W5 Flashcards
What are the significant structural differences between paediatric and adult bones?
Children by definition are still growing, and they grow via the epiphyseal growth plates, and the epiphysis will separate before the ligament ruptures. Hence, children are more susceptible to fractures/dislocations (most important one)
Growth plates act as a shock absorber to protect the joint, it that’s damaged there is potential for interference with growth of the bone (most likely family’s main concern – stunting growth)
Children’s bones have a thick periosteum hence you’re more likely to get partial fractures in children
Children’s bones are more ‘plastic’ – tend to bend, buckle, or more susceptible to a greenstick (break in one side but not the other)
Royal Children’s Hospital Melbourne Clinical Guidelines (Paediatric Fracture Guidelines) provide substantial further knowledge for treating specific fractures
https://www.rch.org.au/clinicalguide/fractures/
How does the healing process from a fracture differentiate in paediatric and adult bones?
Rapid healing in children compared to adults – Heals in about half the time of an adult fracture (nonunion is rare). Time for union from 2 weeks in infants to approximately 6 weeks in older children.
Stiffness post fracture is unusual in children (only if cast if applied incorrectly), adults will be very stiff eg. if they’re in a cast mobilised for 6 weeks.
As physiotherapists, we have a much lesser role in paediatric fractures compared to adult fractures. (Stiffness is main pathology in adult population)
How does fracture remodelling differ in children vs adults?
Children have greater capacity in remodelling – Extensive remodelling capacity, and will correct shortening/angulation (bone does not have to be aligned while a cast is placed even for a displaced fracture).
This is provided that the growth plates still have around 2 more years of growth.
Exceptions – Remodelling may have less of a correction:
If it’s twisted out of position (rotary deformity) or fractured along the diaphysis (midpoint)
Outline the 3 types of metaphyseal fractures which can occur in children
Greenstick fracture
Complete Fracture
Buckle Fracture
How would you manage a buckle fracture of the wrist?
A minor fracture/injury – hence child will be provided with a removable backslab for approximately 3 weeks
Sling is optional (if necessary)
No review (to surgeon, GP, etc.) is necessary unless parent has a concern
What are the features of a diaphyseal fracture? And what types of fractures can occur?
Fractures which affect the midshaft of the bone.
Types of fractures typically only include a complete fracture (most commonly). Greenstick fractures are only prevalent in children or neonates.
What is the Salter Harris Classification? What does it measure and what do the different levels distinguish?
The Salter-Harris classification is a system used to categorise fractures involving the growth plate (physis) in children.
Type 1: Discontinuity on the metaphyseal side of the growth plate
Type 2: The same as type 1 except the bone breaks at an angle where more of the metaphyseal is cut (Most common)
Type 3-4: Fracture goes across the growth plate (Much more serious) – These types often require accurate reduction, are held with pins, and involve joint
Type 5: Compression of the growth plate (Harder to diagnose)
What are the X-Ray rule of Twos?
Two sides, two views, two joints, two times.
What are the 3 principles of fracture management? And how do they apply to childrens’ fractures?
Reduce, Hold and Move.
Reduced
Not held with mild angulation
Could be manipulated under anaesthetic traction if necessary
ORIFs are applicable but less common (unless it’s a type 3-4 fracture under the Salter-Harris classification)
Hold
Cast, sling, collar and cuff, traction
Move
Child is often their own physiotherapist
How would you manage/treat a clavicle fracture of a child?
A clavicle fracture is the most common fracture for a child, it does not need to be reduced. A sling will be implemented for approximately two weeks for comfort.
Remodelling will take place within the next year and the child shouldn’t be left with a bump.
No problems with function and no role for physiotherapy required
Provide a fact sheet to concerned parents to reassure and advise them. (can be found on Royal Children’s Hospital Melb website)
How would you treat a paediatric Supracondylar Fracture?
If UNDISPLACED → Immobilise child with an Above Elbow Backslab for 3 weeks (elbow kept in flexion)
If DISPLACED → Much more serious as it threatens neurovascular damage, hence immediate reduction is required → Often held with percutaneous pins in elbow flexion
Full extension may not return until 6-12 months (typically with a good functional outcome)
If they force extension they may aggravate the healing process
How are shaft of femur fractures managed in children?
Up to 5 years old
Immediate hip spica cast is implemented for 6-8 weeks
5-11 years old
Flexible intramedullary nailing (in intramedullary cavity of bone and across the fracture site)
Define Spondylolysis and Spondylolisthesis
Spondylolysis: A defect at the pars interarticularis
Spondylolisthesis: A forward slip of the superior vertebrae due to bilateral defect of the pars
Can be caused by repetitive excessive extension or rotation
How would you diagnose spondylosis and spondylolisthesis as a physiotherapist?
SE:
Pain during extension? And if they point out their pain to the area of the pars interarticularis
OE:
Check for pain during combined Extension, rotation, lateral flexion
Check with a CXR (MUST corroborate with SE findings before diagnosis is confirmed)
How would you treat spondylosis and spondylolisthesis as a physiotherapist?
Implement stabilising exercises → Eg. Transverse abdominis exercises
No extension exercises, flexion exercises are also not recommended (might aggravate forward slipped disc)
If spondylolisthesis slip > 50% and progressing, it may compress a nerve root resulting in a neurological deficit → Increasing persistent pain.
Commence Posterolateral fusion (PLF) surgery
