Rena Heathcote

INTRODUCTION Incidence Anatomy of the Growing Bone What can we X-ray Injury Patterns What can we X-ray We will look at injury patterns amongst kids Also look at our expanded practice – what we will be x-raying in the future

PEDIATRIC FRACTURES INCIDENCE What makes children susceptible to fractures? Children tend to participate in spontaneous exercise… Childrens bones do not break easier than adults, its just that kids engage in riskier behaviours, jumping, climbing etc

PEDIATRIC FRACTURES INCIDENCE Approximately 20% of children who seek attention for injury = FRACTURE From birth – 16 years, chance of fracture Boys 42% Girls 27% Most commonly involved sites: Distal radius, Hand, Elbow, Clavicle, Radius, Tibia

INJURY PATTERN IN GROWING BONES Bones tend to BOW rather than BREAK Compressive force = Torus/Buckle fracture Force to one side of bone = Greenstick Fracture Only one side of bone breaks Childrens bones are more pliable they bend

GREENSTICK FRACTURE This Greenstick fracture in the humerus of a school child, a direct blow from the direction of the arrow has caused an incomplete transverse fracture. Greenstick fracture most common injury in children Mettler: Essentials of Radiology, 2nd ed., Copyright © 2005 Saunders, An Imprint of Elsevier

TORUS GREENSTICK Torus fracture – because of the softer bone the cortex does not completely break it `buckles`

X Ray – Expanded practice If Point tenderness and/or clear deformity of limb with significant swelling & decreased ROM. Clavicle Humerus Elbow Radius/ulna Wrist Hands/fingers Tib/Fib Ankle Foot/toes With our new expanded practices will be able to do these xrays

CLAVICLE FRACTURES Most occur in the middle third of the bone 80% HISTORY – Generally FOOSH, fall on shoulder, direct trauma Very common fracture in 2-10 year olds

CLAVICLE FRACTURE EXAMINATION Compare with unaffected side Mechanism of injury – Pain with any shoulder movement, holds arm to chest Point tenderness over fracture SubQ crepitus Often obvious deformity Palpate along clavicle, Check Arm.

Generally heal well with limited intervention

Shoulder Dislocation Note with a Shoulder dislocation Apperars Flat A dislocated shoulder occurs when the humerus separates from the scapula at the glenohumeral joint. The shoulder joint has the greatest range of motion of any joint in the body and as a result is particularly susceptible to dislocation and subluxation.[1] Approximately half of major joint dislocations seen in emergency departments are of the shoulder. Partial dislocation of the shoulder is referred to as subluxation

Humerus has seperated from joint

Humerus Fracture Humerus bones thick – less likely to break Mid shaft fractures are rare in kids Generally caused by a fall More likely to see fracture round an elbow Humerous bones are thick, less likely to break. More likely to see fracture around elbow

ELBOW 10% of all fractures in children Most are supracondylar fractures Ensure not a pulled elbow Supracondylar area is the weakest part of the elbow Fracture due to hyperextension injury, especially common in 3-10 year olds Mechanism & position child is holding elbow is key to type of injury

ELBOW FRACTURE EXAMINATION Compare with uninjured elbow Mechanism of injury Gently palpate around elbow – Check limbs above & below Check neurovascular status Immobilize elbow before radiographs to avoid further injury from sharp fragments Flexion 20-30 degrees = least nerve tension Do not force a child into a splint or sling, appreciate they may not want to move ion which case analgesia first!

Radius/Ulna Fracture Childhood forearm fractures very common following a fall onto outstretched hand Young children – Likely to have sustained greater injuries How do you think this injury occurred? Twisting mechanism – indicative of child abuse

Distal Radius Peak injury time coincides with peak growth time Boys 13- 14 Girls 11- 12 Boys 13-14 Girls 11-12

DISTAL RADIUS Examination Mechanism - Most injuries result from FOOSH Compare with unaffected limb Check sensation: CWSP Examine elbow (supracondylar) and wrist (scaphoid) Boys= 13-14, Girls= 11-12 Nerve injury more likely to occur with swelling & angulation

Wrist Fractures 8 small carpal bones in the wrist Rare in children under 12 years Scaphoid fractures most common wrist fractures in adolescents Wrist fracture rare in children because bones soft & not formed, force is taken through distal radius. People often call distal radius a wrist fracture but a true wrist fracture is one of the carpal bones in the wrist.

SCAPHOID FRACTURE Scaphoid fractures are most common in males aged 15 – 30 very rare in young children & infants Why do we worry about Scaphoid fractures? A failure to diagnose these fractures can lead to inadequate healing, avascular necrosis, and ultimately the development of osteoarthritis and limited range of wrist motion. Fracture across neck of scaphoid Best practice is to X-ray scaphoid 10 days after injury before this time difficult to view on xray & it’s the Healing process which shows up on xray

Hand injuries Occur in small bones fingers (phalanges) long bones (metacarpals). Caused from a twisting injury, a fall, a crush injury, or direct contact in sports. Fractures of the hand can occur in either the small bones of the fingers (phalanges) or the long bones (metacarpals). They can result from a twisting injury, a fall, a crush injury, or direct contact in sports.

Hand Injuries Examination Swelling Tenderness Deformity Inability to move the finger Shortened finger Form a fist Depressed knuckle A depressed knuckle is often seen in a "boxer's fracture." This is a fracture of the fifth metacarpal, the long bone below the little finger.

TIBIA/FIB INJURY Tibia and fibula fractures often occur together Mechanism: falls and twisting injury of the foot Tibia is the thicker bone so if that’s broke chances are the thinner fibular is broken With this injury- likely going direct to a cubicle

TODDLER’S FRACTURES Children younger than 3 years old learning to walk No specific injury notable most of the time Child refuses to weight bear on affected leg Toddlers fracture is a spiral fracture to the tibia, often caused by low energy trauma, sometimes after twisting around. Can often be missed on x-ray as very subtle break.

Very subtle toddlers fracture, note the spiral.

Ankle Injuries Typically occur during sports or vigorous play Sports involving lateral motion and jumping like basketball =higher risk for ankle injuries. Inversion & Eversion injuries

OTTAWA ANKLE RULES Ask Mechanism, use ottawa ankle rules Ankle Xray if pain over Malleolar zone AND Pain over lateral or medial malleolus OR inability to weight bear

5th Metatarsal Fracture Avulsion fracture. In an avulsion fracture, a small piece of bone is pulled off the main portion of the bone by a tendon or ligament. This type of fracture is the result of an injury in which the ankle rolls. Avulsion fractures are often overlooked when they occur with an ankle sprain. Really important to check foot with ankle injury

Foot Injuries Most foot fractures in kids are minor Calcaneal fractures - after falls Tarsal fractures – ? X-Ray Site of pain- point tenderness 26 bones in the foot Common sports injuries After a fall – jump from height ensure not masking other injuries Is an Xray going to change the management Toe fractures heal well – only concern is big toe.

Examination of the injured child The Basics History of Trauma? Look – Swollen, Red, COMPARE TO OTHER SIDE Check limbs above & below Feel- CWSP? Tenderness? Specific point? Move – able to move Active/Passive Does the story fit the injury?

Xray Requests Mechanism & Injury Point Tenderness? Previous injury Rule out fracture Biggest error on x-ray requests? Xray needs to know mechanism Also need to know if previous injury Xray need to know what you are querying is it a fracture or a fracture dislocation for example.

XRAY REQUESTS REMEMBER - Anatomically and radiographically, the forearm is not the wrist and the wrist is not the hand STATE – The precise anatomical part to be examined radiographically. Do not use an X-Ray as a substitution for a proper & thorough examination.

CONCLUSIONS Nearly 20% of children with injury have a fracture Most important factors: patient age / mechanism of injury / associated injuries

Apprehensive/questions?