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