OVERVIEW OF PEDIATRIC TRAUMA Presenter: Dr Gituri Philip Moderator: Dr E. Gakuya An 8-year-old boy presents to the emergency department with a Salter-Harris type IV fracture of the distal femur from a football tackle. The fracture has 3mm of displacement and 15 degrees of angulation in the sagittal plane. Because of his young age you know he has excellent potential to remodel. The BEST treatment
option would include: a)Long-leg cast b)Percutaneous pinning in situ c)Open reduction and internal fixation with distal femoral locking plate d)Open reduction and internal fixation of the metaphyseal component but not the epiphyseal component to avoid potential growth arrest e)Open reduction and internal fixation of both components with plates and or screw fixation
OUTLINE 1. Epidemiology of Pediatric Fractures 2. Uniqueness of Children's bones 3. Child abuse/Neglect/ Non-accidental trauma (NAT) 4. Multiply injured Child 5. Principles of Management 6. Specific cases/Precautions INTRODUCTION
over 40% of boys and 25% of girls sustain a fracture by 16 years of age1 properties of the immature skeleton- these injuries have different characteristics, complications, and management than similar adult injuries data from five large epidemiologic studies :distal forearm # most common (nearly 25% of 12,946 fractures), then clavicle # (over 8% of all children's fractures) Mann et al.  reported of 2,650 long bone fractures in children, 30% involved the physis.
PROPERTIES OF THE IMMATURE SKELETON 1. Plastic Deformation- most common in the forearm, particularly the ulna Stressstrain curves for mature and immature bone. The increased strain of immature bone before failure represents plastic deformation.
a. Buckle (Torus) Fractures- most commonly occur at transition between metaphyseal woven bone and the lamellar bone of the diaphyseal cortex 3. Greenstick Fractures - immature bone is more flexible and has a thicker periosteum than mature adult bone Reduction: unlock the impacted fragments on the tension side by initially exaggerating the deformity and then applying traction and a reducing force stable after reduction but have an increased likelihood of refracture
immobilize these fractures for a full 6 weeks 4. Remodeling/Overgrowth -fractures heal more rapidly than those in adults, but once healed, they remodel residual deformity Factors affecting remodellong potential: i. amount of growth remaining (the patient's skeletal age)
ii. the plane of the deformity in relation to adjacent joints iii. the deformity's proximity to the physis and iv. the growth potential of the particular physis 5. Potential for accelerated growth of an injured limb -most frequently seen in diaphyseal femoral fractures.(spontaneously
correctting shortening of up to 2 cm) Theories ascribe this to hyperemia 6. Physeal Injuries 15% to 30% of all fractures in children peak in adolescents growth deformity is rare, occurring in only 1% to 10% of all physeal injuries. Physeal anatomy
Most injuries occur just above area of provisional calcification within the hypertrophic zone. Germinal layer frequently remains intact and attached to the epiphysis CLASSIFICATION OF PHYSEAL INJURIES
Goal in treating physeal fractures i. to achieve and maintain an acceptable reduction without subjecting the germinal layer of the physis to any further damage. ii. determining the limits of an acceptable reduction
iii. Because of the intra-articular component, displaced type III and IV injuries must be reduced regardless of the time that has elapsed since the injury iv. reduction can be maintained with a cast, pins, internal fixation, or some combination of these three COMPLICATIONS OF PHYSEAL INJURIES 1. malunion,
2. infection, 3. neurovascular problems, 4. Osteonecrosis 5. Growth Disturbance CARE OF THE MULTIPLY INJURED CHILD Blunt trauma -leading cause of death in children older than 1 year of age Children possess a number of anatomic and physiologic characteristics
that make their injuries and their injury response different from adults' OPEN FRACTURES Incidence and mechanism of open fractures differ between children and adults their management is similar, requiring an aggressive, thorough, and systematic approach most common open fractures in children involve the hand and upper extremity
Open fractures of the lower extremities, esp tibia, are the result of higherenergy trauma, esp automobilepedestrian or automobilebicycle accidents GUSTILO AND ANDERSON CLASSIFICATION SYSTEM Type I Wound <1 cm long Moderately clean puncture wound
Extensive soft tissue damage to muscles, skin, and Usually inside-out injury neurovascular structures and a high degree of Little soft tissue damage, no crushing contamination
Little comminution Type II Wound >1 cm long Three subtypes: A.
Adequate soft tissue coverage (includes high- No extensive tissue damage energy segmental, comminuted fractures, Slight or moderate crush injury regardless of normal size)
Moderate comminution or contamination Type III B.
Local or free flap required for coverage C. Arterial injury requiring repair Open Fracture Management 1. Thorough assessment for life-threatening injuries 2. Immediate intravenous antibiotics, continue for 48 hours:
i. Grade Ifirst-generation cephalosporin ii. Grades II and IIIfirst-generation cephalosporin + aminoglycoside iii. Barnyard injuriesadd anaerobic coverage (penicillin or metronidazole) 3. 4. 5. 6.
7. 8. Tetanus prophylaxis Thorough operative debridement Adequate fracture stabilization Second operative debridement in 48-72 hours if indicated Early definitive soft tissue coverage Early bone grafting if indicated
CHILD ABUSE/NONACCIDENTAL TRAUMA/BATTERED CHILD SYNDROME 1% to 1.5% of all children are abused each year children are more likely to be abused by caregivers who are young, poor, and of minority status Younger children are also more likely to die from abuse After skin lesions, fractures are the second most common physical
presentation bone that fractures under tension with torsion Femoral shaft, hands and feet fractures in nonambulatory infants Fractures in unusual locations SPECIFIC FRACTURES Cervical spine injuries in children (1% of pediatric fractures and 2% of all spinal injuries )
i. ii. younger than 8 years age - upper cervical spine, older children and adolescents - either the upper or lower C- spine i. Pelvic fractures comprise less than 0.2% of all pediatric fractures ii.two most common classification systems used :Young and Burgess and Tile and Pennal
Torode and Zieg Classification of pelvic fractures in children Hip Fractures: blood supply of the proximal femur comes from two major branches of the profunda femoris arterythe medial and lateral circumflex arteries classified into four types based on the anatomic location of the fracture as described by Delbet
i. ii. iii. iv. Type Type Type Type
I: Transepiphyseal II: Transcervical III: Cervicotrochanteric IV: Pertrochanteric or intertrochanteric Fractures about the Elbow 5% to 10% of all fractures in children distinguishing fractures from the six normal secondary ossification
centers (CRITOE) Spinal Cord Injury Without Radiographic Abnormality(SCIWORA) overwhelmingly found in children (15% to 35% of SCIs in children) most, if not all, will have abnormal findings on MRI spinal column is more elastic than the spinal cord
more common in children under 8 years of age than in older children predisposing factors cervical spine hypermobility, ligamentous laxity, and an immature vascular supply to the spinal cord
Pathologic fractures May results from a. Local causes: primary bone tumors, metastases , osteomyelitis, pronounced bowing of the bone (e.g. in crus varum congenitum , which can then develop into congenital tibial pseudarthrosis ) a. Generalized causes: Osteogenesis
imperfecta , Stuve-Wiedemann syndrome , rickets , juvenile osteoporosis , storage disorders such as Gaucher disease . BIRTH INJURIES Clavicle- commonest site, followed by the humerus and femur Risk factors: Shoulder dystocia, high birth weight and gestational age Proximal and distal humerus, distal femur: Epiphyseal separations due to
birth trauma at best, suspected on an x-ray since the humeral head and distal end of the humerus and femur cartilaginous confirmed sonographically TREATMENT OF FRACTURES IN CHILDREN 1. Closed treatment majority of fractures treated by closed reduction and casting or
traction well-molded cast. Open treatment
Open fractures. Polytrauma. Patients with head injuries. Femoral fractures in adolescents. Femoral neck fractures.
Certain types of forearm fractures. Certain types of physeal injuries. Fractures associated with burns. Types of Fixation i. Treatment of periarticular and articular fractures -3.5 mm cortex screws, 4.0 mm cancellous bone screws (exceptionally 6.5mm), and
cannulated screws ii. epiphyseal and metaphyseal fragments- K-wire fixation iii. Transphyseal wires should be non-threaded iv. External fixation devices for patients with open fractures, polytrauma, and fractures associated with burns(great care exercised not to damage the growth plate) Standard closed intramedullary nailing used in femoral shaft fractures in
adolescents, in younger children the use of elastic titanium nails (TEN)
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