Pediatric Trauma Intro: What makes kids so different? OTA Resident Fracture Course

Top 10 reasons kids are different Biologic activity Periosteum Blood supply Remodeling Physis Mechanical properties of bone Radiographic interpretation Immobilization Compartment syndrome Non-accidental injury

1. Biologic Activity Childhood is a time of growth and development Machinery already “turned on” Rate of healing  age Non-unions rare

2. The Periosteum Thicker, more osteogenic Facilitates healing Minimizes fracture displacement Crucial in fracture reduction

3. Blood Supply Richer in kids Perfusion = healing Certain exceptions Proximal femur Lateral condyle

4. Remodeling Allows for closed rx of many fractures Variable Age Distance from physis Plane of deformity Anatomic region Remember: there is a limit!

Images courtesy of Jack Flynn, MD & Chad Price, MD

5. The Physis Mechanical “weak spot” Physeal vs. ligamentous injuries 15-30% of all fractures Contributes to rapid healing Risk of growth arrest Varies by anatomic region

Salter-Harris Classification for Physeal Fractures

Physeal injury can result in a growth arrest leading to LLD or angular deformities…

6. Mechanical Properties Pediatric bones less brittle than adults Different fracture patterns e.g. incomplete “greenstick”, torus Plastic deformation

7. Radiographs Hard to Read Limited boney landmarks Remember all that cartilage! Ossification centers change with time Contralateral radiographs, arthrograms, or MRI often useful in difficult cases

8. Immobilization Generally safe Risk of stiffness low Exceptions: older adolescents intra-articular knee fractures elbow fractures 9

8. Immobilization Generally safe Risk of stiffness low Exceptions: older adolescents intra-articular knee fractures elbow fractures 9

Remove any cast if there is increasing pain 9

9. Compartment Syndrome Harder to get reliable exam Sentinel finding: increasing pain medicine requirements after a fracture Often the next day Low threshold to split cast! 9

10. Non-accidental Injury Unfortunate mechanism Femur fx and “not yet walking” SH II distal humerus in baby Corner fractures Make appropriate referrals! 3 mo old with SH II dist hum fx 9

Kids can be the same… When is the “pixie dust” gone? C-spine: age 8 Pelvis: when triradiate closes Femur older than 12 Forearm mid teens Elbows and knees fracture that get stiff Displaced Intra-articular fractures

Questions?