Prof. Mamoun KremliAlMaarefa Medical College

Common Pediatric Fractures

Objectives

• How are children’s fractures different

• Discus common fractures in children• X-ray diagnosis

• Principles of management

• Identify Epiphyseal injuries

• Precautions

Statistics

• ~ 42% of boys and 25% of girls, are expected to have a fracture during childhood (Landin 83)

• Percentage of children sustaining a fracture in 1 year: 1.6% to 2.1% (Warlock &Stower 86)

Mamoun Kremli

Statistics

• ~ 42% of boys and 25% of girls, are expected to have a fracture during childhood (Landin 83)

• Incidence increases with age – peak ~ 12-14 yrs

Mizulta, 1987

Introduction

• In Middle East ~50% of population < 20 yrs

• Different from adult fractures

• Varies in various age groups

Statistics

Most frequent sites

74%

, Mizulta, 1987, (923 children)

47%

Fractures specific to children

• Greenstick

• Torus (buckle)

• Deformation

• Physeal injuries

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Mamoun Kremli

Different from adults

• Ends of long bones have thick cartilage:• Not seen on x-rays

• Thick periosteum, good blood supply:• Heal well and quickly

• More elastic, more cancellous:• Incomplete fractures, simple fractures

• Growth plate:• Good remodeling

• Special growth plate injuries

The power of remodeling

• Can accept more angulation and displacement

• Rotational mal-alignment ?does not remodel

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The power of remodeling

• Can accept more angulation and displacement

• Better remodeling near growth plates

The power of remodeling

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The power of remodeling

Treatment

Most fractures in children heal well

Whatever you do!

Choice of treatment

• Stable fractures - incomplete:• Greenstick

• Buckle (Torus)

• Plastic deformation

• Stable fractures – complete:• Undisplaced

• Displaced, reducible

• Unstable fractures:• Bothe bones at same level

• Oblique fractures

• Comminuted fractures

• Preference (patients’ / surgeons’, choice)

Conserv

ative

Operativ

e

Closed reduction

• More commonly used in children

Closed reduction - Casting

• Still the commonest

• Good remodeling power

• Needs careful monitoring• Regular follow-ups

• Swelling subsides:

• cast loose

• displaces

Casting - Problems

• Forearm is a joint – needs anatomic reduction• Mal-union results in loss of supination/pronation

Casting - Problems

• Mal-alignment in LL causes osteoarthritis

Gicquel

Casting - Problems

• Overlap – shortening

• Loss of reduction

Casting - Problems

6 yr old - 5wks 9 yr old

K Willkins, Injury Suppl 36

Surgical treatment

• K-wires

• Intramedullary nails

• Plates

• External Fixator

K-Wires

• The commonest in children

• Very effective• Prevents displacement

• Needs additional casting

• Application:• Percataneous

• Open

Elastic IM Nails

• Unstable fractures – minimal surgery

P. Schmittenbecher

Plating

• For overweight children

• Problems:• Large scars

• Needs removal

Plating

• Bridge plating

• MIPO:• Introduced through small wounds

External fixator

• Open (compound) fractures

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Common injuries

• Clavicle

• Radius

• Forearm fracture – fracture dislocation

• Supracondylar Humerus

• Epiphyseal injuries

• Non-accidental injuries

• Precaution

Clavicle fracture

• Common• Birth injury

• Pseudo-paralysis

• Fall on outstretched hand

• Heals well conservatively

• No functional problems

• Treatment:• Sling or figure of 8 bandage

http://parkingspot.wordpress.com/

Supracondylar fracture

Supracondylar humerus

• A common injury

• Fall on the outstretched hand, elbow hyperextended

• Anatomically thin part of lower humerus

• Nerve or vessel injury possible

Supracondylar humerus

• Fall on outstretched hand - Hyper-extension of elbow (the commonest type)

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Anterior

Supracondylar humerus

• Fall on outstretched hand - Hyper-extension of elbow (the commonest type)

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Anterior

Supracondylar humerus

• Fall on outstretched hand - Hyper-extension of elbow (the commonest type)

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Anterior

Supracondylar humerus

• Fall on outstretched hand - Hyper-extension of elbow (the commonest type)

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Anterior

Supracondylar humerus

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• Fat pad sign

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Fat pad sign

• Fat pad sign:• Indicates a fracture

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X-ray lines in elbow

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• Anterior humeral line• A line drawn on a lateral view along the anterior

surface of the humerus should pass through the middle third of the capitellum

Normal Abnormal

Supracondylar fracture

• Classification (Gartland’s)

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Undisplaced Posterior intact Completely displaced

Supracondylar humerus

• Needs immediate care• Nerve injury: Median N, Radial N

• Vascular injury: Brachial artery (tenting)

• Swelling: compartment syndrome

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Supracondylar humerus

• Needs immediate care• Delay causes more swelling

• More difficulties in reduction

• More vascular compromise

• Undisplaced: Casting

• Displaced:• Closed reduction and fixation with K-wires

• ? Open reduction and fixation with K-wires

6y girl, fell from swing

Injury reduction 3 m 2 yrs

Teddy Slomgo, Bern, Switzerland

Supracondylar humerus

• Closed reduction and percutaneous K-wires

Teddy Slomgo, Bern, Switzerland

Supracondylar humerus

• Neurovascular injury must be ruled out

• Swelling and possible kinking of vessels

• May cause Volkmann's ischemia• A real emergency

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Supracondylar fractures

• Most are displaced and need surgery

• Type I can be managed with long arm cast, forearm neutral, elbow 90o for 4 wks

• Bivalve cast if acute

• Follow-up xrays 3-7 days later to document alignment

• Xrays at 4 weeks to document callus

• Once callus noted at 4 weeks, discontinue cast and start active ROM

Supracondylar fractures

• Delayed complication

• Malunion• Often cubitus varus

deformity

Lateral condyle - humerus

• Mostly cartilaginous• Fracture may be easily

missed

• Displacement may not be appreciated

• Needs fixation even if undisplaced

• If not fixed, may displace

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Forearm – Radius and Ulna

• A joint: supination and pronation• Anatomical reduction is a must

• Treatment:• Closed reduction and casting

• Closed reduction and intramedullary nail

Closed reduction and casting

• Good method if reduction maintained

• Needs close, regular follow-up

http://eorif.com/

Intramedullary nail

• When unstable, or re-displace in cast

Teddy Slongo, Bern, Switzerland

Plating

Kelly D. Carmichae, Orthop 2007

Lower Radius

• Torus (Buckle)• Treatment:

• Casting

• Complete:• Treatment:

• Conservative

• ? K-wire if unstable

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Parikh, Orthopedics, June 2013

Fracture Dislocation

• Montaggia• Fracture ulna, dislocation of head of radius

• Galiazzi• Fracture radius, dislocation of distal radio-ulnar joint

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Monteggia

• Fracture of shaft of ulna, dislocated radial head

• May be missed if two joints not seen on x-ray

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Monteggia

• Fracture of shaft of ulna, dislocated radial head

• May be missed if two joints not seen on x-ray

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X-ray lines in elbow

• Radio-capitellar line• A line drawn through the center of the radial neck

should pass through the center of the capitellum in all views

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X-ray lines in elbow

• Radio-capitellar line• A line drawn through the center of the radial neck

should pass through the center of the capitellum in all views

• If not: dislocated radial head

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Monteggia fracture

• Treatment:• Reduce ulna

• Reduce head of radius

Galeazzi fracture

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• Fractured radius, with

• Dislocation of distal

radio-ulnar joint

• Treatment:• Reduction of radius

• Reduction of DRUJ

Femur

• Problems:• Bleeding

• May bleed more than 1 L

• Conservative treatment:

• Shortening, mal-union

• Operative treatment:

• Another surgery to remove implants

Femur

• Conservative: e.g. 5 year old• Hip spica cast

• 1-2 cm shortening will be compensated by growth

AAOS guidelines, E. Sinkhttp://orthoinfo.aaos.org/

Femur

• Operative: in older children• Good alignment and length

• Nailing better than plating

AAOS. J. BeatyAOFoundation.org

Tibia

• Direct Vs. indirect injury

• Soft tissue injuries

• Compartment syndrome

• Need to correct• Alignment, rotation, and length

Closed reduction - ESIN

• Closed reduction and casting

• Closed reduction and nailing

• Open reduction and plating - less

Physeal injuries

• Incidence:• About 15-20 % of all skeletal injuries in children

• 50% occur in the distal radius

• Problem:• Possibility of growth affection

• Some are intra-articular

Physeal anatomy• Physis: 4 zones

• Germinal zone

• Proliferative zone

• Hypertrophic zone

• Enchondral ossification

Metaphysis

Epiphysis

Weakest zone - fractures

Physeal injuries

More common in• Boys• Peak ~ 12y of age• Upper limb

Classification – Salter- Harris

I II III

VIV

75%

Most common

Treatment – Salter Harris I

• Closed reduction

• Fixation if unstable only

Treatment – Salter Harris I

• Closed reduction

• Fixation if unstable only

Treatment – Salter Harris II

• Need good stable reduction

• Possibly closed reduction, percutaneous fixation

Treatment – Salter Harris III

• Intra-articular

• Anatomic reduction, stable fixation

Treatment: Salter Harris IV

• Intra-articular

• Anatomic reduction and stable fixation

Treatment – Salter Harris V

• No treatment available !

• Diagnosed in retrospect !

Complete Physeal affection

• Usually seen in Salter-Harris type V

Injury films Injured and uninjured wrists after premature physeal closure

Asymmetrical physeal affection• Standard radiography

remains the initial imaging evaluation of choice

• Oblique Park-Harris growth recovery line

Asymmetrical physeal affection

• 12Y, male, Salter-Harris II3y post injury

Beware!

• Non-accidental injuries

• Tumors

Beware!

Non-accidental injuries

• Specific pattern• Femur shaft fracture

• <1 year of age• ( 60-70% non accidental)

• Transverse fracture

Beware!

Non-accidental injuries

• Specific pattern• Femur shaft fracture

• <1 year of age• ( 60-70% non accidental)

• Transverse fracture

• Humeral shaft fracture

• <3 years of age

• Sternal fractures

Beware!

Non-accidental injuries

• Specific pattern• Corner fractures (traction & rotation)

Beware!

Non-accidental injuries

• Specific pattern• Bucket handle fractures (traction & rotation)

Physical Examination

• Undress the child

• Look for areas of bruising • Bruises at different stages of healing

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Physical Examination

• Undress the child

• Look for areas of bruising • Bruises at different stages of healing

• Bruises take shape of inflicting instrument

Physical Examination

• Undress the child

• Look for areas of bruising • Bruises at different stages of healing

• Bruises take shape of inflicting instrument

Physical Examination

• Undress the child

• Look for areas of bruising • Bruises at different stages of healing

• Bruises take shape of inflicting instrument

Physical Examination

• Trunk• Back, palpate rib cage, abdomen

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Physical Examination

• Head - examine for skull trauma, palpate fontanel's if open, consider funduscopic exam for retinal hemorrhage

Physical Examination

• A silent child tells the story!

Physical Examination

• A silent child tells the story!

www.kidspot.com.au

Consider non-accidental if

1. Delay in seeking medical attention

2. Mechanism incompatible with injury

3. Physical location of injury

4. Vague history, lacking the "real truth"

5. Varying history• e.g. one parent contradicting the other

6. Inappropriate parental attitude or behavior• e.g. lack of concern, over-concern, aggression

Consider non-accidental if

7. Inappropriate parent-child interaction

8. Features of failure to thrive or neglect

9. Allegation of assault

10.Signs of prior injury or injuries of different age

11.Characteristic injuries, illnesses or hospital visits

12.Femoral shaft fracture < 2 years

13.Radiological features

Beware!Malignant tumors

• Can present as injury

• History of trauma usual

•12 y old girl• History of trauma• Mild tenderness• Periosteal reaction•Diagnosed as injury

• 2m later, still tender• Ewings sarcoma

Summary

• About 50% of population in ME are children

• Fractures in children are common

• Compare with other side

• Closed reduction still good

• Surgery might be needed

Summary

• Supracondylar humerus needs urgent attention

• Forearm• a joint – needs good alignment

• Look for fracture dislocation in forearm

• In lower limb:• maintain alignment, rotation, and length

• Epiphyseal injuries

• Beware: Non-accidental & Tumors