Prof. Muhammad Shahiduzzaman Head, Department of Orthopaedics & Traumatology Dhaka Medical College Hospital Paediatric 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) Introduction

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)

Children have different physiology and anatomy Growth plate. Bone. Cartilage. Periosteum. Ligaments. Age-related physiology Children are very special

Children have different physiology and anatomy

Growth plate.

Bone.

Cartilage.

Periosteum.

Ligaments.

Age-related physiology

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 Plate

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.

Increased collagen: bone ratio lowers modulus of elasticity Increased cancellous bone reduces tensile strength reduces tendency of fracture to propagate less comminuted fractures Bone fails on both tension and compression commonly seen “buckle” fracture Bone

Increased collagen: bone ratio

lowers modulus of elasticity

Increased cancellous bone

reduces tensile strength

reduces tendency of fracture

to propagate

less comminuted fractures

Bone fails on both tension and

compression

commonly seen “buckle” fracture

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

Increased ratio of cartilage to bone

better resilience

difficult x-ray evaluation

size of articular fragment often under-estimated

Metabolically active more callus, rapid union, increased remodeling Thickness and strength Intact periosteal hinge affects fracture pattern May aid reduction Periosteum

Metabolically active

more callus, rapid union, increased remodeling

Thickness and strength

Intact periosteal hinge affects fracture pattern

May aid reduction

Age related # pattern

Better blood supply, so less incidence of Delayed or non-union. Physiology

Better blood supply,

so less incidence of Delayed or non-union.

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 Pattern

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

Green Stick Fracture

Torus Greenstick Green Stick Fracture

Plastic Deformity Injury Pattern

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. Injury Pattern

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 physis 20% of all skeletal injuries in children Can disrupt growth of bone Injury near but not at the physis can stimulate bone to grow more Physeal Injury

Many childhood fractures involve the physis

20% of all skeletal injuries in children

Can disrupt growth of bone

Injury near but not at the physis can stimulate bone to grow more

SALTER HARRIS CLASSIFICATION 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 Injury

SALTER HARRIS CLASSIFICATION

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.

Fracture passes transversely through physis separating epiphysis from metaphysis. Salter Harris Grade I

Fracture passes transversely through physis separating epiphysis from metaphysis.

Transversely through physis but exits through metaphysis Triangular fragment Salter Harris Grade II

Transversely through physis but exits through metaphysis

Triangular fragment

Crosses physis and exits through epiphysis at joint space. Salter Harris Grade III

Crosses physis and exits through epiphysis at joint space.

Extends upwards from the joint line, through the physis and out the metaphysis. Salter Harris Grade IV

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

Crash Injury to growth plate Salter Harris Grade V

MOST COMMON : Salter Harris II Followed by I, III, IV, V Refer to orthopedics: III, IV, V I and II effectively managed by primary care with casting (most commonly) Parents should be informed that growth disturbance can happen with any physeal fracture Salter Harris

MOST COMMON : Salter Harris II

Followed by I, III, IV, V

Refer to orthopedics: III, IV, V

I and II effectively managed by primary care with casting (most commonly)

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

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

Tremendous power of remodeling

Can accept more angulation and displacement

Rotational mal-alignment ?does not remodel

Malunion-Remodeling Process

Factors 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 remodeling

Factors 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

Children tend to heal fractures faster than adults requiring shorter immobilization time. Anticipate remodeling if child has >2 yrs of growing left – mild angulation deformities often correct themselves but rotational deformities requires reduction. Its good to be young!!!

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

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

Fractures in children may stimulate longitudinal growth – some degree of overlap is acceptable and may even be helpful. Children don’t tend to get as stiff as adults after immobilization. Its good to be young…

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

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

Law of Two’s : Two views Two joints Two limbs Two occasions Two physicians Xray examination 2

Law of Two’s :

Two views

Two joints

Two limbs

Two occasions

Two physicians

Radio-capitaller line Evaluation of paediatric elbow film

Supracondylar Fracture of Humerus Evaluation of paediatric elbow film

Mostly conservative – closed reduction and cast immobilization Open reduction & internal fixation. Principle of Management

Mostly conservative – closed reduction and cast immobilization

Open reduction & internal fixation.

Displaced intra articular fractures ( Salter-Harris III-IV ) fractures with vascular injury ? Compartment syndrome Fractures not reduced by closed reduction ( soft tissue interposition, button-holing of periosteum ) If reduction can not be maintained or could be only maintained in an abnormal position Indication for operative management

Displaced intra articular fractures

( Salter-Harris III-IV )

fractures with vascular injury

? Compartment syndrome

Fractures not reduced by closed reduction

( soft tissue interposition, button-holing of periosteum )

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

Indication for operative management

Casting—the commonest. Method of fixation

Casting—the commonest.

K-wires most commonly used Metaphyseal fractures Method of fixation

K-wires

most commonly used

Metaphyseal fractures

Intramedullary wires, elastic nails Very useful, Diaphyseal fractures Method of fixation

Screws Method of fixation

Screws

Screws Method of fixation

Screws

Plates and screws Multiple Trauma Method of fixation

Plates and screws

Multiple Trauma

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

IMN Nailing (adolescent only)

Chances of growth disturbences.

External Fixation In open Fractures Method of fixation

External Fixation

In open Fractures

Casting - still the commonest K-wires most commonly used Metaphyseal fractures Intramedullary wires, elastic nails Very useful Diaphyseal fractures Screws Plates – multiple trauma IMN - adolescents Ex-fix Combination Method of fixation

Casting - still the commonest

K-wires

most commonly used

Metaphyseal fractures

Intramedullary wires, elastic nails

Very useful

Diaphyseal fractures

Screws

Plates – multiple trauma

IMN - adolescents

Ex-fix

Malunion is not usually a problem (except cubitus varus) Nonunion is hardly seen (except in lateral condyle of humerus) Growth disturbance – epiphyseal damage Vascular - volkmann’s ischemia Infection - rare Complication

Malunion is not usually a problem (except cubitus varus)

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

Growth disturbance – epiphyseal damage

Vascular - volkmann’s ischemia

Infection - rare

Battered Baby Syndrome: Soft tissue injuries - bruising, burns Intra-abdominal injuries Intracranial injuries Delay in seeking treatment # at diff. stage of healing. Non-accidental injury

Battered Baby Syndrome:

Soft tissue injuries - bruising, burns

Intra-abdominal injuries

Intracranial injuries

Delay in seeking treatment

# at diff. stage of healing.

Radiology of child abuse

Corner’s fracture (traction and rotation)

Bucket handle fracture (traction and rotation)

Pathological fracture

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