Prof. Muhammad Shahiduzzaman discusses fractures in pediatric patients. He notes that 60% of the population in Bangladesh is under 20 years old, and fractures account for 15% of injuries in children. Fracture patterns differ from adults due to children having stronger ligaments, more cartilage, and growth plates that allow for remodeling. Common fractures include buckle fractures, greenstick fractures, and Salter-Harris fractures of the physis. Treatment depends on the fracture type but often involves closed reduction and casting, with surgery reserved for more complex cases. Children generally heal faster than adults from fractures.

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

2. 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

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

4. 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

5. 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

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

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

8. Age related # pattern

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

10. 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

11. Green Stick Fracture

12. Torus Greenstick Green Stick Fracture

13. Plastic Deformity Injury Pattern

14. 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

15. 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

16. 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

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

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

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

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

26. Crash Injury to growth plate Salter Harris Grade V

27. 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

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

29. Malunion-Remodeling Process

30. 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

31. 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!!!

32. 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…

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

34. Radio-capitaller line Evaluation of paediatric elbow film

35. Supracondylar Fracture of Humerus Evaluation of paediatric elbow film

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

37. 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

38. Indication for operative management

39. Casting—the commonest. Method of fixation

40. K-wires most commonly used Metaphyseal fractures Method of fixation

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

42. Screws Method of fixation

43. Screws Method of fixation

44. Plates and screws Multiple Trauma Method of fixation

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

46. External Fixation In open Fractures Method of fixation

47. 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

48. 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

49. 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

50. Radiology of child abuse

51. Corner’s fracture (traction and rotation)

52. Bucket handle fracture (traction and rotation)

53. Pathological fracture

57. Thank You