Courtesy: Ashok Shyam, IORG, OrthoTV

Remodeling in Pediatric Fractures

Basic Concept

• Remodeling is the gradual correction of fracture deformity during growth.
• Remodeling occurs through bone drift and physeal remodeling.
• Physeal remodeling is the major mechanism of correction.

Mechanism of Remodeling

Bone drift

• Resorption occurs on the convex side of the deformity.
• Bone deposition occurs on the concave side.
• Contributes only a small amount to overall remodeling.

Physeal remodeling

• Occurs through asymmetric growth at the physis.
• Governed by the Hueter Volkmann law.
• Increased pressure decreases physeal growth.
• Governed by Wolff’s law.
• Bone remodels according to mechanical stress.
• Increased growth occurs on the concave side.
• Reduced growth occurs on the convex side.
• Gradually corrects angular deformity.

Site of Remodeling

• Remodeling occurs predominantly at the physis.
• Remodeling within the shaft is limited.
• Joint alignment may correct while shaft deformity persists.

Clinical Observations

Neonates and infants

• Excellent remodeling potential.
• Even severe angulation may remodel completely.
• Shortening is generally well tolerated.
• Conservative treatment is often appropriate.

Shaft fractures in older children

• Shaft angulation remodels poorly.
• Persistent deformity may remain.
• Functional limitation such as reduced forearm rotation may occur.
• Significant shaft angulation should not be accepted.

Physeal alignment versus shaft alignment

• The physis may gradually become horizontal.
• Shaft angulation may persist despite physeal correction.
• Residual deformity may require corrective osteotomy.

Distal radius fractures

• Excellent remodeling potential.
• Remodeling is greatest when deformity is in the plane of joint motion.

Factors Favoring Remodeling

• Younger age.
• Fractures close to the physis.
• Deformity in the plane of joint movement.
• Mild angular deformity.

Factors Associated with Poor Remodeling

• Midshaft fractures.
• Rotational deformity.
• Large angular deformity in older children.

Acceptable Deformity

Deformities that remodel

• Mild angular deformity near the physis.
• Shortening of approximately 1 to 1.5 cm in younger children.

Deformities that do not remodel

• Rotational deformity.
• Significant shaft angulation.

Clinical Rules

• The physis remodels more effectively than the shaft.
• Rotational deformity does not remodel.
• Younger children have greater remodeling potential.
• Fractures closer to the joint remodel more effectively.

Common Mistakes

• Accepting significant shaft angulation.
• Ignoring rotational deformity.
• Overestimating remodeling potential in older children.
• Failing to consider long term functional impairment.