Overview of Pediatric trauma

Orwa Ian
 An 8-year-old boy presents to the emergency department with a Salter-
Harris type IV fracture of the distal femur from a football tackle. The
fracture has 3mm of displacement and 15 degrees of angulation in the
sagittal plane. Because of his young age you know he has excellent
potential to remodel. The BEST treatment option would include:
a) Long-leg cast
b) Percutaneous pinning in situ
c) Open reduction and internal fixation with distal femoral locking plate
d) Open reduction and internal fixation of the metaphyseal component but
not the epiphyseal component to avoid potential growth arrest
e) Open reduction and internal fixation of both components with plates and
or screw fixation
 outline
1. Epidemiology of Pediatric Fractures
2. Uniqueness of Children's bones
3. Child abuse/Neglect/ Non-accidental trauma (NAT)
4. Multiply injured Child
5. Principles of Management
6. Specific cases/Precautions
 Introduction
• over 40% of boys and 25% of girls sustain a fracture by 16 years of
age1
• properties of the immature skeleton- these injuries have different
characteristics, complications, and management than similar adult
injuries
• data from five large epidemiologic studies :distal forearm # most
common (nearly 25% of 12,946 fractures), then clavicle # (over 8%
of all children's fractures)
• Mann et al. [5] reported of 2,650 long bone fractures in children,
30% involved the physis.
 Why are children’s fractures different?

Children have different physiology and anatomy

• Growth plate.
• Bone.
• Cartilage.
• Periosteum.
• Ligaments.
• Age-related
• physiology
 Why are children’s fractures different?

Children have different physiology and anatomy

• Bone:

– Increased collagen: bone ratio

- lowers modulus of elasticity
 Why are children’s fractures different?

Children have different physiology and anatomy

• 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
 Why are children’s fractures different?

Children have different physiology and anatomy

• Cartilage:

– Increased ratio of cartilage to bone

- better resilience
- difficult x-ray evaluation
- size of articular fragment often under-estimated
 Why are children’s fractures different?

Children have different physiology and anatomy

• Periosteum:

– Metabolically active
• more callus, rapid union, increased remodeling
– Thickness and strength
• Intact periosteal hinge affects fracture pattern
• May aid reduction
 Why are children’s fractures different?

Children have different physiology and anatomy

• Age related fracture pattern:

– Infants: diaphyseal fractures

– Children: metaphyseal fractures
– Adolescents: epiphyseal injuries
 Properties of the immature skeleton
1. Plastic Deformation- most common in the forearm,
particularly the ulna
– Stress–strain curves for mature and immature bone. The increased
strain of immature bone before failure represents plastic
deformation.
a. Buckle (Torus) Fractures- most commonly occur at transition
between metaphyseal woven bone and the lamellar bone of
the diaphyseal cortex
3. Greenstick Fractures - immature bone is more flexible and has a thicker

periosteum than mature adult bone

• Reduction: “unlock” the impacted fragments on the tension side by initially

exaggerating the deformity and then applying traction and a reducing force

• stable after reduction but have an increased likelihood of refracture

• immobilize these fractures for a full 6 weeks

4. Remodeling/Overgrowth -fractures heal more rapidly than those in adults,

but once healed, they remodel residual deformity

Factors affecting remodellong potential:

i. amount of growth remaining (the patient's skeletal age)

ii. the plane of the deformity in relation to adjacent joints

iii. the deformity's proximity to the physis and

iv. the growth potential of the particular physis

5. Potential for accelerated growth of an injured limb -most
frequently seen in diaphyseal femoral
fractures.(spontaneously correctting shortening of up to 2
cm)

Theories ascribe this to hyperemia

6. Physeal Injuries
• 15% to 30% of all fractures in children
• peak in adolescents
• growth deformity is rare, occurring in only 1% to 10% of all physeal injuries.
• Physeal anatomy

Most injuries occur just above area of provisional

calcification within the hypertrophic zone.

Germinal layer frequently remains intact and

attached to the epiphysis

CLASSIFICATION OF PHYSEAL INJURIES
• Goal in treating physeal fractures
i. to achieve and maintain an acceptable reduction without subjecting the
germinal layer of the physis to any further damage.
ii. determining the limits of an acceptable reduction
iii. Because of the intra-articular component, displaced type III and IV injuries
must be reduced regardless of the time that has elapsed since the injury
iv. reduction can be maintained with a cast, pins, internal fixation, or some
combination of these three
 COMPLICATIONS OF PHYSEAL INJURIES
1. malunion,
2. infection,
3. neurovascular problems,
4. Osteonecrosis
5. Growth Disturbance
 Care of the Multiply Injured Child
• Blunt trauma -leading cause of death in children older than 1
year of age
• Children possess a number of anatomic and physiologic
characteristics that make their injuries and their injury
response different from adults'
 Open Fractures
• Incidence and mechanism of open fractures differ between
children and adults
• their management is similar, requiring an aggressive, thorough,
and systematic approach
• most common open fractures in children involve the hand and
upper extremity
• Open fractures of the lower extremities, esp tibia, are the
result of higher-energy trauma, esp automobile–pedestrian or
automobile–bicycle accidents
 Gustilo and Anderson classification system
• Type I • Type III
• Wound <1 cm long • Extensive soft tissue damage to mu
• Moderately clean puncture wound
• Usually “inside-out” injury structures and a high degree of con
• Little soft tissue damage, no crushing
• Three subtypes:
• Little comminution
• Type II A. Adequate soft tissue coverage (inc
• Wound >1 cm long comminuted fractures, regardless
• No extensive tissue damage
B. Local or free flap required for cove
• Slight or moderate crush injury
• Moderate comminution or contamination C. Arterial injury requiring repair

•
 Open Fracture Management

1. Thorough assessment for life-threatening injuries

2. Immediate intravenous antibiotics, continue for 48 hours:

i. Grade I—first-generation cephalosporin

ii. Grades II and III—first-generation cephalosporin + aminoglycoside
iii. “Barnyard” injuries—add anaerobic coverage (penicillin or metronidazole)
3. Tetanus prophylaxis
4. Thorough operative debridement
5. Adequate fracture stabilization
6. Second operative debridement in 48-72 hours if indicated
7. Early definitive soft tissue coverage
8. Early bone grafting if indicated
 Child Abuse/Nonaccidental trauma/Battered child
syndrome
• 1% to 1.5% of all children are abused each year
• children are more likely to be abused by caregivers who are young,
poor, and of minority status
• Younger children are also more likely to die from abuse
• After skin lesions, fractures are the second most common physical
presentation
• bone that fractures under tension with torsion
• Femoral shaft, hands and feet fractures in nonambulatory infants
• Fractures in unusual locations
 Specific Fractures

• Cervical spine injuries in children (1% of pediatric fractures

and 2% of all spinal injuries )
i. younger than 8 years age - upper cervical spine,
ii. older children and adolescents - either the upper or lower C- spine
• Pelvic fractures comprise less than 0.2% of all pediatric
fractures
• two most common classification systems used :Young and
Burgess and Tile and Pennal
Torode and Zieg Classification of pelvic fractures in
children
• Hip Fractures: blood supply of the proximal femur comes from
two major branches of the profunda femoris artery—the
medial and lateral circumflex arteries
• classified into four types based on the anatomic location of
the fracture as described by Delbet
i. Type I: Transepiphyseal
ii. Type II: Transcervical
iii. Type III: Cervicotrochanteric
iv. Type IV: Pertrochanteric or intertrochanteric
 fractures about the Elbow
• 5% to 10% of all fractures in children
• distinguishing fractures from the six normal secondary
ossification centers
– (CRITOE)
 Spinal Cord Injury Without Radiographic
Abnormality(SCIWORA)
• overwhelmingly found in children (15% to 35% of SCIs in children)
• most, if not all, will have abnormal findings on MRI
• spinal column is more elastic than the spinal cord
• more common in children under 8 years of age than in older
children
• predisposing factors
i. cervical spine hypermobility,
ii. ligamentous laxity, and
iii. an immature vascular supply to the spinal cord
 Pathologic fractures

• May results from

a. Local causes: primary bone tumors,
metastases , osteomyelitis,
pronounced bowing of the bone (e.g.
in crus varum congenitum , which can
then develop into congenital tibial
pseudarthrosis )

a. Generalized causes: Osteogenesis

imperfecta , rickets , juvenile
osteoporosis , storage disorders such
as Gaucher disease .
 Birth Injuries
• Clavicle- commonest site, followed by the humerus and femur
• Risk factors: Shoulder dystocia, high birth weight and
gestational age
• Proximal and distal humerus, distal femur: Epiphyseal
separations due to birth trauma at best, suspected on an x-ray
since the humeral head and distal end of the humerus and
femur cartilaginous
• confirmed sonographically
 Treatment of fractures
in children
1. Closed treatment • Open treatment
– majority of fractures treated by closed reduction – Open fractures.
and casting or traction – Polytrauma.
– well-molded cast. – Patients with head injurie
– Femoral fractures in adole
– Femoral neck fractures.
– Certain types of forearm f
– Certain types of physeal in
– Fractures associated with
 Types of Fixation
i. Treatment of periarticular and articular fractures -3.5 mm
cortex screws, 4.0 mm cancellous bone screws (exceptionally
6.5mm), and cannulated screws
ii. epiphyseal and metaphyseal fragments- K-wire fixation
iii. Transphyseal wires should be non-threaded
iv. External fixation devices for patients with open fractures,
polytrauma, and fractures associated with burns(great care
exercised not to damage the growth plate)
• Standard closed intramedullary nailing used in femoral shaft fractures
in adolescents, in younger children the use of elastic titanium nails
(TEN)