Fixation of fractures or osteotomies in children take many forms. The options of fixation in children are many. Take into consideration the child’s age, location, inherent stability, and the likely time for healing. Internal fixation is usually necessary for bony procedures. When fixation is supplemented with a cast, the internal fixation need not be rigid. Often minimal fixation supplemented with a cast is adequate for children.
Plates have a limited role in fixation in children. Plates have inherent disadvantages. They require broad exposure, produce stress risers through end screws, and their removal is a major procedure. Plate fixation is useful for such procedures as the repair of congenital pseudarthrosis of the clavicle.
Intramedullary (IM) fixation has many advantages in children. Flexible, small diameter, IM fixation is adequate for children, making reaming and large nails unnecessary. Adequate fixation is provided by pins, Rush rods, or special-purpose devices. Because of their length and shape, IM rods seldom migrate long distances. Make certain the fixation extends well above or below the site to be fixed. Pins may traverse the growth plate. For tumors, plan to leave fixation until the lesion is healed. For conditions that permanently weaken bone, fixation is best left in place indefinitely. When pins remain for long periods, make certain the ends are deep enough to avoid skin irritation.
External fixators of a variety of types are suitable for children. Pins fixing bone may be stabilized externally with casts, frames, or special devices. They are used for stabilizing fractures and osteotomies, and for correcting deformities involving both bone and soft tissues. External fixators provide exceptional versatility, allowing changes in alignment, apposition, and length. The disadvantages include the risk of pin tract infections, multiple scars, and the prolonged need for close medical attention.
Pins can be for the orthopedist what nails are for the carpenter. Pins may be placed with varied configurations. Pins are versatile, inexpensive, and rapidly applied and removed. Osteotomies fixed with crossed pins require small skin incisions. Generally, smooth pins are most useful; they may traverse growth plates and are left outside the skin for removal in the clinic. Threaded pins may be cut off just beyond the cortex, may not require removal, and should not be placed across the physis. Pins provide adequate fixation for bony procedures in nearly all infants, most children, and some adolescents. The absence of commercial promotion leaves the usefulness of pins often unappreciated.
Tissue grafting involves autogenous and banked bone, fat, fascia, and cartilage. Autologous organ transplants include bone, physeal plates, muscle, blood vessels, and nerves. Organ transfers require microsurgical techniques.
Bone Autografts are widely used, safe, rapidly incorporated, osteogenic, and readily available.
Local grafts Harvest bone from the site of the primary procedure when possible. Calcaneal bone for subtalar fusions, bone iliac bone for acetabular shelf procedure, cranial bone for upper C spine fusions, etc.
Iliac grafts Small amounts of bone can be removed percutaneously using a curette. Bicortical grafts in children are rapidly filled in.
Vascularized grafts Complexity and donor site problems limit the usefulness of vascularized grafts of bone joints or growth plates.
Soft tissue Free fat grafts are commonly used to replace defects in bone following physeal bridge resections.
Organ grafts Composite grafts are used to cover traumatic defects, for toe to finger transfers, etc.
Bone Cadaver bone is convenient, carries a small risk of AIDS transmission, and incorporates more slowly than autogenous grafts. Such grafts are useful in procedures such as calcaneal lengthenings and bone replacement following resection of malignant tumors.
Osteochondral grafts are used for replacing joints for management of malignant tumors or trauma. The survival of cartilage is poor. Bone typing may improve results.