Paediatric Trauma (including NAI) Flashcards
what are the risk factors for kids fractures?
- Boys 60% > Girls 40%
- Age - Older = more likely to of had a fracture
- Previous fracture
- Metabolic bone disease
- Season
Children’s Fracture Principles - childrends fractures heal ______
quickly
Children’s Fracture Principles - childrends fractures heal quickly, how?
- Metabolically active periosteum
- Cellular bone
- Good blood supply
- Often low velocity trauma
Children bone different form adults
Thicker periosteum in children
Children don’t often smoke so good blood supply to bone
what should you avoid when treating fracutres in children?
- Fixation is not usually required
- Do not over immobilise
- Do not over treat
what are the four types of fractures in children?
In adults only really one type of fracture but in children there is 4
Complete Fracture (Complete fracture is the one seen in adults)
Greenstick Fracture
Buckle (Torus) - Buckle due to longitudinal compression – need simple splintage for short period of time and not much follow up
Plastic Deformity - caught in rung of ladder and lots of little cracks, bend causes dislocation at top and bottom of forearm
what type is shown here?
Complete Fracture
what type is shown here?
Greenstick Fracture
what type is shown here?
Buckle (Torus)
what type is shown here?
Plastic Deformity
what is involved in the assessment of a fracture?
- History – Mechanism
- Deformity
- Soft tissues
- Whole limb
- Wounds
- Sensation, Motor function
- Vascular status
DOCUMENT FINDINGS, REPEAT POST-INTERVENTION
Most children’s fractures need simple treatment
what conservative treamtent is avalible?
90% of children fracture done conservatively
Cast
Braces
Splints
Traction
what operative treamtent is avalible?
Elastic nails used in children and mainly rigid ones in adult as can affect growth in children
Most children’s fractures need simple treatment, why is this?
Children’s Fracture Re-model
Most evident in plane of joint movement
- Appositional periosteal growth/resorption
- Differential physeal growth - Can correct angulation
Thick layer of periosteum which is very metabolically active and will smooth out any irregularities in the bone by resorbing the prominises and strengthen the bit where there is a lack of bone
picture - Humeral fracture, mid shaft oblique fracture, displacement stimulates callus formation to stabilise the injury. This process doesn’t happen as well in adults as they have a less active periosteum
what would you do for a femur fracture?
If oblique or spiral in femur they will shorten so use traction
Gallows traction in children
Children’s Fracture Principles:
Remodel well in plane of ____ __________
joint movement
forms callous that gradually changes into bone
Most children’s fractures need simple treatment, such as what?
- Reduce the fracture (if needed)
- Immobilise
- Remove cast/splint when healed
- Joint stiffness rare
- Open fractures debride
Children’s Fracture Principles Reduction - what is it?
Increase the deformity to reduce the fracture
Remember the periosteal hinge
Bark represents the periosteum
why may a curved cast be used?
In greenstick fractures it tends to return to the position it was in even if manipulated so has to be opposed using curved plaster
Bones need bent cast to give a straight limb (Periosteum Tension)
Supplement the cast with fixation when what?
Severe swelling likely
Need to re-inspect wound (e.g. open fractures)
Multiple injuries
Segmental limb injuries - Segmental injuries don’t heal well – 2 different fractures
Fracture very unstable
Approaching skeletal maturity (less period for remodeling)
what are Physeal fractures and its effects?
- Physis acts as a plane of fracture
- Physis weaker than Ligaments
- Growth arrest risk (can get partial or full growth plate arrest)
Growing bones have active physis and skeletal maturity is when these physis close
Fractures involving physes can result in progressive deformity
The Salter-Harris Classification helps to predict injuries that may affect growth
what are the different types?
Distal long bone
Tells you where the fracture is rather than how much it is displaced
1 = fracture in line with growth plate
SH-2 is most common injury around growth plate
Type 1 and 2 there is a good chance these will heal without any growth disturbance particularly if in upper limb
In 3 and 4 there is a much higher risk of growth disturbance, particularly in lower limbs
5 is longitudinal compression of the growth plate
Fractures involving physes can result in progressive deformity and affect growth. Is this more common in upper or lower limbs?
more common in lower limbs
more chance of recovery if in upper limbs
what kind of Salter-Harris fractures involving the physes are most common?
what is shown here?
Ankle SH1
Often difficult to see particularly if undisplaced
what is shown here?
Ankle SH2
commonest
2 x-rays, 90 degrees to each other
what is shown here?
Ankle SH3
•Need for anatomical reduction and fixation if displaced
what is shown here?
Ankle SH4
- Rare
- Management:
- ORIF if displaced
- Monitor for growth arrest
Tibial spine
An Apophyseal injury
what is it?
Apophysis – where the tendon insets to the bone
Due to lligament stronger than the bone
• Avulsion of ACL:
- I Undisplaced
- II Hinged
- III Displaced
- I/II Long leg cast
- II/III ORIF
what is shown here?
Another example of where the tendon is stronger than the bone and bone has been torn off
Usually need operative fixation
In sporty teenagers
what are Transitional Fractures?
•Growth plate closing, age 13-14y
- Central>Medial>Lateral fusion
Children who have almost stopped growing
The last part to fuse is the lateral epiphysis of the distal tibia
Particularly seen around the ankle
what is a Tillaux Fracture?
Ligament connecting tibia and fibula, which twisting movements of the ankle force is exerted on the ligament and in adults the ligament would tear but in children the ligament is stronger than the bone so the piece of bone is pulled off the growth plate where it hasn’t fused
hwat are the surgical options for fracture management?
- External fixator – rarely required
- ORIF (open reduction internal fixation):
- Adolescents
- Comminuted fractures
- Injuries involving joint surface
- Monteggia & Galeazzi (MUSGRI) (forearm fracutres)
Monteggia – ulnar is fractures, superior dislocation of radial head
Galeazzi – radius is fractured and distal ulnar is doslocated
how is Flexible nailing done and what is its effects?
- Need 2yrs predicted growth remaining
- Nancy (where it was developed)
- Allow early ROM
- Wires out when healed
- Minimal disruption (to fracture site so the fractures rapidly heal with callus)
what is shown here?
Combination of treatment
Plate and wire used
what is NAI?
Non-accidental injury
- Be aware
- 50% Recurrence, 10% Fatality
Non-accidental injury or physical abuse is any bodily injury that is deliberately inflicted on a vulnerable person that is considered unacceptable in a given culture at a given time. This may include hitting, kicking, burning, biting or choking
In NAI, you need to look for wanrings such as what?
Inconsistent history
Delay in presentation
Fracture pattern does not fit mechanism
Bruising – pattern and different ages
Burns
Multiple fractures, multiple stages of healing
Metaphyseal #, Humeral shaft # (need a lot of force)
Rib #s
Non-ambulant with # of long bones
what is osteomyelitis like?
Infection of the bone
Can be acute or chronic
- Insidious onset
- Think about it or you will miss it
- Mainly around knee
Often unable to weight bear and painful to move
Huge blood supply to growth plate
Can become septic arthritis if bursts in knee
how is osteomyelitis managed?
- Aim to prevent acute becoming chronic
- Most require prolonged high dose antibiotics
- Mostly staphylococcus
- Rarely require surgery
- Can threaten life and limb
White area on x-ray
Try take blood cultures before antibiotics
Most cured with high dose antibiotics if caught early, typical treatment period is 6 weeks
