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What's New in Pediatric Orthopaedic Trauma: The Lower Extremity
Kathleen D Rickert1,2, Pooya Hosseinzadeh3, Eric W Edmonds1,2
1Pediatric Orthopedics and Scoliosis Center, Rady Children's Hospital.
Insights
This review highlights key findings in pediatric lower extremity trauma, emphasizing conservative management for most tibia fractures and vigilance for compartment syndrome. It also notes that higher-grade pelvic fractures don't worsen splenic/hepatic injuries.
Area of Science:
- Pediatric Orthopaedics
- Trauma Surgery
- Musculoskeletal Research
Background:
- Skeletal trauma is a significant concern in pediatric orthopaedics.
- Recent high-quality studies offer valuable insights into clinical practice.
- This review focuses on lower extremity trauma, excluding upper extremity injuries.
Purpose of the Study:
- To review and synthesize recent significant findings in pediatric lower extremity trauma.
- To identify key advancements in the management of fractures and related injuries.
- To provide an evidence-based summary for clinicians and researchers.
Main Methods:
- PubMed database search for pediatric lower extremity trauma keywords (pelvis, femur, tibia, ankle, foot).
- Review of 835 papers published between January 1, 2012, and July 31, 2017.
- Selection of 25 papers with significant findings, primarily Level IV evidence.
Main Results:
- Eight studies focused on tibial shaft injuries, six on pelvic fractures, and five on femur fractures.
- Four studies addressed ankle injuries, two on foot injuries, and one on trauma and venous thromboembolism.
- The majority of reviewed studies provided Level IV evidence.
Conclusions:
- Higher-grade pediatric pelvic fractures do not correlate with increased splenic or hepatic injury severity.
- Femur fractures in older children achieve successful union with surgeon-preferred surgical methods.
- Conservative management is recommended for most pediatric tibia shaft fractures, but >20% displacement with fibula fractures carries a 40% risk of delayed surgery.
- Vigilance for compartment syndrome and venous thromboembolism is crucial.
- Salter-Harris I distal fibula fractures are often ligamentous injuries.
- Minimally invasive surgery may reduce complications for pediatric calcaneus fractures.
Background:
Skeletal trauma is a primary tenet of pediatric orthopaedics. Many high-quality studies have been published over the last few years with substantial relevance to the clinical practice of pediatric orthopaedic trauma. Because of the volume of literature on the subject, this review excludes upper extremity trauma and focuses on the publications affecting the lower extremity.
Methods:
An electronic search of the PubMed database was performed utilizing keywords for pediatric lower extremity trauma: pelvic injuries, femur fractures, tibial shaft fractures, femur fractures, ankle fractures, and foot fractures. All 835 papers related to the treatment of pediatric orthopaedic trauma of the lower extremity published from January 1, 2012 to July 31, 2017 were reviewed, yielding 25 papers that were believed to contribute significant findings to the profession.
Results:
Of the 25 papers selected for presentation within this review, 8 related to tibial shaft injuries, 6 involved the pelvis, 5 involved femur fractures, 4 related to ankle injuries, 2 involved foot injuries, and 1 regarding trauma and venous thromoembolism. The level of evidence for these studies were either level III or IV.
Conclusions:
Higher-grade pediatric pelvic fractures do not correlate with increased severity of splenic or hepatic injuries. Successful union of femur fractures in older children can be obtained by surgeon preferred method of surgical management. Pediatric tibia shaft fractures should be managed conservatively in most cases; however, fractures with >20% of displacement and associated fibula fractures have a 40% risk of requiring delayed surgical stabilization. Vigilance remains the sin qua non regarding identification and appropriate management of compartment syndrome and venous thromboemobolism in children. Many Salter-Harris I distal fibula fractures are now believed to be ligamentous injury and can be treated as such. Calcaneous fractures remain uncommon in pediatrics, but minimally invasive approaches of surgical reduction and fixation may reduce complications in management.
Level Of Evidence:
Level IV.