Cortex - Paediatric Trauma Flashcards
how is the periosteum different in children
is much thicker and tends to remain intact which can help stability and can assist reduction if required.
what is the role of the periosteum in children
serves to increase the width/circumference of growing long bones
do children fractures heal quicker or slower- why
quicker due to thick periosteum which is a rich source of osteoblasts
what wolffs law
childrens bones change shape with bone laid down along areas of stress- means they have greater potential to remodel
what does growth with bone being formed along the line of stress mean
fractures heal quicker and bones can correct up to 10 degrees of angulation per year of growth remaining in that bone
what happens when a fracture causes a degrees of angulation that is unacceptable (these angles much bigger in children)
less likely than adults to be surgically stabilised-
manipulation and casting (accepting a degree of residual angulation)
what is the difference in surgical stabilisation in childrens fractures
less invasive, temporary pins, wires and flexible rods used
when are plates and screws used in childrens fractures
for very unstable fractures, if associated with a dislocation and loss of position
when is a childs fracture treated like an adults
when they reach puberty- remodelling potential is less
what do fractures around the growth plate risk
disturb growth- shortened limb, angular deformity due to growth arrest on one side
what do salter harris classifications categorise
types of physeal fractures
describe a salter harris I fracture
pure physeal separation
best prognosis
least likely to result in growth arrest
describe a salter harris II fracture
most common
small metaphyseal fragment attached to the physis and epiphysis
likelihood of growth disturbance is low
describe salter harris III and IV fractures
intra‐articular and with the fracture splitting the physis and epiphysis
there is greater potential for growth arrest.
These fractures should be reduced and stabilized to ensure a congruent articular surface and minimize growth disturbance
describe a salter harris V fracture
compression injury to the physis with subsequent growth arrest
cannot be diagnosed on initial x ray- only detected once angular deformity gas occured
where does child abuse occur more commonly
in poverty, in children with special needs/ disability, children whos parents are substance abusers
what should raised the suspicion of NAI
multiple fracture of carying ages (varying amounts of callous formation)
multiple trips to A and E with different injuries
Inconsistent / changing history of events
Discrepancy of history between parents / carers
History not consistent with injury
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
what are common types of distal radius fractures in children
buckle fractures, greenstick fractures, salter harris II
how are distal radius buckle fractures treated
stable, only require 3-4 weeks of splintage
how are distal radius greenstick fractures treated
may be angulated and require manipulation and casting if there is significant deformity
where do salter harris II fractures usually occur in older children
around the distal radial physis
how are angulated salter harris II fractures treated
may need manipulation
what displacement and angulation is more common in complete distal radius fractures
dorsal
what prevents overcorrection of the deformity and aids stability in complete distal radius fractures
the dorsal periosteum usually remains intact
what is the treatment for a complete distal radius fracture
If the fracture is fairly stable, casting may suffice.
If a complete fracture is very unstable after reduction, wire stabilization or plate fixation may be employed.
how do montegiia and galeazzi fractures go against the usual principles of childrens fractures
anatomic reduction and rigid fixation with plates and screws is typically used to treat these injuries
high rate of re‐dislocation of the radial head or distal radio-ulnar joint (DRUJ) if only manipulation and casting is used
what is the usual treatment for angulated fracture of both bones of the forearm in children
usually have an intact periosteum and instability may only be in one plane- controlled with a cast after manipultation
what is the usual treatment for displaced fracture of both bones of the forearm in children
tend to be unstable- flexible intramedullary nail usually used
why are supracondylar injuries common in children
as supracondylar region of the distal humerus is a relatively weak point in the growing upper limb
what is the usual mechanism of injury for a supracondylar fracture of the elbow
extension type fractures most common- heavy fall onto the outstretched hand
flexion injury- occurs with a fall onto the point of a flexed elbow
how are undisplaced supracondylar fractures of the elbow treated
are stable, treated with a splint
how are angulated, rotated or displaced supracondylar fractures of the elbow treated
require closed reduction and pinning with wires to prevent deformity
what can happen to muscles in severely displaced / off‐ended fractures of the supracondylar elbow
brachialis muscle may be tethered in the fracture site- requires open reduction
why is the patient unable to make an OK sign in off ended extension type fractures of the supracondylar humerus
loss of action of FPL and FDP to the index- distal fragment (elbow) displaces posteriorly with stretch and pressure on the brachial artery and median nerve -predominantly its anterior interosseous branch
why should displaced supracondylar fractures be reduced quickly
to avoid swelling which makes reduction more difficult
what happens if the radial pulse is absent or reduced in volume in supracondylar fractures
emergency surgery
Closed reduction may be performed with wiring and the pulse may return if the artery is no longer under stretch. However occasionally the brachial artery will be trapped in the fracture site and if the hand remains pulseless after reduction, open surgical exploration is required
what happens if there is a nerve injury in supracondylar fractures
urgent theatre management
what are the majority of nerve injuries in supracondylar fractures
neurapraxias - improve with time
or occasionally axonotmesis which also improves with time
what might indication entrapment of a nerve
Ongoing neuralgic pain (unpleasant shooting or burning pain radiating to the sensory districution of the nerve) or no improvement in diagnosed neurapraxia or axonotmesis
what can cause a femoral shaft fracture in children
a fall onto a flexed knee or by indirect bending or rotational forces
why can shortening in femoral shaft fractures in younger children be accepted
at overgrowth tends to occur after fracture healing
what is the treatment for a femoral shaft fracture in children under 2
gallows traction and early hip spica cast is appropriate
what is the worry in femoral shaft fractures in children under 2 years old
more than half cause by NAI
what is the treatment for a femoral shaft fracture in children between ages 2 and 6
thomas splint or hip spica cast
what is the treatment for a femoral shaft fracture in children between ages 6 and 12
femur is large enough to accommodate flexible intramedullary nails which obviate the need for traction or cast
what is the treatment for a femoral shaft fracture in children over the age of 12
adult type intramedullary nail
what is the worry in femoral shaft fractures of any age
femur common site for benign and malignant bone tumours- fractures may be pathological with osteolysis and cortical thinning
what is known as the ‘toddlers fracture’
undisplaced spiral fractures of the tibial shaft
what is the treatment for a ‘toddlers fracture’
short time in cast
what is the management for the majority of childrens tibial fractures
cast
is the risk of compartment syndrome in children tibial fractures higher or lower than in adults
lower
how much angulation can be accepted in childrens tibial fractures
10 degrees
greater degrees treated with manipulation and casting
why are serial x rays needed in tibial fractures in the cast
to ensure that the fracture does not drift into excessive angulation in the AP or lateral planes
what is not excepted in tibial fractures
shortening or malrotation
what are the opens for stabilising a very unstable or open tibial fracture in children
flexible intramedullary nails, plates and screws or external fixation
what treatment can adolescents with a closed proximal tibial physis have
adult type intramedullary nail
