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Prof. Muhammad Prof. Muhammad ShahiduzzamanShahiduzzaman
Head, Head, Department of Department of Orthopaedics & TraumatologyOrthopaedics & Traumatology
Dhaka Medical College HospitalDhaka Medical College Hospital
Paediatric FracturePaediatric Fracture
In Bangladesh 60% of population are <20 yrs
Fractures accounts for 15% of all injuries in children.
Different from adult fractures.
Vary in different age groups (Infants, children, adolescents)
IntroductionIntroduction
Children have different physiology and anatomy
Growth plate. Bone. Cartilage. Periosteum. Ligaments. Age-related physiology
Children are very specialChildren are very special
In infants, GP is stronger than bone.
increased diaphyseal fractures
Provides perfect remodeling power.
Injury of growth plate causes deformity.
A fracture might lead to overgrowth.
Growth PlateGrowth Plate
• Increased collagen: bone ratiolowers modulus of elasticity
Increased cancellous bonereduces tensile strengthreduces tendency of fracture
to propagateless comminuted fractures
Bone fails on both tension and compressioncommonly seen “buckle” fracture
BoneBone
• Increased ratio of cartilage to bone• better resilience• difficult x-ray evaluation• size of articular fragment often under-estimated
CartilageCartilage
• Metabolically active• more callus, rapid
union, increased remodeling
• Thickness and strength• Intact periosteal
hinge affects fracture pattern
• May aid reduction
PeriosteumPeriosteum
Age related # patternAge related # pattern
Better blood supply,
so less incidence of Delayed or non-union.
PhysiologyPhysiology
• Bones tend to BOW rather than BREAK• Compressive force= TORUS fracture
• Aka. Buckle fracture
• Force to side of bone may cause break in only one cortex= GREENSTICK fracture• The other cortex only BENDS
• In very young children, neither cortex may break= PLASTIC DEFORMATION
Injury PatternInjury Pattern
Green Stick FractureGreen Stick Fracture
TorusGreenstick
Green Stick FractureGreen Stick Fracture
Plastic Deformity
Injury PatternInjury Pattern
Point at which metaphysis connects to physis is an anatomic point of weakness
Ligaments and tendons are stronger than bone when young Bone is more likely to be injured with force.
Periosteum is biologically active in children and often stays intact with injury• This stabilizes fracture and promotes
healing.
Injury PatternInjury Pattern
Many childhood fractures involve the physisMany childhood fractures involve the physis 20% of all skeletal injuries in children20% of all skeletal injuries in children Can disrupt growth of boneCan disrupt growth of bone Injury near but not at the physis can stimulate Injury near but not at the physis can stimulate
bone to grow bone to grow moremore
Physeal InjuryPhyseal Injury
SALTER HARRIS SALTER HARRIS CLASSIFICATIONCLASSIFICATION Classification system to
delineate risk of growth disturbance
Higher grade fractures are more likely to cause growth disturbance
Growth disturbance can happen with ANY physeal injury
It has grade I upto grade V.
Physeal InjuryPhyseal Injury
Fracture passes transversely through physis separating epiphysis from metaphysis.
Salter Harris Grade ISalter Harris Grade I
Transversely through physis but exits through metaphysis
Triangular fragment
Salter Harris Grade IISalter Harris Grade II
• Crosses physis and exits through epiphysis at joint space.
Salter Harris Grade IIISalter Harris Grade III
• Extends upwards from the joint line, through the physis and out the metaphysis.
Salter Harris Grade IVSalter Harris Grade IV
Crash Injury to growth plate
Salter Harris Grade VSalter Harris Grade V
MOST COMMONMOST COMMON: Salter Harris : Salter Harris II Followed by I, III, IV, VFollowed by I, III, IV, V Refer to orthopedics: III, IV, VRefer to orthopedics: III, IV, V I and II effectively managed by primary care I and II effectively managed by primary care
with casting (most commonly)with casting (most commonly)
Parents should be informed that growth Parents should be informed that growth disturbance can happen with any physeal fracturedisturbance can happen with any physeal fracture
Salter Harris Salter Harris
Power of remodelingPower of remodeling
Tremendous power of remodelingTremendous power of remodeling Can accept more angulation and displacementCan accept more angulation and displacement Rotational mal-alignment ?does not remodelRotational mal-alignment ?does not remodel
Malunion-Remodeling Process
Factors affecting remodeling potentialFactors affecting remodeling potential
•Years of remaining growth – most important factor•Position in the bone – the nearer to physis the better•Plane of motion –greatest in sagittal, the frontal, and least for transverse plane•Physeal status – if damaged, less potential for correction•Growth potential of adjacent physis
•e.g. upper humerus better than lower humerus
Power of remodelingPower of remodeling
Children tend to heal fractures faster than Children tend to heal fractures faster than adults requiring shorter immobilization adults requiring shorter immobilization time.time.
Anticipate remodeling if child has >2 yrs of Anticipate remodeling if child has >2 yrs of growing left – mild angulation deformities growing left – mild angulation deformities often correct themselves but rotational often correct themselves but rotational deformities requires reduction.deformities requires reduction.
Its good to be young!!!Its good to be young!!!
Fractures in children may stimulate Fractures in children may stimulate longitudinal growth – some degree of longitudinal growth – some degree of overlap is acceptable and may even be overlap is acceptable and may even be helpful.helpful.
Children don’t tend to get as stiff as adults Children don’t tend to get as stiff as adults after immobilization.after immobilization.
Its good to be young…Its good to be young…
Law of Two’sLaw of Two’s : : Two viewsTwo views Two jointsTwo joints Two limbsTwo limbs Two occasionsTwo occasions Two physiciansTwo physicians
Xray examinationXray examination
Radio-capitaller line
Evaluation of paediatric elbow filmEvaluation of paediatric elbow film
Supracondylar Fracture of Humerus
Evaluation of paediatric elbow filmEvaluation of paediatric elbow film
Mostly conservative – closed reduction and Mostly conservative – closed reduction and cast immobilizationcast immobilization
Open reduction & internal fixation.Open reduction & internal fixation.
Principle of ManagementPrinciple of Management
Displaced intra articular fracturesDisplaced intra articular fractures
( ( Salter-Harris III-IV Salter-Harris III-IV )) fractures with fractures with vascularvascular injury injury ? ? Compartment Compartment syndromesyndrome Fractures not reduced by closed reductionFractures not reduced by closed reduction
( soft tissue interposition, button-holing of ( soft tissue interposition, button-holing of periosteum )periosteum )
If reduction can not be maintained or could If reduction can not be maintained or could be only maintained in an be only maintained in an abnormal positionabnormal position
Indication for operative managementIndication for operative management
Indication for operative managementIndication for operative management
Casting—the commonest.Casting—the commonest.
Method of fixationMethod of fixation
K-wires K-wires most commonly most commonly
usedused Metaphyseal Metaphyseal
fracturesfractures
Method of fixationMethod of fixation
Intramedullary wires, elastic nailsVery useful, Diaphyseal fractures
Method of fixationMethod of fixation
ScrewsScrews
Method of fixationMethod of fixation
ScrewsScrews
Method of fixationMethod of fixation
Plates and screwsPlates and screws Multiple Trauma
Method of fixationMethod of fixation
IMN Nailing (adolescent only)IMN Nailing (adolescent only) Chances of growth disturbences.
Method of fixationMethod of fixation
External FixationExternal Fixation
In open Fractures
Method of fixationMethod of fixation
Casting - still the commonestCasting - still the commonest K-wires K-wires
most commonly usedmost commonly used Metaphyseal fracturesMetaphyseal fractures
Intramedullary wires, elastic nailsIntramedullary wires, elastic nails Very usefulVery useful Diaphyseal fracturesDiaphyseal fractures
ScrewsScrews Plates – multiple traumaPlates – multiple trauma IMN - adolescentsIMN - adolescents Ex-fixEx-fix
Combination
Method of fixationMethod of fixation
Malunion is not usually a problem Malunion is not usually a problem (except cubitus varus)(except cubitus varus)
Nonunion is hardly seen (except in Nonunion is hardly seen (except in lateral condyle of humerus)lateral condyle of humerus)
Growth disturbance – epiphyseal damageGrowth disturbance – epiphyseal damage Vascular - volkmann’s ischemiaVascular - volkmann’s ischemia Infection - rareInfection - rare
ComplicationComplication
Battered Baby Syndrome:Battered Baby Syndrome:• Soft tissue injuries - Soft tissue injuries -
bruising, burnsbruising, burns• Intra-abdominal injuriesIntra-abdominal injuries• Intracranial injuriesIntracranial injuries• Delay in seeking treatmentDelay in seeking treatment• # at diff. stage of healing.# at diff. stage of healing.
Non-accidental injuryNon-accidental injury
Radiology of child abuse
Corner’s fracture (traction and rotation)
Bucket handle fracture (traction and rotation)
Pathological fracturePathological fracture