Children's Fractures Flashcards by Jane Keery

Fractures in children are more likely to affect which limb?

Upper limb

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What are some important questions to ask about a fracture in a child?

Mechanism

How high

How fast

Forces involved

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A child who is not yet walking with what type of fracture would make you suspicious of NAI?

Long bone fractures

Also metaphyseal injuries in infants are rare

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A child presenting with a fracture and with what other things wrong would make you more suspicious of NAI?

Raised intra-cranial pressure

Intra-abdominal trauma

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If you have any suspicion of NAI, how should these patients be managed?

Admit for safety

Full examination of the child and skeletal survey

History from the parents

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Where in the bone of children is the primary ossification centre?

Where in the bone of children is the secondary ossification centre?

What is the area of the bone which forms the growth plate known as?

What part of children’s bones are mostly cartilage before being differentiated into bone as they get older?

Diaphysis (shaft)

Epiphysis

Physis

Epiphysis

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At what age does the proximal femoral epiphyseal secondary ossification centre appear?

By what age (roughly) will this be completely replaced by bone?

4 months

16 years

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What part of children’s bones are responsible for longitudinal growth?

What part of children’s bones are responsible fo circumferential growth?

Physis

Periosteum

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Children’s bones are more elastic and pliable, which means what in terms of fractures?

They tend to buckle, or partially fracture/splinter with some fibres still attached

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What is the periosteum in children like compared to adults?

What does this mean in terms of fractures?

Thicker

It tends to remain intact which helps stability and can assist reduction

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What are some reasons that childrens fractures tend to heal better than adults?

The thick periosteum is a rich source of osteoblasts

They have greater potential to remodel

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What are the 3 main principles of treatment of children’s fractures?

Reduce

Retain

Rehabillitate

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Children’s fractures tend to be surgically stabilised much less frequently due to their greater healing potential.

If the position is really unacceptable, what may still be all that is required?

Manipulation and casting

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Where do you put a cast for a diaphyseal fracture?

Where do you put a cast for a metaphyseal fracture?

Over the break, and the joint above and below

Only over the adjacent joint

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If surgical stabilisation is really required in a child, what materials tend to be used?

When are plates and screws utilised?

Pins, wires and rods (less invasive)

Very unstable injuries where a fracture is associated with a dislocation

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What are some consequences of a physeal fracture?

Disturb growth which can result in a shortened limb

Angular deformity if only one side of the physis is affected by grwoth arrest

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Overall, what are the exceptions to the rules of conservative management in childrens fractures?

Displaced intra-articular fractures

Displaced physeal fractures

Some open fractures

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At what age do childrens fractures start to be treated the same as adults?

Why?

12-14 (once the child has reached puberty)

Remodelling potential is less

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What is the relationship between the Salter Harris classification of a physeal fracture and its prognosis?

Higher up the classification, the worse the prognosis

What Salter-Harris classification is this fracture?

What does this mean?

What is its prognosis?

Type 1

Complete physeal separation +/- displacement

The best prognosis- very unlikely to result in growth arrest

What Salter-Harris classification is this fracture?

What is this?

Is it likely to cause growth arrest?

Type II

A physeal fracture which produces a chip fracture of the metaphysis

Unlikely, it has a good prognosis

What Salter Harris classification is this fracture?

What is this?

Type III

A physeal fracture whcih extends into the epiphysis

What Salter-Harris classification is this fracture?

What is this?

Type IV

A phseal fracture with epiphyseal and metaphyseal fractures also

What Salter-Harris classification is this fracture?

What is this?

When can these be detected on x-rays?

Type V

A compression of the growth plate with susequent growth arrest

Only once they have caused deformity, not on initial x-rays

Which Salter-Harris fractures are intra-articular? Can these cause growth arrest? How should they be treated?

III and IV Yes Reduced and stabilised to ensure a congruent articular surface and minimise growth disturbance

What type of fracture is this? What is this? Who do these tend to occur in?

Greenstick fracture The bone bends or cracks instead of breaking completely. There is still continuity of some fibres. Children \< 10

How are Greenstick fractures treated? What is usually the mechanism of injury for a Greenstick fracture?

Even mild ones are immobilised in a cast (this holds the bones together and prevents it breaking completely if the child were to fall again) Usually with a fall, most commonly in the arms

What type of fracture is this? What is this?

Torus (Buckle) Fracture Incomplete fractures of the shaft of a long bone which is characterised by the bulging of the cortext

Where do buckle fractures tend to affect? Why do they most commonly occur? How are they treated?

Distal radial metaphysis Following a FOOSH Self limiting, usually splint for 3-4 weeks

What type of fracture is this? What is it? Which bones does this most commonly occur in?

Plastic deformation (bowing) fracture An incomplete fracture of tubular long bones Ulna and radius

How are plastic deformation (bowing) fractures treated? How do children present with these?

No intervention, heal with remodelling Pain and swelling following a fall (often from climbing)

What types of fractures commonly occur at the distal radius?

Buckle, greenstick and Salter Harris type II (can also get complete fractures)

Complete fractures of the distal radius may displace/angulate. In which direction is it more common for this to happen? If complete fractures of the distal radius are stable, what is the treatment? If complete fractures of the distal radius are very unstable, what is the treatement?

Dorsally Casting Wire or plate fixation

How are fracture dislocations treated in children? If both bones of the forearm are fractured but the periosteum is intact and they are fairly stable, how are they treated? If both bones of the forearm are fractured and unstable, how are they treated?

Rigid fixation with plates and screw to avoid re-dislocation Manipulation and casting Flexible IM nail

Which type of supracondylar fracture is more common in children, extension or flexion? How does the extension type occur? How does the flexion type occur?

Extension Heavy FOOSH Fall onto the point of the elbow

What is the treatment for an undisplaced supracondylar fracture? What is the treatment for an angulated/rotated/displaced supracondylar fracture? What is the treatment for a severely displaced supracondylar fracture with damage to the brachialis muscle?

Splint Closed reduction and pinning with wires Open reduction

In the extension type of supracondylar fracture, the distal fragment often displaces posteriorly which can press on which: a) artery? b) nerve? How can you check if there has been damage to the nerve?

Brachial artery Median nerve (predominantly anterior interosseous branch) Ask patient to make 'okay' sign- this tests the FPL and FDP to see if the nerve is damaged

If there is a displaced supracondylar fracture with an absent radial pulse, what is the treatment? If the hand is still pulseless after this, what is the next step?

Emergency reduction Open surgical exploration

What is the mechanism of action for a femoral shaft fracture in children? Why is some limb shortening accepted in these fractures?

Fall onto a flexed knee, or by indirect bending/rotational forces There is usually overgrowth following healing

What is the treatment for a femoral shaft fracture in a child \< 2? What is the treatment for a femoral shaft fracture in a child aged 2-6? What is the treatment for a femoral shaft fracture in a child aged 6-12? What is the treatment for a femoral shaft fracture in a child aged 12+?

Assess for NAI, Gallow's traction and early casting Thomas splint/hip cast Flexible IM nail Adult IM nail

Why should you consider pathological fracture in a child with a femoral shaft fracture?

It is a common site for benign and malignant bone tumours

What type of tibial shaft fracture is common in toddlers? How are these treated? How much angulation is generally tolerated before manipulation is required? What is used for follow up? Is any shortening/malrotation accepted?

Spiral (undisplaced) Casting (compartment syndrome is much less common) 10 degrees Serial x-rays (AP and lateral) No

What investigation is used for children's fractures if: a) The bones are ossified? b) The bones are not ossified? c) There is joint injury? d) More detail is needed?

a) X-ray b) Ultrasound c) Arthrogram d) CT/MRI

In what direction does the epiphysis grow?

Distally

What effect do each of the following forces have on growth? a) Compression? b) Tension?

a) Stimulate growth b) Inhibit growth