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Remodelling in Children’s Fractures and Limits of Acceptability

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Abstract

Remodeling follows inflammatory and reparative phases of bone healing and is very pronounced in children. Unlike adults, in growing children, remodeling can restore the alignment of initially malunited fractures to a certain extent, making anatomic reduction less essential. Remodeling is not universal and ubiquitous. Animal experiments and clinical studies have proven that in a malunited fracture, the angulation corrects maximally by physeal realignment (75%) and partly by appositional remodeling of the diaphysis also known as the cortical drift (25%). Remodeling potential reduces with the increasing age of the child; lower extremities have higher remodeling potential compared to the upper extremity. Remodeling is most pronounced at the growing end of the bone and in the axis of the adjacent joint motion. Correction of a very small amount of rotational malalignment is possible, but it is clinically not relevant. Overgrowth of the bone after a fracture occurs due to hyperaemia of fracture healing. Overgrowth is the most common after paediatric femur fractures, though it is reported after fractures of the tibia and humerus as well. The orthopaedic surgeon treating children’s fractures should be familiar with regional variations of remodeling and limits of acceptance of angulation in different regions. Acceptability criteria for different bones are though well defined, but serve best as guidelines only. For the final decision-making patient’s functional capacity, parents’ willingness to wait until the completion of the remodeling process, and the experience of treating doctor should be considered concurrently. In case of the slightest doubt, a more aggressive approach should be taken to achieve a satisfactory result.

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References

  1. Alman, B. A. (2015). The immature skeleton. Rockwood and Wilkins’ Fractures in Children (8th ed., p. 27). Philadelphia: Wolters Kluwer Health.

    Google Scholar 

  2. Jones, E. T. (2003). Skeletal growth and development as related to trauma. In N. E. Green (Ed.), Skeletal Trauma in Children (3rd ed., pp. 1–18). Philadelphia: Saunders.

    Google Scholar 

  3. von Laer, L. (2004). Corrective mechanisms in the growing skeleton. Pediatric Fractures and Dislocations (1st ed., pp. 11–16). Stuttgart, New York: Thieme.

    Google Scholar 

  4. Gascó, J., de Pablos, J. (1997). Bone remodeling in malunited fractures in children. Is it reliable? Journal of Pediatric Orthopedics Part B. 6(2):126–32. Available from: http://journals.lww.com/01202412-199704000-00008.

  5. Murray, D.W., Wilson-MacDonald, J., Morscher, E., Rahn, B.A., Käslin, M. (1996). Bone growth and remodeling after fracture. The Journal of Bone and Joint Surgery. British Volume 78-B(1):42–50. Available from: http://online.boneandjoint.org.uk/doi/10.1302/0301-620X.78B1.0780042.

  6. Karaharju, E. O., Ryoppy, S. A., & Makinen, R. J. (1976). Remodeling by asymmetrical epiphysial growth. An experimental study in dogs. The Journal of Bone and Joint Surgery Series B., 58(1), 122–126.

    Article  CAS  Google Scholar 

  7. Abraham, E. (1989). Remodeling potential of long bones following angular osteotomies. Journal of Pediatric Orthopedics 9(1):37–43. Available from: http://journals.lww.com/01241398-198901000-00008

  8. Wallace, M.E., Hoffman, E.B. (1992). Remodeling of angular deformity after femoral shaft fractures in children. The Journal of Bone and Joint Surgery. British Volume. 74(5):765–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1527131

  9. Friberg, K.S.I. (1979). Remodeling after distal forearm fractures in children II: the final orientation of the distal and proximal epiphyseal plates of the radius. Acta Orthopaedica Scandinavica 50(6):731–9. Available from: http://www.tandfonline.com/doi/full/10.3109/17453677908991303

  10. Stilli, S., Magnani, M., Lampasi, M., Antonioli, D., Bettuzzi, C., Donzelli, O. (2008). Remodeling and overgrowth after conservative treatment for femoral and tibial shaft fractures in children. Chirurgia degli organi di Movimento 91(1):13–9. Available from: http://link.springer.com/10.1007/s12306-007-0003-6

  11. Malkawi, H., Shannak, A., Hadidi, S. (1986) Remodeling after femoral shaft fractures in children treated by the modified blount method. Journal of Pediatric Orthopedics 6(4):421–9. Available from: http://journals.lww.com/01241398-198607000-00006

  12. Shannak, A.O. (1988). Tibial fractures in children. Journal of Pediatric Orthopedics 8(3):306–10. Available from: http://journals.lww.com/01241398-198805000-00010

  13. Shapiro, F. (1981) Fractures of the femoral shaft in children: The Overgrowth Phenomenon. Acta Orthopaedica Scandinavica 52(6):649–55. Available from: http://www.tandfonline.com/doi/full/10.3109/17453678108992162

  14. Emmnaénus, H., Hedström, Ö. (1965). Overgrowth following fracture of humerus in children. Acta Orthopaedica Scandinavica 35(1–4):51–8. Available from: http://www.tandfonline.com/doi/full/10.3109/17453676508989338

  15. Neer, CS. (1957). Treatment of fractures of the femoral shaft in children. The Journal of the American Medical Association 163(8):634. Available from: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.1957.02970430024008

  16. Clement, D., Colton, C. (1986). Overgrowth of the femur after fracture in childhood. An increased effect in boys. The Journal of Bone and Joint Surgery. British Volume 68-B(4):534–6. Available from: http://online.boneandjoint.org.uk/doi/10.1302/0301-620X.68B4.3733825

  17. Greiff, J., Bergmann, F. (1990). Growth disturbance following fracture of the tibia in children. Acta Orthopaedica Scandinavica 51(1–6):315–20. Available from: http://www.tandfonline.com/doi/full/10.3109/17453678008990805

  18. Flynn, J.M., Hresko, T., Reynolds, R.A.K., Blasier, R.D., Davidson, R., Kasser, J. (2001). Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. Journal of Pediatric Orthopedics 21(1):4–8. Available from: http://journals.lww.com/01241398-200101000-00003

  19. Mazda, K., Khairouni, A., Pennecot, G.F., Bensahel, H. (1997). Closed flexible intramedullary nailing of the femoral shaft fractures in children. Journal of Pediatric Orthopedics B 6(3):198–202. Available from: http://journals.lww.com/01202412-199707000-00008

  20. Park, S.-S., Noh H, Kam M. Risk factors for overgrowth after flexible intramedullary nailing for fractures of the femoral shaft in children. Bone Joint J [Internet]. 2013 Feb;95-B(2):254–8. Available from: http://online.boneandjoint.org.uk/doi/https://doi.org/10.1302/0301-620X.95B2.29491

  21. Gogi N, Khan SA, Varshney MK. Limb length discrepancy following titanium elastic nailing in paediatric femoral shaft fractures. Acta Orthop Belg [Internet]. 2006 Apr;72(2):154–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16768257

  22. Davids, J.R. (1994). Rotational deformity and remodeling after fracture of the femur in children. Clinical Orthopaedics and Related Research (302):27–35. Available from: http://journals.lww.com/00003086-199405000-00006

  23. Brouwer, K.J., Molenaar, J.C., Van Linge, B. (1981). Rotational deformities after femoral shaft fractures in childhood: a retrospective study 27–32 years after the accident. Acta Orthopaedica Scandinavica 52(1):81–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7211321

  24. Buchholz, I. M., Bolhuis, H. W., Bröker, F. H. L., Gratama, J. W. C., Sakkers, R. J. B., & Bouma, W. H. (2002). Overgrowth and correction of rotational deformity in 12 femoral shaft fractures in 3-6-year-old children treated with an external fixator. Acta Orthopaedica Scandinavica, 73(2), 170–174.

    Article  Google Scholar 

  25. Wilkins, K.E. (2005). Principles of fracture remodeling in children. Injury 36(1):S3–11. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0020138304004929

  26. Dwyer, A.J., John, B., Hora, R., Mam, M.K. (2007). Remodeling of tibial fractures in children younger than 12 years. Orthopedics 30(5):393–6. Available from: https://www.healio.com/orthopedics/journals/ortho/2007-5-30-5/%7B76fffea7-c722-4518-821b-dddda68cd03f%7D/remodeling-of-tibial-fractures-in-children-younger-than-12-years

  27. Larsen, C.F., Kiær, T., Lindequist, S. (1990). Fractures of the proximal humerus in children: Nine-year follow-up of 64 unoperated on cases. Acta Orthopaedica Scandinavica 61(3):255–7. Available from: http://www.tandfonline.com/doi/full/10.3109/17453679008993512

  28. Kohler, R., Trillaud, J.M. (1983). Fracture and fracture separation of the proximal humerus in children: report of 136 cases. Journal of Pediatric Orthopedics 3(3):326–32. Available from: http://link.springer.com/10.1007/s12306-008-0050-7

  29. McBride, E.D., Sisler, J. (1965) Fractures of the proximal humeral epiphysis and the juxta-epiphysial humeral shaft. Clinical Orthopaedics and Related Research 38:143–53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/5889085

  30. O’Shaughnessy, M.A., Parry, J.A., Liu, H., Stans, A.A., Larson, A.N., Milbrandt, T.A. (2019). Management of paediatric humeral shaft fractures and associated nerve palsy. Journal of Children's Orthopaedics 13(5):508–15. Available from: https://online.boneandjoint.org.uk/doi/10.1302/1863-2548.13.190012

  31. Caviglia, H., Garrido, C.P., Palazzi, F.F., Meana, N.V. (2005). Pediatric fractures of the humerus. Clinical Orthopaedics and Related Research (432):49–56. Available from: http://journals.lww.com/00003086-200503000-00007

  32. Tan, B. H. M., & Mahadev, A. (2011). Radial neck fractures in children. J Orthop Surg (Hong Kong)., 19(2), 209–212.

    Article  Google Scholar 

  33. Vocke, A.K., von Laer, L. (1998). Displaced fractures of the radial neck in children. Journal of Pediatric Orthopedics 7(3):217–22. Available from: http://journals.lww.com/01202412-199807000-00007

  34. Steele, J.A., Graham, H.K. (1992). Angulated radial neck fractures in children. A prospective study of percutaneous reduction. The Journal of Bone and Joint Surgery. British Volume 74(5):760–4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1527130

  35. Radomisli, T.E., Rosen, A.L. (1998). Controversies regarding radial neck fractures in children. Clinical Orthopaedics and Related Research 353(353):30–9. Available from: http://journals.lww.com/00003086-199808000-00005

  36. Do, T. T., Strub, W. M., Foad, S. L., Mehlman, C. T., & Crawford, A. H. (2003). Reduction versus remodeling in pediatric distal forearm fractures: a preliminary cost analysis. Journal of Pediatric Orthopedics Part B, 12(2), 109–10915.

    PubMed  Google Scholar 

  37. Jeroense, K.T.V., America, T., Witbreuk, M.M.E.H., van der Sluijs, J.A. (2015). Malunion of distal radius fractures in children. Acta Orthopaedica 86(2):233–7. Available from: http://www.tandfonline.com/doi/full/10.3109/17453674.2014.981781

  38. Crawford, S.N., Lee, L.S.K., Izuka, B.H. (2012). Closed Treatment of overriding distal radial fractures without reduction in children. The Journal of Bone and Joint Surgery American Volume 94(3):246–52. Available from: http://journals.lww.com/00004623-201202010-00008

  39. Plánka, L., Chalupová, P., Skvaril, J., Poul, J., Gál, P. (2006). Remodeling ability of the distal radius in fracture healing in childhood. Rozhledy v Chirurgii 85(10):508–10. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17233178

  40. Akar, D., Köroğlu, C., Erkus, S., Turgut, A., Kalenderer, Ö. (2018). Conservative follow-up of severely displaced distal radial metaphyseal fractures in children. Cureus 9(9). Available from: https://www.cureus.com/articles/14423-conservative-follow-up-of-severely-displaced-distal-radial-metaphyseal-fractures-in-children

  41. Vorlat, P., De Boeck, H. (2003). Bowing fractures of the forearm in children. Clinical Orthopaedics and Related Research 413(413):233–7. Available from: http://journals.lww.com/00003086-200308000-00026

  42. Noonan, K.J., Price, C.T. (1998). Forearm and distal radius fractures in children. Journal of the American Academy of Orthopaedic Surgeons 6(3):146–56. Available from: http://journals.lww.com/00124635-199805000-00002

  43. Fuller, D., McCullough, C. (1982). Malunited fractures of the forearm in children. The Journal of Bone and Joint Surgery. British Volume 64-B(3):364–7. Available from: http://online.boneandjoint.org.uk/doi/10.1302/0301-620X.64B3.7096406

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  1. Rainbow Super-Speciality Hospital and Children’s Orthopaedic Centre, Next to Asia School, Behind HDFC Bank, Opposite Drive in Cinema, Bodakdev, Ahmedabad, Gujarat, 380 054, India

    Premal Naik

  2. Honorary Pediatric Orthopedic Surgeon, Smt S C L Hospital, NHL Municipal Medical College, Ahmedabad, Gujarat, India

    Premal Naik

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Naik, P. Remodelling in Children’s Fractures and Limits of Acceptability. JOIO 55, 549–559 (2021). https://doi.org/10.1007/s43465-020-00320-2

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