Paediartic Orthapaedics PDF

Ms Kezia Brown Senior clinical lecturer Consultant orthopaedic surgeon Body in Motion MBChB The young MSK system  MBChB Body in Motion Summary Young MSK...

Ms Kezia Brown Senior clinical lecturer Consultant orthopaedic surgeon Body in Motion MBChB The young MSK system  MBChB Body in Motion Summary Young MSK The growing skeleton Paeds MSK Sports injuries  MBChB Body in Motion Young MSK The growing skeleton  MBChB Body in Motion Mechanisms of bone formation Young MSK Intramembranous ossification Osteoid laid down by osteoblasts within loose fibroconnective tissue of a fibrous membrane Endochondral ossification Osteoid deposited on cartilage scaffolds Related video: “Bone growth”  MBChB Body in Motion EO – Secondary centre of ossification Young MSK Related video: “Bone growth”  MBChB Body in Motion Cessation of skeletal growth Young MSK Related video: “Bone growth”  MBChB Body in Motion Cessation of skeletal growth Young MSK Genetics Altering factors Systemic disease Nutrition Endocrine Infection Trauma Related video: “Bone growth”  MBChB Body in Motion What is a physis Young MSK Hyaline cartilage plate at ends of long bones Responsible for growth Physis longitudinal Perichondrium Endochondral ossification Case courtesy of Dr Matt Skalski, Radiopaedia.org, rID: 29729 Related video: “The physis”  MBChB Body in Motion Microscopic structure Young MSK Resting zone Proliferative zone Hypertrophic zone Metaphyseal bone Related video: “The physis”  MBChB Body in Motion Young MSK Paeds MSK  MBChB Body in Motion Limping child - Age Distribution Young MSK Related video: “The limping child”  MBChB Body in Motion Limping child – Exclude Sepsis Young MSK Full blood count ESR, CRP X rays – AP & frog lateral Ultrasound MRI, bone scan, etc Related video: “The limping child”  MBChB Body in Motion Developmental dysplasia (DDH) Young MSK 1-5/1000 births 5 ‘F’s Female (F:M ratio 5:1) First born Feet first (breach or c-sec) Family history (hereditary influence) Fluid (oligohydramnios) Related video: “The limping child”  MBChB Body in Motion DDH examination Young MSK Barlows Ortolani Skin crease asymmetry Leg length discrepancy Reduced abduction Related video: “The limping child”  MBChB Body in Motion DDH radiographs Young MSK Related video: “The limping child”  MBChB Body in Motion DDH treatment Young MSK Related video: “The limping child”  MBChB Body in Motion Perthes disease Young MSK Osteonecrosis of femoral epiphysis Aetiology poorly understood but likely non-genetic factors Male:female ratio 4:1 4-8 years in majority Lower social class = increased risk Related video: “The limping child”  MBChB Body in Motion Perthes - Radiographs Young MSK Related video: “The limping child”  MBChB Body in Motion Slipped Upper Femoral Epiphysis Young MSK Males (3:1) 13-16 years In females younger, not after menarche Bilateral in 42% Obese or tall and slender Rapid growth 7% risk of a 2nd family member involved Related video: “The limping child”  MBChB Body in Motion SUFE - Radiographs Young MSK Related video: “The limping child”  MBChB Body in Motion SUFE – Clinical Young MSK Acute / Chronic / Acute on Chronic Pain groin, thigh, knee Limp Antalgic gait Externally rotated and adducted limb Related video: “The limping child”  MBChB Body in Motion SUFE - Treatment Young MSK Related video: “The limping child”  MBChB Body in Motion Red flags Young MSK Neonate with painful paralysed SEPTIC looking arm or leg ARTHRITIS/INFECTION Asymmetry of spine or limbs SCOLIOSIS/DDH PERTHES DISEASE School age child with limp SUFE OR TUMOUR Knee pain in adolescent DISCITIS Back pain Non accidental injury Related video: “The limping child”  MBChB Body in Motion NAI - High index of suspicion Young MSK Injury in the non-ambulatory/totally dependant child Injury and history given are inconsistent Delay in seeking medical attention Multiple fractures with no family history of osteogenesis imperfecta Retinal haemorrhage Torn frenulum History of household falls resulting in fracture despite falls being common, fractures are uncommon Related video: “Non-accidental injury”  MBChB Body in Motion Young MSK Paeds MSK trauma  MBChB Body in Motion Plasticity/elasticity Young MSK Less rigid Plastic deformity Incomplete fractures Greenstick (tension) ‘Buckle’ or torus (compression) Related video: “Paeds trauma”  MBChB Body in Motion Plasticity/elasticity Young MSK Less rigid Plastic deformity Incomplete fractures compression tension Greenstick (tension) ‘Buckle’ or torus (compression) Related video: “Paeds trauma”  MBChB Body in Motion Plasticity/elasticity Young MSK Less rigid Plastic deformity Incomplete fractures Greenstick (tension) ‘Buckle’ or torus (compression) Related video: “Paeds trauma”  MBChB Body in Motion Plasticity/elasticity Young MSK Less rigid Plastic deformity Incomplete fractures Greenstick (tension) ‘Buckle’ or torus (compression) Related video: “Paeds trauma”  MBChB Body in Motion Plasticity/elasticity Young MSK Less rigid Plastic deformity Incomplete fractures Greenstick (tension) ‘Buckle’ or torus (compression) Related video: “Paeds trauma”  MBChB Body in Motion Remodelling Young MSK Greatest potential Young age When near a joint Deformity is in same plane as joint Wolf’s law Bone deposited on compression side Bone absorbed on tension side Related video: “Paeds trauma”  MBChB Body in Motion Physeal considerations Young MSK What is a growth plate? Allows longitudinal growth Fuse at around 14-16 Why is a fracture here important? Risk of growth problems Partial or complete arrest +/- articular involvement Related video: “Paeds trauma”  MBChB Body in Motion Salter-Harris classification Young MSK Illustration courtesy of Dr Matt Skalski, Radiopaedia.org, rID: 27144 Related video: “Paeds trauma”  MBChB Body in Motion Growth deformities Young MSK Related video: “Paeds trauma”  MBChB Body in Motion Growth deformities Young MSK Related video: “Paeds trauma”  MBChB Body in Motion Paediatric fractures Young MSK Very different management to adults Good news Thick periosteum aids conservative management Ability to remodel with time and limb growth Heal rapidly Non-union very rare Less morbidity with bed rest vs adult population Bad news Physeal plate injuries before skeletal maturity can cause growth abnormalities and arrests Can be difficult to diagnose Related video: “Paeds trauma”  MBChB Body in Motion Manipulation under anaesthetic Young MSK Related video: “Paeds trauma”  MBChB Body in Motion K-wires and flexible nails Young MSK Related video: “Paeds trauma”  MBChB Body in Motion Bed traction Young MSK Related video: “Paeds trauma”  MBChB Body in Motion Young MSK Sports injuries  MBChB Body in Motion Types of injury Young MSK Acute traumatic Bruising, cuts, abrasions Head injuries Cartilage/meniscal injuries Muscle/tendon/ligament injuries Dislocations Fractures Related video: “Sports injuries intro”  MBChB Body in Motion Types of injury Young MSK Acute traumatic Bruising, cuts, abrasions Head injuries Cartilage/meniscal injuries Muscle/tendon/ligament injuries Dislocations Fractures Related video: “Sports injuries intro”  MBChB Body in Motion Types of injury Young MSK Acute traumatic Chronic overuse Bruising, cuts, abrasions Tendonitis Head injuries Stress fractures Cartilage/meniscal injuries Back pain Muscle/tendon/ligament injuries Dislocations Instability Fractures Related video: “Sports injuries intro”  MBChB Body in Motion Preventing injury Young MSK Causes Prevention Conditioning Improve fitness Technique Gradual build up Equipment Warm up/warm down Anatomy Train correctly Luck Get the right equipment Avoid overstressing Related video: “Sports injuries intro” Mr Mark Gaston Consultant orthopaedic surgeon Royal Hospital for Sick Children, Edinburgh Body in Motion MBChB The limping child  Body in Motion Tutorial content MBChB Limping child Gait in children Transient synovitis DDH Perthe’s disease SUFE Red flags Infection Discitis Malignancy  Body in Motion MBChB The limping child Limping child Common presentation in paediatric orthopaedics Often atraumatic Incidence 180 / 100,000  Body in Motion MBChB Normal Gait in Children Limping child Early Walking Short Stride length Fast cadence Low Velocity Widened base of support Until 30-36 months – poor balance and abductor strength so cannot maintain single leg stance Mature gait age 7 THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB Abnormal Gait Limping child Pain Mechanical problem Neuromuscular problem THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB Age Distribution Limping child THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB History – Pain characteristics Limping child Acute – trauma, infection Constant - malignancy, chronic infection Morning pain / pain after inactivity – Inflammatory joint disorders Night Pain Malignancy, osteoid osteoma, Benign “growing pains” THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB Examination Limping child Gait Spine Asymmetry Deformity Swelling Tenderness Examine all joints Rotational profile THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion Irritable Hip (Transient Synovitis) MBChB Limping child Non-specific, short term inflammatory synovitis with synovial effusion of the hip joint THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB Transient Synovitis - clinical Limping child Painful hip / thigh / knee Often associated with viral infection Synovial fluid effusion Hip held in flexion, lateral rotation and abduction Exclusion of other conditions THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB Investigations – Exclude Sepsis Limping child Full blood count ESR, CRP X rays – AP & frog lateral Ultrasound MRI, bone scan, etc THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB Developmental Dysplasia (DDH) Limping child 1-5/1000 births Hereditary Influence Breach after 32 weeks or Caesarian 1st Born Oligohydramnios Female : male 5:1 THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB DDH - Examination Limping child Barlows Ortolani Skin crease asymmetry Leg length discrepancy Reduced abduction THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB DDH - Radiographs Limping child THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB DDH – Treatment as infant Limping child THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB DDH – Treatment as infant + Limping child THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB Perthes Disease Limping child Osteonecrosis of femoral epiphysis caused by poorly understood non-genetic factors Boys > Girls 4:1 4-8 years in majority Lower social class increased risk THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion Perthes - Radiographs MBChB Limping child THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB Perthes - Treatment Limping child Principles are prevention of stiffness contain femoral head in acetabulum surgical treatment required in certain circumstances outcome depends on how well femoral head remodels THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB Perthes - Treatment Limping child THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB Slipped Upper Femoral Epiphysis Limping child Males (3:1) 13-16 years In females younger, not after menarche Bilateral in 42% Obese or tall and slender Rapid growth 7% risk of a 2nd family member involved THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion SUFE - Radiographs MBChB Limping child  Body in Motion MBChB SUFE – Clinical Limping child Acute / Chronic / Acute on Chronic Pain groin, thigh, knee Limp Antalgic gait Externally rotated and adducted limb  Body in Motion SUFE - Treatment MBChB Limping child THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB Red flags Limping child Neonate with painful paralysed SEPTIC ARTHRITIS / looking arm or leg INFECTION Asymmetry of spine or limbs SCOLIOSIS/DDH PERTHES DISEASE School age child with limp SUFE OR TUMOUR Knee pain in adolescent DISCITIS Back pain Non accidental injury THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB Infection Limping child Cellulitis Osteomyelitis Septic arthritis Usually requires emergent referral for investigation +/- aspiration THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB Discitis Limping child Presentation can be subtle MRI usually required Epidural abscess is surgical emergency THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB Swellings Limping child Beware of atraumatic, painless swellings THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB Swellings Limping child Beware of atraumatic, painless swellings THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB Swellings Limping child Beware of atraumatic, painless swellings THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion MBChB Non accidental injury Limping child What should raise suspicion? Pre-existing disability Vague history from parents Injury inconsistent with history Delay in presentation Multiple bruises of varying age Multiple fractures Burns THE LIMPING CHILD | GAIT PRESENTATION SYNOVITIS DDH PERTHES SUFE RED FLAGS  Body in Motion Tutorial content MBChB Limping child Gait in children Transient synovitis DDH Perthe’s disease SUFE Red flags Infection Discitis Malignancy Welcome to the lecture on non-accidental injury in the paediatric population. 1 In this lecture we will discuss the epidemiology of NAI, talk about some of the injuries that children could sustain, some susceptible conditions that make them more likely to have injuries, and talk about the role of doctors in NAI cases. 2 Although non-accidental injury is relatively uncommon, with an incidence of around 4 cases per 10k children, A 2001 study in the united states estimated that there are around 903k children per year who are victims of maltreatment. Neglect is the most common maltreatment, accounting for just under 60% of cases, but physical abuse is found in around 20% of cases with soft tissue injuries being the most common. 3 Non-accidental injury is the second most common cause of death in children, after accidental injury, and has some sobering statistics associated with it. If the abuse goes unreported, there is a 30-50% chance of further abuse and a 10% chance the child will die from subsequent injury. This means it is imperitive that healthcare professionals have a high index of suspicion for abuse in paediatric trauma. There are a few risk factors that, although in no way guarantee it, increase a child’s likelihood of suffering abuse. We should therefor be careful to keep risk factors in mind but remain non-judgemental when assessing a child with injuries. There are also subtleties to understand with each risk-factor, for example a child with a disability may not be able to communicate fully, akin to a child of a much younger age. 4 As previously mentioned, soft tissue injuries account for the majority of NAIs. Young children are clumsy and lack many of the self-preservation instincts of most adults, as anyone with kids will agree, so are highly susceptible to accidental injury. There are patterns of injury, however, that can help to differentiate a genuine accident from a abusive one. It’s rare for children younger than 18 months to suffer head or facial injuries but they are present in around 60% of NAI cases. Young children who are learning to walk or run can suffer multiple bruises of different ages to their hand, feet and legs due to simple trips and falls. These need to be assessed on an individual basis to look for other worrying signs, which we’ll come back to later on. We’ll now look at a few injuries which are difficult to sustain accidentally and strongly suggest abuse. Some of the images in the next five slides can be distressing so you may wish to listen to the audio alone. 5 Human bitemarks have a characteristic appearance to them and can cause significant pain to a child, with a risk of infection higher than animal bites. The dimensions of bitemark can be used to estimate the size of the person who bit the child. This is important as it is not uncommon for young children to bite classmates in nursery if upset and therefor may be a true accident. Adult bitemarks or multiple injuries, as shown in the image on the left, should be investigated fully. 6 Again, children may suffer burns from true accidents, such as pulling a cup of hot coffee over themselves or touching a lit stove. Many burns have characteristic appearances, such as this cigarette burn or this lighter burn. This 9 month old was held down on the hot plastic of a buggy which had been heated by the sun. He suffered burns over the backs of his calves and required skin grafting. Neglect can also cause injury, as demonstrated by this young boy who was left outside in direct sun without suncream or a shirt. 7 Specific patterns of bruising can be pathognomic of NAI, such as the facial bruising shown here. Grip marks either side of the mouth from force feeding can be seen as a round thumb imprint on one cheek with 3 or 4 finger-tip bruises on the other. Careful examination for intra-oral injuries can often find a torn frenulum, which is the small bridge of tissue from the top lip to the gums. After the initial redness has faded following a slap, petechial bruising, which is small red spots from ruptures blood vessels, appears in a pattern between the fingers of the assailant, as illustrated here. 8 These clinical pictures show some injuries from corporal punishment of children. The child on the left has been spanked with great force, leaving a typical pattern of bruising. You can see how the finger marks are white, with the red areas between the fingers. The child on the right has been punished by repeated blows with a belt, leaving long straight-edged bruises across the buttocks. 9 Bruising can also be a sign of more significant injury, especially when around the abdomen. This infant was punched repeatedly in the abdomen, causing multiple bruises and a liver laceration, as shown in the CT scan. 10 Although soft tissue injuries are most common, fractures account for a significant percentage of injuries. A historical paper from Nottingham looked at fracture incidence by age, comparing accidental to non-accidental injuries. 11 This paper found that 80% of NAI cases occur in children younger than 18 months, while only 2 and half% of accidental injuries occur in the same age group. Children older than 18 months have a much lower annual incidence of NAI but a higher incidence of accidental injury, when compared to the younger age group. 12 The paper also found that children who suffer from non-accidental injuries are also significantly more likely to have multiple injuries, including burns and bruises to multiple areas. 13 We’ll now look at the fractures that are most likely to be due to NAI and can often be viewed as pathognomic. A small fracture as the corner of a bone’s metaphysis, as shown here, is indicative of forceful shaking. As a child’s trunk is shaken back and forth, the limbs move back and forth rapidly with a resultant whiplash or shear force. Multiple microfractures across the metaphysis, with an orientation perpendicular to the long axis of the bone, occur in the immature mineralised bone. These can be very subtle and need careful examination of radiographs. They are the most specific fracture for NAI and occur in around 50% of NAI cases. They occur almost exclusively in children younger than 2, as they are small enough to be picked up to shake and don’t have the muscle tone to protect their own limbs. 14 Rib fractures are also very common in NAI, present in around 50% of cases and often diagnosed by skeletal survey. Multiple posterior rib fractures in particular, as shown here, are highly suspicious that a child has been crushed while being shaken. 15 Although femoral fractures are reasonably common as an accidental injury, they are less common in younger children. Below the age of 3, around 30% of femur fractures are due to NAI and this climbs to almost 100% in children who are non-ambulatory, ie those who are not walking yet. A femur fracture in a non-ambulatory child can still occur by accident, for example by rolling off a nappy-changing table, but should be viewed a NAI until proved otherwise. 16 There are a number of conditions that increase the likelihood of a child to sustain bony injuries which can be a source of great distress to parents who, until diagnosis, are viewed with suspicion of NAI. Osteogenesis imperfecta, known as brittle bone disease to the public, is a group of genetic disorders that lead to defects in type 1 collagen. This gives them extremely fragile bones that are highly susceptible to fracture from very minor trauma. They may have several fractures already by their first birthday and can be easily misattributed to abuse, until a diagnosis is made. Careful consideration is needed here as, due to the risk factors mentioned previously, they may still be vulnerable to abuse. 17 Other susceptible conditions include prematurity and copper deficiency which further complicate assessment due to the former being an independent risk factor for NAI and the latter possibly due to neglect. 18 As doctors, we have a duty to be aware of the problem and how prevalent it is in society. We should be able to recognise unusual injury patterns and know our local guideline for initiating investigation, including liaison with child protection services. 19 We must have a high-index of suspicion when assessing a child with a traumatic injury and even in cases when children present with other non-trauma related conditions. For example, a child who presents with a chest infection may be found to be a victim of abuse when bruises are identified on his abdomen during chest exam. This slide lists a number of features that are highly suspicious for NAI and can be read at your leisure. 20 This final slide is an excellent infographic from the British Dental Association, summarising normal injury patterns on the left, and NAI patterns on the right. 21 Non accidental injury is a distressing presentation that all doctors should be vigilant about. A fine balance is needed to avoid causing unnecessary distress to parents in the absence of abuse but a child’s safety takes priority over this at all times and it’s often better to err on the side of caution. The majority of caring parents will not be upset about procedures to rule out NAI and are often thankful that staff are actively looking out for it. If you would like to read more about NAI, there are links to relevant content below. 22 1 2 The specialty of orthopaedics gets it’s name from the ancient Greek words orthos meaning straight and paedia meaning child, combined in the word orthopaedia. An orthopods goal when managing paediatric fractures and growth deformities is to allow normal skeletal growth and make bones grow straight, although this simplifies things a bit as we like bendy bones to be bendy if they are meant to be. 3 As we’ve already found, kids bones have quite a few important differences to adult bones, including the overall number of bones, which is greater than an adult skeleton when a number of separate bones, for example the illium ischium and pubis, fuse together at the end of adolescent growth to form a single bone, in this example the pelvis. The most obvious difference when looking at a child’s bone on a radiograph is the presence of open physes, which appear as darker lines, and ossicifaction centres, which usually appear as lighter circular areas, both in predictable places depending on the age of the child. 4 Adult bones are rigid and brittle, meaning that when they suffer trauma they can withstand a lot of force but when they fail it is usually in a sudden, catastrophic way. That is the bone breaks completely or even shatters in many bits. You can think of this a bit like breaking a stick of chalk – it suddenly snaps into 2 pieces without any visible bending before it fails. Kids bones on the other hand, have much more elasticity to them, meaning they can bend a little bit then spring back into the position they were in. They also demonstrate considerable plasticity, which is a mechanical property meaning the bone changes shape permanently, ie doesn’t go back to it’s original shape, but doesn’t break into separate bits. You can see a combination of plasticity and elasticity if you bend a paper clip. The metal doesn’t break and it springs back a little bit but not to the same shape it started as. 5 These mechanical properties mean that paediatric fractures have different patterns to adult ones, which we’ll discuss in the trauma videos. The image on the right shows a long bone, for example a radius, with a bending force applied to the top of it. The cortices of the bone experience different forces depending on their orientation to the force. The bone on one side, shown in red, is pulled apart when the bone is bent, meaning it is under tension. The bone on the other side, shown in blue, is forced together and hence is under compression. This leads to different fracture patterns occurring due to the different forces. 6 On the tension side, the bone is pulled apart so much that it can’t hold together and a crack forms. If the force isn’t too great, this crack will only go part way across the bone, ie it is an incomplete fracture, and is known as a greenstick fracture. This name comes from young tree branches, which demonstrate similar incomplete breakages as they are more flexible than larger, more mature branches. 7 On the compression side, the bone is squashed together and, when the force the gets too great, buckles under the pressure and bulges out to the side forming a visible ridge on a radiograph. 8 These 2 different patterns can be seen in a single bone, for example a humerus, or on 2 bones that experience the same bending force. This radiograph shows a radius failing under tension with a buckle fracture highlighted in blue, and an ulna failing under tension, showing a greenstick fracture highlighted in red. Here’s a zoomed view of both fractures. 9 Another major difference between kids bones an adult bones is that the periosteal that covers the surface of the diaphysis is much thicker. It's a bit like a leathery coating on the surface. 10 This has clinical implications as it's much easier to reduce a fracture in children When the bone breaks and the periosteum remains intact that the bones generally don't displace as much and when trying to reduce it the periosteum can act like a hinge so that the bone goes back into him more anatomical position 11 Kids bones have a huge potential for remodelling that is correcting deformity in the bone as it grows. The greatest potential for remodelling happens with young age mainly because the child has a lot of growth left and before their fisies fuse and therefore a lot more time before a lot more time through the growth correction to occur 12 Other factors that affect at the potential for remodelling our how close the fracture is to a joint so the closer it is to a joint the greater potential for remodelling and also the plane of the fracture so if the fracture occurs in the same plane as the movement of the joints so here we've got a diagram that perhaps representing a wrist 13 if the fracture breaks and the angulation of it is in the plane of movements reflection extension of the wrist and it's much more likely to remodel completely 14 We've already found out about wolff's law during the bone Physiology videos but it's worth mentioning again here because this remodelling potential that relies on wolf's law. You remember that wolf's law states that bone remodels according to mechanical stresses placed upon it 15 in this case when a fracture happens and there's a residual angular angular deformity like here , bone will be deposited on the compression side cause that's where most of the mechanical forces going through as it's loaded For example by load bearing in a limb. On the side of the bone that's under tension where least forces are going through it that bone will be resourcd sorry absorbed 16 This means that overtime a quite markedly angulated deformity can straighten out to the extent that it's difficult to tell that there ever was a deformity to begin with. 17 Importantly, because rotational movement doesn’t put much force through the bone at the fracture, there is no potential for remodelling rotational deformities. 18 Here we've got some examples of the remodelling potential of paediatric bones on the left. The first series of images show the tibial shaft fracture assertable Darcy or fracture with the fool tibia and view on the left and zoomed in views of it on the right the trio of images in each section show the time of fracture followed by about six months later and then a year down the line. You can see that with 100% displaced fracture of the tibial shaft in this child who I think was around 5:00 or six years old this has healed completely by six months or there's a bone going right the way across the 19 fracture and it's united and then by a year down the line that quite marked deformity and displacement has been remodelled successfully and restored the and is on its way to restoring the medullary canal 19 Similarly in this image sorry in this set of images of a paediatric femoral fracture we can see again another 100% displaced fracture that's also short By around three months the bone is uniting that's in the second image and in the third image the bonus fully united and is well on its way to uniting at into is well on its way too remodelling into a street femur 20 This last clinical example of remodelling she is a really very displaced distal radius fracture this is a lateral view here with the joint of the wrist at the top of the screen showing that the fracture has displaced 100% and that has shortened and in the final image of this the bone has remodelled very nicely, helped along by the fact that the deformities in the plane of the joint ie the flexion extension access of the wrist 21 A final and possibly the most important differences between paediatric and adult fractures is the fact that children have fisies as we've mentioned. Just two beat the reinforce the concept once again the faces of the part of the bone that allow longtitudinal growth and they usually fuse at the age of 14 and females and 16 in males. 22 So what is fracture surprise fracture here so important. Well there's two main reasons one is that there's the risk of growth problems as we'll see in a moment and the other is that because the price is right next to the joint surface any articular involvement so we call these intra articular fractures will lead to a step in the articular surface. If we don't address this step in the articular surface then it can very quickly lead to damage to the cartilage of the other side of the joint and post traumatic arthritis. 23 We're lucky that we have a very useful classification system in the Salter Harris classification system which describes these fractures based on the pattern around devices it's very useful because it gives us a very definite management plan depending on the grade of the injury that which is something that can be said for all trauma classification systems. It can be remembered by the mnemonic SA ltr or which witch is Salter of the Salter Harris classification and when you're doing this it's easiest to orientate the bone in your mind with the articular surface at the bottom Because we start to refer 24 to the fractures as being above or lower than the devices 24 Type one sorta Harris fractures are the S4 street and that the fracture line goes straight across the vicis these fractures can be quite difficult to diagnose especially if they're completely undisplaced as there's really no evidence that the fracture has been there apart from perhaps some soft tissue swelling around them that this is because the fracture doesn't actually involve any the bone itself and merely goes through the cartilage of the vice itself at. The are the their fractures with a very good prognosis and they are the least likely head of growth abnormality at. Most of these fractures can be treated 25 that conservatively with closed reduction he putting the bone back into place if it's displaced and immobilisation with a cast. Some of these injuries are a bit more severe Some of these injuries have a bit more severe displacement and if they can't be reduced closed then they may need open reduction that is with a surgical incision and fixation usually with wires holding them into place coz they're not unstable when they're reduced. 25 Type 2 fractures are known as a for above in the fracture line exits above the fisis into the metaphysis and they have a wedge of metaphysis still attached to the epiphyseal fragment the most common Salter Harris fracture accounting for probably around 70% of cases and they have a low chance of growth arrest. Treatment again is often with closed reduction and casting and but some of these can be quite unstable or difficult to reduce and they require surgery to open reduce and then fix them with usually a wire across the fracture if they are deemed to be unstable 26 Type 3 fractures or the first of the intra articular type fractures are either the fracture line exits into the joint itself and therefore we need to be worried about a particular step at the fracture line goes out below the fisis so it's L for lower and they have an epiphany or fragment these ones have a chance of growth deformity and therefore need on an atomic reduction with surgery and then monitoring afterwards for growth deformity meline newlight The growth deformity here occurs when the fisis there's been disrupted shown here by the red bar that confuse 27 and I close if it's not reduced properly or if the injuries being particularly severe and this leads to an asymmetric growth where the growth is tethered at the portion that's that's fused and runs away with greater growth the further from that few section you get. You'll see a clinical example of this in a moment. The other intra articular 27 The other intra articular type of fracture is the type 4 furniture which is T for through as the fracture passes through the vice itself With a combined metaphyseal and epiphyseal fragment. Again this Inter articular nature means that the fracture needs to be anatomically reduced and the patient needs to be monitored for a growth deformity as that's reasonably common with this type of injury. Like the sorter Harris 3 the growth deformity happens when the injured area that can be fused leading to growth both on the remaining at metaphyses opificio fragment and the rest of the normal 28 bone shown here 28 The final type in the Salter Harris classification is the ruined typographer ruin which is a crush injury to fisis. This can happen with a fall from height onto the. This has by far the worst prognosis of all of the grades because it often leads to complete growth arrest at the vicis the younger the patient is when they have this injury the worst the prognosis then because the other limb will grow at the normal rate whereas the injured limb that will have a significantly reduced growth. Because of this the treatment for a type 5 is to monitor the growth arrested for occurs and plan epiphyseal thesis which is Fusion of the same vices in the 29 contralateral limb at a point in future to prevent a significant leg length discrepancy 29 This slide summarises all the different types with norm on the top left type one which is straight across across the fisis tattoos above the vices type 3 is lower than the fisis witches into articular type 4 is through the vicis which is Inter ticular as well and type 5 is the crush injury ruined injury to the the fisis which has the worst prognosis due to complete growth arrest. 30 Speaking of growth arrest and deformity here we've got an example of a distal tibial Salter Harris for fracture you can see the fracture lines still on the radiograph here outlined in red and the faces on the medial ankle had fused leaving the fisis laterally in the tibia and the uninjured part which is shown in green to continue growing this has led to an angular deformity and you can see this quite clearly by drawing a line parallel to the ground which is where the talus should be aligned with and actually it's around 15 to 20 degrees in a varus angulation 31 On the right you can see an example of a complete growth the rest of the distal femoral fisis shown and the redline here and this has led to a very significant leg length discrepancy I'm probably around there 5 to 10 centimetres in this five year old girl. This would have been a delayed presentation becausr certainly as an orthopaedic surgeon this would have been hopefully picked up sooner. The treatment for this girl will likely involve Fusion of the controversial fisis and possibly a leg lengthening procedure. 32 So to summarise about paediatric fractures in general their management is very different different 2 adult fractures. The good news about paediatric paediatric fractures is that they have a thick Perry Perry ostium that aids conservative management they have an ability to remodel with time unlim growth. They also heal much quicker then adults for the same fracture patterns. For example a one year old who has a femoral fracture may heal fully in a matter of weeks whereas an adult may take months for the fracture to Unite this means that not only is nonunion very rare and kids but were able to 33 treat fractures with bed rest and traction there for a couple of weeks where we'd have to use traction for three months in an adult. An added benefit in kids is that they don't tend to get as much morbidity with bed rest and immobilistaion as adilts so they don't get joint stiffness and muscle atrophy as much and don't experience the significant sequalae of immobilisation that such as pulmonary emboli pneumonia and bed sores. 33 The bad news about that paediatric fractures is that facial injuries before the child is skeletally mature can cause quite significant growth of abnormalities and arrests meaning care needs to be given to treat these correctly. 34 As clinicians paediatric fractures can be sometimes difficult to diagnose due to the presence of faeces and ossification centres. It's quite common for inexperienced clinicians to diagnose a fracture on a radiograph by not recognising a completely normal physis or ossification centre. For this reason there's often robust safety net set up in hospitales with expert laid trauma triage clinics or on site radiology reports that can advise on ambiguous diagnoses. 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49