FRACTURE in CHILDREN

Muhammad Ihsan Kitta

ihsan.kitta@med.unismuh.ac.id

Children are not just small

adults
Mercer Rang
 What differences exist between
childs
bone and adult?
 A. Anatomy
B. Biomechanic

C. Physiology
 Anatomy
Chondro osseous epiphysis
- Radiolucent
- seperation is difficult
Periosteum :

thick, strong
more readily elevated
 Biomechanic
Bone
Growth plate (physeal)
Periosteum
 Biomechanic of bone
more Haversian canals
less dense
more flexible
more porous
more vascular channels
 Biomechanic of bone
Tolerate more degree of
deformation
Incomplete fracture

Buckle
Bowing
Greenstick
Less comminutive
 Biomechanic of bone
Deformation
 Biomechanic of bone
Deformation
 Biomechanic of bone
Fracture
classification
Bowing (bend)
Buckle (torus)

Greenstick

Complete
 Biomechanic of bone

Bowing (Bend)
plastic deformation
elastic recoil minimal
microscopical fracture
no callus formation
no remodeling
fibula, ulna
 Biomechanic of bone

Buckle (Torus) fracture

Compression of porous
bone
metaphysis
 Biomechanic of bone

Greenstick fracture angulation beyond the limit of

bending
the energy is sufficient to start a
fracture at tension side, bend at
compression side
plastic deformation
elastic recoil
Tx : complete fracturation, mild over
correction
Biomechanic of bone
 Biomechanic of bone
Complete fracture
fast fracture : smooth
slow fracture : rough
classification :
spiral fracture
oblique fracture
transverse fracture
Butterfly fracture
 Biomechanic of bone
Spiral fracture
twist force
periost intact
reduction-immobilization
(point fixation)
cranck-handle cast to
prevent rotation
 Biomechanic of bone
Oblique fracture
axial over load force
shear fracture300 to the
axis of the bone
periost widely open
Tx : plaster or distraction
 Biomechanic of bone
Transverse fracture
force : direct angulation
periost is torn

Tx. : angulation 900

straightening
3 point pressure
fixation
 Biomechanic of bone

Butterfly fracture
force: combination axial and
angulation
blow side : butterfly
fragment
periost rupture on the other
side
unstable
Tx.: small fragment : 3
point fixation
big fragment :
distraction
 Biomechanic of growth plate

Poland :
epiphysiolysis vs rupture of
ligament
Bright & Elmore :
traction
Angulation
rotation
 Biomechanic of growth
plate Type Frequnecy Reduction Prognosis
Physeal injury ++++ Non Good
1
classification Anatomic

2 +++ Non Good

Anatomic

3 ++ Anatomic Fair

4 ++ Anatomic Fair

5 Rare Not Poor

Relevant
Salter-Harris classification of physeal injuries.
The injuries are divided by the plane of the
fracture line relative to the physis
Comparison of physeal injuries.
The type of physeal injury determines the
appropriate management and prognosis
 Biomechanic of periosteum
Thick, strong, less readily
torn in children
Used as hinge and splint
during reduction
Potential for bone
formation
Physiology : fracture healing
Growth remodeling
growth provides the basis
for a greater degree of
remodeling
bone increase in length
and girth
fracture deformity is
corrected by asymmetric
growth of physis and
periosteum
The basis of remodeling
Physiology : fracture healing
Remodeling potential
Remodelling Potential Greatest
Factor
Age Young age

Site In Bone High rate of growth

Growth Rate End of bone

Plane Of Motion In plane of joint motion

Unique Feature Upper humerus, femur, etc.

Several factors should be considered when assessing

the potential for remodeling of fracture deformity
 Physiology
Fracture angulation

Remodeling of upper humeral fracture. A displaced

Humeral fracture in a 6-year-old boy was treated in a
hanging arm cast. The fragments healed in a side to side
position (red arrows). Fracture occurred in May.
Subsequent radiograph were taken in June (yellow).
September (green) and December (blue) showing
Extensive remodeling over just a 6-month period
 Physiology

Overgrowth
Femur fracture heals with some lengthening
Shortening < 2 cm : accepted
 Physiology
Progressive deformity
Permanent damage of G.P. Shortening
or angulation
Physiology
Speed of union
Bone Healing Time
SMALL BONES 4 weeks
Phalanges, Metacarpals-tarsals

MEDIUM SIZED 6 weeks

Radius, Ulna, Fibula, Flat bones

LARGE BONES 6 - 8 weeks

Phalanges, Metacarpals-tarsals

VERY LARGE BONES 8 - 10 weeks [considerably shorter in

infant. May be longer in adolescent]
GROWTH PLATE FRACTURES Require 50 - 60% as much time as for
a bone of equivalent size

Healing time. Some generalizations about healing

time for fractures in children are shown.
The greatest variation occurs in the larger bones
such as the femur or tibia
 Treatment
Mostly conservative
Reduction, immobilisation
Alignment : not grossly angulated
no rotation
Rotational deformity : inexcusable :
never remodel
Slight angulation : acceptable
Slight shortening (femur fr.) : acceptable
(angulated) greenstick fracture
complete fracture
 Degree of correctibility of angular
deformity in long bone in children depend
on :
A. 3 local variables :
1. age of the child
2. distance of fx.from to G.P.
3. amount of angulation
Angulation in the plane
of the neighboring
ginglimus joint
Complete correction : in
flexor surface
Wolffs law, piezo-
electric potentials
 Deformity of or
near femoral neck
never corrected
by remodeling
Degree of correctability
 Surgical indication

1. Intra articular (displaced)

2. SH. III, IV
3. Interposition
4. Open fracture
5. Conservative : fail
6. Fracture with vascular injury
7. Multiple fracture, floating fracture
8. Femoral shaft fracture + head injury
 Complication of fracture
Complication Prevention Treatment
VASCULAR:
NECROSIS Vascular repair Amputation
COMPARTMENT SYNDROME Fasciotomy Tendon lengthening
VOLKMANNS CONTRACTURE Careful fx management Tendon lengthening

NERVE PALSY:
POST REDUCTION/OPERATION Careful technique Never repair
PERONEAL PALSY Avoid external pressure Most will recover with time

INFECTION:
OPEN FRACTURE Careful debridement Antibiotics, debridement
POST OPEN REDUCTION Preop antibiotics Antibiotics, drainage
PIN TRACTS Relieve skin pressure Relieve skin, antibiotics
BONY COMPLICATION:
MALUNION Careful reduction Osteotomy if severe
NONUNION Prolonged fixation Fixation and grafting
OVERGROWTH Allow over-ridding Ephiphysiodesis if severe

PHYSEAL COMPLICATION:
BRIDGE FORMATION SHORTENING Anatomic reduction of
ANGULATION type 3 & 4 fractures Bridge resection

Complication are varied and often preventable

 Complication
Compartment syndrome
Volkmans contracture
Compartment syndrome
 Angulation
Genu valgus
 Physical treatment

Not necessary
Thank you