Paediatric Trauma

Question 1

What is the Salter-Harris classification used for?

Answer 1

Physeal fractures (can be remembered with pneumonic SALTR)

Question 2

Prognosis is poorer as the Salter-Harris classification progresses

T/F

Answer 2

TRUE

Question 3

A child has a Salter-Harris I fracture.

What has happened and what is their prognosis?

Answer 3

Salter-Harris I =

pure physeal separation

It carries the best prognosis and is least likely to result in growth arrest!

Question 4

A child has a Salter-Harris II fracture.

What has happened and what is their prognosis?

Answer 4

Salter-Harris II fractue is the most common type of physeal fracture.

It’s similar to Salter-Harris I but has a small metaphyseal fragment attached to the physis and epiphysis.

Liklihood of growth disturbance is low

Question 5

Two twins present and one has a Salter-Harris III fracture and the other has a Salter-Harris IV fracture,

What has happened and what is their prognoses?

Answer 5

As most things in their life so far, it’s the same for both of them!

Salter-Harris III and IV fractures are intra-articular

They split the physis :. greater potential for growth arrest

Question 6

How would you manage a Salter-Harris III/IV fracture?

Answer 6

These fractures should be reduced and stabilised to ensure a congruent articular surface and minimise growth disturbance

Question 7

A child presents with a Salter-Harris V injury.

What has happened and what’s the prognosis?

Answer 7

Salter-Harris V injury is a compression injury to the physis with subsequent growth arrest

These injuries cannot be diagnosed on initial X-Rays and are only detected once angular deformity has occured.

Question 8

What mneumonic can you use to help you remember the Salter-Harris classification of physeal fractures?

Answer 8

SALTR

• Slipped
• above
• low
• through/transverse/together
• rammed/ruined

Question 9

What should you do if you suspect NAI or child abuse?

Answer 9

• Paediatricians should be involved early
• Child should be admitted for safety and a full examination done
• Skilled history taking from parents or carers should be performed by an experienced doctor

Question 10

Your registrar tells you the child in Bay 4 in A&E has a buckle fracture and you need to go explain to the parents what this means.

Go.

Answer 10

Buckle fractures are fractuers of the distal radius which are stable.

Only require 3-4 weeks of splintage.

Question 11

Your mate in A&E tells you they’ve got their hands very full with a rapidly detoriating patient who’s just been diagnosed with sepsis!!

They’ve just got the radiology result for the child in Bed 2 who has a confirmed angulated Greenstick fracture of the distal radius and have asked you to go and manage it. You’re so sound you agree to lend a hand.

What are you going to do for this child?

Answer 11

Manipulation and casting

(particularly in the older child)

Question 12

How are Monteggia and Galeazzi fractures normally treated?

Answer 12

They go against the usual principles of children’s fractures, in that anatomic reduction and rigid fixation with plates and screws is typically used to treat them

Question 13

Why do Monteggia and Galeazzi fractures get surgical management when most paediatric fractures get splints or casts?

Answer 13

There is a high rate of dislocation of the radial head or distal radio-ulnar joint, if only manipulation and casting is used

Question 14

What are the two main mechanisms of action of supracondylar fractures of the elbow?

Answer 14

1. Extension type fractures are more common and occur due to a heavy FOOSH
2. The less common flexion type injury occurs with a fall onto the point of the flexed elbow

Question 15

How is an undisplaced supracondylar fracture of the elbow managed?

Answer 15

a splint

Question 16

How are angulated/rotated/displaced supracondylar fractures of the elbow managed in kids?

Answer 16

Closed reduction and pinning with wires to prevent deformity

Question 17

A child presents with a very painful elbow after a FOOSH. You think they have a displaced supracondylar fracture.

You want to impress your senior by checking if the distal fragment has displaced posteriorly.

How are you going to do it?

Answer 17

Ask them to make the “OK” sign

With displaced extension type supracondylar fractures of the elbow the distal fragment displaces posteriorly with stretch and pressure on the brachial artery and median nerve

predominantly the anterior interosseous branch of the median nerve and :. the patient is unable to make the OK sign due to loss of Flexor Pollicis Longus and Flexor Digitorum Profundus to the index

Question 18

Displaced (supracondylar) fractures (of the elbow) should be reduced fairly soon to avoid swelling which can make reduction more difficult.

What should you check beforehand and after?

Answer 18

The radial pulse

Question 19

You’ve been managing an 8y/o patient in A&E. You’re very pleased with yourself as you have correctly diagnosed them with a displaced supracondylar fracture of the elbow. You’ve confirmed with a colleague that the correct next step is reduction. When you feel the radial pulse afterwards it is reduced in volume. What do you do next?

a) an X-ray
b) leave it, it’s fine
c) un- reduce the fracture
d) do an ECG
e) organise emergency surgery

Answer 19

e) organise emergency surgery

Closed reduction may be performed with wiring and pulse may return if the artery is no longer under stretch.

However, occasinally the brachial artery will be trapped in the fracture site and if the hand remains pulseless after reduction, open surgical exploration is required.

Question 20

What action usually causes femoral shaft fractures in kids?

Answer 20

Femoral shaft fractures can occur in children due to a fall onto a flexed knee or by indirect bending or rotational forces

Question 21

A 20 month old child presents with a femoral shaft fracture.

What are you worried about?

Answer 21

NAI

In children under 2 y/o >half of femoral shaft fractures are due to NAI/child abuse and other signs of NAI should be looked for and acted upon appropriately.

These other signs may include:

• multiple injuries & bruises of varying age
• atypical injuries
• inconsistent or inappropriate history

Question 22

How would you suggest treating an 18month old child with a femoral shaft fracture?

Answer 22

Gallows traction and an early hip spica cast

Question 23

How would you treat a child aged between 2 and 6 with a femoral shaft fracture?

Answer 23

Thomas splint or a hip spica cast

Question 24

How would you treat a child aged between 6 and 12 with a femoral shaft fracture?

Answer 24

The femur is large enough to accomodate flexible intramedullary nails which obliviate the need for traction or cast

Question 25

For children aged 12 and above an adult type intramedullary nail is typically used.

Question 26

What differential would you want to be thinking about in any child with a femoral shaft fracture?

Answer 26

The femur is a common site for benign and malignant bone tumours and the fracture may be pathological with osteolysis and cortical thinning

Question 27

what is a “toddler’s fracture”?

Answer 27

Undisplaced spiral fracturs of the tibial shaft are common in toddlers :. a.k.a. “toddler’s fracture”

Question 28

What is the mainstay of treatment for the majority of paediatric tibial shaft fractures?

Answer 28

A short time in a cast

Question 29

How is a paediatric tibial shaft fracture different to that of an adult?

Answer 29

• the risk of compartment syndrome is much less than that for an adult
• also up to 10 degress of angulation may be accepted and greater degress of angulation may be treated with manipulation and casting