FRACTURES IN CHILDREN DR MOHD KHAIRUDDIN ORTHOPAEDIC SURGEON Faculty of Medicine CUCMS

Introduction  15% of all childhood injuries  Consideration in differences comparing adult and children adult:  Anatomy Less dense and more porous. Thicker and stronger periosteum. Growth plate and secondary ossification center. – Biomechanical Modulus of elasticity and bending strength is lower than adult. – Physiology Rapid healing of fracture because increased blood flow and cellular activity. Power of remodeling higher

Anatomy

Biomechanical

Physiology (blood supply)

Paediatric Fractures CLINICAL EVALUATION

Clinical History  Different age (ability to communicate)  History from the parents (observe ‘abnormal  changes’ in their children’s physical or  attitude)  Accidental findings of x-ray  Obvious episode of trauma

Physical examination  Ability to cooperate  Look for obvious bruises, swelling  Feel for tenderness  Strict limitation of movements  Must compare with the uninvolved side

Radiological Examination  2 views + 2 joints  Opposite limb if suspected growth plate involvement  2 occasions

Management  Most fractures are treated non-surgically  Specific indication for surgical failure to maintain reduction intra-articular reduction pathological fracture associated neurovascular injury

Common Paediatric Fractures

Physeal fractures Physeal fracture or Salter Harris Fractures

Physeal fractures : Classification Salter Harris : Type I, II, III, IV, V

Salter Harris type I  Transverse # through the entire physis, without metaphyseal fragment.  Most common  Closed reduction if displaced.  Complications – Most heal uneventfully – Growth slowdown/arrest

Salter Harris type II  # extends partially along the physeal-metaphyseal interface, and then propagates into the metaphysis.  Most common after 4 years  Closed reduction.  Complication: majority heal without significant consequences.

Salter Harris type III  # propagates transversely along the physeal- metaphyseal interface and cross the physis, epiphysis, ossification center and articular cartilage – unstable and intraarticular #.  Open reduction may necessary with internal fixation  Complication: Growth arrest angular deformity, osteoarhtritis, non union

Salter Harris type IV  intraarticular # vertical splitting of all zones of the physis.  Open reduction may necessary with internal fixation  Complication: Growth arrest angular deformity, osteoarhtritis, non union

Salter Harris type V C-Crush injury to growth plate.

Incomplete fracture Greenstick fracture of the tibia

Incomplete fracture Torus or buckle fracture of distal end radius

Supracondylar fracture of the humerus Anatomy: –Double column due to Olecranon and Coronoid fossae, making reduction unstable Radiologically –Classified as Gartland I, II, III Complication: Neurologic injury: 7% Vascular injury: 0.5% Other: deformity, stiffness

Monteggia fracture of the forearm  Monteggia Fracture – Proximal ulna # with radial head dislocation. – 0.4% of all forearm #.  Treatment: – Stable and minimal deformity: CMR and casting – Unstable and unacceptable deformity: CMR KIV ORIF. – Older than 10 years treat like adult – Angular deformity may remodel but not in rotation deformity.  Complication: – Malunion, – Nerve injury

Femoral shaft fracture  Treatment – Depend on age, size and type of fracture – Small size and < 2 years : early spica – 2 – 10 years: If overriding > 2 cm: traction until callus and spica later. If < 2cm: early spica – Acceptable angular deformity = 30 degrees(sagittal) / 10 degrees(frontal) – If 10 – 15 yrs: Open # / multiple injury: EF consider Flexible nailing – Other indication for operation: Multiple trauma Head trauma Open # Vascular injury Pathological #  Complication: – Malunion – Overgrowth – Undergrowth – Nonunion – Infection.

Uncommon fractures

Traumatic slipped upper femoral epiphysis