewer
problems compared with the elbow. Up to age
five, the ossification centers in the posterior condylar region of the femur are visible as isolated
structures or as a single irregular ossification center (Fig. 23.1). These are neither signs of infection
nor tumorous processes. Developmental phases
or delayed fusion of the lateral quadrants of the
patella (Figs. 23.2 –23.4) and developmental
phases of the tibial tuberosity (Fig. 23.5) can also
simulate bony injuries (56, 57). The patient’s history and clinical symptoms usually help to distinguish Osgood–Schlatter disease (aseptic necrosis
of the tibial tuberosity) and Sinding–Larsen–Johansson disease from avulsion fractures (aseptic
necrosis of the distal patella).
Fig. 23.1 Ossification center in the posterior
femoral condylar region. Until about age five to seven,
the ossification centers may appear in radiographs as
distinctly separate structures or as an irregular demarcation of the posterior femoral condylar region. Note the
irregularly demarcated center of the barely visible
patella
Wide open growth plates make it significantly
more difficult to diagnose ligament injuries by
clinical examination. This is because the knee in
these patients exhibits lateral and medial opening
and anteroposterior (A-P) translation with both
individual and sex-specific variation. The knee injuries one encounters in patients with wide open
growth plates are almost invariably ligament
avulsions, and radiographs will typically show
avulsed fragments and flakes of varying size. This
means that an initial clinical diagnostic examination should not be attempted. Only patients with
closed growth plates exhibit the taut knee ligaments found in adults. Genuine ligament ruptures
may only be expected to occur in this age group. It
is possible to diagnose these injuries by clinical
examination once the initial pain has subsided
(10, 17, 31, 43, 55, 81). Figure 23.6 shows the major
ligaments of the knee, their origins and insertions, and the possible injuries to them.
In adults, and in adolescents with closed
growth plates, hemarthrosis is invariably a sign of
a serious knee injury. Where a diagnosis cannot
be made on the basis of radiographic and clinical
findings, magnetic resonance imageing (MRI) or
possibly arthroscopy—performed as a therapeutic
procedure—(6, 49, 56, 129, 137, 139, 140, 143,
159,160) will be required to exclude or confirm intraarticular damage to the knee.
In patients with wide open growth plates, superficial capsular tears or marginal retinacular
avulsions can produce significant bleeding. Yet
because these patients will far more often exhibit
radiographic signs of the respective injury, we do
not employ arthroscopy as a primary diagnostic
modality. Instead, we follow this procedure:
The initial A-P and lateral radiographs will exclude a separated epiphysis, avulsion of the intercondylar eminence, or bony avulsion of a collateral ligament. We invariably drain posttraumatic hemarthrosis (at the very least to relieve
pain) and examine it for fat droplets. Large quantities of fat droplets suggest a cancellous injury and
are a sign of an osteochondral flake fracture or a
Knee Injuries
5y
8y
10y
311
Fig. 23.2 Development of
the patella. A central, often
multifocal ossification center
appears in the middle of the
patella only at about age
five. The ossification center
remains extremely irregularly demarcated even in the
further stages of its development. The patella assumes
its final radiographic form at
about age 10, although this
is subject to both individual
and sex-specific variation.
The lateral superior quadrant
only fuses with the actual
patellar ossification center in
the final stages of development. However, this fusion
process may also fail to
occur
Fig. 23.3 Bipartite patella,
a developmental anomaly of
the patella. This was an incidental finding in this nineyear-old boy, in whom the
lateral quadrant had not yet
fused with the actual ossification center of the patella.
Fusion occasionally fails to
occur, in which case radiographs will show a bipartite
patella. The condition is usually bilateral
marginal retinacular avulsion. Absence of fat
droplets in the aspirate suggests a soft-tissue tear.
Once we have completely drained the hemarthrosis, we immobilize the leg in a plaster thigh splint
for three to four days to control pain. Where the
hemarthrosis collects again in the immobilized
knee, we regard this as an indication for further
diagnostic studies.
Where the immobilized knee remains free of
symptoms and pain gradually subsides, we remove the plaster splint after about four days and
clinically evaluate the stability of the knee. Be-
312
Specific Injuries—Lower Extremities
Fig. 23.4 Patellar fracture
and bipartite patella. A unilateral bipartite “patella” detected in a patient who has
suffered trauma is usually a
fracture
0–9y
10y
14–18y
Fig. 23.5 Development of the tibial tuberosity. Up to
age 10, the tibial tuberosity is not detectable as a bony
structure. Ossification centers, often multifocal, only
appear after age 10. These should not be mistaken for
fractures or aseptic necrosis. Whereas the actual growth
plate of the tibia closes during puberty, the apophyseal
growth plate remains open until after puberty. As long
as the actual tibial growth plate remains open, “apophyseal” injuries can result in an increasing posterior
bowing deformity. The risk of such a growth disturbance
and its sequelae can only be excluded with certainty
once the actual tibial growth plate has ossified
cause pain has significantly subsided by this time,
clinical examination will provide more information than when performed on the acute injury.
Where clinical examination fails to demonstrate
instability, we allow the patient to walk on forearm crutches and mobilize his or her knee spontaneously. Where the knee remains free of symptoms following spontaneous mobilization and effusion does not recur, then the patient may begin
spontaneous weight bearing as tolerated. We regard recurrent effusion in the knee within these
initial eight days of spontaneous mobilization
without weight bearing as an indication for
further diagnostic studies.
Where the knee remains asymptomatic
during spontaneous mobilization, mobility is unrestricted, and the ligaments are clinically sufficient, the patient can gradually resume sports activities after another eight days. We regard recur-
rent effusion in the knee during spontaneous
weight bearing or sports activities as an indication for further diagnostic studies. Once the knee
has remained asymptomatic for about three
weeks after the patient resumes sports activities,
we conclude treatment.
The primary task of the diagnostic workup of
nonspecific knee symptoms is to determine
whether the injury is a chondral or osteochondral
flake fracture or rotational trauma with instability. Therefore, we do not feel that protracted immobilization is indicated in the absence of a precise diagnosis.
In this context, a word of caution about the indiscriminate use of elastic bandages is warranted.
A tightly applied elastic bandage can easily produce quadriceps atrophy that can simulate intraarticular damage to the knee, which in turn
would make further diagnostic studies appear
Knee Injuries
313
Fig. 23.6 Ligament insertions and injuries in growing patients with open growth plates. The long fibers
of the collateral ligaments insert into the metaphysis,
whereas the short fibers insert into the epiphysis. Avulsions from the femoral metaphysis in particular may be
associated with injuries to the blood vessels supplying
the growth plate, which can lead to secondary “necrosis
bridges.” Injuries associated with a significant fracture
gap may result in growth disturbances as a result of
banding bridges. Growth disturbances need not be
feared after purely epiphyseal avulsions of the short
fibers, nor will they occur after displaced or nondisplaced avulsions of the intercondylar eminence with the
insertion of the anterior cruciate ligament. However,
they can occur secondary to instability
advisable. For this reason we recommend
functional treatment of rotational trauma
without instability. Where the physician feels that
ointment applications are indicated, they should
be applied at night and wrapped in a gauze bandage; daytime therapy should include intensive
quadriceps training and spontaneous mobilization of the knee.
When we refer to “further diagnostic studies,”
we mean MRI to exclude an associated meniscus
injury and to confirm a cruciate ligament tear or
an avulsed insertion where there is clinical suspicion of a cruciate injury. Depending on findings
and in consultation with the patient and his or her
parents, the next diagnostic and initial curative
modality is arthroscopy. This should be performed under local or general anesthesia, depending on the patient’s age and the intended
procedure.
Knee pain—with and without injuries and
without visible lesions in radiographs—is often
present. Chondromalacia, patellar chondropathy,
cartilage growth disturbance, patella stress syndrome, etc. are among the many terms used to describe knee pain in the adolescent, and the terminology seems to change with fashion: Today
this is commonly referred to as “anterior knee
pain.” There is equal variation in the respective
recommended treatments, which include observation, reduced weight bearing, topical and enteral anti-inflammatory agents, arthroscopic repair with removal of villous folds, and even laser
“sealing” in severe cases. When weighing the
risks and benefits of any treatment, it is important
to remember that even severe symptoms will disappear within a few years regardless of the
specific treatment, and that care must be taken to
avoid causing permanent damage with the treatment.
314
Specific Injuries—Lower Extremities
Distal Femur (0.3%)
Forms
앫 Metaphyseal impacted fractures
앫 Complete metaphyseal fractures
앫 Separated epiphyses (Salter–Harris types I and II)
앫 Epiphyseal fractures (Salter–Harris types III and
IV)
앫 Transitional fractures of late adolescence
Radiographs: A-P and lateral, oblique if necessary.
Limits of correction: No uncorrected axial deviations.
Growth arrest: May occur in 25–35% of all cases secondary to separated epiphyses and epiphyseal fractures (barely visible in the radiograph).
Definition of “displacement”
앫 Fracture gaps exceeding 2 mm in epiphyseal fractures and transitional fractures.
앫 Side-to-side displacement greater than or equal
to one fifth of the width of the metaphysis in
separated epiphyses; any axial deviations.
Definition of “nondisplaced”: No uncorrected axial
deviations.
Technique of conservative fixation: Plaster thigh
splint.
Technique of internal fixation
앫 Separated epiphyses and supracondylar fractures: Closed reduction and percutaneous
pinning with crossed Kirschner wires.
앫 Epiphyseal fractures: Open reduction and
rigid screw fixation that allows motion.
Aftercare
Period of immobilization
앫 With conservative fixation: Five weeks.
앫 With internal fixation: Immediate motion on a
continuous passive motion device.
Consolidation radiographs: Yes.
Initial mobilization
앫 Patient: Immediately on forearm crutches
without weight bearing.
앫 Joint: Spontaneously after removal of plaster
splint.
Physical therapy: None as a matter of course.
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Medical.
앫 Where indication is uncertain or conservative
treatment is indicated: Immobilization in a
plaster thigh splint under pain medication.
Emergency treatment under anesthesia
앫 All displaced supracondylar fractures and
separated epiphyses,
앫 All displaced epiphyseal fractures.
!
All other indications should first be discussed at
length with the patient and his or her parents.
Further treatment without anesthesia or delayed
treatment under anesthesia Secondary displacement of fractures initially treated conservatively.
Sports: Four to six weeks after consolidation.
Removal of metal implants
앫 Percutaneous Kirschner wires: Upon consolidation.
앫 Screws: Three to four months postoperatively.
Follow-up examinations and conclusion: Examinations are performed at three- to four-week intervals
until unrestricted function of the knee is regained
and gait is normal. After that, examinations continue
at six-month intervals until two years after accident.
Treatment is concluded where there is no evidence
of a growth deformity, knee axes are symmetrical,
and there is no difference in leg length. Otherwise,
follow-up examinations are continued every six
months to a year until cessation of growth. Radiographic follow-up studies are indicated where the
knee axes are not symmetrical.
Knee Injuries
Supracondylar Fractures
of the Femur
Forms of Injury
앫 Impacted supracondylar fractures (Fig. 23.7 a)
앫 Complete supracondylar fractures (nondis-
placed and displaced; Fig. 23.7 b)
앫 Separated epiphyses with or without a
metaphyseal wedge (Fig. 23.7 c)
All these extraarticular fractures are relatively
rare (21, 42, 155). The impacted supracondylar
fractures lie at the diaphyseal–metaphyseal junction and exhibit a typical roll of cortical impaction. Often a slight anterior bowing deformity is
also present. Supracondylar bending fractures
practically never occur at this location. The fractures that do occur are nearly always complete
fractures, are usually displaced, and often exhibit
a small metaphyseal halo. Separated epiphyses
315
without a metaphyseal wedge are rare. Usually,
there will be an avulsed small metaphyseal fragment, and this fragment will often lie in a lateral
or medial position and only rarely in an anterior
position.
Diagnosis
These injuries are easily diagnosed. Only nondisplaced separated epiphyses without metaphyseal
involvement may be difficult to diagnosis
(Fig. 23.8). The clinical signs of swelling and pain
are clear signs of such injuries.
Problems and Complications
Impacted fractures generally do not pose any
problems at all. Maintaining reduction can prove
difficult in separated epiphyses and supracondylar fractures that involve a very small metaphyseal fragment.
a
b
c
Fig. 23.7 Metaphyseal fractures of the distal femur.
a Impacted fractures. Metaphyseal impacted fractures
require immobilization in a plaster splint as pain treatment
b Complete fractures. These fractures can be prone to
secondary displacement. Initially displaced fractures
with a small metaphyseal halo often prove difficult to
stabilize
c Separated epiphyses. Separated epiphyses at this location are rarely encountered without a metaphyseal
wedge, but far more often with one. Stabilization of
these injuries can also prove difficult. Growth disturbances are possible
316
Specific Injuries—Lower Extremities
Fig. 23.8 Diagnosis of separated epiphyses. Nondisplaced separated epiphyses
without metaphyseal involvement can also prove
difficult to diagnose in the
distal femur. Swelling and
pain are obvious clinical
signs of injury are indications
for conservative treatment;
radiographic findings include
slight medial widening of the
growth plate in the A-P
image and slight anterior displacement of the epiphysis
in the lateral image. Secondary radiographic findings of a
periosteal bridging callus
confirm the diagnosis of a
fracture
Knee Injuries
Under certain circumstances, severely displaced separated epiphyses or supracondylar
fractures can compromise distal vascular supply.
This is the case when a posteriorly displaced fragment compresses vascular structures in the popliteal fossa.
Growth Disturbances
Posttraumatic stimulation of the growth plates
leading to posttraumatic leg-length alterations
occurs after every one of these fractures.
The chance of a rare partial or complete premature close of the distal femoral growth plate
also increases with the proximity of the fracture to
the growth plate. This is most often observed after
separated epiphyses (15, 62, 75), almost always in
the form of partial posterior closure of the growth
plate. The subsequent abnormal growth creates an
anterior bowing deformity (109; Fig. 23.9). The
posttraumatic valgus or varus deformities described in the literature cannot always be clearly
interpreted as sequelae of a growth disturbance.
Under certain circumstances, these may also be
persistent axial deviations (15, 62). The cause of
317
this growth disturbance is not clear. Certain
authors have postulated a crush injury as the cause
(29, 31, 75). However, this is not a convincing argument because this growth disturbance also occurs
after nearly nondisplaced fractures, which is inconsistent with massive trauma (18, 89). A further
consideration is that separated epiphyses result
from shear forces and not from axial trauma (1),
the postulated cause of the crush injury. This
growth disturbance can occur regardless of
whether a metaphyseal bending wedge is present
and regardless of its location (medial, anterior, or
lateral). The incidence in our own study group was
27% of all cases (108); in the literature it is as high
as 35% (21, 28, 42, 123, 132, 138). This is not surprising, considering the longevity of the distal
femoral growth plate. Given the uncertain causes
of such growth disturbances, we will refrain from
presenting an overly specific and detailed classification of the epiphyseal injuries in this region (15,
80 a, 83, 85). This is also advisable in light of the
fact that such growth disturbances do not necessarily occur in every case, are not predictable, and
cannot be reliably influenced by primary treatment (1, 23, 24, 87, 114)
a
Fig. 23.9 Growth disturbances involving premature
partial closure of the growth plate secondary to separated epiphyses.
a In a six-year-old boy, the separated epiphysis healed
with a small metaphyseal wedge in proper axial align-
ment. Partial closure of the posterior portion of the
growth plate occurred during the further course of
the disorder, resulting in secondary abnormal growth
with an anterior bowing deformity
318
Specific Injuries—Lower Extremities
Fig. 23.9 c and b
c Seven years after the accident and two-and-a-half
years after the last corrective intervention, the
patient again exhibited a severe anterior bowing deformity and a definitive leg shortening deformity
measuring 5 cm. A lengthening osteotomy was performed, which at the time involved the use of a Wagner device and a cancellous graft. The plate fracture
seen here was not an uncommon complication of this
method. The osteotomy healed without problems following internal fixation in a second intervention. The
patient is completely free of subjective symptoms
after removal of the metal implants, and both legs are
the same length (my thanks to Prof. H. R. Henche of
the Orthopedic Clinic of Kreiskrankenhaus Rheinfelden, Switzerland, for making these images available)
b This necessitated a corrective osteotomy on two separate occasions
왘
“Spontaneous Corrections”
Treatment
A posterior bowing deformity caused by anterior
displacement and angulation of the epiphysis can
be spontaneously corrected in young patients
during the course of further growth. A posteriorly
displaced and angulated epiphysis produces an
anterior bowing deformity. As in shaft fractures,
this deformity is spontaneously corrected only to
a certain extent (see Femoral Shaft Fractures). The
static load on the distal femur makes spontaneous
corrections of axial deviations in the coronal
plane possible to a certain extent. As in the shaft,
valgus deformities are less reliably corrected than
varus deformities. These corrections also depend
on the patient’s age: The younger the patient, the
better the correction will be.
The primary goal of treatment in these extraarticular metaphyseal fractures adjacent to the knee is
to symmetrically reconstruct the axes of the knee.
The expenditure of treatment in all of these fractures therefore depends on the severity and direction of displacement and on how easy it is to
maintain reduction of the fracture.
Especially in small children, metaphyseal supracondylar impacted fractures only require immobilization in a plaster splint. Usually, a plaster
thigh splint will suffice. In rare cases, a hip spica
may be required, depending on pain. We also extend the cast to include the contralateral side
down to the knee because this facilitates painfree care, and we mold an abduction bar into the
cast above the knee, which serves as a grip. A
slight anterior bowing deformity is often present
but does not require any correction (Fig. 23.10).
Fig. 23.9 b
Knee Injuries
319
320
Specific Injuries—Lower Extremities
Fig. 23.10 Treatment of metaphyseal impacted
fractures. As these patients are usually very small
children like this one-year-old boy, the slight deformity
in the plane of motion does not require correction. The
fracture is immobilized in a plaster splint. Consolidation
is evaluated by clinical examination
Fig. 23.11 Percutaneous pinning with crossed Kirschner wires in metaphyseal fractures including separated epiphyses. The wires must be introduced into
the epiphysis as far distal as possible and as steeply as
possible in order to securely engage the fragment and
minimize the damage to the growth plate. The point at
which the wires cross must lie proximal to the fracture
gap to prevent the fragments from rotating with respect
to each other
Radiographs in plaster are not required. The
injury is immobilized for a maximum of four
weeks, and healing is evaluated by clinical examination. Once the callus is no longer tender to palpation, the patient is left to his or her own devices.
Even nondisplaced complete supracondylar
fractures do not present any problems. We recommend obtaining a radiograph in plaster on about
the eighth day to exclude possible secondary dislocation.
When displaced, these fractures must be reduced with the patient under general anesthesia.
Like the supracondylar fractures of the humerus,
these fractures are usually easily reduced but the
reduction is difficult to maintain in a cast alone.
As the fracture has to be reduced with the patient
under general anesthesia anyway, it is better to
use this opportunity to achieve definitive stabilization in the form of pinning with crossed Kirschner wires (Fig. 23.11). This naturally requires
that a perfect position in every plane be achieved.
The presence of the metaphyseal halo, usually
small, means that the epiphysis must be engaged
to stabilize the fracture. It is then easy to misjudge
Knee Injuries
the location where wires should be inserted. This
is far distal, almost in the lateral joint space.
Despite all the recommendations in the literature
(15, 47, 115), one should avoid choosing Kirschner
wires that are too thick; growth disturbances involving partial closure of the growth plate can
indeed be induced by inserting Kirschner wires
(Fig. 23.12). Boelitz and Dallek have demonstrated
in an experimental setting that a bony bridge will
invariably form between the metaphysis and
epiphysis after pinning with Kirschner wires that
cross the growth plate. However, this bridge does
not persist, but is spontaneously disrupted during
the course of further growth (9). Because of this,
the wires must be inserted so that they cross the
growth plate as nearly perpendicular as possible.
This means that they must be inserted as far distally as possible. The point where the wires cross
must lie proximal to the fracture gap to prevent
the fragments from rotating around the wires.
Then a posterior plaster thigh splint with lateral
reinforcements should be applied to stabilize the
wire fixation. The two wires are then clipped off
2–3 cm above the level of the skin in the usual
manner. The plaster splint should include an
opening around the wires. Correct position is
verified in radiographs during the same operation.
Open reduction is indicated where interposed
soft tissue prevents closed reduction. In this case,
the fracture is stabilized in the same manner by
percutaneous pinning with crossed Kirschner
wires.
Separated epiphyses with and without a
metaphyseal wedge are treated identically to
complete metaphyseal fractures. Where closed
reduction of displaced fractures is immediately
successful, an exception may be made and these
fractures may simply be immobilized in a plaster
thigh splint (Fig. 23.13). Normally, radiographs to
verify correct position would be indicated after
eight days and any secondary displacement detected would then require late reduction. Now
that could hardly be termed an elegant solution,
and it is certainly not one that patients would enthusiastically welcome. Whenever general anesthesia is required for reduction anyway, then it
is far better to use this same session to achieve immediate definitive stabilization with crossed Kirschner wires (Fig. 23.14).
Open reduction will be required in those cases
where interposed soft tissue prevents closed reduction. Depending on the size of the metaphyseal wedge, the fracture is stabilized by simple
321
metaphyseal screw fixation or, better yet, percutaneous pinning with crossed Kirschner wires to
spare the patient a second operation to remove
the metal implants.
All patients other than those requiring open
reduction are treated on an outpatient basis. It is
crucial to check the splint the next day, especially
in fractures treated by closed reduction with or
without percutaneous pinning.
No further radiographs in plaster are required
after internal fixation (whether reduction was
closed or open). For patients with any other fractures, a radiograph in plaster is required on about
the eighth day depending on the patient’s age and
again on day 14 where indicated. Possible axial
deviations at this location do not respond well to
treatment with a cast wedge and would require
late reduction. For this reason, it is far better to
achieve a definitive correction during the initial
session by means such as percutaneous pinning
with crossed Kirschner wires.
Immobilization and Consolidation
The plaster splint is removed after a total of four to
five weeks in every case, and consolidation radiographs are obtained at this time. Where clinical
examination confirms a good solid periosteal
bridging callus around the fracture, the patient
may begin spontaneous mobilization on forearm
crutches. This is continued until the patient regains unrestricted mobility in the knee, usually
after about 10–14 days. At that time the patient
can begin spontaneous weight bearing. The
patient may resume sports participation once gait
has returned to normal after removal of the splint
(which may usually be expected after about four
to five weeks), the patient is able to walk well on
his or her heels and toes, mobility in the knee is
unrestricted, and both quadriceps muscles have
nearly the same strength.
Follow-up Examinations
As a general rule, no further radiographs are required once the fracture has healed. However, leglength alteration may be expected to occur in any
case. Therefore, the patient should undergo clinical examination at intervals of six months to a
year until two years after the accident or until cessation of growth. Any increasing axial changes in
the knee will require new radiographs. Where the
abnormal growth is attributable to a banding
bridge between the metaphysis and epiphysis,
322
Specific Injuries—Lower Extremities
a
Fig. 23.12 a Growth disturbance secondary to pinning with crossed Kirschner wires. The patient is a
seven-year-old girl with a separated distal femoral
epiphysis with a metaphyseal wedge. The percutaneous
pinning with crossed Kirschner wires was performed in a
proximal to distal direction. The medial wire failed to fix
the fracture but lay only within the peripheral fragment.
The fracture healed in proper position. During the
further course of healing, increasing abnormal valgus
growth occurred due to two small banding bridges between the metaphysis and epiphysis in the lateral portion of the distal growth plate (see CT image). The shape
of the bridges suggests that they are banding bridges
occurring secondary to Kirschner wire fixation
Knee Injuries
323
Fig. 23.12 b The patient did not show up for follow-up
examinations for seven years. The follow-up radiograph
obtained after seven years demonstrates slow spontaneous correction of what was once the valgus deformity (clinical examination revealed nearly symmetrical leg
axes). These findings suggest that the metaphyseal–
epiphyseal banding bridge must have been spontaneously disrupted
b
patients up to age 10 should undergo MRI to allow
evaluation of the severity and shape of the bridge.
Depending on findings, the bridge either may require resection or one will have to accept repeated corrective osteotomies (Fig. 23.9 a,b).
Treatment may be concluded two years after
the accident where normal, symmetrical weight
bearing and function are present in both knees.
Fractures of the
Distal Femoral Epiphysis
combined injury consisting of a partially or
completely separated epiphysis and avulsion of
part of a fragment from the femoral condyle (see
also Chapter 25, Ankle Injuries, p. 412 ff). The
avulsed fragment may involve the anterior, posterior, lateral, or medial quadrant of the femoral
condyles. We refer to transitional fractures
without metaphyseal involvement as “two-plane
fractures” and those with metaphyseal involvement as “triplane fractures”. Triplane fractures
are the ones most often encountered in the distal
femur.
Forms
앫 Typical epiphyseal fractures (Salter–Harris
types III and IV, Fig. 23.15 a).
앫 Transitional fractures of late adolescence
(Fig. 23.15 b).
Both forms are rare. Typical epiphyseal fractures
(127, 142, 162) such as primary described by
Aitken and Magill (1) are encountered far less
often than the transitional fractures of late adolescence (15, 28, 29, 104). These fractures occur
exclusively in late adolescence and represent a
Diagnosis
Such fractures can pose diagnostic problems. In
every injury that appears to be a simple separated
epiphysis, the lateral film should be carefully examined for a possible fracture gap to exclude one
of these forms of transitional fractures (109). Note
this applies only to patients above age 10.
324
a
Specific Injuries—Lower Extremities
Knee Injuries
325
b
왗 Fig. 23.13 Treatment of nondisplaced and slightly
displaced separated distal femoral epiphyses.
a The patient is a 10-year-old boy with a moderately displaced separated left epiphysis with a medial
metaphyseal wedge. A tolerable position was
achieved by closed reduction, and the fracture was
immobilized in a plaster thigh splint. It healed with a
slight anterior bowing deformity
Growth Disturbances
Growth disturbances involving transient stimulation of the distal femoral growth plate with subsequent alteration of leg length are to be expected
in every case.
Growth disturbances involving premature
partial closure of the growth plate can occur secondary to typical epiphyseal fractures in patients
with wide open growth plates. They generally no
longer occur secondary to transitional fractures as
physiological closure of at least part of the growth
plate has already occurred in these patients (see
Ankle Injuries). In younger patients with typical
epiphyseal fractures, growth disturbances involving premature partial closure of the growth plate
b At the six-year clinical follow-up examination, the
axes of the legs were symmetrical and there was no
difference in leg length. A slight anterior bowing deformity of the femoral condyles is visible in the lateral
image. This can be interpreted as a correlate of the
healing deformity but it could also represent a
sequela of an additional posterior growth disturbance
involving premature partial closure of the growth
plate
may occur as a result of a banding bridge or necrosis bridge. Abnormal growth with an anterior
bowing, varus, or valgus deformity may occur, depending on the location of the banding bridge
(Fig. 23.16 a–e).
Treatment
The goal of treatment is to reconstruct the joint and
in so doing achieve more favorable conditions for
preventing or managing a possible banding bridge.
Accordingly, all nondisplaced typical epiphyseal fractures and transitional fractures are
treated conservatively by immobilization in a
plaster thigh splint after hemarthrosis has been
drained.
326
Specific Injuries—Lower Extremities
a
Fig. 23.14 a Treatment of a displaced
separated distal femoral epiphysis. The
patient is a 12-year-old boy with a displaced separated femoral epiphysis with
a small metaphyseal wedge. Closed reduction on the day of the accident was
immediately successful. Percutaneous
pinning with crossed Kirschner wires was
performed in consideration of the
patient’s age. Five weeks later, the fracture exhibited good clinical and radiographic healing in proper alignment
Knee Injuries
327
Fig. 23.14 b The projecting wires were removed,
and no further radiographs were obtained. Seven
months after the accident, another radiographic examination was performed due to drastically increasing shortening of the leg that had suffered the fracture. The central portion of the growth plate was
found to have closed prematurely. The premature
closure of the distal femoral growth plate produced a
shortening deformity in the leg that progressed to a
total of 3.5 cm until growth ceased. The patient has
since decided to undergo the suggested surgical correction of the leg-length difference
b
328
Specific Injuries—Lower Extremities
Fig. 23.15 Epiphyseal fractures in the distal femur.
a “Typical” epiphyseal fractures (Salter-Harris types III
and IV). With and without metaphyseal involvement,
these fractures can occasionally lead to growth disturbances involving premature partial closure of the
growth plate
b Transitional fractures of late adolescence. Transitional
fractures in the distal femur are more common than
“typical” epiphyseal fractures. Growth disturbances
with clinically significant sequelae are no longer to be
expected because part of the growth plate has already physiologically closed
a
b
Displaced epiphyseal fractures of both forms
require precise anatomical reduction and stabilization with internal fixation that achieves interfragmentary compression (Fig. 23.17).
Up until now we have not used absorbable
materials in children, but we interpret it as a good
possibility for adolescents (149).
Immobilization in a plaster splint may be
advisable depending on the patient’s age and disposition.
The risk of secondary displacement in the
plaster splint is negligible. Therefore, there is no
need to obtain additional radiographs in plaster
with nondisplaced fractures.
Conservatively and surgically treated patients
are immobilized for five weeks. The consolidation
radiograph obtained once the splint is removed
should document the beginning of bony union.
Sports Participation and Follow-up
Examinations
Spontaneous mobilization is then continued
without physical therapy for another three weeks
with increasing spontaneous weight bearing. If
after three weeks mobility in the knee is unrestricted, there is no effusion, capsular swelling
has significantly subsided, and both quadriceps
muscles exhibit symmetrical strength, the patient
may participate in sports activities. Where mobilization is significantly delayed, physical therapy
should be begun three weeks after removal of the
cast. Once the patient regains unrestricted mobil-
Knee Injuries
329
a
Fig. 23.16 a Growth disturbances secondary to
“typical” epiphyseal fractures in the presence of
wide open growth plates.
a The patient is a three-year-old girl with an epiphyseal
fracture of the distal femoral epiphysis, which was stabilized by internal fixation with a small fragment lag
screw. Four weeks later, the fracture exhibited good
clinical and radiographic healing. During the next five
months, an increasing anterior bowing deformity occurred. This was attributable to an L-shaped “banding
bridge” in the posterior medial portion of the growth
plate (see CT image). The bridge was resected and the
defect filled with fatty tissue
ity in the knee, he or she can gradually resume
sports. Metal implants are removed after four to
six months. Another radiographic examination is
performed at that time.
Further radiographic examinations are no
longer required once the patient has resumed
sports without any problems. Clinical follow-up
includes measurement of leg-length differences
and leg axes at six-month intervals up to two
years after the accident. This is done to detect
possible growth disturbances and their sequelae.
Treatment may be concluded once both sides exhibit unrestricted function and symmetrical anatomy.
The following still applies: The older the
patient at the time of the fracture, the lesser the
risk of a growth disturbance with clinically significant sequelae.
330
Specific Injuries—Lower Extremities
Fig. 23.16 b At the four-year follow-up examination, 왘
the axes of the legs were symmetrical, and the patient
exhibited unrestricted and symmetrical mobility. A
shortening deformity of slightly less than 2 cm was present in the affected leg. The radiograph shows open
growth plates
b
c
Knee Injuries
331
d
e
Fig. 23.16 c–e With the onset of puberty eight years
after the accident and approximately seven years after
the resection (c), increasing abnormal growth recurred
with an anterior bowing and varus deformity and progressed until cessation of growth (d). The radiograph
shows recurrence of posteromedial closure of the
growth plate. A corticotomy with axial correction, obliteration of the remaining growth plate, and callus distraction was performed one year later to eliminate the
deformity
Fig. 23.17 Treatment of transitional fractures of the distal femur. The patient
is a 12-year-old boy with a typical transitional fracture of the distal femur. The
metaphyseal fracture extends into the joint. The anterior medial quadrant is also
avulsed, and the tibiofibular syndesmosis is torn. The articular surface was recon-
structed, and the suture of the syndesmosis was secured with a positioning screw.
The follow-up examination four years later revealed clinically and radiographically
symmetrical anatomy with unrestricted function and symmetrical leg length
332
Specific Injuries—Lower Extremities
Knee Injuries
333
Proximal Tibia (Epiphysis and Metaphysis, together
0.2%) Epiphyseal Fractures That Do Not Cross the
Growth Plate: Fractures of the Intercondylar Eminence
of the Tibia
Forms
앫 Nondisplaced or slightly displaced (“hanging”)
앫 Completely displaced
Diagnostics:
앫 Radiographs A-P and lateral
앫 Arthroscopy in completely displaced fractures.
Limits of correction: No displacement should be left
uncorrected.
Growth arrest: Invariably iatrogenic; may occur secondary to:
앫 Internal fixation that crosses the growth plate,
앫 Surgery through an anterior approach with
osteotomy of the tibial tuberosity.
Definition of “nondisplaced”: No displacement
should be left uncorrected.
Primary pain treatment
앫 Drainage of the hemarthrosis under anesthesia.
앫 Where emergency treatment under anesthesia is clearly indicated: Medical.
앫 Where indication is uncertain: Immobilization in a plaster cast under pain medication.
Emergency treatment under anesthesia: Not indicated except for postprimary treatment of
completely displaced fractures.
!
All other indications should first be discussed at
length with the patient and his or her parents.
Further treatment without anesthesia or delayed
treatment under anesthesia
앫 Partially displaced fractures in which optimum position cannot be initially achieved.
앫 Completely displaced fractures.
Technique of conservative fixation: Plaster thigh
splint with the knee hyperextended (verify
proper position in lateral radiograph when applying splint).
Technique of internal fixation
앫 Arthroscopic reduction, and
앫 Percutaneous pinning with crossed Kirschner
wires.
앫 Screw crossing the growth plate from distal
(caution: growth disturbance may result).
앫 Open reduction and transepiphyseal absorbable suture.
Aftercare
Period of immobilization: Four to five weeks in a
plaster cast with conservative and internal fixation.
Consolidation radiographs: Yes.
Initial mobilization
앫 Patient: Immediately on forearm crutches with
full weight bearing.
앫 Joint: Spontaneously immediately after removal
of plaster cast; mobilization immediately postoperative in the case of stable internal fixation.
Physical therapy: Delayed therapy may be advisable
after removal of the plaster cast; spontaneous motion initially.
Sports: Four to six weeks after consolidation.
Removal of metal implants
앫 Percutaneous Kirschner wires: Upon consolidation.
앫 Screws: Six weeks postoperatively.
Follow-up examinations and conclusion: Examinations are performed at three to four week intervals
until unrestricted function is regained. After that, examinations continue at six-month intervals. Treatment is concluded where there is no evidence of a
growth deformity or instability. Otherwise, clinical
follow-up examinations are continued annually until
cessation of growth.
334
Specific Injuries—Lower Extremities
Proximal Tibia (Epiphysis and Metaphysis, together
0.2%) Epiphyseal Fractures That Cross the Growth Plate
Forms
1. Epiphyseal fractures (Salter–Harris types III and
IV)
2. Transitional fractures
3. Avulsions of the tibial tuberosity (extraarticular
and intraarticular)
Radiographs: A-P and lateral; oblique if necessary.
Growth arrest:
Re 1. Possible in 30% of all cases.
Re 2. No risk.
Re 3. No risk, posterior part of the growth plate is
already closed.
Definition of displacement
앫 Fracture gap in the epiphysis exceeding 2 mm.
앫 Tibial tuberosity avulsed more than 5 mm.
Definition of “nondisplaced”
앫 Fracture gap less than 2 mm for epiphyseal and
transitional fractures (barely visible in the radiograph).
앫 Fracture gap less than 5 mm for extraarticular
avulsions of the tibial tuberosity.
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Medical.
앫 Where indication is uncertain: Immobilization in a plaster thigh splint.
Emergency treatment under anesthesia: All
completely displaced fractures.
Technique of conservative fixation: Plaster thigh
splint.
Technique of internal fixation: Open reduction and
rigid screw fixation that allows function.
Aftercare
Period of immobilization
앫 With conservative fixation: Five weeks.
앫 With internal fixation: Immediate spontaneous
motion on a continuous passive motion device.
Consolidation radiographs: Yes.
Initial mobilization
앫 Patient: Immediately on forearm crutches
without weight bearing.
앫 Joint: Spontaneously immediately after removal
of plaster cast; spontaneous mobilization immediately postoperatively in surgical patients.
Physical therapy: Often necessary with postprimary
treatment; spontaneous motion initially.
Sports: Four to six weeks after consolidation.
Removal of metal implants
앫 Percutaneous Kirschner wires: Upon consolidation.
앫 Screws: Six weeks postoperatively.
Follow-up examinations and conclusion: Examinations are performed at three- to four-week intervals
until unrestricted function is regained. Then clinical
examinations continue at six-month intervals. Treatment is concluded two years after the accident if
function and leg axes are symmetrical and there is no
difference in leg length. Where growth disturbances
are present, clinical follow-up examinations are continued until cessation of growth.
Knee Injuries
Fractures of the Proximal
Tibial Epiphysis
앫 Typical epiphyseal fractures (Salter–Harris
types III and IV; Fig. 23.18 a)
앫 Apophyseal avulsions (Fig. 23.18 b)
앫 Avulsions of the tibial intercondylar eminence
(Fig. 23.18 c; see Injuries to the Knee Ligaments and Intraarticular Knee Injuries,
p. 357 ff)
“Typical” epiphyseal fractures at this location are
extremely rare injuries and invariably the result
of direct trauma (42, 46, 61, 68, 85, 86, 153, 157,
162). Transitional fractures are rarely seen (150)
and both injuries are easily diagnosed on radiographs.
A growth disturbance involving premature
partial closure of the growth plate with subsequent abnormal varus or valgus growth and
anterior or posterior bowing up to age 12 is
possible but not inevitable. The literature does not
provide any precise figures about the incidence of
these deformities (46, 73, 138, 153, 157, 162).
The goal of treatment is to reconstruct the articular surface of the tibial plateau in the event of
significant displacement and in so doing to ensure
conditions conducive to preventing or managing
a banding bridge (Fig. 23.19).
Accordingly, nondisplaced fractures (those
with a fracture gap barely visible in the radiograph) are treated conservatively by immobilization in a plaster thigh splint.
Displaced fractures are openly reduced and
stabilized by internal fixation that achieves interfragmentary compression.
Conservative treatment does not generally require radiographs to verify correct position as
these fractures are not prone to secondary displacement.
Immobilization or reduced weight bearing is
continued for four to five weeks. The consolidation radiographs obtained after this period should
confirm healing. As in all knee injuries, the joint is
initially mobilized spontaneously after healing,
without physical therapy. Metal implants are removed after 8–12 weeks.
335
Clinical follow-up examinations are continued for up to two years after the accident in
order to detect any sequelae of possible growth
disturbances.
Avulsion of the tibial tuberosity is an injury of
adolescence (33, 61, 85, 128). Signs of this injury
include a localized hematoma over the tibial
tuberosity and inability to lift the leg with the
knee extended. Radiographic examination confirms the clinical suspicion.
However, the injury can also occur as only a
periosteal tendon avulsion without the tibial
tuberosity itself having been avulsed from its bed.
In such a case, clinical findings will determine
what further procedure is indicated.
Because these patients are usually older, there
is hardly any chance of growth disturbances.
Theoretically, premature closure of the
growth plate can occur in younger patients and
lead to a secondary abnormal growth with a posterior bowing deformity of the tibial plateau.
The goal of treatment is functional reconstruction. Displaced fractures are more common
because of the muscular traction on the tibial
tuberosity. These injuries are treated surgically
and fixed with a screw inserted from distal and
anterior toward proximal and posterior
(Fig. 23.20). Especially where the soft-tissue envelope has been avulsed, the injury will require
additional immobilization after reconstruction of
the soft tissue. Where the injury is a simple bony
avulsion treated by internal fixation, functional
aftercare on a continuous passive motion device is
indicated.
Nondisplaced injuries are treated conservatively by immobilization in a plaster cast.
The radiograph out of plaster obtained after
six weeks following conservative or surgical therapy should confirm beginning bony union with
the avulsed fragment. After this, spontaneous
mobilization may begin. Further procedure is
identical to that in other knee injuries. Metal implants placed for internal fixation of fractures are
removed approximately 10–12 weeks postoperatively.
336
Specific Injuries—Lower Extremities
a
b
c
Fig. 23.18
Epiphyseal fractures in the proximal tibia.
a “Typical” epiphyseal fractures in patients with wide
open growth plates (Salter–Harris types III and IV).
This extremely rare injury can occasionally result in a
growth disturbance involving premature partial closure of the growth plate
b Apophyseal avulsions. Regardless of its location, the
avulsion of an apophysis represents an epiphyseal
fracture. As this avulsion most often occurs in adolescents when the posterior portion of the growth plate
is already closed, growth disturbances are not normally to be expected
c Avulsions of the intercondylar eminence of the tibia.
Avulsion of the intercondylar eminence from the tibial
epiphysis represents an epiphyseal fracture. As the
growth plate is not affected, growth disturbances are
not to be expected. With respect to prognosis, we distinguish nondisplaced fractures (left) and incompletely displaced fractures (center) from
completely displaced fractures (right)
Knee Injuries
337
Fig. 23.19 Treatment of “typical” epiphyseal fractures of the proximal tibia. Nondisplaced fractures
with a fracture gap of up to 2 mm are treated conservatively by immobilization in a plaster splint. Displaced
fractures are treated surgically to reconstruct the articular plateau and reduce the size of a possible banding
bridge
Fig. 23.20 Treatment of apophyseal avulsions. As
they are usually displaced, these fractures are treated
surgically and stabilized with a lag screw inserted in a
proximal and posterior direction. Growth disturbances
need not be feared. This 15-year-old patient suffered a
completely displaced intraarticular avulsion of the tibial
tuberosity. Open reduction was performed in an emergency procedure. The injury was stabilized with two cancellous screws to provide rigid internal fixation allowing
motion
338
Specific Injuries—Lower Extremities
Proximal Tibia (Epiphysis and Metaphysis, together
0.2%) Metaphyseal Fractures
Forms
1. Separated epiphyses (Salter–Harris types I and II)
2. Impacted fractures
3. Greenstick fractures
Radiographs: A-P and lateral.
Caution: A gaping medial fracture gap is a sign of a
greenstick fracture with a valgus deformity.
Growth arrest:
Re 1. Possible in 30% of all cases.
Re 2. No risk.
Re 3. No risk.
Growth stimulation:
Re 1. Possible under certain circumstances (clinically insignificant).
Re 2. Possible under certain circumstances (clinically insignificant).
Re 3. In every case:
—Unilateral genu valgum.
—Lengthening (see text).
Definition of “nondisplaced”: No axial deviation.
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Medical.
앫 Where indication is uncertain: Immobilization in a plaster thigh splint.
Emergency treatment under anesthesia: All displaced fractures with imminent or acute compromise of distal neurovascular function.
!
All other indications should first be discussed at
length with the patient and his or her parents.
Further treatment without anesthesia or delayed
treatment under anesthesia
앫 Fractures with moderate initial displacement
are treated with a cast wedge on the eighth
day after the accident.
앫 All fractures in which a cast wedge has failed
to achieve proper position.
Technique of conservative fixation
앫 Plaster thigh splint with the knee extended
(allowing better evaluation of the knee axis).
앫 Cast wedge on the eighth day after the accident (the goal is to achieve correct position).
앫 Thigh splint with the knee extended and varus
stress applied for all greenstick fractures (to
compress the open medial fracture gap).
앫 Cast wedge on the eighth day after the accident (the goal is to compress the medial fracture gap).
Technique of surgical fixation
앫 Percutaneous pinning with crossed Kirschner
wires,
앫 Medial external fixator.
Aftercare
Period of immobilization: Four weeks, with conservative and surgical fixation.
Consolidation radiographs: Yes.
Initial mobilization
앫 Patient: Immediately on forearm crutches
without weight bearing.
앫 Joint: Spontaneously immediately after removal
of plaster cast.
Physical therapy: None.
Sports: Four to six weeks after consolidation.
Removal of metal implants: Upon consolidation.
Follow-up examinations and conclusion: Examinations are performed at three- to four-week intervals
until unrestricted function is regained. Then clinical
examinations continue at six-month intervals. Treatment is concluded two years after the accident if
function and leg axes are symmetrical and there is no
difference in leg length. Where growth disturbances
are present, clinical follow-up examinations are continued at intervals of one to two years until cessation
of growth.
Knee Injuries
Fractures of the Proximal
Tibial Metaphysis
앫 Separated
proximal
tibial
epiphyses
(Fig. 23.21 a)
앫 Proximal metaphyseal impacted fractures
(Fig. 23.21 b)
앫 Proximal metaphyseal bending fractures
(greenstick fractures) (Fig. 23.21 c)
Extraarticular fractures adjacent to the knee are
rare injuries. Because they can significantly alter
the load distribution in the knee, they have been
included in this section on knee injuries.
Separated epiphyses are extremely rare in the
proximal tibia (46, 61). Displaced injuries are no
problem to diagnose. The tibial tuberosity is part
of the epiphysis and is displaced along with it (13,
62, 73). The articular surface remains intact. Nondisplaced fractures, especially those without
metaphyseal involvement, can be overlooked if
the examiner fails to give due consideration to the
associated clinical symptoms of local swelling
and pain. An isolated fracture of the proximal
fibular shaft can be a sign of a nondisplaced separated epiphysis (Fig. 23.22).
Growth disturbances involving partial premature closure of the growth plate are possible (see
Fig. 5.5 a–d).
Growth disturbances involving transient
stimulation of the entire proximal tibial growth
plate with slight posttraumatic leg-length alteration should be expected in any case.
Axial deviations in the coronal plane can be
easily overlooked. Even slight deformities will
subsequently lead to clinically significant
sequelae in the form of unilateral genu valgum or
genu varum. Axial deviations in the sagittal plane,
the main plane of motion of the knee, are spontaneously corrected relatively well. However, this
only occurs slowly in axial deviations the coronal
plane. In young patients, the axial deviations
grow toward the diaphysis, and the epiphysis
slowly moves back into its physiological position
perpendicular to the plane of motion. The unilateral change in the axis of the knee is only compensated for once this process is complete.
However, the deformation in the shaft remains
unchanged, especially in the case of a valgus deformity (111). Varus displacement of the axis of
the tibia appears to be more readily corrected.
The goal of treatment consists primarily of
achieving a symmetrical reconstruction of the
axis of the knee in the coronal plane. This means
339
that any deformity in the coronal plane must be
detected so that it can be corrected. Any malrotation with respect to the contralateral side must be
painstakingly eliminated (see also Chapter 24,
Fractures of the Tibial and Fibular Shaft, p. 373).
Nondisplaced separated epiphyses are treated
conservatively in a plaster thigh splint with the
knee extended. Additional radiographs are not
usually required where the splint has been carefully molded for a good fit. Displaced fractures are
reduced closed. The results of the reduction are
then documented in radiographs during the same
session, which may be done by measuring the
epiphyseal axis angle. Rarely, the presence of interposed soft tissue can prevent reduction (48), in
which case open reduction is indicated. Closed reduction is maintained by immobilizing the injury
in a plaster thigh splint with the knee extended.
This is easier to do with a separated proximal tibial epiphysis than with a separated distal
femoral epiphysis.
A radiograph in plaster obtained after 8–10
days should confirm correct position after the
splint has been closed to form a cast on the fourth
or fifth day after the accident. Any slight secondary deformities can then be corrected with a cast
wedge. Percutaneous pinning with crossed Kirschner wires is recommended for cases where
maintaining correct position proves difficult.
Weight bearing in the cast should be left up to
the patient. Patients will usually begin weight
bearing by themselves around two weeks after
the accident. They need not be prohibited from
doing so.
After four to five weeks, a radiograph out of
plaster and a callus no longer tender to palpation
will confirm that the fracture has healed. Once the
patient has begun spontaneous mobilization and
weight bearing, the next clinical examination is
performed after three weeks. If gait and knee mobility are largely unrestricted at that time, then
the patient may resume sports activities. Further
radiographic examinations are no longer indicated in patients who are free of symptoms with
no axial deviations in the knee. Clinical follow-up
examinations should be continued at intervals of
six months to a year until two years after trauma.
Treatment may then be concluded if both sides
exhibit unrestricted and symmetrical function
and structural alignment.
The metaphyseal impacted fracture usually
involves no axial deviation at all and is treated in
the same manner as a nondisplaced separated
epiphysis. There is no risk of growth disturbances
340
Specific Injuries—Lower Extremities
a
b
c
Fig. 23.21 Metaphyseal fractures in the proximal
tibia.
a Separated epiphyses. As it forms a part of the proximal tibial epiphysis, the tibial tuberosity is also
avulsed in any epiphyseal separation with or without a
metaphyseal wedge
b Impacted fractures. These are stable, straightforward fractures that only require immobilization in a
plaster splint to manage pain
c Bending fractures. Like greenstick fractures of the diaphysis, these fractures can lead to transiently
delayed union on the convex aspect of the deformity.
Impacted soft tissue leads to typical cyst formation.
This consolidation disturbance is associated with
transient partial stimulation of the proximal tibial
growth plate. The resulting growth spurt increases
the initial deformity. A medial gaping fracture gap
means that there is a valgus deformity!
Knee Injuries
341
Fig. 23.22 Diagnosis and treatment of
separated epiphyses in the proximal
tibia. Nondisplaced fractures can pose diagnostic problems. Far proximal fibular fractures can suggest such an injury. In these
cases, pain determines the treatment. The
actual diagnosis can be made secondarily
from findings of a periosteal callus, as in
this 15-year-old boy who was immobilized
in a plaster splint simply because of the
fibular fracture
342
Specific Injuries—Lower Extremities
Fig. 23.23 Treatment of metaphyseal impacted fractures. Metaphyseal impacted fractures do not pose any problems. Growth disturbances and abnormal growth need not be
feared, as illustrated by the case of this threeyear-old girl whose impacted fracture of the
proximal tibia healed without complications
(from: 111)
or secondary axial deviations after these fractures
(111; Fig. 23.23).
Metaphyseal valgus bending fractures (greenstick fractures) of the proximal tibia can occur as
isolated injuries or in combination with fibular
fractures. Initial findings will invariably include a
more or less severe valgus deformity. The injury is
rare but can involve serious late sequelae (20, 65,
80 a, 88, 116).
Diagnosis
Metaphyseal bending fractures are easily diagnosed. However, the small peripheral fragment
often makes it difficult to detect the valgus deformity and judge its severity. The epiphyseal axis
angle should be used in evaluating the injury.
Knee Injuries
!
Any large medial fracture gap is a sign of an initial valgus deformity (see Figs. 23.24, 23.26).
Problems and Complications
The problem associated with this fracture is in
overlooking an initial valgus axial deviation. A
typical growth disturbance and its sequelae exacerbate this initial valgus deformity (Fig. 23.24).
This is one of the rare growth disturbances involving partial transient stimulation. It is caused by a
consolidation disturbance on the medial aspect of
the fracture. The initial valgus deformity that is
invariably present lacks the medial interfragmentary compression required for healing; the situation is similar to the incompletely disrupted cortex in diaphyseal greenstick fractures. Additionally, the lateral side is well covered by muscle in
contrast to the medial side and therefore heals
more rapidly than the medial side. This results in
delayed union across the medial fracture gap, regardless of whether any soft tissue is interposed
(111). The prolonged and intensified remodeling
processes occurring around this consolidation
disturbance, the “partial pseudarthrosis,” lead to
medial stimulation of the adjacent growth plate
with an abnormal medial growth spurt. This
causes the initially present valgus deformity to increase into an unilateral genu valgum.
Almost all authors agree on the presence of
the valgus deformity in the setting of this growth
disturbance (2, 14, 19, 22, 39, 147). Only isolated
cases are described in which a unilateral genu valgum also occurred secondary to an allegedly nondisplaced fracture (45, 87). However, measurement of the respective published radiographs reveals that either a valgus deformity was overlooked (45) or what began as a slight valgus deviation in the cast had increased by the time the
fracture healed (87). It is therefore reasonable to
assume that this growth disturbance occurs secondary to all fractures that heal in a valgus deformity. This will be the case regardless of
whether the fracture was initially completely displaced and reduced in valgus and regardless of
whether the fibula was partially fractured,
completely fractured, or not fractured at all (111).
Any additional uncorrected, medial side-toside displacements will also intensify and prolong
the medial remodeling processes, thereby increasing the function of the medial growth plate
with abnormal valgus growth (Fig. 23.25). This
growth disturbance is transient in every case and
343
is directly proportional to the duration of the remodeling processes. The abnormal valgus growth
will also terminate as soon as there is complete
bony union across the medial fracture gap, at the
latest one to two years after the accident.
Our clinical results to date have failed to confirm the assumption that this abnormal growth is
attributable solely to the interrupted traction of
the periosteum (65) or pes anserinus (116).
However, it is interesting to note that in every case
described in the literature in which the periosteum or pes anserinus was surgically reconstructed and no secondary abnormal valgus
growth occurred, the initial valgus deformity had
invariably been carefully eliminated (91, 116). Unfortunately, it is not possible to avoid this growth
disturbance entirely. The uneven distribution of
soft tissue in the lower leg ensures that every fracture with complete disruption of the medial cortex will heal unevenly: Healing will occur more
rapidly in the lateral aspect of the fracture than in
the medial aspect. The net effect of this is the
stimulation of the medial portion of the growth
plate. Where the initial deformity has been eliminated, this stimulation will only result in slight
additional valgus growth that creates neither a
functional nor cosmetic impairment requiring
correction. However, any uncorrected initial deformity will be increased by the additive effect of
the valgus growth spurt: The greater the initial
valgus deformity, the greater the additional
growth will be (39).
“Spontaneous Corrections”
Anterior or posterior bowing deformities are
rarely encountered at this location. Therefore,
nothing definite can be said about how they
develop over time. As they lie in the plane of motion of the adjacent knee joint, one may assume
that they will be spontaneously corrected.
The valgus deformity described above only
corrects itself indirectly; it grows out into the
shaft region, where it remains unchanged (111,
126). However, there it poses at most a cosmetic
problem. If the patient is young enough at the
time of the fracture, the epiphysis will realign itself perpendicular to the plane of stress during
the course of this distal growth. This means that
symmetrical knee axes will have been restored by
cessation of growth. Such a correction can no
longer be relied on to occur in patients beyond the
age of seven to eight.
Fig. 23.24 Problems associated with metaphyseal bending fractures in
the proximal tibia. The patient is a five-year-old girl with a typical proximal
metaphyseal bending fracture. The initial valgus deformity was overlooked,
and the fracture was immobilized for seven weeks in a plaster thigh cast. The
deformity increased significantly during the further course of healing as a re-
sult of partial stimulation of the medial proximal tibial growth plate. A corrective osteotomy was performed one year after the accident and was stabilized
with a fracture plate. No recurrence of the unilateral genu valgum was observed over a period of three years
344
Specific Injuries—Lower Extremities
Fig. 23.25 Problems associated with metaphyseal bending fractures in the
proximal tibia. The patient is an eight-year-old boy with a completely displaced
fracture of the left proximal tibia and fibula. The injury was reduced with a valgus
deformity of 8⬚ and immobilized in a plaster cast. While this valgus deformity remained unchanged, additional medial side-to-side displacement occurred while
the injury was immobilized. Increased medial remodeling due to the medial displacement and persistent valgus deformity produced a typical growth disturbance
with posttraumatic stimulation. This in turn led to a 4⬚ increase in the initial valgus
deformity (my thanks to Dr. Lusche, Städtisches Krankenhaus, Lörrach, Germany,
for making the radiographs of this case available)
Knee Injuries
345
346
Specific Injuries—Lower Extremities
Treatment
The goal of treatment consists of eliminating any
initial or secondary valgus deformity and in so
doing minimizing the consolidation disturbance
and resulting abnormal growth. This means that
the physician must recognize the initial axial deformity. Any appreciable open medial fracture
gap suggests a valgus deformity. Periosteal tissue
may become interposed when compressing the
medial fracture gap to eliminate the initial deformity. This interposed tissue can lead to slight
stimulation of the growth plate but will be remodeled as time passes. As long as the compression of the medial fracture gap is maintained, a
consolidation disturbance with typical cyst formation will not develop. The partial growth spurt
resulting from this slight stimulation does not become clinically relevant (Figs. 23.26, 23.27).
Fig. 23.26 Treatment of metaphyseal bending fractures of the proximal tibia. With initial valgus deformities of up to 10⬚, the leg is first immobilized in extension
in a plaster thigh cast with varus stress applied, as was
done with this eight-year-old girl. On the eighth day
after the accident, a cast wedge is placed without a prior
radiograph to eliminate the deformity and compress the
medial fracture gap. The results of the cast wedge treat-
These injuries are treated conservatively as a
matter of course (84, 88, 95, 111). Moderate valgus
deformities of up to 10⬚ (determined by measuring the epiphyseal axis angle) are initially immobilized in a plaster splint, which is closed to form a
cast on about the fifth day. The leg should be
placed in the splint with the patient’s knee extended and varus stress applied. On the eighth
day after the accident, a cast wedge is placed
without obtaining a prior radiograph. Then the results of the cast wedge treatment are documented
in radiographs and the wedge is moved if necessary. The valgus deformity must be completely
eliminated. Ideally, the medial cortex should be
slightly impacted (Fig. 23.27). If the wedge fails to
compress the medial fracture gap, then reduction
with the patient under anesthesia is indicated
using the same procedure as in severely displaced
fractures.
ment must be documented in radiographs. Interposed
periosteal tissue will be converted to bone if there is adequate medial compression. This can lead to slight partial
stimulation of the adjacent growth plate. However, the
sequelae are not clinically significant as the one-year
radiographic and clinical follow-up examinations of this
patient demonstrated (from: 111)
Knee Injuries
Deformities exceeding 10⬚ and completely displaced fractures are reduced closed, and the fracture is impacted medially (Fig. 23.27). Medial deformities with side-to-side displacement should
not be tolerated (Fig. 23. 25). After the splint has
been closed to form a cast on about the fifth day, a
radiograph in plaster is obtained on the eighth day
to allow elimination of any deformities with a cast
wedge (Once again: a large medial fracture gap is
always a sign of a valgus deformity).
We regard situations where it is not possible
to achieve ideal reduction (no medial side-to-side
displacement and an epiphyseal axis angle of 0⬚)
as an indication for open reduction (if necessary)
and surgical fixation (151). The same applies to
combined injuries also involving a femoral fracture (161), second and third degree open fractures, etc. Whenever possible, the injury is stabilized using an external fixator applied medially
Fig. 23.27 Treatment of metaphyseal bending fractures of the proximal tibia. Where initial deformities
exceeding 10⬚ are present, the fracture should first be
reduced and then medially impacted as in this 12-yearold boy. The results of the reduction are documented in
radiographs during the same session. Correct position
should be verified by radiographic examination on about
347
(Caution: Take care to avoid injuring the apophyseal growth plate of the tibial tuberosity) to apply
compression to the medial fracture gap. This is
best done using a fixator that can be flexibly assembled such as the Hofmann Compact II manufactured by Stryker Howmedica. We do not reconstruct the periosteum or pes anserinus during the
same session (Fig. 23.28).
Immobilization and Consolidation
In every case, the cast is removed after a total of
five weeks and a radiograph out of plaster is obtained at that time to evaluate healing. We then
allow spontaneous mobilization and weight bearing; the patient will already have begun weight
bearing in the cast anyway. If after about three
weeks gait and knee function are unrestricted,
then the patient may resume sports.
the eighth day to allow placement of a cast wedge to
treat secondary deformities. Consolidation radiographs
should confirm bony union across the medial aspect of
the fracture (centre). There ist no valgus deformity as
demonstrated by the one-year follow-up examination of
this patient (right) (from: 163)
348
Specific Injuries—Lower Extremities
Fig. 23.28 Treatment of metaphyseal bending fractures of the proximal tibia. Where closed reduction
fails to verifiably compress the medial fracture gap, an
external fixator may be used to ensure medial compression
Sports Participation and
Follow-up Examinations
different treatment options are available for
managing these deformities. These options in
turn depend on the extent of the respective banding bridge between the epiphysis and metaphysis.
MRI scans will be required to evaluate the extent
of the bridge.
In patients with only a punctate bridge
(Fig. 23.12 a) and in patients below age 10 (better
yet, below age seven), it is a good idea to wait and
hope for spontaneous disruption even where abnormal growth has already occurred. Where the
thrust of growth disrupts the bridge, sufficient
time will remain for the affected epiphysis to
“spontaneously” realign itself perpendicular to
the plane of stress. Any possible remaining length
difference can then be definitively corrected at
about the time of cessation of growth.
In patients above age 10 with moderately
severe deformities, iatrogenic disruption with the
aid of an Ilizarov fixator (see Fig. 12.6) may be attempted. We have used this technique in only one
patient to date and do not know whether such a
disruption might also lead to premature closure
of the growth plate.
The younger the patient, the more advisable
it is to resect the banding bridge and fill the defect with rib cartilage (25, 32, 72, 75, 83;
Fig. 23.16 a–e).
Patients who remain free of symptoms will not require any additional radiographs as long as the
clinical follow-up examinations reveal symmetrical leg axes. These examinations to evaluate leg
length are performed annually. Treatment may be
concluded where leg length and structural alignment are symmetrical two years after accident.
Most Common Posttraumatic
Deformities of the Distal Femur
and Proximal Tibia
The growth plates of the distal femur and proximal tibia remain open for a long time, and for this
reason we most often see growth disturbances involving premature partial or complete closure of
one or both growth plates at this site. Rarely, transient or persistent conical epiphyses can also lead
to complex deformities at this site, which then
may be only partially correctable or not at all. We
feel that this rare situation does not warrant discussion in greater detail here.
Most frequently, we encounter axial deformities in the frontal and sagittal planes in association with shortening or lengthening in the absence of axial deviation (138, 144, 158). Various
Knee Injuries
The prognosis for further growth after resection appears to be good in patients under age 10
where the bridge is less than one fifth the size of
the entire growth plate. Earlier we used fatty
tissue to fill the defect created by the resection.
We have since converted to the technique advocated by Dalleck (25) and Lennox (74) and now fill
the defect with rib cartilage.
In patients above age 10, one may also attempt
resection of larger banding bridges. However, this
involves an increased risk of precipitating premature closure of the entire growth plate.
Following any resection or iatrogenic disruption, it is important to monitor growth in followup examinations until growth has ceased. Isolated late recurrences of banding bridges during
puberty are possible (Fig. 23.16 c), and their
causes are completely unknown (82). In older
patients above age 10, the physician should attempt to eliminate the sequelae of such a growth
disturbance with one single correction only.
Where the size of the bridge allows neither
disruption nor resection, a corrective osteotomy
is the only remaining option. Depending on the
patient’s age, repeated surgery may be necessary
and will require careful planning (90; Fig.
23.9 a,b).
Where the bridge spans the entire growth
plate region, a lengthening osteotomy will be the
only option.
All osteotomies should be postponed until
after cessation of growth wherever this is feasible
and tolerable for the patient. One reason for this is
to reduce the number of interventions required;
another is to avoid placing the patient at the
mercy of growth reactions that cannot always be
reliably predicted (4). On the other hand, where
there is severe shortening with or without axial
deviation, it is best to perform a distraction
osteotomy early in the presence of a small difference of up to 4–5 cm. This is because significantly
fewer complications may be expected in this
range than when correcting differences over 5 cm.
All of these deformities invariably require
lengthening osteotomies. We always stabilize the
osteotomy with an external fixator. Especially for
opening osteotomies, we prefer the Monotube
because it allows simultaneous axial correction
349
and lengthening. We find it convenient to affix the
Monotube laterally on the thigh and medially or
mediolaterally on the lower leg. If the fixator can
be inserted into the concavity of the deformity
(e.g., on the lateral aspect of the femur in the case
of a valgus deformity), then all the surgeon has to
do to make a simultaneous axial correction is
lengthen the fixator with its rotational clamps
open (Fig. 25.45 and see also 25.44). If the fixator
can only be inserted into the convexity of the deformity (e.g., on the lateral aspect of the femur in
the case of a varus deformity), then a fixed rod or
even a second fixator will have to be affixed parallel to the first fixator. In that case, an axial correction can only be made by lengthening the proximal fixator with its rotational clamps open while
simultaneously shortening the distal fixator with
its rotational clamps open (or, respectively, by
lengthening the fixator against the fixed peripheral rod; Fig. 25.46). If there is also a deformity in
the opposite plane, then this deformity will also
require correction. That would have to be done in
a second session once a callus has already formed.
This is a disadvantage compared with other models of external fixators. However, a prototype has
been developed with an adjustment feature that
allows additional axial corrections in every plane
even during the distraction phase.
The minimum duration for all callus distractions—lengthening with or without an axial correction—can be reliably specified as two months
of the fixator in situ per centimeter of length
gained. Any complications will extend this period
accordingly. It is useless to mislead the patient by
promising an unrealistically short duration of
treatment. All of these interventions require the
patient’s cooperation, and the physician cannot
afford to risk losing that cooperation by providing
false information.
Care is similar to the care of a fracture treated
with an external fixator. One important point is
that good knee mobility and rapid weight bearing
are emphasized from the start. This requires careful and effective pain therapy. The better the
patient can move his or her knee, the fewer complaints there will be when walking. The less pain
is felt, the sooner the patient will be willing to attempt extensive weight bearing.
350
Specific Injuries—Lower Extremities
Proximal Tibia
Where an initial valgus deformity was overlooked
and has progressed to a unilateral genu valgum,
the patient’s complaints should serve as the yardstick for determining which secondary treatment
is indicated. Where the unilateral genu valgum is
so severe that the patient constantly stumbles
over his or her deformed leg when walking at a
brisk pace, then an osteotomy should be performed as early as about a year after the accident.
By then the deformity will have grown out far
enough distally so that a fracture plate can be
used to stabilize an osteotomy performed at the
apex of the axial deviation (Fig. 23.24). However,
parents and patient should be made well aware of
the fact that every second patient may be expected to develop a recurrent deformity whose
severity can exceed that of the valgus deformity
that was initially corrected (19, 22, 37, 77, 105,
106). The cause of the recurrence remains unclear,
and it develops regardless of which fixation
method is used (Figs. 23. 29, 23.30). Therefore, in
smaller children with a posttraumatic unilateral
genu valgum, it is best to wait for “spontaneous
correction” (118) of the valgus deformity (126).
However, any later intervention will involve the
disadvantage of requiring an osteotomy at two
levels because by then the growth plates will have
realigned themselves perpendicular to the plane
of stress.
a
Fig. 23.29 a Corrective osteotomy of posttraumatic
unilateral genu valgum. The patient is a five-year-old
boy with unilateral genu valgum of the right knee following a metaphyseal bending fracture. There is a differ-
ence of 15⬚ to the contralateral side. Because there was
1 cm of leg lengthening, a medial closing osteotomy
was performed. The correction was stabilized with two
Kirschner wires that crossed the osteotomy site
Knee Injuries
351
Fig. 23.29 b
Additionally, the patient’s
leg was also immobilized for
six weeks in a plaster splint.
Three months later, there
was good bony union across
the osteotomy site, and the
axis of the leg showed a
slight varus deviation. At
the late follow-up examination 11 years after the accident, the leg axes exhibited
clinical and radiographic
symmetry and there was no
evidence of any prior recurrence
b
Overview
Most Common Posttraumatic Deformities
of the Distal Femur and Proximal Tibia
1. Genu valgum, genu varum, posterior bowing
deformity, or anterior bowing deformity with
shortening.
2. Genu valgum with lengthening.
3. Increasing shortening without axial deviation.
4. Pseudarthrosis of the intercondylar eminence of
the tibia with extension deficit.
Causes
1. Growth disturbance involving partial premature
closure of the distal femoral or proximal
tibial growth plate.
2. Partial transient stimulation after metaphyseal
bending fractures of the tibia.
3. Complete premature closure of the distal
femoral or proximal tibial growth plate.
4. Improperly treated avulsion of the intercondylar
eminence of the tibia.
Indications for Correction
1. Increasing deformity and functional impairment.
2.–4. Functional impairment.
Time of Correction
1. At that time at which the deformity begins to
represent a functional impairment (e.g., posterior or anterior bowing deformity or genu valgum) in every age group but only after cessation of growth wherever possible.
2. Only after cessation of growth wherever
possible.
3. Depending on patient’s age and severity of
shortening, possibly postpone until only after
cessation of growth.
4. At that time at which malunion with functional
impairment is detected.
352
Specific Injuries—Lower Extremities
a
Fig. 23.30 a–c Corrective osteotomy of unilateral
posttraumatic genu valgum. The patient is a five-yearold boy with unilateral posttraumatic genu valgum following a metaphyseal bending fracture. There is a difference of 20 ⬚ to the contralateral side. Because the boy
was constantly stumbling over his deformed leg, it was
decided that a corrective osteotomy was indicated. As
leg lengthening of 1 cm was present, a medial closing
osteotomy was performed and stabilized with an external fixator. Eight weeks after the osteotomy, the fixator
was removed and the osteotomy exhibited beginning
bony union with a strong bridging callus. The leg axes
were symmetrical
Correction Technique
Aftercare
1. Distraction osteotomy with external fixator.
2. External fixator or fracture plate.
3. Lengthening by distraction with external fixator.
4. Debride, reduce, and fix with absorbable suture
or Kirschner wire (postoperative immobilization
in a plaster splint).
1.–3. Functional aftercare.
4. Immobilization in a plaster cast for four weeks
with full weight bearing.
Knee Injuries
353
Fig. 23.30 b
After eight months, clinical and radiographic examination demonstrated a recurrent deformity with a difference of 5⬚ to the contralateral side
b
Fig. 23.30 c
This difference did not increase during further
growth, as was demonstrated by the clinical followup examination a year and a
half later (before the
osteotomy [left], a year and
half after the osteotomy
[right])
c
354
Specific Injuries—Lower Extremities
Patella Dislocations
It is difficult to distinguish traumatic patella dislocations from chronic recurrent patella dislocations, especially in young girls with hypoplastic
and high-riding patellae. The diagnosis of a dislocation is easily made on the basis of clinical findings. The patella will almost invariably be dislocated laterally. The radiographic examination
(best performed after reduction) should exclude
associated bony injuries (Fig. 23.31). Spontaneous
reductions occur primarily in chronic recurrent
dislocations. Occasionally, small capsular tears
can lead to spontaneous hemarthrosis.
The most common associated injury aside
from the almost invariably present soft-tissue injury (avulsion of the medial retinacula from the
patella or retinacular rupture) is an osteochondral
flake fracture of the medial facette of the patella
and/or lateral femoral condyle (55, 56). These associated injuries are not always detectable on
radiographs, often appearing only on the axial
image (125). Fat droplets in the initial hemarthrosis or a recurrent effusion suggest such an associated injury.
Treatment pursues three goals: primary reduction of the dislocated patella, repair of
possible cartilage damage, and prevention of repeat dislocation, i.e., chronic recurrent dislocation.
Primary reduction of the dislocated patella is
usually easily achieved by extending the knee
with the hip flexed 90⬚. Radiographs of the knee
are then obtained. Where there is no visible as-
Fig. 23.31 Associated injuries in a patella dislocation. The patient is a 13-year-old girl with a traumatic
patella dislocation. Unequivocal radiographic findings of
an osteochondral fragment avulsed from the medial
sociated bony injury, the hemarthrosis is drained
under sterile conditions with the patient under
local anesthesia. We always aspirate from medial
into the superior recess so as not to interfere with
possible subsequent arthroscopy via a lateral approach.
Where there are no signs of associated bony
injury in the A-P and lateral projections, we immobilize the knee in a plaster thigh cast after
draining the hemarthrosis. Arthroscopy should be
performed where the hemarthrosis collects again
within the next three to four days. Where there
are large quantities of fat droplets in the aspirate,
we prefer to perform primary arthroscopy as soon
as possible to exclude an osteochondral flake fracture. Where the injury is a first-time dislocation
without associated bony or cartilaginous injuries,
i.e., no fat droplets were found in the aspirate and
the hemarthrosis did not collect again during the
first three to four days of immobilization, we continue conservative treatment and convert the
plaster thigh splint into a thigh cast. This is left in
place for three weeks. Full weight bearing is allowed, and the patient must engage in intensive
quadriceps training.
Once the cast is removed, the patient spontaneously mobilizes the knee without physical
therapy. Physical therapy to manage delayed
spontaneous mobilization should only be begun
after three weeks. In the absence of any symptoms other than minor decreasing capsular swelling without effusion throughout further mobilization with increasing weight bearing, the patient
may resume sports activities after a total of about
facette of the patella were confirmed intraoperatively.
The fragment was reattached and stabilized at this time
with a screw
Knee Injuries
six weeks once mobility is unrestricted. Once the
patient has resumed sports without any recurrent
effusion or increasing capsular swelling and knee
function and strength in the quadriceps are both
symmetrical, treatment may be concluded for the
time being (i.e., until any possible recurrent dislocation).
Arthrotomy is indicated where radiographic
or arthroscopic examination has confirmed the
presence of bony or cartilaginous injuries and a
flake could not be refixated in a arthroscopic way.
We prefer a slightly lateral straight longitudinal
incision over the center of the patella. We then
open the medial knee, taking care to preserve the
infrapatellar branches of the saphenous nerve.
After identifying the loose fragment, we drain the
hemarthrosis from the wound bed and fix the
small fragments in place with fibrin glue and the
large ones with absorbable pins or preferably
with screws (18). Naturally, the repair of the knee
includes inspection of both menisci, the cruciate
ligaments, and all of the cartilage structures. If a
synovial fold is present, we resect it. Then we perform an extrasynovial lateral release by longitudinally splitting the entire lateral capsule. The medial knee is then closed again, and we reconstruct
the retinacula and tighten the capsule extensively. We dispense with an additional advancement of the tibial tuberosity in girls with open
growth plates.
In patients with closed growth plates who required arthrotomy, we used to routinely perform
additional advancement of the tibial tuberosity
simultaneously with the lateral release and tightening of the medial capsule. Depending on the
patellar injury, the tuberosity was advanced medially only, medially and anteriorly, or medially
and distally. Recently, we have begun to favor performing a horizontal advancement of the vastus
medialis instead of advancing the tibial tuberosity
in addition to the lateral release and tightening of
the medial capsule. Depending on the preoperative situation, the results are not always convincing.
We immobilize all surgical patients for about
three weeks postoperatively in a removable prefabricated splint and have these patients engage
in intensive quadriceps training while in the
splint. Then we allow spontaneous mobilization
outside of the splint without weight bearing for
another three weeks. After a total of six weeks,
patients with closed growth plates and advancement of the tibial tuberosity undergo radiographic examination to document the beginning
355
of bony union in the advanced tuberosity. Then
increasing weight bearing is gradually begun.
After a further three to four weeks, unrestricted
mobility in the knee will usually have been regained and gait will be normal. Sports participation may gradually be resumed at this time.
Where this is possible without any problems,
treatment may be concluded after patients with
advancement of the tibial tuberosity have had the
screw removed under local anesthesia about 12
weeks postoperatively.
In patients who have suffered a chronic recurrent dislocation, we now perform a horizontal advancement of the vastus medialis almost exclusively combined with a lateral release and tightening of the medial capsule to prevent recurrent
dislocations (27, 107). We feel that advancement
of the tibial tuberosity is indicated only in exceptional cases. Under certain circumstances, a proximal tibial osteotomy may have to be performed
during the same session depending on the leg axis
(e.g., genu valgum). Sports participation should
be delayed a bit longer in patients with chronic recurrent dislocations as these patients will be
afraid of recurrent dislocation despite having undergone surgery. This should be taken into consideration.
Patellar Fractures
Direct trauma can produce a variety of patellar
fractures, although on the whole they are rare.
These include longitudinal fractures; fractures of
the patellar margin; and proximal, central, and
distal transverse fractures (Fig. 23.32).
Persistent step-offs in the weight bearing region following transverse fractures and quadrant
avulsions can represent a predisposition to arthritis. Longitudinal fractures usually do not exhibit any incongruity and therefore are not associated with any late sequelae.
Growth disturbances need not be feared. The
goal of treatment is to reconstruct the articular
surface or the extensor tendons, respectively.
Longitudinal fractures are usually nondisplaced
and are treated conservatively by immobilization
in a plaster cast for three to four weeks. Initial
treatment includes draining the hemarthrosis.
The plaster splint applied initially is closed to
form a cast on about the fourth day once softtissue swelling has subsided. It must be carefully
molded for a good fit. Patients may bear weight in
the cast.
356
Specific Injuries—Lower Extremities
Fig. 23.32 a–d Patellar fractures. Longitudinal fractures (a) and lateral quadrant avulsions (b), like nondisplaced transverse fractures of the patella in with intact
extensor tendons (c), are generally treated conservatively. Displaced patellar fractures in which the extensor
tendons are interrupted (d) require surgical repair
Nondisplaced proximal and distal transverse
fractures and nondisplaced avulsions are also
treated conservatively as these injuries leave the
extensor tendons intact. There is no need for
another x-ray in plaster. We have these patients
refrain from weight bearing in the plaster cast
(Fig. 23.33).
Displaced transverse fractures are usually repaired surgically in the usual manner and stabilized with tension banding (Fig. 23.34). Additional
immobilization in a plaster cast should not be
necessary here; instead the knee should be mobilized without weight bearing once the wound
healing has been confirmed.
An x-ray out of plaster is obtained with all
fractures five to six weeks after the beginning of
treatment to demonstrate bony union in the fracture. Where the fracture exhibits good clinical and
radiographic healing, spontaneous mobilization
may be begun on forearm crutches, initially
Fig. 23.33 Treatment of patellar fractures. Where
the extensor tendons are intact, even transverse patellar
fractures are treated conservatively, as in this 15-year-
old boy whose fracture exhibited good clinical and radiographic healing after six weeks
Knee Injuries
357
Fig. 23.34 Treatment of patellar fractures. Where the extensor tendons are torn, the patellar fracture will be displaced to varying degrees. These injuries are treated by tension banding fixation as in this 14-year-old girl
without weight bearing. Two weeks later,
patients may gradually begin full weight bearing.
Physical therapy is indicated where mobilization
of the knee is delayed. Patients may gradually resume sports activities a total of six weeks after the
end of immobilization once pain-free, unrestricted function has been regained. However, adolescents in particular should refrain from unrestricted sports participation during the first three
months after trauma. Metal implants are removed
after about four to six months. If the patient is free
of pain with unrestricted function at that time,
then treatment may be concluded.
Injuries to the Knee Ligaments and
Intraarticular Knee Injuries
The stereotypical pattern of injury for open
growth plates also applies to these injuries.
However, here we must also expect combined injuries of the sort we encounter in adults. The follow-up of cruciate ligament injuries in our study
group has clearly demonstrated two findings:
First, 80% of all bony avulsions of the cruciate ligaments (avulsions of the intercondylar eminence
of the tibia) are sustained below age 12, and, second, 90% of all patients with nonbony cruciate injuries are above age 12 (63). Where the trauma involves associated injuries, these injuries occur
with the same incidence and in the same combinations as in adults regardless of the patient’s age
358
Specific Injuries—Lower Extremities
(63). This means that the patient’s age, not the
mechanism of injury, determines the nature of
the injury to the most important stabilizers of the
knee, the cruciate ligaments. However, the severity of the mechanism of injury determines the incidence and nature of the associated injury (12,
145). This makes differential diagnosis of these
various injuries difficult.
Differentiation is only possible where the
radiographs demonstrate a nondisplaced avulsion of the intercondylar eminence. This type of
injury does not involve any associated injuries
that require treatment. The same applies to nondisplaced bony avulsions of the collateral ligaments from the femoral metaphysis, regardless of
whether they are medial or lateral. In the case of
all other avulsed epiphyseal flakes suggesting
ligament injury, including those visible on radiographs, MRT is indicated to confirm or exclude
relevant associated injuries, which than should
treated in an arthroscopic way.
In practice this means that in patients with
open growth plates (in whom a ligament injury
may be expected to have a radiographic correlate)
who exhibit hemarthrosis with negative radiographs, treatment involves draining the hemarthrosis as described initially in the section on diagnosis (p. 310 ff) and brief immobilization.
Where clinical examination after about three to
four days confirms that hemarthrosis has not recurred during immobilization and the ligaments
are completely stable at the clinical investigation,
no further diagnostic procedures will be required
and the physician may proceed as described in the
introductory chapter. However, where this clinical examination after three to four days reveals
either recurrent hemarthrosis and/or instability
of the knee (positive Lachman test, positive pivotshift test, or lateral instability), further diagnostic
procedures (MRI and possibly arthroscopy for
treatment) are indicated.
Isolated Bony Avulsions of the
Collateral Ligaments from the Femur
These injuries primarily occur at the age at which
the growth plates adjacent to the knee are still
wide open. They occur with the same incidence in
both the deep short collateral ligament fibers inserting into the epiphysis and the superficial collateral ligament fibers inserting into the
metaphysis (see Fig. 23.6).
The diagnosis is primarily made on the basis
of radiographs. Nondisplaced metaphyseal avulsions with small fragments can often be mistaken
for overlapping of the growth plate. Hematoma
and pain are signs of injury. The clinical diagnostic
tests for possible instability should not be performed as this could cause displacement of initially nondisplaced fragments. Completely nondisplaced metaphyseal ligament avulsions do not
normally involve associated injuries. However,
additional intraarticular knee injuries indicative
of damage to the deep fibers of the collateral ligaments are more probable in seemingly nondisplaced epiphyseal avulsions. Therefore, MRI
should supplement diagnostic radiography in
such cases.
Instability problems generally may not be expected after these injuries. Usually, the avulsed
fragments heal perfectly even in the presence of
slight displacement. Functional weight bearing
and the general tightening of the ligaments that
occurs in puberty should compensate for traumatic stretching of the ligaments.
Growth disturbances involving partial premature closure of the growth plate can occur secondary to medial and lateral metaphyseal ligament
avulsions and will lead to abnormal varus or valgus growth, respectively. Yet this is not inevitable
and can occur secondary to injuries with displaced or nondisplaced avulsed fragments. Closure can be caused by formation of a periosteal
bridge, by a banding bridge in the presence of a
larger fracture gap (13, 30, 76, 80 a, 83), or by a
“necrosis bridge” resulting from vascular injury
(103; Fig. 23.35). We are unable to provide any
data on the incidence of these growth disturbances, occurring as they do in the setting of ligament avulsions which themselves are extraordinarily rare.
Because the cause and occurrence of a
possible bridge are not initially predictable, the
growth disturbance cannot be influenced by primary treatment. Open, anatomically precise reduction and screw fixation can avoid a possible
periosteal bridging callus in the case of displaced
avulsions but cannot repair any possible vascular
injury. Remember that the possibility of iatrogenic vascular injury cannot be excluded in any
such operation.
The primary goal of treatment is therefore to
eliminate instability, i.e., displacement of avulsed
fragments, and in so doing to provide the best
possible conditions for avoiding growth disturbances.
Nondisplaced epiphyseal and metaphyseal
avulsions are treated conservatively by immobilization in a plaster thigh cast in an outpatient pro-
Knee Injuries
Fig. 23.35 Growth disturbance secondary to a
metaphyseal ligament avulsion. The patient is a 10year-old girl with a nondisplaced avulsion of the medial
collateral ligament from the medial femoral metaphysis.
After nine months, clinical and radiographic examination of the knee demonstrated severe abnormal varus
359
growth. The radiographs identified partial closure of the
growth plate as the cause of the deformity. In the A-P
image, this closure appears as a marginal periosteal
bridge. The CT scan shows that nearly the entire medial
growth plate has ossified. The size of the bridge suggests that this is the result of vascular injury
Fig. 23.36 Treatment of collateral ligament avulsions. Only displaced metaphyseal and epiphyseal bony avulsions of the collateral ligaments are treated surgically to restore stability, as in this 12-year-old boy
360
Specific Injuries—Lower Extremities
cedure. In the former case, this assumes that MRI
has ruled any associated injuries requiring treatment.
Displaced metaphyseal and epiphyseal ligament avulsions should be openly reduced and
fixed in every case. In epiphyseal avulsions, this is
done solely to restore stability (Fig. 23.36); in
metaphyseal avulsions, it is also done to reduce
the size of a possible periosteal bridge. Any surgical intervention should include MRT evaluation of
the entire knee to detect and allow treatment of
associated meniscus injuries or laxity of the posterior medial capsular triangle. The patients
should be hospitalized until wound healing has
been confirmed. They are immobilized postoperatively in a posterior plaster thigh splint that
is closed to form a thigh cast to allow mobilization
once wound healing has been confirmed. The
knee is then mobilized in the cast with full weight
bearing.
Partial immobilization for a total of four
weeks is required after both conservative and surgical treatment. This means the patient should
perform assisted motion exercises out of the
splint right from the start. The x-ray out of plaster
obtained after this period should confirm bony
union with the fragment. Testing function and
stability this early is not recommended. Patients
will then intensify the motion exercises and begin
increasing weight bearing.
Where spontaneous mobilization proceeds
well, the patient will usually be able to move the
knee freely within three weeks. He or she can also
resume sports at that time if the knee remains
asymptomatic without effusion.
Physical therapy should be initiated if the
knee cannot be spontaneously mobilized within
the first two to three weeks. The patient may resume sports once unrestricted motion has been
regained.
Further radiographic examinations will no
longer be necessary once the patient has resumed
sports without any problems. Clinical follow-up
examinations should be performed at intervals of
six months to a year until two years after trauma,
and in adolescents until cessation of growth. Remember that the risk of a growth disturbance
decreases with increasing age.
Where a growth disturbance involving partial
premature closure of the growth plate has occurred, findings should be documented in radiographs. Even where the A-P radiograph gives the
impression that a marginal periosteal bridge is
clearly responsible, it is best in children under age
10 to obtain an additional MRI scan in order to
ascertain the full extent of the bridge and its
shape if a resection of the bridge is planned (111;
Fig. 23.35). This is not recommended in patients
about to enter puberty because the deformity can
no longer spontaneously correct itself and a corrective osteotomy would be required in any case.
With these patients, it is best to wait until cessation of growth and then perform a single definitive corrective osteotomy at that time. Clinical
symptoms may demand early correction. Depending on the patient’s age, the best strategy
may then be to overcorrect the deformity to spare
the patient the prospect of a second osteotomy.
Where MRI findings in young patients contraindicate bridge resection, there will be no choice but
to perform repeated osteotomies. Because of the
partial shortening that occurs after this growth
disturbance, treatment should invariably involve
an opening osteotomy with a lengthening correction; a shortening osteotomy with removal of a
bone wedge should only be performed as a simultaneous procedure to correct a preexisting known
difference in leg length.
Bony Avulsions of the Cruciate Ligaments
In our study group, 34 out of the 35 bony avulsions were fractures of the intercondylar eminence of the tibia, i.e., avulsions of the anterior
cruciate ligament. In only one case did the injury
consist of a nondisplaced bony avulsion of the
posterior cruciate ligament (63). The fracture of
the intercondylar eminence is the most common
epiphyseal fracture of the proximal tibia. It does
not involve the growth plate.
Diagnosis
When in doubt, the diagnosis can invariably be
made on the basis of the lateral radiograph. Additional files (such as a tunnel view) are not necessary. Clinical symptoms invariably include hemarthrosis. In patients with wide open growth
plates, the injury will most often occur as an avulsion of the entire tibial eminence. Isolated avulsion of one of the two intercondylar tubercles is
only rarely observed.
Forms of Injury
For therapeutic and diagnostic purposes (12), we
must distinguish between nondisplaced and incompletely displaced fractures (113; Fig. 23.18).
Knee Injuries
Problems and Complications
Published data on the late prognosis of these injuries vary greatly and are not specific about the incidence of complications and associated injuries
that affect prognosis (12, 14, 54, 117). In some
cases, posttraumatic instability is reported to remain in up to 50% of all cases without identifying
causal factors (12, 59). Whereas no associated injuries are to be expected in nondisplaced fractures
of the intercondylar eminence of the tibia, this
does not appear to so clear in the case of incompletely displaced “hanging” fractures. It is true
that in the setting of completely displaced fractures (8, 10, 12, 17, 73, 113; Fig. 23.37 a,b) one encounters the most common associated injuries
such as meniscus injuries, collateral ligament
avulsions and ruptures, and direct cartilage damage, all reflective of the greater trauma. Following
the presumptions of a multicenter study (12), we
have consistently performed arthroscopy even in
patients with incompletely displaced fractures
over the last seven years. We failed to find any relevant associated injuries in any of these patients,
which in our opinion confirms that our classification and procedure are appropriate and further diagnostics in hanging fractures are not necessary.
Growth disturbances are only possible where
iatrogenic injury to the apophyseal growth plate
has occurred, either in an incorrect approach involving removal of the tibial tuberosity
(Fig. 23.37) or due to transepiphyseal internal
fixation to achieve interfragmentary compression
(Fig. 23.39 a–c). Pseudarthrosis is possible but will
not necessarily cause symptoms.
361
Arthroscopy is also performed in completely
displaced fractures. The fracture is inspected for
associated injuries, reduced, and stabilized with
two percutaneous Kirschner wires (70, 78, 113,
120, 124). The wires are then cut off above the
level of the skin in the usual manner, and an opening is left in the plaster. The injury is then immobilized in a plaster splint, which is closed to form a
cast once the swelling has subsided.
Arthrotomy is indicated where reduction of
the fracture or sufficient treatment of associated
injuries cannot be achieved by arthroscopic
means. We enter through a slightly lateral longitudinal incision over the patella and open the
joint medially. With a sufficiently large fragment,
anatomically correction reduction and fixation
can be achieved with a small fragment screw
coursing from medial and distal to proximal and
central (8, 13, 47, 67; Fig. 23.39). A screw with
shorter threading may be required under certain
circumstances. The advantage of this type of fixation is that it eliminates the need for a second arthrotomy because the metal implant can be removed in an outpatient procedure with the
patient under local anesthesia. The disadvantage
is that growth disturbances can occur
(Fig. 23.39 b). If the fragment is too small, then the
screw must be inserted from the joint, and a
washer may be required under certain circumstances. This invariably requires a second arthrotomy or repeat arthroscopy to remove the
screw. Therefore, the recommended technique in
these cases is to place a Dexon suture through the
epiphyseal bone without hurting the physis,
eliminating the need for removal of metal implants.
Treatment
The goal of treatment is to eliminate the instability, i.e., the displacement of the fragment, and to
repair any possible associated injuries.
Nondisplaced and incompletely displaced
fractures are immobilized in a plaster thigh splint
with the knee hyperextended after the hemarthrosis has been drained (121). Placing the knee in
hyperextension is painful, and therefore requires
prior administration of adequate medication. The
splint is closed to form a cast after four to five
days. A lateral radiograph (Fig. 23.38) is obtained
to verify the correct position of the fragments.
Arthroscopy is indicated where correct position has not been achieved. The fracture is then
reduced under arthroscopic visualization with
the aid of a hook probe and immobilized in a
plaster splint.
Immobilization and Consolidation
In all of these cases, the patient is immobilized in
a plaster splint for five weeks. Usually, a cast will
be sufficient, which can be subjected to full
weight bearing once it has hardened. The cast
should be closely molded in the supracondylar region to prevent slippage. While in the cast, the
patient must engage in intensive quadriceps
training.
Bony union of the fragment is verified in a
radiograph out of plaster obtained after five
weeks. Then the patient may spontaneously mobilize the knee for the next two to three weeks
while continuing intensive quadriceps training.
Physical therapy is indicated if satisfactory mobility in the knee has not been regained after this
time.
362
Specific Injuries—Lower Extremities
a
Fig. 23.37 a Late sequelae of completely displaced
avulsions of the intercondylar eminence of the tibia.
The patient is an 11-year-old boy who underwent primary surgery for a completely displaced avulsion of the
intercondylar eminence. At the time, access was gained
to the knee through an anterior approach after removing the tibial tuberosity. Both the avulsed intercondylar
eminence and the tibial tuberosity were fixed with
chromic catgut sutures. There was no mention of
possible associated injuries
Knee Injuries
363
Fig. 23.37 b At the follow-up
examination nine years later,
the patient, now age 20, exhibited extensive lateral
degenerative joint disease
(arrows in the A-P image) with
a posterior bowing deformity
of the right tibial plateau. This
was a sequela of a growth disturbance (arrow in the lateral
image) following iatrogenic injury to the tibial tuberosity. It
is not possible to say for certain whether the degenerative
joint disease is attributable to
associated injuries that were
not mentioned or whether it
may be regarded solely as a
sequela of the posterior
bowing deformity with instability of the knee (from: 113)
b
Sports Participation and
Follow-up Examinations
We remove the metal implants once unrestricted
mobility has been regained, within 8–12 weeks of
the accident. Where unrestricted mobility continues after implant removal, the patient may
carefully resume sports activities. Where sports
participation continues without any problems,
treatment may be concluded within three to four
weeks of the resumption of sports.
Further radiographs are only required where
symptoms occur. Patients with open growth
plates will occasionally exhibit an increased anterior drawer sign in the absence of subjective or
objective symptoms. This in itself is not an indica-
364
Specific Injuries—Lower Extremities
a
Fig. 23.38 a u. b Treatment of avulsions of the intercondylar eminence of the tibia. Nondisplaced or incompletely displaced fractures are treated conservatively as a matter of course. In this 13-year-old boy, the
incompletely displaced fracture was reduced by hyperextending the knee after draining the hemarthrosis. The
intercondylar eminence then healed in proper position
(a)
tion for corrective action or further diagnostic
procedures. Physiological tension in the traumatically stretched ligament should be restored at the
latest by the generalized tightening of ligaments
that occurs during and after puberty. Annual
clinical follow-up examinations until cessation of
growth are indicated only where this condition is
accompanied by subjective symptoms.
Nonbony Cruciate Ligament Injuries
This injury is a domain of adolescents above age
12, although it can also rarely occur below age
10–12 (16, 58, 80, 92). In one quarter of these
cases, there is an avulsion from the distal or proximal insertion. Half of all cases involve isolated injuries, whereas the others involve combined injuries (63).
Knee Injuries
365
Fig. 23.38 b At the follow-up
examination seven years later,
clinical and radiographic findings demonstrated symmetrical
anatomy. Function was unrestricted, and the ligaments in
both knees exhibited symmetrical sufficiency (from: 113)
b
Diagnosis
The tentative diagnosis is made on the basis of
hemarthrosis and the findings at primary or postprimary clinical examination of the ligaments.
One can attempt to confirm the diagnosis of a
ligament injury and associated injury by MRI (60).
In spite of technical advances, this remains controversial (3). However, the reasons given are invariably drawn from retrospective experience. Ultrasound evidence of instability may represent
another diagnostic option (97). Arthroscopy
should only be performed where it will directly
affect treatment.
Treatment
The goal of treatment should be to restore stability. In pursuing this goal, we are confronted by
two problems: The first problem, also seen in the
results of anterior cruciate ligament reconstruction in adults, is that restoration of stability can
366
Specific Injuries—Lower Extremities
a
Fig. 23.39 a–c Treatment of avulsions of the intercondylar eminence of the tibia. Completely displaced
fractures are treated by primary surgery. Fixation can be
achieved with a lag screw coursing from distal to proximal, as suggested by Häring (21) and performed in this
15-year-old boy (a)
only be ensured in about 80% of all cases.
Moreover, this success rate is largely independent
of the method of treatment performed. This
forces us to contemplate the unpleasant question
of whether the restoration of stability may be
more readily attributable to aftercare than to the
surgery itself (40, 41). In spite of all efforts to treat
it, instability persists in 20% of all cases (50, 93,
99, 100). The second problem we must bear in
mind is that any ligament reconstruction through
the growth plate like those performed in adults
entails a risk of growth disturbances even if experiments performed to date have failed to confirm any (7, 94, 119, 131, 134, 136). Accordingly,
the indication for reconstruction through the
open growth plate should be narrowly defined,
because in the literature the sexual development
of the patients—as a sign of maturity of the physis
around the knee—analogous to Tanner (156) is
never described. In the treatment of adult trauma,
Knee Injuries
367
b
Fig. 23.39 b The advantage of this method is that the
metal implants can be removed through a small extraarticular stab incision. Because the osteosynthesis crosses
the growth plate, there is a risk of an iatrogenic growth
disturbance. Such a growth disturbance occurred in this
patient although the metal implants had been removed
as early as 12 weeks postoperatively. Despite the fact
that patient was 15 years old at the time of accident, a
premature closure of the anterior growth plate occurred
and led to subsequent abnormal growth with a posterior
bowing deformity
some surgeons have begun to adopt more specific
criteria in defining the indication for reconstruction of isolated anterior cruciate ruptures. They
feel that such intervention is indicated only
where the initial signs of decompensation appear
(50, 122,141, 148, 154). We tend to agree with this
view in principle, and especially so where the
growth plates are not yet closed.
Over the last few years, a number of authors
have reported on transepiphyseal reconstructions
(7, 94) and extraepiphyseal reconstructions (64,
79, 80, 92) of the anterior cruciate ligament in
patients with open growth plates in which
growth disturbances did not occur. The argument
is that 1) reconstruction of the anterior cruciate
ligament, even of an isolated rupture, is absolutely necessary given the poor results of conservative treatment, and 2) growth disturbances
need not be feared because the growth plate can-
not ossify at the site of the graft. Nonetheless, the
indication for reconstruction of an isolated injury
to the anterior cruciate ligament remains extremely questionable especially when one compares the alleged goal of treatment, restoration of
stability, with the late results. Furthermore, the
absence of growth disturbances in these small series of 20–30 patients (including some patients
with premature growth plates) is not conclusive
proof that such operations cannot also result in
vascular injury that damages growth plates. A
possible explanation for the lack of growth disturbances may be that these were adolescents with
premature growth plates. Above age 10, adolescents exhibit an extremely broad range of individual variation in maturation, which is not a
function of age but of the respective Tanner stage.
Such a differentiation of the varying degree of maturity as measured by the Tanner stage has been
368
c
Specific Injuries—Lower Extremities
Fig. 23.39 c The resulting symptoms required a corrective osteotomy
(my thanks to Prof. Gächter, Kantonsspital Basel, Switzerland, for providing the radiographs of the osteotomy)
lacking in the published literature to date. All
things considered, we remain highly skeptical of
this indication and technique, and our procedure
reflects this skepticism.
Regardless of the maturity of the growth
plates, we would invariably reattach an isolated
avulsion of the anterior cruciate ligament from its
insertion, regardless of whether the proximal or
distal insertion is involved. This can readily be
done using a transepiphyseal technique without
the risk of producing growth disturbances. The
ligament is reattached with one suture each of
nonabsorbable and absorbable suture material
through drill holes drilled with a Kirschner wire.
Where the injury is an intrasubstance rupture
of the ligament without any associated injuries
and the patient’s growth plates are still open, we
treat in the same manner as a ligament reconstruction and have the patient undergo physical
therapy with muscular strength training. Then we
Knee Injuries
have the patient use forearm crutches and refrain
from weight bearing for six weeks. After gradually
increasing weight bearing after this period, the
patient may only resume school sports after four
to five months. Patients should refrain from
sports like skiing and soccer for at least one year
after the accident. Where the patient remains
stable and compensated under these conditions,
treatment may be concluded after a year and a
half. The patient should be informed that a ligament reconstruction should be performed where
there are signs of the onset of decompensation.
Where the injury is an anterior cruciate rupture involving associated injuries in a patient with
open growth plates, we suggest repairing the associated injuries in patients under 10 and then
simply suturing the ligament in the hope of reconstructing a base structure along which a stable
cruciate ligament can develop during the course
of functional aftercare (51). Beyond age10–12, we
would then risk reconstruction of the anterior
cruciate ligament in the usual manner regardless
of the status of the growth plates.
Where the injury is an intrasubstance injury
in a patient with closed growth plates, we discuss
the procedure with the patient and his or her
parents and inform them of the respective surgical results (38, 40, 41). If the patient and his or her
parents decide against an operation, then we prescribe muscular training and proceed as described previously. Otherwise, the cruciate reconstruction (open or arthroscopic) is performed
with a free graft from the patellar tendon. Postoperatively, the knee is placed on a continuous
passive motion device in a position ranging from
60⬚ of flexion to full extension. Once wound healing has been confirmed, the patient is mobilized
in a removable thigh splint that allows increasing
weight bearing. The patient undergoes regular
physical therapy while in the splint. Five to six
weeks postoperatively, the patient receives increasing muscular training until the quadriceps
and especially the vastus medialis have
completely stabilized after three months. Where
this therapy is successful without producing any
symptoms, the patient may resume school sports
after five to six months.
In combined injuries (cruciate, collateral,
meniscus, and posterior capsule), the most common associated injuries accompanying the anterior cruciate ligament injury are ruptures or avulsions of the medial collateral ligaments combined
with meniscus injuries, followed by injuries to the
posteromedial capsule and the lateral meniscus
369
and lateral collateral ligament. Direct cartilage
damage may also be observed in the femoral condyles and in the tibial plateau.
The rotational buffer function of the medial
meniscus should be preserved as much as
possible, i.e., it should be reconstructed whenever
possible. For this reason, the injury to the posteromedial capsule should invariably be repaired,
and the meniscus should be sutured whenever
possible. The respective techniques are described
in the applicable literature on adult reconstruction. Only small free cartilage fragments in the
central or anterior portion that do not appear to
warrant reconstruction are resected and removed. We do not reconstruct the medial collateral ligaments in combined injuries but instead
repair the central column, the cruciate ligaments
themselves. In these patients, we only reconstruct
the anterior cruciate ligament. Our preferred
technique is to use a free graft from the patellar
ligament. We invariably prescribe functional aftercare as described previously. Our procedure
also consists of increasing muscular strength
training in the case of complex combined injuries.
Therapy must allow for cases in which a meniscus
suture was performed, and here we reduce the
functional extension exercises accordingly.
Isolated Meniscus Injuries
Isolated meniscus injuries are extremely rare, and
in children the lateral meniscus is involved more
often than the medial meniscus (31, 52, 61, 62,
102, 130, 146). Usually, this lateral prevalence is
attributed to a lateral disk meniscus (52).
As typical clinical symptoms are only present
in exceptional cases, the diagnosis of these injuries must rely on observation of the course of the
disorder and MRI. Secondary blockade and joint
effusion occurring after torsion trauma with or
without primary hemarthrosis are naturally indications for MRI. Treatment of these combined
injuries basically involves as much reconstruction
as possible, i.e., only smaller fragments are removed whereas larger avulsions are sutured. Naturally, this can be done via arthroscopy. The respective techniques are described in the applicable literature on adult reconstruction.
370
Specific Injuries—Lower Extremities
Tibial Diaphysis—Isolated Tibial Fractures (10.8%)
Forms
앫 Greenstick fractures
앫 Complete fractures:
— Oblique fractures (most common form occurring in over 80% of all cases)
— Transverse fractures
Problems
앫 Varus deformity is present in 40% of all cases following the most common oblique fractures (due
to blockage by the fibula). This is best eliminated
by a cast wedge placed on the eighth day.
앫 Compartment syndrome is a rare possibility in
adolescents.
Radiographs: A-P and lateral.
Growth stimulation:
앫 A slight increase in length occurs up to age 10.
앫 A slight decrease in length occurs above age 10.
Further treatment without anesthesia or delayed
treatment under anesthesia
앫 Secondary compartment syndrome,
앫 Cast wedge applied on the eighth day after the
accident,
앫 Where no initial varus deformity was present,
a radiograph to verify correct position is obtained on about the eighth day. A cast wedge is
indicated where varus deformity is present.
Technique of conservative fixation
앫 Plaster thigh splint,
앫 Sarmiento cast in older patients after two
weeks.
Technique of surgical fixation: External fixator.
Aftercare
Limits of correction
앫 No malrotation,
앫 Proper axial alignment.
Period of immobilization
앫 With conservative fixation: Four to five weeks.
앫 With surgical fixation: Immediate spontaneous
motion and weight bearing.
Definition of “nondisplaced”: Varus deformity not
exceeding 5⬚; no valgus deformity; a posterior or
anterior bowing deformity not exceeding 10⬚.
Consolidation radiographs: Only after surgical fixation (rare).
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Medical.
앫 Where indication is uncertain: Immobilization in a plaster thigh splint.
Emergency treatment under anesthesia
앫 Imminent compartment syndrome or other
distal neurovascular dysfunction.
앫 Completely displaced fractures, especially
transverse fractures.
앫 Severe malrotation exceeding 15⬚.
A primary varus deformity of 10–20⬚ that may
often be present is not an indication for emergency treatment.
!
All other indications should first be discussed at
length with the patient and his or her parents.
Initial mobilization
앫 Patient: Immediately on forearm crutches
without weight bearing.
앫 Joints: Spontaneously immediately after removal
of plaster splint.
Physical therapy: None.
Sports: Three to four weeks after consolidation.
Removal of metal implants: Upon consolidation.
Follow-up examinations and conclusion: Examinations are performed at three- to four-week intervals
until unrestricted function is regained. After that, examinations continue at six-month intervals. Treatment is concluded two years after the accident in the
presence of symmetrical function and leg axes
without any difference in leg length. Where a leglength difference is present, follow-up examinations
are continued every year or two until cessation of
growth.
371
24
Fractures of the Tibial and Fibular Shaft
Isolated Tibial Shaft Fractures
Seventy percent of these injuries are isolated fractures of the tibia, whereas both bones are involved in the remaining 30% (44, 61, 71). The isolated fracture of the tibia is the most common
fracture of the lower extremities (61, 71). Isolated
fractures of the tibia are most often spiral fractures with or without a spiral wedge. Rarely, they
occur as complete transverse fractures and greenstick fractures, each with an incidence of slightly
less than 10%.
Diagnosis
The diagnosis is easily made on the basis of the
radiograph. Usually, the injuries are long oblique
fractures of the middle and lower third of the
bone; transverse fractures are rare. Regardless of
the form of the fracture, all tibial fractures except
nondisplaced transverse fractures have the tendency to slip into an increasing varus deformity
because the surrounding musculature has a
shortening effect where the fibula remains intact.
This deformity may be expected to occur in about
half of all cases.
Growth Disturbances
The growth disturbance involving transient
stimulation of the growth plates adjacent to the
fracture leads to a slight alteration in leg length.
During the growth phase, the severity of lengthening will depend on the remodeling of any residual deformities and will vary between 0.5 cm
and 1 cm (35, 36, 44, 110, 112).
“Spontaneous Corrections”
Residual deformities, and varus deformities in
particular, undergo age-related correction during
the course of further growth. Appositional growth
will fill the concavity of the deformity, and the
epiphysis will gradually realign itself perpendicu-
lar to the plane of motion (Fig. 24.1). In younger
children up to the age of 10, varus deformities of
up to 25⬚ are well corrected. Reliable corrections
may no longer be expected beyond this age.
Because they lie in the plane of motion, posterior bowing deformities have a good prognosis.
Deformities measuring up to 20⬚ are spontaneously corrected in patients age 10 or younger
(5, 11, 35, 36, 66). Anterior bowing deformities are
hardly encountered at all. Side-to-side displacement is corrected perfectly at this location. Residual deformities may persist in adolescents.
With respect to fractures in the lower leg, the
consensus in the literature is that malrotation in
the lower leg is not “spontaneously” corrected by
further growth. In principle, this is open to question. Changes in version during the course of
growth also occur in the lower leg. These changes
can cause “spontaneous correction” of malrotation as they do in the femur. However, these physiological retroversion processes are already
complete by about age five, an age at which these
fractures are rare.
This means that for all practical purposes, we
must assume that posttraumatic malrotation in
the lower leg will no longer undergo “spontaneous
correction” because of the patient’s age. There is
no functional compensation for malrotation in the
lower leg as there is in the femur, because the knee
and ankle each essentially have only one plane of
motion. In light of this, one would expect this deformity to promptly and invariably cause increasing symptoms in the knee and/or ankle. However,
this is not the case. Only a few patients with
malrotation in the lower leg report symptoms.
This may be because such malrotation deformities
are clinically and radiographically indistinguishable (in axial measurements of computed tomography [CT] or ultrasound images) from idiopathic
version differences. Upon cessation of growth, we
will encounter idiopathic version differences in
the same incidence and magnitude in individuals
without a fracture as posttraumatic malrotation
deformities (44, 110, 112).
Fig. 24.1 “Spontaneous corrections” in the lower leg. The varus deformity
that frequently occurs secondary to isolated tibial shaft fractures due to the blocking action of the fibula is usually spontaneously well corrected during further
growth, as in this 11-year-old boy. The important thing is that the distal tibial
epiphysis and with it the ankle realign themselves perpendicular to the plane of
motion. Residual side-to-side and varus deformities can persist in adolescents
372
Specific Injuries—Lower Extremities
Fractures of the Tibial and Fibular Shaft
Matters are complicated by another poorly
understood phenomenon: Additional differences
in version appear to occur prior to puberty regardless of whether the patient has suffered a
fracture. The causes, incidence, and magnitude of
these differences are not at all clear.
Treatment
The goal of treatment consists of counteracting
the varus tendency and eliminating any malrotation exceeding the clinical margin of error of 10⬚.
Even if further growth could correct axial deviations in the coronal and sagittal planes, it is best
not to leave such deformities untreated in the interest of minimizing posttraumatic leg-length
differences and for cosmetic reasons (as patients
may find them intolerable).
Because tibial shaft fractures are nearly always stable fractures, treatment is conservative
on an outpatient basis (34, 53, 57, 69, 133). Subcutaneous cerclage, screw fixation, plate fixation
(30, 101), or traction will at best help amortize a
Symmetrical version
Fig. 24.2 Monitoring malrotation in the lower leg.
In isolated tibial shaft fractures, as in fracture of both
bones of the lower leg, care should be taken when applying the splint to ensure correct rotation symmetrical
with the contralateral leg. Most individuals exhibit a
physiological external version of the tibia of about
10–15⬚. With the patient standing or the foot in a neutral
373
hospital’s assets but are rarely in the patient’s best
interest.
In contrast to the femur, malrotation in an
acute lower-leg fracture can be clinically evaluated and even corrected as part of primary treatment. The level of the malleoli (using the foot as
an indicator) is compared with the level of the tibial condyles (using the patella as an indicator).
The surgeon must restore the specific individual
version by achieving symmetry with the contralateral leg. Viewed axially, the great toe will
align with the middle of the patella in 15–20⬚ of
external rotation of the tibia. In the physiological
external rotation of 10–15⬚, the second toe will
align with the middle of the patella (Fig. 24.2).
With nondisplaced fractures, we place the
patient under pain medication and apply a posterior thigh gutter splint with side reinforcements.
Because we continue to employ primary splinting, we do not initially apply a Sarmiento cast
(96). We would only apply this to older children or
adolescents. On about the fourth day, we close the
circumference of the splint to form a cast (or we
Left external
rotational deformity
position (90⬚ position), the second toe should align with
the middle of the patella in the longitudinal axis of the
lower leg. In the most common type of malrotation, the
external rotational deformity, the lateral malleolus migrates posteriorly. Depending on the severity of the deformity, the great toe will then align with the middle of
the patella
374
Specific Injuries—Lower Extremities
remove the splint and apply a Sarmiento cast).
After eight days, we obtain an x-ray in plaster. If
we see a deformity at that time, we eliminate it by
applying a cast wedge. In patients below age 10,
we dispense with radiographic documentation of
the results of the cast wedge treatment. In
patients older than age 10, we do so regularly
(Fig. 24.3).
Slightly displaced fractures (up to 10⬚ of
malrotation and varus deformity) are also immobilized in the usual plaster thigh splint after we
place the patient under pain medication and
eliminate the malrotation. On about the fourth
day, we close the circumference of the splint to
form a cast. Then on the eighth day, we place a
cast wedge without obtaining a prior radiograph.
We then document the results of the cast wedge
treatment in radiographs (Fig. 24.4).
We feel that primary reduction with the
patient under general anesthesia is indicated only
in very rare cases, where severe malrotation is
present and in rare, completely displaced transverse fractures. The results of the reduction must
be documented during the same session (where
reduction was justified, these radiographs will
differ significantly from the initial images of the
acute injury). These reduced fractures receive the
same further treatment and follow-up as initially
nondisplaced fractures.
We would see an indication for surgery—in
contrast to other authors (135, 152)—only in adolescents with closed growth plates who have
suffered transverse fractures at the junction between the distal and middle thirds of the bone.
The same applies to second to third degree open
fractures, imminent compartment syndrome, etc.
We treat these cases with an external fixator
(Fig. 24.5). The external fixator is applied anteromedially as usual.
Fig. 24.3 Treatment of “stable” fractures of the
lower leg, isolated tibial shaft fractures. Where there
is no initial deformity, as in this nine-year-old boy, we obtain an x-ray in plaster on about the eighth day. Where a
varus deformity has occurred, we eliminate it with a cast
wedge. The results of the cast wedge treatment are
documented in radiographs in children above age
10. The x-ray out of plaster obtained after a total of five
to six weeks confirmed sufficient periosteal callus formation. We have since dispensed with consolidation
radiographs in isolated tibial fractures and now rely entirely on clinical examination. No further radiographic
follow-up examinations will be necessary
Fractures of the Tibial and Fibular Shaft
375
Fig. 24.4 Treatment of “stable” fractures of the
lower leg, isolated tibial shaft fractures. The patient is
a nine-year-old boy with an isolated fracture of the tibia
with an initial varus deformity. The acute fracture was
immobilized in a plaster thigh splint at another facility,
and a radiograph in plaster was obtained immediately
after the splint was applied. We left the initial varus de-
formity uncorrected and eliminated it on the eighth day
without a prior radiograph. The results of the cast wedge
treatment were then documented in radiographs. The
fracture exhibited good clinical and radiographic healing
in proper axial alignment. We have since dispensed with
obtaining consolidation radiographs of isolated tibial
fractures
After the splint has been closed to form a cast
on about the fourth day, the patients (depending
on age) are mobilized at home on forearm
crutches without weight bearing under parental
supervision. This is often difficult for children
below age five to six. It is best not to expend a
great deal of effort on physical therapy in the attempt to teach them how to walk on crutches. A
better idea is to leave the patients up to themselves and the support of their loving parents or
older brothers and sisters. This may not be tolerable for the patient, and older patients have significant problems with crutches, such as an extremely long walk to school, etc. In such cases, we
replace the cast with a Sarmiento cast in the sec-
ond week or so. Patients may then begin full
weight bearing once the cast has hardened.
Immobilization and Consolidation
We remove the cast as a matter of course sometime between the fourth and fifth week. An x-ray
out of plaster may be obtained at the discretion of
the physician. We have since dispensed with this
examination entirely. Once the palpable callus is
no longer tender to palpation upon clinical examination, the patient may begin spontaneous
weight bearing. Small patients will usually have
begun doing so as early as during the second or
third week. Here, too, there is no need for any
rules or restrictions.
376
Specific Injuries—Lower Extremities
a
Fig. 24.5 Treatment of isolated tibial shaft fractures
involving imminent compartment syndrome. The
patient is a 12-year-old boy with an isolated tibial fracture. Because a compartment syndrome appeared imminent, emergency surgical decompression of the fascia was performed. The fracture was then stabilized with
an external fixator. A dynamic adjustment was made to
the fixator two weeks postoperatively. The patient
began full weight bearing three weeks postoperatively
(b). After a total of six weeks, the fracture exhibited 왘
stable clinical and radiographic healing (a) that permitted removal of the fixator. The metal implants were
removed without anesthesia; the patient only received
pain medication. No further radiographs were obtained
after this. At the follow-up examination two years later,
the patient was free of subjective symptoms, and the affected leg exhibited 1 cm of posttraumatic lengthening
Where clinical examination of healing reveals
that the callus is still tender to palpation or in the
case of particularly apprehensive patients, we
apply a short-leg walking cast (not a Sarmiento
cast) for another two to three weeks. Once this
walking cast is removed, clinical examination will
suffice.
In patients who have undergone surgical fixation, consolidation is documented in radiographs
after four to six weeks. The metal implants are removed after administration of pain medication
where clinical and radiographic examination confirm healing.
Fractures of the Tibial and Fibular Shaft
377
Sports Participation and Follow-up
Examinations
Most patients will be able to walk without limping three weeks after the cast has been removed,
including walking on their heels and tiptoes.
Where this is the case, they may gradually resume
sports. Otherwise this should be postponed until
after the next clinical examination two to three
weeks later.
Once the patient has resumed normal sports
participation without any symptoms, leg length
should be evaluated with functional clinical
measurements once a year until two years after
the accident. Treatment may be concluded where
both sides exhibit symmetrical function and
structural alignment. Where significant differences in leg length alter the structural alignment
of the spine, we continue clinical follow-up examinations at two-year intervals until cessation
of growth.
b
378
Specific Injuries—Lower Extremities
Tibial and Fibular Diaphysis (2.9%)
Forms
앫 Oblique fractures (approximately 50% of all
cases)
앫 Complete transverse fractures (approximately
50% of all cases)
앫 Greenstick fractures (less than 10% of all cases)
Radiographs: A-P and lateral.
Growth stimulation
앫 A slight increase in length occurs up to age 10.
앫 A slight decrease in length occurs above age 10.
Limits of correction
앫 No malrotation,
앫 Proper axial alignment.
Definition of “nondisplaced”: See Isolated Tibial
Shaft Fractures, p. 370 f.
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Medical.
앫 Where indication is uncertain: Immobilization in a plaster thigh splint.
Emergency treatment under anesthesia
앫 Completely displaced fractures,
앫 Isolated malrotation exceeding 15⬚,
앫 Imminent compartment syndrome or other
distal neurovascular dysfunction.
!
Technique of conservative fixation: Plaster thigh
splint with placement of a cast wedge on the
eighth day where indicated.
Technique of surgical fixation
앫 External fixator for all unstable oblique, comminuted, or torsion fractures,
앫 Intramedullary nailing for transverse fractures.
Aftercare
Period of immobilization
앫 With conservative fixation: Four to five weeks.
앫 With surgical fixation: Immediate spontaneous
motion and weight bearing.
Consolidation radiographs: Yes.
Initial mobilization
앫 Patient: Immediately on forearm crutches
without weight bearing.
앫 Joints:
— Spontaneous immediate mobilization after removal of plaster splint.
—Immediate full weight bearing with an external
fixator.
—Immediate mobilization (gait cycle with normal
heel off and toe off) with intramedullary nailing.
Physical therapy: None.
Sports: Four to six weeks after consolidation.
All other indications should first be discussed at
length with the patient and his or her parents.
Further treatment without anesthesia or delayed
treatment under anesthesia
앫 Secondary compartment syndrome,
앫 Increasing shortening deformity (in an oblique fracture),
앫 Cast wedge applied on the eighth day after the
accident with primary or secondary angulation (in oblique fractures with the fragments
in apposition).
Removal of metal implants
앫 External fixator upon consolidation,
앫 Intramedullary nails two to three months postoperatively.
Follow-up examinations and conclusion: Examinations are performed at three- to four-week intervals
until unrestricted function is regained. After that, examinations continue at six-month intervals. Treatment is concluded two years after the accident in the
presence of symmetrical function and leg axes
without any difference in leg length. Where a leglength difference is present, follow-up examinations
are continued every year or two until cessation of
growth.
Fractures of the Tibial and Fibular Shaft
Tibial and Fibular Shaft Fractures
Shaft fractures of both bones in the lower leg do
not involve the problem of an increasing varus deformity because there is no blockage by an intact
fibula. Accordingly, displaced fractures tend to involve an increasing shortening deformity without
an axial deviation. Varus deformities only occur in
fractures in which a partially fractured fibula still
has a functional blocking effect. Other than this,
these fractures may involve any other axial deviations. A fundamental distinction should be made
between “stable” and “unstable” fractures.
“Stable” fractures may be understood to include
any fractures in which the tibial fragments are
still in apposition regardless of any primary or
secondary axial deviation. “Unstable” fractures
necessarily include any fractures in which at least
the tibia is completely displaced and shortened.
Spontaneous corrections follow the pattern of
tibial fractures. The valgus deformity that can
occur in combined tibial and fibular shaft fractures is only corrected slowly if at all during the
course of further growth.
The goal of treatment consists of achieving a
position with proper axial alignment. This includes any residual deformity that may be regarded as tolerable for the respective age group.
There is a fundamental difference between
“stable” and “unstable” fractures with respect to
achieving this goal.
Nondisplaced “stable” fractures are immobilized in a plaster thigh splint with the patient
under pain medication, taking care to restore
proper version by achieving symmetry with the
contralateral leg. The splint is then closed to form a
cast on about the fourth day. An x-ray in plaster is
obtained on about the eighth day to allow for
eliminating any possible deformities with a cast
wedge (Fig. 24.6). The results of the cast wedge
treatment should be documented in radiographs
as it is possible to overcorrect the injury because of
the fractured fibula. Shortening deformities of up
to 1 cm may be tolerated in oblique fractures in
children where the fragments are locked in apposition. We do not view these cases as indications
for internal or external fixation. Depending on the
patient’s age, the plaster thigh cast can be replaced
with a Sarmiento cast after about two weeks even
in the case of these fractures. In adolescents, an xray in plaster is then obtained in the new cast to
verify proper position. A Sarmiento cast will also
allow use of a cast wedge to eliminate any deformities that may occur.
379
“Unstable” displaced fractures are reduced
with the patient under general anesthesia. Where
stable alignment of the fragments can be achieved
in a transverse fracture, the injury is immobilized
in a plaster thigh splint and treated in the same
manner as a nondisplaced “stable” fracture.
However, in treating “unstable” displaced
short or long oblique fractures requiring reduction with the patient under anesthesia, we have
categorically discontinued all traction therapy. Instead, we stabilize these fractures with an external fixator applied anteromedially (Figs. 24.7,
24.5 b). This means that we no longer view this as
an indication for primary internal fixation only in
adolescents as we once did, but for all patients requiring primary treatment under anesthesia. We
feel that whenever primary treatment is performed with the patient under general anesthesia, that treatment must be definitive. In contrast
to our previous views, we now feel that an external fixator is the appropriate means of stabilization and not plate fixation. Adolescent patients
may disapprove of such treatment for cosmetic
reasons. In this case only, depending on the maturity of the growth plates, we would consider dynamic intramedullary nailing—especially in
transverse fractures (26, 98) where we would
proceed analogously to the recommendations for
femoral shaft fractures—or nailing as practiced in
adults with an interlocked AO or Küntscher nail.
After a total of five weeks after any casts have
been removed, we obtain a radiograph to evaluated fracture healing. Where clinical and radiographic findings confirm solid healing, the patient
may begin with spontaneous weight bearing.
Where pain persists or the patient remains extremely hesitant, we apply a short-leg cast for
another two to three weeks. After this cast is removed, we only perform clinical follow-up examinations. Patients may resume sports participation once they have regained normal gait, including walking on their heels and tiptoes. This
will usually be within about three weeks of
having begun weight bearing.
The remaining follow-up examinations and
the time at which metal implants should be removed are the same as for isolated fractures of the
tibia.
380
Specific Injuries—Lower Extremities
Fig. 24.6 Treatment of
“stable” fractures of the
lower leg—tibial and fibular
shaft fractures. Lower-leg
fractures in adolescents that
are angulated but not
completely displaced (i.e.,
“stable” fractures) should be
treated conservatively, as in
the case of this 14-year-old
girl. The significant deformity
that occurred after application of a new splint was
completely eliminated by cast
wedge treatment on about
the eighth day. The fracture
healed in proper axial alignment
Fractures of the Tibial and Fibular Shaft
Fig. 24.7 Treatment of “unstable” fractures of the
lower leg—displaced tibial and fibular shaft fractures. The patient is an eight-year-old boy with an “unstable” displaced fracture of the tibia and fibula with anterolateral soft-tissue trauma. The fracture was reduced
and stabilized with an external fixator applied medially
Most Common Deformities of
the Tibial and Fibular Shaft
Corrective osteotomies of residual deformities including malrotation should only be performed in
patients with open growth plates where symptoms occur. However, they should be postponed
381
due to the soft-tissue injury. The soft-tissue injury was
treated and healed rapidly. The fracture healed after five
weeks, at which time the metal implants were removed.
After the patient was successfully mobilized and remained asymptomatic with increasing weight bearing,
no further follow-up radiographs were obtained
until one year after the accident. An asymptomatic patient with a residual axial deformity
should undergo clinical follow-up examinations
only until cessation of growth. Surgical correction
should only be performed at that time, depending
on the direction and severity of the residual deformity.
382
25
Ankle Injuries
Diagnostic Notes
Proper radiographic technique is important in obtaining standard anteroposterior (A-P) and lateral
views. A true A-P view means that both malleoli
are parallel to the film cassette. Depending on the
specific tibial version in the individual patient,
the foot must lie on the film cassette in 10–30⬚ of
internal rotation (Fig. 25.1). This fully visualizes
the tibiofibular articulation. However, only the
lateral portion of the ankle and distal fibula are
completely visible; the medial portion of the
ankle is slightly obscured. Medial malleolar fractures at a typical location can occasionally be
missed in this projection. To fully visualize the
medial portion of the joint, the foot must lie perpendicular to the film cassette. However, in this
case the fibula is superimposed over the tibia, and
bony avulsions of the anterior syndesmosis with a
bowl-shaped flake can be overlooked (Fig. 25.26
and 25.27).
Accessory ossification centers (Fig. 25.2) or
normally occurring ossification centers can cause
confusion (see also Chapter 26, Injuries to the
Bones of the Foot). The most commonly occurring
accessory ossification center in the A-P or lateral
view is the os subfibulare, which almost invariably
arises from avulsions of the talofibular ligaments
from the tip of the fibula with a bony flake
(Fig. 25.3).
The contour of the medial malleolus gradually
becomes visible in radiographs between the ages
of seven and nine. A multifocal ossification center
(Fig. 25.2) begins to develop at the tip of the contour of the medial malleolus at about the age of
10–11 but with individual and sex-specific variation, appearing in girls sooner than in boys. Usually, it remains visible for only six months to a year
before fusing with the medial malleolus (12, 37, 39,
49). The full contour of the medial malleolus visible in radiographs will only be visible on radiographs after this has occurred (see Fig. 25.20).
Rarely, this fusion process will fail to occur, and the
ossification center will remain as an accessory
ossification center until the growth plate closes.
The os trigonum often visible posterior to the
talus in the lateral view is not a talus fracture
(Fig. 25.2).
The irregular shape of the distal fibula and its
growth plate change during growth and often
lead to false diagnosis of a separated fibular
epiphysis. From age 10 until shortly before
puberty, the metaphysis often appears wider than
the epiphyseal ossification center of the distal
fibula. The growth plate is irregularly demarcated.
Depending on the projection, the “growth plate”
often appears asymmetrical and often surprisingly far away even in the absence of any separation of the epiphysis (Figs. 25.2 , 25.4).
As regards the diagnosis of a talofibular ligament injury, one should note that lateral instability of the ankle cannot be detected clinically. Even
in the absence of any prior traumatic damage to
the talofibular ligaments, there will be laxity in
the ankle. This laxity exhibits individual, sexspecific, and age-specific variation (70, 73) and
may manifest itself as more or less severe lateral
opening (Fig. 25.4) or even as an anterior drawer
phenomenon. This ligament laxity is more pronounced in girls than in boys. It decreases
markedly with age until the generalized ligament
tightening of puberty occurs. Then symmetrical
tautness in the ligaments of both sides will be
found in about 95% of all individuals (18, 55, 57,
86). Therefore, only a difference with respect to
the contralateral side is a valid parameter of instability. However, a significant difference of 5⬚ that
would be a sign of instability cannot be detected
by clinical measurements. Because this manual
examination is painful, we dispense entirely with
any clinical proof of suspected instability in rotational ankle trauma.
Add to this the fact about 80% of all ligament
avulsions prior to age 12 are periosteal, chondral,
or bony avulsions. In about half of these cases,
avulsed flakes are visible in radiographs. Especially when they are displaced, these flakes are
only partially detectable in the lateral view of the
ankle (Fig. 25.5). Where no bony flakes are found
Ankle Injuries
383
Fig. 25.1 A-P radiographs of the ankle. In
the first A-P view with
the malleoli parallel to
the film cassette, the tibiofibular articular cavity is well visualized.
Lateral epiphyseal fractures (Tillaux fractures)
and avulsions of the
syndesmosis are more
easily detected in this
plane. In the second A-P
view with the foot perpendicular to the film
cassette, the medial
portion of the ankle is
better visualized. The
shadow of the fibula is
superimposed on the
lateral portion of the
epiphysis. Medial malleolar fractures are often
visualized in only one of
these views. Where
clinical findings suggest
medial pathology but
the first A-P view fails to
detect a fracture, a
radiograph in the second A-P project should
also be obtained
in the standard A-P and lateral views, we rely entirely on clinical findings, initiate primary treatment, and dispense with confirmation of lateral
instability.
We see an indication for confirmation of
lateral instability at best in chronic and decompensated cases of instability in which surgical reconstruction is already indicated (see Ankle Injuries Involving the Talofibular Ligaments, p. 406 ff).
The jigs designed for comparative bilateral stress
radiographs in adults only suitable proved for im-
aging with children’s and adolescents’ smaller
feet to a limited extent. For this reason, we have
used the Ross system (56) for a number of years,
which is not age-dependent. This allows nearly
standardized radiographic technique and is easily
applied. Our previous experience with this
method has been good (61, 62, 73; Fig. 25.6 a). This
examination does not require pain medication if
the retaining jig is tightened gradually and incrementally.
384
Specific Injuries—Lower Extremities
Fig. 25.2 Accessory ossification centers in the ankle.
The os subfibulare (thick
arrow) should not be mistaken for a fracture. As well
as to the multifocal ossification centers of the medial
malleolus (outline arrow)
and the os trigonum posterior top the talus (narrow
arrow)
Our experience has confirmed the findings of
other authors that A-P stress radiographs provide
more information than the lateral stress radiographs in growing patients with open growth
plates (21, 61). The talotibial angle is always
measured (Fig. 25.6 b). Given the physiological
laxity of the ligaments in growing patients discussed above, only comparative radiographs of
the contralateral side will provide useful diagnostic information. A difference of 5⬚ or more between both sides is a sign of lateral instability.
This assumes that the patient does not have a history of severe recurrent supination trauma on the
contralateral side.
We feel a lateral stress radiograph is indicated
only in patients with closed growth plates in
whom the A-P stress radiograph does not show
any evidence of lateral instability but clinical findings suggest injury to the anterior talofibular ligament at least. We then perform this study using
the same examination procedure (Fig. 25.6). We
interpret a difference between both sides exceeding 5 mm as instability (Fig. 25.6 c). However, if instability in the ankle is to be documented at all,
then radiographs should not be used. Instead it
should be documented exclusively in ultrasound
scans performed according to the same principles.
With the high incidence of rotational ankle
trauma, the general practitioner or family physician must often decide if and when ankle radiographs are indicated. In principle, none of the
many possible bony or ligamentous injuries can
be clinically excluded in a patient who has
suffered inversion or eversion trauma. We can
neither see nor palpate whether the injury is a
bony avulsion of the syndesmosis or a typical medial malleolar fracture with or without an additional lateral injury. Clinical signs of serious bony
and ligamentous injuries include hemarthrosis
(with protrusion of the capsule beyond the medial malleolus); typical extensive hematomas
over the talofibular ligaments inferior to the
lateral malleolus; and extensive supramalleolar,
medial, and lateral swelling. These symptoms
may occur in injuries such as separated epiphyses.
Radiographic examination is indicated where
signs like these are present. However, negative
radiographic findings cannot always definitively
exclude a bony injury such as a nondisplaced or
spontaneously reduced separated epiphysis
without a metaphyseal wedge. The following procedure can be employed to address this uncertainty: The physician immobilizes the ankle
without a prior radiograph based on findings of
history that include eversion or inversion trauma.
Ankle Injuries
385
Fig. 25.3 Development of the os subfibulare from a
bony avulsion of the talofibular ligaments. The
patient is a 10-year-old boy with rotational ankle
trauma. The initial A-P radiograph shows a fine bony
avulsion of the tibiofibular ligaments with a barely visible
bowl-shaped flake. After conservative treatment in a
short-leg walking cast for two-and-a-half weeks, the
patient was free of symptoms and resumed sports as
before. Over the course of the next three years, an os
subfibulare developed from what was once the avulsed
bowl-shaped flake. The latter radiograph was obtained
to diagnose a subsequent sports injury that also involved rotational ankle trauma
An elastic bandage will suffice where pain and
swelling are moderate, otherwise a plaster splint
is indicated. In isolated rotational trauma without
instability or other associated injuries, pain and
swelling will subside significantly within the first
five days so that the patient will be asymptomatic
when the bandage is removed. These patients can
do without radiographs at that time as well.
However, swelling may persist beyond five
days, the ankle may be tender to palpation, or the
patient may report spontaneous pain. These
patients require diagnostic radiography and, if
necessary, immobilization despite possible negative radiographic findings until pain subsides.
Where the postprimary radiograph was negative,
secondary diagnostic radiographs out of plaster
may be obtained if necessary once the splint has
been removed (Fig. 25.7).
A bone scan can facilitate early diagnosis of a
bony injury (48). However, unlike immobilization, this does not yet treat the patient and involves far greater expense and exposure to ionizing radiation.
We know that injuries to the anterior syndesmosis may occur, either as isolated injuries or associated with separated fibular epiphyses. What
we do not know is how common they actually are.
Ultrasound and magnetic resonance imaging
386
Specific Injuries—Lower Extremities
a
왔
b
왔
Fig. 25.4 Ligament laxity in children. Patients with
open growth plates exhibit opening of the ankle with
age-specific, sex-specific, and individual variation. This
six-year-old girl exhibited significant lateral opening on
the left side (a) after suffering supination trauma. The
contralateral side (b) exhibited “physiological” lateral
opening without a known history of prior trauma. The irregular shape of the distal fibular epiphysis, metaphysis,
and growth plate is normal and should not be mistaken
for a separated epiphysis
Fig. 25.5 Diagnosis of talofibular ligament injuries
in children. Until about age 12, the periosteal, chondral,
or bony ligament avulsions occur in 80% of all cases.
Small avulsed flakes may be observed in about half of
these cases, more often from the fibula than from the
talus. Occasionally, this can only be detected in the
lateral view (from: 73)
Ankle Injuries
387
a
b
c
Fig. 25.6 Stress radiographs of the ankle. These are
only rarely indicated in the presence of decompensated
chronic instability and then only where they will have an
impact of therapy (such as opting for surgical intervention).
a We have used the Ross system for years. This simple
method allows us to obtain largely standardized A-P
and lateral radiographs. However, these stress views
should now be obtained using ultrasound instead of
radiography (from: 73)
b Measurements from the stress views. The A-P stress
view has been shown to provide the most diagnostic
information in growing patients. The talotibial joint
angle is measured in this view
c Lateral stress radiographs are only required in
patients whose growth plates have already closed.
Here, the talotibial distance in the posterior area is
measured to determine the anterior displacement of
the talus
388
Specific Injuries—Lower Extremities
Fig. 25.7 Secondary diagnostics in the ankle. Nondisplaced or spontaneously
reduced separated
epiphyses are not always
clearly identifiable on the
initial trauma radiographs.
Only the callus after two to
three weeks of immobilization in a plaster splint confirms the initial tentative diagnosis
(MRI) can help in identifying them, assessing
their incidence and thus their clinical significance, and initiating the proper treatment.
Nevertheless, it is important to bear in mind
that a specific mechanism of injury in growing
patients does not suggest the presence or absence
of any particular ankle injury.
Ankle Injuries
389
Distal Tibia (Epiphysis and Metaphysis 6.6%):
Metaphyseal Fractures
Forms
1. Impacted fractures
2. Bending fractures
3. Separated epiphyses
Radiographs: A-P and lateral.
Growth arrest
Re 1. No risk.
Re 2. No risk.
Re 3. Possible in 20–30% of all cases.
Growth stimulation
Re 1. Not clinically significant.
Re 2. Invariably occurs; see text.
Re 3. Rarely possible; see text.
Limits of correction
앫 No malrotation,
앫 No axial deviation.
Technique of conservative fixation: Lower-leg
splint with subsequent cast wedge in applicable
cases.
Technique of surgical fixation: Percutaneous pinning with crossed Kirschner wires (percutaneous
cannulated screws may also be used in separated
epiphysis with a large metaphyseal wedge, but
have the disadvantage of requiring a second procedure to remove the metal implants).
Aftercare
Period of immobilization
앫 With conservative and Kirschner wire fixation:
Four weeks.
앫 With screw fixation: Immediate spontaneous motion.
Consolidation radiographs: Yes.
Definition of “nondisplaced”: Varus deformity up
to 5⬚; valgus deformity up to 10⬚; anterior or posterior bowing deformity up to 10⬚; no malrotation.
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Medical.
앫 Where indication is uncertain: Immobilization in a lower-leg splint.
Emergency treatment under anesthesia: All
completely displaced fractures with or without
distal neurovascular dysfunction.
!
All other indications should first be discussed at
length with the patient and his or her parents.
Further treatment without anesthesia or delayed
treatment under anesthesia
앫 All fractures with angulation of the fragments: Cast wedge treatment on about the
eighth day after the accident.
앫 All fractures in which a cast wedge cannot
achieve a tolerable position for the patient’s
age group.
Initial mobilization
앫 Patient: Immediately on forearm crutches
without weight bearing.
앫 Joint: Spontaneously immediately after removal
of plaster splint.
앫 Both: Full weight bearing after consolidation of
the fracture
Physical therapy: None.
Sports: Three to four weeks after consolidation.
Removal of metal implants: Upon consolidation.
Follow-up examinations and conclusion: Examinations are performed at three- to four-week intervals
until unrestricted function is regained. After that,
clinical examinations continue at six-month intervals. Treatment is concluded two years after the accident in the presence of symmetrical function and leg
axes without any difference in leg length. Where
growth disturbances are present, annual follow-up
examinations are continued until cessation of
growth.
390
Specific Injuries—Lower Extremities
Fractures of the Distal
Tibial Metaphysis
Forms of Injury
앫 Impacted fracture (Fig. 25.8 a)
앫 Metaphyseal bending fracture (Fig. 25.8 b)
앫 Separated epiphysis (Fig. 25.8 c)
Metaphyseal impacted fractures are easily treated
as a rule. Usually, a posterior bowing deformity
will be present, rarely there will be an axial deviation in the coronal plane. These fractures very
often occur when the patient’s foot becomes
caught in the spokes of a bicycle wheel (19).
Metaphyseal bending fractures and separated
epiphyses can occur in any rotational trauma.
Separated epiphyses are the most common injuries with peak incidence among children about
age 10 or older.
Problems and Complications
Compartment syndrome is an extraordinarily rare
complication of a separated epiphysis (10, 101),
but nonetheless a possibility that surgeons should
be alert to. Another possible complication is an
adhesion between the flexor hallucis longus tendon and the posterior aspect of the distal tibia.
This can lead to a significant gait impairment.
“Spontaneous Corrections”
There is very good potential for correction in the
supramalleolar region following all metaphyseal
fractures because of the static and functional
loads acting on this region. Axial deviations in the
plane of motion and even deviations in the
coronal plane are well corrected (1, 10, 19, 34, 61).
Posterior bowing deformities up to 30⬚ are spontaneously corrected up to about age 10
(Fig. 25.12). Anterior bowing deformities are rare
Fig. 25.8 Metaphyseal fractures in the distal tibia.
a Impacted fractures. These are harmless fractures
that only require immobilization in a plaster splint to
relieve pain.
b Bending fractures. As in the proximal tibia, metaphyseal bending fractures can also occur in the medial region of the distal tibia. The resulting transient partial
stimulation of the adjacent growth plate leads to an
increase in the valgus deformity initially present. Because it is functionally well compensated for by the talocalcaneonavicular joint, this deformity usually goes
unnoticed upon clinical examination
a
b
Ankle Injuries
391
Fig. 25.8 c Separated
epiphyses. With or
without a metaphyseal
wedge, these fractures
are easily treated conservatively. Rarely,
growth disturbances involving partial premature closure of the
growth plate can occur
in this location. Varus and valgus deformities up
to 20⬚ are corrected in the same age group.
Side-to-side displacement is also fully corrected. The reliability of these corrections decreases markedly in patients beyond the age of 10.
Growth Disturbances
Growth stimulation in the entire distal tibial
growth plate may be expected following any fracture and will only lead to slight posttraumatic alteration of leg length.
The growth disturbance involving transient
partial stimulation of the adjacent distal growth
plate may also occur secondary to distal metaphyseal bending fractures and separated epiphyses
with an initial valgus deformity like it does in the
proximal tibial metaphysis (79). The talocalcaneonavicular joint excellently compensates for
the increase in the valgus deformity that this
causes, with the result that this deformity may
only be briefly apparent as a unilaterally increased talipes equinovalgus deformity. Usually,
however, this deformity is overlooked (Fig. 25.9).
In young patients, this deformity is spontaneously corrected like primary deformities in
this region as further growth restores the physiological alignment of the epiphysis perpendicular
to the plane of motion.
The growth disturbance involving partial premature closure with subsequent abnormal
growth may occur following any metaphyseal
fracture affecting the growth plate. Accordingly,
this complication may also be encountered in the
setting of a separated epiphysis (6, 17, 75, 79;
Fig. 25.10). This growth disturbance may be expected in about 15% of all cases of separated
epiphyses. Because these separations primarily
occur in late childhood with peak incidence at age
12–13, they only rarely lead to severe sequelae.
Their occurrence at this location is independent
of the nature and direction of the mechanism of
injury. Invariably there will be partial closure medially, at the site at which physiological closure
later begins (see Transitional Fractures of the Distal Tibial Epiphysis in Late Adolescence, p. 412 ff
and see Fig. 1.2 a). Because the epiphyseal separations are caused by shear forces, we may exclude
the often postulated “crush injury” as a possible
cause of such rare growth disturbances. The medial location of the banding bridge is also inconsistent with such a mechanism and would suggest
vascular injury instead. In injuries resulting from
the patient's foot becoming caught in the spokes
of a bicycle wheel, the soft-tissue injury may be
deep enough to compromise vascular supply to
the epiphysis or perichondrium. This would in
turn lead to formation of a metaphyseal–epiphyseal bridge and the type of abnormal growth that
creates a shortening deformity (Fig. 25.11).
392
Specific Injuries—Lower Extremities
Fig. 25.9 Metaphyseal bending fractures of the distal tibia. The patient is a six-year-old boy with a
metaphyseal bending fracture resulting in a 10⬚ primary
valgus deformity. A cast wedge was placed on the sixth
day, which partially eliminated the valgus deformity. The
fracture healed in a 4⬚ valgus deformity after six weeks.
This accordingly resulted in delayed union on the medial
aspect, which in turn led to a 3⬚ increase in the primary
deformity due to partial stimulation of the medial distal
tibial growth plate. By the time of the follow-up examination one year after the accident, the deformity of the
distal tibial epiphysis had decreased to its original severity of 4⬚ valgus (from: 79)
Fig. 25.10 Growth disturbance in the setting of a
separated epiphysis. The patient is a 12-year-old boy
with a nondisplaced separated epiphysis with an anterior wedge. No attempt was made to reduce the injury,
which was then immobilized in a lower-leg splint. During
the further clinical course, a medial banding bridge
developed between the epiphysis and metaphysis at the
site at which physiological closure would normally have
begun later. One year after the accident, the patient exhibited a varus deformity of at least 10⬚. An opening
lengthening osteotomy performed after cessation of
growth eliminated the deformity (from: 79)
Ankle Injuries
393
Fig. 25.11 Growth disturbance involving partial
premature closure in an accident in which the patient's
foot became caught in the spokes of a bicycle wheel. The
patient is a seven-year-old girl with a typical injury superficial to the lateral malleolus. The injury to the peri-
chondrium of the lateral fibular growth plate resulted in
partial to complete premature closure of the distal fibular growth plate with corresponding shortening of the
fibula
Fig. 25.12 “Spontaneous corrections” in the distal
tibia. The patient is an 11-year-old boy with a supramalleolar impacted fracture that healed with a slight
posterior bowing deformity. Extensive remodeling of
the slight deformity occured after four months
394
Specific Injuries—Lower Extremities
Treatment is conservative as a matter of course. It
consists of immobilization in a lower-leg splint
for three to four weeks. To prevent the posterior
bowing deformity from increasing, the splint will
often have to be initially molded with the foot in a
talipes equinus position (19, 34). This does not exclude the option of later applying a cast wedge to
the existing talipes equinus position to
completely eliminate the posterior bowing deformity.
The distal metaphyseal bending fractures
(Fig. 25.9) present the same problems as their
proximal counterparts. However, here the talocalcaneonavicular joint provides a more favorable
compensatory mechanism. Especially in older
patients, any initial axial deviation in the coronal
plane should be carefully eliminated using the
epiphyseal axis angle as a reference. This is necessary because stimulation of the adjacent growth
plate will cause the severity of the axial deviation
to increase, and with increasing age the deformity
would no longer be spontaneously corrected.
There should be no remaining varus deformities exceeding 5⬚ and no valgus deformities exceeding 10⬚ in the ankle region at cessation of
growth.
These injuries are also treated by immobilization in a lower-leg splint that is closed to form a
cast on about the fourth day. Primary axial deviations up to 10⬚ are initially left uncorrected and
eliminated later with a cast wedge. Deformities
exceeding 10⬚ should be reduced immediately. In
the first case, the wedge is placed on the eighth
day and then a radiograph is obtained; in the second case, the radiograph is only obtained on the
eighth day at which a wedge may be placed if necessary.
The distal tibia is second only to the distal
radius as the most common location for separated
epiphyses with or without a metaphyseal wedge
and with or without an associated fibular fracture.
Loosened or spontaneously reduced displaced
epiphyseal separations without metaphyseal involvement can easily be overlooked (50, 68). Even
comparative radiographs of the contralateral side
do not help. A bone scan would confirm the tentative diagnosis (48) but would not relieve the
patient’s symptoms. Therefore, we recommend
primary treatment and secondary diagnostics in
cases where supramalleolar swelling and pain
suggest a possible separated epiphysis (Fig. 25.7).
Deformities in the coronal and sagittal plane
should not be left uncorrected in patients age 10
or older. Up to age 10, axial deviations of up to 10⬚
in the coronal and sagittal planes can be tolerated,
as can side-to-side displacement of up to one
quarter shaft width (Fig. 25.13).
The goal of treatment is to maintain the fracture in a position that is tolerable for the patient’s
respective age group while strictly avoiding any
malrotation. Initial therapy will have no influence
on any possible growth deformities.
Separated epiphyses are treated conservatively as a matter of course. In isolated cases interposed soft tissue such as a periosteal fold will re-
Fig. 25.13 “Spontaneous correction” in the distal
tibia. The patient is an eight-year-old girl with a separated epiphysis that healed with a 8⬚ valgus deformity.
This deformity was completely corrected during the
further clinical course. The eight-year follow-up examination revealed symmetrical anatomy in the ankle
Treatment
Ankle Injuries
quire open reduction (22, 27, 33, 75). Many
authors cite an alleged tendency of the periosteum to become interposed in the fracture as an
indication for open reduction and surgical fixation (67, 81, 82, 84). However, both Beck’s experimental studies (5) and our clinical observations
(75) fail to confirm any such tendency. Nondisplaced and slightly displaced fractures (defined as
axial deviations up to 10⬚) are immobilized as
usual in a plaster lower-leg splint after eliminating any possible malrotation. This splint is closed
to form a cast on about the fourth day. After eight
days, radiographs are obtained to verify correct
position especially in adolescents above the age of
10. This will permit placement of a cast wedge to
eliminate any initially present deformities
(Fig. 25.14).
Displaced fractures (defined as any deformities exceeding 10⬚) are reduced immediately with
the patient under general anesthesia. Fractures
that can be readily reduced to a perfect anatomical position and do not spring back into the original deformity, are treated conservatively in a
plaster lower-leg splint. Fractures that can be reduced well, but only against resilient resistance,
should be stabilized by percutaneous pinning
with two crossed Kirschner wires (Fig. 25.15). The
wires are clipped off in the usual manner above
the level of the skin, and the stabilized fracture is
then immobilized in a lower-leg splint with an
opening left in the plaster around the wires. An irreducible fracture suggests a larger interposed
periosteal flap, usually medially, that should be
exposed through a small longitudinal incision and
removed. Surgical fixation will not be necessary
as perfect reduction will invariably be possible
once the interposed tissue has been removed.
Further treatment is conservative as a matter of
course, with immobilization in a plaster splint.
Screw fixation is not required in light of the short
period of immobilization of three to four weeks
and the need for a second intervention under
general anesthesia that this would entail—and it
is not possible in fractures without a metaphyseal
wedge.
Patients with fractures treated by closed reduction are treated on an outpatient basis, as are
those with nondisplaced separated epiphyses.
Patients with openly reduced fractures remain on
395
the ward for about two to three days until wound
healing has been confirmed.
All of these injuries are immobilized in a
plaster lower-leg splint, which is closed to form a
cast on about the fourth day. A radiographic examination to verify correct position on about the
eighth day (except in the case of Kirschner wire
stabilization) will reveal any possible axial deviations. These deviations can then be completely
eliminated by placing a cast wedge.
All metaphyseal fractures (impacted fractures, bending fractures, and separated epiphyses) allow weight bearing in the cast after two
weeks as these are invariably transverse fractures.
Immobilization and Consolidation
The cast is removed after only three to four weeks
depending on the patient’s age because metaphyseal fractures heal quickly. The patient may begin
spontaneous weight bearing where the radiograph out of plaster shows a strong periosteal
bridging callus and clinical findings confirm this.
Sports Participation and Follow-up
Examinations
Gait will usually have returned to normal after
another three to four weeks, including the ability
to walk on heels and tiptoes. Sports can gradually
be resumed at this time. Swelling of the hindfoot,
especially in separated epiphyses, will persist
several weeks and can interfere with sports participation.
Clinical follow-up examinations should be
performed at intervals of six months to a year.
These examinations should evaluate posttraumatic leg-length differences, exclude abnormal
varus growth from a possible growth disturbance,
and monitor spontaneous correction of any
possible residual axial deviations.
Treatment may be concluded where clinical
examination reveals symmetrical function and
structural alignment two years after the accident
and the patient does not report any symptoms.
Additional follow-up radiographs are indicated
only in symptomatic patients.
Fig. 25.14 Treatment of separated distal tibial epiphyses. The patient is a
seven-year-old boy whose separated distal tibial epiphysis with a metaphyseal
wedge was reduced under general anesthesia. Because a valgus deformity of
slightly less than 10⬚ remained, a cast wedge was placed on the seventh day. The
fracture then healed in proper axial alignment
396
Specific Injuries—Lower Extremities
Ankle Injuries
Fig. 25.15 Separated distal tibial epiphysis treated
by closed reduction and percutaneous pinning with
crossed Kirschner wires. The patient is a 13-year-old
boy with a displaced separated distal tibial epiphysis. Reduction was performed in an emergency procedure with
the patient under general anesthesia. Because the fracture sprang back into the original deformity, the reduction was stabilized by percutaneous pinning with
crossed Kirschner wires during the same session. After
397
three-and-a-half weeks the fracture exhibited good clinical and radiographic healing. The wires, which had been
left projecting above the level of the skin, were then removed without anesthesia in an outpatient procedure,
and the patient began spontaneous mobilization. At the
one-year follow-up examination, the patient was free of
symptoms, mobility was symmetrical in both ankles,
and there was no difference in leg length
398
Specific Injuries—Lower Extremities
Distal Tibia (Epiphysis and Metaphysis 6.6%) Epiphyseal
Fractures (Medial and Transitional Fractures) and
Ligamental Injuries
Forms
1. Epiphyseal fractures (Salter–Harris types III and IV
medial malleolar fractures) (p. 399 ff)
2. Transitional fractures of late adolescence (twoplane and type I and II triplane fractures)
(p. 412 ff)
3. Ligamental Injuries
앫 medial (p. 407 ff)
앫 lateral
– Talofibular ligaments (p. 407 ff)
– Syndesmosis (p. 411)
Radiographs: A-P and lateral, where indicated
supplemented by a second A-P view (oblique view) in
cases 1. and 2.
Growth arrest
Re 1. Possible in 20–30% of all cases.
Re 2. Not clinically significant.
Definition of “nondisplaced”: Fracture gap not exceeding 2 mm (see also text regarding transitional
fractures).
Technique of conservative fixation: Lower-leg Sarmiento cast.
Technique of surgical fixation: Open reduction and
screw fixation (for joint reconstruction, see text
regarding medial malleolar fractures [p. 401] and
transitional fractures [p. 419 ff]).
Aftercare
Period of immobilization
앫 With conservative fixation: Four weeks.
앫 With surgical fixation: Immediate spontaneous
motion.
Consolidation radiographs: Yes.
Initial mobilization
앫 Patient: Immediately on forearm crutches
without weight bearing.
앫 Joint: Immediately after internal fixation or spontaneously after removal of plaster splint.
Physical therapy: None.
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Medical.
앫 Where indication is uncertain: Immobilization in a lower-leg splint.
Emergency treatment under anesthesia: All
severely displaced “fracture dislocations.”
!
All other indications should first be discussed at
length with the patient and his or her parents.
Further treatment without anesthesia or delayed
treatment under anesthesia: All fractures with
gaps exceeding 2 mm can be surgically treated in
a postprimary procedure on the first or second
day after the accident.
Sports: Three to four weeks after consolidation.
Removal of metal implants: Three months postoperatively.
Follow-up examinations and conclusion: Examinations are performed at three- to four-week intervals
until unrestricted function is regained. After that,
clinical examinations continue at six-month intervals. Treatment is concluded two years after the accident in the presence of symmetrical function and leg
axes without any difference in leg length. Where
growth disturbances are present, annual follow-up
examinations are continued until cessation of
growth.
Ankle Injuries
Medial Injuries to the Ankle
a
399
“Typical Epiphyseal Fractures” (Fig. 25.16)
앫 Medial malleolar fractures: “Typical epiphy-
Forms of Injury
seal fractures” with open growth plates
(Salter–Harris types III and IV)
앫 Medial ligament injuries
Regardless of the mechanism of injury or its direction, epiphyseal fractures of the distal tibia are
only observed in the medial malleolus in patients
with wide open growth plates up to age 10 (74, 78,
b
Fig. 25.16 Epiphyseal fracture of the distal tibia:
“typical” epiphyseal fractures of the medial malleolus. Whether with extensive metaphyseal involvement
(a), with slight involvement (b), or without metaphyseal
involvement (c), all “typical” epiphyseal fractures invariably lie outside of the area of primary stress transfer in
the joint in the medial malleolus insofar as the growth
plates are wide open. As far as we know, the growth
prognosis for these injuries depends neither on the form
c
of the fracture nor its course in the medial malleolus itself, but exclusively on the patient’s age and the severity
of the displacement. Nearly no significant growth disturbances may be observed following nondisplaced fractures, whereas growth disturbances with severe
sequelae significantly more often occur following displaced fractures. Growth disturbances with clinically significant sequelae are not to be expected after the age of
12–13, with sex-specific variation. (Sketches from: 75)
400
Specific Injuries—Lower Extremities
100). Fractures invariably lie along a line extending upward from the medial edge of the talus
(Fig. 25.16). These may be purely epiphyseal or
epiphyseal–metaphyseal fractures. Only rarely, in
cases involving severe direct trauma, will the fracture gap be located in the lateral epiphysis prior to
physiological closure of the growth plate after age
10 (see Transitional Fractures of the Distal Tibial
Epiphysis in Late Adolescence). Other forms of
medial malleolar fractures only occur in adolescents (67; Fig. 25.17). Possible associated lateral
injuries include separated distal fibular epiphyses
or avulsion or tears of the talofibular ligaments.
Fig. 25.17 Epiphyseal fractures in the distal tibia:
medial malleolar fractures in adolescents. Only in
adolescents do we find forms of fractures in the medial
malleolus that are also observed in adults (seen here in
combination with lateral separation of the epiphysis,
recognizable by the metaphyseal wedge)
Growth Disturbances
Premature partial closure of the growth plate resulting in secondary abnormal growth is the most
dangerous sequela of these fractures (6, 10, 17, 29,
37, 48, 53, 59, 65, 67, 71, 81, 84; Fig. 25.18). This can
result from formation of a banding bridge or
necrosis bridge (see General Science, Treatment,
and Clinical Considerations). The risk of such a
growth disturbance decreases with age and is
hardly ever encountered beyond the age of 13 in
boys and 12 in girls (75). This growth disturbance
is not an inevitable sequela of epiphyseal fractures (Figs. 25.19, 25.20) and only occurs in about
10% of all cases (75, 78). If, when following up
these patients, one allows for the fact that such
growth disturbances only occur at a certain age
(until about 12 or 13) and only secondary to displaced epiphyseal fractures, then this percentage
increases to slightly less than 20%. Narrow physeal bridges that have formed can be spontaneously disrupted by further growth (10, 79),
eliminating any abnormal growth (Fig. 25.21).
Late recurrences of “spontaneously” disrupted
bridges are possible with the onset of puberty, as
is the case in the distal femur (see Figs. 23.16 a–e,
25.22). Primary treatment cannot influence this
growth disturbance. Surgically decreasing the
fracture gap can reduce the size of a possible
banding bridge so that it will not lead to abnormal
growth. However, such treatment cannot control
an existing necrosis bridge, and it may even cause
one (see Fig. 25.18). This growth disturbance is
not to be expected following nondisplaced fractures (75, 81; Fig. 25.20), only following displaced
fractures.
Fractures that heal with displacement should
not be regarded as a condition predisposing to arthritis in the strict sense as the step-off in the articular surface resulting from the fracture always
lies outside of the area of primary stress transfer
in the joint. Young patients up to the age of five at
the time of the fracture can also fully compensate
for slight step-offs with further growth (see
Fig. 25.19). Prospective multicenter studies conducted according to a prospective protocol (73)
would be required in order to obtain exact data
about the actual growth prognosis after these injuries.
Ankle Injuries
401
Fig. 25.18 Growth disturbance following internal
fixation of a “typical” epiphyseal fracture in a nearly
12-year-old girl with wide open growth plates. The typical displaced fracture of the medial malleolus was
treated properly by “watertight” internal fixation with a
small fragment screw parallel to the growth plate to
achieve compression. Despite proper internal fixation
technique, a metaphyseal-epiphyseal banding bridge
developed during the further course of healing, resulting in a secondary abnormal varus growth
Fig. 25.19 Joint remodeling. The patient is a sevenyear-old girl with a “typical” displaced medial malleolar
fracture and open growth plates. Conservative treatment included an unsuccessful attempt at closed reduction followed by immobilization in a plaster cast. A significant step-off in the joint is visible after 12 weeks. A
metaphyseal–epiphyseal banding bridge did not
develop and consequently there was no resulting deformity. During the further clinical course, remodeling
of the step-off occurred. Follow-up radiographs obtained after 13 years revealed that joint symmetry had
been fully restored
402
Specific Injuries—Lower Extremities
Fig. 25.20 Treatment of nondisplaced “typical”
malleolar fractures in patients with wide open
growth plates. As was the case in this 10-year-old girl,
nondisplaced fractures are treated conservatively with a
short-leg cast. There is no risk of growth disturbances.
Note the ossification center in the medial malleolus and
how it disappeared during the two-year observation period
Treatment
to form a full cast or, if indicated, replaced with a
Sarmiento cast on about the fourth day.
The goal of treatment in a displaced fracture is to
reconstruct the joint and achieve more favorable
conditions for preventing possible abnormal
growth resulting from a banding bridge (94).
Nondisplaced fractures (those with a maximum gap of 2 mm) are treated conservatively in a
plaster lower-leg splint (37, 65, 75; Fig. 25.20).
This is closed to form a cast on about the fourth
day. These fractures are not generally prone to
secondary displacement. Therefore, a radiograph
in plaster to verify proper position is not indicated. Weight bearing should be avoided for four
weeks. Where compliance appears to be a problem, a Sarmiento cast is applied on the fourth day.
Displaced fractures are managed by open anatomical reduction and internal fixation with
epiphyseal compression using an AO small fragment lag screw (Figs. 25.18, 25.21). In small
children, internal fixation with a Kirschner wire
may prove less traumatic than attempting to
achieve fixation with a lag screw at any cost,
which can do more harm than good. An associated
separated fibular epiphysis will reduce spontaneously once the medial aspect is reduced and
will not require separate fixation. In the past we
repaired and reconstructed associated ligament
injuries at the same time as the medial internal
fixation. Nowadays, we would treat them conservatively in a functional way.
Patients and parents should understand prior
to surgery that the operation is intended to reconstruct the joint but cannot reliably prevent a
possible growth disturbance. A lower-leg plaster
splint is applied postoperatively, which is closed
Immobilization and Consolidation
After the cast has been removed, the radiograph
should demonstrate the beginning of bony union
in the fracture. Where the fracture is no longer
tender to palpation, progressive weight bearing
on forearm crutches is allowed until after about
two weeks when the patient can tolerate full
weight bearing without support. The patient
should only gradually resume sports participation two weeks after that. The metal implants
should be removed about 10–12 weeks after
surgery.
Sports Participation and Follow-up Examinations
Once the patient has successfully resumed sports
participation, clinical follow-up examinations
should be performed to detect possible leg-length
differences and possible growth deformities due
to partial closure. Axial asymmetry in the hindfoot is an early sign of abnormal growth. Radiographic follow-up studies are indicated in such
cases. Treatment may be concluded on the basis
of clinical examination where growth arrest has
not occurred within two years of the accident and
the patient exhibits symmetrical structural alignment and unrestricted function in both legs.
Medial Ligament Injuries
Medial injuries to the deltoid ligament can rarely
occur in eversion trauma, primarily in adolescents. Significant medial swelling is a sign of this.
Ankle Injuries
403
Fig. 25.21 Treatment of displaced “typical” medial
malleolar fractures in patients with wide open
growth plates. Top: Open reduction of displaced fractures is necessary to reconstruct the joint. The reduced
fracture is then stabilized by internal fixation to achieve
compression. This procedure can reduce possible banding bridges as in this 11-year-old boy, in whom a significant banding bridge was diagnosed in the fracture plane
after five weeks when the fracture had healed. This
bridge was spontaneously disrupted by further growth.
In radiographic follow-up examinations one year and
two years later, the growth plate was found to be
completely open. Follow-up examination after six years
revealed no evidence of any deformity. Below: Disruption of the banding bridge 10 weeks after trauma (from:
79)
Where surgical repair of the lateral aspect of the
ankle is indicated, the medial aspect is also repaired and the ligament reconstructed. Otherwise, conservative functional treatment will suf-
fice: These injuries rarely involve complete ruptures of the medial ligaments, usually only partial
ruptures.
404
Specific Injuries—Lower Extremities
Fig. 25.22 Late recurrence of
a metaphyseal – epiphyseal
bridge following spontaneous disruption. The
patient is a five-year-old boy
with a displaced medial malleolar fracture in the right leg,
which had been conservatively
treated for four weeks in a
lower-leg cast. A radiographic
follow-up study was obtained
three years after the accident.
The cystic radiolucency in the
metaphysis and the “stump” of
the bridge in the epiphysis suggest that spontaneous disruption must have occurred
without any abnormal growth
(see also Fig. 25.21). Ten years
later at the onset of puberty,
abnormal varus growth occurred as if an epiphyseal–
metaphyseal banding bridge
were present (a; see also
Fig. 25.18). However, the oblique images (b) reveal significant narrowing of the anteromedial growth plate as if
premature fatigue of the
growth plate had occurred in
this area (these images are
used with the kind permission
of Dr. Häsen, Klinik Fleetinsel,
Hamburg, Germany)
a
b
Ankle Injuries
Most Common Deformities of
the Middle and Distal Tibia
(See also p. 428.)
The situation here is essentially similar to that
in the femoral shaft. The most common persistent
axial deviation in the lower leg is the varus deformity. This is spontaneously well corrected and
hardly ever requires treatment. Valgus, posterior
bowing, and anterior bowing deformities are
much rarer. The younger the patient, the longer
one should wait before intervening surgically.
Gait abnormalities in older patients are an indication for intervention even while the patient is still
growing and is caused in most cases by a rotational deformity. Otherwise, any corrections are
best delayed until after cessation of growth. These
osteotomies are also stabilized with an external
fixator as described in the section on femoral fractures, page 307 f.
The nearly inevitable sequela of a growth disturbance in the distal tibia is a varus deformity.
Essentially, the same correction criteria and options of spontaneous or iatrogenic disruption,
bridge resection, and corrective osteotomy apply
here as previously described in the section on
femoral fractures. However, bear in mind that
over 80% of these growth disturbances in the distal tibia, whether after separated epiphyses or
after epiphyseal fractures, occur in patients about
10 years old or slightly older. This means that
most of these patients have only a short time left
before definitive closure of the growth plates, so
that bridge resections and iatrogenic disruption
would no longer be worth the trouble. In these
cases, it is best to delay the correction until after
cessation of growth and then definitively restore
proper length and axial alignment (Fig. 25.44 a–c).
Technique and aftercare are identical to that described in the section on Most Common Posttraumatic Deformities of the distal Femur and proximal Tibia, page 348 f.
Extraordinarily rarely, trauma can cause premature closure of the distal tibial growth plate.
The resulting shortening of the fibula need not
have any clinical significant sequelae where tibial
growth is not influenced (Fig. 25. 11). The mortise
of the ankle itself remains stable and mobility unimpaired. Occasionally, and this can also occur
with fibular osteophytes, not only will posttraumatic shortening of the distal fibula occur but also
abnormal valgus growth in the distal tibia (when
closure occurs in very young patients). We regard
such a case as an indication for a distraction
405
osteotomy of the distal fibula. In sufficiently
young patients, the tibia, as fibular length increases, will grow back into the correct plane of
stress (Fig. 25.47 a–c).
Overview
Most Common Posttraumatic Deformities
of the Middle and Distal Tibia
1. Varus, valgus, anterior bowing, or posterior
bowing shaft deformity.
2. Distal varus.
3. Distal anterior or posterior bowing deformity.
4. Shortening of the fibula.
Causes
Re 1. Uncorrected axial deviation.
Re 2. Growth disturbance involving partial premature closure of the medial growth plate.
Re 3. Uncorrected axial deviation.
Re 4. Growth disturbance involving premature closure of the growth plate.
Indication for correction
Re 1. Cosmetic indication (because growth plates
have usually regained their physiological
position perpendicular to the plane of
stress).
Re 2. Varus deformity exceeding 5⬚.
Re 3. Presence of functional impairment (possible
where deformities exceeding 10⬚ are present).
Re 4. Beginning abnormal tibial growth.
Time of correction
Re 1. Either immediately after consolidation
(where growth plates are still oblique) or
otherwise after cessation of growth.
Re 2. Wherever possible, only after cessation of
growth.
Re 3. At the onset of functional impairment.
Re 4. At the onset of abnormal tibial growth.
Technique of correction
Re 1. Where growth plates are still oblique: Depending on length relationship, opening or
closing osteotomy with external fixator or,
after cessation of growth with growth plates
in physiological position, two-level
osteotomy stabilized with external fixator.
Re 2. Distraction osteotomy stabilized with external fixator.
Re 3. Opening or closing osteotomy with or
without external fixator.
Re 4. Lengthening distraction with external fixator.
Aftercare
Functional aftercare with immediate walking and
weight bearing.
406
Specific Injuries—Lower Extremities
Ankle: Talofibular Ligament Injuries
Forms
앫 Below age 12, 80% of all injuries are bony, chondral, and periosteal avulsions.
앫 Above age 12, 80% of all injuries are ligament
ruptures.
Radiographs: A-P and lateral ankle radiographs are
obtained to exclude fractures and bony avulsions,
supplementing clinical examination.
Diagnosis of talofibular ligament injury: Clinical
signs are invariably present (supination trauma, typical hematoma, and edema within the first five days).
Stress radiographs of the acute injury should not be obtained.
Technique of conservative treatment
앫 Short-leg walking cast for two to three weeks
in bony avulsions.
앫 Plaster lower-leg splint for three to eight days
as pain treatment.
앫 Protective measures (splints, shoes, bandages,
etc.) to reduce risk of recurrent injury within
the scope of functional aftercare.
앫 Proprioceptive muscle training as active protection against recurrent injury.
Technique of surgical fixation: Talofibular ligament reconstruction as a secondary measure.
Aftercare
Treatment of acute sequelae of trauma
Goal of treatment
앫 First injury: Pain management and passive
protection against recurrent injury (elastic
bandage, functional splinting, special shoes).
앫 Recurrent injury: Pain management and active protection against recurrent injury (proprioceptive muscle training).
앫 Chronically decompensated instability: After
treatment of recurrent injury has failed, treatment options may include ligament reconstruction with functional aftercare (active
protection against recurrent injury).
Primary pain treatment
앫 Plaster low-leg splint,
앫 Bandages with ointment application.
Emergency treatment under anesthesia: No indication.
Period of immobilization
앫 With conservative fixation: Two to three weeks.
앫 With surgical fixation: Immediate spontaneous
motion.
Consolidation radiographs: No.
Initial mobilization: Immediately on forearm
crutches without weight bearing, then gradually increasing to full weight bearing.
Physical therapy: None except in the case of decompensated instability; then a regime of proprioceptive
exercises.
Sports: Athletes may resume sports in special shoes
two to three weeks after the accident.
Removal of metal implants: Not applicable.
Follow-up examinations and conclusion: Examinations are performed at three- to four-week intervals
after sports have been resumed. Clinical examinations to evaluate stability are performed after six
months and one year.
Ankle Injuries
407
Whereas rotational trauma without instability is
regarded as easily manageable, rotational trauma
with persistent instability is widely thought to
entail an increased risk of early degenerative joint
disease (7, 17, 32, 38, 55, 57, 82). However, this assumption has yet to be confirmed by clinical evidence. Early degenerative joint disease can occur
as a sequela of overlooked flake fractures, posttraumatic lateral osteochondritis (Fig. 25.23), or
pilon fractures of the distal tibia. These latter injuries do not occur in growing patients. Compensated instability without any underlying clinical
pathology such as recurrent injury or recurrent
pain and swelling is asymptomatic and does not
lead to early degenerative joint disease (3, 77).
However, symptomatic instability, i.e., instability
associated with recurrent pain and swelling and
involving recurrent injury, can possibly lead to
early degenerative joint disease. However, this is
only the case where the patient disregards the increasingly severe symptoms and recklessly overburdens existing compensatory mechanisms by
continuing to subject his or her unstable ankle to
excessive athletic or occupational stress. Such a
lack of common sense is totally foreign to children
and adolescents, and they will display such behavior only under parental coercion if at all.
Patients will typically discontinue the activity
causing the symptoms or seek treatment before
joint degeneration is irreversible.
Before the age of 10–12, the ligaments themselves remain intact in about 80% of all cases. The
injury occurs as a periosteal, chondral, or bony
avulsion, most often from the tip of the fibula and
rarely from the talus (61). Growth disturbances
need not be feared even in the presence of larger
Fig. 25.23 Posttraumatic osteochondritis. This 12year-old girl developed posttraumatic osteochondritis
with subchondral cysts and anterior tibial osteophytes
two years after primary surgical repair of a talofibular
ligament injury. At the clinical examination one year
postoperatively, both sides had exhibited symmetrical
stability, and the patient had been asymptomatic and
satisfied with the results of the operation
Ankle Injuries Involving
the Lateral Ligaments
앫 Talofibular ligament injuries and flake frac-
ture of the talus
앫 Separated fibular epiphysis and avulsion of
the syndesmosis
Forms of Injury
Rotational injuries involving the talofibular ligaments with or without instability are the most
common injuries to the ankle. They can occur as
associated injuries in the typical medial malleolar
fractures that are encountered in growing
patients.
Chondral and osteochondral flake fractures of
the talus can occur as associated injuries in rotational trauma with instability (2).
Problems and Complications
408
Specific Injuries—Lower Extremities
avulsed fragments as the distal tibial growth plate
is not involved.
Diagnosis
The diagnosis of rotational trauma of the talofibular ligaments is easily made based on findings of
history that include such an injury and on clinical
findings. Acute trauma will be accompanied by a
typical egg-shaped hematoma above and beneath
the lateral malleolus. A chronic injury will exhibit
severe diffuse swelling beneath the tip of the
fibula that may occasionally include an extensive
distally displaced hematoma along the lateral
margin of the foot.
Wherever severe clinical symptoms are present, we always obtain A-P and lateral radiographs
to exclude other possible ankle injuries such as a
separated epiphysis, medial malleolar fracture,
transitional fracture, avulsion of the syndesmosis,
and bony avulsion of the talofibular ligaments.
The further diagnostic workup after obtaining
the A-P and lateral radiographs is closely linked to
the respective therapeutic procedure for each
clinical situation. We ourselves do not attempt to
initially verify instability because the possible
findings in such a test would not influence our
choice of treatment.
Treatment
Ideally, the goal of treatment would be to eliminate any persistent, symptomatic decompensated
instability and with it the theoretical risk of
degenerative joint disease. However, no initial
criterion can be identified for determining which
patients may be expected to develop permanent
decompensation. Neither generalized ligament
laxity, nor the patient’s weight, nor a certain type
of sport would be a suitable criterion. The group
of patients with uncompensated instability can
only be identified secondarily, after treatment.
Regardless of the initial treatment performed
(surgical reconstruction, conservative treatment
with immobilization in a cast, or conservative
functional therapy), 10% of all patients at the oneyear follow-up examination will exhibit symptoms of decompensation (3, 17, 56, 62, 73, 77, 87).
This means that neither conservative nor surgical
treatment is able to reliably prevent or eliminate
instability and possible decompensation. It follows that the restoration of stability or compensation of instability must involve many other components whose mechanisms are not known.
In light of this, the goal of treatment must be
considerably less ambitious. We can reliably treat
or eliminate only the initial pain, and we can protect the ligaments and the developing scar tissue
against recurrent injury. Therefore, the goal of initial treatment is solely to control pain and provide
protection.
Because there is no way to identify the group
of patients who will later develop symptoms of
persistent decompensated instability, we have
employed a system for many years that reverses
the usual diagnostic procedure. We wait until
symptoms occur before verifying instability. By
proceeding in this manner, we avoid treating
patients who would be asymptomatic with or
without instability, and we spare rotational
trauma patients superfluous diagnostic examinations. Remember that only slightly less than one
third of all initial cases of rotational ankle trauma
exhibit instability, whereas two thirds are stable.
For all of these reasons it is important to differentiate between a first injury, a second injury, and a
recurrent injury.
First Injury
Where the standard A-P and lateral radiographs
demonstrate a nondisplaced flake of bone avulsed
from the tip of the fibula or the talus, we immobilize the injury in a plaster lower-leg splint until
swelling subsides. Then we close the complete
circumference of the splint and convert it into a
short-leg walking cast. This cast is left in place for
three weeks. Once the cast is removed and the region over the tip of the fibula or talus is no longer
painful to palpation, the patient may begin spontaneous mobilization until gait returns to normal
about two to three weeks later. Sports may be resumed at that time. Once this is possible without
any problems and clinical examination verifies
symmetrical structural alignment and function,
then treatment may be concluded if the patient is
free of symptoms.
We no longer operate even where there is a
displaced avulsed fragment. Our follow-up data
have shown that the prognosis is identical for
nondisplaced and displaced avulsed fragments
treated conservatively with a cast wedge. Surgical
refixation was not able to improve the prognosis
with respect to instability. Therefore, these injuries are treated identically to displaced bone
flakes (3).
Where the standard radiographs fail to visualize an avulsed fragment and clinical symptoms
include severe swelling, we inform the patient
Ankle Injuries
about our previous results (symptomatic persistent instability in 10% of all patients following
conservative and surgical treatment) and we suggest conservative functional treatment without
obtaining stress radiographs. Only aspiring champion athletes will not want to lose any time and
usually opt for immediate surgery, which we then
perform after verifying the instability by radiography. All other patients opt for conservative
treatment given that they have nothing to lose but
time and have a good chance of remaining asymp-
409
tomatic without surgery (Fig. 25.24). Depending
on the severity of swelling and pain and on their
personal preference, they receive either a plaster
splint or an elastic bandage to immobilize the injury and relieve pain. Once the pain and swelling
have subsided within the first eight days, dedicated athletes and patients with severe initial
swelling and secondary edemas and extensive hematomas receive a special shoe with lateral reinforcement and a high-cut outer rim (24, 26, 77,
85). All other patients receive an elastoplast band-
Fig. 25.24 Treatment of an
initial talofibular ligament
injury. In managing initial
trauma, surgical and conservative treatments produce
essentially the same results.
Therefore, initial conservative functional treatment is
recommended in such cases.
The patient is a 14-year-old
boy with an injury to the
right ankle involving the
talofibular ligaments that
was managed with conservative functional treatment. At
the follow-up examination
one year later, both sides exhibited symmetrical clinical
and radiographic stability
410
Specific Injuries—Lower Extremities
age or an Aircast splint as protection against recurrent injury and to alert those around them to
be careful with their injured foot.
We apply an elastoplast bandage once or
twice for two weeks each, depending on findings.
Patients wearing these bandages bear full weight
as in an Aircast but only resume sports after a total
of six weeks.
As soon as the patients fitted with a shoe have
become accustomed to wearing it, they may resume normal sports activities. This will be sometime between the second and fourth week after
the accident. We recommend that patients wear
the shoe continuously during everyday activities
and sports for eight weeks. After that, they only
need to wear it regularly until one year after the
accident during sports and when walking on uneven ground.
Our patients undergo clinical follow-up examinations after six months and one year.
We conclude treatment after one year in
patients who have remained free of subjective
symptoms and exhibit symmetrical function and
structural alignment without any swelling of the
hindfoot.
Where subjective symptoms and swelling are
present and the patient reports intermittent recurrent injuries or has had to give up a certain
sport because of symptoms, then all the signs of
decompensated instability are present. We view
this as an indication for stress radiographs as early
as four to six months after the initial accident.
Where these radiographs confirm the clinical suspicion of instability, we recommend that the
patient undergo an intensive regime of proprioceptive exercises for three months to strengthen
the fibular musculature and improve functional
compensation of the existing instability prior to
any ligament reconstruction. We regard ligament
reconstruction as indicated only where this exercise regime has been rigorously and verifiably adhered to and has failed to yield the desired results.
In such cases, we employ the Weber method (82)
using a free graft from the plantaris tendon. In
patients without a plantaris tendon, we use the
second or third extensor tendon from the same
foot. Where there is also instability in the talocalcaneonavicular joint, we use the pedicled half of
the short fibularis tendon for ligament reconstruction according to the Watson-Jones method (80).
These reconstructions are performed regardless of whether the distal tibial growth plate has
closed. Naturally, great care must be taken to
avoid injury to the growth plate if it is still open.
Second or Recurrent Injuries
In patients with a history of decompensation (recurrent injury, unsteady gait, pain and swelling,
etc.) presenting with acute trauma, standard
radiographs are obtained to eliminate a fracture.
Where there is no radiographic evidence of injury,
instability is demonstrated by ultrasound scans.
Once their swelling and pain have been treated,
these patients should undergo intensive proprioceptive training, wherever possible for three
months, prior to any subsequent ligament reconstruction. Where this training leads to compensation of the instability, i.e., the patient is free of
symptoms, surgery will no longer be required.
Where the symptoms persist, then reconstruction
of the ligaments is recommended. Depending on
findings and ligament tissue present, it may be
possible to reconstruct the ligaments by suturing
them to the bone via drill holes. Where this is not
feasible, reconstruction with a periosteal flap
(66), with the plantaris tendon (82), or with the
peroneus brevis tendon (80) may be performed.
The surgical site is then immobilized in a plaster
splint for about four to five days until wound healing has been confirmed, after which the patient is
allowed to fully mobilize the leg in a special shoe
with the same precautions as in the case of a first
injury.
The patient may prefer not to undergo
surgery. In this case, we dispense with a radiographic examination to confirm the suspected instability and prescribe a regime of proprioceptive
exercises. Further clinical follow-up examinations will depend on symptoms and findings.
Usually, it will be sufficient to examine patients
every four to six months to see whether they have
become asymptomatic or whether they themselves have since decided in favor of surgery to
correct persisting symptoms.
Surgical and nonsurgical patients alike undergo a follow-up examination one year after
surgery or after having been fitted with a special
shoe. We conclude treatment at that time in
patients who are free of subjective and objective
symptoms.
Flake fractures of the talus may rarely occur in
injuries of the talofibular ligaments (2, 43). Accordingly, the radiograph should be carefully examined for evidence of such an injury. In any surgical repair, the lateral talar dome should be
thoroughly examined for possible cartilage injuries, including the posterior aspect. Flake fractures are fixed with fibrin glue (Fig. 25.25). Screw
Ankle Injuries
411
fixation should be avoided because of the need for
a second procedure to remove the metal implants.
Separated fibular epiphyses are rare injuries,
although the frequency with which they are mentioned in the literature might lead one to think
otherwise (27). They are associated injuries that
occur with medial malleolar fractures, transitional fractures of late adolescence, or avulsions
or ruptures of the anterior syndesmosis
(Fig. 25.26). They rarely occur as isolated injuries,
and then only in adolescents (78). Clinical signs of
this injury include extreme tenderness to palpation over the distal fibular epiphysis. Usually,
there will be an extensive hematoma over the
lateral malleolus and not beneath it as in the talofibular ligament injuries.
Where the injury is a completely displaced
separated epiphysis without associated injuries,
we immobilize it in a short-leg walking cast for
three weeks.
An isolated displaced separated epiphysis
without associated injuries is reduced closed and
is also immobilized in a short-leg walking cast.
Combined injuries involving a nondisplaced
bony avulsion of the syndesmosis with a bowl-
shaped flake and a nondisplaced separated fibular
epiphysis are also treated conservatively. These
injuries are immobilized in a Sarmiento cast for
four weeks to relieve weight bearing on the mortise formed by the tibia and fibula.
Displaced avulsions of the syndesmosis are
openly reduced and the fragment is fixed in place
with a percutaneous Kirschner wire or screw
(Fig. 25.27). A positioning screw as is used in syndesmosis ruptures is not necessary. This is because the syndesmosis itself remains intact, and
the avulsed fragment can only be repositioned
once the mortise has been precisely reconstructed anyway. In a rupture of the syndesmosis,
a tibiofibular positioning screw will naturally be
required to secure the suture of the syndesmosis
(Fig. 25.28).
After four weeks of reduced weight bearing in
a Sarmiento cast, the x-ray out of plaster should
demonstrate bony integration of the fragment
and a periosteal bridging callus around the separated fibular epiphysis. If a wire had been inserted, it is removed at this time, and the patient
may begin increasing spontaneous weight bearing. Screws are only removed after about eight
Fig. 25.25 Associated injuries in rotational trauma.
The patient is a 14-year-old boy with typical rotational
ankle trauma. The initial standard radiographs demonstrated displacement of an osteochondral flake from the
talar dome, and therefore open reduction was deemed
necessary. The injury was reduced and the flake fixed in
place with fibrin glue. Follow-up studies up to seven
months postoperatively showed uncomplicated bony
union between the fragment and the underlying bone.
The associated ligament injury had been sutured, and
there was no clinical evidence of instability during the
further course. The patient was able to bear weight
completely normally as before
412
Specific Injuries—Lower Extremities
Fig. 25.26 Separated fibular epiphyses and avulsions of the syndesmosis are extremely rare in growing
patients and occur almost exclusively in adolescents.
Then they are usually combined with a bony or periosteal avulsion of the syndesmosis. In this 14-year-old
boy, the metaphyseal wedge in the distal fibula is a sign
of the nondisplaced separated distal fibular epiphysis.
The irregularity in the anterior tibial notch suggests a
bony avulsion of the anterior syndesmosis with a bowlshaped flake. Fibular and tibial periosteal calluses observed in a secondary radiographic examination after
four weeks of reduced weight bearing in Sarmiento cast
confirmed this initial tentative diagnosis
weeks and positioning screws after four weeks,
and those patients are allowed to begin weight
bearing only at that time. Otherwise, spontaneous weight bearing is allowed once the fragment has healed in union with the underlying
bone.
Once unrestricted gait has been regained after
another three to four weeks, the patient may
gradually resume sports participation. Because
there is no risk of growth disturbances, treatment
may be concluded in patients who have resumed
sports without any subjective symptoms and exhibit symmetrical function and structural alignment. Naturally, these patients should be examined for possible idiopathic differences in leg
length.
Physiological closure of the tibial growth plate
begins in the transitional age of late adolescence.
Toward the physiological end of growth, the
balance between proliferation and ossification
with the growth plate increasingly shifts in favor
of ossification. With complete cessation of
growth, ossification gradually spreads from the
metaphyseal portion of the growth plate to the
epiphyseal portion until the growth plate itself
becomes ossified as the metaphysis unites with
the epiphyseal ossification center (58, 59, 79). In
the distal tibia, this process begins eccentrically in
the anterolateral region of the medial malleolus
Transitional Fractures
of the Distal Tibial Epiphysis
in Late Adolescence
Direct and indirect data on the incidence of these
injuries vary in the literature, fluctuating between
10% and 50% of all epiphyseal fractures of the distal tibia (13, 20, 28, 35, 67, 72, 75, 76).
Fig. 25.28 Treatment of ruptures of the syndesmo- 왘
sis. In this 13-year-old boy, the separated fibular epiphysis clearly visible in the radiographs was associated with
clinical signs suggesting a rupture of the syndesmosis.
Therefore, surgical repair of the anterior syndesmosis
was performed, which was found to be ruptured. The
separated fibular epiphysis was reduced and stabilized
with a Kirschner wire, and the suture of the syndesmosis
was secured at this time with a tibiofibular screw. This
screw was removed six weeks later
Ankle Injuries
Fig. 25.27 Treatment of avulsions of the syndesmosis. Often the only radiographic evidence of an avulsion
of the syndesmosis will be a tiny flake of bone. This 10year-old girl underwent surgical repair in which the
413
avulsed fragment was fixed to the tibial epiphysis with a
small fragment screw. The syndesmosis itself had remained intact
414
Specific Injuries—Lower Extremities
(12, 31, 40, 73, 76). From there, mineralization of
the growth plate proceeds posteriorly and then
laterally, with the result that the anterior lateral
quadrant of the growth plate is the last to ossify.
The onset of these mineralization processes in not
detectable in radiographic studies (12, 76) (see
Fig. 1.2 a + b).
Mechanically, the weakest area of a wide open
growth plate is the hypertrophic zone. Shear
trauma can cause separation of the epiphysis in
this zone (Fig. 25.29) and can avulse a metaphyseal wedge of varying size, depending on the additional bending moment present. However, in
late adolescence a portion of this hypertrophic
cartilage is already mineralized and is therefore
stronger than the remaining nonmineralized portion of the growth plate (74, 76, 78). In these
patients, trauma that would normally suffice to
separate the epiphysis will separate the nonmineralized portion of the growth plate. The fracture
line is then deflected at the column of mineralized
hypertrophic cartilage, where it passes obliquely
out of the hypertrophic zone and into the joint
(Fig. 25.30). These transitional fractures of late adolescence are therefore incomplete epiphyseal
separations (76), which, like epiphyseal separations, may exhibit an avulsed metaphyseal wedge
of varying size, depending on the additional
bending moment. In the literature they are seldom differentiated from the “typical” epiphyseal
fractures in growing patients (88, 89, 95, 99).
Forms of Injury
Purely epiphyseal fractures are referred to as
“two-plane fractures.” The fracture planes lie in
the epiphysis and in the nonossified portion of the
growth plate (Fig. 25.32, left).
One refers to “triplane fractures” where the
two planes are accompanied by an additional
metaphyseal wedge. The fracture planes then lie
in the epiphysis, the nonossified portion of the
growth plate, and the metaphysis (Fig. 25.32, center). Depending on the stage of maturity of the
growth plate, the metaphyseal component of a
triplane fracture may continue through the
growth plate into the epiphysis, producing an additional posterior transverse fracture (Fig. 25.32,
right). For this reason, we must differentiate between two types of triplane fractures:
앫 In a type I triplane fracture, the metaphyseal
component, as in a separated epiphysis, ends
in the growth plate; an epiphyseal fracture
component similar to a two-plane fracture is
only present in the anteromedial aspect
(Fig. 25.35).
앫 In contrast, a type II triplane fracture extends
posteriorly into the joint in the manner of a
posterior Volkmann fracture in addition to its
anterolateral or anteromedial epiphyseal fracture component (Fig. 25.36).
Ankle Injuries
Fig. 25.29 The mechanism of injury in a separated
epiphysis. Where the growth plates are still wide open,
simple shear trauma causes separation of the epiphysis
in the metaphyseal region, mechanically the weakest
part of the growth plate
415
Fig. 25.30 The mechanism of injury in a transitional
fracture of late adolescence. Physiological closure of
the growth plate has already begun. The metaphyseal
portion of the growth plate is partially mineralized and
therefore mechanically stronger. Shear trauma that
would normally separate the epiphysis is deflected into
the joint along this column, causing a characteristic articular fracture known as a transitional fracture, which in
essence is an incomplete separation of the epiphysis
A-P
Posterior
Epiphysis
(axial view)
Lateral
Medial
Anterior
Fig. 25.31 Localization of the fracture gap in the A-P
image in transitional fractures. In all three types of
transitional fractures (two-plane, type I triplane, and
type II triplane), the fracture gap can be located either
entirely lateral or entirely medial in the epiphysis. The
farther lateral the epiphyseal fracture lies, the more it
will resemble a bony avulsion of the anterior syndesmosis
416
Specific Injuries—Lower Extremities
Two-plane
Type I triplane
Type II triplane
Lateral
Anterior
Epiphysis
(axial view)
Lateral
Lateral
Posterior
Lateral
Anterior
Medial
Medial
Medial
Posterior
Fig. 25.32 Differentiation of transitional fractures.
Where the fracture is a purely epiphyseal injury without
metaphyseal involvement, we refer to a “two-plane fracture” (left). Where there is an epiphyseal injury with
metaphyseal involvement, we refer to a “triplane fracture.” Where the metaphyseal fracture ends (as in a sep-
arated epiphysis) in the growth plate, the fracture is a
type I triplane fracture (center). However, where the
metaphyseal fracture accompanying the stereotypical
anterior fracture continues into the epiphysis in the
manner of a posterior Volkmann fracture, then the injury is a type II triplane fracture (right)
Depending on the size of the avulsed epiphyseal
fragment, the metaphyseal wedge in a type I triplane fracture will hang on the avulsed lateral
fragment or on the intact medial column. In a type
II triplane fracture, the metaphyseal wedge will
invariably hang on the additional posterior fragment (Figs. 25.35, 25.36).
In all three forms, the epiphyseal fracture gap
in the A-P radiograph may lie in a fully medial
(even inframalleolar), central, or fully lateral location (Fig. 25.31). This depends on the maturity of
the growth plate but not on the direction of
trauma. The farther lateral the fracture, the more
the injury will resemble a bony avulsion of the
anterior syndesmosis with a fragment of varying
size (Fig. 25.33). Where the fracture is medial and
inframalleolar, the avulsed lateral fragment will
consist of nearly the entire area supporting the
joint (see Figs. 25.34, 25.35, 25.36 c). The fracture
will then usually lie outside the joint although in
some cases it can also extend into the periarticular bone supporting the joint (65).
We must therefore differentiate three fundamentally different groups of late adolescent
fractures. The two-plane fractures will most often
involve the avulsion of a lateral quadrant of varying size (a Kleiger or Tillaux fracture), which can
be interpreted as a bony avulsion of the anterior
syndesmosis (Fig. 25.33). Therefore, this fracture
form is often regarded as the sole representative
of transitional fractures (31, 35, 44, 67, 68). Inframalleolar medial fractures are extremely rare
among two-plane fractures (Fig. 25.34).
The type I triplane fractures basically exhibit
the same variations in the course of the fracture.
Here, the fracture almost invariably lies in the medial and central portion of the joint (Fig. 25.35 a).
Rarely, it can also lie outside the joint in an inframalleolar location (74; Fig. 25.35 b).
In type II triplane fractures, the metaphyseal
fracture extends into the joint similarly to a posterior Volkmann fracture, which we only see in
adult trauma. The anterior fracture can lie in a
fully lateral, central, or even inframalleolar me-
Ankle Injuries
417
Fig. 25.33 Two-plane fractures. The fracture gap is
usually located laterally in the A-P radiograph. The portion of the growth plate that lies medial to it is either already completely ossified or at least narrowed. The
anterior lateral quadrant of the epiphysis is avulsed
Fig. 25.34 Two-plane fractures. Inframalleolar forms
are also possible. In these cases, the avulsed quadrant
corresponds to the entire area supporting the joint.
Two-plane fractures require additional radiographic
studies. The severity of the displacement of the fragment and the location of the fracture gap (articular or
extraarticular) together determine which specific treatment is indicated. (Certain diagrams from: 74)
418
Specific Injuries—Lower Extremities
a
b
Fig. 25.35 Type I triplane fractures. In type I triplane
fractures, the same basic fracture form is present viewed
from the joint as in two-plane fractures. The only difference is that here a fragment has also been avulsed from
the metaphysis. The fracture gap in type I triplane fractures is located far more often in the medial (a) to inframalleolar region (b). Previously, we requested CT
studies where the lateral radiograph failed to visualize
the posterior portion of the epiphysis sufficiently precisely. Today, we find that two oblique radiographs will
suffice (see Fig. 25.37) to differentiate these injuries
from type II triplane fractures. In the epiphyseal layer,
the lateral quadrant is seen to be externally rotated,
causing the fracture to open anteriorly. No additional
posterior Volkmann fracture is present. (Certain diagrams and radiographs from: 74)
Ankle Injuries
dial location. Here, too, it is most often observed
in the medial and central portion of the joint (74;
Fig. 25.36).
A complete fracture or separation of all components in a type II triplane fracture is rare. This
occurs where the normally stable medial column
is itself fractured in the manner of a separated
epiphysis (through the ossified growth plate; 53).
Such an injury produces three separate fragments
instead of two as are usually encountered.
Associated injuries are rare and may include
separated distal fibular epiphyses or lower-leg
fractures (92).
Growth deformities with clinically significant
sequelae are not to be expected due to the age of
the patients in which these fracture exclusively
occur.
Problems and Complications
Only rarely are transitional fractures significantly
displaced. Usually, the fracture gaps measure between 2 mm and 4 mm and are frequently missed
on radiographs. The extent to which this leads to
serious late sequelae is not known, even with
fractures that lie in the area of primary stress
transfer in the joint. In light of the high incidence
of these fractures, which 30–40 years ago were
normally treated conservatively, and given the extremely slight incidence of degenerative joint disease in the ankle, one suspects the significant late
sequelae are not to be expected from conservatively treated or even untreated transitional fractures.
In 1999, we performed follow-up examinations of our own patients with transitional fractures of the distal tibia between 1975 and
1998. The average follow-up period was nine
years. We found that conservatively treated injuries with an initial fracture gap exceeding 2 mm
yielded the same good functional and radiographic results as conservatively treated nondisplaced fractures and surgically treated displaced
fractures. Other authors (24, 31, 55) concur with
this apparently favorable late prognosis for moderately displaced transitional fractures. However,
these findings still require confirmation in a multicentric study involving a larger number of
patients.
Diagnosis
Diagnostic examination must detect the epiphyseal injuries as they represent the actual articular
419
injuries. A-P and lateral radiographs will suffice
(96), although computed tomography (CT) or MRI
are sometimes recommended in the literature
(91, 93,98).
The fracture gap in a standard epiphyseal fracture will always appear slightly indistinct as the
fracture lies anteriorly and is not sharply reproduced in the A-P radiograph. In a posteroanterior
(P-A) projection, the fracture gap would appear
more distinct. However, this study is painful for
patients with acute joint trauma. When findings
suggest such a fracture, which must be considered
in any rotational ankle trauma in adolescents over
age 10, then the fracture will also be well visualized in an A-P radiograph.
The additional posterior epiphyseal fracture
component in type II triplane fractures will not be
visible in the A-P radiograph.
The extent of displacement of the stereotypical epiphyseal articular fracture (a fracture gap of
more than 2 mm is displaced) should be evaluated exclusively in the A-P radiograph. An
epiphyseal fracture gap will rarely be visualized in
the lateral radiograph. This is significant for the
triplane fractures as in these cases it can be important to see whether an additional Volkmann
fracture is present and whether this additional
fracture is displaced. The A-P radiograph may
show a nondisplaced epiphyseal fracture, and a
metaphyseal fracture may be visible in the lateral
radiograph, but it may not be possible to evaluate
the epiphyseal situation. In such a case, two oblique images should be obtained to visualize a
possible Volkmann fracture and determine the
extent to which it is displaced (Fig. 25.37). CT
studies (13, 28, 74, 76), which we used in the past
to become familiar with the fracture, are no
longer indicated from a clinical standpoint. MRI
studies are also more a matter of academic interest than clinical necessity.
Treatment
The goal of treatment in the presence of severe
displacement is to reconstruct the articular surface. Naturally, one must consider the stereotypical course of the epiphyseal fracture lines in each
of the three different types of fracture, and one
must ascertain the presence and severity of any
displacement.
Despite our results, I have a hard time defining
an articular fracture with a gap of about 5 mm as
“nondisplaced.” Our series is far too small to
justify this conclusion, and our findings would
420
Specific Injuries—Lower Extremities
c
a
b
Fig. 25.36 a–c Type II triplane fractures. In contrast
to type I, the metaphyseal fracture extends through the
growth plate and into the joint in addition to the fracture
of the anterolateral quadrant. Here too, the fracture gap
is most frequently located in the medial region (a, b),
rarely in the inframalleolar region (c). Previously, we requested CT studies where the lateral radiograph failed to
visualize the exact course of the fracture in the epiphysis. Today, we find that oblique radiographs will suffice
(see Fig. 25.37): In the posterior portion, in addition to
the externally rotated anterolateral quadrant, the axial
view also visualizes a transverse fracture corresponding
to the course of the metaphyseal fracture (from: 74)
Ankle Injuries
a
b
c
421
Fig. 25.37 a–c Diagnosis and treatment of transitional fractures of the
distal tibia. The patient is a 16-year-old
boy with rotational ankle trauma. The
standard radiographs in the A-P and
lateral planes reveal a fibular fracture
and a distal tibia fracture, whose course
cannot be clearly determined. The A-P
image shows an indistinct fracture line
with a gap of 7 mm slightly lateral to
the medial malleolus. In the lateral
image, a vertical fracture gap courses
from the metaphysis and presumably
across the growth plate into the epiphysis. The anterior portion of the epiphysis
appears to be angulated, although the
course of the fracture line is not clearly
visualized (a). Two oblique radiographs
were obtained to permit better evaluation of the injury (b). Whereas the left
image suggests only an inframalleolar
fracture gap, the right image clearly
demonstrates a posterior Volkmann
fracture with a readily discernible stepoff and a gap of 5 mm. Accordingly, this
was diagnosed as a type II triplane fracture. Surgical treatment was indicated
due to the severity of displacement in
the two planes. Here too, open reduction and internal fixation consisted of a
metaphyseal lag screw coursing anteroposteriorly and an epiphyseal–
metaphyseal lag screw coursing from
anterolateral to posteromedial (c)
422
Specific Injuries—Lower Extremities
have to be confirmed in a multicentric study with
a longer follow-up period. For this reason, we follow a more cautious procedure: We inform our
patients about our results, about the small number of cases in our series—47 cases with an average follow-up of nine years (23)—and about our
hesitation. In consultation with the patient, we
then weigh the burden of surgery against the risk
of a posttraumatic condition predisposing to
osteoarthritis of the ankle as a result of conservative treatment. However, for now we tentatively
recommend interpreting any fracture with a gap
exceeding 2 mm as displaced.
After applying a lower-leg splint for four days
until the swelling subsides, we immobilize every
form of nondisplaced fracture with a fracture gap
of 1–2 mm in a Sarmiento cast (Figs. 25.38, 25.39).
We treat displaced fractures surgically as a
matter of course, specifically by open reduction
and screw fixation (Figs. 25.37, 25.40, 25.41). We
have not yet had any experience with arthroscopic management of these fractures (83).
Fig. 25.38 Treatment
of transitional fractures:
Type I triplane fractures.
The patient is a 14-yearold girl with an intramedullary type I triplane fracture of the right
distal tibia. The lateral
radiograph clearly excludes a posterior
Volkmann fracture so
that no further radiographic studies were required. The fracture line
in the epiphysis exhibits a
gap of about 1 mm (the
fracture line is visible, and
the fracture is also extraarticular) so that the
fracture may be defined
as nondisplaced despite
the slight anterior bowing
deformity. Treatment was
conservative. A lower-leg
cast was applied with anesthesia allowing for symmetrical rotation. The
foot was brought back
into alignment in a right
angle, which eliminated
the anterior bowing deformity in the metaphysis. After six weeks the
fracture had consolidated
in proper alignment.
Another radiograph of
the joint was obtained
following a lower-leg fracture four months later.
The growth plate had almost completely closed,
and the joint exhibited
proper alignment and
normal anatomy
Ankle Injuries
a
b
423
Fig. 25.39 Treatment of
transitional fractures of the
distal tibia. The patient is a
15-year-old boy with rotational ankle trauma. The
standard A-P and lateral
radiographs revealed an
epiphyseal fracture in the
central and lateral portion of
the bone (a). Because no
metaphyseal fracture was
present, this was diagnosed
as a two-plane fracture. No
further radiographic studies
were indicated. The fracture
gap was 1 mm. This meant
that conservative treatment
was indicated, and a Sarmiento cast was applied for
four weeks. The consolidation radiograph demonstrates the onset of fracture
healing (b). At the follow-up
examination after one year,
the patient was free of subjective symptoms, both
ankles had the same range
of motion, and there was no
difference in leg length
424
Specific Injuries—Lower Extremities
A single epiphyseal screw is sufficient to fix a
two-plane fracture. As these fractures are usually
located laterally, the screw should compress the
fragment medially and proximally. To achieve
this, the screw should course from distal and anterolateral to proximal and posteromedial
(Fig. 25.40 a,b).
In any type of triplane fracture, rigid internal
fixation that allows motion is best ensured with a
metaphyseal screw that engages the metaphyseal
fragment (including the possible posterior
Volkmann fracture) and an epiphyseal–metaphyseal screw that engages the epiphyseal fragment.
In rare cases where the fracture is entirely medial, a medial approach is used (72). As the growth
plate is not completely closed, the epiphyseal
screw should remain entirely within the epiphysis and not cross the growth plate. This precaution
should be observed despite the fact that growth
arrest due to partial premature closure is improbable and this manner of internal fixation will not
achieve proximal compression of the large
epiphyseal fragment. The metaphyseal screw
courses from anteromedial slightly toward posterolateral because the metaphyseal wedge hangs
on the large epiphyseal fragment (Fig. 25.42).
Because physiological closure of the growth
plate is far advanced in most cases, the fracture
will lie in the central to lateral area. This requires a
lateral approach. The metaphyseal fragment usually hangs on the stable medial epiphyseal portion, i.e., the metaphyseal screw should course
from anterolateral to posteromedial. The anterolateral epiphyseal fragment should be reduced
under compression by a screw through the
growth plate coursing from anterolateral in the
epiphysis to posteromedial in the metaphysis
(Fig. 25.41).
In two-plane fractures as in type I triplane
fractures, a single epiphyseal screw will suffice.
Wherever possible, this screw should not be inserted parallel to the anterior margin of the tibia,
but should course obliquely and posteriorly from
the insertion of the anterior syndesmosis
(Fig. 25.40). The approach depends on the location of the fracture gap. Where the fracture gap
lies in the lateral or central region, the approach is
through a lateral longitudinal incision over the
fibula. Where the fracture gap is medial to center
of the ankle, the better approach is through a medial longitudinal incision over the medial malleolus (72; analogous Fig. 25.42).
In type II triplane fractures, the posterior
Volkmann fracture must initially be reduced and
fixed with an anteroposterior metaphyseal lag
screw. Then the anterolateral quadrant is stabilized with an epiphyseal screw. Occasionally, only
the lateral quadrant is displaced and one cannot
clearly identify the fracture as a type I or type II
triplane fracture in the lateral radiograph. In such
a case it is safest and most conducive to postoperative functional aftercare to first fix the
metaphyseal fracture with an anteroposterior lag
screw before reducing the anterolateral epiphyseal quadrant (Fig. 25.43).
The fibular fracture that often accompanies
these injuries is not managed with internal fixation even when displaced. Correct reconstruction
of the distal tibia will perfectly restore the mortise
of the ankle because the anterior syndesmosis remains intact.
Immobilization and Consolidation
Immobilization or reduced weight bearing continues for five weeks. The x-ray out of plaster obtained after that period should confirm bony
union of the fragment. Then the patient begins
spontaneous motion with increasing weight
bearing. Once normal range of motion has been
restored, the metal implants may be removed.
Single screws can be easily removed under local
anesthesia. However, remember that the screw is
deep and that it is less traumatic to at least partially reopen the incision.
Sports Participation and
Follow-up Examinations
No further radiographic follow-up studies are required after removal of the metal implants provided that the patient has been mobilized
without any problems. The patient can resume
sports once he or she is able to walk without assistance, which is usually three to five weeks after
the fracture has consolidated.
Follow-up examinations to assess functional
leg-length differences are indicated after six
months in older adolescents and after one year in
younger patients. As most patients will have
stopped growing by then, treatment may be concluded.
Ankle Injuries
a
425
Fig. 25.40 Treatment of
transitional fractures of the
distal tibia. The patient is a
15-year-old boy with rotational ankle trauma. The
standard radiographs revealed a displaced anterolateral epiphyseal fracture
without metaphyseal involvement. The growth plate
medial to the fracture was
practically closed. This injury
corresponds to a bony avulsion of the anterior syndesmosis, i.e., a two-plane fracture, Kleiger fracture, or Tillaux fracture (a). Internal
fixation was indicated as the
fracture gap far exceeded
2 mm. This was achieved
using an epiphyseal–
metaphyseal screw from anterolateral to posteromedial
(b and diagram of injury and
internal fixation [c]). Postoperative functional aftercare was prescribed. After
four weeks, the fracture had
solidly healed (b). The metal
implants were removed
under local anesthesia seven
weeks postoperatively. At
the final follow-up examination six months after the accident, the patient was free
of subjective symptoms,
both ankles had the same
range of motion, and the leg
with the fracture was found
to be shortened by 0.5 cm
Fig. 25.40 c 왘
b
426
Specific Injuries—Lower Extremities
Fig. 25.40 c
Fig. 25.42 Diagram of treatment of medial transitional fractures of the distal tibia. Rarely, the fracture
gap will be located medially immediately adjacent to the
medial malleolus. In the case of a type I triplane fracture,
the metaphyseal wedge will usually hang on the large
lateral fragment. During internal fixation, it is best to fix
the metaphyseal fracture even in type I triplane fractures
to facilitate a postoperative functional aftercare. A medial approach should be used. Although growth arrest
due to premature partial closure of the lateral portion of
the growth plate is improbable, the epiphyseal screw
should remain within the epiphysis and course from anteromedial to posterolateral. The metaphyseal screw is
also aligned from anteromedial to posterolateral and
stabilizes the actual or potential Volkmann fracture
Fig. 25.43 Diagram of treatment of transitional
fractures of the distal tibia. Where the injury is a type II
triplane fracture with a posterior Volkmann fracture,
open reduction will be indicated if there is any displacement (see Fig. 25.37). As the fracture usually lies in the
central and lateral region or solely in the lateral region, a
lateral approach is used. We recommend first fixing the
Volkmann fracture with the metaphyseal lag screw
before reducing and fixing the epiphyseal fragment. See
the diagram and Fig. 25.37 for the position and alignment of the screws
Ankle Injuries
427
Fig. 25.41 Treatment of
late transitional fractures
of the distal tibia. The
patient is a 16-year-old boy
with rotational ankle trauma.
The standard A-P radiograph
reveals an epiphyseal fracture with a gap of 7–8 mm in
the lateral portion of the
joint. The lateral radiograph
demonstrates a small posterior metaphyseal wedge that
does not appear to continue
into the growth plate and
epiphysis. Therefore, this
was most probably a type I
triplane fracture (a).
a
c
b
Surgical treatment was indicated due to the displacement in the A-P radiograph. This meant that no further
radiographic studies were required to ascertain whether
a posterior Volkmann fracture was present. The epiphyseal and metaphyseal fractures were both fixed with one
lag screw each to facilitate postoperative functional aftercare (b, c). A lateral approach was used. The fracture
had healed well after four weeks (b), and the metal implants were removed 10 weeks after the accident with
the patient under general anesthesia (at the patient’s request). At the follow-up examination after two years,
the patient was free of subjective symptoms, both
ankles had the same range of motion, and there was no
difference in leg length
428
Specific Injuries—Lower Extremities
Most Common Posttraumatic
Deformities of the Ankle
Tibiofibular synostoses can develop secondary to
separated epiphyses. Resection of the synostosis
even prior to cessation of growth may be indicated because of the increasing posttraumatic
symptoms that invariably occur.
Osteotomies to correct residual deformities or
the sequelae of growth disturbances should be
postponed as long as possible to maximize the effect of the corrective mechanisms of the growing
skeleton and to minimize the need for corrective
surgery. The sequelae of possible growth disturbances involving premature closure of the growth
plate must be eliminated by opening osteotomies
to compensate for the partial shortening (see
Figs. 25.10, 25.44 a–c, 25.45, 25.46).
Once a growth disturbance involving partial
premature closure of the growth plate has occurred, the patient’s age and the extent of the
banding bridge will determine the further procedure (42, 46, 47, 53). The smaller the bridge and
the younger the patient, the greater the probability of spontaneous disruption (8).
In patients below the age of 10, an attempt
should be made to resect the bridge and fill the resulting defect with rib cartilage. Fat (16) is no
longer the only graft material used; rib cartilage
in particular (see also p. 349) and bone from the
iliac crest (43) are increasingly favored. The
nearer the patient is to age 10, the greater the
chance that an opening osteotomy will also be required to eliminate an existing deformity. The
younger the patient is, the greater the chance that
correction of the deformity may be left to the corrective forces of further growth. Obtaining an MRI
study is recommended prior to resection of a
banding bridge (15, 26, 52). Occasionally, the size
and shape of necrosis bridges will prove to be so
unfavorable as to render resection impossible
without causing unnecessary damage to the rest
of the growth plate. In such a case, the only remaining option is to wait until cessation of
growth and then perform one of more opening
osteotomies (70)—not in the physis (97) but supramalleolar.
Resecting a banding bridge is no longer recommended after age 10: The increase in abnormal
growth will only be slight before growth ceases
entirely, and the decreasing effect of spontaneous
correction means that a corrective osteotomy will
be required in any case. Surgical intervention is
best delayed until a single definitive correction
can be made.
Trauma or abnormal growth in the presence
of cartilaginous osteophytes or iatrogenic synsostosis between tibia and fibula (90) can lead to increasing shortening of the fibula. This in turn can
occasionally cause abnormal growth in the tibia.
In such cases, particularly where there are clinical
symptoms, a lengthening osteotomy of the fibula
is indicated (Fig. 25.47 a–c).
Fig. 25.44 Posttraumatic deformities in the distal 왘
tibia. The patient is a 10-year-old girl with a displaced
medial malleolar fracture and displaced separated fibular epiphysis, which presumably displaced secondarily as
a result of the stress radiograph obtained with the foot
in supination. It was decided that open reduction of
both injuries and internal fixation with Kirschner wire
were indicated (a). During the further clinical course,
premature partial closure of the medial portion of the
distal tibial growth plate occurred, resulting in abnormal
varus growth (b). Because the patient was nearly asymptomatic, a watch and wait approach was taken and the
definitive correction postponed until after cessation of
growth. The 20⬚ varus deformity was then corrected by a
callus distraction at age 13 when the patient’s growth
plates had nearly closed. The surgery included both an
axial correction and slight lengthening. After three
months, there was bony union across the osteotomy site
(c), and the metal implants were removed
Ankle Injuries
429
a
b
Fig. 25.44 c 왘
430
Specific Injuries—Lower Extremities
Fig. 25.44 c
Fig. 25.45 Angled callus distraction with the Monotube. Where it
is possible to place fixator in the
concavity of the deformity, it will
suffice to open the rotation jaws
and distract the injury until proper
clinical and radiographic axial alignment has been achieved. Then the
rotation jaws are locked and the injury is further distracted until correct length has been achieved
Open rotational jaws
Fig. 25.46 Angled callus distraction with the Monotube. Where it
is only possible to place the fixator
in the convexity of the deformity,
either a fixation rod or a second fixator parallel to the first one will be required. The outer fixator compresses the injury while the inner
fixator closer to the body distracts
the site (while all rotation jaws are
open) to achieve the axial correction
Open rotational jaws
Ankle Injuries
a
b
c
431
Fig. 25.47 Shortening deformity
of the distal fibula with a valgus
deformity of the distal tibia. The
patient is an 11-year-old boy with an
osteochondroma in the distal fibula,
leading to increasing shortening of
the fibula and then to abnormal valgus growth of the tibia with a deformity of a good 25⬚. Because the
patient was a boy in whom the
growth plate was still wide open (a),
we decided to perform a lengthening osteotomy of the fibula. Slightly
less than 2 cm of distraction reduced the valgus deformity by 10⬚
(b). By the time of the follow-up examination after one year, the distal
tibial growth plate had regained its
physiological position perpendicular
to the plane of stress. The fibula exhibited the correct length relative to
the tibia (ideally, the distal fibular
growth plate should be level with
the joint space of the ankle). The tibial and fibular growth plates appeared to be close to maturity (c) so
that there was negligible risk of
further abnormal growth
432
26
Injuries to the Bones of the Foot
Diagnostic Notes
There are many accessory bones in the foot that
can make it difficult to diagnose an acute bony injury in the foot (5, 7, 10; Fig. 26.1).
Note: Accessory bones, epiphyseal ossification
centers, and other ossification centers are round
and often irregularly demarcated. They are not
painful upon clinical examination.
Aside from the os sustentaculi, os talus, calcaneus secundarius, os vesalium, and os intermetatarseum, it is the os tibiale externum in particular that is important. This latter accessory bone
is often associated with an os naviculare cor-
nutum, making it more prominent and therefore
more vulnerable and easily traumatized. Occasionally, a traumatized os tibiale externum will
lead to chronic symptoms that require treatment
with a shoe insert or even surgical removal.
The development of the apophysis of the calcaneus can be a source of confusion when interpreting radiographs. The first apophyseal ossification centers usually appear between the ages of
five and 10 and are often multifocal. They fuse
with the calcaneus very late, only after puberty.
Aseptic necrosis of the navicular (Köhler type
I) is not to be confused with a posttraumatic condition. The same applies to necrosis of the second
Fig. 26.1 Accessory
bones in the foot. The
most common accessory
bone in the foot is the os
tibiale externum, located
medial to the navicular.
The os vesalianum is found
lateral to the cuboid. In
the lateral view (from
right to left), the accessory bone most commonly encountered is the
os trigonum posterior to
the talus. Other possible
accessory bones include
the talus secundarius,
os sustentaculi, and
calcaneus secundarius
Injuries to the Bones of the Foot
433
metatarsal head (Köhler type II), which is less
common in children, or of the apophysis of the
calcaneus.
Cleft sesamoid bones are not at all rare compared with sesamoid fractures, which for all practical purposes do not occur in growing patients. A
cleft epiphysis of the proximal phalanx of the
great toe can often be differentiated from an
epiphyseal fracture based on the patient’s history
and clinical findings.
Tarsal fractures are rare (1, 10, 19, 23). These
occur in decreasing order of incidence in the calcaneus, talus, and navicular.
Calcaneus fractures are usually intraarticular
(Fig. 26.2), rarely extraarticular.
The diagnosis is usually easily made on the
basis of radiographs. However, nondisplaced fractures can be overlooked. The obvious clinical
symptoms of swelling and typical pain are signs of
a possible injury.
When diagnosing a calcaneus fracture, the examiner should note that the mechanism of injury
may suggest a possible fracture in the lumbar
spine.
Possible late sequelae of displaced or insufficiently reduced articular fractures include severe
derangement of the structural alignment in the
foot with early arthritis in the talocalcaneonavicular joint.
Proper evaluation of the joint situation in any
suspected articular fracture will require a computed tomography (CT) study (8, 15).
Where the CT images demonstrate sufficiently congruent articular surfaces and a Böhler
angle not less than 25⬚, conservative functional
treatment in a plaster cast without weight bearing is indicated. In these patients, we apply a Sarmiento lower-leg cast that we fit with a foot stirrup. This allows motion in the ankle and a certain
measure of motion in the talocalcaneonavicular
joint without allowing the foot to bear weight (9;
Fig. 26.3).
Slightly displaced fractures in which the Böhler angle is not narrowed to less than 25⬚ are
treated identically.
Severely displaced extraarticular fractures
such as an avulsion fracture of the tuberosity of
Fig. 26.2 Calcaneus fractures in growing patients.
Extraarticular fractures do not alter the structural alignment of the calcaneus. Normally, the Böhler angle measures between 25⬚ and 40⬚. Intraarticular fractures usually alter the structural alignment of the calcaneus significantly with narrowing of the Böhler angle to less than
25⬚
Fig. 26.3 Treatment of calcaneus fractures. Further
treatment of conservatively and surgically treated calcaneus fractures includes immobilization in a cast
without weight bearing. The Sarmiento cast is fitted
with a foot stirrup that ensures that the foot does not
bear weight while allowing motion in the ankle and talocalcaneonavicular joint
434
Specific Injuries—Lower Extremities
the calcaneus are treated surgically and stabilized
by screw fixation.
Severely displaced articular fractures must be
reconstructed and stabilized according to the
same criteria as adult fractures—even when good
results after conservative treatment are rarely described (21). It is not always necessary to fill the
cancellous bone defect (2, 3, 6, 11, 16). Should a
patient present with complex calcaneus injuries,
we would invariably consult with adult trauma
specialists and request their active assistance.
Treatment of a complex calcaneus fracture is far
more a routine intervention for an adult trauma
specialist than it is for a pediatric trauma
specialist or pediatric surgeon. Professional prestige should not prevent a surgeon from enlisting
the aid of others who have more extensive experience in dealing with such rare injuries.
Immobilization and reduced weight bearing
are initially continued for six weeks. A radiograph
out of plaster is obtained after that period, and if
necessary a cast allowing functional care without
weight bearing is applied for an additional four to
six weeks. This will depend on the patient’s age
and on radiographic and clinical findings.
Gradually increasing weight bearing may
begin once there is clinical evidence of solid healing. Here, too, the patient will determine the
degree of mobilization that discomfort will allow.
This will depend on the patient’s age.
However, this rule becomes less reliable as the
patient’s age increases.
Once gait is normal and soft-tissue swelling
has almost completely subsided, the patient may
gradually resume sports activities. This will be
about four to five weeks after beginning weight
bearing.
Where this is possible without any problems
and both sides exhibit symmetrical mobility and
gait is normal, then treatment may be concluded
after evaluating leg length.
Fractures of the talus are usually nondisplaced, less often displaced (11, 13). They may
occur as fractures of the talar neck or body of the
talus, or as avulsion fractures of the lateral (20) or
posterior process (Fig. 26.4). Because of the
specific vascular supply to the talus, displaced
fracture dislocations of the talar neck and body of
the talus involve a risk of avascular necrosis that is
not present in avulsion fractures of the processes
(11, 15, 22).
Nondisplaced fractures (those with fracture
gaps less than 2 mm) are treated the same as calcaneus fractures by immobilization in a short leg
Fig. 26.4 Fractures of the talus. Fractures of the
lateral process or posterior process (above) have a good
prognosis even where there is significant displacement.
Displaced fractures of the proximal talar neck and fractures of the body of the talus involve a risk of avascular
necrosis (below)
cast fitted with a foot stirrup to allow motion
without weight bearing in the ankle and talocalcaneonavicular joints.
Displaced fractures are treated by closed reduction and are also immobilized in a nonweightbearing short-leg cast.
Displaced fractures that involve a risk of
avascular necrosis should be treated by closed reduction wherever possible. However, then the
fracture must be stabilized by internal fixation via
a stab incision. Open reduction should be avoided
because any additional soft-tissue traumatization
Injuries to the Bones of the Foot
could greatly increase the existing risk to the
vascular supply to the talus. Fractures treated by
internal fixation are also immobilized postoperatively in a nonweight-bearing short-leg cast.
Immobilization is continued for six to eight
weeks. A radiograph out of plaster obtained after
that period should confirm bony union of the fracture. However, this radiograph cannot definitively
exclude beginning avascular necrosis. Fractures
that do not involve a risk of necrosis may be subjected to increased weight bearing where clinical
and radiographic findings confirm healing. Fractures that entail a risk of avascular necrosis due to
the initial displacement and the location of the
fracture should not bear weight for another four
weeks after this. A bone scan or magnetic resonance imaging (MRI) study obtained at that time
can provide information about the possible onset
of avascular necrosis. Where there are no signs of
such a process, the patient may begin with increasing weight bearing. Where signs of the onset
of avascular necrosis are present, the patient may
have to continue to use walking aids that do not
allow weight bearing for up to one year with follow-up bone scans at three- to four-month intervals.
Once the patient has begun weight bearing
and has regained unrestricted motion in the talocalcaneonavicular joint and normal gait (usually
after three to four weeks), he or she may gradually
resume sports. Clinical and subjective findings
will determine the intensity of sports participation. Certain activities may have to be curtailed
where persistent or increasing swelling occurs.
Because of the risk of avascular necrosis, treatment should only be concluded one year after the
accident based on clinical findings in patients
with unrestricted mobility and symmetrical
structural alignment in both legs. Where symptoms persist, additional radiographic studies will
be required to exclude late avascular necrosis.
Navicular fractures are extremely rare. In displaced fractures, this “keystone of the medial arch
435
Fig. 26.5 Navicular fractures. In nondisplaced navicular fractures (above), the medial arch of the foot remains
intact. In displaced fractures (below), the medial arch
collapses
of the foot” must be reconstructed (Fig. 26.5). The
injury is treated by open reduction and fixation
with a small fragment screw. Nondisplaced fractures are treated conservatively by immobilization in a Sarmiento lower-leg cast. The injury is
immobilized for six weeks in every case. Where
clinical and radiographic findings confirm fracture healing, the patient may begin increasing
weight bearing. The metal implants are removed
three to four months after surgery. Once the
patient has regained unrestricted mobility and
normal gait, he or she may resume full sports participation. Treatment may then be concluded on
the basis of clinical findings once the patient has
resumed sports without any problems.
436
Specific Injuries—Lower Extremities
Metatarsals and Toes (6.9%)
Forms
앫 Separated epiphyses (Salter–Harris types I and II)
앫 Metaphyseal impacted fractures
앫 Rarely: subcapital and diaphyseal fractures
Radiographs: A-P and oblique.
Limits of correction
앫 No malrotation,
앫 No axial deviation in the coronal plane.
Note
앫 The first metatarsal and the phalanges have one
basal growth plate.
앫 The second through fifth metatarsals have one
subcapital growth plate.
Definition of “nondisplaced”: No malrotation, no
axial deviation in the coronal plane, and less than 20⬚
of anterior or posterior bowing.
Primary pain treatment
앫 Where emergency treatment under anesthesia is clearly indicated: Digital block.
앫 Where indication is uncertain or conservative
treatment is indicated: Immobilization in a
“roof shingle” bandage or short-leg walking
cast.
Emergency treatment under nerve block
앫 All fractures with a rotational deformity,
앫 All fractures with an axial deviation in the
coronal plane that cannot be functionally
compensated,
앫 All fractures with an axial deviation in the
sagittal plane exceeding 20⬚.
Technique of conservative fixation
앫 “Roof shingle” bandage,
앫 Short-leg walking cast.
Technique of internal fixation
앫 Percutaneous pinning with crossed Kirschner
wires in subcapital and unstable basal fractures,
앫 Intramedullary nailing with a Kirschner wire
in diaphyseal fractures.
Aftercare
Period of immobilization: With conservative fixation and internal fixation.
앫 Metaphyseal fractures: Two weeks.
앫 Diaphyseal fractures: Three to five weeks.
Consolidation radiographs: None.
Initial mobilization
앫 Patient: Immediately on forearm crutches
without weight bearing.
앫 Joint: Immediate spontaneous mobilization after
removal of the plaster cast.
Physical therapy: None.
Sports: Two to three weeks after consolidation.
Removal of metal implants: Upon consolidation.
Follow-up examinations and conclusion: Examinations are performed at one- to two-week intervals
until unrestricted function is regained. Treatment is
then concluded in the absence of any deformities or
malrotation.
Injuries to the Bones of the Foot
Metatarsal Fractures
Metatarsal fractures (17, 18) occur with approximately the same distribution and incidence as
metacarpal fractures: Subcapital fractures are
most common and often occur as serial fractures
caused by a heavy object falling on the foot,
whereas fractures of the metatarsal shaft or base
are rare (Fig. 26.6).
The diagnosis is usually easily made.
Spontaneous corrections of deformities correspond to those that occur in the bones of the hand.
Here, too, axial deviations in the coronal plane are
not spontaneously corrected. Side-to-side displacement also has a favorable growth prognosis
in these fractures (Fig. 26.7). Axial deviations in
the sagittal plane, the main plane of stress transfer in the foot was well, can cause clinical impairments despite their spontaneous correction
during further growth. This is especially true of
plantar deviations such as can occur in shaft fractures. Malrotation is not spontaneously corrected,
or at least not within a tolerable period of time.
Greenstick fractures with their specific problems of delayed union and repeat fracture can
occur in the diaphysis. This situation should not
be regarded as pseudarthrosis but as a requirement for adequate fracture healing.
Fig. 26.6 Metatarsal fractures. As in the hand, the
growth plates of the second through fourth metatarsals
are distal whereas that of the first metatarsal is proximal. The most common metatarsal fracture is the fracture of the fifth metatarsal base. Separated epiphyses
(IV) and metaphyseal fractures of the base (II) are more
common than shaft fractures (I and III)
437
Isolated shaft fractures in proper axial alignment are treated conservatively in a plaster splint
without reduction.
Displaced fractures with significant axial deviation should be reduced. Where reduction cannot be maintained by conservative means (this
will be apparent on the intraoperative postreduction radiograph), percutaneous pinning with Kirschner wires is indicated. Where this is not immediately successful via the metatarsal head, open
reduction will be necessary. The Kirschner wire is
inserted from the fracture into the distal fragment, advanced through the skin, and the
screwed in retrograde fashion from the fracture
into the proximal fragment.
Where the fracture involves several metatarsals, treatment is conservative as long as there is
no significant displacement (defined as up to 10⬚
of axial deviation, side-to-side displacement less
than one-half shaft width, and 0.5 cm or less of
shortening). Where there is displacement, the
fracture must be reduced in proper axial alignment and stabilized with axial Kirschner wires
(see above; 5, 14). The severity of tolerable deformities understandably decreases with age.
In subcapital fractures of the first metatarsal,
it is important to completely eliminate any axial
deviation in the coronal plane. The persistent hallux valgus or hallux varus deformity that would
otherwise result would require a subsequent subcapital corrective osteotomy.
Subcapital fractures and fractures of the
metatarsal base are immobilized in a short-leg
walking cast for two to three weeks; shaft fractures are immobilized for four weeks. When the
patient may begin weight bearing depends less
on radiographic findings than on clinical findings
such as absence of pain.
The most common injury in the metatarsal region is the fracture of the fifth metatarsal base.
The base of this bone represents the most distal
part of the supination chain and sudden contraction of the peroneus brevis tendon can cause it to
avulse. The fracture is invariably transverse. This
fracture must not be confused with the longitudinal apophyseal growth plate which itself should
not be interpreted as a fracture (Fig. 26.8). For all
practical purposes, separated apophyses do not
occur at this location.
Only rarely will the fracture be significantly
displaced. Usually, the fracture gap does not
exceed 1–2 mm.
The treatment of choice is immobilization in a
short-leg walking cast for three weeks.
438
Specific Injuries—Lower Extremities
Fig. 26.7 Metatarsal fractures. Multiple fractures are
typically the result of a heavy object falling on the foot. A
heavy stone fell on this eight-year-old boy’s forefoot in
the summer. Ignoring the severe swelling, he continued
to go swimming. His mother brought him to a physician
because he was still limping eight days later. The physician diagnosed multiple subcapital fractures of the second through fifth metatarsals; the fractures of the
fourth and fifth metatarsals had side-to-side displacement exceeding half a shaft width with otherwise normal axial alignment. Given that eight days had already
gone by and the boy was adamantly opposed to receiving a cast, and taking into account the direction of displacement and the good growth prognosis, it was decided to continue with “conservative” treatment. After
another three weeks, the patient was free of symptoms
and went back to playing soccer. The radiographic follow-up examination after 10 weeks demonstrated
stable healing of the fractures with a callus and the onset
of remodeling. (My best thanks to Dr. Ruedi Chisten, pediatrician in private practice in Thun, Switzerland, for
making the radiographs available for publication)
Primary open reduction is indicated only in
severely displaced fractures with a significant
step-off. These fractures are stabilized by internal
fixation with tension banding (Fig. 26.9).
After the cast is removed, healing is evaluated
by clinical examination only. The radiograph obtained three to four weeks after the accident
would not demonstrate the onset of bony union at
all. The sight of a visible fracture gap on the radiograph would only unsettle the patient and provoke subjective symptoms that the patient would
not otherwise have reported. It would give rise to
a cascade of follow-up radiographs that would
serve only to amortize the radiographic equipment and would contribute nothing to healing the
patient’s fracture. Where the region of the
metatarsal base remains tender to palpation upon
clinical examination, we apply another cast or an
Fig. 26.8 Diagnosis and treatment of fractures of
the fifth metatarsal base. The fracture is invariably
transverse and must not be confused with the longitudinal apophyseal growth plate at that site (small arrow).
Note that separated apophyses are extremely rare at
this location. Radiographs to verify healing should not
be obtained because the fracture gap will remain visible
for a long time. The example of this nine-year-old boy
shows how bony union of the typical fracture has begun
only slowly, after seven weeks. By that time, the patient
was free of clinical symptoms and had engaged in full
weight bearing for three weeks
elastic bandage for another two weeks, depending on subjective symptoms.
The tenderness to palpation will have subsided after these additional two weeks at the
latest even if slight swelling remains. Then we
allow the patient to begin spontaneous weight
bearing and dispense with any further radiographs. We leave it up to the patient to decide
when to resume sports and do not make this dependent on any radiographic findings.
By not obtaining radiographs after clinical evidence of healing, we avoid unnecessarily treating
possible clinically insignificant pseudarthrosis.
The very rare cases in which pseudarthrosis is actually associated with pain, swelling, and gait impairment require radiographic confirmation.
Then debridement of the pseudarthrosis and tension banding fixation are indicated.
Injuries to the Bones of the Foot
Fig. 26.9 Treatment of fractures of the fifth
metatarsal base. Open reduction is indicated only in
the presence of severe dislocation or persistent symptomatic pseudarthrosis. In such a case, debridement of the
pseudarthrosis may be required, which is then stabilized
by tension banding
439
Fig. 26.10 Fractures of the phalanges of the toes. As
in the hand, the growth plates are located at the bases of
the bones. The most common injuries are separated
epiphyses (I); subcapital fractures (III) and shaft fractures (II, IV) are seen less often
Fractures and Dislocations
of the Phalanges of the Toes
Fractures in the phalanges follow the same pattern as in the fingers (Fig. 26.10). Objects falling on
the foot represent the most common mechanism
of injury, although physical abuse should not be
completely disregarded (12). Most frequently the
examiner will encounter separated epiphyses and
impacted fractures (1, 5, 10). Displaced fractures
are reduced after administering a digital block as
in the bones of the hand and are immobilized
with a Gibney “roof shingle” bandage in which the
injured toe is bound to the adjacent toe
(Fig. 26.11). Injuries with an initial valgus deformity should be bound to the next medial toe, those
with an initial varus deformity to the next lateral
toe. A strip of gauze is placed between the toes to
prevent development of decubital ulcers. The
bandage should be removed after one week and
replaced with a second one if necessary.
This method of immobilization also applies in
principle to fractures of the great toe. Occasionally, the weight of the blanket lying on the
painful toe will disturb patients at night. If a cut
out section of a cardboard box does not provide
adequate protection for the toe at night, the
patient should be offered a short-leg walking cast
with a projecting sole. Depending on the severity
of the subjective symptoms, the patient will
Fig. 26.11 Treatment of toe fractures. The “roof
shingle” bandage is the simplest method of treating toe
fractures. A strip of gauze is placed between the toes to
prevent development of decubital ulcers
440
Specific Injuries—Lower Extremities
either opt for the cast or prefer to stick with the
bandage.
Epiphyseal fractures are extremely rare. In the
great toe as in the thumb, they can take the form
of transitional fractures of late adolescence with
bony avulsions of the collateral ligaments.
Growth disturbances will no longer be a risk. In
younger patients with wide open growth plates,
epiphyseal fractures can occasionally lead to pre-
mature partial or complete closure of the growth
plate with subsequent abnormal growth in the
toe.
Displaced articular fractures require open reduction to allow reconstruction of the joint. Stabilization with Kirschner wires will suffice.
Dislocations can occur and are treated identically to dislocations in the fingers.
441
Appendix
27
Battered Child Syndrome
Causes
Physical abuse of children is a societal problem,
and the somatic battered child syndrome is only
the tip of an iceberg of emotional traumatization,
injury, and harassment of children perpetrated in
the name of civil society. Statutory prohibition of
physical punishment as a means of enforcing discipline in schools is a relatively recent development. Many parents still feel that only a child who
has been rigorously molded into shape will fit into
society. The compulsion to repeat one’s own
negative experiences is also a factor to be considered. This applies equally to the intentional use
of physical punishment as a means of discipline
and to uncontrolled, emotionally charged battery
(9, 24, 46, 59). It also applies to a certain extent to
sexual abuse (75), a topic beyond the scope of the
present discussion.
Parents, and not only those from a background
of social alienation, occasionally will unwittingly
and impulsively seek to reproduce the familiar atmosphere of their own childhood. Lack of reflection about their own childhood experiences and a
low tolerance threshold of emotional stresses in
general and those caused by their own children in
particular induce these parents to beat their
children, especially in infancy (116, 120). Those
precipitating the injury need not be the child’s
parents. This applies equally to baby-sitters,
aunts, uncles, grandparents, in short, to anyone
entrusted with caring for the child for a brief or
extended period of time (9, 46, 59, 89). Often the
precipitating factor in these people is a feeling of
helplessness in attempting to deal with the
screaming child combined with typical childhood
experiences of their own. The caretaker loses his
or her nerves, violently shakes the baby, and finally hits the child to silence it.
Diagnosis and Patterns of Injury
The injuries are easily diagnosed; identifying the
syndrome itself is far more difficult. Parents who
habitually beat their children frequently change
hospitals and doctors. This means that any one
health care professional may only be consulted to
treat a specific acute injury. This will often be only
a peripheral injury such as a hematoma or sudden
bleeding from the ear, nose, or mouth, or occasionally a series of black and blue marks that the
concerned parents fear are caused by bleeding.
The examiner should also look for evidence of
deeper lying injuries.
Radiography is the simplest and most conclusive diagnostic method where child abuse is initially suspected. It is best to use a large film plate
to visualize as much of the skeleton as possible.
Multiple fractures on the radiograph may be regarded as having confirmed the clinical suspicion
and provide a convenient excuse for admitting the
child to the hospital. A bone scan is better than a
“baby film” in that it can also reveal occult fractures in the spine, sternum, scapulae, ribs, and
skull that often escape detection on standard
radiographs. Depending on the neurological, bone
scan, and radiographic findings, additional diagnostic studies such as a skull ultrasound scan,
computed tomography (CT) scan, magnetic resonance imaging (MRI) study, or ophthalmological
examination may also be indicated (7, 16, 43, 55,
132, 137, 138). Bear in mind that vertebral fractures can also occur (7, 27, 46, 81).
Multiple diaphyseal and metaphyseal fractures in the extremities of varying age
(Fig. 27.1 a,b) accompanied by rib fractures
(Fig. 27.1 c) also of varying age and possibly skull
fractures (Fig. 27.1 d, 27.2) must be regarded as
proof of the syndrome. The age difference in the
fractures may be measured by the presence and
density of a callus. Acute fractures will often appear only as avulsed wedges along the metaphyseal margins without a callus. In contrast, older
fractures will exhibit either a periosteal bridging
callus that has not yet solidified (indicating a fracture about 8–12 days old) or a callus that has the
same density as cortical bone (indicating a fracture about three to four weeks old). Monstrous
442
Appendix
callus formations are also evidence of older fractures; here again, the thickness and structure of
the outer layer of the callus are indicative of the
age of the injury. Excessive proliferation of callus
can be indicative of constant motion or of repeated traumatization of the fracture. Variations
in the structure of the outer callus layer can provide important clues. Many authors regard serial
rib fractures, which may be easily overlooked on a
radiograph, as positive proof (9, 46, 55).
Treatment
Acute fractures are immobilized in a plaster cast
to reduce pain. Chronic fractures that are no
longer painful do not require any special treatment. The important thing is to prevent any new
trauma. This in turn is a psychological and social
problem, not a surgical one. Because surgeons and
orthopedists are not exactly experts in dealing
with such issues, many tend to rid themselves of
b
a
Fig. 27.1 a–d Diagnosis of battered child syndrome.
The patient is a four-month-old boy, a premature baby
with slight spasticity who had received physical therapy
from his mother and a therapist since birth. The child
was hospitalized due to increasing swelling with intense
pain in both thighs. The radiographs of the upper extremities demonstrated a healed subcapital fracture of
the left humerus and a small flake of bone callus in the
middle of the ulnar shaft indicative of a significantly
more recent fracture. A possible subcapital infraction
fracture in the right arm cannot be excluded with certainty (a). The lower extremities exhibit metaphyseal infraction fractures in the left distal femur and in both
proximal tibias with calluses extending well into the
shaft region. Judging by the density of the calluses, the
fractures appear to be about four to six weeks old. The
right femur exhibited a still indistinct lateral and medial
periosteal callus indicative of a fracture about 10–14
days old (b)
Battered Child Syndrome
443
Fig. 27.1 c, d The chest
radiograph demonstrates
several rib fractures on the
right side, identifiable by
their callus (c). The skull
radiograph shows two parallel parietal fractures (d). The
presence of multiple fractures of the extremities of
varying age, skull fractures,
and rib fractures provide
unequivocal evidence for
the diagnosis of battered
child syndrome
c
d
444
Appendix
Fig. 27.2 Diagnosis of
skull fractures. Only rarely
are the skull fractures so
numerous and well-defined
that these findings alone
suffice to suggest child
abuse in the absence of a
clear and plausible history
of trauma
the problem simply by accusing the parents of
child abuse and reporting their suspicion to the
appropriate authorities. This eliminates the problem for the surgeon but not for the child.
Suspected child abuse has serious legal ramifications for the parents, child, and attending
physician that are beyond the scope of this book.
The applicable regulations, the responsible public
authorities, and the requirements of statutory reporting procedures vary between countries,
states, provinces, and municipalities. It is the responsibility of the surgeon to know and obey the
statutory requirements of his or her locality.
Our experience in Switzerland may or may
not be directly applicable to other localities. In the
absence of specific child abuse reporting regulations to the contrary, we suggest that the attending physician proceed as follows:
The physician should invariably inform
parents of the suspicion or diagnosis of abuse, regardless of who was responsible for causing it,
and must strongly recommend to the parents that
the child temporarily remain in the hospital for
further diagnostic studies. Here it is important to
convey the impression of being understanding
and not judgmental, and above all to make it clear
to the parents that the physician’s sole concern is
to safeguard the child’s interests. Having done
this, we feel that the next step (to be taken well
before informing the appropriate authorities) is
to immediately alert a team of psychiatrists, psychologists, and social workers. This team will have
the necessary expertise in providing the necessary psychosocial support for the child’s home environment and will be able to contact the appropriate authorities if the need arises. A number of
organizations such as the Swiss Opferhilfe (Aid to
Victims) now exist in many localities to help
address these problems.
When making the diagnosis, the surgeon
must fully understand that whereas he or she has
the necessary expertise to treat the child’s physical injuries, the psychosocial problems of the
parents and the parent–child relationship are beyond the scope of this expertise. Any definitive
treatment, especially prevention, must focus on
the parents and on the full range of their
emotional and social problems (9, 44, 59, 75, 81,
89).
445
28
Birth Trauma
Causes and Type of Injury
The name given to these injuries specifies their
cause: Breech presentations, forceps births, and
even normal births and cesarean sections can result in injuries to the musculoskeletal system (53,
67, 73). Our experience has shown that about two
thirds of these cases involve the shaft region of
the bone, primarily in the femur and less often in
the humerus and the bones of the lower leg.
About one third of these cases involve separated
epiphyses of the proximal and distal humerus
(see also Fig. 18. 10) or the distal femur. Occasionally, plexus injuries of the shoulders may also
occur (68).
have suffered a fracture. Secondary radiographs
demonstrating a large callus (which usually undergoes remodeling during the further course of
healing) will confirm the initial tentative diagnosis.
With a separated proximal humeral epiphysis,
inability to move the arm due to pain often simulates brachial plexus palsy. In such a case it is best
to position the arm as in a plexus injury without
performing physical therapy. Paralysis persisting
longer than five days in the absence of clinical and
ultrasound evidence of callus formation will exclude a fracture. Further plexus treatment may
then be performed.
Treatment
Diagnosis
In the case of shaft fractures, the diagnosis is clear
from the start and does not even require radiographs. Periarticular injuries can be overlooked
initially, and the swollen, painful joint may only
be detected two to three days after birth. Exact diagnosis of a fracture based on radiographic findings is possible only with a great deal of imagination as radiographs often provide only indirect
evidence of a fracture and the ossification centers
are not yet visualized (Figs. 28.1 a, b, 28.2). Even
ultrasound scans often prove unreliable (32, 76).
Often the physician will be caught between a rock
and a hard place with no other choice but to watch
and wait for the further clinical course to confirm
whether the symptoms are due to birth trauma,
periarticular osteomyelitis, or even septic arthritis. The child’s clinical condition is not always
conclusive. Ultrasound can at least be used to exclude septic arthritis. A child who remains
healthy, drinks, and thrives, with swelling that
becomes increasing less tender to palpation
within eight days (indicated by less pain when diapers are changed), may be safely be assumed to
Pain management is the primary objective of
treatment. Small plaster casts or splints are well
suited for this purpose. A plaster hip spica or oneand-a-half hip spica can readily be applied to an
infant, as can a Desault dressing in plaster cast. A
suitable treatment for premature babies is a traction bandage on the arm or leg weighted with a
few grams. Whatever treatment one elects to use,
its primary purpose must be to eliminate pain and
not to improve position. Conservative measures
of this sort will not be able to influence position at
all. Given the good corrective potential of even
severe axial deviations (see Figs. 1.2, 1.3), we have
not yet encountered any situation in which closed
or open reduction would have been indicated.
Prognosis
The growth prognosis is generally good, as axial
deviations invariably undergo reliable “spontaneous” correction. Growth disturbances are
rarely possible (see Fig. 18.10). Special follow-up
examinations other than routine checkups by a
pediatrician are not necessary.
446
a
b
Appendix
Fig. 28.1 Treatment and
follow-up of birth trauma.
Nine days after birth, significant swelling was noticed in
this child’s right knee,
which apparently had been
increasing since birth. The
initial pain subsided. The
radiographs shows the
beginning of a massive callus around the distal end of
the femur; the ossification
center of the distal femur
appears to be laterally displaced. The radiograph two
weeks later confirmed the
initial tentative diagnosis of
a separated distal femoral
epiphysis with posterior displacement (a). After as little
as six months, spontaneous
correction had largely eliminated the anterior bowing
deformity, which further
growth had increasing
shifted into the shaft region
(b)
Birth Trauma
Fig. 28.2 Diagnosis of birth trauma. The patient is a
newborn with swelling in the right elbow that was noticed two days after birth. The initial radiograph failed to
visualize a clearly identifiable fracture. As usual, the contralateral radiograph also failed to provide any useful information in this case as well. After eight days, the swelling was no longer tender to palpation, and the second-
447
ary radiograph demonstrated formation of a large callus
in the supracondylar region of the humerus. Presumably, the injury was either a separated distal
humeral epiphysis that had since healed or a very peripheral supracondylar fracture with a fracture gap that
remained invisible even on the secondary radiograph
448
29
Pelvic Fractures
As a sequela of massive direct trauma, pelvic fractures rarely occur in isolation but most often in
combination with soft-tissue injuries of varying
severity and additional bony injuries. Usually, the
problems posed by the associated injuries
demand the greatest immediate attention (23, 58,
77, 135).
The degree of injury to the various growth
zones (Fig. 29.1) is only a minor factor in the prognosis for bony injuries to the pelvis. A far more important prognostic factor is the trauma-induced
change in shape of the plane of the pelvic inlet (37,
64, 86). Aside from the associated injuries, we
must distinguish between bony and ligamentous
injuries with possible serious late sequelae and
those injuries without possible serious late
sequelae (94).
Fig. 29.1 Apophyseal avulsion fractures in the pelvis. The most common injury of this sort in adolescents
is avulsion of the anterior inferior iliac spine (1), followed
by avulsion of the apophysis of the ischial tuberosity (2)
and the anterior superior iliac spine (3)
Injuries that do not involve serious late
sequelae include apophyseal avulsion fractures,
fractures of the iliac wing, isolated fractures of the
ilium, isolated fractures of the pubic rami, and
isolated loosening of the sacroiliac joint (Fig. 29.
2 a).
Injuries that can involve serious late sequelae
include Malgaigne fractures, ruptures of the pubic
symphysis, and acetabular fractures (74, 98;
Fig. 29.2 b).
Growth disturbances in the apophysis of the
iliac crest secondary to isolated fractures of the
iliac wing can cause cosmetic deformities of the
iliac wing.
Premature closure of all or part of the
triradiate cartilage is possible following an
acetabular fracture. This can lead to secondary hip
dysplasia. However, neither growth disturbances
nor dysplasia are inevitable sequelae (94;
Fig. 29.3).
The published literature does not contain any
descriptions of posttraumatic growth disturbances in the apophyses of the pubic rami.
The periosteal–endosteal corrective system
ensures particularly efficient local remodeling of
bony structures in the pelvis (Fig. 29.4). However,
this only leads to restoration of the individual
bone structures, not to remodeling of the pelvis as
a whole. Deformities in the plane of the pelvic
inlet will persist unchanged during the course of
further growth, regardless of whether they are
caused by displacement of one entire hemipelvis
or by rupture of the pubic symphysis (Fig. 29.5).
The associated injuries are the decisive factor
in choice of treatment, and accordingly they will
also determine the time and expenditure of treatment for managing bony and ligamentous injuries to the pelvis.
Pelvic Fractures
449
Fig. 29.2 a Pelvic fractures without serious late
sequelae. Such late sequelae are not to be expected
after isolated fractures of the iliac wing, ilium, or pubic
rami, or after apophyseal avulsion fractures or isolated
loosening of the sacroiliac joint
Fig. 29.2 b Pelvic injuries with serious late sequelae.
Malgaigne fractures with fractures of the ilium and pubic
ramus (above) or with rupture of the pubic symphysis
and loosening or disruption of the sacroiliac joint (center) can lead to severe symptoms if left untreated. The
acetabular fractures (below) involve the risk of growth
disturbance with increasing secondary hip dysplasia
450
Appendix
Fig. 29.3 a–c Acetabular
fractures. This four-year-old
girl suffered an acetabular
fracture in the form of an
epiphyseal separation of the
triradiate cartilage. This was
treated by insufficient open
reduction that was fixed with
Kirschner wires (a)
a
Pelvic Fractures
451
Fig. 29.3 b Premature closure of the triradiate cartilage occurred during the
further course of healing.
However, this did not lead to
dysplasia during the first
seven years of observation
(b, c, above).
Fig. 29.3 c 왘
b
452
Appendix
Fig. 29.3 c A moderate deformity with acetabular dysplasia only occurred with the
onset of puberty, as demonstrated by this follow-up
radiograph 14 years after the
accident (c, below)
c
Fig. 29.4 “Spontaneous correction” in the pelvis.
This nine-year-old boy suffered an isolated fracture of
the public ramus without associated injuries. Therefore,
the physician opted for conservative treatment. As healing progressed, the original deformity of the anterior
public ramus was largely eliminated by remodeling 왘
within two months (my thanks to Dr. Lusche, Städtisches
Krankenhaus, Lörrach, Germany, for the films of the last
follow-up examination)
Pelvic Fractures
453
454
Appendix
Fig. 29.5 Late sequelae of pelvis fractures. This
three-year-old patient suffered a Malgaigne fracture
with severe deformation of the plane of the pelvic inlet.
Whereas remodeling successfully restored the structure
of the individual bones, the deformation of the plane of
the pelvic inlet persisted unchanged at the follow-up examination 13 years later
Pelvic Fractures
Injuries Without Significant
Late Sequelae
Apophyseal avulsion fractures occur for the most
part only in adolescents (Fig. 29.6). Most often
these injuries involve the origin of the rectus
femoris, the anterior inferior iliac spine. Less
often, these injuries involve avulsions of the
origins of the adductors, the apophyses of the
pubic bone, or avulsion of the sartorius from the
anterior superior iliac spine (36, 117).
The history will provide important diagnostic
information: Such injuries are suggested where
patients report having performed sudden splits,
abduction motions, or forceful muscular contractions (such as in soccer) followed by stabbing pain
in the groin, or at the origins of the adductors in
adolescents. Intense pain prevents the patient
from tensing the muscle group in question. Radiographic examination will reveal a bowl-shaped
fragment of varying size that is displaced in the
direction of the muscular pull.
Treatment consists of reduced weight bearing
with initial pain medication that is continued
until the patient reports that motion without
weight bearing is no longer painful. This will last
about 8–12 days. After that, the patient continues
455
reduced weight bearing as long as weight bearing
continues to cause pain. Once weight bearing is
possible without any pain (after about four to six
weeks), the extensive callus swelling will usually
have ceased to be tender to palpation. We do not
obtain radiographs to verify healing as they do not
provide any additional information or have any
further consequences. At worst, the patient, and
other physicians consulted, may experience
anxiety at the sight of the large callus. This can
often lead to a completely superfluous biopsy of a
suspected “tumor.”
Isolated loosening of the sacroiliac joints is difficult to diagnose, and even a computerized axial
tomography (CAT) scan may be unable to verify its
presence (13, 62). However, the typical intense
pain is a reliable clinical sign. If it will have an impact on the choice of treatment, a bone scan (91)
may be obtained to detect this or other injuries
that cannot be visualized on radiographs.
Isolated fractures of the ilium, iliac wing, and
one of the pubic rami are readily diagnosed on
radiographs.
How these all of these injuries are treated is
determined solely by the patient’s pain insofar as
the fractures are not displaced and there are no
associated injuries. Treatment will involve bed
Fig. 29.6 Treatment of
apophyseal avulsion fractures. This 14-year-old boy
suffered an avulsion fracture
of the anterior inferior iliac
spine with significant distal
displacement while playing
soccer. The injury was
treated conservatively with
reduced weight bearing on
forearm crutches until pain
had subsided. Healing was
assessed by clinical examination only. After six weeks,
the patient had resumed
sports participation
Appendix
rest, reduced weight bearing, and increasing
weight bearing. This means that the patient is
largely left up to his or her own devices, and the
attending physician should leave decisions up to
the patient. Usually, no more bed rest will be required after eight days, and the patient will begin
walking with and without forearm crutches. The
period of reduced weight bearing rarely lasts
longer than two to three weeks. As soon as the
patient feels up to it, her or she may gradually resume sports participation.
Treatment of displaced fractures of an iliac
wing will depend on the severity of the deformity.
Open reduction is indicated for severe deformities that may be expected to leave subsequent
cosmetic impairments. Usually, stabilization with
Kirschner wires will suffice. However, it is important to remember that this will not prevent a
possible growth disturbance and can more likely
even cause one.
Treatment of displaced fractures of the pubic
rami depends on the associated injuries. Where
none are present, the corrective forces of further
growth in this region may be relied upon to correct the deformity (Fig. 29.4). Where surgery is indicated to treat associated injuries, it is advisable
to reduce the displaced pubic ramus. Additional
fixation is not usually necessary.
Isolated loosening of the sacroiliac joints and
fractures of the ilium do not usually exhibit displacement.
Naturally, wherever reduction is required, the
results are documented in radiographs obtained
during the same surgical session. Additional
radiographic studies to verify correct position will
not be necessary where symptoms increasingly
disappear. Healing should be verified in radiographs in all fractures of the iliac wing and pubic
rami. Additional follow-up radiographs will only
be required to demonstrate spontaneous correction of residual deformities that cause cosmetic
impairments.
Treatment should be concluded about one
year after the accident on the basis of a clinical follow-up examination. By that time the callus in
apophyseal avulsion fractures will have disappeared. Treatment of fractures of the iliac wing or
pubic ramus may be concluded where structural
alignment and function are symmetrical and
there is no residual deformity in this region.
Injuries With Serious
Late Sequelae
The diagnosis of isolated ruptures of the pubic
symphysis is often rendered difficult by the agerelated variation in the physiological width of the
symphysis. The Krauss curve (50; Fig. 29.7) can be
very helpful in this regard. The rule that bony
avulsions are far more likely to occur than ruptures in growing patients also applies to these injuries. Therefore, radiographs should be carefully
examined for possible avulsed flakes wherever
clinical symptoms and the patient's history suggest such an injury.
Nondisplaced ruptures of the pubic symphysis are treated with bed rest for about three weeks
to avoid secondary creation of a fracture gap.
Displaced ruptures of the pubic symphysis
were previously treated conservatively in a crossover sling. Today, early surgical intervention is
advisable in the interest of mobilizing the patient
more rapidly. Plate fixation involves the risk of
ossification of the symphysis, which in women
may later lead to birth complications. Presumably, it is better to achieve and stabilize the
reduction with cerclage wire attached to screws,
and to remove these implants as soon as possible,
i.e., after 8–10 weeks.
Once pain has disappeared after about four
weeks, this injury will have healed sufficiently to
allow mobilizing the patient with full weight
bearing. If gait has returned to normal after
another two to three weeks, then the patient may
resume sports participation. Treatment may be
concluded after one year on the basis of radiographic and clinical follow-up examination pro-
mm
12
10
8
6
4
2
Symphysis width
456
2 4
6 8 10 12 14 16 18 20 30 40 50
Age
Fig. 29.7 Physiological width of the pubic symphysis according to the study by Krauss. The width of the
symphysis varies in relation to age, decreasing significantly with increasing age
Pelvic Fractures
vided the patient is free of symptoms, there is no
evidence of the onset of ossification of the symphysis, the symphysis exhibits normal age-related width, and the patient exhibits symmetrical
structural alignment and function in the lower extremities.
Malgaigne fractures are invariably the result
of high-energy trauma and usually involve severe
associated injuries. The diagnosis and evaluation
of the severity of displacement of the sacroiliac
injuries in Malgaigne fractures can only be made
on the basis of CAT scans (13, 35, 134, 135).
Like in adults, displaced fractures should be
reduced. Persistent displacement, subluxation, or
dislocation of the sacroiliac joints does not appear
to be tolerable: Symptoms in the sacroiliac region
are invariably identified as impairments for the
patient at late follow-up examinations. Therefore,
any sacroiliac displacement should be identified
in computed tomography (CT) images and eliminated. The injury can be reduced and stabilized
with the aid of an external fixator (25, 62, 71, 79).
Further mobilization continues as soon as
possible, depending on pain and other associated
subjective symptoms. Sports participation may
usually be gradually resumed within four weeks
of beginning mobilization.
Acetabular fractures are extraordinarily rare
(58, 64, 109, 126, 133) and usually occur in the
form of epiphyseal separation of the triradiate
cartilage with and without metaphyseal involvement. Of course, premature partial closure of part
of the growth plate can occur here, too, with subsequent abnormal growth. However, one should
457
not succumb to the illusion that such a growth
disturbance can be avoided by surgical intervention.
Surgery should, can, and must restore the congruity of the joint and nothing more.
Conservative treatment is indicated for
slightly displaced fractures, i.e., those in which
the only displacement is with respect to the pubic
bone whereas the articular portion of the bone remains intact. These injuries are immobilized in a
hip spica for three to four weeks.
Displaced fractures are treated surgically, depending on the patient’s age. The reduction is stabilized with fracture plates or individual screws,
and the injury is then immobilized for four to six
weeks. The radiograph obtained after that period
should demonstrate bony union. Patients with
these injuries are then mobilized with increasing
weight bearing in the same manner as patients
with Malgaigne fractures.
Radiographic and clinical follow-up examinations are continued at six-month intervals until
two years after the accident. Treatment may be
concluded where the patient exhibits symmetrical structural alignment and function with no
signs of premature closure of the growth plate or
abnormal growth.
Wherever this is not the case and increasing
hip dysplasia occurs as a result of premature closure of the triradiate cartilage, a pelvic osteotomy
(acetabular reconstruction, triple osteotomy, etc.;
29, 30, 34, 71, 97) will have to be performed at a
later date to improve the coverage of the femoral
head by the roof of the acetabulum.
458
30
Spinal Disorders and Injuries
앫 Rotational blockades
앫 Vertebral fractures
Whereas vertebral fractures are rare in children,
that is in patients with open growth plates, rotational blockades with painful torticollis are
extraordinarily common. They nearly exclusively
affect the upper cervical spine, rarely the lower
cervical spine.
In obtaining the patient’s history, the examiner will usually experience the parents’ urgent desire to identify some sort of cause of the
condition: Parents will readily attribute the sudden symptoms to falls on the head or shoulder
that occurred several days earlier. Often only a
loud yawn, laughter, or a “clumsy motion” will be
reported. It appears doubtful whether upper respiratory infections such as colds actually do lead
to an increased incidence of rotational blockades
(Grisel syndrome), as has repeatedly been maintained in the literature (96). Given the normally
inconclusive patient history, the diagnosis is primarily made on the basis of clinical findings: The
head is inclined to one side and rotated away from
the side toward which it is inclined (Fig. 30.1). The
muscles on the extended side are severely and
painfully tensed. Attempts to spontaneously extend the neck or rotate it back toward the side to
which it is inclined are reported as being particularly painful.
Radiographic examination is not required in a
first-time occurrence of the disorder with a brief
clinical course and a typical history that does not
suggest trauma.
However, where there is a history of trauma,
the disorder is recurrent, and its clinical course
persists longer than five days, radiographic examination of the cervical spine is indicated to exclude fractures, instability, and congenital vertebral malformations.
Radiographic examination of a “typical” torticollis will usually reveal only an unusual extension posture indicative of pain. Occasionally, there
will be what some claim is “subluxation” of a
Fig. 30.1 Rotational blockade of the cervical spine.
The patient shows the typical posture with the head inclined to one side and rotated to the contralateral
shoulder. The extended side is extremely painful
vertebra with an axial deviation or kyphosis.
Small children may often exhibit as much as 5 mm
of anterior displacement of the vertebrae relative
to one another. The anteroposterior (A-P) radiograph will demonstrate scoliosis corresponding
to the torticollis. If there is no kyphosis, only an
extension posture, then it will not be possible to
localize the blockade on standard radiographs
(Fig. 30.2). Only stress radiographs would then be
able to identify the most common location of the
blockade, between C2 and C3, in a function diagram (12; Fig. 30.3). Where the blockade lies between C1 and C2, the transbuccal A-P radiograph
will be able to identify the position and direction
of the blockade due to the position of the odontoid (3, 17, 96; Fig. 30.4).
The goal of treatment is to release the rotational blockade by direct or indirect means.
Therefore, one aspect of treatment is to avoid ex-
Spinal Disorders and Injuries
459
Fig. 30.2 Rotational blockade of the cervical spine.
This radiograph in a patient with a history of trauma and
a clinical course persisting longer than five days was intended to exclude fractures and malformations. The A-P
film demonstrates the scoliosis that was also observed
in the clinical examination. The lateral film shows an extreme extension posture producing kyphosis of the cervical spine. The blocked segment, here C3 –C4, cannot
always be identified radiographically without resorting
to stress radiographs
amination techniques that would cause any additional pain and aggravate the tensed, hardened
muscles.
In adolescent patients, precise manual
manipulation can usually eliminate the torticollis
quickly and easily (12, 17). This requires a careful
prior palpatory examination (which must not be
painful) to identify the blocked segment.
Rough attempts at manipulation (51) can also
have the effect of immediately eliminating the
torticollis. However, they can also be painful in
contrast to precise manipulative maneuvers. Such
manipulation should not be attempted in patients
with a history of genuine trauma.
The purpose of indirect medical or physical
treatment is to reduce the reactive edema around
the blocked joints and to ease muscle tension and
hardening. The application of heat is soothing and
helps relieve subjective symptoms on the tensed,
extended side. A warm wrap alone is often sufficient to eliminate the extraordinarily painful disorder. Because of this intense pain, one should initially be very generous with simple pain medications.
Patients find a foam rubber collar soothing in
particularly persistent cases.
Brief traction therapy for a few hours in a Glisson sling can be very helpful in eliminating the
blockade in particularly severe cases, especially
where a posttraumatic condition cannot be excluded.
Primary pain neutralization is the most important aspect of healing. Usually, symptoms will
disappear completely within three to four days
460
Appendix
Fig. 30.3 Functional diagram of the cervical spine.
Clinical examination and the lateral radiograph may fail
to identify the location of the blocked segment, and
further treatment may require that information. In such
cases, lateral stress radiographs of the cervical spine in
maximum extension and flexion may be obtained. By
tracing the range of motion of each segment on the
standard radiographs, the examiner obtains a functional
diagram that will normally show about the same anterior and posterior excursions in each segment (above). If
one of the segments does not exhibit any excursion, that
segment is the site of the blockade (below)
Fig. 30.4 Rotational blockade of C1 –C2. The direction of rotation and the location of the blocked segment
can be identified on transbuccal A-P radiographs from
the position and direction of the odontoid and the
lateral mass of the atlas
Normal
Right rotation of C1
Right rotation of C2
Spinal Disorders and Injuries
and the cervical spine will have regained its full
range of motion in every direction. Treatment
may then be concluded without the need for any
further follow-up examinations. In older adolescents, impairments at the end of the range of motion may persist more tenaciously. Where precise
manipulation is not successful in eliminating the
blockades, one should look for disturbances of the
structural alignment of the spine (such as a leglength difference that has led to development of a
secondary scoliotic posture). This should then be
treated and, if necessary, followed by a regime of
strengthening exercises.
Sudden, drastically worsening torticollis
without prior trauma that occurs in small
children or infants and fails to respond to application of heat and/or physical therapy is an indication for neurological examination. At worst, it
may be a symptom of a cerebellar tumor.
Vertebral fractures are rare in growing
patients. They most often involve the thoracic
spine, rarely the lumbar spine, and even more
rarely the cervical spine (10, 19, 38, 40, 47, 85, 103,
111, 122, 124, 127, 129). These injuries are most
often serial fractures; fractures of isolated vertebrae are rare.
In terms of treatment, it is advisable to differentiate between nondisplaced or slightly displaced fractures and severely or completely displaced fractures. The usual classification in stable
and unstable fractures only has a certain degree of
therapeutic relevance if one expands the interpretation of instability as Magerl and co-workers
do (56). Janis’ classification in fractures with and
without involvement of the growth zones (39)
also lacks clear therapeutic relevance.
Fundamentally, the same criteria for the respective treatment apply as in adults. However, in
contrast to adults, certain “spontaneous corrections” of deformities can render primary treatment easier. As is the case throughout the growing skeleton, deformities in the main plane of motion, the sagittal plane, are excellently corrected
by further growth here as well (38, 47, 80;
Fig. 30.5). However, combined deformities in the
coronal and sagittal planes represent a special
case. Not only will the coronal deformity persist;
often the deformity in the sagittal plane will
largely fail to undergo correction as well (39, 80;
Fig. 30.6).
Vertebral fractures are invariably diagnosed
on the basis of radiographic findings. In addition
to a band of thickening indicative of impacted
cancellous bone, a wedge-shaped vertebra is an
461
important sign of a fracture. Findings of history
and acute pain help to distinguish fractures from
wedge-shaped vertebrae from other causes, such
as status post Scheuermann disease, histiocytosis,
aneurysmatic bone cysts, etc.
The stable fracture is characterized by compression of the vertebral body of varying severity.
Unstable fractures also include fractures of the articular processes, vertebral arches, or pedicles; or
they include additional ligamentous injuries. Instability is not always detectable on initial radiographs. Tomographic methods can be helpful in
visualizing associated injuries to bony structures,
whereas careful stress radiographs can help detect ligamentous injuries.
There have been repeated warnings (2, 39, 69,
70, 80) about the risk of growth disturbances following injuries to the growth zones of vertebra
(superior and inferior endplates). However, their
sequelae do not differ from the increasingly
severe deformities due to unfavorable structural
alignment in the adult spine. Individual variation
in the loading of the respective spinal segments
undoubtedly has some influence as well. Therefore, it is impossible to say with certainty whether
increasing deformities (development of wedgeshaped vertebrae and scoliosis) secondary to injuries of the vertebral endplates may be defined
as the result of growth disturbances or of unfavorable structural alignment. However, these
considerations do not have any great clinical significance as reconstruction of the growth zones
that would preserve function is not feasible even
by surgical means.
The goal of treatment in every case is to restore the stability and structural alignment of the
spinal column.
Stable wedge-shaped vertebral fractures that
are nearly nondisplaced or in which the deformity
lies in only the sagittal plane and in which the
height of the anterior margin is not less than 50%
of the posterior margin, receive functional treatment. The patient remains in bed until he or she is
free of pain; isometric back training may also be
prescribed. The patient is fully mobilized once the
pain has completely subsided. Spinal mobility
may be or already have been partially impaired at
one or more sites. Where this is the case, a regime
of exercise to improve posture is indicated.
The first follow-up radiographs to verify healing should be obtained after about six weeks.
Where the deformity does not increase and the
patient remains free of symptoms, the patient
may continue normal weight bearing. A final
Fig. 30.5 “Spontaneous corrections” in the spine. As in this 13-year-old boy, deformities in the sagittal plane are largely corrected by further growth, as seen here
over a two-year period of observation
462
Appendix
Spinal Disorders and Injuries
463
Fig. 30.6 Limits of “spontaneous correction” in the
cervical spine. In this 14-year-old boy, vertebral compression occurred in the coronal and sagittal planes.
Despite prolonged treatment in a Milwaukee orthosis,
the position of the vertebra remained completely unchanged during the following two years of further
growth
clinical examination is performed after six
months. Treatment may then be concluded if
findings have not worsened, the spine exhibits
normal mobility and is fully compensated, and
the patient is free of subjective symptoms.
Stable compression fractures with deformities
in both planes and impaction not exceeding half
the anterior or lateral height are treated conservatively with bed rest on roll cushions until pain disappears, followed by mobilization in a plaster corset. Depending on the further clinical course, the
corset may have to be replaced after six weeks.
Where structural alignment appears poor with a
tendency to worsen, a three-point brace or even a
Milwaukee orthosis may then have to be worn.
Patients should undergo annual clinical and
radiographic follow-up examinations until two
years after trauma.
Nondisplaced or only slightly displaced unstable fractures are treated with immobilization
in a plaster cast for six to eight weeks. The patient
is then mobilized in a plaster corset once radiographic and clinical examinations have verified
healing. Where the segment exhibits an increasing deformity (this will be apparent in a radiograph out of plaster obtained in the twelfth week)
then a three-point brace or Milwaukee orthosis
(depending on the level of the injury) will have to
be worn for six months or more.
Follow-up examinations will be required until
up to two years after the accident at the longest,
provided there has been no worsening of structural alignment in the spine.
Displaced stable fractures with a deformity in
one or both planes with a loss of height of over
50% should be treated surgically (18, 21, 38). With
or without collapse of the endplates, the structural alignment of the segment is so severely disturbed that even if closed reduction or treatment
with a roll cushion could succeed in bringing the
vertebral body into proper alignment, subsidence
would most probably recur once the spine is mobilized. This potential risk of increasing subsidence applies especially to the segments of the
464
Appendix
lower thoracic spine and lumbar spine, which
must bear greater loads. Another fact to consider
is that surgical treatment of these potentially unstable fractures (56) spares the patient protracted
immobilization in bed and allows far more rapid
mobilization. Anterior spinal fusion should be
avoided as long as the spine is still growing; only
posterior fusion should be performed. Wherever
the size of patient and the respective segment
permit, the fracture may be reduced and stabilized with an external fixator (21).
All fracture dislocations with or without distal
neurological deficits entail a risk of persistent instability due to the severe associated ligamentous
injuries. Immediate reduction and stabilization
are indicated; internal fixation should be used
wherever possible. Closed reduction followed by
a longer period of bed rest and several years of
treatment in a corset has occasionally been suggested as a method of managing unstable fractures without neurological symptoms. Considering the obvious advantages of surgical management, we no longer feel that this method is a viable option.
The patient is mobilized postoperatively in a
plaster cast or Ortholen corset. Regardless of
whether wire or an internal fixation was used for
the posterior spinal fusion, the patients immediately begin progressive mobilization once wound
healing has been verified. Once the fracture has
consolidated after 8–12 weeks, the corset is increasingly set aside.
Nondisplaced odontoid fractures can occasionally be difficult to diagnose, especially in
patients below the age of seven at the time of the
accident (6, 88, 92, 96, 129; Fig. 30.7). The clinical
sign of the child holding his or her head suggests
this injury. If the fracture cannot be diagnosed
from the A-P and transbuccal radiographs, then
lateral stress radiographs must be obtained with
the spine carefully supported. The range of motion used in these studies must be limited to the
range that the patient can actively achieve on his
or her own.
Nondisplaced odontoid fractures are treated
conservatively in a neck-and-chest cast for 6–10
weeks. Displaced fractures are carefully reduced
and also immobilized in a plaster cast (Fig. 30.8).
In older children and adolescents, displaced
fractures with and without neurological symptoms are reduced and surgically stabilized.
Wherever possible, this is done by anterior screw
fixation.
Birth
Body Ossification
Dens center
Age two: Apical ossification
center (ossicle), synchondrosis, incomplete closure
of posterior arch.
Fracture up to age seven
Fracture above age
seven
Fig. 30.7 Development of the odontoid process
(dens) and odontoid fractures in growing patients.
One ossification center for the body of the second cervical vertebra and one for the odontoid process are present at birth. By about age two, these two centers are
only divided by the narrow synchondrosis. The apex of
the odontoid process then exhibits its own ossification
center, the ossicle. Up to age seven, odontoid fractures
occur through the synchondrosis, essentially as separated epiphyses. Above age seven after the synchondrosis has ossified, the fractures course outside of the body
region through the odontoid process itself
Spinal Disorders and Injuries
465
a
Fig. 30.8 a–c Odontoid fracture
in a small child. The patient is a
two-year-old girl who suffered an
odontoid fracture without neurological deficits (a, left). The fracture
was reduced closed by carefully applying traction to the child’s head
and was then immobilized in a Minerva jacket. The radiograph in
plaster verifies the good position of
the fracture (a, center). The followup radiograph obtained after the
first cast was replaced six weeks
later also demonstrates good position and the onset of bony union in
the fracture (a, right). After a total
of 10 weeks, the cast was removed
and lateral stress radiographs were
obtained in flexion (b, left) and extension (b, right), which demonstrated stability. The anterior and
posterior periosteal bridging callus
is readily visible
Fig. 30.8 c 왘
b
466
Appendix
The x-ray out of plaster that is then obtained
should confirm fracture healing. As this is not always easy to evaluate, additional stress radiographs should carefully be obtained.
Patients may gradually resume sports once
unrestricted mobility in the cervical spine has
been regained after about another four to six
weeks. Treatment may be concluded about three
to four weeks after resuming sports participation,
provided the patient remains free of subjective
symptoms and function is unrestricted. However,
when treatment may be concluded also depends
on theoretical considerations: The basal cartilage
plate of the odontoid process remains open until
about age seven; if this structure is not a growth
plate but merely a synchondrosis (11, 42, 63, 87),
then there would be no risk of growth disturbances involving retardation of the growth of the
odontoid process. In that case, treatment can be
concluded even in patients of this age once they
are free of symptoms. However, if the structure is
a true growth plate, then patients below the age of
six to seven at the time of the accident would require additional radiographic follow-up examinations until two years after the accident. The fracture is too rare for the literature to provide any
conclusive results, let alone a consensus opinion.
Fig. 30.8 c In the follow-up radiograph obtained seven
months after the fracture healed, the basal cartilage
plate of the odontoid process appears to have closed,
and there is no evidence of odontoid dysplasia. Only
further follow-up examinations will show whether the
basal cartilage plate of the odontoid process is a true
growth plate or merely a synchondrosis
467
31
Toddler’s Fractures
Definition, Incidence, and Cause
History
“Toddlers” is a common term for small children
who are learning to walk. This age group ranges
from infants who have just begun to walk (about
age one) to those who have become proficient at
walking unaided (about age three to four).
“Toddler’s fractures” are fissure and infraction
fractures occurring at varying locations. These are
often also referred to in the literature as occult
fractures (99, 108, 119, 121, 128, 139, 140). Very
often it is impossible to identify any causative
mechanism of injury (110, 112,131, 136), and
therefore these injuries are often interpreted as
stress or “fatigue” fractures (113, 114, 140). This
interpretation is suggested by the fact that they
are invariably nondisplaced and barely visible or
even undetectable on primary radiographs (106,
110, 121, 141; see also Diagnosis, below). They become clinically apparent especially in the lower
extremities when the child suddenly develops a
limp.
These injuries are usually attributed to
children’s innate drive to become and remain mobile and the pleasure they derive from the discovery of their environment and motor capabilities. This leads to frequent collisions with objects,
dance-like rotational motions (106, 140), frequent
jumping from chairs and tables (100, 101, 110,
128), and to stumbles and falls even on level
ground. Simply put, the growing skeleton occasionally becomes fatigued from the unending
strain of the toddler’s proud and playful dancing.
The most common sites for such fractures
specified in the literature are in decreasing order
of incidence: the tibial shaft (104, 106, 110, 113,
114, 118, 140), the proximal tibial metaphysis
(140), the fibula (107), the calcaneus (115, 128,
139), the cuboid (100, 101, 112), the metatarsals
(113, 121), and the femoral shaft (104, 130).
In at least half of all cases, the patient’s history
will not provide any specific clues to suggest a
possible mechanism of injury (106, 110, 113, 121,
131, 141). The child “suddenly began to limp
yesterday”—or the day before, or whenever. The
limp will typically have improved if time has
passed since the observation was first made.
These patients are invariably healthy children
who are free of fever or other illness at the time
they present and have been in the recent past
prior to presenting.
The child will typically not have suffered any
previous fractures, nor will family members have
noticed any fragility of the child’s bones. The
family and social environment are typically
stable, and there is no reason to suspect child
abuse.
Clinical Findings and Course
Usually, the mother carries the healthy child into
the examining room. When asked to walk, the
child exhibits a slight unilateral painful limp. The
child can clearly identify which side hurts but can
only approximately specify the location of the
pain. The child typically has no fever.
Typically there will be no local erythema,
swelling, or warming.
Hip mobility is unrestricted.
Initial radiographs will often fail to demonstrate any abnormal findings. Only secondary
radiographs obtained after two weeks will demonstrate periosteal callus flakes (Fig. 31.1) or, in
the tarsal region, zones of intraosseous condensation indicative of a healed fracture.
With or without treatment, the pain and limp
persist about as long as 10–14 days with decreasing severity. Depending on the child’s specific
temperament and desire for physical contact, he
or she will want to be carried for a varying length
of time and may well extend this desire beyond
these two weeks. The pain definitely decreases
468
Appendix
with time, and will have disappeared within three
weeks at the latest. After that, the child will again
exhibit his or her normal gait.
Diagnosis
Fig. 31.1 Secondary diagnosis of a toddler’s fracture. The patient is L. N., a three-year-old girl. Two
weeks previously, she had suddenly exhibited a “spontaneous” limp on the right side without any history of injury. The child was healthy and had no fever or recent
history of fever. A posterior plaster thigh splint was applied to relieve pain and was removed two weeks later.
The radiograph obtained at that time demonstrated a
significant callus on the lateral and posterior tibial shaft
without a visible fracture line. Clinically, this region was
no longer tender to palpation. At the follow-up examination after another 10 days, the child was free of symptoms and gait was normal. (The defect in the lateral
ankle was from known healed osteomyelitis that had occurred in infancy). The primary clinical findings, clinical
course, and secondary radiographic findings after two
weeks confirmed the diagnosis of a toddler’s fracture of
the tibia even in the absence of a visible fracture line
The diagnostic workup begins with clinical findings of a healthy child with a slight limp. The child
has no fever, skin color is normal, and teeth and
sclerae are normal.
The clinical examination should begin with
the “healthy” side. The examiner feels the child’s
skin temperature with the back of his or her hand,
gently palpates the child’s leg from proximal to
distal to show the child what to expect on the
other side, and then evaluates mobility in the hip.
Then one proceeds similarly on the other side,
noting the painful region and taking care not to
have to touch it. Here, too, the examiner evaluates
mobility in the hip without touching the painful
region. Where mobility is unrestricted in both
hips, which excludes synovitis, the examiner
should discuss the probable clinical course with
the parents, and they should agree on the further
diagnostic and therapeutic procedure.
Before this is done, a differential diagnosis is
required. This should consider osteogenesis imperfecta, battered child syndrome, inflammatory
changes in the hip and bone, and even a possible
Ewing sarcoma.
A positive family history and a compatible
patient history of general health that includes
blue discoloration of the sclerae and changes in
the teeth suggest osteogenesis imperfecta.
Child abuse may only be suspected where the
general physical examination reveals multiple hematomas of uncertain origin and the radiographic
examination, which would then be indicated to
clarify the cause of the hematomas, demonstrates
multiple fractures of varying age in the region
visualized. Note, however, that battered child
syndrome is relatively rare at this age and is more
common in children who are not yet able to walk
(130).
Unrestricted mobility in both hips excludes
synovitis. The child is healthy and alert and does
not exhibit any signs of disease except the painful
leg. The child has not had any mysterious episodes
of fever and does not have a fever during the examination.
Unrestricted hip mobility, a healthy child, and
absence of fever largely exclude the possibility of
acute osteomyelitis close to the joint, at least initially. Primary chronic osteomyelitis could cause
Toddler’s Fractures
these same symptoms and would also escape detection on the initial radiograph. However, it
would cause increasing pain during the further
clinical course of the disorder.
Given the brief history, a Ewing sarcoma
would also escape detection on the initial radiograph. However, it, too, would cause increasing
pain that would immediately necessitate further
diagnostic studies.
The next step is an informative discussion with
the parents, in which the physician must be careful not to alarm the parents but to reassure them.
It should go something like this:
!
The most common cause for a spontaneous limp
at this age, aside from acute transient synovitis
of the hip, is what is known as a “toddler’s fracture.” This injury will only rarely be identifiable as
a hairline crack or fracture on initial radiographs.
A definitive diagnosis will probably only be
possible from a secondary radiograph obtained
in about two weeks (see Fig. 31.1). The unrestricted mobility in both hips excludes the possibility of transient synovitis.
It would be possible to order a bone scan (99,
105, 108, 119) or a magnetic resonance imaging
(MRI) examination. However, these are costly,
elaborate studies that would be of only slight diagnostic value in this case and would not have
any impact on the choice of treatment. This minimal benefit would hardly justify the work involved, which is why we do not recommend
these studies.
Theoretically, one possible differential diagnosis
could be osteogenesis imperfecta, if there were
history of that disease in the family; another
possibility would be a bone inflammation
without fever, such as occurs in primary chronic
osteomyelitis. However, these two diagnostic
methods would at best only help to confirm the
suspicion. The only way to make a definitive diagnosis is to obtain a biopsy. A toddler’s fracture
is the only case in which we can make a definitive
diagnosis from a secondary radiograph and the
further clinical course alone, without having to
perform a biopsy.
The most reliable way to deal with the situation
is to treat the pain first and wait to see how the
further clinical course develops. This spares the
child unnecessary diagnostic examinations and
puts the focus on the child’s most pressing concern, which is eliminating the pain.
If pain increases or the child develops a fever,
then extensive diagnostic studies will be required
anyway.
469
Treatment
Most parents agree with the suggested approach:
no primary radiographs, pain management with a
posterior plastic splint, further observation, and a
late definitive diagnosis—where indicated with a
secondary radiograph obtained two weeks later.
The child can move around with the splint and do
whatever he or she wants. A posterior plastic
splint protects the leg, helps relieve pain (regardless of whether or not the injury is a fracture), and
it can prevent secondary displacement of a fracture. The child can walk in the splint and bear
weight as he or she desires until it is removed
after a maximum of 10–14 days.
By the time of the follow-up examination,
about 8–10 days after the splint has been removed, the child’s gait will have returned to normal. The healed fracture can then be diagnosed
directly or indirectly on the basis of the secondary
radiograph (see Fig. 31.1).
Follow-up Examinations
No further diagnostic studies will be required
once gait has verifiably returned to normal within
two to three weeks and the child is free of symptoms. Treatment may then be concluded with the
diagnosis of a toddler’s fracture.
470
32
Pathological Fractures
Pathological fractures occurring in the setting of
tumors, histiocytosis, generalized fibrous dysplasias (Jaffé–Lichtenstein disease, Albright syndrome, etc.), osteomyelitides, etc. will not be
covered here. The discussion will be limited to
only the most common pathological fractures:
앫 Stress fractures and “spontaneous limp,” (see
Chapter 31, Toddler’s Fractures, p. 467),
앫 Juvenile bone cysts,
앫 Fibrous dysplasia,
앫 Osteogenesis imperfecta.
Genuine stress fractures occur nearly exclusively
in adolescents in the proximal tibia, and rarely in
the metatarsals, following prolonged physical exertion. They are treated the same as normal fractures, with immobilization in a plaster splint. As
these injuries are only cancellous infraction fractures, they heal quickly within two to three
weeks.
“Spontaneous limping“ in small children between the ages of two to four is usually attributable to an infraction fracture of the tibia, fibula, or
calcaneus (see Chapter 31), rarely to other causes
(such as acute transient synovitis of the hip,
osteomyelitis, or tumor).
Although this book focuses exclusively on
fractures, dislocations, posttraumatic conditions,
etc., a differential diagnosis of a “spontaneous
limp” must consider acute transient synovitis of
the hip. This is the most common cause of pain
hips in childhood, with its peak incidence at about
age five. Transient synovitis is not a single disease
entity but is a syndrome of numerous other disorders. These range from minor viral infections to
septic arthritis, Legg–Calvé–Perthes disease,
rheumatic joint disorders. The diagnosis of “transient synovitis associated due to a minor viral infection” is made on the basis of the primary clinical picture and the brief clinical course, which we
have observed in 80% of all cases. This means that
the physician may initially dispense with primary
diagnostic studies for a differential diagnosis of all
possible disease entities in an otherwise healthy
child without a fever presenting with a spontaneous limp and limited mobility in the hip. Instead the physician may proceed to treat the
patient, which, not surprisingly, is the patient’s
reason for coming in the first place. The goal is to
verify the transience of the disorder. Where
symptoms significantly subside within 48 hours
under antiinflammatory treatment, further diagnostic studies may be dispensed with. The diagnosis is then clear from the clinical findings and
course: transient synovitis due to a minor viral
infection. Where the child presents with a fever
or the symptoms do not promptly subside under
antiinflammatory medication, then further diagnostic studies including cAMP receptor protein
(CRP), a blood count, and possibly additional
radiographs are indicated (8, 26, 31, 48, 49, 60, 66,
72).
Juvenile bone cysts play an important role in
pathological fractures due to their high incidence
(5, 41, 52, 78). Cysts occur primarily in the
humerus and femur, although they may also affect any other bone in the skeleton, such as the
fibula or calcaneus (1, 4, 61). Usually, they occur as
isolated lesions, although rarely they can occur
simultaneously in the upper and lower extremities (45).
Diagnosis
The diagnosis of juvenile bone cysts may be difficult, especially with respect to differentiating
them from aneurysm bone cysts and solitary
fibrous dysplasia. Juvenile bone cysts almost invariably lie within the metaphysis close to the
epiphysis (123). The cysts do not cross the growth
plate, and the epiphysis itself is invariably free of
cysts (pathological changes in the epiphysis suggest chondroblastomas, malignant tumors, or
similar lesions). The cysts are often multilocular.
Further growth displaces them distally into the
shaft region. In the diaphysis, they are not always
distinguishable from fibrous dysplasia (20). In
children below the age of 10, the diagnosis may be
Pathological Fractures
made solely on the basis of the localization in the
metaphysis and the typical radiographic findings
(Fig. 32.1).
Problems and Complications
The problems associated with juvenile bone cysts
include the risk of fracture and the high incidence
of recurrence. The incidence of recurrence reported after surgery ranges between 10% and
40%; the average is about 20–25% (5, 15, 28, 41,
84). As a rule, the prognosis for juvenile bone
cysts is extraordinarily favorable as they all heal
spontaneously before the cessation of skeletal
growth. Note that the time at which any one cyst
will heal cannot be predicted. It is not determined
exclusively by the patient’s age but apparently by
the age of the individual cyst as well (95;
Fig. 32.2). We do not yet know to what extent the
specific trauma of surgery, aspiration, or fracture
accelerates this process of spontaneous healing
(22, 54, 65, 102). We have only observed impaired
spontaneous healing or healing deficiencies following surgical inventions (4). Recurrences have
also been observed after resections (52). This
extraordinarily favorable prognosis should be
taken into consideration when determining
whether a specific therapeutic approach is indicated. Here, it is important to distinguish—
wherever possible—between cysts in weightbearing locations and cysts in nonweight-bearing
locations, and between active and inactive cysts.
Fig. 32.1 Treatment of juvenile bone cysts. This
seven-year-old patient suffered an infraction fracture of
the proximal humeral metaphysis in the presence of juvenile bone cysts. Because the fracture was not displaced, it was treated conservatively. At the follow-up
examination three years later, the humeral head was ob-
471
Active cysts exhibit a very thin cortex, are wider
than the metaphyseal or diaphyseal shaft, and
usually lie close to the growth plate (Fig. 32.2,
left). Inactive cysts exhibit a pronounced sclerotic
halo, a thick cortex, and are embedded in the
metaphysis or diaphysis (Fig. 32.2, right). Inactive
cysts usually require only slight trauma to heal
spontaneously; often a fracture will suffice. Active
cysts require repeated trauma or permanent
decompression to heal.
Treatment
The goal of treatment is to accelerate the inactivation of the cysts and so force them to heal spontaneously, eliminating the risk of primary and recurrent fractures.
In the case of obviously inactive cysts in the
upper and lower extremities that are incidental
findings in diagnostic studies, we recommend a
watch and wait approach for the upper extremity
and aspiration for the lower extremity. In the latter
case, one can try the technique practiced by Scaglietti and other authors (7, 65, 84; Fig. 32.3) except
that we do not inject cortisone but repeatedly perforate the wall of the cyst with a drill. This procedure is performed with the patient under
general anesthesia. Two trocars are advanced into
the cyst or cysts under fluoroscopy, and then removed and contents aspirated. Then we perforate
the walls of the cyst or cysts at several locations
with the trocars and remove the needles.
served to have grown away from the cyst (far right
image). The cyst had partially refilled with fluid. As the
cyst walls exhibited a sufficiently thick cortex and the
patient was free of subjective symptoms, the decision
was made not to undertake any therapy at this time
either
472
Appendix
Fig. 32.2 Pathological fractures associated with juvenile cysts. The patient is K. B., a one-year-old girl.
Presence of a juvenile cyst was first detected when an infraction fracture of the cyst wall occurred. The threemonth follow-up radiograph obtained after conservative treatment demonstrated the fracture of the cyst
more clearly, and the patient was free of symptoms at
that time. It was decided that a cancellous graft was indicated, which was then performed a total of five
months after the initial accident. After transient im-
provement in the situation, a second infraction fracture
occurred after one year. The radiograph obtained at that
time showed a distinct recurrent cyst, which then began
to heal spontaneously without any further treatment
during the next four years (until the patient was nearly
six years old). A radiographic follow-up examination
after 17 years demonstrated a visible residual scar. At
that time, the patient was completely free of subjective
symptoms
In the case of active and inactive cysts in the
upper extremities, we recommend doing nothing
and waiting. However, emotional and social factors play an important role in deciding which approach is best for the patient. Fear of a repeat fracture is a major reason why enthusiastic athletes
seek treatment, whether they are motivated by
personal desire or social pressure. In such cases,
we recommend elastic reinforcement with intramedullary nailing. Where the diagnosis is not a
source of anxiety for parents and patient, we recommend observing the further clinical course,
which may include one or more infraction fractures. Naturally, patient and parents should fully
understand all the consequences of such an approach and give their informed consent. The cyst
will heal spontaneously over time in any case.
In the case of active and inactive cysts in the
lower extremities, especially where weight-bearing bones are involved, structural stability and the
far greater expenditure of treatment that would
be required for reconstruction following a frac-
ture are the key issues. Here, a more active approach is warranted. Depending on the location of
the cysts, treatment may employ intramedullary
splinting or angled plates, for example, in the
femoral neck (Fig. 32.4). Intramedullary splinting
should offer the advantage of reinforcement (protection) while permanently draining the cysts
(125). This accelerates their inactivation, which is
usually achieved within one to two years. Accordingly, the splinting should be left in situ for an appropriately long period of time. The important
thing is to ensure that splinting opens and drains
all of the cysts (83).
We see a possible indication for cannulated
screws only in the upper extremities if at all.
However, we feel we can do without them entirely as they do not provide protection against repeat fractures here either.
We have since stopped using cancellous grafts
because these procedures have the highest incidence of recurrence in the literature (4).
Pathological Fractures
473
Fig. 32.3 Treatment of juvenile bone cysts. In this
six-year-old boy, an inactive juvenile bone cyst in the intertrochanteric region of the femur was detected as an
incidental radiographic finding. Because the cyst was
obviously inactive, we aspirated the cyst, perforated it
repeatedly, and injected cortisone, which was still the
practice at that time. Within a year and a half, the cyst
had closed spontaneously without any further intervention. Three years after this treatment, the patient was
free of subjective symptoms, there was no difference in
leg length, and mobility in the joints of the lower extremities was unrestricted
We have also given up filling the cysts with
foreign material as this could conceivably interfere with spontaneous healing.
Treatment by resection is repeatedly recommended in the literature (98), ostensibly to prevent recurrence and repeat fracture. However, we
feel that there is insufficient justification for such
an elaborate and invasive treatment given the
favorable prognosis of juvenile bone cysts.
In summary, with pathological fractures of the
upper extremities involving juvenile bone cysts,
we are inclined to proceed as if a cyst were not
present and we recommend observation of the
further clinical course. Naturally, the patient and
his or her parents must fully understand and give
their informed consent to this approach, and
everyone involved must be convinced that the
chosen procedure is appropriate. With respect to
the lower extremities, we invariably favor a more
active approach and recommend surgery even for
cysts without fractures.
Wherever an active approach is taken, we recommend taking a biopsy and confirming the diagnosis even in the presence of clear clinical and
radiographic findings. At the same time, we
would repeatedly perforate the wall