Paediatric Trauma Flashcards
what are the different orthopaedic injuries children experience?
because their bones are more elastic/pliable they 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?
supports but no traction for shoulder, collar and cuff traction - for humerus
for a diaphyseal fracture?
immobilise joint above and below to prevent rotation
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 periosteum?
it increased the width/circumference of growing long bones
rich source of osteoblasts
children - the periosteum is 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?
children have a greater potential to remodel as 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 - if surgery is done less invasive procedures are favoured
what age do fractures get treated the same as adults?
once the child’s reached 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
(larger the SH number worse the prognosis)
when to suspect NAI?
multiple fractures of varying ages (varying amounts of callus/healing)
multiple bruises of varying ages
multiple trips to A&E with different injuries
inconsistent history of events
discrepancy of history between parents/carers
history doesn’t make sense for the injury
age of child doesn’t line up with injury
atypical injuries (cigarette burns, genital injuries, lower limb and trunk burns)
rib fractures
metaphyseal fractures in infants
management of NAI?
paediatricians involved early
child admitted for safety
full exam and skilled history should be done by an experienced doctor
common children’s fractures
distal radius fractures forearm fractures supracondylar fractures of the elbow femoral shaft fractures tibial fractures
distal radius buckle fractures (these ones involve the periosteum)
stable
only need 3-4 weeks of splintage
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
growth problems are highly unlikely
what do complete fractures of the distal radius do?
may displace and angulate
dorsal displacement and angulation is more common than volar
doral periosteum tends to remain intact - prevents overcorrection of the deformity and helps stability
Management of distal radius fractures
casting may be enough if the fracture is relatively stable
if a complete fracture is very unstable after reduction - may need wore stabilisation or plate fixation
what is a Monteggia fracture - dislocation?
fracture of the proximal ulna with displacement of the radial head
What is a Galeazzi fracture - dislocation?
fracture of the 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
because - if only manipulation and casting is used there is a hogh rate of re-dislocation of the radial head/distal radio-ulnar joint (DRUJ)
Undisplaced monteggia and galeazzi fractures
usually have an intact periosteum and instability
may only be in one plane which can be controlled with a cast after manipulation
displaced monteggia and galeazzi fractures
usually unstable
flexible IMN are usually used
What are supracondylar fractures of the elbow?
pretty common - relatively common weak point
extension-type fractures are more common - usually due to a heavy fall onto an outstretched hand
flexion-type injuries are less common, usually due to a fall onto the point of the flexed elbow
how are undisplaced supracondylar fractures of the elbow managed?
stable and treated with splint
how are angulated/rotated/displaced supracondylar fractures of the elbow managed?
need closed reduction and pinning with wires to prevent deformity
open reduction may be needed where close reduction isn’t possible (e.g. severely displaced/offended fracture - long bone fracture which is displaced by more than the width of the bone)
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
causes 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
sometimes open surgery needed - 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?
neuralgic pain with no improvement - can be entrapment
URGENT theatre management - surgical release
majority are neurapraxias sometimes axonotmesis
how do children get femoral shaft fractures?
children falling onto flexed knee
indirect bending/rotational forces
in children, overgrowth tends to occur after fracture so some shortening is accepted
femur is a common site of benign/malignant bone tumours so the fracture may be pathological with osteolysis and cortical thinning
femoral shaft fractures in less than 2s
mostly due to NAI/child abuse
treat with Gallows traction and early hip spica cast
femoral shaft fractures in 2-6
treat Thomas splint or hip spica cast
femoral shaft fractures in 6-12s
treat with 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
treat with 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
the risk of compartment syndrome is much less than an adult
what level of tibial angulation is accepted in children after fracture?
10 degrees
anymore treatment with manipulation and casting
management of tibial fracture once in cast?
need to do serial X-rays in the cast
make sure fracture doesn’t drift into excessive angulation in the AP/lateral planes
Don’t Accept shortening/malrotation
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
or
external fixation