PRINCIPLES OF PAEDIATRIC FRACTURE

MANAGEMENT
GROWTH PLATE INJURIES NURSEMAIDS
ELBOW

PRESENTATION BY:
DR M. JUNAID SALEEM
PGR
 PRINCIPLES OF PAEDIATRIC
FRACTURE MANAGEMENT

• Many principles of the pediatric fracture management are same as

those of the adult fractures
• Including the initial resuscitation and pain management. Followed by
REDUCE-HOLD-MOVE.
• Immature skeleton heals rapidly and remodels. So most of the
treatment skews towards non operative approach.
 OPERATIVE MANAGEMENT

• Do not think that all fractures will remodel and adequate reduction is
unnecessary.
• Know the anatomy of the physis
• If open reduction is necessary, reposition the fragments as anatomically
as possible, especially the physis
• Use fixation that can be removed easily
• Use smooth rather than threaded pins
• Try not to cross the physis
rather stay parallel to it in
the epiphysis and
metaphysis.

• Avoid unnecessary drill holes

that may later become
pathological fractures

• Avoid pin penetration in

the joints
• Use of subcuticular suture

• Immobilize a noncompliant child adequately

• Watch for neurovascular insufficiency

• Warn pts about complications like angular deformity and osteonecrosis

GROWTH PLATE INJURIES
• Growth plate is a highly specialized cartilaginous band between
epiphysis and metaphysis. It provides longitudinal growth.
• It is weaker than the surrounding bone making it vulnerable to injury
resulting in permanent structural damage and premature arrest of
growth plate.
• Premature arrest occurs in about 2% of cases of growth plate injuries.
• PARTIAL ARREST: arrest in damaged
region, the healthy region continues to
grow , leading to the angular deformity.

• COMPLETE ARREST: results in shortened

bone.
SALTER-HARRIS CLASSIFICATION
TYPE 1:
transverse through
physis

TYPE 2:
physis + metaphysis
TYPE 3:
Physis + epiphysis

TYPE 4:
Physis + epiphysis +
metaphysis
TYPE 5:
Crush injury Physis

TYPE 6:
Injury to perichondrial ring
MANAGEMENT OF PHYSEAL INJURIES
• TYPE 1 AND 2:
Displaced or minimally displaced managed with casting.
Displaced fractures are manipulated gently within 5 days and cast applied
• TYPE 3 AND 4:
These need prompt open reduction and fixation keeping in mind not to
cross the physis.
• TYPE 5:
Cant be improved surgically but can be corrected with salvage procedures
after closure of physis.
 FOLLOW UP OF PHYSEAL INJURIES
• Careful follow-up of high risk fractures for 18-20 months is needed.
• HIGH RISK:
• Salter type 3,4,5,6
• High energy physeal fractures of any type
• Distal femoral fractures
• Proximal tibial fractures
 LATE SURGERY FOR DEFORMITY
• It requires realignment surgery with osteotomy and fixation
 NURSEMAIDS ELBOW
• Also called pulled elbow
• The radial head subluxates through the annular ligament
• Common from 6 months to 4 yrs with peak age of 2 to 3 years
• Male to female ratio 1:2
• Left elbow 70% cases
• Reoccurrence rate 5-30%
• Proximal radioulnar joint is conferred by the annular ligament.
• Annular ligament is reinforced by the radial collateral ligament.
MECHANISM OF
INJURY

• Longitudinal traction force on

extended elbow.
• With forearm in pronation
• Clinical presentation:

• Pt presents with a clear hx of sudden

longitudinal traction
• Pt hangs the upper extremity with the
elbow flexed and forearm pronated with
refusal to use the hand.
• Slight tenderness over the ant and lat
aspect of the elbow joint
• Pain on supination
• TREATMENT
Closed reduction done in
majority of the cases after x
ray to be certain that no
fracture is present.
Open reduction is rarely
required for chronic and
recurrent cases.

2 METHODS
• Supination technique
• Hyper pronation technique