Pediatric Fracture Lecture Powerpoint

Question 1

Epiphysis and what does a fracture here require?

Answer 1

Rounded end of long bone, where articular cartilage is, fracture here often needs surgical correction

Question 2

Physis (physeal)

Answer 2

Growth plate, segment of bone responsible for lengthening, begins as cartilage and eventually closes and growing ceases (damage here could stunt growth)

Question 3

Metaphysis

Answer 3

Wider part of end of shaft of long bone, neck that is stronger point of bone connecting the physis and diaphysis, seen more often on elbow fractures

Question 4

Diaphysis

Answer 4

Shaft of long bone

Question 5

Periosteum

Answer 5

Thick nutrient layer that wraps circumferentially around bones serving a major role in healing the outer layers of bones

Question 6

On an x ray for pediatrics, have to be able to differentiate between a….

Answer 6

…Physis (growth plate) which will appear round and in expected area and a fracture which will be sharp and in an unexpected location

Question 7

If children have a pain, not wanting to bear weight, or move extremity, this is a sign of ___ because kids almost never get ___

Answer 7

fracture, sprains (ligaments are stronger than their bones)

Question 8

Principles for choosing x rays in children (2)

Answer 8

• Choose x ray that includes the joint above and below the fracture to look for associated dislocations
• can image opposite side of body as a control but not routinely***

Question 9

Children radiation absorption vs adults

Answer 9

Children are more sensitive and absorb more radiation, increase risk of developing radiation related cancer is several times higher than for an adult

Question 10

Factors that influence fracture remodeling and healing (4)

Answer 10

• age (children heal quickly due to rapid, thicker, more active periosteum)
• location (adjacent to the physis under greatest amount of remodeling
• degree of deformity
• plane of deformity

Question 11

History questions on a pediatric fracture (5)

Answer 11

• mechaniism of injury
• activity level since injury
• dominant hand
• other injuries
• last PO intake (important for sedation and anesthesia)

Question 12

Physical exam on a pediatric fracture (6)

Answer 12

• make the child comfortable
• deformities
• walking, reaching playing
• check the 5 p’s (pulseless, pallor, paralysis, pain, paresthesia, polkiothermia)
• signs of child abuse
• check distal to injury and document that neurovascular integrity is in check (if splint put on improperly then can cause it!)

Question 13

Plastic deformation pediatric fracture pattern

Answer 13

Bone bends beyond elastic limmit but cortices remain intact, no visible fracture on x ray, less than 20 degrees under 4 years old will correct itself, greater than 20 degrees needs reduction

Question 14

Torus (buckle) fracture pediatric fracture pattern

Answer 14

Compression of bone that usually occurs at the junction of the metaphysis and the diaphysis (metaphysis vulnerable because of thin cortex), commonly seen in distal radius usually a FOOSH mechanism, inherently stable and heals in 3-4 weeks with simple immobilization, can use a waterproof cast for this

Question 15

Greenstick fracture pediatric fracture pattern

Answer 15

Bone breaks on side opposite the distracting force, fracture thru a single cortex does not extend to the opposite side, sometimes necessary to break the bone on concave side to restore normal alignment

Question 16

Complete fracture pediatric fracture pattern (3 subtypes)

Answer 16

Fracture of both cortices, classified depending on direction of the fracture as spiral (rotational force), oblique (diagonally across the bone) and transverse (3 point bending force breaking at right angle to the long plane of the bone)

Question 17

Physeal fractures pediatric fracture pattern

Answer 17

Can be caused by crushing, vascular compromise of the physis, bone growth bridging from the metaphysis to the bony portion of the epiphysis, damage may result in progressive angular deformity, limb length discrepancy, or joint incongruity, most heal in 3 weeks leaving limited window for reduction, twice as common in adolescent males, distal radius involvement in 45% of cases

Question 18

Salter harris classification

Answer 18

System of classification to identify physeal injuries categorized type I-V with higher category increasing risk for growth abnormalities
I - fracture occurs transversely thru the physis, separating epiphysis from metaphysis (closed reduction and cast immobilization to treat, greater risk than II for growth arrest)
II - fracture thru portion of physis that extends thru the metaphysis (most common, closed reduction and cast immobilization to treat)
III - fracture extends thru portion of physis that extends thru the epiphysis and into the joint (typically treated ORIF)
IV - fracture across metaphys, physis, and epiphysis, increased risk of growth arrest (typically treated ORIF)
V - crush injury to the physis (may be radiologically undetectable)

Question 19

SALTER acronym for salter harris classification

Answer 19

Type I - straight across
II - above
III - lower 
IV - through
V - ERasure of the growth plate (highest risk)

Question 20

Any physeal fracture can cause…

Answer 20

…growth arrest

Question 21

Evaluation of a physeal growth arrest (4)

Answer 21

• limp
• angular deformity
• limb length discrepancy
• MRI of joint and physis

Question 22

Elbow fractures in children

Answer 22

Very common, 60% supracondylar, may be hard to visualize on x ray but cast typically to ensure no risk for neuropraxia (peripheral nerve injury that results in motor weakness)

Question 23

Fat pad sign

Answer 23

X ray test on the elbow where a broken bone filled with blood displaces the fat pad of the elbow outward which normally wraps anteriorally and posteriorally around the distal humerus

Question 24

Radial head sublaxation/nursemaid’s elbow

Answer 24

Occurs frequently in children, will see refusal to use arm, hold in flexion, often point to pain at wrist and may elicit tenderness over elbow, treated by popping back into place

Question 25

Femoral shaft fractures are high risk for…

Answer 25

….child abuse

Question 26

Slipped capital femoral epiphysis

Answer 26

Salter harris I fracture through proximal femoral physis, presents with pain on the anterior thigh, linked to obesity

Question 27

Child abuse evaluation (3)

Answer 27

• history
• detailed PE including fundoscopic exam and full skeletal survey
• skeletal films and head CT