Templo, Allain Joseph S.
GDA
4/F
Chief Complaint: Fall
Place: Patient’s House
Date: 01/22/2018
Time: 6:30PM
Mechanism: Fall
Unwitnessed
Mother just saw the child lying face down
On inspection, noted to have gross deformity on the
ulnar aspect of the left forearm
Hence rushed at the ER and was subsequently
admitted
PAST MEDICAL HISTORY
(+)Bronchial Asthma since 2yrs of age
No episodes of exacerbation
Family History
No Asthma, hypertension, diabetes mellitus
Immunizations
Complete via the AP
Unrecalled recent immunizations
Personal/Social History
Lives with 5 household members
Only Child
Primary Caregiver: Father
No smoke exposure
No pets
Drinking Water: Mineral Water
Physical Examination
Vital Signs: BP 90/60 102bpm 22cpm 37.2C
Skin: Warm, Moist skin
HEENT: anicteric sclera, pink palpebral conjunctiva, non-
sunken eyeballs, no nasal discharge, non-hyperemic post.
Pharyngeal wall, no exudates, no cervical
lymphadenopathies.
Chest: Symmetrical Chest Exp., Clear Breath Sounds
Heart: Adynamic Precordium, Normal Rate, Regular
Rhythm
Gastrointestinal: Flat, Normoactive Bowel Sounds,
Tympanitic, No Tenderness
Peripheral/Extremities: (+)Gross Deformity on the
Ulnar Aspect of the Left Forearm, No limitation on
the Right Upper and both lower extremities. No
abrasions.
Full Pulses, CRT<2
(+) Incomplete oblique fracture at the midshaft of the
left radius
(+) Complete undisplaced oblique fracture at the
midshaft of the left ulna
Primary Working Impression: Fracture Closed
Complete Oblique at the mid 1/3 of the Left Radius
and Ulna.
Plans
For Closed Reduction
IVF: D5NM 1L at 54cc/hr
Paracetamol 250mg/5ml, 5ml every 6hrs for pain
Left Forearm APL after OR
s/p Closed Reduction of Radio-Ulnar Fracture, Left
Left Forearm APL: Fair anatomic alignment of the
fractured fragments.
Discussion
Pediatric Bone
Less dense
More porous
increased porosity of pediatric bone prevents
propagation of fractures
thereby decreasing the incidence of comminuted
fractures.
Penetrated throughout by capillary channels
Lower modulus of elasticity, lower bending strength,
and lower mineral content
Low bending strength induces more strain in pediatric
bone than for the same stress on adult bone
Low modulus of elasticity allows for greater energy
absorption before failure
Physis (Growth Plate)
Located at the ends of
the long bone
Responsible for
longitudinal growth
Thick Periosteum
Responsible for growth
in thickness
Pediatric Fracture Patterns
Mechanisms of fracture change as children age
Younger children are more likely to sustain a fracture
while playing and falling on an outstretched arm.
Older children tend to injure themselves while playing
sports, riding bicycles, and in motor vehicle accidents.
A Child’s ligaments are stronger than those of an
adult, forces which would tend to cause a sprain in an
older individual will be transmitted to the bone and
cause a fracture in a child.
Plastic Deformation
refers to the bone bending but
remaining intact.
Children's bones can be bent
to 45 degrees before the cortex
is disrupted and a greenstick or
a complete fracture occurs.
Unique in Children
Most Common site: Ulna and
Fibula
Buckle Fracture
Compression failure of bone
that usually occurs at the
junction of the metaphysis and
the diaphysis
Commonly seen in distal
radius
Greenstick Fracture
Refers to a fracture where one
side of the bone breaks from a
distracting force while the
other side bends but stays
intact
Fracture line does not
propagate to the concave side
of the bone, therefore showing
evidence of plastic
deformation.
Greenstick Fracture
Refers to a fracture where one
side of the bone breaks from a
distracting force while the
other side bends but stays
intact
Fracture line does not
propagate to the concave side
of the bone, therefore showing
evidence of plastic
deformation.
Complete Fracture
Fracture completely propagates through the bone.
Classified as spiral, transverse, or oblique, depending on
the direction of the fracture line.
Spiral Fracture
Created by a rotational force.
Low-velocity injuries
Transverse Fracture
results from angulation and
usually has an intact periosteal
hinge on the compression side
Oblique Fracture
due to axial overload with
sheering forces
Physeal Fractures
Fractures to the growth plate can be caused by:
Crushing
Vascular Compromise of the physis
bone growth bridging from the metaphysis to the bony
portion of the epiphysis
Damage to growth plate may result in progressive
angular deformity, limb-length discrepancy or joint
incongruity
The distal radial physis is the most frequently injured
physis.
Differences between Pediatric
and Adult Fracture Healing
Fracture Remodeling
Overgrowth
Progressive Deformity
Rapid Healing
Fracture Remodeling
Process that occurs over time as a child’s bone reshapes itself to an
anatomic position.
The amount of remaining bone growth provides the basis for
remodeling. Thus, the younger the child, the greater remodeling
potential, and the less important reduction accuracy is.
Occurs over several months following injury.
Factors affecting amount of remodeling:
Age: younger children have greater remodeling potential.
Location: fractures adjacent to a physis undergo greatest amount
of remodeling.
Degree of deformity
Plane of deformity with respect to adjacent joint: remodeling
occurs more readily in the plane of a joint than with deformity
not in the plane of the joint.
Overgrowth
Caused by physeal stimulation from the hyperemia
associated with fracture healing.
Prominent in long bones (ex. femur).
Growth acceleration is usually present for 6 months to 1
year following injury.
Does not present a continued progressive overgrowth unless
complicated by a rare arteriovenous malformation.
> 10 years of age, overgrowth is less of a problem and
anatomic alignment is recommended.
Progressive Deformity
Injuries to the physis can be complicated by progressive
deformities with growth.
The most common cause is complete or partial closure
of growth plates.
Deformities can include angular deformity, shortening
of bone, or both.
The magnitude of deformity depends on the physis
involved and the amount of growth remaining.
Rapid Healing
Pediatric fractures heal more quickly than adult
fractures due to children’s growth potential and a
thicker, more active periosteum.
the periosteum contributes the largest part of new bone
formation around a fracture.
As children reach their growth potential, in
adolescence and early adulthood, the rate of healing
slows to that of an adult.
There is one downside to rapid healing, however;
refractures.
Common Causes of Pediatric
Fractures
Common Causes of Pediatric
Fractures
