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Common Pediatric Fractures

Common Pediatric Fractures. Prof. Mamoun Kremli AlMaarefa Medical College. Objectives. How are children’s fractures different Discus common fractures in children X -ray diagnosis Principles of management Identify Epiphyseal injuries Precautions. Statistics.

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Common Pediatric Fractures

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  1. Common Pediatric Fractures Prof. Mamoun Kremli AlMaarefa Medical College

  2. Objectives • How are children’s fractures different • Discus common fractures in children • X-ray diagnosis • Principles of management • Identify Epiphyseal injuries • Precautions

  3. Statistics • ~ 42% of boys and 25% of girls, are expected to have a fracture during childhood (Landin 83) • Percentage of children sustaining a fracture in 1 year: 1.6% to 2.1% (Warlock &Stower 86) Mamoun Kremli

  4. Statistics • ~ 42% of boys and 25% of girls, are expected to have a fracture during childhood (Landin 83) • Incidence increases with age – peak ~ 12-14 yrs Mizulta, 1987

  5. Introduction • In Middle East ~50% of population < 20 yrs • Different from adult fractures • Varies in various age groups

  6. Statistics Most frequent sites 47% 74% , Mizulta, 1987, (923 children)

  7. Fractures specific to children • Greenstick • Torus (buckle) • Deformation • Physeal injuries www.radiologyassistant.nl/ www.wheelessonline.com/ Mamoun Kremli www.imageinterpretation.co.uk/

  8. Different from adults • Ends of long bones have thick cartilage: • Not seen on x-rays • Thick periosteum, good blood supply: • Heal well and quickly • More elastic, more cancellous: • Incomplete fractures, simple fractures • Growth plate: • Good remodeling • Special growth plate injuries

  9. The power of remodeling • Can accept more angulation and displacement • Rotational mal-alignment ?does not remodel www.brokenarmanswers.com/

  10. The power of remodeling • Can accept more angulation and displacement • Better remodeling near growth plates

  11. The power of remodeling http://www.acep.org/

  12. The power of remodeling

  13. Treatment Most fractures in children heal well Whatever you do!

  14. Choice of treatment • Stable fractures - incomplete: • Greenstick • Buckle (Torus) • Plastic deformation • Stable fractures – complete: • Undisplaced • Displaced, reducible • Unstable fractures: • Bothe bones at same level • Oblique fractures • Comminuted fractures • Preference (patients’ / surgeons’, choice) Conservative Operative

  15. Closed reduction • More commonly used in children

  16. Closed reduction - Casting • Still the commonest • Good remodeling power • Needs careful monitoring • Regular follow-ups • Swelling subsides: • cast loose • displaces

  17. Casting - Problems • Forearm is a joint – needs anatomic reduction • Mal-union results in loss of supination/pronation

  18. Casting - Problems • Mal-alignment in LL causes osteoarthritis Gicquel

  19. Casting - Problems • Overlap – shortening • Loss of reduction

  20. Casting - Problems 9 yr old 6 yr old - 5wks K Willkins, Injury Suppl 36

  21. Surgical treatment • K-wires • Intramedullary nails • Plates • External Fixator

  22. K-Wires • The commonest in children • Very effective • Prevents displacement • Needs additional casting • Application: • Percataneous • Open

  23. Elastic IM Nails • Unstable fractures – minimal surgery P. Schmittenbecher

  24. Plating • For overweight children • Problems: • Large scars • Needs removal

  25. Plating • Bridge plating • MIPO: • Introduced through small wounds

  26. External fixator • Open (compound) fractures www0.sun.ac.za/ortho

  27. Common injuries • Clavicle • Radius • Forearm fracture – fracture dislocation • Supracondylar Humerus • Epiphyseal injuries • Non-accidental injuries • Precaution

  28. Clavicle fracture http://parkingspot.wordpress.com/ • Common • Birth injury • Pseudo-paralysis • Fall on outstretched hand • Heals well conservatively • No functional problems • Treatment: • Sling or figure of 8 bandage

  29. Supracondylar fracture

  30. Supracondylar humerus • A common injury • Fall on the outstretched hand, elbow hyperextended • Anatomically thin part of lower humerus • Nerve or vessel injury possible

  31. Supracondylar humerus • Fall on outstretched hand - Hyper-extension of elbow (the commonest type) Anterior www.radiologyassistant.n

  32. Supracondylar humerus • Fall on outstretched hand - Hyper-extension of elbow (the commonest type) Anterior www.radiologyassistant.n

  33. Supracondylar humerus • Fall on outstretched hand - Hyper-extension of elbow (the commonest type) Anterior www.radiologyassistant.n

  34. Supracondylar humerus • Fall on outstretched hand - Hyper-extension of elbow (the commonest type) Anterior www.radiologyassistant.n

  35. Supracondylar humerus • Fat pad sign www.radiologyassistant.n www.radiologyassistant.n

  36. Fat pad sign • Fat pad sign: • Indicates a fracture www.radiologyassistant.nl/

  37. X-ray lines in elbow • Anterior humeral line • A line drawn on a lateral view along the anterior surface of the humerus should pass through the middle third of the capitellum Abnormal Normal www.radiologyassistant.nl

  38. Supracondylar fracture • Classification (Gartland’s) http://tidsskriftet.no/ Posterior intact Completely displaced Undisplaced

  39. Supracondylar humerus • Needs immediate care • Nerve injury: Median N, Radial N • Vascular injury: Brachial artery (tenting) • Swelling: compartment syndrome www.wheelessonline.com/ www.mendelsonortho.com/

  40. Supracondylar humerus • Needs immediate care • Delay causes more swelling • More difficulties in reduction • More vascular compromise • Undisplaced: Casting • Displaced: • Closed reduction and fixation with K-wires • ? Open reduction and fixation with K-wires

  41. 6y girl, fell from swing Injury reduction 3 m 2 yrs Teddy Slomgo, Bern, Switzerland

  42. Supracondylar humerus • Closed reduction and percutaneous K-wires Teddy Slomgo, Bern, Switzerland

  43. Supracondylar humerus • Neurovascular injury must be ruled out • Swelling and possible kinking of vessels • May cause Volkmann's ischemia • A real emergency www.studyblue.com

  44. Supracondylar fractures • Most are displaced and need surgery • Type I can be managed with long arm cast, forearm neutral, elbow 90o for 4 wks • Bivalve cast if acute • Follow-up xrays 3-7 days later to document alignment • Xrays at 4 weeks to document callus • Once callus noted at 4 weeks, discontinue cast and start active ROM

  45. Supracondylar fractures • Delayed complication • Malunion • Often cubitus varus deformity

  46. Lateral condyle - humerus • Mostly cartilaginous • Fracture may be easily missed • Displacement may not be appreciated • Needs fixation even if undisplaced • If not fixed, may displace www.radiologyassistant.nl

  47. Forearm – Radius and Ulna • A joint: supination and pronation • Anatomical reduction is a must • Treatment: • Closed reduction and casting • Closed reduction and intramedullary nail

  48. Closed reduction and casting • Good method if reduction maintained • Needs close, regular follow-up http://eorif.com/

  49. Intramedullary nail • When unstable, or re-displace in cast Teddy Slongo, Bern, Switzerland

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