APPROACH TO COMMON FRACTURES OF THE IMMATURE SKELETON / GROWTH PLATE Flashcards
History & Physical
General Approach:
Life
Limb
Injury
Things to ask:
Trauma: Forces Involved, “How hard was the impact”
Mechanism: “Recreate the scene - How did the injury happen”
Events after the Injury: “What happened after – continues playing vs. stop activity”
Age: extremes of age
PMHx
Medications
Previous Injuries
Vocation / Recreation
Hand Dominance
Look for:
Address Life, Limb, Wound
Inspect:
Circumferentially – check for “open”
Compare to opposite side
Palpation:
Neurovascular exam of every compartment
Exam joints above and below
Thoroughly feel the entire bone to r/o multiple injuries Point of maximal tenderness
ROM:
Joint or limb prior to the XRAY
Neurological Exam of Upper Extremity
RADIAL:
Motor - Wrist / finger extension
Sensory - Dorsal thumb / first finger web space
ULNAR:
Motor - Flexor carpi ulnaris intrinsic hand muscles
Sensory - Fifth digit
MEDIAN:
Motor - Forearm/most wrist flexors/flexion and opposition of thumb
Sensory - Palmar thumb, first and second fingers
ANTERIOR INTEROSSEOUS (OFF MEDIAN):
Motor - Distal phalanx flexion (thumb and first finger)
AXILLARY:
Motor - Abduction of shoulder
Sensory - Lateral upper arm “regimental patch”
Investiations
XRAY:
Order proper series
Order 2 views (min)
CT if unclear
DDx of a normal XRAY
SCARED OF
Septic
Compartment Syndrome
Abuse
Referred Pain / Report is False
Dislocated / Subluxation
Operative Soft Tissue Injury
Fracture
Description of a fracture
Open or closed
Location: proximal, middle, distal thirds
Fracture Pattern: Transverse, Oblique, Spiral, Comminuted; Angulation
Dislocation /
Subluxation: direction of dislocation, distal anatomy relative to proximal
Displacement: degree of displacement, distal anatomy relative to proximal
Angulation: Deviation from the mid like, volar vs. dorsal, distal relative to proximal
List and describe the 3 relevant areas of the bone
Diaphysis: Shaft of the long bong. Comprised of cortical bone and bone marrow
Metaphysis: wider part of the long bone closest to the epiphyseal plate.
Epiphysis: Rounded end of a long bone at it’s joint with the adjascent bone. Secondary ossification center separated from the rest of the bone by the epiphyseal or growth plate or physis.
List 5 DDx for fractures of the immature skeleton / growth plate
Buckle Fracture Greenstick Fracture Avulsion Fracture Bowing Fracture Salter Harris Fracture I-V
Torus (Buckle) Fracture: Mechanism & Pattern; Management
Compressive Load -> stable fracture where bone buckles without cortical disruption.
Most commonly distal radius (metaphyseal).
Distal Radial buckle fracture immobilized with plaster back slab
OR removable wrist splint for 3 weeks
Greenstick Fracture: Mechanism & Pattern
Management
Bowing Deformity of Cortex ->
Unilateral cortical disruption with the periosteum on the contralateral (compressed) side.
Most commonly at diaphysis-metaphysis junction
May need to complete the fracture to reduce
Immobilize with plaster / fiberglass splint
Avulsion Fracture: Mechanism
Management
Forceful contraction of strong muscular attachment
Conservative with rest and altered weight bearing
Bowing Fracture: Mechanism & Management
Complications
Histologically true fracture.
Microfractures leading to plastic deformation with pain and deformity.
Classic fracture line not present
If > 20 degrees deformation, reduce with 3-point force
Immobilize
May not remodel
Salter Harris I: Mechanism, XRAY findings, Management, Complications
Mechanism: fracture STRAIGHT throught the physis;
XRAY Findings: Radiographically silent. Usually POMT over physis
Reduce if displaced. Treat with splint (plaster or removable) for 4 weeks
Complications: Rarely associated with growth disturbance
Salter Harris II: Mechanism, Management, Complications
Mechanism: Transverse fracture through the physis and extends ABOVE through metaphysis
Treatment: Reduced if displaced. Splint with plaster or removable splint for 4 weeks
Complications: good prognosis
Salter Harris III: Mechanism, Management, Complications
Mechanisms: Transverse fracture through the physis and a vertical fracture extending BELOW into the epiphysis; INTRA-ARTICULAR
Management: Most require open reduction and internal fixation
Complications: risk of disruption and post-traumatic arthritis
Salter Harris IV: Mechanism, Management, Complications
Mechanism: Vertical fracture THROUGH the metaphysis, physis and the epiphysis; intra-articular
Management: open reduction, internal fixation
Complications: High Risk of growth disruption
