| |
Growth in length occurs through the cartilaginous epiphyseal
plates and growth in width through the periosteal membrane.
The latter is a thick fibrous layer that covers the bone
and provides stability to torus (Figure
18.68) and greenstick
fractures (Figure 18.69).
Epiphyseal plate fractures are classified by location and by
the path of the fracture line across the epiphyseal plate (Figure
18.70).
If the growth potential of the epiphyseal cartilage is damaged,
the growth pattern will be altered and deformity of the extremity
is likely.
Evaluation
Identify the fracture by findings of tenderness, swelling,
bruising and deformity. Obtain X-rays, if available. If you
cannot identify a fracture, consider the possibility of infection.
Joint instability in children occurs because of torn ligaments
and epiphyseal fractures. Take an X-ray while applying stress
across the joint to show the location of the instability.
Treatment
| :: |
Treat
epiphyseal fractures with gentle closed reduction. Make
one or two attempts only, as repeated manipulation will
further injure growth potential. |
| :: |
Minor
residual deformity in fractures of type I and II will
remodel. Type III and IV fractures involve the joint
cartilage as well as the epiphyseal plate. If displacement
of more than a few millimetres remains in these structures
after closed reduction, consider open reduction. |
| :: |
In
general, fractures not involving the growth plate will
heal in an acceptable position as long as the general
alignment of the limb is maintained. The remodelling
potential declines with age, and younger children are
able to correct greater deformities. |
Expected correction following long bone fractures in children |
| Length |
1.5–2
cm
|
| Angulation |
30
degrees
|
| Rotation |
None
|
| Displacement |
100
% |
Specific fracture types
Supracondylar fractures of the humerus
| Age |
Most
common from 18 months to 5 years |
| Mechanism |
Fall
on extended arm |
| Evaluation |
Pain,
swelling and deformity just above elbow
Examine the vascular and nerve function in the forearm and hand |
| X-ray |
Helpful
but not essential. Do not delay treatment if X-ray is
unavailable (Figure 18.71).
|
Treatment
| 1 |
With
the patient lying face up, apply traction on the forearm
with the elbow near full extension. |
| 2 |
While
maintaining traction, grasp the distal fragment of the
humerus and correct medial and lateral displacement and
rotation (Figure 18.72).
|
|
| 3 |
Next,
flex the elbow slowly while pushing the distal fragment
forward into the reduced position (Figure
18.73).
|
|
| 4 |
Check
the radial pulse before and after the reduction. If it
diminishes as the elbow is flexed, extend the forearm
until the pulse returns. Immobilize the arm in a posterior
splint at 120 degrees of flexion or in the position where
the pulse remains intact. |
| 5 |
If
the circulation is in question, or if it is not possible
to obtain a satisfactory reduction, treat the patient
in olecranon or Dunlap’s traction (see page 7–5). |
Triplane
fractures of the distal tibia (Figure
18.74)
| Age |
12–15
years, at the time of closure of the distal tibial epiphysis |
| Mechanism |
Abduction,
external rotation force to the ankle joint |
| Evaluation |
Painful,
swollen ankle with or without other deformity
X-ray is needed to make the diagnosis but, if unavailable, begin treatment |
Treatment
| 1 |
Apply
longitudinal traction to the foot by holding the mid-foot
and heel. |
| 2 |
Invert
the heel, bring the ankle from plantar flexion to neutral
(90 degrees) and internally rotate the foot.
|
| 3 |
Maintain
the reduction by grasping the great toe, allowing the
foot to hang, while a three-way splint is applied. |
| 4 |
Mould
the plaster as it dries. |
| 5 |
Obtain
post-reduction X-rays when possible. |
|
|
|
