Chapter 16 Salter Made

SPESIFIC FRACTURES AND JOINT INJURIES IN CHILDREN

Oleh: Made Dwi Pratiwi (I11111031)Pembimbing: dr. Oktavianus, Sp.OT (K) Spine

Fakultas Kedokteran Universitas TanjungpuraRSAU DR. M. SOETOMO- PONTIANAK

2015

Special Features of Fractures and dislocations in Children

1) Fracture more commonThe higher incidence of fractures in children is explained by the combination of their relatively slender bones and their carefree capers. Crack or hairline fractures, buckle fractures, and greenstick fractures are not serious. Intra-artricukar fractures and epiphyseal plate fractures are very serious indeed.

2) Stronger and more active periosteumThe stronger periosteum in children is less readily torn across at the time of a fracture; consequently there is more often an intact periosteal hinge that can be used during closed reduction of the fracture. Furthermore, the periosteum is much more osteogenic in children than it is in adults.

3) More rapid fracture healingThe rate of healing in bone varies much more with age, particulary during childhood than it does in any others tissue in the body. This is closely related to the osteogenic activity of the periosteum and endosteum, a process that is remarkably active at birth, becomes progressively less active with each year of childhood and remains relatively constant from early adult life to old age. Fracture of the shaft of the femur serve as an example of this phenomenon.

4) Special Problems of Diagnosis5) Spontaneous correction of certain residual deformities In adults, the deformity of a malunited fracture is permanent, but in children certain residual deformities tend to correct spontaneously either by extensive remodeling or epiphyseal plate growth, and sometimes by a combination of both.

Angulation

6. Differences in Complications

7. Different Emphasis on Methods of Treatment8. Torn Ligaments and Dislocations Less Common

9. Less Tolerance of Major Blood Loss

Special Types of Fractures in Children

• There are two special type:

1. fractures that involve the epiphyseal plate

The risk becoming complicated by serious disturbance of local growth and the consequent development of progressive bony deformity during the remaining years of skeletal growth.

Diagnosis of Epiphyseal Plate Injuries

• Clinically in any injured child who exhibits (signs such as local swelling and tenderness), a traumatic dislocation, or a ligamentous injury (including a sprain)

• At least two projections at right angles to each other are essential.

Salter-harris Classification of Epiphyseal Plate injuries

The classification is based on the mechanism of injury as well as the relationship of the fracture line to the growing cells of the epiphyseal plate

Healing of Epiphyseal plate Injuries

• After reduction of a separated epiphysis, as in type I, II, III injuries, endochondral ossification on the metaphyseal side of the epiphyseal plate is only temporarily disturbed. Within 2 or 3 weeks of replacement of the epiphysis.

• Type IV injuries by contrast must healin the same manner as any other fracture through cancellous bone, and type V injuries usually heal by a bony bridge across the epiphyseal plate.

Prognosis Concerning Growth Disturbance

• Type of injury• Age of the child• Blood supply to the epiphysis• Method of reduction• Open or closed injury• Velocity and force of the injury

Possible Effects of Growth Disturbance

• 85% of epiphyseal plate injuries are uncomplicated by growth disturbance

Special Considerations in the Treatmentof Epiphyseal Plate Injuries

• Type I dan II injuries can nearly treated by closed reduction

• Displaced type III injuries and displaced type IV injuries always require open reduction and internal fixation. The period of immobilization required for types I, II, and III injuries is only half that required for a metaphyseal fracture of the same bone in a child of the same age

Avulsion of traction epiphyses

• A sudden traction force applied through either a ligament or a tendon to a traction epiphysis may result in an avulsion of the epiphysis through its epiphyseal plate.

• Exampel of such injuries are avulsion of the medial epicondyle of the humerus and the lesser trochanter of the femur.

Birth Fractures

• During the difficult delivery of a large baby, especially a breech presentation, when the threat of fetal anoxia may necessitate rapid extraction of the baby, one limb may be difficult ti disengage from the birth canal and a bone may be inadvertently fractured or an epiphysis separated.

Spesific Birth Fractures

• Clavicle• Humerus

• Femur

• Spine Fortunately, birth injuries of the spine are rare. But they are extremely serious because they may be complicated by complete paraplegia

Special Fractures and Dislocations

• The Hand

The wrist and forearm

• Distal radial epiphysis

• Distal third of radius and ulna incomplete fractures

• Complete fractures

• Middle third of radius and ulna

Proximal third of radius and ulna

The elbow and arm

Pulled elbow

Children of preschool age are particullary vulnerable to a sudden longitudinal pull or jerk on their arms and frequently sustain the common minor injury

Proximal radial epiphysis Fracture- separation of the proxymal radial epiphysis is produced by a fall that exerts a compression and abduction force on the elbow joint. It’s a type II epiphyseal plate injury with a characteristic metaphyseal fragment and the radial head becomes tilted on the neck.

Dislocation of the elbow

Posterior dislocation of the elbow joint occurs relatively frequently in young children as a result of a fall on the hand with the elbow flexed.

Medial epicondyle

Avulsion of the medial epicondyle (a traction epiphysis) result from a sudden traction force through the attsched medial ligament in association with two types of injuries.