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    Common Pediatric Fractures

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    awaisjinnah
    This document discusses common pediatric fractures. It begins by introducing fracture patterns that are unique to growing bones, including torus/buckle fractures caused by compression, greenstick fractures where one cortex breaks and the other bends, and plastic deformation where neither cortex breaks in young children. It then covers physeal/growth plate injuries and the Salter-Harris classification system. Specific sites of fractures are discussed like the distal radius. The relevance of fractures in childhood and importance of adequate imaging is emphasized. Treatment principles focus on maintaining function and normal growth. Child abuse is also addressed.

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    © All Rights Reserved
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    Common Pediatric Fractures

    Uploaded by

    awaisjinnah
    327 views48 pages
    This document discusses common pediatric fractures. It begins by introducing fracture patterns that are unique to growing bones, including torus/buckle fractures caused by compression, greenstick fractures where one cortex breaks and the other bends, and plastic deformation where neither cortex breaks in young children. It then covers physeal/growth plate injuries and the Salter-Harris classification system. Specific sites of fractures are discussed like the distal radius. The relevance of fractures in childhood and importance of adequate imaging is emphasized. Treatment principles focus on maintaining function and normal growth. Child abuse is also addressed.

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    COMMON PEDIATRIC FRACTURES

    Original Title

    COMMON PEDIATRIC FRACTURES

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    This document discusses common pediatric fractures. It begins by introducing fracture patterns that are unique to growing bones, including torus/buckle fractures caused by compression, greenstick fractures where one cortex breaks and the other bends, and plastic deformation where neither cortex breaks in young children. It then covers physeal/growth plate injuries and the Salter-Harris classification system. Specific sites of fractures are discussed like the distal radius. The relevance of fractures in childhood and importance of adequate imaging is emphasized. Treatment principles focus on maintaining function and normal growth. Child abuse is also addressed.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    327 views48 pages

    Common Pediatric Fractures

    Uploaded by

    awaisjinnah
    This document discusses common pediatric fractures. It begins by introducing fracture patterns that are unique to growing bones, including torus/buckle fractures caused by compression, greenstick fractures where one cortex breaks and the other bends, and plastic deformation where neither cortex breaks in young children. It then covers physeal/growth plate injuries and the Salter-Harris classification system. Specific sites of fractures are discussed like the distal radius. The relevance of fractures in childhood and importance of adequate imaging is emphasized. Treatment principles focus on maintaining function and normal growth. Child abuse is also addressed.

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    You are on page 1of 48

    COMMON PEDIATRIC

    FRACTURES

    INTRODUCTION
    ANATOMY OF THE GROWING BONE
    INJURY PATTERN OF BONE

    PHYSEAL INJURIES
    SPECIFIC SITES
    DISTAL RADIUS
    ELBOW
    CLAVICLE
    TIBIA

    CHILD ABUSE

    RELEVANCE
    Nearly 20% of
    children who
    present with an
    injury have a
    fracture
    42% boys, 27% girls
    will sustain fracture
    in childhood

    INJURY PATTERN IN GROWING


    BONES
    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 PATTERN IN GROWING


    BONES
    Bones tend to BOW rather than BREAK
    Compressive force= TORUS fracture
    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 PATTERN IN GROWING


    BONES

    Bones tend to BOW rather than BREAK


    Compressive force= TORUS fracture
    sForce to side of bone may cause break in
    only one cortex= GREENSTICK fracture
    The other cortex only BENDS
    Buckle fracture

    DIn very young children, neither cortex may


    break= PLASTIC DEFORMATION
    In very young children, neither cortex may
    break= PLASTIC DEFORMATION

    INJURY PATTERNS
    CONT

    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 PATTERNS
    CONT

    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 than soft
    tissue
    Periosteum is biologically active in children
    and often stays intact with injury
    This stabilizes fracture and promotes healing

    Fractures Peculiar to
    Children
    Torus or buckling

    A.
    B. Greenstick
    C. Bowing
    D. Epiphyseal

    Often only incomplete fracture line is seen

    There are a variety of fractures that are more peculiar to children, and
    included in this list are the torus or the buckling fracture. The cortex
    becomes buckled or has a bump as a result of a compressive twisting
    injury. A greenstick fracture, much like when you try to break off a
    piece of a lilac bud on campus and it comes halfway off, breaks through
    one cortex and the other remains intact. A similar type of injury can
    occur in children. The bowing fracture, smooth curvature to the bone
    without disruption of the cortex. Epiphyseal fractures, a variety of
    fractures that actually involve the epiphyseal plate in various extents.
    Often only an incomplete fracture line will be identified.

    Buckle (TORUS) fracture


    Compression failure of bone that
    usually occurs at the junction of the
    metaphysis and the diaphysis
    Commonly seen in distal radius.
    Inherently stable
    Heal in 3-4 weeks with simple
    immobilization.

    Torus Fracture Radius

    Can you identify the torus fracture on this pair of wrist films before I put
    the arrows in place? Look carefully; look for any disruption of the
    contours of the cortex. Normally the contour should be very smooth
    with no sharp angulations. Here we see a small bump on the cortex
    representing the site of the torus fracture; its also noted on the lateral
    view as well.

    Torus Fracture Radius

    Here is another example of a torus fracture involving the radius with


    buckling of the cortex as indicated by the yellow arrows.

    Bowing
    Fracture
    Bowing fracture
    of right fibula
    Buckle fracture
    of right tibia
    Normal left for
    comparison
    Note the bowing fracture of the right fibula. The fibula has a slight
    curvature convexity directed medially as a result of injury. There is also
    on the same individual a buckling of the distal tibia, a buckle fracture.
    Remember in paired bones, frequently both bones will either be
    fractured or there will be a fracture dislocation. The left lower leg,
    which is normal, is included for comparison purposes.

    Greenstick fracture
    Bone is bent and the tensile/convex
    side of the bone fails.
    Fracture line does not propagate to
    the concave side of the bone,
    therefore showing evidence of plastic
    deformation.

    Greenstick
    Fracture Radius

    Dorsal cortex
    remains intact
    Ventral cortex is
    disrupted
    Angulation is ventral
    Here is an example of an individual with a
    greenstick fracture. The dorsal cortex
    remains intact while the ventral cortex is
    disrupted. There is angulation directed
    towards the ventral or palmar aspect or
    anterior aspect of the forearm with the
    patient in anatomic position.

    If the bone undergoes plastic


    deformation, it is necessary to break
    the bone on the concave side to
    restore normal alignment, as the
    plastic deformation recoils the bone
    back to the deformed position

    Complete fracture
    Fracture completely propagates
    through the bone.
    Classified as spiral, transverse, or
    oblique, depending on the direction
    of the fracture line.

    ANATOMY OF GROWING
    BONE

    Epiphysis
    Physis
    Metaphysis
    Diaphysis
    Periosteum

    Terminology
    Epiphyseal Plate = Growth Plate = Physis
    Epiphysis

    Secondary Ossification Center


    Epiphysis and growth plate are NOT synonyms
    The epiphysis is the bone located between the
    articular surface and the physis

    Metaphysis

    Bone adjacent to the physis on the opposite side of


    the epiphysis.

    Diaphysis

    The shaft of the bone

    Growth Plate Injuries


    Occur by various mechanisms
    Fracture
    Frostbite
    Disuse
    Chronic Stress
    Radiation Iatrogenic injury
    Infection Neural involvement
    Tumor
    Electrical Injuries
    Vascular impairment Burns
    Metabolic abnormality

    Growth Plate Injuries


    When entire physis is arrested
    Bone length is retarded
    If bone ends are arrested, longitudinal
    bone growth ceases completely

    When only part of physis is damaged


    Length retardation can be accompanied
    by angular deformity

    PHYSEAL INJURIES
    Many childhood fractures involve the
    physis
    20% of all skeletal injuries in children
    Can disrupt growth of bone
    Injury near but not at the physis can
    stimulate bone to grow more

    SALTER HARRIS
    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

    SALTER HARRIS CLASSIFICATION


    I
    Fracture passes
    transversely
    through physis
    separating epiphysis
    from metaphysis

    II
    III
    IV
    V

    SALTER HARRIS CLASSIFICATION


    I

    II
    Transversely through
    physis but exits through
    metaphysis
    Triangular fragment

    III
    IV
    V

    SALTER HARRIS CLASSIFICATION


    I
    II

    III
    Crosses physis and
    exits through epiphysis
    at joint space

    IV
    V

    SALTER HARRIS CLASSIFICATION


    I
    II
    III

    IV
    Fracture extends
    upwards from the joint
    line, through the
    physis and out the
    metaphysis

    SALTER HARRIS CLASSIFICATION

    I
    II
    III
    IV

    V
    Crush injury to growth
    plate

    PHYSEAL FRACTURES
    MOST COMMON: Salter Harris ___

    PHYSEAL FRACTURES
    MOST COMMON: Salter Harris _II_
    I 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 YOUNG


    Children tend to heal fractures faster
    than adults
    Advantage: shorter immobilization times
    Disadvantage: misaligned fragments
    become solid sooner

    Anticipate remodeling if child has > 2


    years of growing left
    Mild angulation deformities often correct
    themselves
    Rotational deformities require reduction
    (dont remodel)

    ITS GOOD TO BE YOUNG


    Fractures in children may stimulate
    longitudinal bone growth
    Some degree of bone overlap is acceptable
    and may even be helpful

    Children dont tend to get as stiff as adults


    after immobilization
    After casting, callus is formed but still may
    be fibrous
    Avoid contact activities for 2-4 weeks once out
    of cast

    Diagnosis:
    Need Adequate Imaging
    Supplement
    plain x-rays
    High Index of
    Suspicion
    Comparison
    Views
    CT scan
    MRI

    Adequate Imaging
    Child
    with
    knee
    pain
    Fracture
    difficult
    to see

    Adequate Imaging
    Oblique Xray
    Easy to see
    Salter III of
    the distal
    femur

    Adequate Imaging
    Final after
    reduction and
    internal fixation
    with
    comparison
    view

    Adequate Imaging
    Child with
    ankle pain
    Fracture
    difficult to
    see

    Adequate Imaging
    CT shows a Salter
    III (Tilleaux)
    fracture of the
    distal tibia
    Tilleaux Fractures
    occur near the end
    of growth as
    medial portion of
    distal tibial physis
    closes before the
    lateral side closes

    Tilleaux Fracture
    Post-operative and final x-rays after
    hardware removal without residual deformity

    Treatment
    Goal of treatment of all physeal fractures
    is to maintain function and normal growth
    Attainment of these goals is most likely when
    all structures are anatomically reduced
    Therefore goal is to obtain and maintain
    anatomic reduction
    May be done by open or closed means
    All reductions should be gentle to prevent damage to
    the delicate physeal cartilage
    Forceful, repeated manipulations should be avoided!
    PetersonHA.PhysealInjuriesandGrowthArrest.InBeaty
    JH,KasserJR,eds.FracturesinChildren.Philadelphia,PA:
    LippincottWilliamsandWilkins,2001;91130.

    FRACTURES OF ABUSE
    Majority of fractures in child < 1 year are
    from abuse
    High percentage of fractures <3yo = abuse

    Greater risk of abuse: first-born, premature


    infants, stepchildren, children with learning
    or physical disabilities
    Most common sites: femur, humerus, tibia
    Also: radius, skull, spine, ribs, ulna, fibula

    Child Abuse Concerns


    Unexplained fractures in different
    stages of healing as shown on radiology
    Femoral fracture in child < 1 year
    Scapular fracture in child without a clear
    history of violent trauma
    Epiphyseal and metaphyseal fractures
    of the long bones
    Corner or chip fractures of the
    metaphyses

    CHILD ABUSE
    If suspected, skeletal survey should
    be considered
    Bone scan may be useful as
    complementary study

    CONCLUSIONS
    Nearly 20% of children with injury
    have a fracture
    Always take post-reduction x-rays
    Physeal injuries are common and
    may have no radiographic findings
    Treat as fracture!!

    Dont forget to tell Mom and Dad


    about possible growth problems

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