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IMAGING OF PEDIATRIC FRACTURE

ELYSANTI DWI MARTADIANI DEPARTMENT OF DIAGNOSTIC RADIOLOGY UDAYANA MEDICAL FACULTY / SANGLAH GENERAL HOSPITAL OVERVIEW

Unique Features of Pediatric Skeleton

Type of Pediatric Fractures

Imaging Modality

Take Home Points PEDIATRIC SKELETON

Prevents propagation of More porous and fractures Comminuted elastic in early fractures << childhood

Resist stress and Stronger ligaments torsional forces Fracture of and tendons than growth plate the physis << PEDIATRIC SKELETON

Incomplete fractures Thick periosteum Better healing

Puberty  Increase in muscle strength Avulsion and rapid growth fracture OVERVIEW

Unique Features of Pediatric Skeleton

Type of Pediatric Fractures

Imaging Modality

Take Home Points INCOMPLETE FRACTURES

• Plastic Deformity / Bowing Fracture • Buckle / • Greenstick Fracture Plastic Deformity / Bowing Fracture

• Angulation of the beyond its elastic limit, but the energy is insufficient to produce a fracture • No fracture line is visible radiographically • Unique to children • >> in the ulna, occasionally in the fibula. • Bend in the ulna of < 20° in a 4 year old child should correct with growth

http://www.rch.org.au/fracture-education/biomechanics/Biomechanical_differences_between_adult_and_child/ PLASTIC DEFORMITY / BOWING FRACTURE

https://www.med-ed.virginia.edu/courses/rad/ext/2elbow/ Buckle / Torus Fracture

• Compression failure of bone that usually occurs at the junction of the metaphysis and the diaphysis

• Commonly seen in distal .

• Heal in 3-4 weeks with simple immobilization

http://www.rch.org.au/fracture-education/biomechanics/Biomechanical_differences_between_adult_and_child/ TORUS / BUCKLE FRACTURE

http://o.quizlet.com/

http://www.healio.com/~/media/Journals/PedAnn/2014/5/_ Greenstick Fracture

• Bone is bent and the tensile/convex side of the bone fails.

• Fracture line does not propagate to the concave side of the bone, therefore showing evidence of plastic deformation.

http://www.rch.org.au/fracture-education/biomechanics/Biomechanical_differences_between_adult_and_child/ http://www.kidsfractures.com/forearm/ PHYSEAL INJURY

Salter-Harris Fractures SALTER HARRIS FRACTURE

• Classification system to delineate risk of growth disturbance • Higher grade fractures are more likely to cause growth disturbance • Growth disturbance can happen with ANY physeal injury SALTER-HARRIS FRACTURES

S A L T R SLIPPED ABOVE LOWER THROUGH RUINED

Image source : http://openi.nlm.nih.gov/detailedresult.php?img=3019033_JMedLife-03-70-g003&req=4 SALTER-HARRIS I • Separation through the physis • ~ 5-7% of cases. • >> phalanges. • Germinal layer and vessels not disturbed  Growth disturbance : uncommon • Best identified by comparing with normal site  physis widening • Excellent prognosis

Image source : http://www.radiologyassistant.nl/en/p50335f3cb7dc9/ankle-special-fracture-cases.html SALTER-HARRIS II

• Fracture through a portion of the physis that extends through the metaphyses. “corner sign” • Most common type (~ 75% of cases) • Distal radius >> • Minimal shortening, good outcomes.

http://www.radiologyassistant.nl/en/p50335f3cb7dc9/ankle-special-fracture-cases.html SALTER-HARRIS III • Fracture through a portion of the physis that extends through the epiphysis and into the joint • ~ 8% of cases • Usually seen after partial epiphyseal plate closure in and distal femur • Some deformity can occur • Most problems : fracture entry into joint space https://www.hawaii.edu/medicine/pediatrics/pemxray/v1c18.html SALTER-HARRIS IV

• Fracture across the metaphysis, physis and epiphysis • ~ 10 % cases • Most common : distal femur & tibia • Damage to germinal layer and epiphyseal blood supply  joint deformity  surgical repair SALTER-HARRIS V

• Crush injury to the physis • < 1% cases • Immediate radiographs : show no abnormality other than soft tissue swelling • Later studies : abnormal bone growth • Growth arrest, formation of bone bridges  requiring surgical repair https://www.hawaii.edu/medicine/pediatrics/pemxray/v1c18.html SALTER-HARRIS VI, VII, VIII, IX

• Rare types of Salter-Harris fractures • VI - Injury to perichondrial structures • VII - Isolated injury to epiphyseal plate • VIII - Isolated injury to metaphysis • IX - Injury to periosteum COMPLETE FRACTURE Complete fracture

• Fracture completely propagates through the bone. • Type : depending on the direction of the fracture line.

http://www.rch.org.au/fracture-education/biomechanics/Biomechanical_differences_between_adult_and_child/ Transverse fractures

http://eorif.com/Pediatrics/Humeral%20shaftIM.html http://www.rch.org.au/fracture-education/biomechanics/Biomechanical_differences_between_adult_and_child/ Spiral fractures

Created by a rotational force

http://coronertalk.com/wp-content/uploads/2014/07/xray-coroner-talk-child-abuse.jpg http://www.rch.org.au/fracture-education/biomechanics/Biomechanical_differences_between_adult_and_child/ Oblique Fracture

Occur diagonally across the diaphyseal bone at 30° to the axis of the bone.

http://www.wheelessonline.com/image4/i1/tibbb1.jpg http://www.rch.org.au/fracture-education/biomechanics/Biomechanical_differences_between_adult_and_child/ Common fracture in pediatric

• Elbow • Distal radius • Clavicle • Tibia

Supracondylar fracture Lateral condyle fracture Supracondyler fracture • Weakest part of the elbow joint where humerus flattens and flares • Most common fracture is extension type • Marked pain and swelling of elbow Non-displaced supracondyler fracture?

Fat pad sign may be SAIL only clue SIGN

Normal Anterior fat pad

http://www.radiologyassistant.nl/en/p4214416a75d87/elbow-fractures-in-children.html http://www.wikiradiography.net/page/The+Paediatric+Elbow A visible fat pad sign without the demonstration of a fracture should be regarded as an occult fracture Basic landmarks on lateral view give clues to distinguish fracture from normal

Disruption = displaced fracture Anterior humeral line : should pass through the middle third of the capitellum Supracondyler fracture

SAIL SIGN Gartland classification I II III

Minimal displacement Displacement fracture Completely dislocated fractures Intact posterior cortex  risk for malunion Difficult to see on X- and neurovascular rays complications Clue : positive fat pad sign http://www.wikiradiography.net/page/The+Paediatric+Elbow Radiocapitellar line : should pass throught the centre of the capitellum Disruption of radiocapitellar line LATERAL CONDYLAR FRACTURES • Fracture line begins in distal humeral metaphysis and extends to just medial to capitellar physis into the joint

• Neurovascular injury rarely

http://images.radiopaedia.org/images/526567/38b1236e01ddbcf65424f922e72147.jpg -Dislocation

• Fracture of the ulna shaft • Dislocation of the radial head (proximal radioulnar joint) • If an is

present, always look for a http://radiopaedia.org/articles/monteggia-fracture-dislocation radial head dislocation Monteggia Fracture- Dislocation

Posterior border of the ulna should also be assessed

http://www.rch.org.au/clinicalguide/guideline_index/fractures/Monteggia_fracturedislocations_Emergency_Department_setting/ BADO CLASSIFICATION

http://www.orthobullets.com/trauma/1024/monteggia-fractures http://www.rch.org.au/clinicalguide/guideline_index/fractures/Monteggia_fracturedislocations_Emergency_Department_setting/ -dislocations

• Fracture of distal radius

• Dislocation of distal radioulnar joint (DRUJ)  Volar or dorsal dislocation

• Intact ulna

http://www.orthobullets.com/pediatrics/4016/galeazzi-fracture--pediatric http://www.rch.org.au/clinicalguide/guideline_index/fractures/Galeazzi_fracturedislocations_Emergency_Department_setting/ A Galeazzi equivalent fracture

Distal radial fracture Distal ulnar physeal fracture Without disruption of the DRUJ

http://www.rch.org.au/clinicalguide/guideline_index/fractures/Galeazzi_fracturedislocations_Emergency_Department_setting/ Distal Radius Fractures

• Metaphyseal • Physeal • Salter II most common • Torus • Greenstick • Complete • Volar angulation with dorsal displacement most common CLAVICULAR FRACTURE

• AP view often sufficient to diagnose if midshaft • Consider 45o cephalic tilt view if needed

http://www.rch.org.au/clinicalguide/guideline_index/fractures/ Clavicle_fractures_Emergency_Department CLAVICULAR FRACTURE

• In displaced fracture: sternocleidomastoid pulls upward to displace medial clavicle, lateral fragment pulled downward by weight of TIBIA • Tibia and fibula fractures often occur together • Toddler’s fracture : >>

TODDLER’S FRACTURES • Children younger than 2 years old learning to walk • No specific injury notable most of the time • Child refuses to bear weight on leg •  caused by torsion or rotational force OVERVIEW

Unique Features of Pediatric Skeleton

Type of Pediatric Fractures

Imaging Modality

Take Home Points RADIOGRAPH

• Most cases : begins with radiographs • Very few patients require imaging beyond plain films • Radiographs : at least 2 orthogonal views • Toddler’s fracture  spiral fracture  addition of oblique views CT SCAN

• Pelvic trauma • Separation of physis in triplane fracture • Tillaux fractures  determine fragment displacement • Detection of loose bodies or bone fragments http:// www.The Radiology Assistant Elbow - Fractures in Children.htm MRI • Identification of fractures that are not clearly seen on plain radiographs • Able to visualize : Bone bruising Cartilaginous cannot be seen radiographically Soft tissue injury • Detection of loose bodies without a calcified component • Detect fragments of bone as well as cartilage fragments. MRI Bone bruising

MRI Cartilaginous lesion

http://www.The Radiology Assistant Elbow - Fractures in Children.htm MRI… • Elbow trauma : The use of MRI  may not result in the alteration of treatment or improved clinical outcomes • MRI findings in the pediatric knee  alter management in most cases • Knee trauma : Growth-plate fractures Avulsion fractures Injuries to ligaments Bone-marrow edema Effusion Soft tissue injuries Patellar dislocation Meniscal tears (Figure 15).

• MRI is indicated in the evaluation of the pediatric knee in cases where plain films are equivocal MRI… • Delineate physeal abnormality & marrow edema  can alter Salter-Harris classification of growth plate injuries prior to the development of growth arrest by detecting physeal bar

• Avulsion injuries that involving: Tibial spines (Figure 13) Lower pole of the patella Medial epicondyle of the distal humerus MRI Physeal bar Young is Better

• Children tend to heal • Disadvantage: misaligned fractures faster than adults fragments become “solid” • Advantage: shorter sooner immobilization times • Rotational deformities • Mild angulation deformities require reduction (don’t often correct themselves remodel) OVERVIEW

Unique Features of Pediatric Skeleton

Type of Pediatric Fractures

Imaging Modality

Take Home Points Take Home Points

• Pediatric skeletal is unique • Type of pediatric fracture including incomplete fracture, physeal injury (Salter Harris fracture), and complete fracture • Imaging modalities for evaluation pediatric fracture including plain radiograph, CT scan and MRI THANK YOU