Paediatric Fractures

1
Fractures in Children
Mamoun Kremli
2
General Principles

• Immature skeleton differs from that of the adult
  in both the normal and pathological states.
• Capable of plastic deformation before they fail.
• Comminuted fractures are rare.

3
General Principles

• Failure of union is rare.
• Few fractures require operative treatment.
• Presence of growth plate presents a challenge to
  the surgeon.
• Special considerations
• Pathological fractures
• Child abuse

4
General PrinciplesDevelopment and Growth

• A fracture in an immature bone can cause growth
  to speed up or slow down.
• Fractures heal very rapidly.
• Depending on the age of the child and direction
  of the deformity, can remodel with correction of
  most angular malunion.
• Most important area of injury is physis.

5
General PrinciplesRegulation of Epiphyseal Growth

• Physis is the primary centre for growth in most
  bones.
• Four functional zones
• Growth.
• Matrix.
• Transformation.
• Remodeling.

6
General PrinciplesRegulation of Epiphyseal Growth

• Physis responds to compression as well as
  distraction.
• Other stimuli to growth are insults from
• Implants.
• Fractures.
• Infections.
• Repeated attempts at reduction.

7
General PrinciplesGrowth and Remodeling of the
Metaphyseal Bone

• Zone of transition between the physis and
  diaphysis.
• Site of most rapid changes in bone structure.

8
General Principles

• Skeletal trauma accounts for 10-15 of all
  childhood injuries
• Physeal disruptions make about 15 of all
  skeletal injuries in children

9
Overall Frequency of Fractures

• Percentage of children sustaining at least one
  fracture from 0 to16 years of age
• Boys 42
• Girls 27
• Percentage of children sustaining a fracture in
  one year 1.6 2.1
• Percentage of children who are hospitalized
  because of a fracture
• During entire childhood (0 to 16 y) 6.8
• Each year 0.43

10
(No Transcript)
11
(No Transcript)
12
General PrinciplesIncidence of Fracture Type

• In one study 30 involved the physis.
• Of all physeal injuries, 50 occur in the distal
  radius.
• Second most commonly injured area is the distal
  humerus.

13
General PrinciplesIncidence of Fracture Type

• High energy trauma is the most common cause of
  death in children.
• Musculo-skeletal injuries are second to the CNS
  as the most frequent traumatic cause of permanent
  pediatric disability.

14
General PrinciplesClinical Examination of
theInjured Child

• Examination of the spine
• 3 of all pediatric injuries.
• Incidence of spinal fractures is about 12 in
  postmortem examination of children who died from
  high energy trauma.

15
General PrinciplesClinical Examination of
theInjured Child

• Examination of the spine
• Upper cervical spine is the most commonly injured
  area.
• Pain, torticollis, limitation of movement and
  muscle spasm raise the suspicion.

16
General PrinciplesClinical Examination of
theInjured Child

• Examination of the pelvis
• Most paediatric pelvic fractures are stable.
• Acetabular fractures represent 6 of pelvic
  fractures.
• Injury to triradiate cartilage can lead to growth
  arrest and dysplasia.

17
General PrinciplesClinical Examination of
theInjured Child

• Examination of the extremities
• Examined systematically one by one from distal to
  proximal.
• Neurovascular examination.
• Limb should be splinted before x-ray, if child
  complains of pain.

18
General PrinciplesExamination of theInjured
Child

• X-ray examination and other imaging
• AP and lateral.
• Comparison x-rays of the uninjured side help to
  evaluate growth plate injuries.
• CT for spine, pelvis and some intra-articular
  fractures.

19
General PrinciplesXray Examination of
theInjured Child

• Law of Two-s
• Two views
• Two joints
• Two limbs
• Two occasions
• Two physicians

20
General PrinciplesXray Examination of
theInjured Child

• Law of Two-s

21
General PrinciplesXray Examination of
theInjured Child

• Law of Two-s

22
General PrinciplesXray Examination of
theInjured Child

• Law of Two-s

23
Periarticular andArticular Fractures(
Epiphyseal Injuries )
24
Periarticular and Articular FracturesGeneral
Principles and Classification

• Inevitably involve the growth plate.
• Treatment and prognosis depends upon the pattern
  of injury.
• Frequently used classification is Salter-Harris.
• Muller proposed classification based upon three
  subdivisions.

25
Periarticular and Articular FracturesMullers
Classification

• Type A (Salter-Harris Types I and II)

26
Periarticular and Articular FracturesMullers
Classification

• Type B (Salter-Harris Types III and IV)

27
Periarticular and Articular FracturesMullers
Classification

• Type C (Salter-Harris Type V)

28
Epiphyseal Injuries
29
Epiphyseal Injuries
30
Epiphyseal Injuries
31
Epiphyseal Injuries
32
Epiphyseal Injuries
33
Epiphyseal Injuries
34
Pathological Fractures
Bone Cyst
35
Pathological Fractures
Osteopetrosis
36
Pathological Fractures
37
Supracondylar Fracture of HumerusLateral X-rays
38
Radiological Evaluation of Elbow

• Ant. fat pad
• Post. Fat pad
• Ant. Humeral line
• Radial head contour
• Radio-capitellar line
• Ossification centers
• Hourglass sign
• Distal humerus
• Ulna / olecranon
• Clinical correlation

39
Radiological Evaluation of Elbow

• Radio-capitellar line

40
Supracondylar Fracture of Humerus
41
Supracondylar Fracture of Humerus
42
Supracondylar Fracture of HumerusClosed Reduction
43
Supracondylar Fracture of HumerusComplications
44
Fracture of Lateral Humeral Condyle
45
Fracture of Lateral Humeral Condyle
46
Fracture of Lateral Humeral Condyle
47
Fracture of Medial Humeral Condyle
48
Pulled Elbow
49
Special Considerations
Child Abuse
50
Torus Fracture
51
Forearm Fractures
52
Closed Reduction of Forearm Fractures
53
Closed Reduction of Forearm Fractures
54
Forearm Fractures
55
Unstable Forearm Fractures
56
Monteggia
57
Monteggia
58
Galleazzi
59
Unstable Reduction
60
Unstable Reduction
61
X-ray Quiz !
62
Toddlers Fracture
63
Referances
64
Thank You
Mamoun Kremli