common pediatric fractures
DESCRIPTION
Common Pediatric Fractures. Prof. Mamoun Kremli AlMaarefa Medical College. Objectives. How are children’s fractures different Discus common fractures in children X -ray diagnosis Principles of management Identify Epiphyseal injuries Precautions. Statistics. - PowerPoint PPT PresentationTRANSCRIPT
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Prof. Mamoun KremliAlMaarefa Medical College
Common Pediatric Fractures
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Objectives
• How are children’s fractures different
• Discus common fractures in children• X-ray diagnosis
• Principles of management
• Identify Epiphyseal injuries
• Precautions
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Statistics
• ~ 42% of boys and 25% of girls, are expected to have a fracture during childhood (Landin 83)
• Percentage of children sustaining a fracture in 1 year: 1.6% to 2.1% (Warlock &Stower 86)
Mamoun Kremli
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Statistics
• ~ 42% of boys and 25% of girls, are expected to have a fracture during childhood (Landin 83)
• Incidence increases with age – peak ~ 12-14 yrs
Mizulta, 1987
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Introduction
• In Middle East ~50% of population < 20 yrs
• Different from adult fractures
• Varies in various age groups
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Statistics
Most frequent sites
74%
, Mizulta, 1987, (923 children)
47%
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Fractures specific to children
• Greenstick
• Torus (buckle)
• Deformation
• Physeal injuries
www.imageinterpretation.co.uk/
www.radiologyassistant.nl/
www.wheelessonline.com/
Mamoun Kremli
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Different from adults
• Ends of long bones have thick cartilage:• Not seen on x-rays
• Thick periosteum, good blood supply:• Heal well and quickly
• More elastic, more cancellous:• Incomplete fractures, simple fractures
• Growth plate:• Good remodeling
• Special growth plate injuries
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The power of remodeling
• Can accept more angulation and displacement
• Rotational mal-alignment ?does not remodel
www.brokenarmanswers.com/
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The power of remodeling
• Can accept more angulation and displacement
• Better remodeling near growth plates
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The power of remodeling
http://www.acep.org/
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The power of remodeling
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Treatment
Most fractures in children heal well
Whatever you do!
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Choice of treatment
• Stable fractures - incomplete:• Greenstick
• Buckle (Torus)
• Plastic deformation
• Stable fractures – complete:• Undisplaced
• Displaced, reducible
• Unstable fractures:• Bothe bones at same level
• Oblique fractures
• Comminuted fractures
• Preference (patients’ / surgeons’, choice)
Conserv
ative
Operativ
e
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Closed reduction
• More commonly used in children
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Closed reduction - Casting
• Still the commonest
• Good remodeling power
• Needs careful monitoring• Regular follow-ups
• Swelling subsides:
• cast loose
• displaces
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Casting - Problems
• Forearm is a joint – needs anatomic reduction• Mal-union results in loss of supination/pronation
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Casting - Problems
• Mal-alignment in LL causes osteoarthritis
Gicquel
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Casting - Problems
• Overlap – shortening
• Loss of reduction
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Casting - Problems
6 yr old - 5wks 9 yr old
K Willkins, Injury Suppl 36
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Surgical treatment
• K-wires
• Intramedullary nails
• Plates
• External Fixator
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K-Wires
• The commonest in children
• Very effective• Prevents displacement
• Needs additional casting
• Application:• Percataneous
• Open
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Elastic IM Nails
• Unstable fractures – minimal surgery
P. Schmittenbecher
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Plating
• For overweight children
• Problems:• Large scars
• Needs removal
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Plating
• Bridge plating
• MIPO:• Introduced through small wounds
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External fixator
• Open (compound) fractures
www0.sun.ac.za/ortho
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Common injuries
• Clavicle
• Radius
• Forearm fracture – fracture dislocation
• Supracondylar Humerus
• Epiphyseal injuries
• Non-accidental injuries
• Precaution
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Clavicle fracture
• Common• Birth injury
• Pseudo-paralysis
• Fall on outstretched hand
• Heals well conservatively
• No functional problems
• Treatment:• Sling or figure of 8 bandage
http://parkingspot.wordpress.com/
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Supracondylar fracture
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Supracondylar humerus
• A common injury
• Fall on the outstretched hand, elbow hyperextended
• Anatomically thin part of lower humerus
• Nerve or vessel injury possible
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Supracondylar humerus
• Fall on outstretched hand - Hyper-extension of elbow (the commonest type)
www.radiologyassistant.n
Anterior
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Supracondylar humerus
• Fall on outstretched hand - Hyper-extension of elbow (the commonest type)
www.radiologyassistant.n
Anterior
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Supracondylar humerus
• Fall on outstretched hand - Hyper-extension of elbow (the commonest type)
www.radiologyassistant.n
Anterior
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Supracondylar humerus
• Fall on outstretched hand - Hyper-extension of elbow (the commonest type)
www.radiologyassistant.n
Anterior
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Supracondylar humerus
www.radiologyassistant.n
• Fat pad sign
www.radiologyassistant.n
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Fat pad sign
• Fat pad sign:• Indicates a fracture
www.radiologyassistant.nl/
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X-ray lines in elbow
www.radiologyassistant.nl
• 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
Normal Abnormal
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Supracondylar fracture
• Classification (Gartland’s)
http://tidsskriftet.no/
Undisplaced Posterior intact Completely displaced
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Supracondylar humerus
• Needs immediate care• Nerve injury: Median N, Radial N
• Vascular injury: Brachial artery (tenting)
• Swelling: compartment syndrome
www.wheelessonline.com/ www.mendelsonortho.com/
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Supracondylar humerus
• Needs immediate care• Delay causes more swelling
• More difficulties in reduction
• More vascular compromise
• Undisplaced: Casting
• Displaced:• Closed reduction and fixation with K-wires
• ? Open reduction and fixation with K-wires
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6y girl, fell from swing
Injury reduction 3 m 2 yrs
Teddy Slomgo, Bern, Switzerland
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Supracondylar humerus
• Closed reduction and percutaneous K-wires
Teddy Slomgo, Bern, Switzerland
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Supracondylar humerus
• Neurovascular injury must be ruled out
• Swelling and possible kinking of vessels
• May cause Volkmann's ischemia• A real emergency
www.studyblue.com
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Supracondylar fractures
• Most are displaced and need surgery
• Type I can be managed with long arm cast, forearm neutral, elbow 90o for 4 wks
• Bivalve cast if acute
• Follow-up xrays 3-7 days later to document alignment
• Xrays at 4 weeks to document callus
• Once callus noted at 4 weeks, discontinue cast and start active ROM
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Supracondylar fractures
• Delayed complication
• Malunion• Often cubitus varus
deformity
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Lateral condyle - humerus
• Mostly cartilaginous• Fracture may be easily
missed
• Displacement may not be appreciated
• Needs fixation even if undisplaced
• If not fixed, may displace
www.radiologyassistant.nl
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Forearm – Radius and Ulna
• A joint: supination and pronation• Anatomical reduction is a must
• Treatment:• Closed reduction and casting
• Closed reduction and intramedullary nail
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Closed reduction and casting
• Good method if reduction maintained
• Needs close, regular follow-up
http://eorif.com/
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Intramedullary nail
• When unstable, or re-displace in cast
Teddy Slongo, Bern, Switzerland
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Plating
Kelly D. Carmichae, Orthop 2007
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Lower Radius
• Torus (Buckle)• Treatment:
• Casting
• Complete:• Treatment:
• Conservative
• ? K-wire if unstable
www.radiologyassistant.nl/
Parikh, Orthopedics, June 2013
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Fracture Dislocation
• Montaggia• Fracture ulna, dislocation of head of radius
• Galiazzi• Fracture radius, dislocation of distal radio-ulnar joint
www.mysportphysio.com
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Monteggia
• Fracture of shaft of ulna, dislocated radial head
• May be missed if two joints not seen on x-ray
www.medisuite.ir/medscape
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Monteggia
• Fracture of shaft of ulna, dislocated radial head
• May be missed if two joints not seen on x-ray
www.medisuite.ir/medscape
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X-ray lines in elbow
• Radio-capitellar line• A line drawn through the center of the radial neck
should pass through the center of the capitellum in all views
www.radiologyassistant.nl/
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X-ray lines in elbow
• Radio-capitellar line• A line drawn through the center of the radial neck
should pass through the center of the capitellum in all views
• If not: dislocated radial head
www.radiologyassistant.nl/
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Monteggia fracture
• Treatment:• Reduce ulna
• Reduce head of radius
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Galeazzi fracture
www.pemcincinnati.com
• Fractured radius, with
• Dislocation of distal
radio-ulnar joint
• Treatment:• Reduction of radius
• Reduction of DRUJ
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Femur
• Problems:• Bleeding
• May bleed more than 1 L
• Conservative treatment:
• Shortening, mal-union
• Operative treatment:
• Another surgery to remove implants
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Femur
• Conservative: e.g. 5 year old• Hip spica cast
• 1-2 cm shortening will be compensated by growth
AAOS guidelines, E. Sinkhttp://orthoinfo.aaos.org/
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Femur
• Operative: in older children• Good alignment and length
• Nailing better than plating
AAOS. J. BeatyAOFoundation.org
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Tibia
• Direct Vs. indirect injury
• Soft tissue injuries
• Compartment syndrome
• Need to correct• Alignment, rotation, and length
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Closed reduction - ESIN
• Closed reduction and casting
• Closed reduction and nailing
• Open reduction and plating - less
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Physeal injuries
• Incidence:• About 15-20 % of all skeletal injuries in children
• 50% occur in the distal radius
• Problem:• Possibility of growth affection
• Some are intra-articular
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Physeal anatomy• Physis: 4 zones
• Germinal zone
• Proliferative zone
• Hypertrophic zone
• Enchondral ossification
Metaphysis
Epiphysis
Weakest zone - fractures
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Physeal injuries
More common in• Boys• Peak ~ 12y of age• Upper limb
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Classification – Salter- Harris
I II III
VIV
75%
Most common
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Treatment – Salter Harris I
• Closed reduction
• Fixation if unstable only
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Treatment – Salter Harris I
• Closed reduction
• Fixation if unstable only
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Treatment – Salter Harris II
• Need good stable reduction
• Possibly closed reduction, percutaneous fixation
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Treatment – Salter Harris III
• Intra-articular
• Anatomic reduction, stable fixation
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Treatment: Salter Harris IV
• Intra-articular
• Anatomic reduction and stable fixation
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Treatment – Salter Harris V
• No treatment available !
• Diagnosed in retrospect !
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Complete Physeal affection
• Usually seen in Salter-Harris type V
Injury films Injured and uninjured wrists after premature physeal closure
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Asymmetrical physeal affection• Standard radiography
remains the initial imaging evaluation of choice
• Oblique Park-Harris growth recovery line
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Asymmetrical physeal affection
• 12Y, male, Salter-Harris II3y post injury
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Beware!
• Non-accidental injuries
• Tumors
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Beware!
Non-accidental injuries
• Specific pattern• Femur shaft fracture
• <1 year of age• ( 60-70% non accidental)
• Transverse fracture
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Beware!
Non-accidental injuries
• Specific pattern• Femur shaft fracture
• <1 year of age• ( 60-70% non accidental)
• Transverse fracture
• Humeral shaft fracture
• <3 years of age
• Sternal fractures
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Beware!
Non-accidental injuries
• Specific pattern• Corner fractures (traction & rotation)
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Beware!
Non-accidental injuries
• Specific pattern• Bucket handle fractures (traction & rotation)
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Physical Examination
• Undress the child
• Look for areas of bruising • Bruises at different stages of healing
emedicine.medscape.com
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Physical Examination
• Undress the child
• Look for areas of bruising • Bruises at different stages of healing
• Bruises take shape of inflicting instrument
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Physical Examination
• Undress the child
• Look for areas of bruising • Bruises at different stages of healing
• Bruises take shape of inflicting instrument
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Physical Examination
• Undress the child
• Look for areas of bruising • Bruises at different stages of healing
• Bruises take shape of inflicting instrument
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Physical Examination
• Trunk• Back, palpate rib cage, abdomen
mandyb87.weebly.com www.mecourse.com
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Physical Examination
• Head - examine for skull trauma, palpate fontanel's if open, consider funduscopic exam for retinal hemorrhage
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Physical Examination
• A silent child tells the story!
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Physical Examination
• A silent child tells the story!
www.kidspot.com.au
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Consider non-accidental if
1. Delay in seeking medical attention
2. Mechanism incompatible with injury
3. Physical location of injury
4. Vague history, lacking the "real truth"
5. Varying history• e.g. one parent contradicting the other
6. Inappropriate parental attitude or behavior• e.g. lack of concern, over-concern, aggression
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Consider non-accidental if
7. Inappropriate parent-child interaction
8. Features of failure to thrive or neglect
9. Allegation of assault
10.Signs of prior injury or injuries of different age
11.Characteristic injuries, illnesses or hospital visits
12.Femoral shaft fracture < 2 years
13.Radiological features
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Beware!Malignant tumors
• Can present as injury
• History of trauma usual
•12 y old girl• History of trauma• Mild tenderness• Periosteal reaction•Diagnosed as injury
• 2m later, still tender• Ewings sarcoma
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Summary
• About 50% of population in ME are children
• Fractures in children are common
• Compare with other side
• Closed reduction still good
• Surgery might be needed
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Summary
• Supracondylar humerus needs urgent attention
• Forearm• a joint – needs good alignment
• Look for fracture dislocation in forearm
• In lower limb:• maintain alignment, rotation, and length
• Epiphyseal injuries
• Beware: Non-accidental & Tumors