Orthopaedic trauma
Trauma is the most common cause of
childhood deaths. It is often due to falls especially in the home environment
(home> sports > school > road traffic accident).
Road traffic accident is the
leading cause of death. NAI should be con-sidered.
Generally boys > girls with a
peak incidence at 12yrs of age, although specific injuries peak at different
ages, e.g. NAI at 1yr, femoral fractures at 3yrs, pedestrian vs car at 6yrs,
lateral condyle/supracondylar fractures at 7yrs, physeal injury at 11–12yrs. 4%
are multiple fractures. Children’s fractures usually are more frequent in
summer than in winter.
•
Stabilize
according to resuscitation principles.
•
Full
history (including nature of injury, left/right handedness) and examination.
•
Is the
fracture open/closed?
•
Is the
limb neurovascularly intact? Is there a compartment syndrome?
•
Is the
associated joint dislocated?
•
Splint
limb for comfort; analgesia; elevate.
•
X-ray
affected bone +/– joint above and below.
•
Liaise
with orthopaedic team.
•
Neurovascular problems: e.g. median nerve paraesthesia
with distal radius fractures,
median/ulnar nerve paraesthesia with supracondylar fractures, radial nerve in
humeral shaft fractures, common peroneal nerve with proximal fibula fractures.
•
Compartment syndrome: especially associated with closed
low energy mid-shaft tibia fractures.
•
Joint stiffness: especially fractures around the
elbow.
•
Malunion: usually well tolerated if malunion
is within plane of motion; may be
compensated in younger children with remodelling.
•
Overgrowth: occurs in long bones due to
physeal stimulation (from hyperaemia).
Femoral fractures in children may overgrow by 1–3cm.
•
Deformity: if epiphysis is damaged, child may
develop progressive deformity several
months later. Require long-term follow-up
Non-union:
rarely shaft of tibia/ulna.
The most common fracture pattern
is a complete fracture of both cortices (e.g. spiral, transverse, oblique,
multifragmentary). However, the following fractures are specific to children.
•
Buckle/torus fractures: children <10yrs. Usually caused
by a fall on an outstretched hand
(causing compression of one cortex resulting in ‘buckle’ on the X-ray)
resulting in a metaphyseal distal radius fracture. Inherently stable. Treatment
immobilize in plaster of Paris/backslab; fracture clinic follow-up within 2–3
days. Remove plaster in 3–4wks and mobilize.
•
Plastic deformation or bend
fractures: traumatic
bending/bowing of bone, but
insufficient energy to produce a fracture. No fracture seen on X-ray (limb may
appear ‘bent’). Commonly ulna (look out for radial head dislocation);
occasionally fibula. Treat as for torus fracture. If severe bowing or
dislocation require manipulation under anaesthetic.
•
Greenstick fractures: like bending a young twig, the
cortex will break on the tension side
and bend on the compression side. The energy is insufficient to result in
complete bicortical fracture. It may require manipulation under anaesthesia.
•
Salter–Harris fractures (physeal
injuries): 20% of
all children’s fractures involve the
physis (most commonly the distal radius). It is usually extra-articular, but
fractures in the proximal femur/humerus, radial neck, distal fibula may be
intra-articular.
Some fractures may indicate NAI,
e.g. spinal fracture or femoral shaft fracture in the non-ambulant, rib
fractures, two separate fractures at different stages of healing. These
children should be referred for full investigation.
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