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

2. 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

3. Anatomy

4. Biomechanical

5. Physiology (blood supply)

6. Paediatric Fractures CLINICAL EVALUATION

7. 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

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

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

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

11. Common Paediatric Fractures

12. Physeal fractures Physeal fracture or Salter Harris Fractures

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

14. 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

15. 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.

16. 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

17. 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

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

19. Incomplete fracture Greenstick fracture of the tibia

20. Incomplete fracture Torus or buckle fracture of distal end radius

21. 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

23. 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

26. 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.

28. Uncommon fractures

33. Traumatic slipped upper femoral epiphysis