Fraktur pada Anak

Fraktur pada AnakChildren Are Not Miniature AdultsOpen Growth PlatesRemodeling PotentialPlastic BoneRELEVANCENearly 20% of children who present with an injury have a fracture42% boys, 27% girls will sustain fracture in childhood

Growth Plate Principles

Growth Plate Anatomy

INJURY PATTERN IN GROWING BONESBones tend to BOW rather than BREAKCompressive force= TORUS fractureAka. Buckle fractureForce to side of bone may cause break in only one cortex= GREENSTICK fractureThe other cortex only BENDSIn very young children, neither cortex may break= PLASTIC DEFORMATION

INJURY PATTERNSCONTPoint at which metaphysis connects to physis is an anatomic point of weaknessLigaments and tendons are stronger than bone when youngBone is more likely to be injured with forcePeriosteum is biologically active in children and often stays intact with injuryThis stabilizes fracture and promotes healingPHYSEAL INJURIESMany childhood fractures involve the physis20% of all skeletal injuries in childrenCan disrupt growth of boneInjury near but not at the physis can stimulate bone to grow more

SALTER HARRISClassification system to delineate risk of growth disturbanceHigher grade fractures are more likely to cause growth disturbanceGrowth disturbance can happen with ANY physeal injury11Higher likelihood with higher salter harris classes

I S =Slip (separated or straight across). Fracture of the cartilage of the physis (growth plate)II A =Above. The fracture lies above the physis, orAway from the joint.III L =Lower. The fracture is below the physis in the epiphysis.IV TE =Through Everything. The fracture is through the metaphysis, physis, and epiphysis.V R =Rammed (crushed). The physis has been crushed.

(alternatively SALTER can be used for the first 6 types - as above but adding Type V: 'E' for Everything or Epiphysis and Type VI:'R' for Ring)

SALTER HARRIS CLASSIFICATIONIFracture passes transversely through physis separating epiphysis from metaphysisIIIIIIVV

SALTER HARRIS CLASSIFICATIONIIITransversely through physis but exits through metaphysisTriangular fragmentIIIIVV

SALTER HARRIS CLASSIFICATIONIIIIIICrosses physis and exits through epiphysis at joint spaceIVV

SALTER HARRIS CLASSIFICATIONIIIIIIIVFracture extends upwards from the joint line, through the physis and out the metaphysisV

SALTER HARRIS CLASSIFICATIONIIIIIIIVVCrush injury to growth plate

PHYSEAL FRACTURESMOST COMMON: Salter Harris ___PHYSEAL FRACTURESMOST COMMON: Salter Harris _II_Followed by I, III, IV, VRefer to ortho III, IV, VI and II effectively managed by primary care with casting (most commonly)Dont forget to tell Mom and Dad that growth disturbance can happen with any physeal fracture

ITS GOOD TO BE YOUNGChildren tend to heal fractures faster than adultsAdvantage: shorter immobilization timesDisadvantage: misaligned fragments become solid soonerAnticipate remodeling if child has > 2 years of growing leftMild angulation deformities often correct themselvesRotational deformities require reduction (dont remodel)ITS GOOD TO BE YOUNGFractures in children may stimulate longitudinal bone growthSome degree of bone overlap is acceptable and may even be helpfulChildren dont tend to get as stiff as adults after immobilizationAfter casting, callus is formed but still may be fibrousAvoid contact activities for 2-4 weeks once out of castCOMMON FRACTURESDistal radiusElbowClavicleTibia

DISTAL RADIUSPeak injury time correlates with peak growth timeBone is more porousMost injuries result from FOOSHCheck sensation: median and ulnar nerveNerve injury more likely to occur with significant angulation of fragment or with significant swellingExamine elbow (supracondylar) and wrist (scaphoid)Acceptable limitsAngulation:< 9 years: 150> 9 years: 100Malrotation:< 9 years: 450> 9 years: 300Shorteningusually not problem

DISTAL RADIUSTorus fracturesUsually nondisplaced- strong periosteumSubtle, may be best seen on lateralGreenstick fracturesCompression of dorsal cortex, apex volar angulationComplete (transverse) fracturesTORUS FRACTURESNo reduction neededIf > 48 hours old, ok to cast at first visitOtherwise splint and cast at 5-7 daysShort arm cast for 4 weeksRepeat x-rays unnecessary unless no clinical improvement after 4 weeksSplint an additional 2 weeks

GREENSTICK FRACTURESIf non-displacedShort arm castIf displaced >15 degrees, reduce and immobilize in long arm4 weeks cast, 2 weeks splint

DISTAL RADIUS PHYSIS FRACTURENon-displaced Salter I can appear normal on plain filmsPresence of pronator fat pad along volar distal radius on lateral film = occult fractureIf tender over physis, treat as fracture

SALTER HARRIS II

DISTAL RADIUS FRACTURESDisplaced fractures= reduce asapNon-displaced fractures= short arm cast for 3-6 weeksThe older the child, the longer immobilizationIf x-rays are normal initially but tenderness is over growth plate, immobilize for 2 weeksBring child back to re-examine and re-xrayIf no callus, fracture is unlikely

ELBOW10% of all fractures in childrenDiagnosis and management complexEarly recognition and referralMost are supracondylar fracturesSequence of ossification:Come Read My Tale Of LoveCapitellum, Radial head, Medial epicondyle, Trochlea, Olecranon, Lateral epidondyleAge 1, 3, 5, 7, 9, 1134Need to know normal ossification to help distinguish fracture from normal finding in the elbowWhen in doubt, image other side!!ELBOW FRACTUREEXAMINATIONCheck neurovascular statusFlex and extend fingers and wrist Oppose thumb and little fingerPalpate brachial and radial pulsesCapillary refill in fingersImmobilize elbow before radiographs to avoid further injury from sharp fragmentsFlexion 20-30 degrees = least nerve tension

Know basic landmarks on lateral view to give clues to distinguish fracture from normal

Anterior humeral linemiddle 1/3 capitellumRadiocapitellar linepoints directly to capitellumDisruption = displaced fractureFat pad sign may be only clue if non-displacedFat Pad sign (aka. Sail Sign)Anterior fat pad sign can be normalPosterior always abnormal

SUPRACONDYLAR FRACTURESWeakest part of the elbow joint where humerus flattens and flaresMost common fracture is extension typeOlecranon driven into humerus with hyperextensionMarked pain and swelling of elbowPotential for vascular compromiseCheck pulse!!! Reduce fracture if pulse compromisedCheck nerve function in hand39Compartment syndrome of the forearm can complicate fracture- unrelenting pain, severe swelling, paresthesiaSUPRACONDYLAR FRACTURE CLASSIFICATIONType I- non-displaced or minimally displacedType II- displaced distal fragment with intact posterior cortexType III- displaced with no contact between fragmentsAnterior Humeral Line

Radiocapitellar Line

SUPRACONDYLAR FRACTURESMANAGEMENTMost are displaced and need surgeryType I can be managed with long arm cast, forearm neutral, elbow 90o for 4 wksBivalve cast if acuteFollow-up xrays 3-7 days later to document alignmentXrays at 4 weeks to document callusOnce callus noted at 4 weeks, discontinue cast and start active ROMSUPRACONDYLAR FRACTURESCOMPLICATIONSMalunionOften varus deformity at elbow with loss of full extension (gunstock deformity)Cosmetic concerns, usually no functional deficit

Hyperextension DeformityCubitus Varus Gunstock DeformityLATERAL CONDYLAR FRACTURESSecond most common elbow fractureMost common physeal elbow injuryFOOSH + Varus force = lateral condyle avulsionExam: focal swelling at lateral distal humerusLATERAL CONDYLAR FRACTURESMost common x-ray findings:Fracture line begins in distal humeral metaphysis and extends to just medial to capitellar physis into the jointNeurovascular injury rarely

MEDIALLATERALLATERAL CONDYLAR FRACTURESMANAGEMENTIntraarticular = open reductionIf non-displaced, can treat with castingPosterior splint acutely, elbow 90oAt follow-up (weekly), check for late displacementIf stable x 2 weeks, long arm cast for another 4-6 weeksComplications: growth arrest, non-unionCLAVICLEMost occur in the _____ third of the boneCLAVICLEMost occur in the middle third of the bone80%15% distal third, 5% proximal thirdFOOSH, fall on shoulder, direct traumaClinical: pain with any shoulder movement, holds arm to chestPoint tender over fracture, subQ crepitusOften obvious deformityCLAVICULAR FRACTUREAP view often sufficient to diagnose if midshaftConsider 45o cephalic tilt view if needed

CLAVICULAR FRACTUREIn displaced fracture: sternocleidomastoid pulls upward to displace medial clavicle, lateral fragment pulled downward by weight of arm

CLAVICULAR FRACTUREMANAGEMENTSling versus figure-of-eight bandageFracture fully healed when pt has painless ROM at shoulder and non tender to palpation at fractureGenerally back to full activity by 4 weeksProtect from contact sports x 6 weeksWarn of the healed bulge

TIBIATibia and fibula fractures often occur together If you see a tibial fracture, hunt for a fibular oneFibular fracture could be plastic deformityMechanism: falls and twisting injury of the footLow force, intact periosteum and support from fibula prevent displacement commonlyTIBIAL FRACTUREWhen to refer:Displaced fractureTib/fib fracturesFractures with > 15o varus angulation

TIBIAL FRACTUREMANAGEMENTPosterior lower leg splint if acuteNon-displaced fractures: long leg cast for 6-8 weeksRepeat radiographs weekly to check positionRefer if angulates more than 15oTODDLERS FRACTURESChildren younger than 2 years old learning to walkNo specific injury notable most of the timeChild refuses to bear weight on legExamine hip, thigh and knee to r/o other causes of limpingTODDLERS FRACTURESIf you suspect it, get AP and lateral views of entire tib/fib areaTypical: nondisplaced spiral fracture of tibia with no fibular fractureInitial x-ray often normal, diagnosis on f/u films with lucent line or periosteal reaction

TODDLERS FRACTURESConsider and rule out abuse when neededExamine for soft tissue injury to buttocks, back of legs, head, neckTransverse fractures of mid-shaft are more suspicious for child abuseManagement: long leg cast x 3-4 weeksWeight bearing as toleratedHeals completely in 6-8 weeksFRACTURES OF ABUSEMajority of fractures in child < 1 year are from abuseHigh percentage of fractures