Paediatric trauma

Question 1

Define Salter-Harris fracture

Answer 1

A fracture that involves the epiphyseal growth plate. These fractures can result in progressive deformity (classification helps predict effect on growth).

Question 2

Define Greenstick fracture

Answer 2

A fracture of the bone, in which one side of the bone is broken and the other side only bent.

Question 3

Define Torus/buckle fracture

Answer 3

Extremely common injury in children. Since they have softer, more flexible bones, one side of bone may buckle upon itself without disrupting the other side of bone (incomplete fracture) causing symptoms.

Question 4

What pneumonic can be used for Salter-Harris type 1-5 growth plate fractures

Answer 4

SALTR

Slipped, Above, Lower, Transverse, Rammed

Question 5

Describe Salter-Harris Type 1 growth plate fracture

Answer 5

Slipped.
15%
Fracture plane passes all the way through the growth plate, not involving bone.
Cannot occur if growth plate is fused
Good prognosis.

Question 6

Describe Salter-Harris type 2 growth plate fracture

Answer 6

Above
50% (by far most common)
Fracture plane passes across most of growth plate and up through metaphysis (above)
Good prognosis

Question 7

Describe Salter-Harris type 3 growth plate fracture

Answer 7

Lower.
25%
Fracture plane passes some distance along the growth plate and then down through the epiphysis.
Poorer prognosis as the proliferative and reserve zones are interrupted.

Question 8

Describe Salter-Harris type 4 growth plate fracture

Answer 8

Through/transverse
Intra-articular
<5%
Fracture plane passes directly through the metaphysis, growth plate and down through the epiphysis. (vertical)
Poor prognosis as the proliferative and reserve zones are interrupted.

Question 9

Describe Salter-Harris type 5 growth plate fracture

Answer 9

Ruined or rammed
<5%
Crushing type injury does not displace the growth plate but damages it by direct compression.
Has worst prognosis

Question 10

What are common sites of non-accidental injury (NAI)

Answer 10

Forearm (25-50%) – distal radial fractures (80%), Shaft fractures (20%)
Knee – physeal injury, physeal arrest, tibial spine fracture, tibial tubercle fracture, patellar fracture (rare), patellar dislocation.
Ankle - Salter-Harris fracture, Transitional fracture

Question 11

What are suspicious features of non-accidental injuries?

Answer 11

Incongruent history (incompatible) 
Bruising 
Burns 
Multiple #
Metaphyseal #, humeral shaft #
Rib #
Non-ambulant #

Question 12

What are the principles of children fractures healing and treatment?

Answer 12

They heal quickly:
-	Metabolically active periosteum 
-	Cellular bone 
-	Good blood supply 
-	Often low velocity trauma
So usually treated conservatively.

Question 13

What are the conservative treatment options for children’s fractures?

Answer 13

Cast. Braces. Splints. Traction.

Question 14

What are the operative Rx options for child fractures?

Answer 14

External fixation: monolateral, circular.

Internal fixation – IM nail (rigid or elastic), Plate fixation.

Question 15

When would you supplement the cast with fixation?

Answer 15

Severe swelling likely.
Need to re-inspect wound (e.g. open fractures)
Multiple injuries
Segmental limb injuries 
Fractures very unstable. 
Approaching skeletal maturity

Question 16

How do you treat Salter-Harris type 1 +2 ankle fracture?

Answer 16

Displaced <3mm – cast for 6 weeks

Displaced >3mm – manipulation under anaesthesia then cast for 6 weeks

Question 17

How do you treat Salter-Harris type 3 ankle fracture?

Answer 17

Undisplaced – cast for 6 weeks

Displaced – open reduction + inter-fragmentary screw fixation

Question 18

How do you treat Salter-Harris type 4 ankle fracture?

Answer 18

ORIF surgery

Monitor for growth arrest

Question 19

Describe cause, classification + Rx of apophyseal injury at tibial spine

Answer 19

Avulsion of ACL: I – undisplaced, II – Hinged, III – displaced.
I/II – long leg cast. III – ORIF.

Question 20

What are complications of childhood fractures?

Answer 20

Compartment syndrome (can result in Volkmann’s #)
5% non-union, 5% re-fracture
Radioulnar synostosis (abnormal connection): Proximal>distal; High energy 

PIN injury (post interosseous n.)
Superficial radial nerve injury
Distal RUJ/radio-capitellar problems

Persistent displacement
Growth arrest risk