PAEDS FRACTURE ARTICULAR CARTILAGE

1. Paediatrics fracture
1. Physeal injury
2. Supracondylar of humerus
fracture
3. Paediatric abuse
SALMIAH BAHRI

2. Anatomical difference (Children vs adult
bone)
• The long bone in a child is
divided into four regions: the
diaphysis, metaphysis, physis
and the epiphysis.
• In the adult, only the metaphysis
and diaphysis are present
https://www.rch.org.au/fracture-education/anatomy/Anatomic_differences_child_vs_adult/

3. Biomechanical difference between adult &
child
• The osteoid density of a child's
bone is less than an adult's.
• Juvenile bone is more porous
than adult bone because the
Haversian canals occupy a much
greater part of the bone
• This is the principal reason a
child's bone can bend more than
an adult's bone.
https://www.rch.org.au/fracture-
education/biomechanics/Biomechanical_differences_between_adult_and_child/

4. Fracture pattern in children
• The ability to bend before breaking leads to unique
fracture patterns in children such as:
• Buckle injury
• Greenstick injury
• Plastic bowing

5. Buckle injury
• Failure of a child's bone in
compression results in a
"buckle" injury, also known as a
"torus" injury.
• Most commonly occur in the
distal metaphysis, where
porosity is greatest
https://www.rch.org.au/fracture-
education/biomechanics/Biomechanical_differences_between_adult_and_child/

6. Greenstick deformity
• A greenstick fracture occurs
when there is sufficient energy
to start a fracture but
insufficient energy to complete
it.
• The cortex fails on the tension
side and the cortex on the
compression side bends but
remains intact.
https://www.rch.org.au/fracture-
education/biomechanics/Biomechanical_differences_between_adult_and_child/

7. Plastic bowing
• Long bones may bend without breaking
the cortex.
• Children's bones can be bent to 45
degrees before the cortex is disrupted
and a greenstick or a complete fracture
occurs.
• If the bending force is released the bone
may only partially return to its pre-bent
position-> plastic bowing.
• Most commonly affected:ulna and fibula.
https://www.rch.org.au/fracture-education/biomechanics/Biomechanical_differences_between_adult_and_child/

8. Physeal injury
• The key difference between the child's bone and that of an
adult is the presence of a physis.
• Physeal injuries are very common in children, making up 15-
30% of all bony injuries.
• The growth plate, or physis, is the translucent, cartilaginous disc
separating the epiphysis from the metaphysis and is responsible
for longitudinal growth of long bones.
https://www.rch.org.au/fracture-education/growth_plate_injuries/Physeal_growth_plate_injuries/

9. Growth plate
https://www.rch.org.au/fracture-education/growth_plate_injuries/Physeal_growth_plate_injuries/

11. Physeal plate on xray

12. 6%
75% -> most
common
8%
10%
1%, difficult to
see on xray

13. QUIZ time

14. Salter Harris Type 1
• AP and lateral x-ray of 10 year
old girl with Salter-Harris type I
fracture.
• Difficult to see on x-ray and are
primarily diagnosed on clinical
findings.
• The key clinical sign is localised
tenderness.
https://www.rch.org.au/clinicalguide/guideline_index/fractures/Dist
al_radial_physeal_fractures_Emergency_Department_setting/

15. Salter Harris Type 5
• A fracture will not be visible in
an acute injury but is usually
recognised later because of
growth arrest and progressive
deformity.
• This AP and lateral x-ray shows a
bony bar extending across the
growth plate of the distal radius,
indicating the presence of a
growth arrest
https://www.rch.org.au/clinicalguide/guideline_index/fractures/Distal_radial_p
hyseal_fractures_Emergency_Department_setting/

16. Approach
History Clinical features Examination Xray
• The peak age for injury to the
growth plate is in the pre-adolescent
growth spurt.
• Fall on an outstretched hand.
Extension of the wrist at the time of
injury causes the distal fragment to
be displaced dorsally (posteriorly).
• Pain
• Swelling
• Deformity
• Diminished
spontaneous
movement
• Look for swelling,
bruises, wound
• Localised tenderness
at fracture site
• Assess ROM
• Neurovascular
• Compartment
• Widen physeal gap
• Incongruity of the
joint
https://www.rch.org.au/clinicalguide/guideline_index/fractures/Distal_radial_physeal_fractures
_Emergency_Department_setting/

17. Management
Salter harris classification (undisplaced) Treatment
Type 1-2 Splinting the part in cast for 2-4 weeks
Type 3-4 • Splinting the part in cast for 2-4 weeks
• Repeat xray after 4days and 10days -> to rule out displacement
Salter harris classification (displaced) Treatment
Type 1-2 CMR then cast for 3-6 weeks
Type 3-4 • CMR then cast for 4-8weeks -> check xray after 4days and
10days to ensure anatomical position has been attained
• If failed, open reduction and K-wire insertion then splinting the
limb for 4-6weeks
Injuries of the physis, Apley and Solomon's concise system of orthopaedics and trauma, pg 332-333

18. Complications
• Growth arrest
1. Complete growth arrest leads
to length discrepancy
2. Partial growth arrest leads to
angulation
• Deformity of bone

19. How it occur?
• Physeal bars are interruptions of
the normal growth plate
cartilage, due to the formation
of a bony or fibrous bridge
between the epiphysis and
metaphysis.
• Left untreated, physeal bars can
cause abnormal bone angulation
or limb length discrepancies
https://radiopaedia.org/cases/physeal-bar
https://www.rch.org.au/fracture-education/growth_plate_injuries/Physeal_growth_plate_injuries/

20. Supracondylar fracture
• A supracondylar fracture occurs
through the thin part of the
distal humerus above the level
of the growth plate.
• occur most commonly in
children aged 5-7years
• M = F

22. Posteriorly vs anteriorly displaced #
• Flexion-type (rare) - distal fragment
is displaced anteriorly
• Extension-type (98%) - distal
fragment is displaced posteriorly
• The Gartland classification system
is used to describe the severity of
displacement for extension-type
supracondylar fractures.
https://www.rch.org.au/clinicalguide/guideline_index/fr
actures/Supracondylar_fracture_of_the_humerus_Emer
gency_Department/

23. Supracondylar fracture of humerus

24. QUIZ time

25. Approach
History Clinical feature Examination Radiology
• Mechanism of injury: fall
on outstretched hand
• Elbow hyperextended
• Force is trasmitted up
through the ulnar and into
distal humerus
• Fall directly on elbow
rather than outstretched
hand
• Pain
• Swelling
• Bruises
• Wound
• Look for swelling, bruises,
wound
• Assess compartment
• Neurovascular
• ROM
• Breach in cortex of bone
• Baumann angle
• occult sign of fracture:
posterior fat pad sign,
exaggerated anterior fat pad
sign
• Ossification centers of elbow
1.https://www.orthobullets.com/pediatrics/4007/supraco
ndylar-fracture--pediatric
2.https://www.rch.org.au/clinicalguide/guideline_index/fr
actures/Supracondylar_fracture_of_the_humerus_Emerg
ency_Department/

26. Nerves involved in supracondylar fracture

27. Nerve assessment
• Anterior interosseus nerve
neuropraxia: motor innervation
- can't make OK sign
• median nerve injury
- loss of sensation over volar aspect
of index finger
• Radial nerve palsy
-inability to extend wrist or MCP
joints
• Ulnar nerve palsy (involved in
flexion type #)
- weakness in adductor pollicis

28. Xray: Baumann's angle
• AP view
• normal is 70-75°
• best judge is a comparison of the contralateral side
• deviation of >5-10° indicates coronal plane deformity and should not be accepted
https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture--pediatric

29. Xray: Anterior humeral line
• xray: True lateral view
• line along the anterior surface
of of the humerus should pass
the middle 3rd of capitellum
• capitellum moves posterior to
this reference line in ->
extension type fractures
• capitellum moves anteriorly in
flexion type fracture
https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture--pediatric

30. Ossification centre (orthobullet)
mnemonic: C-R-I-T-O-E
C: Capitulum
R: Radial head
I : internal (medial epicondyle)
T: Trochlea
O: Olecranon
E: External (lateral epicondyle)
https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture--
pediatric

31. Relevance of ossification centre
• Not to be mistaken for fracture
fragments
• Epiphyseal displacement will not
be detected before these age ->
need to use baumnann's angle

32. Management
Type Management
Gartland 1 • Nondisplaced
• Treated with cast immobilization x 3-4wks,
with radiographs at 1 wk
Gartland 2 • Displaced posterior cortex and posterior
periosteal hinge intact
• Deformity is in the sagittal plane only
• Typically treated with CRPP
Gartland 3 • Displaced, often in 2 or 3 planes
• Treated most commonly with CRPP or open
reduction if needed
https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture-
-pediatric

33. Complications
• Vascular injury
• Nerve injury
• Malunion
• Compartment syndrome
• Elbow stiffness
• Cubitus varus deformity (gun
stock deformity) -> late ulnar
palsy

34. Vascular injury
https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture--pediatric

35. Advice for parents
• There may be swelling of the elbow, hand and fingers -> rest as much as possible with the elbow and
hand supported on pillows (elbow and hand above the heart)
• The sling may be removed when your child is lying down.
• Encourage your child to bend and straighten the fingers regularly.
• Check their fingers often for movement, feeling and circulation.
• The elbow will be painful initially -> Give a simple painmedication such as paracetamol

36. Advice for parents
Take your child immediately back to the
hospital emergency department, when,
even after elevating the limb for 30
minutes:
1. the fingers remain very swollen
2. the fingers remain white or blue
3. the child complains of pins and needles,
or numbness in the fingers
4. the child is not be able to move their
fingers, or complains of pain when you
move them
5. there is severe pain that is not relieved
by the recommended medication at the
recommended dose.
Take your child to the hospital you
attended, or the local doctor if:
1. the backslab is cracked, soft, loose or
tight, or has rough edges that hurt
2. you are worried that an object has
been pushed inside the backslab
3. there is increasing pain.

37. Paediatric abuse
• child abuse is the 2nd most
common cause of death in
children behind accidental injury
• head injury is the most frequent
cause of long term physical
morbidity in the child
• 90% of fractures due to abuse occur
in children < 5 years of age
• 50% of fractures in children < 1 year
of age are attributable to abuse
• 30% of fractures in children < 3 years
of age are attributable to abuse
• the most common cause of femur
fractures in the non ambulatory
infant is non accidental trauma

38. Risk factors
Child Parents
• first-born
• unplanned pregnancy
• premature
• disabilities (cerebral palsy)
• step-children
• single-parent home
• recent social stressor (move, job loss)
• unemployment
• drug-use
• personal history of abuse as a child
• lower socioeconomic status
• lack of support system

39. • types (can have more than one
type present):
1. neglect 78%
2. physical abuse 18%
3. sexual 9%
4. psychological 8%
• Prognosis:
If unreported, 30-50% chance of
repeat abuse and 5-10% chance of
death from abuse

40. Differential diagnosis
• true accidental injury
• osteogenesis imperfecta
• osteopenia of prematurity
• disuse osteopenia
(nonambulatory or minimally
ambulatory children)
• chronic disease (kidney and
liver)

41. Approach
History Clinical features Radiology Management
• injury often
inconsistent with
history
• delay in seeking care
• long bone fractures in
nonambulatory child
• pain related to
fractures
• bruises: old and new
• deformity
• xray of the involved
bones and joints
• skeletal survey
• report abuse to
appropriate agency
• hospital admission
• cast application

42. References
• https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture--
pediatric
• https://www.rch.org.au/clinicalguide/guideline_index/fractures/Supracondyla
r_fracture_of_the_humerus_Emergency_Department/
(royal children's hospital of melbourne)
• https://www.orthobullets.com/pediatrics/4002/physeal-considerations
• https://www.rch.org.au/fracture-
education/growth_plate_injuries/Physeal_growth_plate_injuries/
• https://www.orthobullets.com/pediatrics/4001/pediatric-
abuse?expandLeftMenu=true