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Paediatrics: 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).

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.

 

Fractures

 

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.

 

Principles of management

 

   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.

 

Complications

 

Early

 

   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.

 

Intermediate

 

   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.

 

Late

 

   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.

Common fracture patterns

 

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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