Paediatric Trauma

Question 1

how do childrens bones differ to adult bones?

Answer 1

more elastic and palpable and tend to buckle or partially fracture/splinter rather than break completely
thicker periosteum and tends to remain intact

Question 2

how does the thicker periosteum affect fracture healing in children?

Answer 2

tends to remain intact which can help stability

rich source of osteoblasts in periosteum means fractures heal faster

Question 3

how do children bones have a greater remodelling potential?

Answer 3

as they grow with bone being formed along the line of stress

- can correct angulation up to 10 degrees per year

Question 4

how do childrens fractures differ from adult fractures in terms of management?

Answer 4

tend not to need surgical stabilization as often - and less invasive temporary pins wires etc used when it is needed
greater degrees of angulation and displacement can be accepted
if unstable - manipulation and cast often enough
plates and screws rarely used, only in some very unstable fractures

Question 5

why are childrens fractures more easily managed?

Answer 5

greater remodelling potential

Question 6

at what age are fractures treated as “adult fractures”?

Answer 6

once puberty reached

- usually 12-14

Question 7

why are fractures of the physis (growth plate) potentially difficult?

Answer 7

can disturb growth resulting in a shortened limb or angular deformity if only one side of the growth plate effected

Question 8

how are physeal fractures classified?

Answer 8

salter harris classification

Question 9

types of physeal fractures?

Answer 9

salter harris 1 = pure physeal separation
salter harris 2 = most common, fracture extends into metaphysis
salter harris 3 = fracture extends down from physis through epiphysis
salter harris 4 = down through metaphysis, growth plate and epiphysis
salter harris 5 = compression injury to they physis with subsequent growth arrest

Question 10

features of non accidental injury?

Answer 10

multiple fractures at various stages of healing
inconsistent story/history
injuries not in line with age - i.e non walking child
multiple bruises of varying age
atypical injuries - cigarette burns etc
trunk burns
rib fractures
metaphyseal fractures

Question 11

name 3 common distal radial fractures which occur in children

Answer 11

buckle fractures
greenstick
salter harris 2 (distal radius physis)

Question 12

how is a buckle fracture of the distal radius managed?

Answer 12

usually require only 3-4 weeks splintage

Question 13

how are greenstick fractures of the distal radius managed?

Answer 13

may need manipulation and casting if significant deformity - particularly in older child

Question 14

how are salter harris 2 fractures of distal radius physis managed?

Answer 14

manipulation if angulation/deformity

Question 15

in which direction are distal radial fracture more likely to displace?

Answer 15

dorsally

Question 16

what prevents overcorrection of dorsal displaced fracture?

Answer 16

dorsal periosteum remains intact

- also aids stability

Question 17

stable distal radius fracture management?

Answer 17

casting

Question 18

unstable distal radial fracture management?

Answer 18

wire stabilization or plate fixation

Question 19

name 2 common forearm fractures which go against the usual principles of childrens fractures, how are they managed instead?

Answer 19

monteggia and galeazzi fractures

anatomic reduction and rigid fixation with plates and screws as redislocation is common if casting is used

Question 20

how are fractures of both bones of the forearm usually managed and why?

Answer 20

manipulation and casting if instability only in one plane

flexible intramedullary nail if displaced and unstable

Question 21

what commonly causes supracondylar fractures?

Answer 21

extension - FOOSH = most common

flexion - fall onto point of flexed elbow = less common

Question 22

how are undisplaced supracondylar fractures managed?

Answer 22

splint

Question 23

how are angulated, rotated or displaced fractures managed?

Answer 23

require closed reduction and pinning with wires

Question 24

when is open reduction used in supracondylar fracture?

Answer 24

severely displaced/off ended fractures where brachialis is tethered

Question 25

how does an off ended extension type fracture commonly displace and what are the risks of this?

Answer 25

posteriorly

stretch and pressure on median nerve and brachial artery (cant make “OK” sign)

Question 26

when is emergency surgery required for supracondylar fracture?

Answer 26

if radial pulse is absent or reduced in volume

in presence of a nerve injury

Question 27

types of emergency surgery for supracondylar fracture?

Answer 27

closed reduction with wiring

if pulse doesn’t return - open reduction

Question 28

how is nerve injury after a supracondylar fracture managed?

Answer 28

urgent theatre management
most improve with time
ongoing neuralgic pain or no improvement suggests entrapment which may need surgical release

Question 29

what commonly causes femoral shaft fractures in children?

Answer 29

fall onto flexed knee

indirect bending or rotational forces

Question 30

why does shortening sometimes occur in femoral shaft fractures in children?

Answer 30

overgrowth tends to occur after fracture healing

Question 31

what is the most common cause of femoral shaft fracture in children less then 2 yrs?

Answer 31

NAI

Question 32

management of femoral shaft fracture in <2s?

Answer 32

gallows traction and early hip spica

Question 33

management of femoral shaft fracture in ages 2-6?

Answer 33

Thomas splint
or
hip spica cast

Question 34

femoral shaft fracture management in ages 6-12?

Answer 34

flexible intramedullary nail

Question 35

femoral shaft fracture management in ages 12+?

Answer 35

adult type intramedullary nail

Question 36

what is a toddlers fracture and how is it managed?

Answer 36

undisplaced spiral fracture of the tibial shaft, commonly seen in toddlers
treatment = short time in cast

Question 37

mainstay of treatment for most tibial fractures in children?

Answer 37

casting

serial X rays while in the cast

Question 38

what can and cannot be accepted in tibial fracture in children?

Answer 38

acceptable = up to 10 degrees angulation
unacceptable = >10 degrees angulation, shortening, malrotation

Question 39

options for stabilizing very unstable or open fractures of tibia?

Answer 39

intramedullary nails
plates and screws
external fixation
adult type intramedullary nail in adolescents with closed proximal tibial physis