Cortex - Paediatric trauma 1 (fractures)

Question 1

What are the main differences in bones between adults and children ?

Answer 1

• Kids bones are more elastic and pliable - so they tend to buckle or partially fracture or splinter.
• Like breaking a green stick from a tree, hence the terms ‘‘buckle fracture’’ or ‘‘greenstick fracture’’ can be used
• Periosteum tends to be thicker and more likely to stay intact
• Thicker periosteum means a more rich source of osteoblasts hence greater remodelling potential

Question 2

How does the management of kids fractures tend to differ from adults ?

Answer 2

Kids fractures are less likely to be surgically stabilised due to greater remodelling potential which can accommodate greater degrees of displacement or angulation.

Question 3

If surgical stabilisation is required in a kid what tends to be used ?

Answer 3

Less invasive temporary pins, wires and flexible rods rather than plates and screws (these are reserved for very unstable fractures)

Question 4

In terms of fracture treatment when does a kid start getting treated as an adult ?

Answer 4

Roughly puberty age (12-14)

Question 5

What can fractures at the growth plate in kids result in ?

Answer 5

Can cause a shortened limb or an angular deformity

Question 6

Physeal (growth plate) fractures are classified how ?

Answer 6

By salter harris classification:

There is 5 different types:

• Salter harris I to V

Question 7

Describe what a salter-harris I fracture is

Answer 7

A pure physeal separation

Question 8

Describe a salter harris II fracture

Answer 8

Fracture passes across most of the growth plate and up through the metaphysis creating a metaphyseal fragment attached to the physis and epiphysis

Question 9

Describe a salter harris III fracture

Answer 9

Fracture passes through some of the physis and then straight down through the whole of the epiphysis

Question 10

Describe a salter harris IV fracture

Answer 10

Fracture plane passes directly through the metaphysis, growth plate and down through the epiphysis

Question 11

Describe a salter harris V fracture

Answer 11

Crushing type injury that does not displace the growth plate but damages it by direct compression

Question 12

Which type of salter harris fracture has the best and which has the worse prognosis ?

Answer 12

• Best prognosis - type I
• Worst prognosis - type III & IV

Question 13

What is the treatment of type I and II salter harris fractures ?

Answer 13

Conservative

Question 14

What is the treatment of salter harris type III and IV fractures ?

Answer 14

Reduction and stabilisation

Question 15

What is the most common type of salter harris fracture ?

Answer 15

Type II

Question 16

What is the difficulty with salter harris V fractures ?

Answer 16

They cannot be diagnosed on X-ray they are only detected once angular deformity has occurred

Question 17

What features rasies the suspicious of NAI (non-accidental injury i.e. child abuse)?

Answer 17

Multiple fractures of varying ages (with varying amounts of callus or healing) or multiple trips to A&E with different injuries raises the suspicion of NAI

Other features which should raise suspicion include:

• History and injury don’t add up (i.e. the history doesn’t correlate with the injuries shown or the history is inconsistent)
• Injuries not consistent with age of child eg non walking child
• Multiple bruises of varying ages
• Atypical injuries eg cigarette burns, genital injuries, torn frenulum, dental injuries, lower limb and trunk burns
• Rib fractures
• Metaphyseal fractures in infants

Question 18

What are the 3 main common fractures of the distal radius in kids ?

Answer 18

1. Buckle/torus
2. Greenstick
3. Salter harris II

Question 19

What is a buckle fracture ?

Answer 19

A fracture which one side of the bone may buckle upon itself without disrupting the other side of the bone

Question 20

What is a greenstick fracture ?

Answer 20

Fracture where one side of the bone is broken and the other only bent.