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Operative Techniques in Pediatric Orthopaedic Surgery

PEARLS AND PITFALLS

Compartment syndrome

■ A high index of suspicion is required. ■ The surgeon must maintain vigilance throughout the postoperative period for late development. ■ Increasing pain and anxiety are the first signs of pediatric compartment syndrome. ■ Rigid frames may lead to delayed union. ■ Care should be taken to use appropriately sized pins and to dynamize early. ■ Fluoroscopic guidance is used to avoid growth plates. ■ Incisions should be carefully chosen to avoid compromised skin. ■ Low-profile plates may help avoid irritation from the plate before fracture healing. ■ Fractures that are very distal or proximal, or highly comminuted, should be treated by other techniques. ■ Proper nail contouring and size selection are important to maintain stability of the fracture. ■ The nails should be the same diameter to provide balanced fixation ( FIG 4A ). ■ Nails should be passed carefully to avoid the “creeping vine” effect. ■ If the nails spiral around each other, the elastic recoil, and thus the stability of the technique, will be lost ( FIG 4B ).

External fixation

Plate fixation

Elastic intramedullary

■ Care should be taken to avoid physeal injury. ■ Nails should be cut short to avoid irritation.

FIG 4 ● Potential pitfalls in nail placement. A. The nails are of differing diameter, inducing a valgus moment that needs to be controlled in a cast. Note the incidental nonossifying fibroma. B. “Spiraling nails.” The elasticity afforded by three-point fixation is lost, making the construct less stable.

A

B

POSTOPERATIVE CARE

■ In general, prolonged stiffness is unusual in pediatric patients. ■ It is better to overimmobilize in questionable cases to avoid malalignment and regain motion later with aggres- sive physiotherapy. ■ Removal of symptomatic hardware (ie, nails or plate) should be delayed until fracture healing and remodeling are complete. ■ I prefer to remove elastic nails electively in all patients 6 to 12 months after injury, as the nails will become com- pletely intramedullary with significant continued growth, thus making late removal extremely difficult. ■ Ideally, plate removal is delayed for a year, after remodel- ing is complete. ■ Most tibial fractures in childrenwill heal uneventfully, although healing difficulties can occur, especially in older patients. 5,10 ■ Slongo 15 noted that most complications seen in his series were a result of improperly applied technique, particularly residual distraction at the fracture site, leading to a “pseud- arthrosis model” even in children. ■ Bar-On and associates 2 noted increased callus formation and shorter time to union in the elastic intramedullary nailing group versus external fixation (7 weeks compared with 10) in a femur model.

■ For patients treated with external fixation, a splint is used for 7 to 10 days to allow the tissues to recover. ■ For stable fractures, progressive weight bearing is initiated in reliable patients. ■ Unstable or comminuted fractures require waiting until visible callus is present before weight bearing. ■ Depending on fracture stability, dynamization of the fix- ator is initiated early, after sufficient callus is seen. The frame is removed in the office or the operating room after healing is noted radiographically. ■ Most patients benefit from short-term support with a bivalved cast after removal. ■ Patients treated with plate fixation begin a progressive weight-bearing program, with immobilization discontinued after sufficient radiographic healing is present, usually by 6 weeks. ■ Patients treated with elastic intramedullary fixation are usu- ally splinted for 7 to 10 days, followed by progressive weight bearing. The plan is modified based on fracture stability, soft tissue injury, and patient reliability. ■ Patients with substantial (over 50%) cortical contact may begin weight bearing as tolerated after soft tissue healing has occurred.

OUTCOMES