Paediatric Trauma Flashcards
what are the different orthopaedic injuries children experience?
Bones more elastic/pliable so tend to buckle or partially fracture/splinter rather than completely break
what children do we suspect NAI in if they get a fracture?
neonates and infants - under 2s not walking yet so hard for them to break a bone
when is conservative management not the first point of call in managing fractures in children?
-Displaced intra-articular fractures
-Displaced growth plate fractures
-Open fractures
general principles of fracture management
reduce retain rehabilitate
What should be looked for in a neurovascular exam?
colour
cap refill
skin temp.
O2 stats
pulse
sensation
sweating
skin wrinkling on immersion in water
how is a neurovascular issue diagnosed?
ultrasound
athrogram CT/MR for detail
what is a broad arm sling for?
Humerus
supports but no traction for shoulder, collar and cuff traction -
Management for a diaphyseal fracture?
immobilise joint above and below to prevent rotation
Management for a metaphyseal fracture?
immobilise the adjacent joint
risk with distal femur fracture?
risk of premature closing of the growth plate
when to use external fixation?
-Contaminated wounds
-Soft tissue problems
-Acute vascular injury
-Burns
-Multiple injuries
what is the use of periosteum?
A lot thicker and tends to stay intact useful for stability and can assist in reduction
what is the advantage of children’s thicker periosteum?
allows fractures to heal more quickly in children
what is the effect of children’s greater remodelling ability?
They grow with bone being formed along the line of stress
Children can correct angulation of up to 10 degrees per year of growth
Surgery is therefore performed less in children
what age do fractures get treated the same as adults?
Puberty (12-14 years)
Wolf’s law
bone in a healthy person/animal will adapt to the loads under which it is placed
Hueter-Volkmann law (used to explain scoliosis)
bone growth during skeletal immaturity is delayed by mechanical compression on the growth plate and accelerated by growth plate tension
What is the Salter-Harris classification for?
physeal fractures
Salter-Harris 1
pure physeal separation (best prognosis, least likely to cause growth arrest)
Salter-Harris 2
most common,
- Physeal fractures, has a small metaphyseal fragment attached to the physis and epiphysis
-Likelihood of growth disturbance is low
Salter-Harris 3 and 4
-Intra-articular fracture splits the physis
-Greater potential for growth arrest
-Fractures should be reduced and stabilised to ensure a congruent articular surface and minimise growth disturbance
Salter-Harris 5
-Compression injury to the physis causes growth arrest
-Can’t be diagnosed initially on x-rays only detected once angular deformity has occurred
common children’s fractures
- Distal radius
-Forearm
-Supracondylar fractures of the elbow
-Femoral shaft fractures - Tibial fractures
Distal radius - Greenstick fractures
-May be anguated
-May need manipulation and casting if there is significant deformity (esp in an older child)
distal radius - salter harris II fractures
-Common around the distal radial physis in older children
-Angulation with deformity requires manipulation
what do complete fractures of the distal radius do?
-May displace and angulate (dorsal more common than volar )
Management of distal radius fractures
Stable: Casting
Unstable after reduction - may need more stabilisation or plate fixation
what is a Monteggia fracture - dislocation?
fracture of proximal ulna with displacement of the radial head
What is a Galeazzi fracture - dislocation?
Fracture of distal radius with dislocation of the distal radioulnar joint
How are Monteggia and Galeazzi fractures managed?
-Anatomic reduction and rigid fixation with plates and screws
- if only manipulation and casting is used there is a high rate of re-dislocation of the radial head/distal radio-ulnar joint (DRUJ)
Undisplaced monteggia and galeazzi fractures
-Usually intact periosteum
-Instability may only be in one plane so can be controlled with a cast after manipulation
displaced monteggia and galeazzi fractures
usually unstable
flexible IMN usually used
how are undisplaced supracondylar fractures of the elbow managed?
stablised and treated with splint
how are angulated/rotated/displaced supracondylar fractures of the elbow managed?
-Closed reduction + pinning with wires to prevent deformity
-Open reduction may be needed where close reduction isn’t possible
Test with off-ended extension type fractures in supracondylar fractures of the elbow?
patient is unable to make OK sign with hand
because the distal fragment displaces posteriorly causing pressure on the brachial artery and median nerve (mainly anterior interosseous branch of the median nerve)this result in loss of FPL and FDP to the index
How are displaced fractures of supracondylar fractures of the elbow managed?
reduce early to avoid swelling -
(swelling makes reduction more difficult)
-If the radial pulse is absent/reduced in volume do EMERGENCY SURGERY
can do closed reduction with wiring, pulse may return if artery is no longer under stress
open surgery needed sometimes - if brachial artery is trapped in the fracture site OR if the hand remains pulseless after reduction
what are the signs of and management of nerve injury and supracondylar fractures of the elbow?
Signs: neuralgic pain with no improvement -
URGENT theatre management - surgical release majority are neurapraxias sometimes axonotmesis
how do children get femoral shaft fractures?
-Falling onto flexed knee
-Indirect bending/rotational forces
femoral shaft fractures in less than 2s
mostly due to NAI/child abuse
Treat with Gallows traction and early hip spica cast
Treatment of femoral shaft fractures in 2-6
Thomas splint
OR
Hip spica cast
Treatment of femoral shaft fractures in 6-12s
Flexible IMN (can use as the femur is now large enough)
this will show if there is need for traction or cast
femoral shaft fracture in over 12s
Adult type IMN
What fracture is known as the toddlers fracture?
-Undisplaced tibial spiral fractures
Require a short time in cast
what is the standard management for tibial fractures in children?
a cast
risk of compartment syndrome much less than an adult
what level of tibial angulation is accepted in children after fracture?
10 degrees
management of tibial fracture once in cast?
Serial X-rays in the cast
Make sure fracture doesn’t drift into excessive angulation
How are unstable/open tibial fractures managed?
Flexible IMN (adolescents with a closed proximal tibial physis can have an adult type IMN)
Plates and screws
External fixation
