Paediatric Trauma

Question 1

what are the different orthopaedic injuries children experience?

Answer 1

because their bones are more elastic/pliable they tend to buckle or partially fracture/splinter rather than completely break

Question 2

what children do we suspect NAI in if they get a fracture?

Answer 2

neonates and infants - under 2s

not walking yet so hard for them to break a bone

Question 3

when is conservative management not the first point of call in managing fractures in children?

Answer 3

displaced intra-articular fractures
displaced growth plate fractures
open fractures

Question 4

general principles of fracture management

Answer 4

reduce
retain
rehabilitate

Question 5

What should be looked for in a neurovascular exam?

Answer 5

colour 
cap refill 
skin temp. 
O2 stats 
pulse
sensation 
sweating 
skin wrinkling on immersion in water

Question 6

how is a neurovascular issue diagnosed?

Answer 6

ultrasound
athrogram
CT/MR for detail

Question 7

what is a broad arm sling for?

Answer 7

supports but no traction for shoulder, collar and cuff traction - for humerus

Question 8

for a diaphyseal fracture?

Answer 8

immobilise joint above and below to prevent rotation

Question 9

for a metaphyseal fracture?

Answer 9

immobilise the adjacent joint

Question 10

risk with distal femur fracture?

Answer 10

risk of premature closing of the growth plate

Question 11

when to use external fixation?

Answer 11

contaminated wounds 
soft tissue problems 
acute vascular injury 
burns 
multiple injuries

Question 12

what is the periosteum?

Answer 12

it increased the width/circumference of growing long bones
rich source of osteoblasts
children - the periosteum is a lot thicker and tends to stay intact
useful for stability and can assist in reduction

Question 13

what is the advantage of children’s thicker periosteum?

Answer 13

allows fractures to heal more quickly in children

Question 14

what is the effect of children’s greater remodelling ability?

Answer 14

children have a greater potential to remodel as they grow with bone being formed along the line of stress
children can correct angulation of up to 10 degrees per year of growth
surgery is therefore performed less in children - if surgery is done less invasive procedures are favoured

Question 15

what age do fractures get treated the same as adults?

Answer 15

once the child’s reached puberty (12-14 years)

Question 16

Wolf’s law

Answer 16

bone in a healthy person/animal will adapt to the loads under which it is placed

Question 17

Hueter-Volkmann law (used to explain scoliosis)

Answer 17

bone growth during skeletal immaturity is delayed by mechanical compression on the growth plate and accelerated by growth plate tension

Question 18

What is the Salter-Harris classification for?

Answer 18

physeal fractures

Question 19

Salter-Harris 1

Answer 19

pure physeal separation (best prognosis, least likely to cause growth arrest)

Question 20

Salter-Harris 2

Answer 20

most common, physeal fractures, has a small metaphyseal fragment attached to the physis and epiphysis
likelihood of growth disturbance is low

Question 21

Salter-Harris 3 and 4

Answer 21

intra-articular fracture splits the physis
greater potential for growth arrest
fractures should be reduced and stabilised to ensure a congruent articular surface and minimise growth disturbance

Question 22

Salter-Harris 5

Answer 22

compression injury to the physis
causes growth arrest
can’t be diagnosed initially on x-rays
only detected once angular deformity has occurred
(larger the SH number worse the prognosis)

Question 23

when to suspect NAI?

Answer 23

multiple fractures of varying ages (varying amounts of callus/healing)
multiple bruises of varying ages
multiple trips to A&E with different injuries
inconsistent history of events
discrepancy of history between parents/carers
history doesn’t make sense for the injury
age of child doesn’t line up with injury
atypical injuries (cigarette burns, genital injuries, lower limb and trunk burns)
rib fractures
metaphyseal fractures in infants

Question 24

management of NAI?

Answer 24

paediatricians involved early
child admitted for safety
full exam and skilled history should be done by an experienced doctor

Question 25

common children's fractures

Answer 25

``` distal radius fractures forearm fractures supracondylar fractures of the elbow femoral shaft fractures tibial fractures ```

Question 26

distal radius buckle fractures (these ones involve the periosteum)

Answer 26

stable | only need 3-4 weeks of splintage

Question 27

Distal radius - Greenstick fractures

Answer 27

may be anguated | may need manipulation and casting if there is significant deformity (esp in an older child)

Question 28

distal radius - salter harris II fractures

Answer 28

common around the distal radial physis in older children angulation with deformity requires manipulation growth problems are highly unlikely

Question 29

what do complete fractures of the distal radius do?

Answer 29

may displace and angulate dorsal displacement and angulation is more common than volar doral periosteum tends to remain intact - prevents overcorrection of the deformity and helps stability

Question 30

Management of distal radius fractures

Answer 30

casting may be enough if the fracture is relatively stable | if a complete fracture is very unstable after reduction - may need wore stabilisation or plate fixation

Question 31

what is a Monteggia fracture - dislocation?

Answer 31

fracture of the proximal ulna with displacement of the radial head

Question 32

What is a Galeazzi fracture - dislocation?

Answer 32

fracture of the distal radius with dislocation of the distal radioulnar joint

Question 33

how are Monteggia and Galeazzi fractures managed?

Answer 33

anatomic reduction and rigid fixation with plates and screws because - if only manipulation and casting is used there is a hogh rate of re-dislocation of the radial head/distal radio-ulnar joint (DRUJ)

Question 34

Undisplaced monteggia and galeazzi fractures

Answer 34

usually have an intact periosteum and instability | may only be in one plane which can be controlled with a cast after manipulation

Question 35

displaced monteggia and galeazzi fractures

Answer 35

usually unstable | flexible IMN are usually used

Question 36

What are supracondylar fractures of the elbow?

Answer 36

pretty common - relatively common weak point extension-type fractures are more common - usually due to a heavy fall onto an outstretched hand flexion-type injuries are less common, usually due to a fall onto the point of the flexed elbow

Question 37

how are undisplaced supracondylar fractures of the elbow managed?

Answer 37

stable and treated with splint

Question 38

how are angulated/rotated/displaced supracondylar fractures of the elbow managed?

Answer 38

need closed reduction and pinning with wires to prevent deformity open reduction may be needed where close reduction isn't possible (e.g. severely displaced/offended fracture - long bone fracture which is displaced by more than the width of the bone)

Question 39

Test with off-ended extension type fractures in supracondylar fractures of the elbow?

Answer 39

patient is unable to make OK sign with hand because the distal fragment displaces posteriorly causes pressure on the brachial artery and median nerve (mainly anterior interosseous branch of the median nerve) this result in loss of FPL and FDP to the index

Question 40

How are displaced fractures of supracondylar fractures of the elbow managed?

Answer 40

reduce early to avoid swelling - swelling makes reduction more difficult if the radial pulse is absent/reduced in volume do EMERGENCY SURGERY can do closed reduction with wiring, pulse may return if artery is no longer under stress sometimes open surgery needed - if brachial artery is trapped in the fracture site OR if the hand remains pulseless after reduction

Question 41

what are the signs of and management of nerve injury and supracondylar fractures of the elbow?

Answer 41

neuralgic pain with no improvement - can be entrapment URGENT theatre management - surgical release majority are neurapraxias sometimes axonotmesis

Question 42

how do children get femoral shaft fractures?

Answer 42

children falling onto flexed knee indirect bending/rotational forces in children, overgrowth tends to occur after fracture so some shortening is accepted femur is a common site of benign/malignant bone tumours so the fracture may be pathological with osteolysis and cortical thinning

Question 43

femoral shaft fractures in less than 2s

Answer 43

mostly due to NAI/child abuse | treat with Gallows traction and early hip spica cast

Question 44

femoral shaft fractures in 2-6

Answer 44

treat Thomas splint or hip spica cast

Question 45

femoral shaft fractures in 6-12s

Answer 45

treat with flexible IMN (can use as the femur is now large enough) this will show if there is need for traction or cast

Question 46

femoral shaft fracture in over 12s

Answer 46

treat with adult type IMN

Question 47

What fracture is known as the toddlers fracture?

Answer 47

undisplaced tibial spiral fractures | require a short time in cast

Question 48

what is the standard management for tibial fractures in children?

Answer 48

a cast | the risk of compartment syndrome is much less than an adult

Question 49

what level of tibial angulation is accepted in children after fracture?

Answer 49

10 degrees | anymore treatment with manipulation and casting

Question 50

management of tibial fracture once in cast?

Answer 50

need to do serial X-rays in the cast make sure fracture doesn't drift into excessive angulation in the AP/lateral planes Don't Accept shortening/malrotation

Question 51

How are unstable/open tibial fractures managed?

Answer 51

flexible IMN (adolescents with a closed proximal tibial physis can have an adult type IMN) plates and screws or external fixation