OVERVIEW OF PEDIATRIC TRAUMAPresenter: Dr Gituri Philip

Moderator: Dr E. Gakuya

An 8-year-old boy presents to the emergency department with a Salter-Harris type IV fracture of the distal femur from a football tackle. The fracture has 3mm of displacement and 15 degrees of angulation in the sagittal plane. Because of his young age you know he has excellent potential to remodel. The BEST treatment option would include:

a)Long-leg cast

b)Percutaneous pinning in situ

c)Open reduction and internal fixation with distal femoral locking plate

d)Open reduction and internal fixation of the metaphyseal component but not the epiphyseal component to avoid potential growth arrest

e)Open reduction and internal fixation of both components with plates and or screw fixation

OUTLINE

1. Epidemiology of Pediatric Fractures

2. Uniqueness of Children's bones

3. Child abuse/Neglect/ Non-accidental trauma (NAT)

4. Multiply injured Child

5. Principles of Management

6. Specific cases/Precautions

INTRODUCTION

• over 40% of boys and 25% of girls sustain a fracture by 16 years of age1

• properties of the immature skeleton- these injuries have different characteristics, complications, and management than similar adult injuries

• data from five large epidemiologic studies :distal forearm # most common (nearly 25% of 12,946 fractures), then clavicle # (over 8% of all children's fractures)

• Mann et al. [5] reported of 2,650 long bone fractures in children, 30% involved the physis.

PROPERTIES OF THE IMMATURE SKELETON

1. Plastic Deformation- most common in the forearm, particularly the ulna• Stress–strain curves for mature and immature bone. The increased

strain of immature bone before failure represents plastic deformation.

a. Buckle (Torus) Fractures- most commonly occur at transition between metaphyseal woven bone and the lamellar bone of the diaphyseal cortex

3. Greenstick Fractures - immature bone is more flexible and has a

thicker periosteum than mature adult bone

•Reduction: “unlock” the impacted fragments on the tension side by initially

exaggerating the deformity and then applying traction and a reducing force

•stable after reduction but have an increased likelihood of refracture

•immobilize these fractures for a full 6 weeks

4. Remodeling/Overgrowth -fractures heal more rapidly than those in

adults, but once healed, they remodel residual deformity

Factors affecting remodellong potential:

i. amount of growth remaining (the patient's skeletal age)

ii. the plane of the deformity in relation to adjacent joints

iii. the deformity's proximity to the physis and

iv. the growth potential of the particular physis

5. Potential for accelerated growth of an injured limb -most

frequently seen in diaphyseal femoral fractures.(spontaneously

correctting shortening of up to 2 cm)

Theories ascribe this to hyperemia

6. Physeal Injuries• 15% to 30% of all fractures in children• peak in adolescents• growth deformity is rare, occurring in only 1% to 10% of all physeal injuries.

• Physeal anatomy

Most injuries occur just above area of

provisional calcification within the

hypertrophic zone. Germinal layer frequently

remains intact and attached to the epiphysis

CLASSIFICATION OF PHYSEAL INJURIES

• Goal in treating physeal fractures

i. to achieve and maintain an acceptable reduction without subjecting the germinal

layer of the physis to any further damage.

ii. determining the limits of an acceptable reduction

iii. Because of the intra-articular component, displaced type III and IV injuries must be

reduced regardless of the time that has elapsed since the injury

iv. reduction can be maintained with a cast, pins, internal fixation, or some

combination of these three

COMPLICATIONS OF PHYSEAL INJURIES

1. malunion,

2. infection,

3. neurovascular problems,

4. Osteonecrosis

5. Growth Disturbance

CARE OF THE MULTIPLY INJURED CHILD

• Blunt trauma -leading cause of death in children older than 1 year of age

• Children possess a number of anatomic and physiologic characteristics that make their injuries and their injury response different from adults'

OPEN FRACTURES

• Incidence and mechanism of open fractures differ between children and adults

• their management is similar, requiring an aggressive, thorough, and systematic approach

• most common open fractures in children involve the hand and upper extremity

• Open fractures of the lower extremities, esp tibia, are the result of higher-energy trauma, esp automobile–pedestrian or automobile–bicycle accidents

GUSTILO AND ANDERSON CLASSIFICATION SYSTEM

• Type I• Wound <1 cm long

• Moderately clean puncture wound

• Usually “inside-out” injury

• Little soft tissue damage, no crushing

• Little comminution

• Type II • Wound >1 cm long

• No extensive tissue damage

• Slight or moderate crush injury

• Moderate comminution or contamination

•

• Type III

• Extensive soft tissue damage to muscles, skin, and

neurovascular structures and a high degree of

contamination

• Three subtypes:

A. Adequate soft tissue coverage (includes high-

energy segmental, comminuted fractures,

regardless of normal size)

B. Local or free flap required for coverage

C. Arterial injury requiring repair

Open Fracture Management

1. Thorough assessment for life-threatening injuries2. Immediate intravenous antibiotics, continue for 48 hours:

i. Grade I—first-generation cephalosporin ii. Grades II and III—first-generation cephalosporin + aminoglycoside iii. “Barnyard” injuries—add anaerobic coverage (penicillin or metronidazole)

3. Tetanus prophylaxis4. Thorough operative debridement5. Adequate fracture stabilization6. Second operative debridement in 48-72 hours if indicated7. Early definitive soft tissue coverage8. Early bone grafting if indicated

CHILD ABUSE/NONACCIDENTAL TRAUMA/BATTERED CHILD

SYNDROME• 1% to 1.5% of all children are abused each year

• children are more likely to be abused by caregivers who are young, poor, and of minority status

• Younger children are also more likely to die from abuse

• After skin lesions, fractures are the second most common physical presentation

• bone that fractures under tension with torsion

• Femoral shaft, hands and feet fractures in nonambulatory infants

• Fractures in unusual locations

SPECIFIC FRACTURES

• Cervical spine injuries in children (1% of pediatric fractures and 2% of all spinal injuries )

i. younger than 8 years age - upper cervical spine, ii. older children and adolescents - either the upper or lower C- spine

i. Pelvic fractures comprise less than 0.2% of all pediatric fractures

ii.two most common classification systems used :Young and Burgess and Tile and Pennal

Torode and Zieg Classification of pelvic fractures in children

• Hip Fractures: blood supply of the proximal femur comes from two major branches of the profunda femoris artery—the medial and lateral circumflex arteries

• classified into four types based on the anatomic location of the fracture as described by Delbet

i. Type I: Transepiphysealii. Type II: Transcervicaliii. Type III: Cervicotrochantericiv. Type IV: Pertrochanteric or intertrochanteric

Fractures about the Elbow

• 5% to 10% of all fractures in children

• distinguishing fractures from the six normal secondary ossification centers• (CRITOE)

Spinal Cord Injury Without Radiographic

Abnormality(SCIWORA)• overwhelmingly found in children (15% to 35% of SCIs in children)

• most, if not all, will have abnormal findings on MRI

• spinal column is more elastic than the spinal cord

• more common in children under 8 years of age than in older children

• predisposing factors • cervical spine hypermobility, • ligamentous laxity, and • an immature vascular supply to the spinal cord

Pathologic fractures

• May results from a. Local causes: primary bone tumors,

metastases , osteomyelitis, pronounced bowing of the bone (e.g. in crus varum congenitum , which can then develop into congenital tibial pseudarthrosis )

a. Generalized causes: Osteogenesis imperfecta , Stuve-Wiedemann syndrome , rickets , juvenile osteoporosis , storage disorders such as Gaucher disease .

BIRTH INJURIES

• Clavicle- commonest site, followed by the humerus and femur

• Risk factors: Shoulder dystocia, high birth weight and gestational age

• Proximal and distal humerus, distal femur: Epiphyseal separations due to birth trauma at best, suspected on an x-ray since the humeral head and distal end of the humerus and femur cartilaginous

• confirmed sonographically

TREATMENT OF FRACTURESIN CHILDREN

1. Closed treatment• majority of fractures treated by

closed reduction and casting or traction

• well-molded cast.

• Open treatment• Open fractures.• Polytrauma.• Patients with head injuries.• Femoral fractures in adolescents.• Femoral neck fractures.• Certain types of forearm fractures.• Certain types of physeal injuries.• Fractures associated with burns.

Types of Fixation

i. Treatment of periarticular and articular fractures -3.5 mm cortex screws, 4.0 mm cancellous bone screws (exceptionally 6.5mm), and cannulated screws

ii. epiphyseal and metaphyseal fragments- K-wire fixation

iii. Transphyseal wires should be non-threaded

iv. External fixation devices for patients with open fractures, polytrauma, and fractures associated with burns(great care exercised not to damage the growth plate)

• Standard closed intramedullary nailing used in femoral shaft fractures in adolescents, in younger children the use of elastic titanium nails (TEN)