This document discusses fractures in children, focusing on fractures of the humerus. It notes that children's bones are more malleable, growing, and have a thick periosteum. Physeal injuries account for 30% of fractures in children. The Salter-Harris classification system is described, along with treatments like closed reduction, open reduction, and internal fixation. Complications of humerus fractures in children can include deformities, growth disturbances, and neurovascular injuries due to the bone's proximity to joints, growth plates, nerves and arteries. Proper diagnosis, reduction, immobilization, and rehabilitation are needed to achieve good outcomes and prevent complications.

1. Fractures in Children
Prof. Dr. Shrikant Gore
Dept. of Orthopaedics
G.M.C. Latur

2. The Bones
 Soft & Malleable - Bowing, Greenstick
 Growing - Physis & Epiphysis Growth
disturbance
 Thick periosteum - Intraperiosteal Fractures
Less - displacement & Compound
 Remodeling - in the direction of movements
poor in rotational & Varus -Valgus

3. Physeal Injuries
 30% of childhood fractures
 Upper/Lower extremity ratio 2 : 1
 Relative radiolucency difficult to diagnose
underestimation of displacement
 Extension of fracture in joint common
 Growth disturbance & secondary arthritis
common

4. Salter-Harris classification
 Type-1 Epiphyseal Separation
 Type-2 Epiphyseal Separation with metaphyseal
spike
 Type-3 Epiphyseal Separation with fracture of
epiphysis
 Type-4 fracture through Metaphysis Physis
Epiphysis entering in joint
 Type-5 Compression if physis
 Type-6 Peripheral contusion

5. Salter-Harris classification
1,2,3—4,5,6

6. Treatment
 Closed reduction under anesthesia &
immobilization in plaster cast
 Manipulation should be gentle
not multiple times to avoid injury to physis &
growth disturbance
 As remodeling has its limitations open reduction &
int. fixation is needed in certain cases when
satisfactory reduction & stabilization is either
not possible or failed

7. Surgery- Gen. principles
Exposure
 Minimal exposure
 Minimal soft tissue & periosteal
stripping
 Gentle handling of soft immature bone
& physis
 Anatomical closure of wound

8. Surgery- Gen. principles
Implant
 Fixation
 Adequate
 Easily removable
 Smooth rather than threaded implants
 implant not to cross epiphysis

9. Complications
 Bony bridge
 AVN
 Deformity - angular, rotational
 Growth disturbance
 Infection

10. Functional Loss
 More if deformity is
Varus, Extension, distally placed
in both extremities length
discrepancy In lower extremity-
 Progressive
if associated with injury to epi-physis
resulting in late progressive deformity with
growth even if immediate results are
satisfactory

11. S/C # Humerus
 Age 5 to 10 yrs Sex Male
 Thin flat bone- Three dimensional displacement
* Difficult X-ray reading varus/valgus & rotational
displacement Pre & post reduction
* Unstable reduction tendency to re displace
* Sharp spike at proximal fragment –
* Buttonholing in Brachialis muscle - skin -
Compound #
 Close vicinity of- Radial, Ulnar, Median nerves &
Brachial artery - Prone to neuro - vascular injuries

12. S/C # Humerus
 Large hematoma – edema – massive swelling
skin vascularity – Blebs
Vascular compression –
Compartment syndrome - VIC
 Proximity to epiphyseal plate -Growth disturbance
 Proximity to joint -deformity, stiffness
 Massive displacement -periosteal stripping
–Myositis ossificanse

13. S/C # Humerus
Mechanism of injury
 Posterior tilt
 Posterior displacement
 Proximal displacement
 Lateral or medial displacement
 Rotation pronation or supination

14. Displacements
Grade
 1 Un displaced
 2 Displaced with intact post cortex
 3 Displaced with loss of contact

15. Clinical features
 Age 3 to 10 years Sex Male
 Pain, Swelling, Deformity around elbow
following H/O fall
 Swelling, Deformity around elbow
maintaining three point relation, shortening
of arm
 May be associated with neurovascular
complication

16. Clinical

17. Investigations
 X-Ray elbow AP/LAT view
 Pre anesthesia assessment investigations
 Color Doppler Vascular integrity
 Nerve conduction Integrity of nerves
 Intra compartmental Pressure measurement
 MRI Compression injury

18. – X-Ray AP

19. X-ray- lateral

20. Radiological Tips
 Move C-arm not the limb while taking AP/Lat Xray
 Crescent sign Medial or lateral tilt
 Unequal width of fragments Rotational malposition
 Ant. spike on lat. X-ray Rotational malposition
 Baumann angle - (Long axis of humerus with lat. Condylar
epiphysis)
Average 72 degree (64 to 81) Better
assessed by comparing with normal

21. Crescent sign

22. Crescent sign

23. Baumann’s angle

24. Neurovascular
 Brachial artery Radial pulse, nail bed circulation
 Skin Blebs
 Compartment Finger movements, stretch sign
compartmental tenseness
 Radial nerve Wrist drop
 Median nerve pointing finger
 Ulnar nerve ulnar claw

25. Swelling, edema, eccimosis

26. Management
 Gentle CR under anesthesia under radiological
control & immobilization in plaster slab
 Gentle CR under anesthesia under radiological
control & Stabilization by closed pining
 Open reduction & internal fixation
 Perfect anatomical reduction is essential to avoid
deformity

27. Closed reduction
 Supine position
 General anesthesia Avoid Ketamine
 Correction of rotation - Reversal of
pronation/supination
 Correction of lat. Shift – gentle push by palm
 Correction of over riding - Traction in 30degree
elbow flection
 Correction of post. Shift -pushing with thumbs

28. Closed reduction
 Correction of post. Angulation – flexing the elbow
 Pronation to prevent varus tilt
 Check distal circulation- Radial pulse & nail bed
 Radiograph AP & Lat. View by moving the C-arm
not the limb if red. Not satisfactory manipulation
repeated not more than twice
 AE slab in maximum flexion after conforming
anatomical reduction in both views

29. Complications
Early
 Injury to Brachial artery
 Injury to Radial, Median, Ulnar nerves
 Massive swelling & edema - Skin blebs,
Vascular compression, Compartment
syndrome
 Button holing of proximal fragment in
Brachialis muscle soft tissue
interposition & injury to skin –skin necrosis

30. Management of vascular
complication
 Immediate release of encircling bandage
 Extension of elbow
 Color Doppler
 Dunlop Traction
 Vascular repair
 Decompression - faciotomy

31. Post Op Care
 Post operative elevation
 Watch for Distal edema, Nail bed circulation
Finger movements, Stretch test, pain
 Check x-ray 3rd & 7th day ? Re displacement
 Active movements of fingers encouraged
 Removal of slab at 4 weeks

32. Mobilization
 Active exercises to develop muscles of arm,
forearm, shoulder & hand - static exercises
 Smooth, repeated, continuous, Active
stretching within limit of pain -
dynamic exercises avoiding jerky
movements
 Takes few weeks to months for complete
recovery

33. Complications
Intermediate
 Vascular compression due to flexion
position tight bandage & edema
 Compartment syndrome
 Nerve entrapment during reduction
Nerve compression due to edema,
positioning, tight bandaging

35. Complications
Late
 Mal union Cubitus varus
 Myositis ossificanse - Massage, vigorous
jerky mobilization
 Progressive deformity due to epiphyseal
damage
 Volkmann's ischemic contracture -
Undiagnosed compartment syndrome

37. Cubitus varus