OVERVIEW OF PEDIATRIC
TRAUMA
Presenter: Dr Gituri Philip
Moderator: Dr E. Gakuya
An 8-year-old boy presents to the emergency department with a Salter-Harris type IV
fracture of the distal femur from a football tackle. The fracture has 3mm of
displacement and 15 degrees of angulation in the sagittal plane. Because of his
young age you know he has excellent potential to remodel. The BEST treatment
option would include:
a) Long-leg cast
b) Percutaneous pinning in situ
c) Open reduction and internal fixation with distal femoral locking plate
d) Open reduction and internal fixation of the metaphyseal component but not the
epiphyseal component to avoid potential growth arrest
e) Open reduction and internal fixation of both components with plates and or screw
fixation
OUTLINE
1. Epidemiology of Pediatric Fractures
2. Uniqueness of Children's bones
3. Child abuse/Neglect/ Non-accidental trauma (NAT)
4. Multiply injured Child
5. Principles of Management
6. Specific cases/Precautions
INTRODUCTION
• over 40% of boys and 25% of girls sustain a fracture by 16 years of age1
• properties of the immature skeleton- these injuries have different
characteristics, complications, and management than similar adult injuries
• data from five large epidemiologic studies :distal forearm # most common
(nearly 25% of 12,946 fractures), then clavicle # (over 8% of all children's
fractures)
• Mann et al. [5] reported of 2,650 long bone fractures in children, 30%
involved the physis.
PROPERTIES OF THE IMMATURE
SKELETON
1. Plastic Deformation- most common in the forearm, particularly the ulna
• Stress–strain curves for mature and immature bone. The increased strain of
immature bone before failure represents plastic deformation.
a. Buckle (Torus) Fractures- most commonly occur at transition between
metaphyseal woven bone and the lamellar bone of the diaphyseal cortex
3. Greenstick Fractures - immature bone is more flexible and has a thicker
periosteum than mature adult bone
• Reduction: “unlock” the impacted fragments on the tension side by initially
exaggerating the deformity and then applying traction and a reducing force
• stable after reduction but have an increased likelihood of refracture
• immobilize these fractures for a full 6 weeks
4. Remodeling/Overgrowth -fractures heal more rapidly than those in
adults, but once healed, they remodel residual deformity
Factors affecting remodellong potential:
i.
amount of growth remaining (the patient's skeletal age)
ii.
the plane of the deformity in relation to adjacent joints
iii.
the deformity's proximity to the physis and
iv. the growth potential of the particular physis
5. Potential for accelerated growth of an injured limb -most frequently seen
in diaphyseal femoral fractures.(spontaneously correctting shortening of up
to 2 cm)
Theories ascribe this to hyperemia
6. Physeal Injuries
• 15% to 30% of all fractures in children
• peak in adolescents
• growth deformity is rare, occurring in only 1% to 10% of all physeal injuries.
• Physeal anatomy
Most injuries occur just above area of provisional
calcification within the hypertrophic zone.
Germinal layer frequently remains intact and
attached to the epiphysis
CLASSIFICATION OF PHYSEAL INJURIES
• Goal in treating physeal fractures
i.
to achieve and maintain an acceptable reduction without subjecting the germinal
layer of the physis to any further damage.
ii.
determining the limits of an acceptable reduction
iii.
Because of the intra-articular component, displaced type III and IV injuries must be
reduced regardless of the time that has elapsed since the injury
iv. reduction can be maintained with a cast, pins, internal fixation, or some combination
of these three
COMPLICATIONS OF PHYSEAL
INJURIES
1. malunion,
2. infection,
3. neurovascular problems,
4. Osteonecrosis
5. Growth Disturbance
CARE OF THE MULTIPLY INJURED
CHILD
• Blunt trauma -leading cause of death in children older than 1 year of age
• Children possess a number of anatomic and physiologic characteristics that
make their injuries and their injury response different from adults'
OPEN FRACTURES
• Incidence and mechanism of open fractures differ between children and
adults
• their management is similar, requiring an aggressive, thorough, and
systematic approach
• most common open fractures in children involve the hand and upper
extremity
• Open fractures of the lower extremities, esp tibia, are the result of higherenergy trauma, esp automobile–pedestrian or automobile–bicycle
accidents
GUSTILO AND ANDERSON
CLASSIFICATION SYSTEM
• Type I
• Wound <1 cm long
• Moderately clean puncture wound
• Usually “inside-out” injury
• Little soft tissue damage, no crushing
• Little comminution
• Type II
• Wound >1 cm long
• Extensive soft tissue damage to muscles, skin, and
neurovascular structures and a high degree of
contamination
• Three subtypes:
A.
Adequate soft tissue coverage (includes high-
• No extensive tissue damage
energy segmental, comminuted fractures,
• Slight or moderate crush injury
regardless of normal size)
• Moderate comminution or contamination
•
• Type III
B.
Local or free flap required for coverage
C.
Arterial injury requiring repair
Open Fracture Management
1. Thorough assessment for life-threatening injuries
2. Immediate intravenous antibiotics, continue for 48 hours:
i.
ii.
iii.
3.
4.
5.
6.
7.
8.
Grade I—first-generation cephalosporin
Grades II and III—first-generation cephalosporin + aminoglycoside
“Barnyard” injuries—add anaerobic coverage (penicillin or metronidazole)
Tetanus prophylaxis
Thorough operative debridement
Adequate fracture stabilization
Second operative debridement in 48-72 hours if indicated
Early definitive soft tissue coverage
Early bone grafting if indicated
CHILD ABUSE/NONACCIDENTAL
TRAUMA/BATTERED CHILD SYNDROME
• 1% to 1.5% of all children are abused each year
• children are more likely to be abused by caregivers who are young, poor,
and of minority status
• Younger children are also more likely to die from abuse
• After skin lesions, fractures are the second most common physical
presentation
• bone that fractures under tension with torsion
• Femoral shaft, hands and feet fractures in nonambulatory infants
• Fractures in unusual locations
SPECIFIC FRACTURES
• Cervical spine injuries in children (1% of pediatric fractures and 2% of all
spinal injuries )
i.
ii.
younger than 8 years age - upper cervical spine,
older children and adolescents - either the upper or lower C- spine
• Pelvic fractures comprise less than 0.2% of all pediatric fractures
• two most common classification systems used :Young and Burgess and Tile
and Pennal
Torode and Zieg Classification of
pelvic fractures in children
• Hip Fractures: blood supply of the proximal femur comes from two major
branches of the profunda femoris artery—the medial and lateral circumflex
arteries
• classified into four types based on the anatomic location of the fracture as
described by Delbet
i.
ii.
iii.
iv.
Type I: Transepiphyseal
Type II: Transcervical
Type III: Cervicotrochanteric
Type IV: Pertrochanteric or intertrochanteric
Fractures about the Elbow
• 5% to 10% of all fractures in children
• distinguishing fractures from the six normal secondary ossification centers
• (CRITOE)
Spinal Cord Injury Without
Radiographic Abnormality(SCIWORA)
• overwhelmingly found in children (15% to 35% of SCIs in children)
• most, if not all, will have abnormal findings on MRI
• spinal column is more elastic than the spinal cord
• more common in children under 8 years of age than in older children
• predisposing factors
i.
ii.
iii.
cervical spine hypermobility,
ligamentous laxity, and
an immature vascular supply to the spinal cord
Pathologic fractures
• May results from
a. Local causes: primary bone tumors,
metastases , osteomyelitis, pronounced
bowing of the bone (e.g. in crus varum
congenitum , which can then develop
into congenital tibial pseudarthrosis )
a. Generalized causes: Osteogenesis
imperfecta , Stuve-Wiedemann syndrome
, rickets , juvenile osteoporosis , storage
disorders such as Gaucher disease .
BIRTH INJURIES
• Clavicle- commonest site, followed by the humerus and femur
• Risk factors: Shoulder dystocia, high birth weight and gestational age
• Proximal and distal humerus, distal femur: Epiphyseal separations due to birth
trauma at best, suspected on an x-ray since the humeral head and distal
end of the humerus and femur cartilaginous
• confirmed sonographically
TREATMENT OF FRACTURES
IN CHILDREN
1. Closed treatment
• majority of fractures treated by
closed reduction and casting or
traction
• well-molded cast.
• Open treatment
•
•
•
•
•
•
•
•
Open fractures.
Polytrauma.
Patients with head injuries.
Femoral fractures in adolescents.
Femoral neck fractures.
Certain types of forearm fractures.
Certain types of physeal injuries.
Fractures associated with burns.
Types of Fixation
i.
Treatment of periarticular and articular fractures -3.5 mm cortex screws, 4.0
mm cancellous bone screws (exceptionally 6.5mm), and cannulated
screws
ii.
epiphyseal and metaphyseal fragments- K-wire fixation
iii. Transphyseal wires should be non-threaded
iv. External fixation devices for patients with open fractures, polytrauma, and
fractures associated with burns(great care exercised not to damage the
growth plate)
• Standard closed intramedullary nailing used in femoral shaft fractures in adolescents, in
younger children the use of elastic titanium nails (TEN)