Paediatric Trauma Master Deck

Question 1

Why are children’s fractures given special attention?

Answer 1

• Bones are more elastic and so tend to buckle/partially fracture/splinter, with a degree continuity of some “fibres” of bone, i.e: “buckle fracture” and “greenstick fracture”
• Periosteum is thicker and tends to remain intact and can assist reduction if required
• Heal more quickly due to thicker periosteum (rich source of osteoblasts); children have greater potential to remodel

These all mean that children’s fracture are surgically stabilised less frequently and greater degrees of angulation can be accepted

Question 2

Why do children’s bones have greater potential to remodel? Clinical importance?

Answer 2

According to Wollf’s law, change shape with bone being laid down along lines of stress

Children grow with bone being formed along these lines so children can correct angulation up to 10 degrees per year of growth remaining in that bone

Question 3

General treatment of children’s fractures?

Answer 3

Unacceptable fracture position - manipulation and casting (accept a degree of residual angulation or displacement)

Surgical stabilization is required for more unstable injuries (less invasive temporary pins, wires and flexible rods tend to be used); plates and screws reserved for:
• Very unstable peri-articular injuries
• If fracture is assoc. with a dislocation and loss of position may result in redislocation (e.g: Monteggia and Galeazzi injuries of the forearm)

Question 4

When are fractures treated as adult fractures?

Answer 4

Once child reaches puberty, i.e: 12-14 years old (remodeling potential decreases)

Question 5

Consequences of fractures around the physis (growth plate)?

Answer 5

Potential to disrupt growth and could result in a shortened limb or an angular deformity, if one side of the physis is affected by growth arrest

Question 6

How are physeal fractures classified?

Answer 6

Salter-Harris I - pure physeal separation (best prognosis and least likely to cause growth arrest)

Salter-Harris II (most common) - has a small metaphyseal fragment attached to the physis and epiphysis (growth disturbance is unlikely)

Salter-Harris III and IV - intra-articular and with the fracture splitting the physis, there is greater potential for growth arrest

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

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Question 7

Treatment of Salter-Harris III and IV physeal fractures?

Answer 7

Reduced and stabilised to ensure congruent articular surface and to minimise growth disturbance

Question 8

Ix for Salter-Harris V physeal fractures?

Answer 8

Cannot be diagnosed on initial X-ray and are only detected once angular deformity has occurred

Question 9

Signs of non-accidental injury (NAI)?

Answer 9

• Multiple fractures of varying ages (varying amounts of callus or healing) and multiple A&E trips
• Inconsistent / changing history of events, discrepancy of history between parents / carers
• History not consistent with injury and injuries not consistent with age of child, e.g: non walking child
• Multiple bruises of varying ages
• Atypical injuries, e.g: cigarette burns, genital injuries, torn frenulum, dental injuries, lower limb
and trunk burns
• Rib fractures
• Metaphyseal fractures in infants

Question 10

Common fractures in children?

Answer 10

1. Distal radius fractures
2. Forearm fractures
3. Supracondylar fractures of the elbow
4. Femoral shaft fractures
5. Tibial fractures

Question 11

Types of distal radius fractures in children?

Answer 11

1. Buckle fractures
2. Greenstick fractures
3. Salter-Harris II fractures (commonly occur around the distal radial physis in older children but growth problems are unlikely)

Question 12

Treatment of Buckle fractures?

Answer 12

Stable so only require 3-4 weeks splintage

Question 13

Treatment of greenstick fractures?

Answer 13

May be angulated and may require manipulation and casting if there is significant deformity, particularly in the older child

Question 14

Treatment of Salter-Harris II fractures?

Answer 14

Angulation with deformity requires manipulation

Question 15

Describe complete fractures of the distal radius in children

Answer 15

May displace as well as angulate (dorsal displacement and angulation more common than volar)

Dorsal periosteum usually remains intact, which prevents overcorrection of the deformity and aids stability

Question 16

Treatment of complete distal radial fractures in children?

Answer 16

If the fracture is fairly stable, casting may suffice

If a complete fracture is very unstable after reduction, wire stabilization or plate fixation may be used

Question 17

Types of forearm fractures in children?

Answer 17

Monteggia and Galeazzi fracture-dislocations can occur in adults and children

Question 18

Treatment of Monteggia and Galeazzi fracture-dislocations in children?

Answer 18

Anatomic reduction and rigid fixation with plates and screws is usually used (goes against normal principles of fracture Mx in children)

High rate of re‐dislocation of the radial head or distal radio-ulnar joint (DRUJ) if only manipulation and casting used

Question 19

Treatment of fractures of both bones of the forearm in children?

Answer 19

Angulated fractures usually have an intact periosteum and the instability may only be in one plane - controlled with a cast after manipulation.

Displaced fractures tend to be unstable - flexible IM nail

Question 20

Occurrence of supracondylar fractures of the elbow?

Answer 20

Common as this region of the distal humerus is a relatively weak point in the growing upper limb

Extension type fractures are more common (occur due to a heavy fall onto the outstretched hand)

Less common flexion type injury occurs with a fall onto the point of the flexed elbow

Question 21

Treatment of undisplaced supracondylar fractures of the elbow?

Answer 21

Undisplaced fractures are stable and are treated with a splint

Question 22

Describe severely displaced or off-ended supracondylar fractures of the elbow and treatment

Answer 22

Brachialis muscle may be tethered in the fracture site requiring open reduction if the fracture cannot be reduced by closed means

Question 23

Describe off-ended extension type fracture

Answer 23

Distal fragment displaces posteriorly with stretch and pressure on the brachial artery and median nerve (predominantly its anterior interosseous branch, i.e: unable to make “OK” sign due to loss of FPL and FDP to the index)

Question 24

Treatment of displaced/angulated/rotated supracondylar fracture of the elbow?

Answer 24

Closed reduction (quickly to reduce swelling) and pinning with wires to prevent deformity

If the radial pulse is absent/reduced in volume, emergency surgery is required; closed reduction may be performed with wiring and the pulse may return if the artery is no longer under stretch
Occasionally brachial artery will be trapped in fracture site and, if the hand remains pulseless after reduction, open surgical Ix is required

Question 25

Nerve injuries with supracondylar fracture of the elbow?

Answer 25

Majority are neurapraxias (improve with time) and occasionally an axonotmesis (should also improve)

Ongoing neuralgic pain (unpleasant shooting or burning pain radiating to the sensory distribution of the nerve) OR no improvement may indicate entrapment of the nerve; this may require surgical release

Question 26

Occurrence of femoral shaft fracture in children?

Answer 26

Fall onto a flexed knee OR by indirect bending OR rotational forces

In children <2 years old, > 1/2 of femoral shaft fractures are due to NAI so look for other signs

Femur is a common site for benign and malignant bone tumors, so fracture may be pathological with osteolysis and cortical thinning

Question 27

Treatment of femoral shaft fractures in children <2 years?

Answer 27

Gallows traction + early hip spica cast

Question 28

Treatment of femoral shaft fractures in children 2-6 years?

Answer 28

Thomas splint OR a hip spica cast

Question 29

Treatment of femoral shaft fractures in children 6-12 years?

Answer 29

Femur is large enough to accommodate flexible IM nails (obviate need for traction or cast)

Question 30

Treatment of femoral shaft fractures in children 12 years or above?

Answer 30

Adult type IM nail is used

Question 31

What compromises can be made in femoral shaft fracture healing in children?

Answer 31

Overgrowth tends to occur after fracture healing and so some shortening can be accepted (more with younger children)

Question 32

Occurrence of tibial fractures in children?

Answer 32

Undisplaced spiral fractures of the tibial shaft are common in toddlers (AKA “toddler’s fracture”)

Question 33

Treatment of toddler’s fracture?

Answer 33

Short time in a cast with serial X-rays to ensure that the fracture does not drift into excessive angulation in the AP or lateral planes

Up to 10° of angulation may be accepted and greater degrees may be treated with manipulation and casting; shortening or malrotation is not accepted

Question 34

Treatment options for other types of tibial fractures in children?

Answer 34

Stabilizing very unstable or open fractures can occur with:
• Flexible IM nails, plates and screws or external fixation

Adolescents with a closed proximal tibial physis can have an adult type IM nail

Question 35

What is uncommon in tibial fractures in children?

Answer 35

Compartment syndrome is less likely than in an adult