● The treatment method of children's fracture is different from that of adults. Improper reduction is prone to fracture complication "cubitus varus"
● The epiphyseal line is the weakest and most vulnerable part of children's epiphyses to fracture. The use of "absorbable nails" in fracture surgery is easy to "break" the epiphyseal line, affecting growth and development
Three year old Xiao Yan suffered from pain and swelling after falling. His father, Mr. Zhang, took Xiaoyan to a small hospital and diagnosed her with supracondylar fracture of the humerus. After the doctor gave her manual reduction and plaster, he sent her home. Mr. Zhang was not at ease. The next day, he sent his daughter to the big hospital for further consultation. He took photos and found that the fracture was displaced. After the operation of open reduction and internal fixation with steel nails, Xiaoyan's elbow joint returned to normal.
Xiao Li is 21 years old this year. When she was 5 years old, she hurt her elbow joint due to wrestling. At that time, she had a simple plaster treatment. After the elbow joint could move, her family did not care about her anymore. However, after that, Xiao Li's elbow had a "cubitus varus". When he dropped his arm, he always turned 30 degrees inwards, which made it inconvenient to lift things. Last year, Xiao Li underwent osteotomy and orthopedic plate fixation. A year later, she took off the steel plate and lived a normal life.
Experts pointed out that because children are in the growth and development stage, there are great differences between children and adults in tissue anatomy, physiology and other aspects. Some adult treatments for fractures are not suitable for children. If not properly treated, it will cause epiphyseal line damage, bone growth delay, bone joint deformity, limb growth disorder, or sequelae and complications in adulthood.
Article/Reporter Mo Guanting Correspondent Li Bingjie
Medical guidance/Dr. Zhang Ying, Vice President of the Orthopaedic Hospital of Guangzhou General Hospital of Guangzhou Military Region and Director of Trauma Orthopaedic Department
Supracondylar fracture of elbow
Elbow varus is easy to occur due to improper treatment
Children's upper limb fractures are more than lower limb fractures. Elbow, wrist and forearm fractures are more common, among which elbow joint injuries are the most common. According to Zhang Ying, about 30% of children's fracture clinics belong to supracondylar fractures of the humerus, that is, fractures occur 2~3cm above the elbow.
Cubitus varus is the most common complication of supracondylar fracture of humerus in children. Zhang Ying said that children's bones are in the stage of growth and development. Once a fracture occurs, it is easy to cause epiphysis injury. Without reduction or poor reduction, it will lead to bone growth disorder and induce secondary malformations. "Elbow varus is the most common; of course, few may also appear cubitus valgus." What is cubitus varus? Zhang Ying explained that under normal circumstances, the natural elbow valgus angle of the elbow joint is called the "carrying angle", and the normal range of the carrying angle of women is generally 10-20 degrees; The male is 5~10 degrees. When the carrying angle decreases and disappears or even becomes negative, it is called cubitus varus.
Zhang Ying introduced that the diagnosis of children's fractures starts with physical examination. Doctors can judge the existence of fractures through observation and touch, such as abnormal activities, deformities and "bone frictions", which are unique signs of fractures. In addition, X-ray examination is indispensable to determine the type of fracture, displacement and whether there is primary disease. "But it should be noted that, especially for the patients who are in plaster for examination, the epiphyseal line is easily misdiagnosed as the fracture line by X-ray examination." Zhang Ying said that at this time, we can judge by comparing the two sides, or further do CT and MRI to improve the diagnostic level.
Conservative treatment
Manual reset+fixation
"Conservative treatment and surgical treatment are common treatment methods for children's fractures." Zhang Ying said that manual reduction can be used for supracondylar fractures of the elbow, ulnar and radial fractures of the medial forearm, and tibial and fibular fractures of the lower leg. After resetting, it needs to be fixed. In traditional Chinese medicine, splints are usually used for fixation, while in western medicine, plaster is used for fixation. "However, during fixation, we should pay attention to prevent compression. If we tie it too tightly or cause osteofascial space syndrome, it may cause ischemic contracture, or it may cause ischemic necrosis of the limbs." Zhang Ying reminded us that we should also prevent tightness and looseness, and we should avoid "displacement" of the fracture due to loosening of the plaster after detumescence. Therefore, we should take films regularly for reexamination. Generally, 3 days after fixation is the peak of edema. The injured part may appear purple color, numbness, swelling, pain and aggravation of compression. The first reexamination should be carried out. As the swelling gradually subsides, it is recommended to take a film again a week later. Next, take pictures once a half month. Since then, they have been filmed and tracked monthly.
If the above treatment is unsuccessful, traction treatment can be considered for reduction and fixation. The femoral shaft fracture of children under 5 years old can be treated with suspension traction. "Traction therapy can be used as the ultimate treatment, and can also prepare for pain relief before surgery."
surgical treatment
It is better to fix it with steel needle
Zhang Ying said that the operation method can generally achieve the good effect of anatomical reduction and reduce the complications and sequelae after fracture. Therefore, it is increasingly recognized by the public, but the requirements are relatively high. "In children's fracture surgery, steel needles and plates are generally used for fixation, and intramedullary nails are not used for fixation." He introduced that steel needles are thinner than screws, with less damage and space occupation. For small fractures that need to pass through the epiphysis, steel needles have a better effect. In case of intra-articular fractures such as supracondylar fractures of the humerus and knee fractures, steel needles with a diameter of about 1.5mm are generally used to fix the fractures. "If the plate is used for fixation, the screw should be avoided from entering the epiphyseal line as much as possible during the operation. When the steel needle must be used to pass through the epiphyseal line, it is required to succeed once and avoid repeated passing. If the fracture block is large, two needles can be inserted at an angle to each other to strengthen the fixation." The children's supracondylar fracture of the humerus should be treated with steel needle fixation, and the steel needle can be taken out 4 to 5 weeks after the operation.
Although many hospitals have used absorbable nails in children's fracture surgery in recent years, they believe that absorbable nails have the "advantage" of not needing to be removed by a second operation. However, Zhang Ying believes that from a professional point of view, absorbable nails are not worth promoting in the treatment of children's fractures. He explained that the fracture can be fixed with two steel needles in general, but if the absorbable nail is used, it is easy to damage the epiphyseal line because of its relatively thick diameter, which is generally 2.7~3.5mm. Moreover, the thread of the absorbable nail is small, the holding force is poor, and the fixation failure is easily caused. In addition, it is difficult to predict the consequences of using absorbable nails, because the materials of absorbable nails will produce acid substances in the process of degradation in the human body, which may have adverse effects on the bone development of children.
Epiphyseal line
Children's unique growth function structure
According to the statistics of the Ministry of Health last year, falls, drowning and road traffic injuries (car accidents) were listed as the "three killers" of children in China. Zhang Ying, vice president of the Orthopaedic Hospital of Guangzhou General Hospital of the Guangzhou Military Region and director of the Orthopaedic Trauma Department, said that children's fractures are different from adult fractures. Children's bones are in the growth stage, with abundant and active osteoblasts and osteoclasts, and the fracture healing speed is fast. One month old babies can heal in two weeks, while adults need at least 100 days.
Epiphyseal line is an important tissue of children's skeleton, which is closely related to growth and development. According to Zhang Ying, the cortical bone of adults is hard and lamellar. Children's bones have good flexibility and elasticity, but there is no obvious lamellar structure, and the hardness is not enough. There are epiphyseal lines at both ends of the long tubular bone in children. The epiphyseal line appears as a wavy line in the X-ray film, which is essentially a layer of cartilage like tissue, and is used for growing cartilage. The smaller the age, the wider the epiphyseal line, the more obvious. Generally, 14 years later, the long bone is only composed of the shaft and bone end, the epiphyseal line gradually closes and disappears, and people no longer grow tall. "Therefore, if the epiphyseal line is damaged during the development process, it will affect the bone development." Zhang Ying mentioned that in addition to the growth function, children's bone is also one of the hematopoietic organs.
