Paediatric fracture

$: Paediatric fracture$
Prof. Muhammad Prof. Muhammad ShahiduzzamanShahiduzzaman

Head, Head, Department of Department of Orthopaedics & TraumatologyOrthopaedics & Traumatology

Dhaka Medical College HospitalDhaka Medical College Hospital

Paediatric FracturePaediatric Fracture

In Bangladesh 60% of population are <20 yrs

Fractures accounts for 15% of all injuries in children.

Different from adult fractures.

Vary in different age groups (Infants, children, adolescents)

IntroductionIntroduction

Children have different physiology and anatomy

Growth plate. Bone. Cartilage. Periosteum. Ligaments. Age-related physiology

Children are very specialChildren are very special

In infants, GP is stronger than bone.

increased diaphyseal fractures

Provides perfect remodeling power.

Injury of growth plate causes deformity.

A fracture might lead to overgrowth.

Growth PlateGrowth Plate

• Increased collagen: bone ratiolowers modulus of elasticity

Increased cancellous bonereduces tensile strengthreduces tendency of fracture

to propagateless comminuted fractures

Bone fails on both tension and compressioncommonly seen “buckle” fracture

BoneBone

• Increased ratio of cartilage to bone• better resilience• difficult x-ray evaluation• size of articular fragment often under-estimated

CartilageCartilage

• Metabolically active• more callus, rapid

union, increased remodeling

• Thickness and strength• Intact periosteal

hinge affects fracture pattern

• May aid reduction

PeriosteumPeriosteum

Age related # patternAge related # pattern

Better blood supply,

so less incidence of Delayed or non-union.

PhysiologyPhysiology

• Bones tend to BOW rather than BREAK• Compressive force= TORUS fracture

• Aka. Buckle fracture

• Force to side of bone may cause break in only one cortex= GREENSTICK fracture• The other cortex only BENDS

• In very young children, neither cortex may break= PLASTIC DEFORMATION

Injury PatternInjury Pattern

Green Stick FractureGreen Stick Fracture

TorusGreenstick

Green Stick FractureGreen Stick Fracture

Plastic Deformity


Point at which metaphysis connects to physis is an anatomic point of weakness

Ligaments and tendons are stronger than bone when young Bone is more likely to be injured with force.

Periosteum is biologically active in children and often stays intact with injury• This stabilizes fracture and promotes

healing.


Many childhood fractures involve the physisMany childhood fractures involve the physis 20% of all skeletal injuries in children20% of all skeletal injuries in children Can disrupt growth of boneCan disrupt growth of bone Injury near but not at the physis can stimulate Injury near but not at the physis can stimulate

bone to grow bone to grow moremore

Physeal InjuryPhyseal Injury

SALTER HARRIS SALTER HARRIS CLASSIFICATIONCLASSIFICATION Classification system to

delineate risk of growth disturbance

Higher grade fractures are more likely to cause growth disturbance

Growth disturbance can happen with ANY physeal injury

It has grade I upto grade V.

Physeal InjuryPhyseal Injury

Fracture passes transversely through physis separating epiphysis from metaphysis.

Salter Harris Grade ISalter Harris Grade I

Transversely through physis but exits through metaphysis

Triangular fragment

Salter Harris Grade IISalter Harris Grade II

• Crosses physis and exits through epiphysis at joint space.

Salter Harris Grade IIISalter Harris Grade III

• Extends upwards from the joint line, through the physis and out the metaphysis.

Salter Harris Grade IVSalter Harris Grade IV

Crash Injury to growth plate

Salter Harris Grade VSalter Harris Grade V

MOST COMMONMOST COMMON: Salter Harris : Salter Harris II Followed by I, III, IV, VFollowed by I, III, IV, V Refer to orthopedics: III, IV, VRefer to orthopedics: III, IV, V I and II effectively managed by primary care I and II effectively managed by primary care

with casting (most commonly)with casting (most commonly)

Parents should be informed that growth Parents should be informed that growth disturbance can happen with any physeal fracturedisturbance can happen with any physeal fracture

Salter Harris Salter Harris

Power of remodelingPower of remodeling

Tremendous power of remodelingTremendous power of remodeling Can accept more angulation and displacementCan accept more angulation and displacement Rotational mal-alignment ?does not remodelRotational mal-alignment ?does not remodel

Malunion-Remodeling Process

Factors affecting remodeling potentialFactors affecting remodeling potential

•Years of remaining growth – most important factor•Position in the bone – the nearer to physis the better•Plane of motion –greatest in sagittal, the frontal, and least for transverse plane•Physeal status – if damaged, less potential for correction•Growth potential of adjacent physis

•e.g. upper humerus better than lower humerus

Power of remodelingPower of remodeling

Children tend to heal fractures faster than Children tend to heal fractures faster than adults requiring shorter immobilization adults requiring shorter immobilization time.time.

Anticipate remodeling if child has >2 yrs of Anticipate remodeling if child has >2 yrs of growing left – mild angulation deformities growing left – mild angulation deformities often correct themselves but rotational often correct themselves but rotational deformities requires reduction.deformities requires reduction.

Its good to be young!!!Its good to be young!!!

Fractures in children may stimulate Fractures in children may stimulate longitudinal growth – some degree of longitudinal growth – some degree of overlap is acceptable and may even be overlap is acceptable and may even be helpful.helpful.

Children don’t tend to get as stiff as adults Children don’t tend to get as stiff as adults after immobilization.after immobilization.

Its good to be young…Its good to be young…

Law of Two’sLaw of Two’s : : Two viewsTwo views Two jointsTwo joints Two limbsTwo limbs Two occasionsTwo occasions Two physiciansTwo physicians

Xray examinationXray examination

Radio-capitaller line

Evaluation of paediatric elbow filmEvaluation of paediatric elbow film

Supracondylar Fracture of Humerus

Evaluation of paediatric elbow filmEvaluation of paediatric elbow film

Mostly conservative – closed reduction and Mostly conservative – closed reduction and cast immobilizationcast immobilization

Open reduction & internal fixation.Open reduction & internal fixation.

Principle of ManagementPrinciple of Management

Displaced intra articular fracturesDisplaced intra articular fractures

( ( Salter-Harris III-IV Salter-Harris III-IV )) fractures with fractures with vascularvascular injury injury ? ? Compartment Compartment syndromesyndrome Fractures not reduced by closed reductionFractures not reduced by closed reduction

( soft tissue interposition, button-holing of ( soft tissue interposition, button-holing of periosteum )periosteum )

If reduction can not be maintained or could If reduction can not be maintained or could be only maintained in an be only maintained in an abnormal positionabnormal position

Indication for operative managementIndication for operative management

Indication for operative managementIndication for operative management

Casting—the commonest.Casting—the commonest.

Method of fixationMethod of fixation

K-wires K-wires most commonly most commonly

usedused Metaphyseal Metaphyseal

fracturesfractures


Intramedullary wires, elastic nailsVery useful, Diaphyseal fractures


ScrewsScrews


Plates and screwsPlates and screws Multiple Trauma


IMN Nailing (adolescent only)IMN Nailing (adolescent only) Chances of growth disturbences.


External FixationExternal Fixation

In open Fractures


Casting - still the commonestCasting - still the commonest K-wires K-wires

most commonly usedmost commonly used Metaphyseal fracturesMetaphyseal fractures

Intramedullary wires, elastic nailsIntramedullary wires, elastic nails Very usefulVery useful Diaphyseal fracturesDiaphyseal fractures

ScrewsScrews Plates – multiple traumaPlates – multiple trauma IMN - adolescentsIMN - adolescents Ex-fixEx-fix

Combination


Malunion is not usually a problem Malunion is not usually a problem (except cubitus varus)(except cubitus varus)

Nonunion is hardly seen (except in Nonunion is hardly seen (except in lateral condyle of humerus)lateral condyle of humerus)

Growth disturbance – epiphyseal damageGrowth disturbance – epiphyseal damage Vascular - volkmann’s ischemiaVascular - volkmann’s ischemia Infection - rareInfection - rare

ComplicationComplication

Battered Baby Syndrome:Battered Baby Syndrome:• Soft tissue injuries - Soft tissue injuries -

bruising, burnsbruising, burns• Intra-abdominal injuriesIntra-abdominal injuries• Intracranial injuriesIntracranial injuries• Delay in seeking treatmentDelay in seeking treatment• # at diff. stage of healing.# at diff. stage of healing.

Non-accidental injuryNon-accidental injury

Radiology of child abuse

Corner’s fracture (traction and rotation)

Bucket handle fracture (traction and rotation)

Pathological fracturePathological fracture

Paediatric fracture

Health & Medicine

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