Paediatric Fracture
Prof. Muhammad Shahiduzzaman
Head, Department of
Orthopaedics & Traumatology
Dhaka Medical College Hospital
Introduction
In Bangladesh 60% of population are <20 yrs
Fractures accounts for 15% of all injuries in children.
Different from adult fractures.
Vary in different age groups (Infants, children,
adolescents)
Children are very special
Children have different physiology and anatomy
Growth plate.
Bone.
Cartilage.
Periosteum.
Ligaments.
Age-related physiology
Growth Plate
In infants, GP is stronger than bone.
increased diaphyseal fractures
Provides perfect remodeling power.
Injury of growth plate causes deformity.
A fracture might lead to overgrowth.
Bone
• Increased collagen: bone ratio
lowers modulus of elasticity
Increased cancellous bone
reduces tensile strength
reduces tendency of fracture
to propagate
less comminuted fractures
Bone fails on both tension and
compression
commonly seen “buckle” fracture
Cartilage
• Increased ratio of cartilage to bone
• better resilience
• difficult x-ray evaluation
• size of articular fragment often under-estimated
Periosteum
• Metabolically active
• more callus, rapid
union, increased
remodeling
• Thickness and strength
• Intact periosteal
hinge affects
fracture pattern
• May aid reduction
Age related # pattern
Physiology
Better blood supply,
so less incidence of Delayed or non-union.
Injury Pattern
• Bones tend to BOW rather than BREAK
• Compressive force= TORUS fracture
• Aka. Buckle fracture
• Force to side of bone may cause break in only one
cortex= GREENSTICK fracture
• The other cortex only BENDS
• In very young children, neither cortex may break=
PLASTIC DEFORMATION
Green Stick Fracture
Green Stick Fracture
To ick
rus s t
en
Gre
i t y
f o rm
ic De
st
Pla
Injury Pattern
Injury Pattern
Point at which metaphysis connects to physis is an
anatomic point of weakness
Ligaments and tendons are stronger than bone
when young Bone is more likely to be injured with
force.
Periosteum is biologically active in children and
often stays intact with injury
• This stabilizes fracture and promotes healing.
Physeal Injury
Many childhood fractures involve the physis
20% of all skeletal injuries in children
Can disrupt growth of bone
Injury near but not at the physis can stimulate
bone to grow more
Physeal Injury
SALTER HARRIS CLASSIFICATION
Classification system to
delineate risk of growth
disturbance
Higher grade fractures are
more likely to cause growth
disturbance
Growth disturbance can
happen with ANY physeal
injury
It has grade I upto grade V.
Salter Harris Grade I
Fracture passes
transversely through
physis separating
epiphysis from
metaphysis.
Salter Harris Grade II
Transversely through
physis but exits through
metaphysis
Triangular fragment
Salter Harris Grade III
• Crosses physis and exits
through epiphysis at joint
space.
Salter Harris Grade IV
• Extends upwards from the
joint line, through the
physis and out the
metaphysis.
Salter Harris Grade V
Crash Injury to growth plate
Salter Harris
MOST COMMON: Salter Harris II
Followed by I, III, IV, V
Refer to orthopedics: III, IV, V
I and II effectively managed by primary care with
casting (most commonly)
Parents should be informed that growth
disturbance can happen with any physeal fracture
Power of remodeling
Tremendous power of remodeling
Can accept more angulation and displacement
Rotational mal-alignment ?does not remodel
Malunion-Remodeling Process
Power of remodeling
Factors affecting remodeling potential
•Years of remaining growth – most important factor
•Position in the bone – the nearer to physis the better
•Plane of motion –greatest in sagittal, the frontal, and
least for transverse plane
•Physeal status – if damaged, less potential for
correction
•Growth potential of adjacent physis
•e.g. upper humerus better than lower humerus
Its good to be young!!!
Children tend to heal fractures faster than adults
requiring shorter immobilization time.
Anticipate remodeling if child has >2 yrs of growing
left – mild angulation deformities often correct
themselves but rotational deformities requires
reduction.
Its good to be young…
Fractures in children may stimulate longitudinal
growth – some degree of overlap is acceptable and
may even be helpful.
Children don’t tend to get as stiff as adults after
immobilization.
Xray examination
Law of Two’s :
Two views
Two joints
Two limbs
Two occasions
Two physicians
Evaluation of paediatric elbow film
Radio-capitaller line
Evaluation of paediatric elbow film
Supracondylar Fracture of Humerus
Principle of Management
Mostly conservative – closed reduction and cast
immobilization
Open reduction & internal fixation.
Indication for operative management
Displaced intra articular fractures
( Salter-Harris III-IV )
fractures with vascular injury
? Compartment syndrome
Fractures not reduced by closed reduction
( soft tissue interposition, button-holing of
periosteum )
If reduction can not be maintained or could be only
maintained in an abnormal position
Indication for operative management
Method of fixation
Casting—the commonest.
Method of fixation
K-wires
most commonly used
Metaphyseal
fractures
Method of fixation
Intramedullary wires, elastic nails
Very useful, Diaphyseal fractures
Method of fixation
Screws
Method of fixation
Screws
Method of fixation
Plates and screws
Multiple Trauma
Method of fixation
IMN Nailing (adolescent only)
Chances of growth disturbences.
Method of fixation
External Fixation
In open Fractures
Method of fixation
Casting - still the commonest
K-wires
most commonly used
Metaphyseal fractures
Intramedullary wires, elastic nails
Very useful
Diaphyseal fractures
Screws
Plates – multiple trauma
i o n
IMN - adolescents
a t
Ex-fix b i n
om
C
Complication
Malunion is not usually a problem (except
cubitus varus)
Nonunion is hardly seen (except in lateral
condyle of humerus)
Growth disturbance – epiphyseal damage
Vascular - volkmann’s ischemia
Infection - rare
Non-accidental injury
Battered Baby Syndrome:
• Soft tissue injuries - bruising,
burns
• Intra-abdominal injuries
• Intracranial injuries
• Delay in seeking treatment
• # at diff. stage of healing.
Radiology of child abuse
Corner’s fracture (traction and rotation)
Bucket handle fracture (traction and rotation)
Pathological fracture
