Martin J. Herman

Pediatric pelvic fractures.

Abstract Pediatric pelvic fractures account for only 1% to 2% of fractures seen by orthopaedic surgeons who treat children. They are typically associated with high‐energy trauma, requiring a comprehensive workup for concomitant life‐threatening injuries. Anteroposterior radiographs and rapid‐sequence computed tomography are the standards of diagnostic testing to identify the fracture and recognize associated injuries. Treatment is individualized based on patient age, fracture classification, stability of the pelvic ring, extent of concomitant injuries, and hemodynamic stability of the patient. Most pelvic injuries in children are treated nonsurgically, with protected weight bearing and gradual return to activity. Open reduction and internal fixation is required for acetabular fractures with >2 mm of fracture displacement and for any intra‐articular or triradiate cartilage fracture displacement >2 mm. To prevent limblength discrepancies, external fixation is necessary for pelvic ring displacement >2 cm. Fractures involving immature triradiate cartilage may lead to growth disturbance of the acetabulum, resulting in acetabular dysplasia, hip subluxation, or hip joint incongruity. Osteonecrosis of the femoral head may develop after acetabular fractures associated with hip dislocation. Other complications include myositis ossificans and neurologic deficits secondary to sciatic, femoral, and/or lumbosacral plexus nerve injuries.

Spondylolysis and Spondylolisthesis in Children and Adolescents: I. Diagnosis, Natural History, and Nonsurgical Management

Spondylolysis and spondylolisthesis are often diagnosed in children presenting with low back pain. Spondylolysis refers to a defect of the vertebral pars interarticularis. Spondylolisthesis is the forward translation of one vertebral segment over the one beneath it. Isthmic spondylolysis, isthmic spondylolisthesis, and stress reactions involving the pars interarticularis are the most common forms seen in children. Typical presentation is characterized by a history of activity-related low back pain and the presence of painful spinal mobility and hamstring tightness without radiculopathy. Plain radiography, computed tomography, and single-photon emission computed tomography are useful for establishing the diagnosis. Symptomatic stress reactions of the pars interarticularis or adjacent vertebral structures are best treated with immobilization of the spine and activity restriction. Spondylolysis often responds to brief periods of activity restriction, immobilization, and physiotherapy. Low-grade spondylolisthesis (< or =50% translation) is treated similarly. The less common dysplastic spondylolisthesis with intact posterior elements requires greater caution. Symptomatic high-grade spondylolisthesis (>50% translation) responds much less reliably to nonsurgical treatment. The growing child may need to be followed clinically and radiographically through skeletal maturity. When pain persists despite nonsurgical interventions, when progressive vertebral displacement increases, or in the presence of progressive neurologic deficits, surgical intervention is appropriate.

Spondylolysis and spondylolisthesis in the child and adolescent athlete.

Spondylolysis and spondylolisthesis are common causes of low back pain in the competitive athlete. Repetitive loading of the lumbar spine results in stress reactions and spondylytic defects of the pars interarticularis. Spondylolysis and lesser degrees of spondylolisthesis frequently respond to activity restrictions, bracing (in specific situations), and physiotherapy. Spinal fusion is indicated for spondylolysis and spondylolisthesis that remain painful despite nonoperative measures and progressive, high-grade spondylolisthesis. Return-to-play guidelines are made for each athlete individually based on his or her specific diagnosis, response to treatment, and sporting activity.

Management of Supracondylar Humerus Fractures in Children: Current Concepts

&NA; Supracondylar humerus fractures are the most common elbow fractures in the pediatric population. Type I fractures are managed nonsurgically, but most displaced injuries (types II, III, and IV) require surgical intervention. Closed reduction and percutaneous pinning remains the mainstay of surgical management. Numerous studies have reported recent alterations in important aspects of managing these fractures. Currently, many surgeons wait until 12 to 18 hours after injury to perform surgery provided the childs neurovascular and soft‐tissue statuses permit. Increasingly, type II fractures are managed surgically; cast management is reserved for fractures with extension displacement only. Two to three lateral pins are adequate for stabilizing most fractures. Evolving management concepts include those regarding pin placement, the problems of a pulseless hand, compartment syndrome, and posterolateral rotatory instability.

Tibial shaft fractures in children and adolescents.

&NA; Tibial shaft fractures are among the most common pediatric injuries managed by orthopaedic surgeons. Treatment is individualized based on patient age, concomitant injuries, fracture pattern, associated soft‐tissue and neurovascular injury, and surgeon experience. Closed reduction and casting is the mainstay of treatment for diaphyseal tibial fractures. Careful clinical and radiographic follow‐up with remanipulation as necessary is effective for most patients. Surgical management options include external fixation, locked intramedullary nail fixation in the older adolescent with closed physis, Kirschner wire fixation, and flexible intramedullary nailing. Union of pediatric diaphyseal tibial fractures occurs in approximately 10 weeks; nonunion occurs in <2% of cases. Some clinicians consider sagittal deformity angulation >10° to be malunion and indicate that 10° of valgus and 5° of varus may not reliably remodel. Compartment syndromes associated with tibial shaft fractures occur less frequently in children and adolescents than in adults. Diagnosis may be difficult in a young child or one with altered mental status. Although the toddler fracture of the tibia is one of the most common in children younger than age 2 years, child abuse must be considered in the young child with an inconsistent history or with suspicious concomitant injuries.

CERVICAL SPINE DISORDERS IN CHILDREN

Care of children with disorders of the cervical spine requires an understanding of the anatomic and biologic features particular to the developing pediatric spine. Congenital and developmental alterations further complicate evaluation and treatment of children. Basic knowledge of pediatric cervical spine disorders in Down syndrome, Klippel-Feil syndrome, osteochondrodysplasias, mucopolysaccharidoses, and post-traumatic instability is essential for all orthopedic surgeons. Thorough patient evaluation and appropriate early management may prevent potentially serious neurologic injury and other complications related to cervical spine pathology.

Fractures of the lateral humeral condyle: Role of the cartilage hinge in fracture stability

This study investigates the hypothesis that the integrity of the cartilage hinge at the distal humeral epiphysis determines the stability of fractures of the lateral humeral condyle. Sixteen patients with lateral humeral condyle fractures were studied with radiographs and magnetic resonance imaging (MRI). The clinical course of each patient was compared using these imaging studies to determine whether initial fracture displacement and the integrity of the cartilage hinge correlated with fracture stability. Radiographically, 4 fractures were considered unstable (with initial fracture displacement >3 mm) and 12 were stable (initial displacement ≤3 mm). On MRI, 6 fractures were complete (with disruption of the lateral cartilage hinge) and 10 were incomplete. All unstable fractures had complete fractures on MRI. Ten of the 12 patients with radiographically stable injuries had incomplete fractures on MRI. None of these displaced during treatment. Two patients had radiographically stable fractures and complete fractures on MRI. One of these fractures displaced, confirming the hypothesis that the stability of lateral humeral condyle fractures is related to the integrity of the cartilage hinge.

Hip fractures in children

&NA; Hip fractures account for <1% of all pediatric fractures. Most are caused by high‐energy mechanisms, but pathologic hip fractures also occur, usually from low‐energy trauma. Complications occur at a high rate because the vascular and osseous anatomy of the child’s proximal femur is vulnerable to injury. Surgical options vary based on the child’s age, Delbet classification type, and degree of displacement. Anatomic reduction and surgical stabilization are indicated for most displaced hip fractures. Other options include smooth‐wire or screw fixation, often supplemented by spica cast immobilization in younger children, or compression screw and side plate fixation. Achievement of fracture stability is more important than preservation of the proximal femoral physis. Capsular decompression after reduction and fixation may diminish the risk of osteonecrosis. Osteonecrosis, coxa vara, premature physeal closure of the proximal femur, and nonunion are complications that account for poor outcomes.

Cervical spine issues in Down syndrome.

Down syndrome, with an incidence of 1 in 660 live births, remains the most common human malformation pattern. Individuals with Down syndrome have an increased incidence of congenital heart disease (50%), ophthalmologic disorders (35%), gastrointestinal disorders (13%), thyroid disease (8%), and leukemia (1%). Rheumatoid disease and dementia are more frequent in older individuals with Down syndrome than in the corresponding general population. Motor development is usually delayed with Down syndrome, but motor ability at maturity is variable and exhibits a spectrum from significant functional disabilities to highly developed athletic skills. While the average IQ of studied populations with Down syndrome is 50, there are wide variations in cognitive development, from severe retardation to normal intelligence. Musculoskeletal problems commonly occur in Down syndrome and include patellofemoral instability, hip disease and instability, bunions, severe flatfeet, and instability of the cervical spine. Degenerative changes of hips and knees may impair ambulation ability. Instability of the cervical spine may result in cord compromise, with serious neurologic impairment or death. Cervical spine instability associated with Down syndrome has been of concern since it was first reported by Spitzer in 1961. The association of cervical instability in Down syndrome was promulgated to the lay population through the efforts of the Special Olympics. In 1983, the Special Olympics Inc. disseminated its recommendation that every athlete with Down syndrome who planned to participate in the Special Olympics required a neurologic evaluation and radiographic examination of the cervical spine. Unfortunately, national protocols have not been established, and interpretations of the Special Olympics recommendations vary significantly from state to state. Recommendations may require clinical and radiographic evaluation of the cervical spine at only one time in one state, while another state may require annual examinations and radiographs of the cervical spine before an athlete is permitted to participate. Despite reports of neurologic compromise in individuals with Down syndrome, the natural history of development of cervical instability or degenerative disc or facet joint changes within the cervical spine has yet to be elucidated. Primary care clinicians are aware of the potential of evolving cervical instability in this population and usually order flexionextension lateral radiographs of the cervical spine. These clinicians commonly rely on the interpretation of the images by radiologists who may or may not be experienced in analysis of the cervical spine in Down syndrome. These studies differ significantly from radiographs of the cervical spine in the general population. Despite decades of observation and study, interpretation of radiographic findings and the determination of integrity of the cervical spine in the Down syndrome population remain controversial. A variety of problems contribute to the difficulty of radiograph assessment of the cervical spine in children with Down syndrome. Due to impaired cognition and anxiety, positioning of the patient to obtain technically competent radiographs of the cervical spine can be extremely difficult. To obtain meaningful information, a lateral view of the cervical spine must be accomplished with the spine in neutral position (ie, without rotation or tilt of the head or neck). Neutral alignment may be difficult to obtain on a standard lateral radiograph of the cervical spine and is even more difficult to obtain with the addition of flexion and/or extension lateral views of the cervical spine. When neutral views of the cervical spine cannot be obtained by plain radiography, cineradiography of the cervical spine is effective to position the head and neck in neutral alignment in flexion and extension (Fig. 1). This technique also allows clinical assessment of the patient’s degree of effort during neck flexion and extension. Patients may be quite apprehensive during neck motion and may not fully cooperate with the degree of effort necessary to show instability. With insufficient effort or resistance by the patient during flexion and extension stress of the cervical spine, radiographic images may underestimate the presence of instability and may be interpreted as normal studies. Once technically correct flexion and extension lateral radiographs of the cervical spine have been obtained, the occipitocervical junction, atlantodens interval, and each cervical level must be accurately visualized and critically evaluated (Fig. 2). Universally accepted radiographic limits of cervical vertebral translation or angular displacement in the general population should not be applied to radiographs of the cervical spine of the patient with Down syndrome. Instability implies pathologic intersegmental motion that jeopardizes neurologic integrity. Hypermobility refers to increased excursions noted in the Down cervical spine compared with normal controls but does not connote loss of structural integrity of the anatomic restraints that protectneural tissues.Theconcept From St. Christopher’s Hospital for Children, Philadelphia, PA, and the Department of Orthopaedic Surgery, Drexel University College of Medicine, Philadelphia, PA. Reprints: Peter D. Pizzutillo, MD, St. Christopher’s Hospital for Children, Front Street at Erie Avenue, Philadelphia, PA 19134 (e-mail: peter. pizzutillo@tenethealth.com). Copyright 2005 by Lippincott Williams & Wilkins

Spondylolysis and spondylolisthesis in children and adolescents: II. Surgical management.

Abstract Surgical management is indicated for children and adolescents with spondylolysis and low‐grade spondylolisthesis (≤50% slip) who fail to respond to nonsurgical measures. In situ posterolateral L5 to S1 fusion is the best option for those with a low‐grade slip secondary to L5 pars defects or dysplastic spondylolisthesis at the lumbosacral junction. Pars repair is reserved for patients with symptomatic spondylolysis and low‐grade, mobile spondylolisthesis with pars defects cephalad to L5 and for those with multiple‐level defects. Screw repair of the pars defect, wiring transverse process to spinous process, and pedicle screw‐laminar hook fixation are surgical options. The ideal surgical management of high‐grade spondylolisthesis (>50% slip) is controversial. Spinal fusion has been indicated for children and adolescents with high‐grade spondylolisthesis regardless of symptoms. In situ L4 to S1 fusion with cast immobilization is safe and effective for alleviating back pain and neurologic symptoms. Instrumented reduction and fusion techniques permit improved correction of sagittal spinal imbalance and more rapid rehabilitation but are associated with a higher risk of iatrogenic nerve root injuries than in situ techniques. Wide decompression of nerve roots combined with instrumented partial reduction may diminish the risk of neurologic complications. Pseudarthrosis and neurologic injury presenting as L5 radiculopathy and sacral root dysfunction are the most common complications associated with surgical management of high‐grade spondylolisthesis.