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Introduction to Pediatric Orthopaedics: Common Fractures Stephen P. England, MD MPH Department of Orthopaedic Surgery Park Nicollet Orthopaedics Slide 2 Slide 3 The Pediatric Skeleton Children are not simply small adults (though some adults are simply large children) Slide 4 Pediatric Skeleton Less dense and more porous Lower bending strength Lower mineral content Periosteum is very thick Presence of growth plates (physes) Ends of long bones are nonossified cartilage Tendon may be stronger than bone insertion sites (adolescents) Slide 5 The Pediatric Skeleton Comminuted fractures are uncommon Large pores in the immature cortex can prevent propagation (greenstick) Long plastic phase with loading relative to mature bone (plastic deformation) Fail with compression - buckle fracture Remodeling potential of fractures Slide 6 Anatomy of the Pediatric Skeleton Slide 7 Anatomic Differences Epiphysis - the cartilaginous end with a secondary ossification center Physis - the growth plate Metaphysis - cylindrical end of long bones. This portion is more porous and has a thinner cortex than the shaft Diaphysis principal portion of the long bone or the shaft Slide 8 Anatomic Differences Growth Plates The most obvious difference is the presence of growth plates and thick periosteum Growth plate injuries may lead to significant growth disturbances if managed poorly Reduction of the growth plate injury must be precise Slide 9 Anatomic Differences Periosteum Periosteum has greater bone forming potential in children It helps to maintain alignment of simple fractures It also reduces the amount of displacement of fractures Can aid in the reduction of fractures Slide 10 Anatomic Differences Remodeling Remodeling may make reduction accuracy somewhat less important than in an adult Occurs in the plane of a joint (25 degrees / metaphyseal region / less than 8 years old) Will not occur for rotational deformity or for angular deformity not in the plane of the joint >10 degrees of angulation in the midportion of long bones is not acceptable Slide 11 Remodeling and Healing The younger the patient the greater the remodeling potential Side-to-side apposition of long bone fracture fragments may be acceptable as long as shortening doesnt occur Intra-articular fractures must be anatomically reduced and will not remodel Nonunions are virtually unheard of in simple pediatric fracture Slide 12 Classification of Childrens Fractures Plastic deformation Buckle/Torus factures Greenstick fractures Complete fractures Epiphyseal or Growth plate fractures Slide 13 Plastic Deformation Unique to children Most commonly seen in the ulna and fibula May rarely occur in the femur as well Slide 14 Plastic Deformation The angular deformity may be permanent Without a hematoma, no significant callus will form A fracture on the tension does not propagate Slide 15 Buckle or torus fractures Injury primarily in early childhood Occurs at metaphyseal- diaphyseal junction Secondary to compressive force Very common Heal in 2-3 weeks Slide 16 Buckle fractures Also known as torus fractures Treated in a short cast or splint for 2-3 weeks No long term sequelae Slide 17 Torus fracture = Buckle fracture Torus = Latin for a cushion of this shape Slide 18 Torus fracture = Buckle fracture Torus = Ring at column base Slide 19 Torus fracture = Buckle fracture Torus = Ring at column base Slide 20 Greenstick Fractures Occur when a bone is bent with failure of the tension side Fracture doesnt propagate entirely through the bone Compressive side undergoes plastic deformation Incomplete fracture Slide 21 Complete Fractures Spiral fractures Oblique fractures Transverse fractures Epiphyseal fractures Slide 22 Spiral Fractures Created by a rotational force on the bone An intact periosteum enables easy reduction by reversing the rotational injury Broad fracture surface area Slide 23 Oblique Fractures Occur diagonally across diaphyseal bone Usually at approximately 30 degrees to the axis of the bone May cause significant disruption of the periosteum Broad fracture surface area Slide 24 Transverse Fractures Occur from three- point bending Butterfly fragments may occur Small fracture contact/surface area Slide 25 Epiphyseal Fractures Injuries to the epiphysis of a bone usually involve the growth plate Problems are uncommon but potentially serious Distal radial physis is the most commonly injured physis Growth plate heals quickly in 3-6 weeks Slide 26 Salter-Harris Salter-Harris Epiphyseal Fracture Classification Slide 27 Salter-Harris Type I The periosteum usually stays intact and prevents displacement The fracture runs directly through the growth plate Slide 28 Salter-Harris Type II The injury passes through the growth plate and out through a portion of the metaphysis Slide 29 Salter-Harris Type III An intra-articular fracture that passes through the epiphysis until it hits the growth plate Usually occurs when the growth plate is partially closed Slide 30 Salter-Harris Type IV An intra-articular fracture which involves the epiphysis as well as the metaphysis The fracture line crosses the growth plate The physis must be anatomically reduced to prevent osseus bridge formation Slide 31 Salter-Harris Type V Originally described as a crush injury to the growth plate. Difficult to diagnosis May appear to be a Type I Fortunately, an uncommon injury Slide 32 Common Fractures Buckle fracture of the distal radius/ulna Supracondylar humerus fracture Femoral shaft fractures Proximal tibial metaphyseal fracture Toddlers tibial shaft fracture Distal fibular Salter-Harris Type I/II fracture Special Circumstances Pelvic Avulsion Fractures Slide 33 Buckle fractures of the radius Secondary to routine falls onto an extended limb Present with varied pain Treatment = short arm cast or splint for approximately 3 weeks Follow-up with x-rays to assess healing No long term sequelae Slide 34 Treatment =Short Arm Cast (SAC) May be applied with a waterproof liner Should allow for full motion of the thumb and fingers A well molded splint works just as well as a cast Slide 35 Common elbow fracture after a fall onto an extended limb Graded Types 1,2, or 3 based up displacement of fragments Require referral for orthopaedic management Supracondylar Humerus Fractures Slide 36 Supracondylar fracture Type 1 Non-displaced fracture Require approximately 3-4 weeks in a long arm cast Do not need to be manipulated or pinned Heal with no consequence if well aligned Slide 37 Supracondylar fracture Type 2 Ang ulation of fractures noted on the lateral x- ray Most common type is extended Will require reduction of angulation while sedated May require pins to assure stability while casted for 3-4 weeks Slide 38 Supracondylar Fracture Type 3 Fracture is angulated and displaced Requires a reduction and pinning to maintain alignment Will require 3-4 weeks of casting Common referral from adult orthopaedist Slide 39 Femoral Shaft Fractures Treatment depends upon age of patient and location/configuration of the fracture Operative management is replacing traction and spica casting High energy injury Child abuse should be considered in non- walkers Slide 40 Femoral Shaft Fractures Spica casting is still commonly used for children