Paediatric Fractures and Management.pptx

Presentation Slide regarding on fractures in children

1. Paediatric Fractures By: Farisan Salahaudin Fazreen

2. Introduction Different from adult fracture. Periosteum more thicker, less displacement Young children has more cartilage, cant see in x-ray. Need to compare for both limb Bone has more cellular activity and less britlle Heal rapidly (better blood supply), non union is rare (periosteum is thicker, stabilize the fracture and promote healing) High frequency of incomplete fracture than adult

3. Physeal fracture 10% of the childhood injury Boys > girls usually result from fall due to road accidents/ during sports. Weak part of the bone Fracture usually runs transverse Can disrupt bone formation (growth) Fracture run through the cellular reproductive layer of the plate → premature ossification → stop growth

4. anatomy of the bone

5. Salter-Harris classification Widely used classification of physeal fracture. Has 5 type. Higher type more likely to cause growth disturbance

6. Type 1 Fracture passed transversely through calcified zone of the plate Growing zone usually not injured Growth disturbance are uncommon

7. Type 2 Same as type 1, but towards the edge, the fracture deviates away from physis , and split of triangular piece of metaphyseal bone Growth usually no affected

8. Type 3 Fracture running partly along physis and split through epiphysis into the joint May cause growth disturbance (damage the reproductive zone in the physis )

9. Type 4 Same as type 3 but fracture split form epiphysis extend to the metaphysis Liable to displacement. May cause asymmetrical growth

10. Type 5 Longitudinal compression injury of the physis . No visible fracture. Growth plate is crush May result growth arrest.

11. Clinical feature Deformity usually minimal. Pain & tenderness around fracture area.

12. Treatment Undisplaced fracture Splinting in a cast or close-fitting plaster slab for 2-4 weeks Type 3 & 4 need to re x-rays after 4 & 10 days – not to miss late displacement. Displace fracture Type 1 & 2 – reduce A.S.A.P (closed reduction and splint for 3-6 weeks) Tpe 3 & 4 – need perfect anatomical reduction ( gentle manipulation under GA), then held limb in a cast (4-8 weeks) If cannot be accurately reduced → open reduction & internal fixation with smooth K – wires → held limb in a cast (4-6 weeks)

13. K wires

14. Complication Premature fusion Type 3,4 & 5 more likely to cause premature fusion → cessation of growth and deformity of the bone end Deformity Asymmetrical growth Malunion of a displaced fracture

15. Greenstick fracture Bone bend & cracks instead of breaking completely into separate pieces Due to softer & more flexible bone in children Clinical feature : Intense pain Swelling Deformity may be present

16. X-ray of greenstick fracture

17. Treatment Reduce and casted for about 6 weeks May take a long time to heal – commonly occur at the middle, slower growing part of the bone

18. Torus fracture a.k.a buckle fracture/incomplete fracture Form from longitudinal compression & results in a localized cortical bulge A compression fracture of a long bone Common in children Occur when Falling with outstretched hand.

19. X-ray of torus fracture

20. Treatment Immobilization – casting of the affected limb for 3-4 week

21. Fractures of the Upper Limb

22. Fractures of the upper limb in children Fractures of distal humerus Supracondylar humerus fractures Condylar fractures Epicondylar fractures Fractures of the radius and ulna shaft Galeazzi fracture Monteggia fracture

23. Anatomy

24. Normal paediatric elbow X-ray?

25. Fractures of the distal humerus in children Supracondylar fractures Condylar fractures Epicondylar fractures Boys> girls >50% are under 10 years old Fall directly on the point of the elbow/ onto the outstretched hand with the elbow forced into valgus / varus .

26. Supracondylar fractures Commonest fracture of elbow in children Distal fragment may be displaced Posteriorly (95%) Anteriorly Medially Laterally rotated

27. Anterior humeral Line A line drawn on a lateral view along the anterior surface of the humerus should pass through the middle third of the capitellum . In cases of a supracondylar fracture the anterior humeral line usually passes through the anterior third of the capitellum or in front of the capitellum due to posterior bending of the distal humeral fragment

28. Posteriorly displaced Distal fragment is displaced backward

29. Anteriorly displaced Distal fragment is displaced forward

30. Clinical features Pain Swollen elbow S deformity of the elbow (in posterior fracture)

31. S-deformity

32. Gartland classification Type 1- are  undisplaced or minimally displaced fractures Type 2- are partially displaced (fragments are nearly aligned, some bony contact is present) Type 3- are completely displaced

33. X-ray Undisplaced fractures

34. Type 2

35. Type 3

36. Treatment Type 1 fractures   Elbow flexed at 90  with p laster cast (2-3 weeks) Type 2 fractures   Closed reduction Elbow flexed at 90  with p laster cast (3 weeks) Type 3 fractures Conservative If failed, percutaneous crossed K-wires

37. Complications Compartment syndrome and vascular injury Volksmann’s ischemic contracture Nerve injury Ulnar and median nerves Malunion deformity Elbow stiffness

38. Fractures of the lateral condyle These fractures occur when a varus force is applied to the extended elbow. Tendency to be unstable and displaced due to muscle pull

39. Milch classification Type I Fracture line is lateral to trochlear groove Type II Fracture line into trochlear groove

40. Since most of the structures involved are cartilageneous , the fracture line through the cartilage is not visible on radiograph. It is very difficult to know the exact extent of the fracture . In suspected case, try xray in oblique view or compare with contralateral limb.

41. Treatment Undisplaced fracture Splint elbow (2 weeks) Displaced fracture Manipulation If failed, ORIF (screws and K-wires) Cast Wires moved after 3-4 weeks

42. Complications Nonunion and malunion Cubitus valgus Ulnar nerve palsy Recurrent dislocation

43. Separation of the medial epicondylar apophysis Mostly in early adolescence boys. Mechanism of injury acute valgus stress due to a fall on the outstretched hand or sometimes due to armwrestling . Chronic injuries do occur in young athletes (little league elbow).

44. Clinical Features Epicondaylar fragment might be trapped into elbow joint Swollen Tender

45. Treatment Minor displacement elbow splint (2-3 weeks) exercises Markedly displaced sutured back to position Removal of trapped fragment in the joint If displaced Manipulation with elbow in valgus & wrist hyperextended in order to pull on the flexor muscles

46. Fractures of the radius and ulna Mechanism of injury Twisting force producing spiral fractures Direct blow/ angulating force causes transverse fractures Fractures may be of greenstick type (incomplete) or complete Clinical features Pain Swelling Deformity

47. Treatment Closed reduction Full length cast (6-8 weeks) With elbow at 90 degrees Forearm is supinated if fracture is proximal to pronator teres If distal to pronator teres , forearm in neutral position Hand and shoulder exercises is encouraged

48. Complications Nerve injury Posterior interosseous nerve Compartment syndrome Delayed union and non union Malunion

49. Radial shaft fractures ( Galeazzi fractures) Defined as solitary fractures of the distal third of the radius With subluxation or dislocation of the distal radio- ulnar joint ( DRUJ ) Reverse Monteggia's fracture ( Galeazzi is more common than Monteggia ) Mechanism of injury fall on to an extended, pronated wrist. Clinical features Pain and tenderness Swelling Deformity

50. Treatment In paediatric case closed reduction If DRUJ is unstable, fixed with K-wire Splint the forearm with cast (6 weeks) Complication   Nonunion   Malunion (unstable fracture)  Limitation of pronation or supination

51. Monteggia's fractures Characteristic Fractures of the proximal third of ulnar shaft With dislocation of radial head Mechanism of injury fall on to an outstretched, extended and pronated elbow, A direct blow. Clinical features Pain swelling

52. Treatment Closed reduction Long-arm cast (elbow flexed at 90  and forearm supinated ) ORIF if reduction is unstable Complications Restricted elbow flexion due to imperfect reduction

53. Outline Fracture of femoral shaft Fracture of tibial shaft Fracture of distal tibia triplane Non-accidental injury

54. FRACTURE OF FEMORAL SHAFT

55. MECHANISM OF INJURY In older children, high energy trauma (e.g. motor vehicle accidents) is the mechanism of injury 90% of the time.  In younger children, these fractures are usually due to falls. As many as 30% of femoral shaft fractures in children younger than 4 years may be the result of child abuse The most common cause of femur fractures in the nonambulatory infant is nonaccidental trauma.  Factors suggestive of child abuse include bruises, burns, multiple fractures in various stages of healing, and late presentation

56. CLINICAL PRESENTATION Severe thigh pain The thigh is noticeably swollen or deformed Unable to stand or walk limited range of motion of the hip or knee allowed by the child because of pain. Shortening

57. IMAGING

58. Treatment AGE ORTHOPAEDIC TREATMENT OPTION 0-6 months Pavlik harness Immediate spica cast 6 months to 5 years Immediate spica cast Traction- spica cast 5-11 years Flexible intamedullary nailing 11 years- skeletal maturity Rigid tronchateric entry nailing Submuscular plating Flexible intramedullary nail (only if <50 kg)

59. Femoral Shaft Fractures: 0 - 6 Months Pavlik harness To keep the distal femoral fragment in alignment with the proximal fragment. The rapid healing and significant remodeling potential of children in this age group permit this easy method of immobilization. Stable union typically achieved within 5 weeks

60. Immediate spica cast Applied with reduction under sedation or with general anesthesia The patient is placed on a spica table and an assistant holds the lower extremities while the surgeon places the cast A short leg cast is first placed on the fractured side, the fracture is pulled out to length, and a one-and-a-half spica cast is placed The cast need not include the foot on the injured side so as to prevent fracture angulation when the foot is actively plantar-flexed against the cast Shortening in the cast should be < 2 to 3 cm, depending on the child's age. Parents are advised that the child may have a limp for 6 to 12 months following cast removal

61. Traction followed spica casting In school-aged children, acceptable closed reduction without excessive shortening may be difficult to attain or maintain in an immediate spica cast. If this is the case, an initial period of skin or skeletal traction for 2 or 3 weeks followed by spica casting may be employed.

62. Complication Leg length discrepancy Angular deformity Rotational deformity Delayed union-should unite in 100 days +/- 20 days Nonunion Malunion Muscle weakness Infection- open injury Neurovascular injury Compartment syndrome

63. TIBIAL FRACTURE

64. Mechanism of injury: falls and twisting injury of the foot Among the most frequently encountered pediatric fractures. Consists: traumatic tibial shaft +/- fibula fractures most commonly due to pedestrian vs vehicle (50%) Toddler's fracture

65. Toddler's fracture characteristics nondisplaced  spiral or oblique fracture of tibial shaft only fibula remains intact also known as childhood accidental spiral tibial (CAST) fractures age group children< 3 years (walking toddlers) unlike child abuse injury, which occurs in children not yet walking mechanism low energy trauma with rotational component involves distal half of tibia unlike non-accidental injury, which typically involves proximal half of tibia Pathopysiology Dt shear stress and lack of displacement due to the periosteum that is relatively strong compared to the elastic bone in young children.

66. CLINCAL PRESENTATION Symptoms pain bruising limping or refusal to bear weight Physical exam warmth, swelling over fracture site tender over fracture site pain on ankle dorsiflexion always have high suspicion for compartment syndrome

67. Management Acute case - posterior lower leg splint. Non-displaced fractures: long leg cast for 6-8 weeks. Repeat radiographs weekly to check position.

68. COMPLICATIONS Compartment syndrome with both open and closed fractures Leg-length discrepancy Angular deformity varus  for tibia only fractures valgus  for tibia-fibula fractures Associated physeal injury  proximal or distal Delayed union and nonunion usually only after external fixation

69. DISTAL TIBIA TRIPLANE FRACTURE

70. EPIDEMIOLOGY A triplane fracture of the distal tibia usually occurs during adolescence and occurs before complete closure of the distal tibial physis (growth plate) most commonly in patients aged 12-15 years. It represents 5-10% of all pediatric intra- articular ankle injuries. Male-to-female frequency ratio varies in the literature from 1:1 to 2:1. In studies indicating a higher incidence in males, this is postulated to be caused by later closure of the lateral tibial growth plate in males than in females , thereby lengthening the period of vulnerability to injury for males.

71. ANATOMY Growth plate is a weak area which closes from central to medial and then to lateral. Medial Central lateral

72. triplane  fractures involving all three planes: may be 2, 3, or 4 part fractures Sagittal (epiphysis)  Transverse (growth plate) Coronal (metaphysis)

73. MECHANISM OF INJURY External rotation of the foot on the tibia Plantar flexion of he foot Create stress to a partially open distal lateral tibial growth plate Triplane fracture

74. CLINICAL PRESENTATION Pain Swelling Possible ecchymosis Possible ankle deformity Inability to bear weight on the injured ankle

75. 2 part triplane fracture 3 part triplane fracture

76. Management Undisplaced (<2mm displacement) Immobilization with short leg cast (4-6 weeks). Displaced (> 2mm displacement) Closed reduction Followed with above-knee-casting (4-6 weeks) Replaced with a below the knee cast for another 4 weeks ~ to allow limited weight bearing. ORIF placement of epiphyseal screws parallel to the joint surface ~ avoid the growth plate and the ankle joint

77. Complication Complications include the following: Tibial length growth retardation or deformity around the ankle secondary to epiphyseal growth plate injury Posttraumatic arthritis Postoperative infection Osteomyelitis Pressure sores from the cast Fracture blisters Compartment syndrome

78. NON ACCIDENTAL INJURY

79. Nonaccidental trauma, or child abuse, continues to be a significant cause of morbidity and mortality in children today. Second only to burns and bruises, fractures are the second most common manifestation of nonaccidental trauma. Certain fracture patterns are considered more suggestive than others for nonaccidental trauma, including spiral humeral fractures, metaphyseal corner fractures of the distal femur and tibia, and others. Spiral fractures in general have been thought to have a high likelihood of nonaccidental trauma because of the typical “twisting” mechanism required to cause such a fracture. Fractures of children younger than 1 year are highly associated with nonaccidental trauma, because infants do not have the mobility required to sustain accidental trauma with sufficient energy to cause a fracture.

80. Drug / alcohol - abusing parents Single-parent homes Family with low socioeconomic status Young < 3 years First born children Disabled children Stepchildren RISKS FACTOR

81. Inconsistent history of injury Delay in presentation Reported mechanism of injury insufficient to explain injury Parents/caregivers may be hostile or indifferent Suspect !

82. Multiple fractures in different stages of healing Soft tissue injuries - bruising, burns Intra-abdominal injuries Intracranial injuries Associated features

83. Femur fracture in child < 1 year old Humeral shaft fracture in < 3 year old Sternal fractures Metaphyseal corner (bucket-handle) fractures Posterior rib fracture Digit fractures in nonambulatory children Fractures commonly seen

84. Careful search for signs of acute or chronic trauma * Sign - bruises, abrasions, burns * Head - examine for skull trauma, palpate fontanelles if open, consider funduscopic exam for retinal hemorrhage * Trunk - palpate rib cage, abdomen * Extremities - careful palpation * Genitalia – consider exam for sexual abuse Physical examination

85. 101

86. 102 Diaphyseal fracture in children < 3 years old are very suggestive of NAI Spiral is also one of the injury in NAI, Result - twisting force to the limb, but Constitute only 8-36% in NAI Also commonly occur in accidental injury

87. TREATMENT Non-operative report abuse to appropriate agency Indications: Physicians are mandated reporters, and are legally obligated to report suspected child abuse and neglect. Physicians are granted immunity from civil and criminal liability if they report in good faith, but may be charged with a crime for failure to report early involvement of social workers and pediatricians is essential 2. hospital admission Indications: admit infants with fractures to the hospital and consult child protective services obtain social service consult Operative definitive treatment as indicated for particular injury