Common Pediatric
Fractures
Prof. Mamoun Kremli
AlMaarefa Medical College
Objectives
• How are children’s fractures different
• Discus common fractures in children
• X-ray diagnosis
• Principles of management
• Identify Epiphyseal injuries
• Precautions
Statistics
• ~ 42% of boys and 25% of girls, are expected
to have a fracture during childhood
(Landin 83)
• Percentage of children sustaining a fracture in
1 year: 1.6% to 2.1% (Warlock &Stower 86)
Mamoun Kremli
Statistics
• ~ 42% of boys and 25% of girls, are expected
to have a fracture during childhood
(Landin 83)
• Incidence increases with age – peak ~ 12-14
yrs
Mizulta, 1987
Introduction
• In Middle East ~50% of population < 20 yrs
• Different from adult fractures
• Varies in various age groups
Statistics
Most frequent sites
47%
74%
, Mizulta, 1987, (923 children)
Fractures specific to children
• Greenstick
• Torus (buckle)
• Deformation
• Physeal injuries
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Mamoun Kremli
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Different from adults
• Ends of long bones have thick cartilage:
• Not seen on x-rays
• Thick periosteum, good blood supply:
• Heal well and quickly
• More elastic, more cancellous:
• Incomplete fractures, simple fractures
• Growth plate:
• Good remodeling
• Special growth plate injuries
The power of remodeling
• Can accept more angulation and displacement
• Rotational mal-alignment ?does not remodel
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The power of remodeling
• Can accept more angulation and displacement
• Better remodeling near growth plates
The power of remodeling
http://www.acep.org/
The power of remodeling
Treatment
Choice of treatment
• Stable fractures - incomplete:
• Greenstick
• Buckle (Torus)
• Plastic deformation
• Stable fractures – complete:
• Undisplaced
• Displaced, reducible
• Unstable fractures:
•
•
•
•
Bothe bones at same level
Oblique fractures
Comminuted fractures
Preference (patients’ / surgeons’, choice)
Closed reduction
• More commonly used in children
Closed reduction - Casting
• Still the commonest
• Good remodeling power
• Needs careful monitoring
• Regular follow-ups
• Swelling subsides:
• cast loose
• displaces
Casting - Problems
• Forearm is a joint – needs anatomic reduction
• Mal-union results in loss of supination/pronation
Casting - Problems
• Mal-alignment in LL causes osteoarthritis
Gicquel
Casting - Problems
• Overlap – shortening
• Loss of reduction
Casting - Problems
9 yr old
6 yr old - 5wks
K Willkins, Injury Suppl 36
Surgical treatment
• K-wires
• Intramedullary nails
• Plates
• External Fixator
K-Wires
• The commonest in children
• Very effective
• Prevents displacement
• Needs additional casting
• Application:
• Percataneous
• Open
Elastic IM Nails
• Unstable fractures – minimal surgery
P. Schmittenbecher
Plating
• For overweight children
• Problems:
• Large scars
• Needs removal
Plating
• Bridge plating
• MIPO:
• Introduced through small wounds
External fixator
• Open (compound) fractures
www0.sun.ac.za/ortho
Common injuries
• Clavicle
• Radius
• Forearm fracture – fracture dislocation
• Supracondylar Humerus
• Epiphyseal injuries
• Non-accidental injuries
• Precaution
Clavicle fracture
http://parkingspot.wordpress.com/
• Common
• Birth injury
• Pseudo-paralysis
• Fall on outstretched hand
• Heals well conservatively
• No functional problems
• Treatment:
• Sling or figure of 8 bandage
Supracondylar fracture
Supracondylar humerus
• A common injury
• Fall on the outstretched
hand, elbow hyperextended
• Anatomically thin part of
lower humerus
• Nerve or vessel injury
possible
Supracondylar humerus
• Fall on outstretched hand - Hyper-extension of
elbow (the commonest type)
Anterior
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Supracondylar humerus
• Fall on outstretched hand - Hyper-extension of
elbow (the commonest type)
Anterior
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Supracondylar humerus
• Fall on outstretched hand - Hyper-extension of
elbow (the commonest type)
Anterior
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Supracondylar humerus
• Fall on outstretched hand - Hyper-extension of
elbow (the commonest type)
Anterior
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Supracondylar humerus
• Fat pad sign
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Fat pad sign
• Fat pad sign:
• Indicates a fracture
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X-ray lines in elbow
• Anterior humeral line
• A line drawn on a lateral view along the anterior
surface of the humerus should pass through the
middle third of the capitellum
Abnormal
Normal
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Supracondylar fracture
• Classification (Gartland’s)
http://tidsskriftet.no/
Undisplaced
Posterior intact
Completely displaced
Supracondylar humerus
• Needs immediate care
• Nerve injury: Median N, Radial N
• Vascular injury: Brachial artery (tenting)
• Swelling: compartment syndrome
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Supracondylar humerus
• Needs immediate care
• Delay causes more swelling
• More difficulties in reduction
• More vascular compromise
• Undisplaced: Casting
• Displaced:
• Closed reduction and fixation with K-wires
• ? Open reduction and fixation with K-wires
6y girl, fell from swing
Injury
reduction
Teddy Slomgo, Bern, Switzerland
3m
2 yrs
Supracondylar humerus
• Closed reduction and percutaneous K-wires
Teddy Slomgo, Bern, Switzerland
Supracondylar humerus
• Neurovascular injury must be ruled out
• Swelling and possible kinking of vessels
• May cause Volkmann's ischemia
• A real emergency
www.studyblue.com
Supracondylar fractures
• Most are displaced and need surgery
• Type I can be managed with long arm cast,
forearm neutral, elbow 90o for 4 wks
• Bivalve cast if acute
• Follow-up xrays 3-7 days later to document
alignment
• Xrays at 4 weeks to document callus
• Once callus noted at 4 weeks, discontinue
cast and start active ROM
Supracondylar fractures
• Delayed complication
• Malunion
• Often cubitus varus
deformity
Lateral condyle - humerus
• Mostly cartilaginous
• Fracture may be easily
missed
• Displacement may not be
appreciated
• Needs fixation even if
undisplaced
• If not fixed, may displace
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Forearm – Radius and Ulna
• A joint: supination and pronation
• Anatomical reduction is a must
• Treatment:
• Closed reduction and casting
• Closed reduction and intramedullary nail
Closed reduction and casting
• Good method if reduction maintained
• Needs close, regular follow-up
http://eorif.com/
Intramedullary nail
• When unstable, or re-displace in cast
Teddy Slongo, Bern, Switzerland
Plating
Kelly D. Carmichae, Orthop 2007
Lower Radius
• Torus (Buckle)
• Treatment:
• Casting
• Complete:
• Treatment:
• Conservative
• ? K-wire if unstable
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Parikh, Orthopedics, June 2013
Fracture Dislocation
• Montaggia
• Fracture ulna, dislocation of head of radius
• Galiazzi
• Fracture radius, dislocation of distal radio-ulnar joint
www.mysportphysio.com
Monteggia
• Fracture of shaft of ulna, dislocated radial
head
• May be missed if two joints not seen on x-ray
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Monteggia
• Fracture of shaft of ulna, dislocated radial
head
• May be missed if two joints not seen on x-ray
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X-ray lines in elbow
• Radio-capitellar line
• A line drawn through the center of the radial neck
should pass through the center of the capitellum in
all views
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X-ray lines in elbow
• Radio-capitellar line
• A line drawn through the center of the radial neck
should pass through the center of the capitellum in
all views
• If not: dislocated radial head
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Monteggia fracture
• Treatment:
• Reduce ulna
• Reduce head of radius
Galeazzi fracture
• Fractured radius, with
• Dislocation of distal
radio-ulnar joint
• Treatment:
• Reduction of radius
• Reduction of DRUJ
www.pemcincinnati.com
Femur
• Problems:
• Bleeding
• May bleed more than 1 L
• Conservative treatment:
• Shortening, mal-union
• Operative treatment:
• Another surgery to remove implants
Femur
• Conservative: e.g. 5 year old
• Hip spica cast
• 1-2 cm shortening will be compensated by growth
http://orthoinfo.aaos.org/
AAOS guidelines, E. Sink
Femur
• Operative: in older children
• Good alignment and length
• Nailing better than plating
AOFoundation.org
AAOS. J. Beaty
Tibia
• Direct Vs. indirect injury
• Soft tissue injuries
• Compartment syndrome
• Need to correct
• Alignment, rotation, and length
Closed reduction - ESIN
• Closed reduction and casting
• Closed reduction and nailing
• Open reduction and plating - less
Physeal injuries
• Incidence:
• About 15-20 % of all skeletal injuries in children
• 50% occur in the distal radius
• Problem:
• Possibility of growth affection
• Some are intra-articular
Physeal anatomy Epiphysis
• Physis: 4 zones
• Germinal zone
• Proliferative zone
• Hypertrophic zone
Weakest zone - fractures
• Enchondral ossification
Metaphysis
Physeal injuries
More common in
• Boys
• Peak ~ 12y of age
• Upper limb
Classification – Salter- Harris
Most common
I
II
III
75%
IV
V
Treatment – Salter Harris I
• Closed reduction
• Fixation if unstable only
Treatment – Salter Harris I
• Closed reduction
• Fixation if unstable only
Treatment – Salter Harris II
• Need good stable reduction
• Possibly closed reduction, percutaneous
fixation
Treatment – Salter Harris III
• Intra-articular
• Anatomic reduction, stable fixation
Treatment: Salter Harris IV
• Intra-articular
• Anatomic reduction and stable fixation
Treatment – Salter Harris V
• No treatment available !
• Diagnosed in retrospect !
Complete Physeal affection
• Usually seen in Salter-Harris type V
Injury films
Injured and uninjured wrists after
premature physeal closure
Asymmetrical physeal affection
• Standard radiography
remains the initial
imaging evaluation of
choice
• Oblique Park-Harris
growth recovery line
Asymmetrical physeal affection
• 12Y, male, Salter-Harris II
3y post injury
Beware!
• Non-accidental injuries
• Tumors
Beware!
Non-accidental injuries
• Specific pattern
• Femur shaft fracture
• <1 year of age
• ( 60-70% non accidental)
• Transverse fracture
Beware!
Non-accidental injuries
• Specific pattern
• Femur shaft fracture
• <1 year of age
• ( 60-70% non accidental)
• Transverse fracture
• Humeral shaft fracture
• <3 years of age
• Sternal fractures
Beware!
Non-accidental injuries
• Specific pattern
• Corner fractures (traction & rotation)
Beware!
Non-accidental injuries
• Specific pattern
• Bucket handle fractures (traction & rotation)
Physical Examination
• Undress the child
• Look for areas of bruising
• Bruises at different stages of healing
emedicine.medscape.com
Physical Examination
• Undress the child
• Look for areas of bruising
• Bruises at different stages of healing
• Bruises take shape of inflicting instrument
Physical Examination
• Undress the child
• Look for areas of bruising
• Bruises at different stages of healing
• Bruises take shape of inflicting instrument
Physical Examination
• Undress the child
• Look for areas of bruising
• Bruises at different stages of healing
• Bruises take shape of inflicting instrument
Physical Examination
• Trunk
• Back, palpate rib cage, abdomen
mandyb87.weebly.com
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Physical Examination
• Head - examine for skull trauma, palpate
fontanel's if open, consider funduscopic exam
for retinal hemorrhage
Physical Examination
• A silent child tells the story!
Physical Examination
• A silent child tells the story!
www.kidspot.com.au
Consider non-accidental if
1. Delay in seeking medical attention
2. Mechanism incompatible with injury
3. Physical location of injury
4. Vague history, lacking the "real truth"
5. Varying history
• e.g. one parent contradicting the other
6. Inappropriate parental attitude or behavior
• e.g. lack of concern, over-concern, aggression
Consider non-accidental if
7. Inappropriate parent-child interaction
8. Features of failure to thrive or neglect
9. Allegation of assault
10.Signs of prior injury or injuries of different age
11.Characteristic injuries, illnesses or hospital
visits
12.Femoral shaft fracture < 2 years
13.Radiological features
Beware!
Malignant tumors
• Can present as injury
• History of trauma usual
•12 y old girl
• History of trauma
• Mild tenderness
• Periosteal reaction
•Diagnosed as injury
• 2m later, still tender
• Ewings sarcoma
Summary
• About 50% of population in ME are children
• Fractures in children are common
• Compare with other side
• Closed reduction still good
• Surgery might be needed
Summary
• Supracondylar humerus needs urgent
attention
• Forearm
• a joint – needs good alignment
• Look for fracture dislocation in forearm
• In lower limb:
• maintain alignment, rotation, and length
• Epiphyseal injuries
• Beware: Non-accidental & Tumors