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Imaging of Pediatric Fracture

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Imaging of Pediatric Fracture 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 / Torus Fracture • Greenstick Fracture Plastic Deformity / Bowing Fracture • Angulation of the bone 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 radius. • 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 tibia 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 Elbow Fracture 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 Monteggia Fracture-Dislocation • Fracture of the ulna shaft • Dislocation of the radial head (proximal radioulnar joint) • If an ulna fracture 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/ Galeazzi fracture-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 arm 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 • Spiral fracture 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
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