Paediatric fracture


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  • Figure 8-178 Greenstick fracture. In the humerus of this elementary school child, a direct blow from the direction of the arrow has caused an incomplete transverse fracture.
  • Paediatric fracture

    1. 1. Prof. Muhammad Shahiduzzaman Head, Department of Orthopaedics & Traumatology Dhaka Medical College Hospital Paediatric Fracture
    2. 2. <ul><li>In Bangladesh 60% of population are <20 yrs </li></ul><ul><li>Fractures accounts for 15% of all injuries in children. </li></ul><ul><li>Different from adult fractures. </li></ul><ul><li>Vary in different age groups (Infants, children, adolescents) </li></ul>Introduction
    3. 3. <ul><li>Children have different physiology and anatomy </li></ul><ul><ul><li>Growth plate. </li></ul></ul><ul><ul><li>Bone. </li></ul></ul><ul><ul><li>Cartilage. </li></ul></ul><ul><ul><li>Periosteum. </li></ul></ul><ul><ul><li>Ligaments. </li></ul></ul><ul><ul><li>Age-related physiology </li></ul></ul>Children are very special
    4. 4. <ul><li>In infants, GP is stronger than bone. </li></ul><ul><li> increased diaphyseal fractures </li></ul><ul><li>Provides perfect remodeling power. </li></ul><ul><li>Injury of growth plate causes deformity. </li></ul><ul><li>A fracture might lead to overgrowth. </li></ul>Growth Plate
    5. 5. <ul><li>Increased collagen: bone ratio </li></ul><ul><ul><li>lowers modulus of elasticity </li></ul></ul><ul><li>Increased cancellous bone </li></ul><ul><ul><li>reduces tensile strength </li></ul></ul><ul><ul><li>reduces tendency of fracture </li></ul></ul><ul><ul><li> to propagate </li></ul></ul><ul><ul><li>less comminuted fractures </li></ul></ul><ul><li>Bone fails on both tension and </li></ul><ul><li>compression </li></ul><ul><ul><li>commonly seen “buckle” fracture </li></ul></ul>Bone
    6. 6. <ul><li>Increased ratio of cartilage to bone </li></ul><ul><ul><li>better resilience </li></ul></ul><ul><ul><li>difficult x-ray evaluation </li></ul></ul><ul><ul><li>size of articular fragment often under-estimated </li></ul></ul>Cartilage
    7. 7. <ul><li>Metabolically active </li></ul><ul><ul><li>more callus, rapid union, increased remodeling </li></ul></ul><ul><li>Thickness and strength </li></ul><ul><ul><li>Intact periosteal hinge affects fracture pattern </li></ul></ul><ul><ul><li>May aid reduction </li></ul></ul>Periosteum
    8. 8. Age related # pattern
    9. 9. <ul><li>Better blood supply, </li></ul><ul><li>so less incidence of Delayed or non-union. </li></ul>Physiology
    10. 10. <ul><li>Bones tend to BOW rather than BREAK </li></ul><ul><li>Compressive force= TORUS fracture </li></ul><ul><ul><ul><li>Aka. Buckle fracture </li></ul></ul></ul><ul><li>Force to side of bone may cause break in only one cortex= GREENSTICK fracture </li></ul><ul><ul><li>The other cortex only BENDS </li></ul></ul><ul><li>In very young children, neither cortex may break= PLASTIC DEFORMATION </li></ul>Injury Pattern
    11. 11. Green Stick Fracture
    12. 12. Torus Greenstick Green Stick Fracture
    13. 13. Plastic Deformity Injury Pattern
    14. 14. <ul><li>Point at which metaphysis connects to physis is an anatomic point of weakness </li></ul><ul><li>Ligaments and tendons are stronger than bone when young Bone is more likely to be injured with force. </li></ul><ul><li>Periosteum is biologically active in children and often stays intact with injury </li></ul><ul><ul><li>This stabilizes fracture and promotes healing. </li></ul></ul>Injury Pattern
    15. 15. <ul><li>Many childhood fractures involve the physis </li></ul><ul><ul><li>20% of all skeletal injuries in children </li></ul></ul><ul><ul><li>Can disrupt growth of bone </li></ul></ul><ul><ul><li>Injury near but not at the physis can stimulate bone to grow more </li></ul></ul>Physeal Injury
    16. 16. <ul><li>SALTER HARRIS CLASSIFICATION </li></ul><ul><ul><li>Classification system to delineate risk of growth disturbance </li></ul></ul><ul><ul><li>Higher grade fractures are more likely to cause growth disturbance </li></ul></ul><ul><ul><li>Growth disturbance can happen with ANY physeal injury </li></ul></ul><ul><ul><li>It has grade I upto grade V. </li></ul></ul>Physeal Injury
    17. 17. <ul><li>Fracture passes transversely through physis separating epiphysis from metaphysis. </li></ul>Salter Harris Grade I
    18. 19. <ul><li>Transversely through physis but exits through metaphysis </li></ul><ul><li>Triangular fragment </li></ul>Salter Harris Grade II
    19. 21. <ul><li>Crosses physis and exits through epiphysis at joint space. </li></ul>Salter Harris Grade III
    20. 24. <ul><li>Extends upwards from the joint line, through the physis and out the metaphysis. </li></ul>Salter Harris Grade IV
    21. 26. Crash Injury to growth plate Salter Harris Grade V
    22. 27. <ul><li>MOST COMMON : Salter Harris II </li></ul><ul><ul><li>Followed by I, III, IV, V </li></ul></ul><ul><ul><li>Refer to orthopedics: III, IV, V </li></ul></ul><ul><ul><li>I and II effectively managed by primary care with casting (most commonly) </li></ul></ul><ul><li>Parents should be informed that growth disturbance can happen with any physeal fracture </li></ul>Salter Harris
    23. 28. <ul><li>Tremendous power of remodeling </li></ul><ul><li>Can accept more angulation and displacement </li></ul><ul><li>Rotational mal-alignment ?does not remodel </li></ul>Power of remodeling
    24. 29. Malunion-Remodeling Process
    25. 30. <ul><li>Factors affecting remodeling potential </li></ul><ul><li>Years of remaining growth – most important factor </li></ul><ul><li>Position in the bone – the nearer to physis the better </li></ul><ul><li>Plane of motion – greatest in sagittal, the frontal, and least for transverse plane </li></ul><ul><li>Physeal status – if damaged, less potential for correction </li></ul><ul><li>Growth potential of adjacent physis </li></ul><ul><ul><li>e.g. upper humerus better than lower humerus </li></ul></ul>Power of remodeling
    26. 31. <ul><li>Children tend to heal fractures faster than adults requiring shorter immobilization time. </li></ul><ul><li>Anticipate remodeling if child has >2 yrs of growing left – mild angulation deformities often correct themselves but rotational deformities requires reduction. </li></ul>Its good to be young!!!
    27. 32. <ul><li>Fractures in children may stimulate longitudinal growth – some degree of overlap is acceptable and may even be helpful. </li></ul><ul><li>Children don’t tend to get as stiff as adults after immobilization. </li></ul>Its good to be young…
    28. 33. <ul><li>Law of Two’s : </li></ul><ul><ul><li>Two views </li></ul></ul><ul><ul><li>Two joints </li></ul></ul><ul><ul><li>Two limbs </li></ul></ul><ul><ul><li>Two occasions </li></ul></ul><ul><ul><li>Two physicians </li></ul></ul>Xray examination 2
    29. 34. Radio-capitaller line Evaluation of paediatric elbow film
    30. 35. Supracondylar Fracture of Humerus Evaluation of paediatric elbow film
    31. 36. <ul><li>Mostly conservative – closed reduction and cast immobilization </li></ul><ul><li>Open reduction & internal fixation. </li></ul>Principle of Management
    32. 37. <ul><li>Displaced intra articular fractures </li></ul><ul><ul><li>( Salter-Harris III-IV ) </li></ul></ul><ul><li>fractures with vascular injury </li></ul><ul><li>? Compartment syndrome </li></ul><ul><li>Fractures not reduced by closed reduction </li></ul><ul><ul><li>( soft tissue interposition, button-holing of periosteum ) </li></ul></ul><ul><li>If reduction can not be maintained or could be only maintained in an abnormal position </li></ul>Indication for operative management
    33. 38. Indication for operative management
    34. 39. <ul><li>Casting—the commonest. </li></ul>Method of fixation
    35. 40. <ul><li>K-wires </li></ul><ul><ul><li>most commonly used </li></ul></ul><ul><ul><li>Metaphyseal fractures </li></ul></ul>Method of fixation
    36. 41. Intramedullary wires, elastic nails Very useful, Diaphyseal fractures Method of fixation
    37. 42. <ul><li>Screws </li></ul>Method of fixation
    38. 43. <ul><li>Screws </li></ul>Method of fixation
    39. 44. <ul><li>Plates and screws </li></ul><ul><ul><li>Multiple Trauma </li></ul></ul>Method of fixation
    40. 45. <ul><li>IMN Nailing (adolescent only) </li></ul><ul><ul><li>Chances of growth disturbences. </li></ul></ul>Method of fixation
    41. 46. <ul><li>External Fixation </li></ul><ul><ul><li>In open Fractures </li></ul></ul>Method of fixation
    42. 47. <ul><li>Casting - still the commonest </li></ul><ul><li>K-wires </li></ul><ul><ul><li>most commonly used </li></ul></ul><ul><ul><li>Metaphyseal fractures </li></ul></ul><ul><li>Intramedullary wires, elastic nails </li></ul><ul><ul><li>Very useful </li></ul></ul><ul><ul><li>Diaphyseal fractures </li></ul></ul><ul><li>Screws </li></ul><ul><li>Plates – multiple trauma </li></ul><ul><li>IMN - adolescents </li></ul><ul><li>Ex-fix </li></ul>Combination Method of fixation
    43. 48. <ul><li>Malunion is not usually a problem (except cubitus varus) </li></ul><ul><li>Nonunion is hardly seen (except in lateral condyle of humerus) </li></ul><ul><li>Growth disturbance – epiphyseal damage </li></ul><ul><li>Vascular - volkmann’s ischemia </li></ul><ul><li>Infection - rare </li></ul>Complication
    44. 49. <ul><li>Battered Baby Syndrome: </li></ul><ul><ul><li>Soft tissue injuries - bruising, burns </li></ul></ul><ul><ul><li>Intra-abdominal injuries </li></ul></ul><ul><ul><li>Intracranial injuries </li></ul></ul><ul><ul><li>Delay in seeking treatment </li></ul></ul><ul><ul><li># at diff. stage of healing. </li></ul></ul>Non-accidental injury
    45. 50. Radiology of child abuse
    46. 51. Corner’s fracture (traction and rotation)
    47. 52. Bucket handle fracture (traction and rotation)
    48. 53. Pathological fracture
    49. 57. Thank You