Fracture in a child Flashcards
Which fractures are common in neonates?
Clavicle - from shoulder dystocia; snap may be heard at delivery or present with reduced arm movement on the affected side. No treatment usually reqiured and good prognosis.
Humerus/femur - midshaft usually occurring during breech deliveries or humerus fracture in shoulder dystocia; there is deformity, reduced movement and pain on mobilisation. Heals rapidly with immobilisation.
List some subtypes of fractures seen in children.
- Complete fracture - both sides of cortex breached
- Toddlers fracture
- Plastic deformity
- Greenstick fracture
- Buckle fracture
What is a toddlers fracture? What is their cause?
- Oblique fracture of the distal shaft of the tibia with an intact fibula.
- Periosteum intact and bone stable.
- Caused by twisting injury
What is the injury pattern in plastic deformity?
Stress on bone results in deformity without cortical disruption
What is a greenstick fracture?
Unilateral cortical breach only
What is a buckle fracture? What is it also known as?
Incomplete cortical disruption resulting in periosteal haematoma only
AKA Torus fracture
What system is used to classify growth plate fractures, which may occur in children?
Salter-Harris system
- I - Fracture through the physis only (x-ray often normal)
- II - Fracture through the physis and metaphysis
- III - Fracture through the physis and epiphyisis to include the joint
- IV - Fracture involving the physis, metaphysis and epiphysis
- V - Crush injury involving the physis (x-ray may resemble type I, and appear normal)
Which type of Salter-Harris fracture is most common?
Type 2 - occurs in 75% of cases
What is the management of Salter-Harris fractures? What is a complication?
- Growth plate tenderness is usually assumed to mean underlying fracture even if XR appears normal.
- Types III-V will usually require surgery
- Type V is often associated with disruption to growth
Which signs in paediatric fracture are indicative of non-accidental injury?
- Delayed presentation
- Delay in attaining milestones
- Lack of concordance between proposed and actual mechanisms of injury
- Multiple injuries
- Injuries at sites not commonly exposed to trauma
- Children on the at risk register
How likely is each of these to be accidental (1 = likely, 2= may be inflicted, accidental or underlying disorder; 3 = unlikely)?
- Any fracture in a non-mobile child (excluding fragile bones)
- Long bone fracture in a young but mobile child
- Rib fractures
- Skull fracture in a young child
- Multiple fractures (excluding significant accident such as RTA)
- Fracture in school-age child with witnessed trauma e.g. fall from swing
- Multiple fractures at different ages
- Any fracture in a non-mobile child (excluding fragile bones) - 3
- Long bone fracture in a young but mobile child - 2
- Rib fractures - 3
- Skull fracture in a young child - 2
- Multiple fractures (excluding significant accident such as RTA) - 3
- Fracture in school-age child with witnessed trauma e.g. fall from swing - 1
- Multiple fractures at different ages - 3
From this description, what are the concerning features? What are the positive features? Who else should be involved?
A general paediatrician sees a 6-year-old boy for recurrent abdominal pain resulting in missing 20% of school this year. The boy and his mother are accompanied by his 3 months old sister. The boy is all over the clinic room – climbing onto the examination couch, turning the ophthalmoscope on and off, crawling under the desk, trying to get hold of the computer keyboard and turning the water tap of the handbasin on and off. The baby is crying, but her mother is holding her at arm’s length and not comforting her or taking any notice of her son’s behaviour. With the help of the clinic nurse, the boy is shown some toys and settles down and shows good ability to put a simple jigsaw puzzle together. The baby keeps crying until the mother eventually gives her a bottle of formula from her bag. The mother’s affect is very flat and is vague about the history of abdominal pain and why so much school has been missed. Examination shows that he is on the 50th centile for weight and height. His mother says she has lost his personal child health record. He is in school uniform and is clean but his hair is not brushed. He has dental caries but mother cannot remember when he last saw the dentist. The boy says that he cleans his teeth twice a day. He has some bruising to the shins but examination is otherwise normal.
Should also involve.. to investigate this.
- GP - about mother’s flat affect
- Health visitor
- School nurse
- Children’s social services - contact to see if they are known to the system.
- Hospitals - is the child known to other hospitals?
Need to ask further questions about who else is at home, what suppoort is available, mother’s own health and others in the household, social work involvement previously.
What is a genetic cause of fractures in children?
Osteogenesis imperfecta - type I is the most common form which is autosomal dominant
Osteopetrosis (marble bone disease) - autosomal recessive, bones are dense but brittle
What are the clinical features of osteogenesis imperfecta?
- Fractures during childhood
- Blue appearance to the sclerae
- May develop hearing loss
What is the pathophysiology of osteogenesis imperfecta?
Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine.
Failure of maturation of collagen in all the connective tissues.
Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.
What is shown? When is it most common? What is the management?
Buckle/Torus fracture - characterised by bulging of the cortex
Most common in 5-10 years olds
Typically self limiting and may be managed with splinting and immobilisation rather than cast
What is the most common fracture in children? (body part) How does it happen?
Distal radial - usually a Torus/buckle fracture
Occurs due to a simple fall on an outstretched hand with the wrist in extension
What is the most common type of fracture around the elbow in children? What are the complications of this type of fracture?
Supracondylar fracture
Must be recognised and treated promply as there is potential to damage vasculature (brachial artery) and nerves (anterior interosseous nerve). Assess capillary refill and sensation.
Displaced fractures can be manipulated with K wires as shown below.
What type of fracture is shown?
Galeazzi fracture - distal radio-ulnar joint dislocates with a fracture occurring at the junction of distal third an middle third of the radius. In adults this is internally fixed whereas in children a long arm cast is sufficient after reduction under general anaesthetic.
What is shown? What is the management? What are the complications?
Greenstick or buckle fracture - common in children after a fall.
Manage by plaster immobilisation if angulated, otherwise splint.
No complications.
