Pediatric Fracture Lecture Powerpoint Flashcards
Epiphysis and what does a fracture here require?
Rounded end of long bone, where articular cartilage is, fracture here often needs surgical correction
Physis (physeal)
Growth plate, segment of bone responsible for lengthening, begins as cartilage and eventually closes and growing ceases (damage here could stunt growth)
Metaphysis
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
Diaphysis
Shaft of long bone
Periosteum
Thick nutrient layer that wraps circumferentially around bones serving a major role in healing the outer layers of bones
On an x ray for pediatrics, have to be able to differentiate between a….
…Physis (growth plate) which will appear round and in expected area and a fracture which will be sharp and in an unexpected location
If children have a pain, not wanting to bear weight, or move extremity, this is a sign of ___ because kids almost never get ___
fracture, sprains (ligaments are stronger than their bones)
Principles for choosing x rays in children (2)
- 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***
Children radiation absorption vs adults
Children are more sensitive and absorb more radiation, increase risk of developing radiation related cancer is several times higher than for an adult
Factors that influence fracture remodeling and healing (4)
- 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
History questions on a pediatric fracture (5)
- mechaniism of injury
- activity level since injury
- dominant hand
- other injuries
- last PO intake (important for sedation and anesthesia)
Physical exam on a pediatric fracture (6)
- 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!)
Plastic deformation pediatric fracture pattern
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
Torus (buckle) fracture pediatric fracture pattern
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
Greenstick fracture pediatric fracture pattern
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
Complete fracture pediatric fracture pattern (3 subtypes)
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)
Physeal fractures pediatric fracture pattern
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
Salter harris classification
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)
SALTER acronym for salter harris classification
Type I - straight across II - above III - lower IV - through V - ERasure of the growth plate (highest risk)
Any physeal fracture can cause…
…growth arrest
Evaluation of a physeal growth arrest (4)
- limp
- angular deformity
- limb length discrepancy
- MRI of joint and physis
Elbow fractures in children
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)
Fat pad sign
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
Radial head sublaxation/nursemaid’s elbow
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
Femoral shaft fractures are high risk for…
….child abuse
Slipped capital femoral epiphysis
Salter harris I fracture through proximal femoral physis, presents with pain on the anterior thigh, linked to obesity
Child abuse evaluation (3)
- history
- detailed PE including fundoscopic exam and full skeletal survey
- skeletal films and head CT
