Physeal Injuries And

Pediatrics Trauma
Dr. Aamar Munir
Introduction
• Always look to see if physis is open
• Unique principals in pediatric bone

• Elasticity
• Remodeling Potential
• Elasticity
• More elastic which leads to unique
fracture patterns
• Buckle fractures/Torus fractures

• Greenstick fractures 
 • Remodeling potential
• Open physes (growth plates) can allow extensive bone
deformity remodeling potential
• Occurs more rapidly in plane of joint motion

• Occurs more at the most active physes, due to most

growth and potential for remodeling
• Most active physes in upper extremity

• proximal humerus 

• distal radius

• Most active physes in lower extremity

• distal femur 

• proximal tibia

• Same principles as adult bone

• intra-articular fractures must be reduced
Physis Anatomy
Physeal
Anatomy
Physeal Injuries
Classification

1. Salter-Harris Classification

2. Ogden Classification
Salter-Harris Classification

Type I - Physeal separation

Type II - Fracture traverses physis and exits metaphysis

Type III - Fracture traverses physis and exits epiphysis

Type IV - Fracture passes through epiphysis, physis,

metaphysis

Type V - Crush injury to physis

Type II - Fracture
traverses physis and exits
metaphysis
Type III - Fracture
traverses physis and
exits epiphysis
Type IV - Fracture
passes through
epiphysis, physis,
metaphysis
Treatment
I. Closed reduction and POP casting

II. CRPP

III. ORIF
Principles Of Fixation
Repeated attempts to reduce the Physeal injuries may
further injure the physis .

Necessary to have perfectly reduction

Internal fixation device should not cross the physis

Type I Type II
Type 3
Type 4
Complications
1. Growth arrest

2. Angular or rotational deformities

3. Limb shortening
Causes Of Physeal Arrest
1. Trauma
2. Infection
3. Tumor

Commonest area of growth arrest are

i. Distal femur
ii. Proximal tibia
iii. Distal tibia
Fractures In Skeletally Immature
Treatment principles are same as in adult.

More healing potential

More Remodeling potential

Greater remodeling potential at ends of long bones

that contribute most to longitudinal growth
Deformity is more acceptable in plane of motion of
adjacent joint

Indication for operative intervention are rare in

children

Non union occurs rarely

A 5 year old child presented in
A & E Department with H/O
fall while playing in the park
at monkey bars 2 hours ago.
He is crying with pain and not
moving his right upper limb.
On Examination :
Significant swelling of the right
elbow.
Distal radial artery is not
palpable.
All peripheral nerves are intact.
Objectives
Enlist possible injuries around the elbow of falling on
outstretched hand.

How will you assess the patient?

How will you assess the vascular injury?

How will you manage the patient?

What are the possible acute and late complication of fractures

around elbow ?
 Years at
Years at fusion (appear
Ossification center ossification (appear on
on xray) (1)
xray) (1)
12
Capitellum 1
15
Radius 4
17
Medial epicondyle 6
Trochlea 8 12
Olecranon 10 15
Lateral epicondyle 12  12
(1) +/- one year, varies between boys and girl
 
Common Paediatric Fractures
Upper Limb
1. Supracondylar fracture Humerus
2. Larteral Condyle fracture Humerus
3. Fracture Radial head and neck
4. Monteggia Fracture Disocation
5. Olecranon fracture
6. Nursemaids Elbow
7. Fracture radius ulna shaft
8. Distal radius fracture
 Pediatric Elbow Injury Frequency
% elbow Peak
Fracture Type Requires OR
injuries Age
Supracondylar
41% 7 majority
fractures
Radial Head
28% 3 rare
subluxation
Lateral condylar
11% 6 majority
physeal fractures
Medial epicondylar
8% 11 minority
apophyseal fracture
Radial Head and Neck
5% 10 minority
fractures
Elbow dislocations 5% 13 rare
Medial condylar
1% 10 rare
physeal fractures
Lower Limb
1. Fracture shaft femur
2. Salter Harris injuries distal Femur
3. Fracture shaft of tibia
4. Salter Harris injuries ankle
 Supracondylar Fracture Humerus
Epidemiology
Incidence
 extension type most common (95-98%)
Demographics
occur most commonly in children aged 5 to 7
M=F

Pathophysiology
Mechanism of injury

 fall on outstretched hand

Associated injuries
Nerve Injuries
 Anterior interosseous nerve neurapraxia (branch of median n.)
 the most common nerve palsy seen with supracondylar humerus fractures   

 Radial nerve palsy

 second most common (close second)

 Ulnar nerve palsy

 seen with flexion-type injury patterns  

 nearly all cases of neurapraxia following supracondylar humerus fractures

resolve spontaneously, and therefore, further diagnostic studies are not

indicated in the acute setting
Vascular injury (1%)
 rich collateral circulation can maintain circulation despite vascular injury
Ipsilateral distal radius fractures
Classification
Gartland Classification
Type I
Type II
Type III
Radiograpic Views
AP and lateral x-ray of the elbow
Findings
Posterior fat pad sign 
 Lucency along the posterior distal humerus and olecranon fossa is
highly suggestive of occult fracture around the elbow

Displacement of the anterior humeral line

 Anterior humeral line should intersect the middle third of the

capitellum 
 Capitellum moves posteriorly to this reference line in extension

type fracture
Treatment
Nonoperative

Long arm posterior splint then long arm casting

with less than 90° of elbow flexion
Indications
  Type I  
  Type II
Operative
1. Closed reduction and percutanous pinning   
Indications
  Type II and III supracondylar fractures
2. Open reduction with percutaneous pinning
Indications
 adequate reduction cannot be obtained closed
 more frequently required with flexion type fractures
1. Immediate closed reduction and percutanous
pinning
indications
vascular compromise is present (e.g, pale, cool hand)
"floating elbow"
 ipsilateral supracondylar humerus and forearm fractures
necessitate immediate pinning of both fractures to decrease
risk of compartment syndrome 
Complications
Acute
Vascular injury
Nerve injury
Compartment syndrome
Late
VIC
Pin migration
Infection
Cubitus varus/cubitus valgus
Lateral Condyle Fracture
Epidemiology
Incidence
 17% of all distal humerus fractures in the pediatric population
Demographics
 typically occurs in patients aged 5-10 years old
Location
 most commonly are Salter-Harris IV fracture patterns of the
lateral condyle 
Pathophysiology
Mechanism of injury
 pull-off theory
 avulsion fracture of the lateral condyle that results from the pull of the

common extensor musculature

 push-off theory
 fall onto an outstretched hand causes impaction of the radial head into the

lateral condyle causing fracture

Prognosis
outcomes have historically been worse than supracondylar
fractures
 articular nature, missed diagnosis, and higher risk of malunion/nonunion
Classification
Type I Type II
Radiographs recommended views
 AP
 Lateral
 Oblique views
Nonoperative
Long arm casting
i. Undisplaced
ii. < 2 mm of displacement

Operative
Open reduction and fixation
if > 2-4mm of displacement
any joint incongruity 
fracture non-union
Complications
Non union
AVN
Malunion
Cubitus valgus deformity elbow
Nursemaid's Elbow
Epidemiology
most common in children
from 2 to 5 years of age.
Pathophysiology
Mechanism
 caused by longitudinal
traction applied to an
extended arm
Pathoanatomy
 caused by subluxation of the
radial head and
interposition of the annular
Femur Fractures
High suspicion for child abuse required 
Abuse must be considered if child is < 5 years
 especially if present in a patient before walking age
Femur fractures are the 2nd most common child abuse
associated fracture after humerus fractures
Epidemiology
Bimodal distribution
 increased rate in toddlers age 2-4 yrs.
 increased again in adolescents 
Mechanism
 falls most common cause in toddlers
 high energy trauma is responsible for second peak in
adolescents
 MVC or ped vs vehicle

Fractures after minor trauma can be the result of a

pathologic process
 bone tumors, OI, osteopenia, etc
Clinical Picture

Presentation
•Symptoms
• thigh pain, inability to walk, report of deformity or instability
•Physical exam
• gross deformity, shortening, swelling of the thigh
Radiographs
AP and lateral of femur
typically allow complete
evaluation of the
fracture location,
configuration and
amount of displacement

Ipsilateral AP and lateral

of knee and hip
required to rule out
associated injuries
 Treatment Guidelines
< 6 months • Any fx pattern
7m - 5 • < 2 - 3 cm shortening
years • > 2 - 3 cm shortening
•polytrauma/multiple fx/open
fx
6 - 11 years • length stable fx (transverse • Flexible intramedullary nails
or oblique fx patterns)
• length unstable fx
(comminuted or spiral)
• very proximal or distal fx
Approachin • length stable
g skeletal • patient weighs < 100 lbs
maturing
(>11 years) • length unstable
• patient weighs > 100 lbs
• length unstable
• very proximal or distal fx
• Pavlik harness 
• Early spica casting
• Early spica casting 
• Traction with delayed spica
casting  
• ORIF with submuscular bridge
plating
• Flexible nails
• External fixator
   
• ORIF with submuscular bridge
plating  
• External fixation 
• polytrauma patients for
damage control 
• Flexible intramedullary nails  
• Antegrade IM nail
with trochanteric or lateral
starting point
• ORIF with submuscular bridge
plating
Hip Spica Cast
External Fixtor
Flexible IM Nail
Complication
Non union
Malunion
Femoral Head AVN
Limb length shortening
Refracture