CHAPTER 16

Specific Fractures and Joint Injuries in Children

Special Features of Fractures and Dislocations in Children:

1. Fractures more common
Combination of relatively slender bone & carefree capers.
Not serious crack / hairline, buckle, greenstick.
Serious intra-articular, epiphyseal plate
2. Stronger & more active periosteum
Periosteum is much more osteogenic
3. More rapid fracture healing
More rapid osteogenic activity
Nonunion in child rare unless open operation has
damaged the blood supply to the fracture fragment /
complicated by infection, widely displaced fracture of lateral
condyle of the humerus.
4. Special problems of diagnosis
Variant ro before & after development of 2nd center of
ossification not easy to remember!
May be mistaken for fracture line.
So, compare ro with the normal side.
5. Spontaneous correction of certain residual deformities
Either by extensive remodelling / epiphyseal plate growth or
both.
Angulation
If the angulation near an epiphyseal plate provided
that the plane deformity is same as the plane of motion
in the nearest joint expected to correct.
Plastic deformation gentle bend in the middle of a
growing bone without an obvious fracture occult
microfractures.
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 Incomplete Apposition
Side to side bayonet, the contour of the healed
fracture improves greatly through active process of
remodelling (Wolffs law).
Shortening
Disruption of nutrient artery compensatory increase
blood flow at the epiphyseal end of the bone
temporary acceleration of longitudinal growth in the
bone for 1 year after fracture same length.
Rotation
6. Differences in complications
Growth distrurbance after epiphyseal plate injuries only in
child.
2nd OM after open surgey destroy epiphyseal plate.
Volkmanns ischemia, posttraumatic myositis ossificans,
refracture more common in child.
Persistent joint stiffness uncommon in child.
Fat embolism, PE, accident neurosis rare in child.
7. Different emphasis on methods of treatment
Closed reduction ( manipulation & continuous traction all
fracture of the long bones.
ORIF displaced intra-articular, femoral neck, certain type of
epiphyseal plate injuries.
8. Torn ligaments & dislocations less common
In child, ligament are strong & resilient so, sudden powerful
traction result in separation of epiphyseal plate rather than
ligament tear.
9. Less tolerance of major blood loss
Percentage of blood loss relation to shock.
Total volume blood in child < adult.
Approx. blood volume is 75mL/kg/body.

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Special Types of Fractures in Children

Fractures that Involve the Epiphyseal Plate (Physis)

Serious disturbance of local growth & progressve bony deformity.
o

Anatomy, Histology, and Physiology

The weakest area calcifying cartilage (provisional
calcification) zone line of separation.
The blood supply enters from its epiphyseal surface so if
epiphysis loses its blood become necrotic & growth ceases.
The cartilaginous epiphyseal plate is weaker than bone,
epiphysis is firmly attached to its metaphyseal peripherally by
union of pericondrium & periosteum.
In lower limb more growth in knee > hip & ankle.
In upper limb shoulder & wrist > elbow.

Diagnosis of Epiphyseal Plate Injuries

Suspect epiphyseal plate if there is a fracture near the end of a
log bone, traumatic dislocation, ligamentous injury.
Precise diagnosis: ro at least 2 projections include the normal
site.

Salter-Harris Classification of Epiphyseal Plate Injuries

W. Robert Harris & R. Bruce Salter based on mechanism of
injury & relationship to fracture line to the growing cells of the
epiphyseal plate:
Type I
Complete separation of entire epiphysis.
Result from shearing force.
More common in newborn (birth injury).
Th/: closed reduction ( periosteal attachment still intact)
Prognosis: excellent
Type II (most common)
Line of fracture extends along the epiphyseal plate &
out through a portion of the metaphysis produce
triangular-shaped metaphyseal fragment.
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Result from shearing & bending forces .

Usually in older child epiphyseal plate is relatively thin
Periosteum is intact in concave side, but torn in convex
side.
Th/: closed reduction is easy.
Prognosis: excellent
Type III (uncommon)
Intra-articular, extends from the joint surface to the
deep zone of the epiphyseal plate, then along the plate
to its periphery.
Result from intra-articular shearing force.
Usually limited to the distal tibial epiphysis in a
teenager (one part of epiphyseal plate has already
closed but other part is still open).
Variant: triplane fracture (AP type III, Lateral: type II)
best assessed by CT.
Th/: ORIF.
Prognosis: good.
Type IV
Intra-articular, extends from the joint surface to the
epiphysis, across the entire thickness of the epiphyseal
plate through a portion of the metaphysis.
Most common in fracture of the lateral condyle of the
humerus.
Th/: ORIF
Prognosis: bad unless perfect reduction.
Type V (uncommon)
Result from a severe crushing force applied through the
epiphysis to one area of the epiphyseal plate.
Most likely in knee & ankle.
Must avoid weight bearing at least 3 weeks prevent
further compression of epiphyseal plate.
Prognosis: poor.
Type VI (by Rang)

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Rare injury to the peripheral perichondrial ring, or zone

of Ranvier, that encircles the plate. Often caused by
slicing mechanism of sharp object than direct blow.
Prognosis: bad
Ogden 9 types & 18 subtypes.
o

Prognosis Concerning Growth

Type of injury
Age of the child the younger, the more serious
Blood supply to the epiphysis disruption of blood
supply poor prognosis
Method of reduction unduly forceful / unskilled open
reduction crush epiphyseal plate
Open or Closed Injury open injury risk of infection
destroy epiphyseal plate
Velocity & Force of the Injury high velocity worse

Possible Effects of Growth Disturbance

85% of all epiphyseal plate injuries are uncomplicated by
growth disturbance.
Entire epiphyseal plate ceases to grow in a single bone limblength discrepancy.
If the involved bone is one of a parallel pair (radius-ulna, tibiafibula) angulatory in neighboring joint.
If only one part of the plate ( medial side ) angulatory
deformity.
Resection of bony bridges: bony bridge tethering the epiphyseal
plate resect filled with autogenous fat graft to prevent
recurrence (Langenskiold). Peterson fill defect with a variety
of materials including cranioplast (methylmethacrylate without
barium). Microvascular surgery transplantation of an
expendable autogenous epiphyseal plate.

Special Considerations in the Treatment of Epiphyseal Plate

Injuries
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Type I & II nearly always be treated by closed reduction.

Displaced type III & IV always require ORIF.
The period of immobilization require for type I, II & III only half
that required for metaphyseal fracture of the same bone in a
child in same age.
Type V healed through bony bridge.

Birth Fractures
Delivering a large baby, especially breech presentation fetal
anoxia rapid extraction of the baby, one limb may be difficult to
disengange from the birth canal.
Multiple fracture almost always pathological (osteogenesis
imperfecta).Birth fracture of tibia almost always pathological
congenital pseudoarthrosis of the tibia.
Obstetrician feels / hears the bone break.
o

Clavicle
Most susceptible. The infant tends not to move the affected limb
during the 1st week pseudoparalysis.
This fracture will unite very fast 10 days (clinical & ro).
Th/: simple protection (sling).

Humerus
Usually during difficult breech delivery, associated with a radial
nerve injury (neuropraxia) . It will recovered completely. The
arm is obviously floopy.
Th/: shoulder should be bandaged to chest for 2 weeks, any
mild residual angulatory deformities will improve, but rotational
deformities are permanent.

Femur
The lower limb is floopy. Usually happened in midshaft.
Th/: overhead (Bryants) skin traction of both lower limbfor 3
weeks. Alternative: immediate hip spica for full term baby /
Pavlik harness for a tiny premature baby.
Traumatic separation of distal femoral epiphysis escape
detection until knee becomes enlarged by extensive new bone
formation.
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Traumatic separation of the proximal femoral epiphysis

differentiate dislocation of the hip. Within 3 weeks ro reveals
new bone formation in the metaphyseal region. Th/:
immobilization of the hip in abduction & flexion in a spica cast
for 2 weeks, prognosis: good.
o

Spine rare

Specific Fractures and Dislocations

The Hand
Less common in children.
Mallet finger immobilized with the distal joint in extension for 3
weeks.
Phalangeal fractures accurately reduced to avoid persistent
angulatory deformity.
Rotational deformity occurred through separation of the proximal
phalangeal epiphyseal plate.
Angulatory / rotational malunion of proximal phalanx finger to
cross over its neighbor when the fingers are completely flexed.
Displaced intra-articular fractures of finger joint ORIF
Metacarpophalangeal dislocation of the thumb common in
hyperextension injury the 1st metacarpal head escapes through a
small tear in the joint capsule tends to grip the narrow neck of the
metacarpal buttonhole. Th/: open reduction immobilization of
the joint in the stable position of moderate flexion for 3 weeks.
Fracture of the neck if the mobile 5th metacarpal (older boys fight)
boxers fracture / street-fighters fracture respond well to
closed reduction. The depressed metacarpal head can be elevated
by pressure along the axis of proximal phalanx with
metacarpophalangeal joint flexed to a right angle immobilized for
4 weeks in moderate flexion.

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Fractures of carpal bones rare, cause their large cartilaginous

component during the growing years.

The Wrist and Forearm

Common, because of frequent fall forces are transmitted from
the hand to the radius & ulna.
o

Distal Radial Epiphysis

Its a type II fracture.
Frequent in older child.
May accompanied by a greenstick fracture of the ulna.
Result in forced hyperextension & supination injury.
Can be reduced by a combination of flexion & pronation.
Should be immobilized in an above-elbow cast with forearm in
pronation for 3 weeks .

Distal 3rd of radius & ulna

Incomplete fractures:
The most frequent fracture in this region: buckle protection
alone for 3 weeks.
Greenstick fracture closed reduction angulation is
gradually corrected to the point where the remaining intact part
of cortex is heard & felt to crack through.
Complete fractures:
Displaced fractures common. Its difficult to reduce unless the
significant periosteal hinge.
When radius alone from supination injury, reduction is most
stable in pronation.
When both are fracture reduction is more stable in the neutral
position for 6 weeks.
Moderate angulation tends to correct spontaneously.

Middle 3rd of radius & ulna

Greenstick fracture closed manipulation.
Displaced fracture difficult to reduce, to assess the angulation
& rotation is best from childs forearms.
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Angulation & rotation must be corrected.

Side to side (bayonet) aposition is acceptable. Immobilization: 8
weeks.
Unstable fracture must be examined by ro each week for at
least 4 weeks.
If angulation recurs remanipulation about 2 weeks after
injury (in which fracture sites have become more sticky &
reduction is likely to be more stable.
Loss of aposition result in overriding, corrected by
remanipulation as soon as possible.
There is no indication for open reduction of these fractres.
In older children with unstable fractures of the forearm IM
flexible nails / Kirschner wire after reduction.

Proximal 3rd of radius& ulna

Monteggia fracture-dislocation shaft ulna combined with
dislocation of the radiohumeral joint, the dislocation isnt
frequently recognized remains untreated.
Cant become angulated because firm attachment through
fibrous interosseous membrane unless radius also injured.
Treated by closed reduction to ulnar fracture thereby the
radial head is in proper relationship with the capitellum.
Neglected residual dislocation if more than 1year better left
unreduced because elbow stiffness after surgical correction.

The Elbow and Arm - common

o Pulled elbow
Result from sudden longitudinal pull / jerk on the extended
elbow ( parent, nurse-maid, nanny, older sibbling ) while lifting
small child up a step by the hand /puling them away from
danger.
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Child cry & refuse to use arm, protect arm by holding it with
the elbow flexed & forearm pronated.
Diagnosis: painful limitation of forearm supination, ro is
negative.
Pathological anatomy: its a transient subluxation of the radial
head (theory that radial head > radial neck wrong!) distal
attachment of the annular ligament to the radial neck is thin &
weak it tears & slips into the radiohumeraljoint- trapped. Pain
is result from the pinched annular ligament.
Postmortem studies sudden supination of the forearm while
the elbow is flexed frees the incarcerated part normal
position.
Treatment: deft supination of child forearm while elbow is flexed
click pain is relieved, function is restored. Followed by
sling or 2 weeks to allow tear to heal.
o

Proximal Radial Epiphysis

Result from fall that exerts a compression & abduction force to
elbow joint. Its a type II epiphyseal injury. Characterized by
metaphyseal fragment & radial head becomes tilted on the
neck.
Treatment: closed reduction pressing upward & medially on
the tilted radial head while an assistant holds the arm with the
elbow extended & adducted. If impossible K-wire
percutaneously into the displaced radial head use as joystick
reduce fracture separation. Residual angulation less than 40 o
is acceptable. Open reduction is important to restore joint
congruity between radial head & capitellum. Internal fixation
isnt necessary. Radial head cant never be excised although
it has lost all soft tissue attachment produce a discrepancy in
length. Hand become deviated toward the radial side.
After reduction immobilize for 3 weeks with forearm
supinated.
Complications: displaced fracture blood supply to intraarticular complicated by avascular necrosis of epiphysis.
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Dislocation of elbow
Posterior more frequent.
Result from fall on the hand with flexed elbow distal end of
humerus is driven through the anterior capsule as radioulnar
dislocate posteriorly.
Treatment: closed reduction by reversing the injury mechanism
applied traction to the flexed elbow through forearm
maintain in stable position (flexed above the right angle) for 2
weeks.
Complications: posttraumatic myositis ossificans

Medial Epicondyle
Result from sudden traction force through the attached medial
ligament - medial epicondyle is avulsed when posterior
dislocation of the elbow & carried posteriorly.
It also can result from severe abduction of extended elbow
with / without transient lateral dislocation of the joint.
Physical exam: local swelling & tenderness.
Treatment: joint stability is very important avulsion of medial
epicondyle requires only immobilization with elbow in flexion for
3 weeks. Even if healed by fibrous union no growth
disturbance. If joint is unstable ORIF.
Complications: traction injury of the ulnar nerve. Nerve recovery
is excellent.

Lateral Condyle
Common, frequently complicated & regrettably.
Fracture line begin at joint surface, passes through the
cartilaginous portion of medial epiphysis to capitellum, crosses
the epiphyseal plate & extends to metaphysis Type IV.
These fracture are unstable, caused they are predominantly
intra-articular.
The periosteum covering is completely disrupted.
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Less serious variant (Rang): part of articular cartilage remains

intact prevent significant lateral displacement of condyle.
Ro: may be undetected ( comparable projection ).
Treatment: May be treated initially by immobilization of the arm
in a plaster cast with elbow repeat ro within first 2 weeks if
fracture become displaced ORIF.
More effective method: percutaneous pinning of lateral condyle
insitu prevent displacement.
Because this is a type IV even a slightest displacement must
be perfectly reduced.
Immobilization: 3 weeks.
Complications: overgrowth of lateral side cubitus varus
( hyperemia & delayed union ), growth disturbance in central
part of epiphysis, avascular necrosis of capitellum, 2nd
enlargement of radial head, complete nonunion, resultant
cubitus valgus (result from tardy ulnar palsy).
o

Supracondylar Fracture of the Humerus

Most serious & most common.
Pathology anatomy:
Posterior indent: olecranon fossa.
Anterior indent: coronoid fossa.
Makes it relatively weak, so hyperextension injury/ fall on the
hand with elbow flexed force transmitted through the elbow
joint grips the distal end of humerus like right-angle monkey
wrench.
The resultant fracture is proximal to the elbow joint (follow
through) driven through the anterior periosteum & overlying
brachialis muscle into the plane of brachial artery & median
nerve rest in subcutaneous fat.
Diagnosis:
Obvious deformity in elbow region, grossly swollen & tense
result from extensive internal hemorrhage. The stage of
peripheral circulation & nerve assess immediately.
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Impairment of circulation urgent reduction.

Ro: can obviously detect displacement but little soft tissue
injury.
The distal fragment displaced medially (more often) / laterally.
If medially there is an intact medial hinge of periosteum.
If laterally intact lateral hinge.
Treatment:
Undisplaced immobilization arm with elbow flexed for 3
weeks.
Displaced closed reduction (gentle traction on the forearm
with elbow being slightly flexed avoiding traction to brachial
artery). This manuver will tightens the posterior hinge of
periosteum.
If medially forearm: pronated tighten medial hinge, prevent
varus deformity.
If laterally forearm: supinated tighten lateral hinge, prevent
valgus deformity.
After reduction ro in AP & lateral position, then maintain by
percutaneous pinning immobilized in less thn 90o of flexion in
a posterior plaster splint (nonencircling).
The child should be admitted to hospital at least for few days
observation of peripheral circulation.
Persistent pain signal for volkmanns ischemia shouldnt
mask by sedation.
After plaster splint & pins removal lacks of elbow extension
active exercise. Passive stretching is deleterious.
If the fracture is really unstable & excessive soft tissue swelling
continuous skeletal traction (pin / vertical screw) in olecranon.
Rare type flexion type distal fragment is displaced
anteriorly not serious. Requires closed reduction &
immobilization in extension position.
Complications:
volkmanns ischemia (brachial artery trapped & kinked),
can only be relieved by reduction. Excessive flexion of
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the elbow aggravates the tightness of the deep fascia in

antecubital fossa compress the brachial artery.
peripheral nerve injury commonly median nerve.
Malunion common complication residual cubitus
varus. If severe supracondylar osteotomy after full
ROM regained because this deformity isnt caused by
a growth disturbance correction doesnt need to await
the end of skeletal growth.

Shaft of Humerus
Not common.
Undisplaced stable fracture sling & thoracobrachial bandage
binds arm to chest.
Displaced fracture closed reduction followed by shoulder
spica cast for 6 weeks.
Unstable fracture continuous skeletal traction for few weeks
sticky sugar-tong plaster cast from axilla.
Most common complication: associated injury of radial nerve.
Prognosis: baik.

The Shoulder
o Proximal Humeral Epiphysis
Type II large metaphyseal fragment in child because joint
capsule is stronger than epiphyseal plate.
Displacement is only slight no reduction sling &
thoracobrachial bandage for 3 weeks.
Displacement is considerable there is anterolateral angulation
traction to the arm held directly iver the childs head in line
with the trunk it will pull the distal fragment into line with
epiphysis statue of liberty / forward (football) pass
position awkward position, may choose percutaneous
pinning.
Spontaneous correction up to 60o.
No indication for open reduciton.
o

Clavicle
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Most common, least serious.

Result from when child land on their hands, elbows, or
shoulders.
This fracture is rapidly unite no permanent sequelae.
Greenstick sling for 3 weeks.
Displaced under 10 years old: snug figure eight bandage,
tighten each day within 2 weeks, complete by 3 months.
Displaced older than 10 years old: pull the shoulder up &
back before applying figure of 8 bandage. If very active add
cast over the bandage.
No indication for ORIF.
The Spine more flexible so less susceptible to fracture &
dislocation. Elastic recoil of soft tissue of spine SCIWORA
(Spinal Cord Injury Without Radiographic Abnormality).
Suspect spinal injury ro at least 4 projection: AP, lateral, right &
left oblique), sometimes CT scan, MRI & cineradiography.
o

Cervical spine
Rotatory Subluxation of the Atlantoaxial Joint
Atlantoaxial joint (C1-2) allows the head to turn from side to
side. Sudden twisting type of injury locked in position of
rotatory subluxation.
This is common in child.
Risk factor: recent throat infection because 2nd inflammation
in deep cervical glands soften the ligaments of upper
cervical spine joint become less stable subluxation
could occur even without injury.
Diagnosis: acute & painful wry neck caused by muscle
spasm. The child support head with hands / lie down.Ro:
difficult to interpret try open mouth projection to reveal
asymmetry.
Treatment: risk of reduction slight risk of producing
further displacement. Safest method: mild continuous
traction through a head halter for few days supported by a
cervical ruff for few weeks.
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Anterior Subluxation of the Atlantoaxial Joint

Caused by severe fall on the top of the head (diving into
shallow water, from falls on the head from a considerable
height, body contact sports).
Reduction: continuous traction through halo , then
stabilized by arthrodesis (fusion) prevent recurrence

Subluxations at Other Levels of the Cervical Spine

Best reduced by halo traction then maintain with halo
vest or a halo cast for 8 weeks. If still unstable local
posterior spinal arthrodesis.

Thoracic spine
Uncommon.
Possibility of pathologic fracture.
Compression fracture may caused by severe fall.
Th/: immobilization in body cast for 8 weeks.

Lumbar spine
These are particularly mobile.
When child wears lap seat belt involved in a head-on
automobile accident acute flexion of the lumbar spine
flexion-distraction that shears off a vertebral body end-plate &
fractures the pedicle Chance fracture.
More often in adult.
Th/: closed reduction body cast for 8 weeks. Residual
instability spinal instrumentation & arthrodesis.

The Foot
o Fractures of the Metatarsals
Single metatarsal fracture uncommon.
Several metatarsal fracture common caused by crushing
injury (heavy object dropped on the childs foot).
Usually, local arteries & veins are injured soft tissue swelling.
Th/: elevation, not weightbearing for at least 3 weeks then
walking cast for 3 weeks.
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Avulsion Fracture of the Base of the 5th Metatarsal

Caused by sudden inversion injury avulsion of bony insertion
of the peroneus brevis tendon into the base of the 5 th
metatarsal.
Th/: walking cast in eversion position for 4 weeks.

Fracture of the Os Calcis

Relatively resistant to fracture.
Caused by crush / compression / fall from considerable height
lands on his/ her heels examine the spine too! coexistent
compression fracture CT.
Th/: bed rest with elevated foot for few days crutches without
bearing weight for several weeks.
Intra-articular fracture ORIF.

The Ankle and Leg

All significant fracture around the ankle involve an epiphyseal plate.
o

Type I Injury of the Distal Fibular Epiphysis

If epiphysis returns immediately to normal position looks like
the child only suffered from ankle sprain.
Th/: below-knee walking cast for 3 weeks.

Type II Injury of the Distal Tibial Epiphysis

Th/: closed reduction molding of plaster cast for 3 weeks.

Type III Injury of the Distal TIbial Epiphysis

Caused by severe ankle injury fracture the anterolateral
corner of the distal tibial epiphysis.
Ro: detected in lateral projection.
This is an intra-articular ORIF.

Type IV Injury of the Distal Tibial Epiphysis

Caused by severe inversion injury through medial portion of the
distal tibial epiphyseal plate.
This is an unstable fracture.
Th/: ORIF.
A slight residual disparity serious growth disturbance.
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Type V Injury of the Distal Tibial Epiphysis

When a child gets one foot caught between pickets of a fence
then falls severe angulation of the ankle tremendous
compression force on distal tibial epiphysis & epiphyseal plate.
Prognosis: poor (growth disturbance is inevitable excision of
the bony bar that crosses the epiphyseal plate).
Th/: non weight bearing for at least 3 weeks.

Fracture of Tibia
This fracture is relatively undisplaced because strong
periosteal sleeve stable closed reduction then maintain
with long-leg cast with knee flexed to right angle for 4 weeks
then walking cast for 4 weeks.
No indication for open reduction.
Alignment correction in closed reduction is very important to
prevent any valgus / varus deformities in the proximal
metaphysis of tibia. If any of these occurred caused by flap
of interposed pes anserinus & periosteum preventing accurate
reduction must be released surgically.
Displaced risk of injury to anterior & posterior tibial artery
compartment syndrome.

The Knee and Thigh

o Avulsion Fracture of the Anterior Tibial Spine
This is an intra-articular fracture associated with
hemarthrosis.
The frature extends both medial & lateral into articular cartilage
so reduction must be complete then immobilzed for 4
weeks.
If cant be reduced because an entrapped meniscus open
arthroscopic reduction & internal fixation.
o

Type II Injury of the Proximal Tibial Epiphysis

Attachment of proximal tibial epiphysis to metaphysis is strong
because the irregular contour.
Caused by severe hyperextension injury.
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Uncommon, but serious risk of popliteal artery injury.

Type II Injury of the Distal Femoral Epiphysis

Distal is more often separated from metaphysis than proximal.
Caused by hyperextension injury.
May injured popliteal artery, medial / lateral popliteal nerve.
Physical exam: gross swelling of knee (hemarthosis).
This fracture is difficult to reduced unless the child is lying facedown. Traction is applied to the leg knee slightly flexed afte
which epiphysis can be pushed into normal position.
Maintain with percutaneous pinning combined with a long-leg
cast with knee flexed slightly for 3 weeks.

Type IV Injury of the Distal Femoral Epiphysis

Uncommon.
Reduction must be perfect subsequent growth can be
prevent by accurate ORIF.

Traumatic Dislocation of the Patella

Older children (especially girl) who have some degrees of genu
valgum & generalized ligamentous laxity lateral patella
dislocation due to abduction, external rotation to knee. Patient
experience sharp pain, her knee gives way completely & she
falls.
Physcial exam: gross swelling knee (hemarthosis), patella felt
lying on the lateral aspect of the knee. Sometimes it slid back
into normal position.
Ro: tangential superoinferior position (skylie) detect
osteochondral fracture either medial edge of the patella / lateral
lip of patellar groove, site of impact.
Treatment: no osteochondral fracture closed reduction in
knee extended position cylinder cast (ankle to groin) in
extension for 6 weeks. If there is osteochondral fracture
indication for open operation with fragment removal & torn soft
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tissue repair. Exercise the quadriceps femoris to prevent

recurrence of dislocation.
Complication: recurring dislocation articular cartilage of
patella in reinjured chondromalacia of the patella. Recurring
dislocation is an indication for reconstructive operation to
release the tight structure, repair fibrous joint capsule, redirect
the line of pull of the patellar tendon by tenodesis. In growing
child- safer with tibial tubercle transplantation.
o

Internal Derangements of the Knee

Semilunar cartilage (menisci) is resilient & relatively resistant to
disruption.
Uncommon.
Older child / adolescent skiing, football, and hockey.

Fracture of the Femoral Shaft

Displaced are common, usually at the middle 3rd of the femur.
May be transverse, oblique, spiral or comminuted.
Significant displacement strong periosteal sleeve still
remains intact.
Treatment: unstable temporary splint (thomas splint) before ro
prevent pain & further injury to femoral artery.
From birth 5 years
Initial skin traction for few days molded hip spica
cast in hip & knee slightly flexed.
Up to 2 years Bryants traction.
2-5 years thomas splint & child on inclined frame.
Contraindication to hip spica: initial shortening > 3
cm at fracture site, multiple injuries, head injury.

5 10 years
Skin traction for few days closed reduction hip
spica / blind insertion of flexible IM nails.
Alternative: external skeletal fixation.

Older than 10 years

Traction blind insertion of rigid, locked IM nails at
both proximal & distal control rotation.

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Can begin full weight the next day.

Alternative: ORIF with plate & screw.
Temporary overgrowth of the fractured femur always occures
after displaced fractures of femoral shaft. Average amount of
overgrowth is 1 cm, any residual discrepancy in length 1 year
after fracture is permanent. So ideal position is bayonet (side
to side) 1 cm overriding compensated after 1 year.
Complications: Volkmanns ischemia of nerve & muscle
shouldnt be given analgesic. Pain in the calf impending
ischemia remove all encircling bandage, replace skin traction
with skeletal traction through distal metaphysis of femur with
the hip & knee flexed.
o

Fracture of the Subtrochanteric Region of the Femur

Femoral fracture is distal to trochanter muscle inserted into
proximal fragment (illiopsoas & glutei) pull it into acute flexion,
external rotation & abduction.
Th/: continuous skeletal traction through distal metaphysis of
the femur with thigh flexed, externally rotated & abducted
bring distal fragment up to & in line with proximal fragment.
Older children blind, locked IM rod / ORIF.

The Hip
o Fracture of the Femoral Neck
Not common, but serious.
High incidence of posttraumatic avascular necrosis severe
injury & disruption of blood supply.
This fracture is unstable.
Treatment: displaced absolute indication for closed reduction
& internal fixation (percutaneous pinning & threaded pins) no
weight bearing so hip spica until 3 months (unite).
Complications: nonunion coxa vara deformity; posttraumatic
avascular necrosis (ossific nucleus stop growing for at least for
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6 months revascularized & reossified absolute

radiopaque).
o

Type I Injury of the Proximal Femoral Epiphysis

Uncommon, but serious.
Risk of premature closure of the underlying epiphysea plate.
Th/: internal skeletal fixation (2 / more threaded wires)
Diagnosis: characterized by flexion, adduction & internal
rotation. Traumatic anterior dislocation opposite.

Traumatic Dislocation of the Hip

Most vulnerable location when it is flexed & adducted.
May occurred from dashboard injury / fall on flexed knee.
Force is transmitted along the shaft of femur drive the femoral
head posteriorly over the labrum, or lip, of acetabulum
produce a posterior dislocation.
Femoral head escapes through a rent in the capsule extracapsular dislocation. Dd/ with congenital intracapsular.
Treatment:
As long as the hip dislocated torn capsule & surrounding
structure constrict vessels & jeopardize blood supply
emergency should be reduced (complication of avascular
necrosis).
Golden period: 8 hours. ( <8 hours low, > 8 hours 40%).
Closed reduction upward traction on flexed thigh & forward
pressure on the dislocated femoral head from behind hip
spica at extension, abduction & external rotation for 6 weeks.
Complications: posttraumatic avascular necrosis, residual
subluxation (caused by soft tissue interposition of capsule /
labrum in joint) degeneratice arthritis surgically removed.

Pelvis
More flexible & yielding serious fracture is uncommon.
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Most important: associated complication ( extensive internal

hemorrhage & extravasation of urine from rupture).
Diagnosis: Physical exam local swelling & tenderness, instability
of pelvic ring. 3-D concept: AP, tangential of pelvic ring ( tube
directed upward 50o, inlet projection looking down into pelvic ring
(tube directed downward 60o)
Treatment: recognition & treat shock, bladder rupture. Pelvic
fracture will unite rapidly because its blood supply is abundant &
cancellous type.
o

Stable Fractures of the Pelvis

Do not transgress the pelvic ring do not interfere stability do
not require reduction.
Result from sudden violent pull on the hamstring muscles
avulse the origin (ischial apophysis).
This injury usually heals & result in fibrous union.
Isolated fracture of ilium little significant protection from
weightbearing until pain go away for few weeks.
Straddle injur one / more fractures of the inferior pubic rami &
urethra tear.

Unstable Fractures of the Pelvis

Complete separation of symphisis pubis & opening out of pelvic
ring.
Reduced by internally rotatin both hips maintain with molded
hip spica cast.
Lateral compression bucket-handle th/: externally rotating
the lowerl limb then molded hip spica.
Unstable fracture in which one half of the pelvis is driven
proximally continuous skeletal traction. Alternative: external
skeletal fixation & ORIF with plates.

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Child Abuse
Repeated & multiple musculoskeletal injuries battered baby
syndrome / nonaccidental injury.

Diagnosis
History on injury given by parents is often vague & misleading.
Mysterious mishap incompatible with history.
Physical exam: multiple bruises varying stages of resolution.
Child sad countenance.
Ro: skull, chest, all four limbs.
MRI: soft tissue injury.

Treatment
Complete investigation.
Moral, legal obligation to report the suspicion to local authorities.
Record of previous attendance at hospital should be studied.

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