“99% of lawyers give the rest a bad name”.

Steven Alexander Wright (1955)

American stand-up comedian, actor, writer and film producer.

The Bone & Joint Journal 360 provides a treasure trove of academic content in its back catalogue, all of which is hugely synergistic with our own instructional techniques.  This month it is a pleasure to revisit some of the high points in paediatric fracture management from both publications.

Even though the management of paediatric fractures is now in the main the remit of specialists, if only for academic reasons all orthopaedic surgeons should read “The lost art of conservative management of paediatric fractures” by James Hunter and his team at Nottingham University Hospitals, UK for both its breadth and succinctness in covering the subject.  Their well-chosen opening quotation by Mercer Rang “Children are not just small adults” is very clearly expanded upon throughout the article, in particular in terms of the significant and differential ability of the paediatric skeleton to remodel fracture malunion. There is also an excellent illustrated introduction to the mechanics of wedging casts to correct deformity.

The section on supracondylar humeral fractures, is very well referenced as is the rest of the article and has a particularly useful photograph detailing a recommended traction set up for managing these difficult injuries conservatively. The authors also provide food for thought by describing the increasing trend for immediate operative deformity correction in this cohort of patients despite the considerable remodelling potential of paediatric fractures.

Another excellent article from Bone & Joint 360 is “Staying out of trouble with paediatric supracondylar fractures” by Alistair Mayne & Donald Campbell, from Ninewells Hospital, Dundee.  This detailed and comprehensively referenced article is as good a description of acute supracondylar fractures and how to manage them surgically as I have read.

The difference between the common extension pattern fractures and far rarer flexion type fracture patterns and the implications of this are clearly described as are the indications for surgical fixation and different options for K-wire placement to limit the incidence of nerve injury.  The dreaded complications of nerve and also vascular injury in these paediatric patients are also very well covered, as are papers referencing the outcomes of this aspect of the injury. There is an excellent photographically supported quick test signs for neurological injury in the child included with the article, as are the BOA recommendations for surgery on paediatric supracondylar fractures.

On the OrthOracle platform, we cover a number of paediatric orthopaedic fracture techniques.

Ed Bache’s K-wiring of a supracondylar flexion pattern fracture gives an excellent overview of these injuries and the decision making about both when to operate and when not to operate.  Ed’s surgical technique demonstrates also very clearly the reduction manoeuvres required, clearly interspaced with image intensifier pictures as well as the practical issues of operating on a small paediatric upper limb. Sam Chan’s Fixation of proximal physeal fracture using Synthes PHILOS plate demonstrates very well both the anterior approach to the proximal humerus needed for this Salter-Harris 2 fracture, as well as the intricacies of setting up and using the PHILOS plating system.  Ed Bache’s use of the Fassier-Duval telescopic nailing system for a femoral fracture in osteogenesis imperfecta  provides an excellent overview of the condition and also management of the fracture.  It is not a situation that many of us will face but it is highly informative to see exactly how these injuries are managed with modern surgical implants.