Paediatric Trauma

Question 1

Describe risk factors for fractures in children?

Answer 1

• Boys 60% Girls 40%
• Age
• Previous fracture
• Metabolic bone disease
• Season

Question 2

What are the principles of childrens fractures?

Answer 2

• Heal quickly
  
  • Metabolically active periosteum
  • Cellular bone
  • Good blood supply
• Due to this
  
  • Fixation not usually required
  • Do not over immobilise
  • Do not over treat
• Most fractures need simple treatment
  
  • Conservative treatment
    
    • Cast
    • Braces
    • Splints
    • Traction
  • When operative treatment is required
    
    • External fixation
      
      • Monolateral or circular
    • Internal fixation
      
      • IM nail – rigid or elastic
      • Plate fixation
• Remodel well in plane of joint movement
• Reduction as treatment
  
  • Increase deformity to reduce fracture
  • Bones need bent cast to give straight limb (periosteum tension)
• Supplement the cast with fixation when
  
  • Severe swelling likely
  • Need to re-inspect wound (such as open fractures)
  • Multiple injuries
  • Segmental limb injuries
  • Unstable fracture

Question 3

Why do childrens fractures heal quickly?

Answer 3

• Metabolically active periosteum
• Cellular bone
• Good blood supply

Question 4

How does the principle that childrens fractures heal quickly impact treatment?

Answer 4

• Fixation not usually required
• Do not over immobilise
• Do not over treat

Question 5

What treatment is usually used for childrens fractures?

Answer 5

• Most fractures need simple treatment
  
  • Conservative treatment
    
    • Cast
    • Braces
    • Splints
    • Traction
  • When operative treatment is required
    
    • External fixation
      
      • Monolateral or circular
    • Internal fixation
      
      • IM nail – rigid or elastic
      • Plate fixation

Question 6

When should the cast be supplemented with fixation?

Answer 6

• Severe swelling likely
• Need to re-inspect wound (such as open fractures)
• Multiple injuries
• Segmental limb injuries
• Unstable fracture

Question 7

What are the 4 types of fracture in children?

Answer 7

• Complete fracture
• Greenstick fracture
• Buckle (torus)
• Plastic deformity

Question 8

In what plane does remodelling occur in children?

Answer 8

Most evident in plane of joint movement:

• Appositional periosteal growth/resorption
• Differential physeal growth

Question 9

In physeal fractures what does the physis act as?

Answer 9

Physis acts as plane of fracture

Question 10

What are possible complications of physeal fractures?

Answer 10

• Growth arrest risk due to closeness to growth plate
• Physis weaker than ligaments
• Can result in progressive deformity
  
  • Salter-Harris classification used to predict injuries that may affect growth
    
    • Tells you where fracture is and not how much it is displaced

Question 11

What is used to predict injuries that may affect growth?

Answer 11

• Salter-Harris classification used to predict injuries that may affect growth
  
  • Tells you where fracture is and not how much it is displaced

Question 12

Describe Salter-Harris classification?

Answer 12

Question 13

What does SH classification stand for?

Answer 13

Saltire harris classification

Question 14

Which SH grade is most common?

Answer 14

Question 15

What SH class has most risk of growth disturbances?

Answer 15

Most risk of growth disturbance is in III and IV:

• Or if in femur, even if SH I injury

Question 16

What is the apophysis?

Answer 16

Apophysis is where tendon inserts into bone

Question 17

How does apophysis injury differ in children compared to adults?

Answer 17

Ligament can be stronger than bone, so injury can cause avulsion of ligament, such as:

• Tibial spine and ACL
• Tibial tubercle and patella tendon
  
  • Usually requires operative fixation

Question 18

What are 2 locations where ligament is often stronger than bone?

Answer 18

• Tibial spine and ACL
• Tibial tubercle and patella tendon
  
  • Usually requires operative fixation

Question 19

What are the different grades of avultion of ACL?

Answer 19

• I Undisplaced
• II Hinged
• III Displaced

Question 20

Describe the treatment for avulsion of ACL?

Answer 20

• I/II long leg cast
• II/III ORIF

Question 21

What are transitional fractures?

Answer 21

Occur in children who have almost stopped growing:

• Growth plate closing, age 13-14 years
• Standard sequence of growth plate closing
  
  • Central > medial > lateral

Question 22

What is the standard sequence of growth plate closing?

Answer 22

• Central > medial > lateral

Question 23

Where does transitional fracture usually occur?

Answer 23

Usually occurs above ankle, such as Tilliax fracture which occurs due to the lateral side of growth plate closing last:

• In adult ligament would tear
• But in child, ligament stronger than bone so bone pulled off growth plate where the plate hasn’t fused

Question 24

What are possible complications of Tilliax fracture?

Answer 24

• Growth arrest
  
  • Can be asymmetrical growth arrest
  • Affecting gait – walk on outer side of foot

Question 25

Describe the management of Tilliax fracture?

Answer 25

* Surgical correction * External fixator – rarely required * ORIF (open reduction/internal fixation) * Indications – adolescents, comminuted fractures, injuries involving joint surface, forearm fractures (Monteggia and Galeazi – these both describe fractures of forearm bones) * Flexible nailing * Need 2 year predicted growth remaining * Advantages – allow early ROM, wires out when healed, minimal disruption

Question 26

What does ORIF stand for?

Answer 26

Open reduction/internal fixation

Question 27

What are indications for ORIF in transitional fracture?

Answer 27

* Indications – adolescents, comminuted fractures, injuries involving joint surface, forearm fractures (Monteggia and Galeazi – these both describe fractures of forearm bones)

Question 28

What does NAI stand for?

Answer 28

Non-accidental injury

Question 29

Describe the epidemiology of NAI? | (% recurrence, % fatality)

Answer 29

* 50% recurrence * 10% fatality

Question 30

What are warning signs for NAI?

Answer 30

* Inconsistent history * Delay in presentation * Fracture pattern does not fit mechanism * Bruising * Abnormal pattern or places * Or not explained by what child is doing * Burns * Multiple fractures with multiple stages of healing

Question 31

What is done if warning signs for NAI are seen?

Answer 31

* Skeletal survey * X-ray of whole skeleton * If we see many fractures at different stages usually means NAI if metabolic bone diseases been excluded

Question 32

What are common NAI fracture locations?

Answer 32

* Metaphyseal fractures * Humeral shaft fractures * Rib fractures * Requires large degree of force

Question 33

What is osteomyelitis?

Answer 33

Infection of the bone

Question 34

What are the 2 groups of osteomyelitis?

Answer 34

* Acute osteomyelitis * Chronic osteomyelitis

Question 35

Describe the aetiology of acute osteomyelitis?

Answer 35

* Mostly staphylococcus

Question 36

Describe the presentation of acute osteomyelitis?

Answer 36

* Insidious onset * Fever * Unable to weight bear * Pain * Mainly around knee

Question 37

What investigations are done for acute osteomyelitis?

Answer 37

* Blood culture * X-ray

Question 38

Describe the management of acute osteomyelitis?

Answer 38

* Prolonged high dose antibiotics * Aim to prevent acute becoming chronic * Rarely requires surgery

Question 39

Describe complications of acute osteomyelitis?

Answer 39

* Can threaten limb and life

Question 40

Describe the prognosis of acute osteomy * Cured if caught early and treated * Can progress to chronic elitis?

Answer 40

* Cured if caught early and treated * Can progress to chronic