This is the assignment assigned to us (the final year, Rural Health Sciences students) here at Modilon Hospital.

1. Supervisor: Dr. J. Kuzma, MD, PhD
Faculty of Health Sciences
Department of Rural Health
“Diagnosis and Management of common Pediatrics Fractures”
Name: Chris ANDREW
ID#: 6415
Year: RH4
Due: Week 6
HE221: SURGERY
ORTHOPAEDIC ASSIGNMENT

2. Supervisor: Dr. J. Kuzma, MD, PhD
Introduction
In fact there are obvious differences between the different types of bones in pediatrics and that of the
adults in terms of its anatomy and the biomechanics that they have. Since they have differences in
anatomy and biomechanics, the fracture of the pediatrics bones are not that similar to the fracture
patterns of the adult’s bone. Also the healing mechanisms and the management of the bone fractures
within these two parties are unique. Pediatric bone is significantly less dense in comparison to the adult
bone. They are more porous and penetrated throughout by capillary channels. The pediatric bone
typically has a property of having a lower modulus of elasticity, lower bending strength, and lower
mineral content. The low bending strength induces more strain in pediatrics bone than for the same
stress on the adult bone and the increased porosity of pediatric bone prevents propagation of the
fractures, thereby decreasing the incidence of comminuted fractures. The pediatric periosteum is
stronger and thick, functioning in the reduction and maintenance of fracture alignment and healing.
1. Buckle or Torus Fracture
Diagnosis:
Take the full history of the patient; that includes:
Patient’s particulars
Take note of the main presenting complaints
[Note down the onset of the above chief complaint (s)]
In order to diagnose a Torus fracture, the foremost thing is to ask the patient or rather his or her
caregiver the cause of what he or she sustained, whether the patient fall or had sustained other injuries.
Then look for the symptoms like:
 Pain/swelling in the injured area (Ask for the: Location, intensity, quality of pain, onset of pain &
duration of pain, progress of pain, is it radiating, any aggravating or alleviating factors).
 Difficulty moving or using the injured body part
 Warm, bruising or redness in the injured are
 Take note of any indicators of neurovascular status (i.e. change in/ loss of sensation, cold, pale
or paralyzed limb), and mechanism of injury.
Physical examination: assessment of the joint (?), screening exam of the entire skeleton, funduscopy as
well as an abdominal and cutaneous appraisal for other signs of trauma.
Inspection: Patient movement & Discrepancy in limb movement
Palpation: Assess the local temperature, warmth and tenderness, existence of swelling/mass, tightness,
spasticity, contractures, any deformity of either bone/joint, evaluate anatomic axis of limb
Range of Motion: Assess and record the active/passive range of motion of a joint
Neurovascular assessment of the injured area: look at the color of the limbs, feel the pulse &
temperature.
X-rays (to look at the position of the bones).

3. Supervisor: Dr. J. Kuzma, MD, PhD
Management:
 Apply to the affected limb the correct-sized splint (cast plaster). [For 3 weeks but may be
removed earlier if the child is comfortable].
 They should be encouraged to return to the ED for review if the child is experiencing a lot of
pain even with the splint and regular analgesia
 They can wean from the splint, using it only when symptomatic
 Parents and patient can be advised that they can remove splint for bathing/showering without
risk to the fracture.
 No follow-up is required as this fracture heals very well with very low range of displacement.
 Advice the parent and patient to re-attend the ED should they be experiencing increasing
symptoms of pain or stiffness, & sporting activities should be avoided for a total of 6 weeks.
2. Supracondylar Fracture
Diagnose:
Ask the guardian:
 What was the patient doing at that time of incident
 What was the nature or mechanism of the incident? (a kick, a stick or a fall etc. )
 Then the magnitude of applied forces
 If he/she could give or point to where the pain is, the intensity, the quality of pain,
onset, duration and the progress of pain. Also ask if the pain is radiating, and ask about
any aggravating or alleviating factors.
Look for any obvious indications of neurovascular status (e.g. change in or loss of
sensation, cold, pale, paralyzed limb).
Physical Examination Findings
Inspection:
 Asymmetry of contour (deformity, angulation)
 Asymmetry of posture (position) e.g. external rotation of limb in fractured femoral nerve.
 Local swelling, grazing, bruising and haematoma.
 Laceration
Palpation:
 Local tenderness (tender spot over trauma is not characteristic of fracture)
 Palpate any section of the bone to see if you will elicit the pain over the fracture
 See if you can feel the sharp edges at the fractured bone ends
 Crepitus & abnormal mobility
NB: Always check for the presence of Brachial artery, and must also confirm that capillary return is
normal [<2sec.] and finally see that the sensor-motor function of the distal part of the limb.

4. Supervisor: Dr. J. Kuzma, MD, PhD
Management/Treatment
Assess the circulation in the affected part. If there are signs of impaired circulation (absent
radial pulse, pallor, coldness etc., an immediate referral (within 6hrs). Close reduction is
necessary under general anaesthesia.
Apply the elbow-straight splint (safest immobilization option) while waiting for referral. Elevate
the hand to reduce swelling. A collar and cuff is sufficient if displacement assessed on X-ray is
minimal. Always check again the radial pulse after every manipulation/immobilization, if not
palpable, extend the elbow, elevate hands and refer urgently.
If refer is difficult or impossible, children <10yrs can be safely treated by putting the straight arm
up in skin traction can improvise by using a drip stand the best with attached pulley, traction
weight for children <4yrs 1.5kg; for older 2 to 2.g kg.
3. Green Stick Fracture
Diagnose: (Diagnosis is finally done by clinical findings and confirmed by plain x-rays).
History
 At that time of incident, what was the patient doing?
 Ask about the nature or mechanism of the incident.
 What was the magnitude of applied force
 The location of the pain [is the pain localized to a particular region or does it involve a larger
area].
 Any indications of compromised neurovascular status (e.g. person unable to walk after injury
must arouse suspicion of fracture.

The main symptoms that you would consider to diagnose Green stick fracture are:
 Intense pain
 Swelling
 Obvious deformity

Physical Examination
Inspection
 Look for deformities and angulations
 Look at the asymmetry of posture (position)
 See if there would be any lacerations, bruising, local swelling, grazing. [check the skin for the
presence of any wound related to the fracture].

5. Supervisor: Dr. J. Kuzma, MD, PhD
 X-rays are done mostly to reveal green stick fractures in children. However some green stick
fractures are difficult to see because a small bed in the bone may never show up as well on x-
rays.
Palpation
 Gently feel for the local tenderness
 Gently palpate any segment of the bone and see if you could elicit any pain over the fractured
bone.
 Feel for sharp edges at the fractured bone ends
 Abnormal mobility
And check distal pulse, capillary return and senso-motor function of the distal part of the limb.
Management
 Below elbow pull plaster cast and elevation in sling
 Plaster check day 1 after application of cast
 Plaster check and x-rays 1 week after the fracture
 Suggest removal of plaster after the 4 weeks after the fracture and a clinical examination
 After removal of the plaster, advice no contact sports, etc. for four weeks
 The parents should be strongly reassured that any mild bend in the wrist on x-rays will gradually
correct or remodel over time as the child grow.
4. Plastic Deformation
Diagnose:
Full History of the patient
 What was the patient doing at the time of incident?
 Ask for the mechanism of the incident. (was it by fall, a kick or a stick) *Usually
produced by fall on an outstretched arm, which most of the times produces deformity
of the forearm.
 Ask the patient, otherwise if he or she could not converse well, ask the guardian about
the magnitude of the applied forces.
 Then, you go ahead asking about the location of the pain.
 Finally you ask the patient if he or she had encountered any loss of activity bodily
function. (E.g. a patient unable to walk after sustaining the initial injury.
Clinically;
 Usually produced by fall on an outstretched arm
 Usually produce deformity of the forearm

6. Supervisor: Dr. J. Kuzma, MD, PhD
 If the shoulder is internally rotated and the forearm is pronated, an angulated fracture of radius
with bowing of ulna will result.
 If the shoulder is externally rotated and the forearm is supinated, will produce a fracture of the
ulna with bowing of the radius.
 A combination of forces may lead to plastic bowing of both radius and ulna.
Inspection;
you look for deformity and angulation
consider the asymmetry of posture
see if you can spot any significant local swelling, haematoma, bruising, grazing
laceration- always check skin for the presence of any wound related to the fracture
Palpation;
 Gently feel for tenderness
 Palpate any segment of the bone to see if you could elicit the pain over the fracture
 Palpate to see if you could finally if you could feel the sharp edges at the fractured bone ends
 Feel for crepitus, esp. when the bone fractured ends are moved
 Abnormal mobility
NB: Always check distal pulse, capillary return and senso-motor function of the distal part of the
limb.
Management/Treatment
1. If the child is <4 years old, angulations <20 degrees will usually remodel
2. Those children who are over 4 years of age, generally requires surgical correction
3. Correction is generally indicated for plastic bowing fracture which restricts movement or
prevents reduction of an adjacent fracture or dislocations