Fractures in Children

Humaryanto

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General Principles

• Immature skeleton differs from that of the adult in both the normal and pathological states.

• Capable of plastic deformation before they fail.

• Comminuted fractures are rare.

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General Principles

• Failure of union is rare.

• Few fractures require operative treatment.

• Presence of growth plate presents a challenge to the surgeon.

• Special considerations :

– Pathological fractures

– Child abuse

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Musculoskeletal Differences in Children

• Epiphyseal growth plate present

• Bones are growing / heal faster

• Bones are more pliable

• Periosteum thicker and more active

• Abundant blood supply to the bone

• The younger the child the faster the healing.

General Principles

Development and Growth

• A fracture in an immature bone can cause growth to speed up or slow down.

• Fractures heal very rapidly.

• Depending on the age of the child and direction of the deformity, can remodel with correction of most angular malunion.

• Most important area of injury is “physis”.

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INJURY PATTERN IN GROWING BONES

• 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

General Principles

• Skeletal trauma accounts for 10-15 % of all childhood injuries

• Physeal disruptions make about 15 % of all skeletal injuries in children

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Overall Frequency of Fractures

• Percentage of children sustaining at least one fracture from 0 to16 years of age : – Boys 42 %

– Girls 27 %

• Percentage of children sustaining a fracture in one year : 1.6 – 2.1 %

• Percentage of children who are hospitalized because of a fracture : – During entire childhood (0 to 16 y) 6.8 %

– Each year 0.43 %

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General Principles

Incidence of Fracture Type

• In one study 30 % involved the physis.

• Of all physeal injuries, 50% occur in the distal radius.

• Second most commonly injured area is the distal humerus.

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General Principles

Incidence of Fracture Type

• High energy trauma is the most common cause of death in children.

• Musculo-skeletal injuries are second to the CNS as the most frequent traumatic cause of permanent pediatric disability.

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General Principles

Clinical Examination of the Injured Child

• Examination of the spine:

– 3% of all pediatric injuries.

– Incidence of spinal fractures is about 12% in postmortem examination of children who died from high energy trauma.

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General Principles

Clinical Examination of the Injured Child

• Examination of the spine:

– Upper cervical spine is the most commonly injured area.

– Pain, torticollis, limitation of movement and muscle spasm raise the suspicion.

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General Principles

Clinical Examination of the Injured Child

• Examination of the pelvis:

– Most paediatric pelvic fractures are stable.

– Acetabular fractures represent 6% of pelvic fractures.

– Injury to triradiate cartilage can lead to growth arrest and dysplasia.

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General Principles

Clinical Examination of the Injured Child

• Examination of the extremities:

– Examined systematically one by one from distal to proximal.

– Neurovascular examination.

– Limb should be splinted before x-ray, if child complains of pain.

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General Principles

Examination of the Injured Child

• X-ray examination and other imaging:

– AP and lateral.

– Comparison x-rays of the uninjured side help to evaluate growth plate injuries.

– CT for spine, pelvis and some intra-articular fractures.

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General Principles

Xray Examination of the Injured Child

• Law of Two-s :

– Two views

– Two joints

– Two limbs

– Two occasions

– Two physicians

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General Principles

Xray Examination of the Injured Child

Law of Two-s

Fractures in Children 18

General Principles

Xray Examination of the Injured Child

Law of Two-s

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General Principles

Xray Examination of the Injured Child

Law of Two-s

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Fracture Patterns

Weakest layer is the physis (growth plate)

Hypertrophic cell zone

Susceptible to shearing/bending yields fracture

Peds; 2 types of Fracture (Fx); Open Physis vs closed Physis

Definitions

• Physis; ephyiseal cartilage

• Epiphysis; part of long bone (not shaft) a center of ossification, separated from shaft by layer of cartilage

• Metaphysis; a conical section of bone b/t the Epiphysis & diaphysis of Long Bones

• Diaphysis; “THE SHAFT”

Periarticular and Articular Fractures

( Epiphyseal Injuries )

Periarticular and Articular Fractures

General Principles and Classification

• Inevitably involve the growth plate.

• Treatment and prognosis depends upon the pattern of injury.

• Frequently used classification is Salter-Harris.

• Muller proposed classification based upon three subdivisions.

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Salter Harris Classificaion • Type I: epiphysis seperates

from Metaphysis thru the Growth Plate only

• Type II: Thru Physis & Metaphysis

• Type III: Thru Physis & Epiphysis

• Type IV: Thru Epiphysis, Physis & Metaphysis

• Type V: Crushing of Condrocytes; Physis Crushed

Epiphyseal Injuries

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Epiphyseal Injuries

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Epiphyseal Injuries

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Epiphyseal Injuries

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Epiphyseal Injuries

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Epiphyseal Injuries

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Salter-Harris Classification

If injury involves growth plate in an immature bone, growth disturbance may follow.

• Classification system describes the injury and the potential for growth disturbance.

Tx of Salter Harris Fx’s

Type I:

• Pt tenderness over physis after injury; joint swelling & joint effusion possibly seen on Xray

• Periosteal attachments intact

• Low risk of growth disruption

• Splint, cold compress & elevation

Type II: closed reduction of any displacement

• Immobilization, Ice, elevation

• Ortho follow up

• Don’t forget the pain meds…

Salter Harris fx tx

• Type III:

Open Reduction definative Ortho Tx

Type IV: ORIF

Type V: Casting, Ortho monitoring, anticipation of Bone growth arrest

Torus Fractures…

• Buldging or buckling of periosteum “AKA Bluckle Fx”

• No visible deformity 2 shape of extermity, soft tissue swelling and tenderness.

• Reduction rarely necessary, splint, ortho follow up

Torus Fracture

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Greenstick fx’s

• Cortical disruption & periosteal tearing on the convex side of the bone and intact periosteum on the concave side of the Fx

• More stable & less Pain than complete Fx

• Need for reduction is determined by the angulation of Fx, age of child, anatomic location of injury

Clavical Fx

2 distinct times; newborn childbirth & childhood

Fx newborn usually birth

Injury, may have upper extemity bracheal plexus injury (palsy) or paralysis 2º pain

DO NOT need specific Tx, pain

control and careful handling of infant

Clavical Fx

• Childhood Fx possibly abuse

• Middle 1/3 most common

• Tx Arm Sling

• Lateral or medial end may require ORIF b/c ligamentous attachments

Humoral Fx • May occur at Proximal humorus, humoral dyaphsysis and supracondylar fx

• Fx Proximal Humorus good healing…May occur at physis or proximal

humoral metaphysis • Physeal Fx; more common in adolescence; relatively weak during growth

spurt

• Proximal Humoral Metaphyseal Fx are more common in Pre-adolesence

• Tx depends on age of child & degree of displacement • >30º displacement often need closed reduction & immobilization

Fx Humoral Diaphysis (Uncommon)

• Suspect Abuse, strong Force Required!!!

• Closed reduction maybe required

• Radial Nerve Injury assoc

• Document Radial Nerve Function!!!

Supracondylar Fx • Most common Fx child < 8 peak 5-7y/o’sCause; fall

on out stretched Hand

• Classification based on Fracture fragment displacement

• Type I: minimal to no displacement stable

• Type II: displaced w/ variable displacement but Posterior cortex intact Ortho consult

• Type III: Need Ortho consult – IIIa: Post med rotated; radial nerve risk damage

– IIIb: Post Lat rotated; bracheal art & med nerve risk

Supracondylar Fracture of Humerus

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Supracondylar Fracture of Humerus

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Supracondylar Fracture of Humerus Closed Reduction

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Supracondylar Fracture of Humerus Complications

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Lateral Condylar Fx

• Usually Salter Harris IV; 10% of elbow Fx in children

• Varous stress with forearm in supination (arm up & flat)

• Complications; nonunion, malunion, osteonecrosis, cubitus valgus, pardy ulnar nerve palsy

• STAT Ortho CONSULT

Fracture of Lateral Humeral Condyle

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Fracture of Lateral Humeral Condyle

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Fracture of Lateral Humeral Condyle

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Medial Epicondylar Fx

• 10-14y/o’s

• Not TRUE SH fx

• Simple Fx of Medial Epicondyle are Extra-articular limited soft Tissue involvement

• ½ assoc w/ elbow dislocation

• Ortho Consult

Fracture of Medial Humeral Condyle

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Distal Humoral Physeal Fx

• Twisting MOA, shears off distal epiphysis

• Often Abuse

• Often < 2yrs age

Olecranon Fx

• Gen result from fall to elbow

• If displaced < 5 mm may be immobilized

• > 5 mm displacement Ortho Consult

• Maybe part of Monteggia lesion, careful eval of Radial head

Radial head Fractures

• Uncommon in children

• Radial neck > Radial Head

• Most common MOA; Fall

• Ortho consult obtained to guide Tx

Elbow Dislocation • Most freq males, fall outstretched

Hand • Most common POSTERIOR

dislocation • Neuro Injury ~10%; ulnar

neuropathy most common • Assoc w/ Medial Epicondyle

entrapment • Arterial Injury rare • Obtain Post reduction film • Good long term prognosis

Nurse Maid’s Elbow • Peak 2-3 yo Girls> boys L> Right

• MOA; sudden longitudinal traction on outstreatched arm

• Annular ligament of Radius displaces into Radio-capitellar articulation (baby will not move arm)

• Adducted semiflexed in Prone position (think Jerry’s kids)

• No significant pt tenderness to palpation

• Attempts to pronation/supination PAIN

Pulled Elbow

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Reduction Nursemaid’s Elbow

• Supination technique: hold elbow 90º firmly supinate the wrist, then flex elbow (firmly)

• Hyperpronation Technique: hold elbow 90º & firmly pronate wrist

• Full arm function should return w/in 30 minutes…if not consider Alternative to diagnosis (ie fracture)

Forearm Injury’s

• Isolated injury to ulna is extremely rare… typically same force causes fracture/dislocation to Radius

• Combination of Ulnar Fx + Dislocation Radial Head = Monteggia Fx; immediate eval by Ortho

• Galeazzi Fx; radial shaft fx, w/ assoc dislocation of distal radioulnar joint; immediate ORTHO eval

Forearm Fractures

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Closed Reduction of Forearm Fractures

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Closed Reduction of Forearm Fractures

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Forearm Fractures

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Monteggia

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Monteggia

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Galleazzi

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Wrist Injuries

• Fx of Carpal bones quite rare in children

• Scaphoid fx in older kids MOA; Fall outstretched Hand w/ snuffbox TTP, suspected fx even w/o radiographic finding; thumbspika splint and Ortho f/u

Phalangeal Fx

• Most common injury to distal phalanx is child catches his or her hand in a door

• Any distal Tuft fx be immobilized

• If nail bed injury “Open” Antibiotics indicated

• Significantly rotated or displaced fx need reduced & Ortho Consult

And No Hitting BELOW THE BELT

• Pelvic Fx; Infrequent in Peds… due to cartilage

Require tremendous Force, except Avulsion injury due to sudden muscle contractions (ie kicking soccer ball), mngt conservatively… Ortho Referral

NON-avulsion; Most common MOA; MVC

Hip Injury

• Proximal Femur Fx; rare… Involving head or Neck of Femur risk of Avascular Necrosis & Growth Arrest (unlike Trochanteric & Subtrochanteric Fx)

• Hip Dislocations; Most (in adolescence) POSTERIOR & Trama… < 10yrs can occur w/ minimal trauma. IF Reduction in > 6 hrs, 20X risk of Avascular Necrosis of Femoral Head

Post Hip dislocation

Lower Extemity

• Femoral Shaft Fx; Significant Force Boys> Girls

Falls, MVC, Ped vs Automobile, ABUSE if KID NOT WALKING YET!!! Immediate ORTHO CONSULT

Knee Injuries

• Ligamentous Injury < common than Fx

• OTTAWA Knee rules validated for ≥ 2y/o

need xray; > 55y/o, TTP Fibular Head, Isolated TTP Patella, Inability flex knee to 90º, inability to take 4 steps immediately after injury & in ED

Fx thru Distal Femoral Physis; uncommon, signif complications… popliteal artery lies close to Dist Metaphysis, peroneal Nerve may be injured… risk Growth Arrest 2º physeal damage

Knee Injury • Patellar dislocation; most common cause of traumatic

Hemarthrosis in children… MOA pivot knee of fixed LE

May reduce w/o waiting for XRAY. XRAY post REDUCTION

Proximal Tibial Injury; ACL inserts on tibial emminance… ligament & insertion much stronger than epiphyseal bone in kids…

Tibial Tuberosity Fx; 3 types;

Tpye I; Fx thru small distal portion tibial tuberosity; Tx; immobilization

Type II Fx; Fx splits the growth plate of the tuberosity of the proximal tibia

Type III; Involve joint; risk compartment syndrome

Displaced Type II & III need reduction & immediate Ortho Consult

Knee Injury

• Proximal tibial Physis Fx; uncommon, most SH Type I. Vascular injury to Popliteal Artery risk

DOCUMENT INTACT PULSES!!!

Tib Fib Fx

• Toddler’s Fx; spiral Fx Distal 1/3 of tibia…

child limping, unable to bear wt pain w/ palpation & rotation distal tibia… Xray maybe normal, F/U Bonescan or xray 1 week Immobilize long leg splint w/ Ortho F/U

Toddler’s Fracture

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Ankle Injuries

• May involve distal tibula, fibula or both. Most SH type I, SH type III 25% of distal tibial fx & require ORIF

• Tillaux Fx; SH III of Anterior LAT portion of Distal tibia surgical reduction

• Triplane fx; Sagittal, Coronal & Transverse planes… SH IV Multiple Fx Fragments… ORTHO

Foot & Phalanx Fx

• Hind foot = calcaneous & talus

• Mid foot = navicular, cuboid, 2nd 3rd cuneiforms

• Metatarsals

• Phalanges

Fx to forefoot common… hind & mid foot uncommon

Non-displaced fx metatarsals & phalanges splint & Ortho referral

Displaced Fx & intra-articular involvement may require ORIF

Special Considerations

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Child Abuse

• Battered child syndrome, shaken infant syndrome, stress-related infant abuse and non accidental trauma are all terms to describe the complex of non-accidental injuries in infants and young children as a result of abuse.

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• The term shaken infant syndrome probably best describes the classic pattern of injuries.

• The child is held around the chest and violently shaken back and forth.

• This causes the extremities and the head to flail back and forth in a whiplash movement. Intracranial injury occurs as a result of severe angular acceleration, deceleration and direct impact as the head strikes a solid object.

• The chest is compressed resulting in rib fractures.

• Arms and legs move about in a whiplash movement resulting in the typical 'corner' or 'bucket-handle'-fractures in the metaphyseal region

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Traction

Buck Traction

Principles of Traction

• Counter traction with weights

• Make sure all ropes and pulleys are aligned and weights are hanging freely

• Do not remove weights unless instructed to do so

• Traction must be applied at all times

Bryants Traction

• Used for child under 3 yrs

• Hip dysplasia / fractured femur

• Buttocks do not rest on mattress

• Assess neurovascular and restriction by ace bandages – compartment syndrome

Skeletal Traction

Pull directly applied to bone by pin

Pin care

Increased risk of infection

Ball & Bindler

External Fixator

External Fixation

RWChandler MD

External Fixator

Ball & Bindler

External Fixator

Plates and Pins

R.Chandler MD

Plates, screws, and wires are used to align bone fragments.

Pulmonary Embolism

• A complication of a fractured leg is a pulmonary embolism. Fat escapes the marrow when the bone is fractured and can travel through the blood stream and become lodged in small vessels like the arterioles and capillaries of the lung.

• Primary symptom is shortness of breath and chest pain.

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