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Flashcards in Paediatric trauma/fracturs Deck (15):
1

What kind of fractures do children get?

Children’s bones are more elastic and pliable and tend to buckle or partially fracture or splinter with some degree of continuity of some “fibres” of bone (like breaking a green stick from a tree) rather than break completely. Hence the terms “buckle fracture” and “greenstick fracture”.

2

What is different about the treatment of paediatric fractures?

Children’s fractures tend to be surgically stabilized less frequently and greater degrees of displacement or angulation can be accepted. If the fracture position is unaccepatable, manipulation and casting may be all that is required accepting a degree of residual angulation or displacement.

Furthermore, if surgical stabilization is required for more unstable injuries, less invasive temporary pins, wires and flexible rods tend to be used with plates and screws reserved for very unstable periarticular injuries or where a fracture is associated with a dislocation and loss of position may result in redislocation (eg Monteggia and Galeazzi injuries of the forearm).

3

At what age are fractures treated as an adult fracture?

Once a child has reached puberty (around 12‐14), fractures tend to be treated as an adult’s fracture would as the remodeling potential is less.

4

What is the risk of fracture around the growth plate?

Fractures around the physis (growth plate) also have the potential to disturb growth which could result in a shortened limb or an angular deformity if one side of the physis is affected by growth arrest.

5

What is the salter-harris classification of physeal fractures?

A Salter‐Harris I fracture is a pure physeal separation. This carries the best prognosis and is least likely to result in growth arrest.

Most physeal fractures are Salter‐Harris II fractures. A Salter‐Harris II fracture is similar but has a small metaphyseal fragment attached to the physis and epiphysis. Again the likelihood of growth disturbance is low. Salter‐Harris II fractures are the commonest physeal farctures.

Salter‐Harris III and IV fractures are intra‐articular and with the fracture splitting the physis, there is greater potential for growth arrest. These fractures should be reduced and stabilized to ensure a congruent articular surface and minimize growth disturbance.

A Salter‐Harris V injury is a compression injury to the physis with subsequent growth arrest. These injuries cannot be diagnosed on initial x‐rays and are only detected once angular deformity has occurred.

6

What are three common distal radial fractures?

Buckle fractures can occur which are stable and require only 3‐4 weeks of splintage.

Greenstick fractures may be angulated and may require manipulation and casting if there is significant deformity, particularly in the older child

Salter‐Harris II fractures commonly occur around the distal radial physis in older children. Angulation with deformity requires manipulation. Growth problems are highly unlikely (as with most Salter Harris II fractures).

7

What is the treatment of distal radius fractures

Complete fractures may displace as well as angulate with dorsal displacement and angulation more common than volar. The dorsal periosteum usually remains intact which prevents overcorrection of the deformity and aids stability. If the fracture is fairly stable, casting may suffice. If a complete fracture is very unstable after reduction, wire stabilization or plate fixation may be employed.

8

What forearm fractures are common in children?

Both Monteggia and Galeazzi fracture‐dislocations can occur in children and adults. These injuries go against the usual principles of children’s fractures, in that anatomic reduction and rigid fixation with plates and screws is typically used to treat these injuries. There is a high rate of re‐dislocation of the radial head or distal radio-ulnar joint (DRUJ) if only manipulation and casting is used.

9

What is the treatment of both fractures of forearm?

With fractures of both bones of the forearm, angulated fractures usually have an intact periosteum and the instability may only be in one plane which can be controlled with a cast after manipulation. Displaced fractures tend to be unstable and flexible intramedullary nail are usually used.

10

What kind of elbow fractures occur in children?

Supracondylar fractures
-The supracondylar region of the distal humerus is a relatively weak point in the growing upper limb and supracondylar elbow fractures are fairly common injuries.

-Extension type fractures are more common and occur due to a heavy fall onto the outstretched hand. The less common flexion type injury occurs with a fall onto the point of the flexed elbow.

11

What is the treatment of supracondylar fractures in children?

-undisplaced = stable and treated with a splint
-angulated/rotated/displaced = closed reduction and pinning with wires, this is done ASAP to avoid swelling
-if radial pulse absent/reduced in volume = emergency surgery required. Brachial artery occasionally trapped in fracture site and if hand remains pulseless = open surgical exploration is required
-if nerve injury = emergency surgery

12

If a patient cant make an OK sign what is lost?

With off‐ended extension type fractures the distal fragment displaces posteriorly with stretch and pressure on the brachial artery and median nerve

(predominantly its anterior interosseous branch – the patient is unable to make the “OK” sign due to loss of FPL and FDP to the index).

13

How are femoral shaft fractures managed in:
-in children less than 2
-children aged 2-6
-children aged 12 and above

In children less than 2 years old, more than half of femoral shaft fractures are due to NAI / child abuse – other signs of NAI should be looked for (see previous section; multiple injuries & bruises of varying age, atypical injuries, inconsistent or inappropriate history etc.) and acted upon appropriately. In this age group, treatment with Gallows traction and early hip spica cast is appropriate.

With children aged between 2 and 6, options include a Thomas splint or a hip spica cast.

For children between 6 and 12 the femur is large enough to accommodate flexible intramedullary nails which obviate the need for traction or cast.

For children aged 12 and above, an adult type intramedullary nail is typically used.

One should remember that the femur is a common site for benign and malignant bone tumors and the fracture may be pathological with osteolysis and cortical thinning.

14

What is a toddlers fracture?

Undisplaced spiral fractures of the tibial shaft are common in toddler’s (the injury is known as a “toddler’s fracture”) and these require a short time in cast.

15

what is the management of a tibial fracture?

Management in a cast is the mainstay for the majority of children’s tibial fractures. The risk of compartment syndrome is much less than that for an adult. Up to 10° of angulation may be accepted and greater degrees of angulation may be treated with manipulation and casting. Serial xrays in the cast are required to ensure that the fracture does not drift into excessive angulation in the AP or lateral planes. Shortening or malrotation should not be accepted.

Options for stabilizing very unstable or open fractures include flexible intramedullary nails, plates and screws or external fixation. Adolescents with a closed proximal tibial physis can have an adult type intramedullary nail.