Paediatric trauma (MSK cortex) Flashcards
How are children’s bones differen from adult’s?
- more elastic and pliable
- tend to buckle or partially fracutre or splinter rather than break
- periosteum is thicker (tends to remain intact)
When are children’s fractures treated like adult’s?
puberty (12-14)
Children’s fractures heal more quickly than adults due to?
Thicker peristeum
more osteoblasts
What is remodelling?
grow with bone being formed along the line of stress - changing shape
after fracture children can correct angulation up to 10° per year of growth remaining in that bone
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children’s fractures tend to be surgically stabilized less frequently and greater degrees of displacement or angulation can be accepted
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If the fracture position is unaccepatable then manipulation and casting may be all that is required
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What effect do fractures around the physis have?
physis = growth plate
disturb growth if one sided
- short limb
-angular deformity
What is a Salter-Harris I fracture?
pure physeal separation
What is a Salter-Harris II fracture?
Mostly pure physeal seperation with small metaphyseal fragment attached to the physis and epiphysis
What are Salter‐Harris III and IV fractures?
intra‐articular and with the fracture splitting the physis
What is a Salter‐Harris V injury
compression injury to the physis with subsequent growth arrest
Which salter-harris injury/fracture carries the best prognosis?
Salter‐Harris I - least likely to result in growth arrest
Which salter-harris injury/fracture is the commonest?
Salter-Harris II
Salter-Harris II has a - prognosis
good - likelihood of growth disturbance is low
How should Salter‐Harris III and IV fractures be treated?
Often require open reduction and internal fixation as whole bits of bone have been torn off (intraarticular, usually displaced)
reduction - corrects displacement
fixation - encourages growth/healing
Salter‐Harris V injury cannot be diagnosed on initial x‐rays
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When can Salter‐Harris V injury be detected?
once angular deformity has occurred.
Signs on on-accidental injury?
- Inconsistent / changing history of events
- Discrepancy of history between parents / carers
- History not consistent with injury
- Injuries not consistent with age of child eg non walking child
- Multiple bruises of varying ages
- Atypical injuries eg cigarette burns, genital injuries, torn frenulum, dental injuries, lower limb
- and trunk burns
- Rib fractures
- Metaphyseal fractures in infants
Where do children’s fractures commonly occur?
- distal radius
- Supracondylar space of elbow
- Femoral shaft
- tibia
Which types of fractures commonly occur in the distal radius?
buckle, greenstick and Salter‐Harris II
salter harris 2 is fractyre above physis into metaphysis
buckle fracture is plastic deformity on one side (stable)
greenstick fracture is plastic deformity on one side and fracture on other (usually at a funny angle)
Distal radius buckle fracture treatment?
External fixation via 3‐4 weeks of splintage (immoblise wrist)
Distal radius greenstick fracture treatment?
may be angulated if unstable
may require OPEN manipulation if there is significant deformity, particularly in the older child
casting and splintage for healing
Distal radius Salter‐Harris II fracture treatment?
Angulation with deformity requires manipulation. Growth problems are highly unlikely
closed manipulation and plaster cast usually
If a complete fracture is very unstable after reduction, wire stabilization or plate fixation may be employed.
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Complete fractures may displace as well as angulate with - displacement and angulation more common than -.
dorsal, volar
In complete fractures the dorsal periosteum usually remains intact, this prevents what?
overcorrection of deformity and aids stability
Monteggia and Galeazzi fracture‐dislocations can occur in children and adults
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How are Monteggia and Galeazzi fracture‐dislocations managed in children?
anatomic reduction and fixation with plates and screws
In Monteggia and Galeazzi fracture‐dislocations what increases the risk of re‐dislocation of the radial head or distal radio-ulnar joint ?
treatment consisting only of manipulation and casting
What are the usual features of angulated fractures of both bones of the forearm?
Intact periosteum
Instability in one plane - can be controlled with a cast after manipulation
How are displaced fractures of both bones of the forearm treated?
flexible intramedullary nail as they are usually unstable
Which part of the humerus is weak in the growiing upper limb?
supracondylar region of distal humerus
In the elbow, which type of fractures are more common?
Extension type fractures are more common and occur due to a heavy fall onto the outstretched hand
How does an injury of flexion occur in the elbow?
fall onto the point of the flexed elbow.
How are undisplaced fratures of the elbow treated?
a splint
How are Angulated, rotated or displaced fractures of the elbow treated?
closed reduction and pinning with wires to prevent deformity
What is a complication of severely displaced / off‐ended fractures of the elbow?
Tethering of brachialis muscle to the fracture site
How are severely displaced / off‐ended fractures of the elbow treated?
open reduction (due to ttehtering of brachialis muscle) may be required
What are the TWO major concerns with reducing elbow fractures?
- Pressure on brachial artery, if radial pulse absent require urgent surgical intervention
can try closed reduction with wiring before tho - Median nerve pressure, predominantly anterior interrosus branch, check if patient can use FPL and FDL to make an OK
check ONGOING neuralgic pain no improvement with time
Neuropraxia requires immediate surgical attention
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Neruopraxia is temporary loss of nerve conduction, improves with time
How do femoral shaft fractures most often occur?
fall onto a flexed knee or by indirect bending or rotational forces.
In femoral shaft fractures, limbs get shorter
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overgrowth often occurs, some surgical shortening can be accepted w young hildred
What is the commonest cause of a femoral shaft fracture in children less than 2 years old?
Non accidental injury
How is a femoral shaft fracture in children less than 2 years old treated?
Gallows traction followed by hip sica cast
How is a femoral shaft fracture in children aged between 2 and 6 treated?
Thomas splint or a hip spica cas
How is a femoral shaft fracture in children aged between 6 and 12 treated?
flexible intramedullary nails - femur ;large enough for this, no need traction or cast
How is a femoral shaft fracture in a children aged 12+ treated?
adult type intramedullary nail
What is a “toddler’s fracture”?
Undisplaced spiral fractures of the tibial shaft
How are undisplaced spiral fractures of tibial shaft treated?
short time in cast
Management in a cast is the mainstay for the majority of children’s tibial fractures. The risk of compartment syndrome is much less than that for an adult
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In tibial shaft fractures Up to 10° of angulation may be accepted and greater degrees of angulation may be treated with manipulation and casting
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After casting a tibial fractures - what next?
Serial xrays in the cast are required to ensure that the fracture does not drift
Shortening or malrotation should not be accepted
Unstable or open fractures of the tibial shaft can be treated with?
flexible intramedullary nails, or external fixation. Adolescents with a closed physis can have an adult type intramedullary nail.
