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Prof. Muhammad Shahiduzzaman Head,  Department of  Orthopaedics & Traumatology Dhaka Medical College Hospital Paediatric F...
<ul><li>In Bangladesh 60% of population are <20 yrs </li></ul><ul><li>Fractures accounts for 15% of all injuries in childr...
<ul><li>Children have different physiology and anatomy </li></ul><ul><ul><li>Growth plate. </li></ul></ul><ul><ul><li>Bone...
<ul><li>In infants, GP is stronger than bone. </li></ul><ul><li> increased diaphyseal fractures </li></ul><ul><li>Provide...
<ul><li>Increased collagen: bone ratio </li></ul><ul><ul><li>lowers modulus of elasticity </li></ul></ul><ul><li>Increased...
<ul><li>Increased ratio of cartilage to bone </li></ul><ul><ul><li>better resilience </li></ul></ul><ul><ul><li>difficult ...
<ul><li>Metabolically active </li></ul><ul><ul><li>more callus, rapid union, increased remodeling </li></ul></ul><ul><li>T...
Age related # pattern
<ul><li>Better blood supply, </li></ul><ul><li>so less incidence of Delayed or non-union. </li></ul>Physiology
<ul><li>Bones tend to BOW rather than BREAK </li></ul><ul><li>Compressive force= TORUS fracture </li></ul><ul><ul><ul><li>...
Green Stick Fracture
Torus Greenstick Green Stick Fracture
Plastic Deformity Injury Pattern
<ul><li>Point at which metaphysis connects to physis is an anatomic point of weakness </li></ul><ul><li>Ligaments and tend...
<ul><li>Many childhood fractures involve the physis </li></ul><ul><ul><li>20% of all skeletal injuries in children </li></...
<ul><li>SALTER HARRIS CLASSIFICATION </li></ul><ul><ul><li>Classification system to delineate risk of growth disturbance <...
<ul><li>Fracture passes transversely through physis separating epiphysis from metaphysis. </li></ul>Salter Harris Grade I
 
<ul><li>Transversely through physis but exits through metaphysis </li></ul><ul><li>Triangular fragment </li></ul>Salter Ha...
 
<ul><li>Crosses physis and exits through epiphysis at joint space. </li></ul>Salter Harris Grade III
 
 
<ul><li>Extends upwards from the joint line, through the physis and out the metaphysis. </li></ul>Salter Harris Grade IV
 
Crash Injury to growth plate Salter Harris Grade V
<ul><li>MOST COMMON : Salter Harris  II </li></ul><ul><ul><li>Followed by I, III, IV, V </li></ul></ul><ul><ul><li>Refer t...
<ul><li>Tremendous power of remodeling </li></ul><ul><li>Can accept more angulation and displacement </li></ul><ul><li>Rot...
Malunion-Remodeling Process
<ul><li>Factors affecting remodeling potential </li></ul><ul><li>Years of remaining growth –  most important factor </li><...
<ul><li>Children tend to heal fractures faster than adults requiring shorter immobilization time. </li></ul><ul><li>Antici...
<ul><li>Fractures in children may stimulate longitudinal growth – some degree of overlap is acceptable and may even be hel...
<ul><li>Law of Two’s  : </li></ul><ul><ul><li>Two views </li></ul></ul><ul><ul><li>Two joints </li></ul></ul><ul><ul><li>T...
Radio-capitaller line Evaluation of paediatric elbow film
Supracondylar Fracture of Humerus Evaluation of paediatric elbow film
<ul><li>Mostly conservative – closed reduction and cast immobilization </li></ul><ul><li>Open reduction & internal fixatio...
<ul><li>Displaced intra articular fractures </li></ul><ul><ul><li>(  Salter-Harris  III-IV  ) </li></ul></ul><ul><li>fract...
Indication for operative management
<ul><li>Casting—the commonest. </li></ul>Method of fixation
<ul><li>K-wires  </li></ul><ul><ul><li>most commonly used </li></ul></ul><ul><ul><li>Metaphyseal fractures </li></ul></ul>...
Intramedullary wires, elastic nails Very useful, Diaphyseal fractures Method of fixation
<ul><li>Screws </li></ul>Method of fixation
<ul><li>Screws </li></ul>Method of fixation
<ul><li>Plates and screws </li></ul><ul><ul><li>Multiple Trauma </li></ul></ul>Method of fixation
<ul><li>IMN Nailing (adolescent only) </li></ul><ul><ul><li>Chances of growth disturbences. </li></ul></ul>Method of fixat...
<ul><li>External Fixation </li></ul><ul><ul><li>In open Fractures </li></ul></ul>Method of fixation
<ul><li>Casting  -  still the commonest </li></ul><ul><li>K-wires  </li></ul><ul><ul><li>most commonly used </li></ul></ul...
<ul><li>Malunion is not usually a problem (except cubitus varus) </li></ul><ul><li>Nonunion is hardly seen (except in late...
<ul><li>Battered Baby Syndrome: </li></ul><ul><ul><li>Soft tissue injuries - bruising, burns </li></ul></ul><ul><ul><li>In...
Radiology of child abuse
Corner’s fracture (traction and rotation)
Bucket handle fracture (traction and rotation)
Pathological fracture
 
 
 
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Paediatric fracture

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Paediatric fracture

  1. 1. Prof. Muhammad Shahiduzzaman Head, Department of Orthopaedics & Traumatology Dhaka Medical College Hospital Paediatric Fracture
  2. 2. <ul><li>In Bangladesh 60% of population are <20 yrs </li></ul><ul><li>Fractures accounts for 15% of all injuries in children. </li></ul><ul><li>Different from adult fractures. </li></ul><ul><li>Vary in different age groups (Infants, children, adolescents) </li></ul>Introduction
  3. 3. <ul><li>Children have different physiology and anatomy </li></ul><ul><ul><li>Growth plate. </li></ul></ul><ul><ul><li>Bone. </li></ul></ul><ul><ul><li>Cartilage. </li></ul></ul><ul><ul><li>Periosteum. </li></ul></ul><ul><ul><li>Ligaments. </li></ul></ul><ul><ul><li>Age-related physiology </li></ul></ul>Children are very special
  4. 4. <ul><li>In infants, GP is stronger than bone. </li></ul><ul><li> increased diaphyseal fractures </li></ul><ul><li>Provides perfect remodeling power. </li></ul><ul><li>Injury of growth plate causes deformity. </li></ul><ul><li>A fracture might lead to overgrowth. </li></ul>Growth Plate
  5. 5. <ul><li>Increased collagen: bone ratio </li></ul><ul><ul><li>lowers modulus of elasticity </li></ul></ul><ul><li>Increased cancellous bone </li></ul><ul><ul><li>reduces tensile strength </li></ul></ul><ul><ul><li>reduces tendency of fracture </li></ul></ul><ul><ul><li> to propagate </li></ul></ul><ul><ul><li>less comminuted fractures </li></ul></ul><ul><li>Bone fails on both tension and </li></ul><ul><li>compression </li></ul><ul><ul><li>commonly seen “buckle” fracture </li></ul></ul>Bone
  6. 6. <ul><li>Increased ratio of cartilage to bone </li></ul><ul><ul><li>better resilience </li></ul></ul><ul><ul><li>difficult x-ray evaluation </li></ul></ul><ul><ul><li>size of articular fragment often under-estimated </li></ul></ul>Cartilage
  7. 7. <ul><li>Metabolically active </li></ul><ul><ul><li>more callus, rapid union, increased remodeling </li></ul></ul><ul><li>Thickness and strength </li></ul><ul><ul><li>Intact periosteal hinge affects fracture pattern </li></ul></ul><ul><ul><li>May aid reduction </li></ul></ul>Periosteum
  8. 8. Age related # pattern
  9. 9. <ul><li>Better blood supply, </li></ul><ul><li>so less incidence of Delayed or non-union. </li></ul>Physiology
  10. 10. <ul><li>Bones tend to BOW rather than BREAK </li></ul><ul><li>Compressive force= TORUS fracture </li></ul><ul><ul><ul><li>Aka. Buckle fracture </li></ul></ul></ul><ul><li>Force to side of bone may cause break in only one cortex= GREENSTICK fracture </li></ul><ul><ul><li>The other cortex only BENDS </li></ul></ul><ul><li>In very young children, neither cortex may break= PLASTIC DEFORMATION </li></ul>Injury Pattern
  11. 11. Green Stick Fracture
  12. 12. Torus Greenstick Green Stick Fracture
  13. 13. Plastic Deformity Injury Pattern
  14. 14. <ul><li>Point at which metaphysis connects to physis is an anatomic point of weakness </li></ul><ul><li>Ligaments and tendons are stronger than bone when young Bone is more likely to be injured with force. </li></ul><ul><li>Periosteum is biologically active in children and often stays intact with injury </li></ul><ul><ul><li>This stabilizes fracture and promotes healing. </li></ul></ul>Injury Pattern
  15. 15. <ul><li>Many childhood fractures involve the physis </li></ul><ul><ul><li>20% of all skeletal injuries in children </li></ul></ul><ul><ul><li>Can disrupt growth of bone </li></ul></ul><ul><ul><li>Injury near but not at the physis can stimulate bone to grow more </li></ul></ul>Physeal Injury
  16. 16. <ul><li>SALTER HARRIS CLASSIFICATION </li></ul><ul><ul><li>Classification system to delineate risk of growth disturbance </li></ul></ul><ul><ul><li>Higher grade fractures are more likely to cause growth disturbance </li></ul></ul><ul><ul><li>Growth disturbance can happen with ANY physeal injury </li></ul></ul><ul><ul><li>It has grade I upto grade V. </li></ul></ul>Physeal Injury
  17. 17. <ul><li>Fracture passes transversely through physis separating epiphysis from metaphysis. </li></ul>Salter Harris Grade I
  18. 19. <ul><li>Transversely through physis but exits through metaphysis </li></ul><ul><li>Triangular fragment </li></ul>Salter Harris Grade II
  19. 21. <ul><li>Crosses physis and exits through epiphysis at joint space. </li></ul>Salter Harris Grade III
  20. 24. <ul><li>Extends upwards from the joint line, through the physis and out the metaphysis. </li></ul>Salter Harris Grade IV
  21. 26. Crash Injury to growth plate Salter Harris Grade V
  22. 27. <ul><li>MOST COMMON : Salter Harris II </li></ul><ul><ul><li>Followed by I, III, IV, V </li></ul></ul><ul><ul><li>Refer to orthopedics: III, IV, V </li></ul></ul><ul><ul><li>I and II effectively managed by primary care with casting (most commonly) </li></ul></ul><ul><li>Parents should be informed that growth disturbance can happen with any physeal fracture </li></ul>Salter Harris
  23. 28. <ul><li>Tremendous power of remodeling </li></ul><ul><li>Can accept more angulation and displacement </li></ul><ul><li>Rotational mal-alignment ?does not remodel </li></ul>Power of remodeling
  24. 29. Malunion-Remodeling Process
  25. 30. <ul><li>Factors affecting remodeling potential </li></ul><ul><li>Years of remaining growth – most important factor </li></ul><ul><li>Position in the bone – the nearer to physis the better </li></ul><ul><li>Plane of motion – greatest in sagittal, the frontal, and least for transverse plane </li></ul><ul><li>Physeal status – if damaged, less potential for correction </li></ul><ul><li>Growth potential of adjacent physis </li></ul><ul><ul><li>e.g. upper humerus better than lower humerus </li></ul></ul>Power of remodeling
  26. 31. <ul><li>Children tend to heal fractures faster than adults requiring shorter immobilization time. </li></ul><ul><li>Anticipate remodeling if child has >2 yrs of growing left – mild angulation deformities often correct themselves but rotational deformities requires reduction. </li></ul>Its good to be young!!!
  27. 32. <ul><li>Fractures in children may stimulate longitudinal growth – some degree of overlap is acceptable and may even be helpful. </li></ul><ul><li>Children don’t tend to get as stiff as adults after immobilization. </li></ul>Its good to be young…
  28. 33. <ul><li>Law of Two’s : </li></ul><ul><ul><li>Two views </li></ul></ul><ul><ul><li>Two joints </li></ul></ul><ul><ul><li>Two limbs </li></ul></ul><ul><ul><li>Two occasions </li></ul></ul><ul><ul><li>Two physicians </li></ul></ul>Xray examination 2
  29. 34. Radio-capitaller line Evaluation of paediatric elbow film
  30. 35. Supracondylar Fracture of Humerus Evaluation of paediatric elbow film
  31. 36. <ul><li>Mostly conservative – closed reduction and cast immobilization </li></ul><ul><li>Open reduction & internal fixation. </li></ul>Principle of Management
  32. 37. <ul><li>Displaced intra articular fractures </li></ul><ul><ul><li>( Salter-Harris III-IV ) </li></ul></ul><ul><li>fractures with vascular injury </li></ul><ul><li>? Compartment syndrome </li></ul><ul><li>Fractures not reduced by closed reduction </li></ul><ul><ul><li>( soft tissue interposition, button-holing of periosteum ) </li></ul></ul><ul><li>If reduction can not be maintained or could be only maintained in an abnormal position </li></ul>Indication for operative management
  33. 38. Indication for operative management
  34. 39. <ul><li>Casting—the commonest. </li></ul>Method of fixation
  35. 40. <ul><li>K-wires </li></ul><ul><ul><li>most commonly used </li></ul></ul><ul><ul><li>Metaphyseal fractures </li></ul></ul>Method of fixation
  36. 41. Intramedullary wires, elastic nails Very useful, Diaphyseal fractures Method of fixation
  37. 42. <ul><li>Screws </li></ul>Method of fixation
  38. 43. <ul><li>Screws </li></ul>Method of fixation
  39. 44. <ul><li>Plates and screws </li></ul><ul><ul><li>Multiple Trauma </li></ul></ul>Method of fixation
  40. 45. <ul><li>IMN Nailing (adolescent only) </li></ul><ul><ul><li>Chances of growth disturbences. </li></ul></ul>Method of fixation
  41. 46. <ul><li>External Fixation </li></ul><ul><ul><li>In open Fractures </li></ul></ul>Method of fixation
  42. 47. <ul><li>Casting - still the commonest </li></ul><ul><li>K-wires </li></ul><ul><ul><li>most commonly used </li></ul></ul><ul><ul><li>Metaphyseal fractures </li></ul></ul><ul><li>Intramedullary wires, elastic nails </li></ul><ul><ul><li>Very useful </li></ul></ul><ul><ul><li>Diaphyseal fractures </li></ul></ul><ul><li>Screws </li></ul><ul><li>Plates – multiple trauma </li></ul><ul><li>IMN - adolescents </li></ul><ul><li>Ex-fix </li></ul>Combination Method of fixation
  43. 48. <ul><li>Malunion is not usually a problem (except cubitus varus) </li></ul><ul><li>Nonunion is hardly seen (except in lateral condyle of humerus) </li></ul><ul><li>Growth disturbance – epiphyseal damage </li></ul><ul><li>Vascular - volkmann’s ischemia </li></ul><ul><li>Infection - rare </li></ul>Complication
  44. 49. <ul><li>Battered Baby Syndrome: </li></ul><ul><ul><li>Soft tissue injuries - bruising, burns </li></ul></ul><ul><ul><li>Intra-abdominal injuries </li></ul></ul><ul><ul><li>Intracranial injuries </li></ul></ul><ul><ul><li>Delay in seeking treatment </li></ul></ul><ul><ul><li># at diff. stage of healing. </li></ul></ul>Non-accidental injury
  45. 50. Radiology of child abuse
  46. 51. Corner’s fracture (traction and rotation)
  47. 52. Bucket handle fracture (traction and rotation)
  48. 53. Pathological fracture
  49. 57. Thank You
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