Week 6 - A - Paediatric Trauma - Salter Harris, N.A.I, Buckle/Greenstick, Monteggia/Galeazzi, Supracondylar, Femoral shaft, Tibial

Question 1

Children’s bones are more elastic and pliable Do their bones tend to fracture or buckle therere? Do children’s fractures heal more quickly?

Answer 1

As children’s bones are more elastic and pliable, the bones tend to buckle or partially fracture or splinter rather than break completely

They heal more quickly as the periosteum is much thicker and therefore a richer source of osetbolasts

Question 2

As children’s fractures tend to heal more quickly and have a greater potential to remodel, how does the treatment of children’s fractures tend to be treated differently from adults?

Answer 2

The children’s fractures tend to be surgically stablised less frequently and greater degrees of displacement or angulation can be accepted

Manipulation and casting is often preferred in children

Question 3

Childrens fractures tend to be treated as adult fractures once children have reached what age?

Answer 3

Tend to be treated as adult fractures once children have reach 12-14 years of age (puberty) as the remodeling potential is less

Question 4

Fractures around which part of the bone can attend to fix growth in the child?

Answer 4

Fractures around the physis (growth plate)

Question 5

How are physeal fractures in children classified?

Answer 5

They are classified using the Salter Harris classification system

Question 6

Which of the Salter Harris classification of physeal fractures is a pure physeal separation and which is the most common?

Answer 6

A Salter‐Harris I fracture is a pure physeal separation.

This carries the best prognosis and is least likely to result in growth arrest.

Most physeal fractures are Salter‐Harris II fractures.

Question 7

Salter‐Harris III and IV fractures are intra‐articular and with the fracture splitting the physis, there is greater potential for growth arrest What is the difference in how they look?

Answer 7

Salter harris fracture III - fracture comes from intraarticular and then travels along the physis

Salter Harris type 4 - fracture goes diagnoally through the physis from intra-articular

Question 8

A Salter‐Harris V injury is a compression injury to the physis with subsequent growth arrest. Why is it likely these fractures result in growth arrest?

Answer 8

They cannot be diagnosed on xray and are only detected once angular deformity has formed

Question 9

Describe the 5 types of Salter-Harris classification again (mnemonic SALTER)

Answer 9

S - separated growth plate

A - Above growth plate (involves metaphysis)

L - BeLow growth plate (through epiphyses)

T - Through growth plate (throw epiphyses, physis and metaphysis)

ER - ERasure of growth plate - physis collapses from compression

Question 10

Which salter-Harris classification are SUFE (slipped upper femoral epiphysis associated with)?

Answer 10

Type 1 Salter Harris fractures - the fractured physis causes the epiphysis to slide

Question 11

What type of boy is more likely to get a slipped upper femoral epiphysis?

Answer 11

Overweight prepubertal adolescent boys - the physiis has not fused

Question 12

What are the symptoms of a SUFE?

Answer 12

Externally rotated le (loss of internal rotation)

Knee pain / hip pain (groin)

Limp

Unable to weight bear

Overweight pre-pubertal adolescent boy (shorter leg on one side- rare)

Question 13

What features should raises suspicion of NAI (non accidental injury) in a child?

Answer 13

Multiple fractures at varying ages

Incoherent stories

Child walks and gets fracture before child should be able to walk ^^ history does not match childs age

Delayed presentation

Vague and changing history

Rib fractures

Question 14

If you suspect a child is at risk of non accidental injury, what should happen?

Answer 14

Pediatrician should be informed immediately and a full examination of the child by an experience worker, potentially ask for advice of the hospital child protection services

Question 15

Children can get distal radial fractures eg Buckle, Greenstick and Salter Harris Type II What is a Buckle fracture? (also known as a torus fracture)

Answer 15

Buckle fractures are incomplete fractures of the shaft of a long bone that is characterised by bulging of the cortex - one side of the bone bends or buckles but doesn’t break all the way

Question 16

Are Buckle fractures stable or unstable * and how are they treated?

Answer 16

Buckle fractures can occur which are stable and require only 3‐4 weeks of splintage.

Question 17

What is a greenstick fracture? How are they treated?

Answer 17

This is where the bone buckles and breaks and may be angulated

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

The side of compression bends but the other side is fractured

Question 18

What is a torus fracture also known as?

Answer 18

This is also known as a buckle fracture

Question 19

Both Monteggia and Galeazzi fracture‐dislocations can occur in children and adults. Describe each fracture (way to remember Mugger)

Answer 19

Monteggia MU - ulnar fracture with proximal radial head dislocation (monteggiA - proximal)

Galeazzi GR - radial fracture with distal radioulnar joint dislocation (galeaZZi - distal)

Question 20

What is the treatment of Monteggia and Galeazzi fractures?

Answer 20

Monteggia - ulnar fracture with radial dislocation at the elbow

Galeazzi - radial fracture with ulnar dislocation at the distal radioulnar joint

These injuries go against the usual principles of children’s fractures

• Anatomic reduction and rigid fixation with plates and screws is typically used to treat these injuries

Question 21

The supracondylar region of the distal humerus is a relatively weak point in the growing upper limb and supracondylar elbow fractures are fairly common injuries. What can get injured in a supracondylar fracture?

Answer 21

Can injure the brachial artery and median nerve

Question 22

How do supracondylar fractures of the elbow tend to occur?

Answer 22

Extension type fractures are more common and occur due to a heavy fall onto an outstrtched hand

The less common flexion type injury occurs due with a fall onto the point of the flexed elbow

Question 23

What are the two most common types of nerve injuries?

Answer 23

Neuropraxia - temporary conduction problem due to compression but will resolve

Axonotmesis - prolonged compression of the nerve causing the distal to the injuery long axons to die (wallerian’s degenration) - recovery is variable

Question 24

Femoral shaft fractures can occur in children due to a fall onto a flexed knee or by indirect bending or rotational forces. With femoral shaft fractures in children, overgrowth tends to occur after fracture healing and therefore some shortening can be accepted (more with younger children). Inchildren under 2, what is the main cause of the femoral shaft fracture?

Answer 24

Non accidental injury - other signs such as multiple injuries & bruises of varying age, atypical injuries, inconsistent or inappropriate history etc should be looked for

Question 25

What are the treatment options for a femoral shaft fracture in children aged 2 to 6?

Answer 25

This would be Thomas splint or hip spica cast

Question 26

With children aged between 6 and 12 or 12 and over, what is the treatment of a femoral shaft fracture?

Answer 26

6to12 - flexible intramedullary nail - femur is large enough to accommodate these nails now 12 and over - adult intramedullary nail

Question 27

What is a toddler’s fracture?

Answer 27

This is a spiral fracture of the tibia - child twisting leg during a fall

Question 28

What is the usual treatment of a toddler’s fracture? (tibial fracture)

Answer 28

Short time in cast

Question 29

Which salter Harris classification fractures are intraarticular?

Answer 29

This would be salter Harris classification Type III and IV