Associate Professor of Orthopaedic Surgery, Dr. Robert Bielski, gives a presentation on the management of long bone fractures in children.
DR ROBERT BIELSKI: So my name is Bob Bielski, I'm a pediatric orthopedic surgeon, and can everyone hear me OK? Yes OK thank you. I apologize for my picture that's in the program because it looks like it's my son. It's about from 12 years ago so if you're expecting a young, vibrant speaker, I'm going to disappoint you. I have, I'm not going to, this talk will be relevant depending on how old you are and I'm not rude enough to ask people their age. But I will say how many of you started practicing before 1995? OK good, so about half of you at least. OK so good. So a lot of what we're going to be talking about today with femur fractures, and managing long bone fractures in children in general, will be very relevant to those who started practicing before '95, because things have changed dramatically over the past two decades. So we're going to talk about damage control orthopedics which is a concept that's practiced mainly in adult trauma patients, but is also practiced in pediatric patients and we're going to talk about when we do that. We'll talk in general about the benefit of fixation of fractures in children and then I'm going to talk specifically about femur fractures and tibia fractures, which are the main fractures that we have to deal with in the polytrauma patient. And the final thing, which is what Dr [INAUDIBLE] was just touching on, some of the miracles, that you see the need to assume full recovery in pediatric trauma and that's why we're so aggressive about fixing everything. So 63% of pediatric polytrauma patients have extremity fractures, and obviously the orthopedic surgeons want to come in and fix the bones. But initial resuscitation is always the same. You want to prevent acidosis, prevent hypothermia, and prevent coagulopathy. Children are especially prone, as you all know, to hypothermia because they have a large surface area. And if you go in the Trauma Bay, they're often exposed for a long period of time, depending on where all their injuries are, and they get quite cold. And if you then have to bring them up to the operating room emergently, you're starting out behind the eight ball because they're already at a core temperature of 35 degrees, and you're playing catch up the rest of the case. Oftentimes our cases involve a lot of blood loss which gets you further behind. So, the benefits of fracture in a pediatric trauma patient are very similar to what you would see in the adult trauma patient. It allows a patient to be upright for pulmonary toilet so if they have associated chest injuries, that's important. Obviously it decreases pain. And many of our patients need to be sent back and forth to CT scans, MRI's for follow up on their brain injuries, their spinal cord injuries, et cetera. And if you have somebody with a femur fracture losing traction and you're trying to take them back and forth to an MRI, it's incredibly painful and unfair to them. So that's an obvious benefit. And it's a more rapid return to home and to school and that seems kind of obvious. We're going to talk about some statistics, about why we are so aggressive maybe, maybe that's the wrong word but why it's so helpful for the families when you fix them early. It definitely decreases the burden on the family, if you have a family helicoptered in from far away and is here for three weeks, managing a femur fracture is a lot different than if they can be home in three or four days. So what is damage control orthopedics? Well we know from studies back in the '80s that if you did early stabilization of femur and pelvis fractures, it would reduce complication rates and this is in the adult literature. And the biggest things that you would prevent would be pulmonary compromise and sepsis and probably DVT. And so that led to this rush, I would say not rush, but then in the '90s people were very aggressive in the 2000s about fixing fewer fractures as early as possible in adult patients, so if a patient came with a femur fracture, trying to get them rodded within 24 hours, to decrease the chances that they would get a pulmonary emboli, ARDS. But this concept of the second hit started to come into play, where if you look at the blood loss and the fluid shifts that go on in the first 24 hours of resuscitation gives you a very harmful systemic, inflammatory response and this idea of the second hit taking somebody who's already mounting this gigantic inflammatory response to the trauma, and then getting them into a big operation where they're going to have a lot of blood loss and a lot of fluid shifts would get them quite sick. So we get these patients who are already acidotic, who were not fluid resuscitated appropriately and you are trying to fix things so rapidly that again, you got behind and it got actually sicker. So this is a really nice study, a journal of orthopedic trauma. It was a multicenter study looking at when you should treat adult trauma patients. Again this is not a pediatric study. But if you look at acidosis and high lactate levels, and lactate is among, across many studies is one of the biggest predictors of multiple complications, these are predictors of pneumonia and ARDS. So if acidosis was persistent after resuscitation or if it was an inadequate resuscitation measured by low pH, a high lactate, then you would institute damage control orthopedics. And we'll talk a little bit more about that but the those kind of high quality studies with large numbers in pediatrics don't exist. So we're right now just trying to apply the lessons that we know in adults in pediatrics. Now as you know, not everything's the same between adults and kids and one of the big things that we're trying to prevent in adults is ARDS and the different lung issues. But acute lung injury is about six times lower in children than it is in adults in multi trauma situations. So we don't have that much of a problem. An inflammatory response is different in children. Oftentimes children will get a multi-organ failure early in treatment, but they recover rapidly whereas adults will have sequential organ failure that will start one to two days after the initial trauma. So although those studies don't exist in children yet, it would be wise to look at what we know for the adult literature and apply it to the pediatric literature. So it's a balancing act between early stabilization to avoid some of the complications, but not to rush in foolishly and get into other complications. So, in the last 10 years, especially in adult trauma situations damage control orthopedics is kind of the sexy term that everybody uses. And again if you have somebody who comes in with an unstable injury, rather than at 2 o'clock in the morning with your overnight nurses who maybe don't know your equipment that well, and a very strained nursing staff and resident staff trying to fix all the fractures and getting into a lot of blood loss and do damage control orthopedics. Getting the fracture stabilized enough so that you can get the patient to their MRI and CT scan, but then come back to fight another day and do definitive fixation. So this is actually the first year I was here, this is a 14-year-old who was brought in, helicoptered in, he was ejected from a car. He had a huge splenic laceration and multiple fractures. And general surgery resuscitated him stabilized him and wanted us to hold off until he was better. And you'll see he has a displaced hip fracture, a basic four extremity trauma, a displaced hip fracture, forearm fracture. He's got a tibia fracture here that in and of itself is not a big deal but when all the other extremities are fractured, you need to fix that as well. And a displaced wrist fracture. So he gets resuscitated and then 48 hours later we fix everything. We fix the hip, and now because we're doing this in the light of day rather than in the middle the night we have two orthopedic teams, so while one's working on the hip the other one's working on the contralateral leg and then we switch and we get it done in half the time. Here's another one which is very illustrative of it. So, there's a 13-year-old car versus pedestrian, he's about 75 kilograms. He's got a closed head injury in addition to his femoral shaft fracture he also has a pretty bad open wrist fracture, and an open olecranon fracture, which is pretty powdered and all of these things need to be fixed. But neurosurgery colleagues feel it's not really safe to do a long case on him, so literally we were told we had 60 minutes and so we did. We put an external fixator on, we washed out all open fractures and then come one week later and do definitive fixation, fix the femur and then plate the olecranon fractures. So I mean it's a pretty simple concept. The damage control orthopedics, and it's much more practiced in adults than pediatrics because the physiology is a little bit different but certainly you can use that same term when you're talking about someone who has a head injury, and we're going to damage control orthopedics until the head injury recovers. Now I will admit that sometimes yes, we fight with our neurosurgery colleagues and just tell it that we want to fix somebody and would you please let us take this patient to the operating room but you know we usually get along. Well I see laughter in the back, so OK. So when I was asking about when we did people start practice, so because if you were in training in the '80s and early '90s you were probably used to walking around the pediatric wards and you would see children all over the place hanging in traction. So until late 1980's, almost all isolated femoral shaft fractures were treated with traction and casting. You'd see kids in spica casts all over the place. But as the manufacturers got smart they started making implants smaller and smaller. And so both of these kids in traction here, are at least 12 years old I mean 12 years, that picture's at least 12 years old. I think in the nine years I've been here in Chicago I put two people total in skeletal traction. When I started practice in the early '90s I would have one to two kids every week in traction during the summertime from femur fractures. So this was a traditional thing they'd go in the casting for a couple weeks so the bone got sticky and they would go into a body cast. But since the early '90s basically in every comparison study done over the past 25 years clearly shows a better result in children treated with operative intervention if they were 10 or above. And the more we go out, the more that age drops. So clearly 8 and above everyone does better with fixation and now there's more studies showing six and above do better with operative fixation and I'll show you one that's even lower than that which is almost hard to believe. So this is again that's already 11-year-old study is the death knell for casting. They compared children 8 and above who had titanium elastic nails which we'll talk about versus traction and cast. The complication rate was much higher with a spica cast, there was only 21% in the operative group and these are very minor complications. And besides that, the social cost of a family taking care of child with traction casting can be enormous. Most patients are going to need a full time caregiver for 12 weeks or more if they're treated with traction casting. Because they're two to three weeks in traction and then six weeks in a spica cast. So the days when you had the housewife cleaning and waxing her floors doesn't exist too much anymore. 64% of mothers with kids under 18 work for pay, and 48% of mothers with kids under 18 work full time. And even for children under age of six, 58% are working. And the modern two parent homes is significantly less. And as a result when you have kids going home to families that don't have enough people to care for them, they come back with these kind of body casts that are full of urine and other things and so we try to fix them and make it easier on the family. So we'll talk very briefly about how we fix them because it's definitely different between what you see in adults and what you see in kids. So we'll first have a rigid intramedullary rods, that's the gold standard for adult fractures. Basically everyone in here if you get it by a car today, or broke you femur from some over place, you would have a large metal rod placed in your femur. End of story. That probably takes care of 90, 95% of all femur fractures. And initially they didn't fit into femoral canals in children. And then in the '90s the manufacturer started downsizing them and pieces of paper started coming out showing that they work quite well if you use the right size. But, shortly thereafter like everything else and nothing ruins results like follow up, you found out that kids were getting avascular necrosis because if you put the nails in the same way you put them in an adult, this blood vessel that supplies the femoral head in children was at risk and that's right where the nail goes down. So kids were showing up six months after their surgery with a dead femoral head. So again, when as long as there's money to be made there will be manufacturer who will figure out a way to get around it. So they started moving the nails out laterally. So instead of inserting in that area where all the blood supply comes in, these are called trachanteric entry nail and we're able to use these and they work great. But when kids are under the age of eight even that trochanter where that one goes in over here, I don't have a pointer with me but it's too small to accommodate a typical nail So flexible nails are used in children and these were really a breakthrough in fracture care. They came out in the late '90s and all these kids that we were treating with spica casts are being treated with flexible nails. They're ideal for children under 50 kilograms, once they are above 50 kilograms they don't do very well, in children less than 10. So a patient like this, when I started a new practice would either go into traction or have gotten an external fixator. Now you've put it with flexible nails when they leave a fairly small scar, this is early on, you'll see actually as you get better with them and you use less and less these two flexible nails. And for the right fracture they give a nice cosmetic incision. They're easy to put in very, very easy to learn how to use them. And so here's a six-year-old isolated femoral shaft again. Years ago, I would have treated this in a spica cast. I was already doing a case at 11 o'clock he rolled into the trauma, or he got transferred in and it was about midnight, and I said, well as long as I'm here if he was stable, we did it. But he went home post op day number two, and you can see how small the incisions are at that point. So yes, I put sunglasses on everybody to protect their identity. In the '90s you saw a lot of kids using external fixators for fractures. They are great, you can put them on very fast and there's not much blood loss. They're great for damage control orthopedics, so if you need something in the middle the night, for kids who have head injuries and unstable patient that's great. And when someone has a bad soft tissue-- we'll talk a little bit more about this kid later-- but when you have a bad open fracture, heavily contaminated, you don't want to put any metallic implants in the canal, so an external fixator can work very well. A lot of kids have spasticity as they come out of coma and external fixator is very rigid. It can take a long time for them to heal, so we don't use them as much as we used to. And they often refracture when you take them out, not often but that is one of the risks about 12% of the time. But when you have an awful soft tissue involved like this, unfortunately this doesn't project all that well, but this patient had skin loss basically from his groin all the way down to his ankle. You really don't have any other option but an external fixator. Again talking about damage control orthopedics, this is a U of C patient. This is a car they were pinned under a semi, mom lost control of the car and it got dragged underneath the semi. She has a depressed skull fracture, very unstable. She has this femur fracture and again she has to go to the operating room and have a decompression of her brain injury. And again we're told, just please get in and out as fast you can. So again in an hour you put this external fixator on her. In her situation we actually used that towards completion of the treatment. The final thing to talk about in kids is a thing called MIPO, minimally invasive plate osteosynthesis. So all these things are age and weight related so little kids they get the flexible nails, the unstable kids get external fixators, the kids who are adolescents, heavy, greater than 100 pounds or 150 kilos, usually will get some type of a nail, and then there's that in between zone where they're too heavy. You know we have a lot of obesity on the south side of Chicago, we sometimes have seven and eight year olds who have femoral fractures who already weight 150, 160 pounds but they're too small to have a nail put in, they don't have a big enough canal to put a nail in. So then we use this minimally invasive plating. The nice thing about this is, as opposed to traditional plating, where we would open up the whole fracture site, in this you don't open the fracture at all. You make an incision high, you make an incision low. You slide the plate underneath the muscle and then percutaneously fire your screws and it pulls the bone to the plate, just like pulling a twisted tomato plant to a stick. And it works great it's a lot less blood loss, it's not the easiest technique to learn, but at the end of the procedure you have, is this one or two large incisions with the smaller incisions where you put the screws in, and this is an intraoperative photograph. So here's a fourteen year old with an isolated injury. We certainly could put a nail in this patient. At the time, we used this minimally invasive plate. And they heal quite quickly. So the question is should you fix them all? I said that for sure 10 and above, actually the literature is very clear eight and above, everybody should be fixed and now there's more studies coming out, six and above. This is a study out of Sweden I believe, it's a fracture in preschool children. Average age was 4.1 years, in fact they started at one and a half years of age and they put flexible nails in every single one of them and the results were fabulous. And I would say in the United States that's not quite where people are at. I would say anybody who's six and above in most centers gets fixed. I personally will fix pretty much everybody who's four and above if they have the right pattern, but I would say six and above, that would be the standard of care now in the United States. We'll talk real briefly about tibial shaft, actually it's not as much of a problem. You still treat the majority of these with nonoperative treatment. The same options are like we use in adults. External fixation, flexible nails, rigid nails and a plate. We don't use rigid nails very much because although it's a standard of care in adults, the entry point is at the top of the tibia right where the growth plate is. And so, unless their growth plates are closed, so you're talking about 14 and above, it's really not a good option. So we don't use it very much kids. So there's an entry point right there. You can use external fixation, it's actually a great option. And the nice thing is on my femurs when we take an external fixator up a fever they can break very easily. Well in the tibia, when you take the fixator off, you could put them in a walking cast for three to four weeks or protect it and you don't have to worry about refracture. They're actually quite easy to remove and you can actually let the kids take them out themselves. You take the frame off first and you put this screwdriver on and you do the first turn to show them that it doesn't hurt, the screws are conical. And you do the first turn and they really doesn't hurt and I would say anybody who's about 10 and above, you can actually just do this in the office and they can take the screws out themselves. And I always have this picture because people don't believe me when I, all what I do here. OK. So again though for open fractures where you don't want to put anything permanent, you could put an external fixator on. This shows it on the night of the injury. They're tolerated very well. The kids actually once they get used to the shock when they wake up, they like them because they can still take a shower, they can still wear their regular shoe as opposed to if they had a cast on. And again, you take those out in the office. You can use flexible nails in smaller kids and it works pretty well, I won't belabor that. But again they leave like a really, really nice scar, so for the right kid it's a nice option. So the great thing about taking care of kids, is that you can expect full recovery in children. So all these cases that we show, some are more involved than others and there's really no such thing as a kid who shouldn't be fixed because they're not going to make it or they're not going to do well or brain injuries too bad. Really the only time I don't fix somebody who needs fixation, is if the family is going to withdraw care or they're going to be an organ donor or they've been brain dead, because otherwise you should expect full recovery. And about a week ago I had to go, if any of you are older, you're my age or older, y'all know Sherman and Peabody. So I had to go to the Wayback Machine to find this article and in fact I lost the original copy of it. So I had to go in to stacks, in the University of Chicago medical school library, which is a spooky place now because no students use books anymore right? So I'm down at stacks and it's like dark, I had to take my flashlight on my phone and find this old article. So I went all the way back to 1978, there's this classic article by Mark Hoffer and I would expect that things are better than that even from now right? But so Rancho Los Amigos, which doesn't exist anymore, was a rehab hospital in California and they looked at 65 consecutive patients treated at Rancho Los Amigos for rehabilitation of head injury. And up to 18 years of age they had at least one year of followup. And what they found, if the patients didn't have post traumatic hydrocephalus, they basically had amazing results. And that they looked at the Ommaya criteria for coma, I won't go over the whole list, but basically level two basically meant you were emerged enough from coma, capable of purposeful activity and ability to follow commands. You didn't have to be normal, and level three is still basically in a coma, level two is coming out of a coma. So if you did that, we saw that the duration of coma was all the way up to six weeks. At one year follow up, 93% of those patients were ambulatory. Which is amazing in itself. But if you look at patients who are in a coma for six weeks to three months, ultimately 62% of those patients are still ambulatory. So you have to assume that they're going to make a full recovery and you treat them as such. We see or we have a fair number of kids that come in from the international community, we have all taken care of here, where I've taken care of some awful femur fractures that the kid had a bad injury, they're treated in Dubai, and they don't treat it they just let it heal in a cast and it's totally angulated and shortened because they assumed the kid wasn't going to make it and yet they come around. So here's a case one, this is a 15 month old female who was in a car and she was ejected, she was unrestrained. There's an open brain injury. She was unresponsive for one week , she had a left femur fracture and bilateral tibia fractures and all the fractures were fixed the night of the injury. And this is her in my office three weeks post injury. So I had to put a smiley mask on her because, to protect her identity, I wanted to be able, on this girl to show her eyes because she's wide awake and alert and other than the scar on her head, you wouldn't know anything had happened to her, and I guess the cast on her leg, but she had full recovery. But if you look at this picture back here, you would say that's not going to happen. So this is, this is another one of my patients, a five year old struck by a semi and dragged down a rural highway. He has an open femur, open tibia. And I'd shown you his pictures earlier, he had a degloving injury and they went from his femur, from his groin all the way down to his ankle. So within the first day or two, all this skin was starting to slough and ultimately had to be just completely resected. He has a severe closed head injury, he has had part of his skull removed to allow for edema. He's got a tracheostomy, he's comatose for four weeks. He has a dense spastic left hemiplegia as he awakes. Here the skin's totally degloved, and then after we debrided all the way, this is all missing, the central portion of his tibia lost all it's blood supply, it was necrotic, had to be removed. But then after multiple debridements, multiple skin grafts for his right leg everything heals, all of his growth plates remained open. This is his skull that had been removed. This is his defect, and he comes back seven months later to have it replaced, and this is him at seven months, no I going to take it back, this is, these fixators are removed at seven months and this is in at one year post injury. So, he certainly has some residual neurologic deficit but he's ambulatory kid, functions and goes to school. And so again, you see those original pictures you wouldn't think that that's possible but it happens. Children with multiple injuries and multiple fractures benefit from fixation. A variety of methods can be used, even in very young patients. And though pediatric trauma patients don't have as many systemic problems as adult patients, damage control orthopedics may need to be practiced in the unstable patient. And the potential is remarkable in kids, and patients should be treated as if they will obtain full recovery. Thanks.
