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PAEDIATRIC RADIOLOGY

Session plan

• Brief revision about fractures

• Kiddy specific stuff

• General management of fractures

• A few pictures!

Bits of the bone

Bits of the bone

Describing fractures

Describing fractures

• Location

• Open or closed

• Type of fracture

• Displacement

• Rotation

• Angulation

• Eponymous names and classifications

Growth plate injuries

• Salter Harris classification

Growth plate injuries

• Salter Harris classification:

S – straight - I

A – above - II

L – lower - III

T – through - IV

ER – everything ruined – V

Type I and II

• Type I

– Radiograph initially normal

– There is calcification at 7-10 days

– Look for fat pads

– Act on your clinical suspicion

– Immobilise

• Type II

– Most common type

– Generally do well

Type III + IV

• Type III

– Accurate reduction essential

– Distal tibial epiphysis most common site

• Type IV

– Distal Tibia again a common site

– Accurate reduction essential

– Prognosis guarded

Triplane Fracture

• Occurs during an 18 month window, prior to physeal closure

• CT is useful to determine extent of injury &

displacement – Articular surface more

deranged than you think

• With articular derangement they need manip +/- fixation

Tillaux Fracture

• SHIII Fracture of Distal Tibia

• An ATFL Avulsion Fracture

in adolescents again

Type V

• Type V

– Can be difficult to spot on radiographs

– Consider in patients with axial load

– Prognosis guarded

Kiddy specific stuff

• Ligaments may be stronger than the bone

and growth plate

– Injuries to growth plates and buckle fractures

are common

– Physeal separations are more common than

dislocations

– Fractures often accompany dislocations

Kiddy specific stuff

• Bones are soft and elastic

– Bowing fractures

– Buckle fractures

Kiddy specific stuff

• Children rarely complain persistently

unless there is something wrong

• Can be hard to pinpoint the problem

• Have a low index for imaging

• May need to image more broadly than you

would like

• Usually don’t need comparison views

Kiddy specific stuff

• Films can be hard to interpret

Fracture healing

• Growth plate injuries heal most rapidly

• Active growth plates heal the fastest

• Growth plate injuries can impair growth

• Rate of remodelling is inversely related to

age

• Remodelling is maximal near, and in the

plane of action of, the nearest joint

• Bones grow more rapidly after injury

Management in general

• Don’t forget the ABCs

• Early analgesia

• Recognise true orthopaedic emergencies

– Open fractures and dislocations

– Neurovascular compromise

• Test and document neurovascular function

• Request appropriate radiographs

• Always consider NAI

Analgesia for kids with fractures

• Non pharmacological

– Child-centred approach

– Involve the parents

– Splintage / traction

– Distraction

– Play therapy

Analgesia for kids with fractures

• Pharmacological

– Base on severity of pain and NPO status

– Options • Entonox

• Paracetamol

• Codeine

• NSAIDs

• IN diamorphine

• IV morphine

– Don’t forget nerve blocks

Reduction of fractures or

dislocations in the ED

• May be indicated if

– It’s straightforward

– Neurovascular compromise

– Skin integrity threatened (eg) fracture-

dislocation ankle

– Delay in reduction not desirable (eg) elbow

dislocations

Open fractures

• Size doesn’t matter

• Tetanus prophylaxis

• IV antibiotics

• Clean wound or cover with saline

soaked/clear dressing

• Urgent ortho/plastics consult

Compartment syndrome

• Beware in kids: ‘rest and elevation’ is easier said than done

• Take early signs seriously

• Remember to look for: – Pain – esp with passive extension of fingers or toes

– Paraesthesia

– Purple colour or pallor

– Pulselessness

– Paralysis

– Perishingly cold

What do you think about this elbow X-

ray?

Haemarthrosis (positive fat pad

sign) without fracture

Many will have occult

fracture (usually

supracondylar or radial

head)

•C&C

•Review 10-14 days

•Can investigate further but

unlikely to affect

management

Kohler’s Disease

• Osteochondritis of the navicular

• Presents with mid-foot pain in children under 10yrs

Antalgic Gait (‘limping child’)

Tenderness in region of navicular

Localised inflammation

Osgood-Schlatter’s Disease Traction apophysitis of tibial tuberosity

Sever Disease • Calcaneal Apophysitis

(Osgood Schlatter’s Disease

of the heal)

• Occurs in 7-15 yrs (usually 10-12)

One of the so-called ‘growing pains’

• Presents with • Severe pain in the heal on exercise

• Aching on awaking

• Tenderness posterior aspect of heal

Iselin’s Disease

Pelvic Avulsion Fractures

• Usually in athletic individuals during

exercise

• Occur during acceleration bursts

• Most commonly occur during puberty

• M:F 2:1

• Ischial Tuberosity>AIIS>ASIS

• This is why you must palpate all your bony

landmarks and have a low threshold to x-

ray the young

Pelvic Avulsion Fractures

Avulsion Fractures

Iliac Crest Avulsion

ASIS Avulsion Fracture

Lesser Trochanter Avulsion

Fracture

This 8yr old presented to the dept with left

hip pain and a limp

Perthe’s Disease

• Avascular necrosis of

the femoral head

• Radiographic diagnosis.

• There is a flattening and

fragmentation of the

femoral head.

Questions ?

Summary

• Describing fractures

• Paediatric considerations

• Imaging

• Management in general

• Specific injuries