Introduction
Traumatic injuries in immature skeletons have increased in recent years.[1]
[2] Each year, at least 2% of children suffer some type of fracture.
Joeris et al.,[3] in an epidemiological study with 2,716 children treated between 2009 and 2011, observed
2,840 fractures of long bones, 59% in the radius/ulna; 21% in the humerus; 15% in
the tibia/fibula, and 5% in the femur. The mean age in this study was 8.2 years old,
6% of which were infants; 26% preschoolers; 40% school children, and 28% adolescents.
Fractures in adolescents were more common in males. Twenty-seven percent of fractures
in children were related to a fall from height; 50% took place in recreational and/or
domestic activities; 11% in traffic accidents; and 8% of the fractures occurred in
the school environment. Twenty-six percent of the patients were overweight or obese.
The authors concluded that the difference in fracture distribution is mainly related
to the patients' sex and age, and report that overweight and obesity increase the
risk of fractures in children.
Fractures in children and adolescents, with some frequency, can lead to complications,
some of them exclusively linked to the growth of the extremities. The growth cartilages,
located in the metaphysis of the long bones, due to their firmer anatomy and consistency,
often act as protectors of the articular surface, as they partially absorb the impact/trauma
at said extremity. However, when injured, they can lead to unique complications and
harmful consequences to the growing skeleton, such as deformities and bone shortening.[4] On the other hand, in some types of fractures, the growth provided by epiphyseal
cartilages can also act as a great ally in the correction of residual deformities.
Other favorable factors in children's fractures are the greater plasticity of the
bone, the thicker and active periosteum, and the faster consolidation process, because
the periosteum functions as a stabilizing and facilitating element of conservative
treatment. This bone remodeling will not occur or will not be adequate in fractures
that compromise the joint, the epiphyseal cartilage or those that affect the diasphysis
and produce deviations and/or with excessive shortening.[4]
The change in the physician's behavior in relation to the type of treatment, conservative
or surgical, in some fractures in children, has been influenced by several factors:
technological development, availability of imaging equipment in surgical centers,
safer anesthesias, better bone implants designed specifically for the pediatric skeleton
and orthopedists' surgical training in minimally invasive surgeries. These resources
have introduced a new way to diagnose, evaluate, and treat traumatic, bone and/or
ligament injuries, and, as it could not fail to be, also fractures in children.
Orthopedics and traumatology, as other medical specialties, changed and ended up suffering
an irreversible division into subareas.[5]
[6] With this specialization, the physician also had better knowledge and preparation
to perform surgeries that, in part, can influence the time of hospitalization, the
ease of care by the parents and give a faster rehabilitation.
In view of the above, some questions can be raised and constitute the main objective
of this update article: (1) Are we really turning more aggressive in the approach
to fractures in children? (2) If this new approach to pediatric fractures is true,
is it supported by evidence-based medicine?
Special Aspects In Traumatic Injuries Of The Immature Skeleton
The bones in children are very cellularized, have a high coefficient of elasticity
and, sometimes, when they suffer trauma, they deform without presenting an evident
trace of fracture (plastic deformation). Subperiosteal lesions at the junction of
the metaphysis with the diaphysis may also hinder the diagnosis if radiographs are
evaluated by less experienced professionals.[7] In the elbow, as well as in other bone extremities, the multiple ossification centers
may confuse the physician and lead to a mistaken fracture diagnosis.
Mardani-Kivi et al.[8] evaluated the influence of emergency physicians, not specialized in orthopedics,
on decisions related to pediatric fractures, especially of the forearm and elbow.
Fractures of 108 patients under the age of 14 years were evaluated by two physicians,
one emergency physician and one orthopedist. Sixty-four percent of the fractures received
the same diagnosis, but, in the other 36%, there were statistically significant differences,
mainly in relation to fractures of the lateral condyle of the elbow and in fractures
of the distal radius compromising the growth cartilage. The authors concluded that
in institutions that have emergency physicians, they should be better educated about
fractures in children.
Some fractures are exclusive to children and adolescents, including obstetric fractures
and accidental and non-accidental fractures (maltreatment) that affect the epiphysis
cartilage (physis) and/or the diasis of long bones. Non-accidental fractures related
to violence against children and adolescents require medical knowledge for their diagnosis
and constitute a major public health problem.[9]
[10]
Surgeries in fractures in children require special care regarding lower tolerance
to blood loss, injury to growth areas, and the possibility of significant complications
in cases of infection.
The Treatment of Fractures in Children
Blount,[11] in 1955, reported that due to the anatomical and physiological characteristics of
the immature bone, surgical treatment is rarely indicated in children. Charnley,[12] in his classic treatise: “The Incrusing Treatment of Frequent Fractures” states: “we are not yet in a position to compare conservative treatment with surgery due to
the great technical difficulties and complications of fixations”. In the same book, in the 2003 edition, he ratified his preference for conservative
treatment. Ogden,[13] in 1984, wrote that the principles of reduction and surgical fixation for adult
fractures should not be extrapolated for the treatment of fractures in children, since,
almost always, they are related to delayed consolidation. According to him, surgeries
for fractures in children should be reserved for fractures of the humerus' lateral
condyle and the femoral neck.
Few reports of surgeries on children's fractures occurred until the 1990s. One of
the pioneers to draw attention to surgical fixation of fractures in children was Wilkins,[14] who, in 1991, stated that the quality of images facilitates the diagnosis and treatment
of skeletal lesions, making clearer the indications for surgical interventions in
pediatric fractures.
Since then, reports on fracture fixation have become more frequent, especially in
fractures of the elbow and forearm—in the upper limbs—and femur and tibia—in the lower
limbs. This surgical trend has been increasing progressively in the last three decades.[15]
Literature Data
Data obtained from the medical records of patients treated in trauma centers show
that there is a significant percentage increase in the surgical treatment of fractures
in children. Cheng et al.,[16] in 1999, reported an increase from 3 to 22% between 1985 and 1995 in the percutaneous
fixations of supracondylian fractures of the elbow, distal radius, and diaphysary
fractures of the femur. Helenius et al.,[17] between 1997 and 2006, observed a 22% increase in the rate of fractures attended
when compared to previous years, and an increase of 28% in surgeries in upper limbs
fractures and 4% in lower limbs fractures. Some records also demonstrate the significant
increase in forearm bone surgeries using intramedullary fixation.[2]
[18]
[19] Meling et al.[20] analyzed data from a center in Norway and observed that 61% of fractures in children
are treated conservatively, 31% through percutaneous fixation and 8% through internal
fixation.
In relation to upper limb fractures, these represent 70 to 90% of fractures in the
pediatric population. Fractures in the proximal humerus, even in older children, are
rarely treated surgically for the ease of bone consolidation and remodeling provided
by the large range of motion of the shoulder joint.[21] Even with good results with the non-surgical treatment of these fractures, Dobbs
et al.[22] suggest a reduction in deviated fractures that affect adolescents over 12 years
of age who present significant deviation. They also suggest percutaneous fixation
of fractures that are unstable. In unacceptable reductions, they propose open reduction
through access to the fracture focus by the deltopectoral groove. Hannonen et al.[23] studied 300 patients under 16 years of age with proximal humerus fractures treated
at a pediatric trauma center between 2005 and 2015. These authors pointed out that
the incidence of this fracture remains stable, but the rate of surgical treatment
in relation to the conservative one has increased, even though the reasons for such
elevation remain uncertain.
The supracondylar fracture of the humerus is the second most frequent in the upper
limbs in children, and its peak incidence is between 5 and 8 years of age. Among the
fractures of the upper limbs, this is the one that has the most expressive results
in relation to surgical stabilization. Surgery in this fracture is associated with
lower rates of neurovascular lesions, compartment syndrome and residual deformities,
such as varus.[24] A Finnish study[25] evaluated a sample of 9,017 supracondylar humerus fractures surgically treated over
a 30-year period. The authors noted that, over time, surgeons began to perform osteosynthesis
of the distal humerus four times more frequently. In the same study, they also noted
a significant reduction in late reconstructive procedures, such as those necessary
for the treatment of sequelae of compartment syndromes and osteotomies for the correction
of residual deformities. Few fractures benefit from both treatment standardization
(unscrupulous reduction and percutaneous fixation with Kirschner wires) and supracondylar
humerus fracture. Surgical management, in Gartland grade IIb or III devious fractures,
minimizes complications and virtually eliminates the chances of reinterventions, besides
favoring functional recovery in a few weeks. The configuration in the placement of
the pins in the fixation of this fracture, crossed or unilateral divergent, has been
the subject of some controversy. Lamdan et al.[26] concluded that, under normal implantation conditions, two divergent lateral wires
offer satisfactory mechanical stability. In addition, lateral placement of the wires
prevents iatrogenic injury of the ulnar nerve. Vascular changes may be present in
10 to 20% of the diverted supracondylar fractures, but, most of the time, the perfusion
is restored soon after the reduction of the fragments. Nerve lesions are usually neuropraxias,
which occur in 6.5 to 19% of cases and improve spontaneously. At first, there is no
indication for surgical exploration of the fracture and/or injured nerve in the initial
treatment. Open reductions are reserved for open fractures, vascular lesions without
capillary filling for more than 10 minutes after reduction, or failures in the reduction
in the fracture approach.[27]
On the treatment of forearm fractures in children and adolescents, it is known that,
although the unscrupulous reduction followed by plastered immobilization is considered
the gold standard, there has been a growing trend towards surgical stabilization of
diaphysary fractures.[28] In general, studies suggest that surgery should be reserved for cases in which satisfactory
alignment is not achieved by closed reductions.[29]
Kim et al.[30] analyzed the results of intramedullary fixation with flexible stems in 40 children
and adolescents with diaphyseal or meta-diaphyseal fractures of the forearm. Eight
out of 40 patients required open fracture reduction, and consolidation time occurred,
on average, after 8.3 weeks. In 38 patients, the result was good and, in 2, excellent
(recovery of mobility in rotation). The authors concluded that the method produces
satisfactory results maintaining adequate stability and mobility of the segment.
Pogorelić et al.[31] retrospectively evaluated 173 forearm fractures treated with flexible intramedullary
nail stems with a mean follow-up of 68 months. They demonstrated that this type of
minimally invasive fixation promotes good results both functional and cosmetic, has
very low complication rates, and often dispenses with the use of additional stabilization
by a casted apparatus.
Stöckell et al.[32] evaluated the stage of development of the four elbow ossification centers, according
to the Classification of Sauvegrain and Dimeglio, and correlated its development with
possible alterations in the consolidation of forearm fractures treated with intramedullary
fixation with flexible stems. They suggest that, in stages equal to or greater than
6 of the olecranon ossification nucleus, the occurrence of changes in consolidation
is more frequent.
Volpon,[33] in 2008, recommended that diaphyseal fractures of forearm bones in children be fixed,
when necessary, with titanium rods. According to him, these fractures are among those
that most benefit from surgical treatment. He emphasized that the correct diagnosis
and reduction of the poor alignment of forearm bones should be taken to maximum values
of 20° in the metaphysis; 15° in the diaphysis, and 10° in the proximal region. He
also established that these values should be lower the older the child is. He draws
attention to the importance of the approach to fractures in the transition from metaphysis
to the diasphysis and also to monteggia fractures-dislocations. It also proposes to
establish the first treatment as the definitive one, avoiding re-interventions.
Liu et al.[34] compared two types of treatment in 175 fractures of the distal third of forearm
bones in children between 8 and 14 years of age. One hundred and fourteen were fixed
percutaneously and 61 submitted to unscrupulous reduction and immobilization in plastered
apparatus. Postreduction angulation, residual angulation in the last follow-up, radiation
exposure, total immobilization time, time of absence from school, total costs, and
complications were evaluated. Postreduction angulation was significantly lower in
the group submitted to percutaneous fixation, but after 6 months of follow-up, the
residual deformity was similar. According to the authors, patients undergoing non-operative
reduction received more radiation than those treated surgically through percutaneous
fixation.
In the lower limbs, some fractures, such as proximal fractures of the femur, deserve
special care. Diagnosis should be rapid and appropriate, as they require adequate
stabilization and anatomical reduction to minimize the possibility of serious complications
such as osteonecrosis.[35]
Freitas,[36] in his study published in 2006, already warns of the severity of femoral neck fracture
in children due to high rates of complications (40%). Alluri,[37] when evaluating a national database in the USA, demonstrates an increase in the
rates of fixation of femoral diaphyseal fractures with flexible intramedullary stems
of 35 and 58%, respectively, for the 4- and 5-year-old age groups, between 1997 and
2012. According to him, this increase is related to several factors, including the
fact that spica casting entails greater risks of vicious consolidation, delay in joint
mobilization and demand greater care by parents. Santili et al.,[38] in 2002, used flexible titanium rods in 8 patients aged 8 to 12 years with femoral
diaphyseal fractures and found an important reduction in hospitalization time, evolution
to support in the fractured limb and early joint mobility. Even though these are preliminary
results, the authors are optimistic about the surgical treatment that progresses to
consolidation and functional recovery without major complications. In 2012, Soni,[39] when retrospectively evaluating[24] pediatric femur diaphyseal fractures, suggested that titanium elastic intramedullary
rods are related to good results in unstable fractures.
Leet et al.[40] studied the treatment of femoral fractures in children with cerebral palsy. They
evaluated 47 fractures, 22 in non-ambulatory patients, and 15 in ambulatory patients.
Even with complications, such as residual deviations and pseudoarthrosis, in fractures
treated with unscrupulous treatment and/or surgeries, the authors recommend that fractures
in children with non-ambulatory cerebral palsy be addressed in a non-surgical manner.
Its follow-up should be careful to avoid major residual deviations or areas of pressure
by the plaster. However, surgical alignment and fixation in femoral fractures should
be considered in paralyzed cerebral patients with good walking capacity.
In the case of tibia fractures, the third most common fracture of the child's long
bones, a retrospective study also showed increased rates of surgical treatment over
time. Kleiner et al.[41] evaluated[24]166 diaphyseal tibial fractures over a 12-year period and observed that the highest
incidence of fixation was in the age groups between 5 and 9 years, older adolescents,
and in patients with associated fractures of the femur. Although traditionally treated
conservatively,[42] Rickert et al.[43] suggest that fractures of the tibia with more than 20% deviation and associated
with fibula fracture are operated, as they present a 40% risk of residual deformities
that will culminate in late surgical intervention.
Weber et al.[44] reported that, among 168 tibia fractures in children treated in the emergency room
between 2005 and 2017, 38 were surgically treated, 36 of which were fixed with flexible
rods or plate and two stabilized with external fixator. The mean age of the patients
treated conservatively was statistically lower (6 years old) when compared to that
of the operated patients (10.2 years old). They concluded that, up to 4 years of age,
tibial fractures are simpler and quickly consolidate with conservative treatment,
while fractures fixed with intramedullary nail stems are related to a longer time
of consolidation. Despite this, the rehabilitation time was similar in both groups.
Civan et al.[45] investigated the time of consolidation of tibia fractures in 46 patients with a
mean age of 9.5 years old, relating it to variables of age, type of fracture (closed
or exposed), location in bone (diaphysary or metaphysary), association with fibula
fracture, and type of treatment instituted (unscrupulous reduction and plaster or
surgery). The consolidation score was evaluated at 4, 6, and 8 weeks after the fracture,
and the authors noted that there is a negative correlation between age and the consolidation
score. Conservative treatment is related to better consolidation score, and open fractures,
or those associated with fibula fracture, have significantly lower consolidation score.
The level of the fracture in the bone showed no differences in relation to the consolidation
score.
In recent decades, children have started to participate in riskier sports and recreational
activities that expose them to a higher risk of fractures. Traffic accidents, collisions
and/or hit-and-run also directly impact the increase in fractures in children and
adolescents.[14] A greater exposure to accidents may be related to the appearance of new patterns
of injuries, of high energy, in this age group.[14] Thus, these new types of injury, related or not to polytrauma, may also impact on
the change in behavior of surgeons when deciding between non-surgical and surgical
options in infant fractures.[2]
Some protocols have been developed by international societies to guide orthopedists
in decision making and patient care. Although very useful, they are unclear and have
no high level of evidence.[46]
[47] It is important to emphasize that, even with apparent benefits, surgical treatment
of fractures in children is a therapeutic method that requires general anesthesia
for its execution and, often, a second procedure, also under anesthesia, to remove
the synthesis material. Surgeries in children, as well as in adults, are also related
to other complications of higher morbidity, such as infection and changes in bone
consolidation.[48]
Scientific Evidence
Fractures in which surgery has been most frequently indicated are: supracondylar of
the humerus ([Figure 1]), forearm bones ([Figure 2]), and femoral dyaphysis ([Figure 3]). It is not discussed that surgical reduction with percutaneous fixation of the
supracondylar humerus fracture brought benefits to patients, reducing complications
and the need for reoperations. In the same way, fixation with flexible rods in fractures
of long bones, in upper and lower limbs, they promote early consolidation and rehabilitation.
Fig. 1 Radiographs in anteroposterior (A) and profile (B) incidences of an 8-year-old female
patient evidencing supracondylar humerus fracture, submitted to incruent reduction
and percutaneous fixation with two divergent Kirschner wires with entrance by lateral
condyle (C and D).
Fig. 2 Radiographs in anteroposterior (A) and profile (B) incidences of a 9-year-old female
patient with fractures of the distal third of the radius and ulna diaphysis, treated
with closed reduction and fixation with flexible intramedullary titanium rods (C and
D).
Fig. 3 Radiographs in anteroposterior (A) and profile (B) incidences of a 7-year-old female
patient showing diaphyseal fracture of the femur, with indication of closed reduction
and osteosynthesis with flexible intramedullary titanium stems (C and D).
Although increased surgical tendency exists for supracondylar fracture of the humerus,
fractures of the forearm, femoral neck, femoral and tibia diaphysis, most of the studies
that recommend it are levels IV and V. Similarly, articles of the same scientific
level show excellent functional results in fractures of the forearm, femur, tibia,
and even of the distal humerus, with non-operative treatment. Thus, the lack of controlled
studies prevents the establishment of protocols with evident superiority of surgical
methods over conservative ones. It is very difficult to affirm that, in the long term,
surgical treatment is superior to conservative treatment, even if some benefits are
evident in the care and rehabilitation of some fractures with surgery.
Final Considerations
Certainly, in recent decades, the increase in the indication of surgical treatment
for pediatric fractures has been evident. There are, however, gaps in the literature
in determining the best treatment for each fracture in children and adolescents.
Randomized controlled trials have many ethical limitations in these cases. Thus, it
is not possible to determine with safety whether the surgical treatment, already consolidated,
is superior to the non-operative treatment.
Thus, the surgical indication should be individualized and conducted in accordance
with the experience of the surgeon, with the available technological resources, based
on the literature and the family's wishes.
