5 pediatric #
DESCRIPTION
Basic Orthopedic for M.B.B.S. students Classification Management comlicationsTRANSCRIPT
![Page 1: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/1.jpg)
Fractures in ChildrenProf. Dr. Shrikant GoreDept. of Orthopaedics
G.M.C. Latur
![Page 2: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/2.jpg)
The Bones
Soft & Malleable -Bowing, Greenstick Growing - Physis & Epiphysis Growth
disturbanceThick periosteum - Intraperiosteal
Fractures Less - displacement & Compound Remodeling - in the direction of
movements poor in rotational & Varus -Valgus
![Page 3: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/3.jpg)
Physeal Injuries
30% of childhood fractures
Upper/Lower extremity ratio 2 : 1
Relative radiolucency difficult to diagnose underestimation of displacement
Extension of fracture in joint common
Growth disturbance & secondary arthritis common
![Page 4: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/4.jpg)
Salter-Harris classification
Type-1 Epiphyseal Separation
Type-2 Epiphyseal Separation with metaphyseal spike
Type-3 Epiphyseal Separation with fracture of epiphysis
Type-4 fracture through Metaphysis Physis Epiphysis entering in joint
Type-5 Compression if physis
Type-6 Peripheral contusion
![Page 5: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/5.jpg)
Salter-Harris classification1,2,3—4,5,6
![Page 6: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/6.jpg)
Treatment
Closed reduction under anesthesia & immobilization in plaster
cast
Manipulation should be gentle not multiple times to avoid
injury to physis & growth disturbance
As remodeling has its limitations open reduction & int. fixation is needed in certain cases when satisfactory reduction & stabilization is either not possible or failed
![Page 7: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/7.jpg)
Surgery- Gen. principlesExposure
Minimal exposure
Minimal soft tissue & periosteal stripping
Gentle handling of soft immature bone & physis
Anatomical closure of wound
![Page 8: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/8.jpg)
Surgery- Gen. principlesImplant
Fixation
Adequate
Easily removable
Smooth rather than threaded implants
implant not to cross epiphysis
![Page 9: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/9.jpg)
Complications
Bony bridge
AVN
Deformity - angular, rotational
Growth disturbance
Infection
![Page 10: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/10.jpg)
Functional Loss
More if deformity is Varus, Extension, distally
placed in both extremities length discrepancy In lower
extremity-
Progressive if associated with injury to
epi-physis resulting in late progressive deformity with growth even if immediate results are satisfactory
![Page 11: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/11.jpg)
S/C # Humerus
Age 5 to 10 yrs Sex Male
Thin flat bone- Three dimensional displacement * Difficult X-ray reading varus/valgus &
rotational displacement Pre & post reduction * Unstable reduction tendency to
re displace * Sharp spike at proximal fragment – * Buttonholing in Brachialis muscle - skin - Compound #
Close vicinity of- Radial, Ulnar, Median nerves & Brachial artery - Prone to neuro - vascular
injuries
![Page 12: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/12.jpg)
S/C # Humerus
Large hematoma – edema – massive swelling skin vascularity – Blebs
Vascular compression – Compartment syndrome - VIC
Proximity to epiphyseal plate -Growth disturbance
Proximity to joint -deformity, stiffness
Massive displacement -periosteal stripping –Myositis ossificanse
![Page 13: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/13.jpg)
S/C # HumerusMechanism of injury
Posterior tilt
Posterior displacement
Proximal displacement
Lateral or medial displacement
Rotation pronation or supination
![Page 14: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/14.jpg)
DisplacementsGrade
1 Un displaced
2 Displaced with intact post cortex
3 Displaced with loss of contact
![Page 15: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/15.jpg)
Clinical features
Age 3 to 10 years Sex Male
Pain, Swelling, Deformity around elbow following H/O fall
Swelling, Deformity around elbow maintaining three point relation, shortening of arm
May be associated with neurovascular complication
![Page 16: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/16.jpg)
Clinical
![Page 17: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/17.jpg)
Investigations
X-Ray elbow AP/LAT view
Pre anesthesia assessment investigations
Color Doppler Vascular integrity
Nerve conduction Integrity of nerves
Intra compartmental Pressure measurement
MRI Compression injury
![Page 18: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/18.jpg)
– X-Ray AP
![Page 19: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/19.jpg)
X-ray- lateral
![Page 20: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/20.jpg)
Radiological Tips
Move C-arm not the limb while taking AP/Lat Xray
Crescent sign Medial or lateral tilt
Unequal width of fragments Rotational malposition
Ant. spike on lat. X-ray Rotational malposition
Baumann angle - (Long axis of humerus with lat. Condylar epiphysis)
Average 72 degree (64 to 81) Better assessed by comparing with normal
![Page 21: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/21.jpg)
Crescent sign
![Page 22: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/22.jpg)
Crescent sign
![Page 23: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/23.jpg)
Baumann’s angle
![Page 24: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/24.jpg)
Neurovascular
Brachial artery Radial pulse, nail bed circulation
Skin Blebs
Compartment Finger movements, stretch sign compartmental tenseness
Radial nerve Wrist drop
Median nerve pointing finger
Ulnar nerveulnar claw
![Page 25: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/25.jpg)
Swelling, edema, eccimosis
![Page 26: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/26.jpg)
Management
Gentle CR under anesthesia under radiological control & immobilization in plaster slab
Gentle CR under anesthesia under radiological control & Stabilization by closed pining
Open reduction & internal fixation
Perfect anatomical reduction is essential to avoid deformity
![Page 27: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/27.jpg)
Closed reduction
Supine position
General anesthesia Avoid Ketamine
Correction of rotation - Reversal of pronation/supination
Correction of lat. Shift – gentle push by palm
Correction of over riding - Traction in 30degree elbow flection
Correction of post. Shift -pushing with thumbs
![Page 28: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/28.jpg)
Closed reduction
Correction of post. Angulation – flexing the elbow
Pronation to prevent varus tilt
Check distal circulation- Radial pulse & nail bed
Radiograph AP & Lat. View by moving the C-arm not the limb if red. Not satisfactory manipulation repeated not more than twice
AE slab in maximum flexion after conforming anatomical reduction in both views
![Page 29: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/29.jpg)
ComplicationsEarly
Injury to Brachial artery
Injury to Radial, Median, Ulnar nerves
Massive swelling & edema - Skin blebs, Vascular compression, Compartment syndrome
Button holing of proximal fragment in Brachialis muscle soft tissue interposition & injury to skin –skin necrosis
![Page 30: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/30.jpg)
Management of vascular complication
Immediate release of encircling bandage
Extension of elbow
Color Doppler
Dunlop Traction
Vascular repair
Decompression - faciotomy
![Page 31: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/31.jpg)
Post Op Care
Post operative elevation
Watch for Distal edema, Nail bed circulation Finger movements, Stretch test, pain
Check x-ray 3rd & 7th day ? Re displacement
Active movements of fingers encouraged
Removal of slab at 4 weeks
![Page 32: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/32.jpg)
Mobilization
Active exercises to develop muscles of arm, forearm, shoulder & hand - static exercises
Smooth, repeated, continuous, Active stretching within limit of pain - dynamic exercises avoiding jerky movements
Takes few weeks to months for complete recovery
![Page 33: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/33.jpg)
ComplicationsIntermediate
Vascular compression due to flexion position tight bandage & edema
Compartment syndrome
Nerve entrapment during reduction Nerve compression due
to edema, positioning, tight bandaging
![Page 34: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/34.jpg)
![Page 35: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/35.jpg)
ComplicationsLate
Mal union Cubitus varus
Myositis ossificanse - Massage, vigorous jerky mobilization
Progressive deformity due to epiphyseal damage
Volkmann's ischemic contracture - Undiagnosed compartment syndrome
![Page 36: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/36.jpg)
![Page 37: 5 pediatric #](https://reader031.vdocuments.site/reader031/viewer/2022012922/556485eed8b42a8c5e8b5689/html5/thumbnails/37.jpg)
Cubitus varus