Common paediatric fractures and growth-plate injury — branching viva

Branching framework

Open with the one-sentence problem representation and the growth-plate framing. A child's long bone fractures differently from an adult's because of the open growth plate, the thick periosteum and the plasticity of immature bone, and the fellowship task is to read the pattern — Salter-Harris for the growth plate, greenstick and buckle for the pliable bone, Gartland for the supracondylar — and to let the pattern decide the management. State the growth plate as the prognostic organ before you discuss any single fracture. [1] [5]

Reproduce the Salter-Harris classification and its prognosis. Type I is a pure physeal separation, type II passes through the physis and out through the metaphysis carrying the Thurston-Holland fragment and is the commonest at roughly three-quarters, type III crosses the epiphysis into the joint, type IV crosses the epiphysis, the whole physis and the metaphysis and carries the highest growth-arrest risk, and type V is a crush injury with a normal initial radiograph. Be ready for the prognosis probe — the higher the type, the worse the growth-arrest risk — and for the Peterson refinement that added further variants. [1]

Branch to the Gartland III supracondylar and the threatened hand. The displaced extension-type supracondylar is classified by Gartland — III is fully displaced — and it goes to theatre for emergency closed reduction and percutaneous pinning. State that the anterior interosseous nerve is the commonest nerve injured and is tested with the OK sign, and that a pale, pulseless, cold hand is reduced immediately because restoring alignment often restores the pulse, with brachial artery exploration reserved for the hand that stays white. [5]

Branch to the lateral-entry pinning and the ulnar nerve. Two or three divergent lateral-entry pins are preferred over crossed pins, because a medial pin risks transfixing the ulnar nerve at the medial epicondyle. The meta-analysis of randomised trials and the Skaggs pin-placement study showed that lateral-entry pins reduce the iatrogenic ulnar nerve injury rate while maintaining fixation stability. State that a medial pin is reserved for when lateral fixation is insufficient and is placed through a small incision to visualise the nerve. [4] [5]

Branch to the torus fracture and the FORCE evidence. The buckle or torus fracture of the distal radius is inherently stable and never displaces, so it is managed with a soft bandage or a removable splint for around three weeks. The FORCE equivalence trial showed that offering a bandage was no worse than rigid immobilisation and gave children better function and less pain, and the systematic review confirmed bandage or splint over a cast. The examiner rewards the candidate who knows that the contemporary evidence favours the least restrictive immobilisation for the stable buckle. [3]

Close with the safeguarding duty and the growth plate. The classic metaphyseal lesion — the corner or bucket-handle fracture at the distal femur or proximal or distal tibia in a non-mobile infant — and the femoral fracture in a non-walker demand the safeguarding pathway, not the plaster room. Kleinman showed the classic metaphyseal lesion is far more prevalent in infants at high risk for abuse. The examiner rewards the candidate who frames the paediatric fracture around three ideas — the growth plate that must be followed, the remodelling that accepts malunion, and the safeguarding duty that investigates the inconsistent injury. [9] [1]