Paediatric Trauma

Question 1

what are the different orthopaedic injuries children experience?

Answer 1

Bones more elastic/pliable so tend to buckle or partially fracture/splinter rather than completely break

Question 2

what children do we suspect NAI in if they get a fracture?

Answer 2

neonates and infants - under 2s not walking yet so hard for them to break a bone

Question 3

when is conservative management not the first point of call in managing fractures in children?

Answer 3

-Displaced intra-articular fractures
-Displaced growth plate fractures
-Open fractures

Question 4

general principles of fracture management

Answer 4

reduce retain rehabilitate

Question 5

What should be looked for in a neurovascular exam?

Answer 5

colour
cap refill
skin temp.
O2 stats
pulse
sensation
sweating
skin wrinkling on immersion in water

Question 6

how is a neurovascular issue diagnosed?

Answer 6

ultrasound
athrogram CT/MR for detail

Question 7

what is a broad arm sling for?

Answer 7

Humerus

supports but no traction for shoulder, collar and cuff traction -

Question 8

Management for a diaphyseal fracture?

Answer 8

immobilise joint above and below to prevent rotation

Question 9

Management for a metaphyseal fracture?

Answer 9

immobilise the adjacent joint

Question 10

risk with distal femur fracture?

Answer 10

risk of premature closing of the growth plate

Question 11

when to use external fixation?

Answer 11

-Contaminated wounds
-Soft tissue problems
-Acute vascular injury
-Burns
-Multiple injuries

Question 12

what is the use of periosteum?

Answer 12

A lot thicker and tends to stay intact useful for stability and can assist in reduction

Question 13

what is the advantage of children’s thicker periosteum?

Answer 13

allows fractures to heal more quickly in children

Question 14

what is the effect of children’s greater remodelling ability?

Answer 14

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

Question 15

what age do fractures get treated the same as adults?

Answer 15

Puberty (12-14 years)

Question 16

Wolf’s law

Answer 16

bone in a healthy person/animal will adapt to the loads under which it is placed

Question 17

Hueter-Volkmann law (used to explain scoliosis)

Answer 17

bone growth during skeletal immaturity is delayed by mechanical compression on the growth plate and accelerated by growth plate tension

Question 18

What is the Salter-Harris classification for?

Answer 18

physeal fractures

Question 19

Salter-Harris 1

Answer 19

pure physeal separation (best prognosis, least likely to cause growth arrest)

Question 20

Salter-Harris 2

Answer 20

most common,
- Physeal fractures, has a small metaphyseal fragment attached to the physis and epiphysis
-Likelihood of growth disturbance is low

Question 21

Salter-Harris 3 and 4

Answer 21

-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

Question 22

Salter-Harris 5

Answer 22

-Compression injury to the physis causes growth arrest
-Can’t be diagnosed initially on x-rays only detected once angular deformity has occurred

Question 25

common children's fractures

Answer 25

- Distal radius -Forearm -Supracondylar fractures of the elbow -Femoral shaft fractures - Tibial fractures

Question 27

Distal radius - Greenstick fractures

Answer 27

-May be anguated -May need manipulation and casting if there is significant deformity (esp in an older child)

Question 28

distal radius - salter harris II fractures

Answer 28

-Common around the distal radial physis in older children -Angulation with deformity requires manipulation

Question 29

what do complete fractures of the distal radius do?

Answer 29

-May displace and angulate (dorsal more common than volar )

Question 30

Management of distal radius fractures

Answer 30

Stable: Casting Unstable after reduction - may need more stabilisation or plate fixation

Question 31

what is a Monteggia fracture - dislocation?

Answer 31

fracture of proximal ulna with displacement of the radial head

Question 32

What is a Galeazzi fracture - dislocation?

Answer 32

Fracture of distal radius with dislocation of the distal radioulnar joint

Question 33

How are Monteggia and Galeazzi fractures managed?

Answer 33

-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)

Question 34

Undisplaced monteggia and galeazzi fractures

Answer 34

-Usually intact periosteum -Instability may only be in one plane so can be controlled with a cast after manipulation

Question 35

displaced monteggia and galeazzi fractures

Answer 35

usually unstable flexible IMN usually used

Question 37

how are undisplaced supracondylar fractures of the elbow managed?

Answer 37

stablised and treated with splint

Question 38

how are angulated/rotated/displaced supracondylar fractures of the elbow managed?

Answer 38

-Closed reduction + pinning with wires to prevent deformity -Open reduction may be needed where close reduction isn't possible

Question 39

Test with off-ended extension type fractures in supracondylar fractures of the elbow?

Answer 39

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

Question 40

How are displaced fractures of supracondylar fractures of the elbow managed?

Answer 40

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

Question 41

what are the signs of and management of nerve injury and supracondylar fractures of the elbow?

Answer 41

Signs: neuralgic pain with no improvement - URGENT theatre management - surgical release majority are neurapraxias sometimes axonotmesis

Question 42

how do children get femoral shaft fractures?

Answer 42

-Falling onto flexed knee -Indirect bending/rotational forces

Question 43

femoral shaft fractures in less than 2s

Answer 43

mostly due to NAI/child abuse Treat with Gallows traction and early hip spica cast

Question 44

Treatment of femoral shaft fractures in 2-6

Answer 44

Thomas splint OR Hip spica cast

Question 45

Treatment of femoral shaft fractures in 6-12s

Answer 45

Flexible IMN (can use as the femur is now large enough) this will show if there is need for traction or cast

Question 46

femoral shaft fracture in over 12s

Answer 46

Adult type IMN

Question 47

What fracture is known as the toddlers fracture?

Answer 47

-Undisplaced tibial spiral fractures Require a short time in cast

Question 48

what is the standard management for tibial fractures in children?

Answer 48

a cast risk of compartment syndrome much less than an adult

Question 49

what level of tibial angulation is accepted in children after fracture?

Answer 49

10 degrees

Question 50

management of tibial fracture once in cast?

Answer 50

Serial X-rays in the cast Make sure fracture doesn't drift into excessive angulation

Question 51

How are unstable/open tibial fractures managed?

Answer 51

Flexible IMN (adolescents with a closed proximal tibial physis can have an adult type IMN) Plates and screws External fixation